Routine Curettage at Delivery*

Vol. 74, No. 2 August, 1957

OBSTETRICS AND GYNECOLOGY Obstetrics ROUTINE CURETTAGE AT DELIVERY* jAMES

B.

LouNSBURY,

M.D.,

WILMINGTON,

N. C.

(From the James Walker Memorial Hospital)

T

HE purpose of this presentation is merely to record the procedure and results of curettage of the uterus at the time of df'livery, not as an Pmergency measure but as a routine practice. lVIy 1 interest in the control of postpartum bleeding began in 1940. Although trained in the consrrvative as opposed to the radicaF school of treatment of incomplete abortion, I later ohst>rved that more frequent curettage and emptying of the aborting uterus saved blood, h•ssenecl morbidity, and possibly often preservPcl fertility. ·with thP observation that the postabortal r·ourse was shortened by removal of blood clots, placental debris, membranes, and drciclua, the question arose as to why such a practice should not as well he· applird at full-term delivery as at abortion. In 1947, with a few papcrsa-s cautiously appt>aring about manual palpation of the uterus following delivt>ty, I initiated the maneUV('r of routinely invading the uterus. 'fhe availability of antibioties, of course, lent n•assurance where only a few years previously one would have been horrified to attempt such a transgression of ohstt>trieal teaching. Actually, Holmstrom'sn paper on the bacterial flora of the uterus shows why invasion of the postpartum uterus immediately following delivery is not very likely to cause infection, for it is after the first +8 hours that pathogenic baeteria begin to appenr. Entering the uterus with the hrmcl, as in the more and more widely accepted practice of manual rrmoval o:f the placenta, not only may not arouse bleeding but may very efficiently control it. *Condensed from a paper presented at a meeting of the North Carolina Obstetrical ancl Society, April 29, 1956.

r:~·necological

233

234

LOUN~BURY

:\rr1.

_l. Ohs.t. & Gynec. August, 1~57

The danger of perforation of the uterus with a curette is a relative matter. With ordinary care, this accident will not happen unless there is mechanical difficulty in entering the uterus as in the presence of cervical stenosis or carcinoma. Method 1'hc curette* used is a large sharp instrument with a blade, the loop of which is 1 inch wide. The shaft is malleable to allow adaptation to the varying axes in which one finds the uterine canal. The blade is large, not to avoid perforation but to effect a more complete scraping of the interior of the uterus than would be possible with ordinary cnrettes. Since the uterine cavity is often :flattened anteroposteriorly when eontracted, it may not be possible to rotate such a large curette; in this case it is simply withdrawn and reinserted after rotation. The free hand is placed on the -abdomen in contact with the top of the fundus. By this means the curette' can be felt to impinge against the top of the fundus from within as it is inserted. This gives an accurate~ knowledge of its depth of penetration, which is quite different from the situation in curetting the smaller postabortal uterus. With this hand also, the axis of the fundus can be adjusted to the direction of the curette much as one would manipulate a carton to scrape out the eontents with a spoon. The hand is more sensitive to the feeling of the curette against the wall of the fundus than one might suppose: the feeling of the presence of membranes gives a slippery, mushy sensation; placental tissue is more doughy; and clean uterine wall gives the sandy scraping usually noted in curettage of the nongravid uterus. Results 'fhe accompanying tables will be seen to he more or less self-explanatory. Thct·e arc some features of each, howevPr, that will be worthy of comment. TABLE

I. MORBIDI'l'Y NO. CASES

%

715

Total for study

N onmorbid.Tenlperature: Normal 100-101 o F. once only 12-18 hours post partum 100-101° F. once only 24-72 hours post partum Single temperature elevation

95

Total *Made to order by the J. Sklar Manufacturing Co.

