Refining Ultrasound-Guided Dilation and Curettage in Complex Gynecologic Surgery

Table of Contents

• Procedure Summary
• Authors
• Youtube Video
• What is Refining Ultrasound-Guided Dilation and Curettage in Complex Gynecologic Surgery?
• What are the Risks of Refining Ultrasound-Guided Dilation and Curettage in Complex Gynecologic Surgery?
• Video Transcript

Video Description

This video highlights advanced ultrasound-guided techniques in dilation and curettage for managing complex gynecologic cases like ectopic pregnancies, emphasizing safety, precision, and effective outcomes.

Presented By

Affiliations

North York General

University of Toronto

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What is Refining Ultrasound-Guided Dilation and Curettage in Complex Gynecologic Surgery?

Refining Ultrasound-Guided Dilation and Curettage in Complex Gynecologic Surgery refers to the use of advanced, minimally invasive techniques to enhance the safety and efficacy of D&C procedures for complex gynecologic conditions, such as ectopic pregnancies or unusual pathology. Here’s what it entails:

• Ultrasound Guidance: Real-time imaging improves visualization of uterine and cervical structures, reducing risks like uterine perforation and ensuring accurate targeting of pathology.
• Preoperative and Intraoperative Innovations: Techniques like retro-filling the bladder, injecting Vasopressin for hemorrhage control, and mapping placental or gestational structures optimize surgical planning and outcomes.
• Minimally Invasive Techniques: Use of suction curettage over sharp curettage minimizes tissue trauma and bleeding while preserving uterine integrity.
• Postoperative Enhancements: Diagnostic hysteroscopy and intracervical Foley balloon placement ensure effective tissue removal and hemostasis, reducing complications.

This refined approach integrates evidence-based techniques to improve outcomes in complex gynecologic surgeries while minimizing risks and preserving reproductive potential.

What are the Risks of Refining Ultrasound-Guided Dilation and Curettage in Complex Gynecologic Surgery?

Video Transcript: Refining Ultrasound-Guided Dilation and Curettage in Complex Gynecologic Surgery

Simple solutions for complex problems. This video will examine the role of ultrasound, guided dilation and curettage in gynaecologic surgery. These are the learning objectives of the surgical video. Dilation and curettage, also termed D&C, is generally considered to be the simplest and most basic gynaecological procedure. While D&C is a very safe procedure with complications being rare, complications include uterine perforation, with subsequent haemorrhage or injury to surrounding viscera, cervical injury, infection, and the formation of intrauterine adhesions.

Trans-abdominal ultrasound guidance is a useful tool when performing D&C for unusual pathology. Although performance of D&C without ultrasound is acceptable for uncomplicated procedures for pregnancy termination, or losses, evidence generally shows that ultrasound guidance increases the safety of D&C procedures performed in more complex cases.

The first case is a 40-year-old G4A2P1 who presented with a live cervical ectopic pregnancy, measuring six weeks and five days on ultrasound, who required surgical management after failing inpatient medical management with multi dose methotrexate. In her ultrasound images, the gestational sac with a live foetal heart rate was seen at the proximal portion of the cervical canal, just below the level of the internal os.

When using trans-vaginal ultrasound to evaluate for cervical ectopic pregnancy, the presence of a foetal heart rate and negative sliding sign between the gestational sac and the cervical canal is strongly suggestive of this diagnosis.

In the operating room, concurrent, real time trans-abdominal ultrasound was performed. The first step was to retro-fill the bladder with sterile water. Retro-filling of the bladder allows for the creation of an acoustic window to better visualise uterine pathology. Here, we can visualise a cervical ectopic pregnancy in relation to the anteverted uterus. The next step was then the infiltration of concentrated Vasopressin into the cervix, which acts as a potent vasoconstrictor when locally injected at the cervix, which is mainly composed of fibrous connective tissue.

