A 26-year-old woman is undergoing a suction dilation and curettage for a missed abortion. During the procedure, the physician notes a sudden loss of resistance while advancing the suction curette. Upon withdrawing the instrument, yellow, fatty tissue is seen within the cannula. The patient is under monitored anesthesia care. Her blood pressure is 105/65 mm Hg and heart rate is 102/min.
Arrange the following management steps in the most appropriate chronological sequence for this patient's acute complication.
- 1Immediately halt the procedure to prevent further trauma.
- 2Assess hemodynamic stability and ensure adequate intravenous access.
- 3Perform a diagnostic laparoscopy or laparotomy to inspect the abdominal cavity.
- 4Surgically repair the uterine perforation and any associated visceral injuries.
Answer
The correct sequence is: immediately halt the procedure, assess hemodynamic stability, perform a diagnostic laparoscopy/laparotomy, and then surgically repair any identified defects.
When a uterine perforation is suspected during a dilation and curettage, the most critical initial step is to stop the procedure immediately to prevent further damage. The presence of fatty tissue indicates that the curette has entered the peritoneal cavity and grasped omentum. This mandates an immediate assessment of the patient's hemodynamic status to prepare for surgery. Because abdominal contents have been drawn into the uterus, a diagnostic laparoscopy or laparotomy is required to thoroughly inspect the bowel and other viscera. Finally, definitive surgical repair of the uterus and any injured adjacent structures is performed.
Step-by-Step Solution
Key Concept
Management sequence for complicated uterine perforation with suspected visceral injury.