72

46

Total Morbid.Undetermined cause Cystitis Ante/intrapartum sepHis Postpartum sepsis (foul lochia) Enteritis Mastitis Packing Aspiration bronchitis Infectious mononucleosis Abscess of Bartholin gland Respiratory infection Hematoma

514

Hl

20

655

92

12 18

1.6

11 3

2 4 2

1

1 1 2 3 60

8.4

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ROUTINE CURETTAGE AT DELI\lBRY

Voiume i4 Number 2

The total number of records reviewed for this study has been 715, from which the percentage figures are derived. The single elevations of temperature noted in Table I are of interest. The temperature, normal on admission, usually is not again checked until following delivery and often not until the patient has been returned to her room. The elevations, at least through 18 hours post partum, are conceivably due to dehydration. Those which rose 24 to 72 hours post partum are probably due to a transient bacteremia; but this is not necessarily in any way related to the process of curettage, for the same elevations arc frequently found in patients who have not been curetted. The morbidity statistics are a little more critical than the customary standard of temperatures of 100.4° F., for I have used a level of 100.0° or over for 2 successive days excluding the day of delivery. There was no mortality. It is note\vorthy that curettage ''vas done in those patients \~lith antepartum and intrapartum sepsis as well as one with an acute abscess of the Bartholin gland without apparent complication of the course of recovery. Perhaps this is again due to the antibiotic drugs. The 12 patients (1.6 per cent) who exhibited morbidity without any explainable reason were the only ones in whom curettage might have been a factor in producing morbidity. This was not apparent, however, £or there was no evidence of foul lochia, tender uterus, or pelvic phlebitis for which such a procedure might be condemned. In Table II is shown the number of patients in whom antibiotics were used and the reasons therefor. The 34 patients given penicillin prophylactically were those early in the course of the study at which time I was not certain of the safety of the procedure. It also includes those in whom possible contamination was feared. Nonetheless, only 9.9 per cent were given penicillin primarily because of the curettage. T}.. BLE II.

.L.t\.NTIBIOTICS NO. CASES

%

715

Total for study No antibiotic Antibiotics given for expected morbid states Antibiotics given for present morbid states Total unrelated to curettape Antibiotics used: Prophylactically For unexplained fever For foul lochia (nonmorbid) Total possibly related to curettage TABLE

Ill.

530

74

114

16

64 50

34 34

3 71

9.9

RESULTS OF CURETTAGE NO. CASES

654

No unusual feature mentioned on record Fragment of membranes removed Fragment of placenta removed

Total effective prevention of hemorrhage Additional comments: Hemorrhaged until curetted Marked amount of decidua

%

715

Total for study

91

47 9

56 1

4

7.8

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Am.

J. Obst.

& Gyncc.

August, 1957

In Table III the 7.8 per cent of patients in whom curettage removed tissue is to be compared with the 6 per cent incidence of retained placental tissue reported by Weekes and O'Toole 1 " as a cause of postpartum hemorrhage. Shulman and associates 11 reported 9 per cent of delayed postpartum hemorrhages to be due to retained secundines. It is a comforting feeling to remove pieces of placenta or membranes after inspection of the placenta and membranes has in many eases shown no deficiency grossly. In one patient, so much membmne was removed by the cmrette that further inspection of the placenta showed this must have been the entire chorion. This comment is found on the delivery note of another patient who had had hydrorrhea since the fifth month: ''Curettage removed quite a quantity of fragments of necrotic membranes; placenta apparently normal." On several occasions it was noted that "curettage removed a large amount of decidua." One patient was found on manual removal of the placenta to have an incomplete septum of the uterus. 'l'he placenta was found in one cornu, while an unusually abundant quantity of decidua was curetted from the opposite cornu. Of what significame this disproportionate amount of decidua may be is pure conjeeture. All tlwse patients had normal postpartum lochia. I suspect it might ha vc been abnormally heavy or prolonged had curettage not been donP. For several reasons tissue was not prepared routinely for microscopic examination. A number of sections, unselected, were made of samples of curettings and examination of the slides shows the following common features: (1) sheets and strips of decidua in all cases; (2) within the decidua, numerous flattened, thin-walled, endothelium-lined sinusoicls, most of which were empty; (3) no or very slight evidence of inflammatory infiltration of round cells, except in those patients who had had previous rupture of the membranes or a morbid intrapartum course; ( 4) scant evidence of placPntal villi; (5) occasional strips of myometrium, but less than one mig·ht presuppose; (6) small, thick-walled vessels with occasional fresh thrombus formation. In evaluation of Table IV, it should be n•alized that the grc·at majority of these patients were delivered under low spinal anesthesia with which the ']'ABLE

IV.

BLOOD LOSS A'l' DELIVERY

NO. CASES

Total deliveries Bleeding not described

31 684

Total for study Minimal or scanty* bleeding Normal bleeding

%

715

63 584

1'otal normal blood loss

Moderately heavy bleeding: Uterine, from ether anesthesia Extrauterine (lacerations, varices, etc.)

