Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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122 Surgery and Healing in the Developing World
Complete Abortion
No surgical intervention is necessary.
Second Trimester (Through 20 Weeks)
Threatened Abortion
Admit the patient for observation and support.
Inevitable or Incomplete Abortion
Wait for the fetus to pass. If the abortion remains incomplete, make the patient
NPO, establish IV access and begin fluid resuscitation. Administer methyergine
and/or begin an oxytocin drip. If the POCs still are not expelled, you must evacuate
the uterus. Place the patient in dorsal lithotomy position, prep and drape, and administer
appropriate anesthesia. Empty the bladder.
If you are unable to insert your finger, dilate the cervix cautiously with Hegar or
Pratt dilators. Then try to perform a digital evacuation (“finger curettage”) of the
uterus, using your nondominant hand to press down on the fundus as in a bimanual
exam. Consider careful use of a curette as a last resort since there is a risk of perforating
the uterus, especially with a septic abortion. If you must use a currette, administer
an ergot amine which will contract the uterus and reduce the risk of perforation.
Gently scrape the uterine walls until you have released the retained POCs and perform
a final bimanual exam to explore the uterine cavity. You may need to use polyp
forceps or sponge forceps to remove adherent pieces of placenta. Monitor the patient
overnight. If bleeding persists, use methyergine or an equivalent drug IM or
IV, and/or oxytocin if available.
Management of Late Pregnancy Bleeding
Worrisome causes of antepartum bleeding in the third trimester include placenta
previa and abruption. More commonly, a small amount of bleeding can be
traced to bloody show (labor is beginning), or vaginal lesions (lacerations, condyloma,
etc.) Both placenta previa and abruption can lead you to the operating theater
to perform a Cesarean section.
Placenta Previa
This condition exists in about one in every 250 pregnancies. Bleeding from placenta
previa is typically painless. It can occur suddenly and need not be associated
with activity or trauma. Onset is typically early in the third trimester when change
in the lower uterine segment begins.
To make the diagnosis, perform a careful speculum exam to confirm the source
of the bleeding and attempt to determine the amount of cervical dilatation. Monitor
the fetus by whatever methods are available. Monitor for contractions. If ultrasound
is available, determine the location of the placenta. If previa is confirmed,
management will involve a Cesarean section. If the fetus is beyond 37 weeks by
good dating, proceed to section. If the bleeding is severe and unabated, the mother
becomes hemodynamically unstable, or the fetus becomes distressed, proceed to
Cesarean section regardless of fetal maturity. If, however, the bleeding becomes controlled
and the fetus and mother appear stable, manage expectantly by placing the
patient on bedrest, observation, and avoidance of sexual intercourse.
Rarely, bleeding from ruptured vasa previa will be encountered. This is recognizable
if you have access to a microscope and some Wright’s stain. Bleeding in placenta