Without need for dilation a 9 mm suction curette was then inserted into the cervix under ultrasound guidance, until the opening of the curette was at the level of the gestational sac. In general, a larger-width curette will allow more content to pass through more easily and quickly and is less likely to perforate. This video shows the disappearance of the cervical ectopic on ultrasound, as suction curettage is performed. Copious products of conception were aspirated.

We then performed diagnostic hysteroscopy. The 10 mm resectoscope with a loop electrode was used using glycine as a distension media. Here we can see the space in the Upper Cervical Canal that was occupied by the gestational sac. And beyond this, we can see a normal uterine cavity through hysteroscopic inspection. Haemostasis in this case was excellent and post-operatively the patient had no more vaginal bleeding upon immediate discharge from the hospital. At her follow-up she was doing well and voiced no ongoing issues.

In our second case we have an asymptomatic 30-year-old G4A2P1 presenting with ultrasound findings of a type one C-section scar pregnancy. Here we see the ultrasound images which show a gestational sac that distends the space within the C-section scar defect, with the preserved myometrial layer, with the gestational sac abutting the endometrial cavity. After being counselled on medical and surgical options the patient opted for surgical management.

Like the first case, the bladder was retro-filled and Vasopressin injected into the cervix. Here we can clearly see the type one C-section scar ectopic pregnancy on real time trans-abdominal ultrasound scanning. A 10 mm suction curette was used without need for dilation, and we can see the involution of the gestational sac as it is pulled into the suction tubing. Once adequate tissue was obtained, we proceeded with hysteroscopy using the 10 mm resectoscope and glycine and noted a normal endometrial cavity.

One can note the large C-section niche which previously contained the gestational sac. Residual pieces of gestational tissue were resected without energy. We did not feel the need to proceed with laparoscopy as the products of conception were felt to have been adequately resected and bleeding was controlled. Once hysteroscopy was completed some ongoing bleeding was noted coming from the uterus. An 18 Fr Foley catheter was inserted into the C-section and inflated to 20 ccs. We used a metal Foley catheter guide to aid with placement.

The bleeding immediately abated, and the catheter was kept in situ for the next 24 hours. The patient received antibiotic prophylaxis with Ancef. After the Foley balloon was deflated the patient was discharged the following day. At her follow-up, she was doing well and had resumed regular menses.

We have presented two cases where suction D&C has historically been associated with risk of haemorrhage. We present an approach to suction D&C that can be safe and effective in the treatment of various complex surgical conditions. Firstly, we highlight the utility of intraoperative real time ultrasound in both of these cases. Being able to maintain visualisation during the procedure decreases the risk of uterine perforation and allows for active monitoring of procedural efficacy.

Retro-filling of the bladder is also a useful technique to improve visualisation and correct sharp uterine anteversion. Secondly, the use of Vasopressin to aid in minimisation of blood loss is especially important in cases where haemostasis cannot be reliant on myometrial contraction.

Other techniques for pre-emptive haemostasis, such as trans-vaginal ligation of the cervical vaginal vessels and uterine artery embolization have also been described. One could also consider preoperative tranexamic acid administration. Thirdly, we recommend avoiding the use of sharp curettage, if possible, as this may result in tissue trauma and excessive bleeding. Proceeding with diagnostic hysteroscopy following section curettage allows for the visualisation and targeted removal or retrieval of residual tissue or pathology.

Fourthly, the use of intrauterine or intracervical Foley balloon is a low cost, simple intervention that is an effective adjunct for obtaining haemostatic control. By attaching the catheter to a drainage bag monitoring of ongoing bleeding is possible as well. A rigid metal catheter guide can be a useful tool for Foley placement. Prophylactic antibiotics can be considered as long as the Foley is in situ as well.

In this video we show that surgical management of complex ectopic pregnancies can be managed safely and effectively using simple surgical techniques, such as a suction curettage, which is both a minimally invasive and uterine-sparing technique. We propose the aforementioned approach to minimise bleeding and other complications during and after the procedure.