647 5

27

1'otal moderately heavy blood loss

Excessive blood loss: Uterine Lacerations 1'otal excessive blood loss *Bleeding so slight as just to stain the perineal drape.

9(i

32 2 3

5

0.7

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ROUTLNE CURETTAGE AT DELIVERY

Volume 74 Number 2

blood loss at deliverv is considerablv less than with the use of general anesthesia, especially ether. Only 0.7 p~r cent had an exaggerated loss of blood and this was unrelated to curettage. In Table V there was one instance of postpartum hemorrhage truly from retained secundines. Curettage was repeated about 2 hours after delivery and a strip of membrane removed described as 1 by 4 inches in size. This episode showed that thorough and careful curettage is important. The curette must "feel" a clean uterus, that is, produce the sandy scraping previously noted. TABLE

V.

LOCHIA DURING HOSPITAL PERIOD

14 694

Scant Normal

Total with lochia withi-n normal limits Postpartum hemorrhage: Thrombocytopenic purpura Retained secundines Ambulation on day of delivery Subinvolution sixth day Hematoma "More than normal," transfused

VI.

99.1

7

0.9

1 1 1 1 2

1

Total with excessive lochia TABLE

708

LOCHIA AFTER DISCHARGE FROM HOSPITAL NO. CASES

40

675

Total for study No comment (assumes lochia less than 3 weeks) Lochia 3 days to 3 weeks

618 18

Total with lochia less than 3 weeks Lochia lasting 4 weeks Lochia lasting 5 weeks Lochia lasting 6 weeks

636

11

hemorrhlolge; retained secundines'' (no slide) hemorrhage, thrombocytopenic purpura hemorrhage, subinvolution sixth day hemorrhage, subinvolution ninth day hemorhage, endometritis (12-15 days postpartum)

Total with

94

10 1

21

Total with moderately abnormal lochia Late Late Late Late Late

%

715

Total deliveries No follow-up

32

4.1

7

1.0

1* 1 2+:·

1* 2*

•See discussion in text.

The two cases of extraordinarily scant lochia seen in Table VI are of particular interest. They represent the same patient, her delivery in 1949 followed by no lochia whatever until the seventh day. I have never encountered this before and was daily expecting severe hemorrhage to occur. In her postpartum course in 1952 she had very scanty lochia for only 3 days,

238

Am.]. Obst. & Gynec.

LOUNSBURY TABLE

VII.

August, 1957

RETURN OF MENSTRUATION NO. CASES

151

Total adequately followed for study Onset of menstruation: 4 weeks 6 weeks to 3 months 'l'otal

%

715

Total deliveries No follow-up

men~truating

564

19 306 by 3 months

3 to 8 months No period before next pregnancy Specific onset unknown; regular by later history

58

142 3 83

Total menstruating by 8 months

:!24

39

Grand total with onset of menstruation within normal range

549

97

Amenorrhea to last contact at 6 months Menses irregular 1 year or more Amenorrhea 21 months (Sheehan's syndrome) Subsequent bleeding problem, functional

1

2 1 11

Total subsequent menstrual abnormality TABLE

VIII.

15

SUBSEQUENT FERTILITY

Inadequate follow-up

180 535

Total adequate follow-up for study Contraception Sterilized Widowed Later hysterectomy

205 38 3 3

249

Total excluded from possible fertility

286

Corrected total for study Delivered Delivered Delivered Delivered Delivered Delivered Delivered Delivered

1 2 3 4 5 6 7 8

2.6

year later years later years later years later years later years later years later years later

41 95 65 21

18

6 2

2

Total normal next pregnancies Patients having 2 more babies, also curetted

40

Aborted subsequent pregnancy Therapeutic abortion, subsequent pregnancy Criminal abortion, subsequent pregnancy Placenta previa, subsequent pregnancy Abruptio placentae, subsequent pregnancy Ruptured ectopic pregnancy 1 year later Congenital abnormality, subsequent pregnancy Sterility problem later (of these, husband 1, endometriosis 1)

19 3 3 1* 1* 1 2 6

Total ~'nsatisfactory later history •Normal babies obtained.

250

88

36

12

Vulume 74 Number 2

ROUTINE CURETTAGE AT DELIVERY

239

following which there was nothing more than a normal leukorrhea. I have seen this occur in one other patient curetted since then who is not included in this study. "Retained secundines" was a presumptive diagnosis on the hospital records without tissue proof in 2 cases in which the lochia continued to six weeks and one which was so designated at the seventh day. In the light of studies of the tissue obtained in those with "late hemorrhage," the diagnosis of "retained secundines" was probably incorrect. Six of the cases designated as "late hemorrhage" were originally diagnosed on the hospital records as "retained secundines." A review of the slides made from the curettings at the time of their hemorrhages, however, proves otherwise. In one of these the slide has been lost and, remembering the character of the patient, I am inclined to think that her hemorrhage was due to subinvolution from activity rather than to "retained secundines" as shown in the table. Examination of the slides in the remainder of these 6 cases shows no chorionic villi. The slides show myometrium with endometrial glands, fresh hemorrhage, and infiltration of inflammatory cells. Thus, there was no case of late hemorrhage due to retained secundines. Of the 2 cases of late hemorrhage 12 to 15 days post partum, one patient had previously had a partial placenta accreta followed by 21 months of amenorrhea. This time again she had a partial placenta acccreta requiring manual removal of the placenta. Table VII, showing a 97 per cent normal return to menstruation, seems sufficient evidence to refute the preposterous statements found in the literature regarding the effect of curettage, two of which are quoted: Dr. J. Mathieu 12 of Lyon observes that "amenorrhea is seen more frequently when dilatation and curettage is done post partum than when done after abortion. Extensive scarring and formation of intrauterine adhesions obliterate the cavity. Hysterographic examination usually reveals deformity of the cavum uteri, '\vith or '\Vithout visible adhesions.'' "In an otherwise excellent discussion of postpartum amenorrhea, your consultant seems to have neglected to mention the most probable etiological factor in this case, namely, curettage. This procedure, particularly when done in the early postpartum period, is certainly not a rare causative factor in prolonged or permanent amenorrhea." 13 The lack of harmful effect on subsequent fertility is shown in Table VIII. A normal outcome of 88 per cent of further pregnancies is well above the accepted figure of 20 per cent pregnancy wastage so often quoted.H- 16 Conciusions

A study of the routine curettage of the uterus immediately post partum in 715 patients has been presented. The evidence tends to show that it is not a dangerous procedure. The morbidity rate may be moderately improved, blood loss at delivery is reduced, and 7.8 per cent of patients were found to have retained tissue at delivery which might have caused later hemorrhage. Postpartum lochia is both lessened and shortened, and subsequent menstruation and fertility are not adversely affected. References 1. 2. 3. 4.

Lounsbury, .J. B.: AM • .J. OBST. & GYNEC. 40: 111, 1940. Safford, H. B., and Longworth, E. F.: AM . .J. OBST. & GYNEC. 59: 398, 1950. Gillard, .J. L.: Discussion of paper by Black, W. T., .Jr.: South. M . .J. 36: 510, 1943. Sewall, C. W., and Coulton, D.: AM . .J. OBST. & GYNEC. 52: 5641 1946,

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Obst. & Gynec. August, 1957

Dieckmann, W. J., et al.: AM. J. 0BST. & GYNEC. 54: 415, 1947. Carroll, B. ·H., Meier, H. H., and Stone, 0. H.: AM. J.' OBsT. & GYNEC. 55: 620, 1948. Erving, H. W., and Power, H. A.: AM. J. OBST. & GYNEC. 53: 1019, 1947. Cacciarelli, R. A.: AM. J. OBST. & GYNEC. 57: 351, 1949. Holmstrom, E. G., and Murata, M.: AM. J. 0BST. & GYNEC. 56: 531, 1948. Weekes, L. R., and O'Toole, D. M.: AM. J. OBsT. & GYNEC. 71: 45, 1956. Shulman, A., et al.: AM. J. 0BST. & GYNEC. 71: 37, 1956. Mathieu, J.: Lyon chir. 50: 470, 1955. Degasis, A. J.: J. A. M. A. 156: 1469, 1954. Wiehl, D. G.: Milbank Mem. Fund Quart. 16: 80, 1938. Malpas, A. W.: J. Obst. & Gynaec. Brit. Emp. 45: 932, HJ38. Stander, H. J.: Textbook of Obstetrics, ed. 3, New York, 1945, D. Appleton-Century n ........................... -. vvll.Lpa.-u.r' P• ~.

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