Erpoc Cme

Evacuation of Retained
Product of Conception
(ERPOC)
Sharon Jesicca Stephen

 Introduction
 Preparing for ERPOC
 Dilatation & Curettage
-indication
-technique
-post procedure..
 Contraindications
 Risks and Complication
 Take Home Notes
OUTLINE
 Small operation done to treat an
incomplete or delayed miscarriage or
termination of pregnancy
 Surgical management of miscarriage or

partially retained placenta after delivery
 Performed under a general anesthesia
INTRODUCTION
 Consent
Proposed Procedure • Describe the nature of the procedure
Intended Benefit • Aim of the procedure is to treat
incomplete/ missed miscarriage/ retained
placental tissue
Risks (Serious & • Separate serious from frequently
Frequent) occurring risks.
• Increased risk in certain cases
Additional Procedures • Diagnostic laparoscopy to :
-exclude ectopic
-Uterine perforation (to see the extent of
damage)
• Second ERPOC
Sensitive to disposal of fetal tissue
-If tissue is sent for histology, the reasons should be explained.
PREPARATION FOR ERPOC

 Preprocedural Ultrasound
 Blood test (FBC)

 Current Hb and TWC levels
 Prepare blood supply (in case of post prodecural bleeding)
 Preop Prophylaxis Antibiotics

 Dilation refers to the opening of the
cervix. Curettage refers to the aspiration
or removal of tissue within the uterus with
an instrument called a curette
 Treatment for miscarriage, retained

placenta after vaginal delivery, or as a
method of first-trimester elective
abortion.
DILATATION & CURETTAGE

 INDICATIONS
Missed miscarriage Molar pregnancy

 TECHNIQUE
1. Administer preoperative antibiotic prophylaxis.
2. Administer anesthesia
3. Position the patient (Lithotomy)
4. Ensure adequate lighting is available and bed
height is appropriate.
4. Perform a bimanual examination to determine
the cervix dilatation, uterine size and fundal
position
5. Prepare the patient's vulva, perineum, and

inside the vagina with Betadine
6. Perform urine catheterization.
7. Drape the patient under sterile precautions
8. Place a sterile speculum (operative or deep

weighted) in the patient's vagina to adequately
visualize the cervix
9. Place a tenaculum on the anterior lip of the
cervix (12 o'clock position) and use for gentle
traction
10. Perform an
intracervical or
paracervical block with
10-20 mL of 1% lidocaine.
11. Uterine sound may be performed to confirm

uterine size and position
12. Choose suction curette according to uterine or
pregnancy estimated size (available in sizes 6-14)
13. Curette is inserted into

the uterine cavity while
the cervix is stabilized
with a tenaculum. The
suction valve should be
turned off then attached
to the curette.
14. Rotate the curette 360 º continuously until no

more material is aspirated.
*Avoid jerking movements to decrease risk of perforation.

15. Sharp endometrial
curettage can be
performed. Vibrations,
or a gritty texture, felt
(uterine "cry“) is an
indication that
adequate tissue has
been removed.
16. Remove the tenaculum from the anterior lip of

the cervix
17. Remove speculum. Complete course of

prophylactic antibiotics
 Send all specimens to pathology and for genetic
analysis (e.g placenta for HPE) in cases such as
molar pregnancy & recurrent miscarriage
 Complete course of prophylactic antibiotics
 Administer RhoGAM within 72 hours after

procedure if patient's blood type is Rh negative.
< 13 weeks gestation 13 weeks gestation or more
IM 50 mcg x 1 used IM 300 mcg x 1 is used
POST PROCEDURE….
Anaesthesia General Specific
Headaches / Pain: Uterine perforation:
Dizziness -similar to period pain -puncturing of the
-controlled with uterus
Nausea analgesics -(risk: <5 in 1000)
-laparoscopy will be
Vomiting Bleeding: done to assess the
-normal to expect damage
Hypotension some amount of
bleeding Incomplete
Bradycardia -similar to that of a evacuation
period -might need for a
Post GA atelectasis -rarely needs blood another ERPOC
transfusion
Rash Cervical damage:
Infection: -cervix is stretched
Anaphylaxis -endometritis open
*Excessive curettage -
Asherman's syndrome
RISKS & COMPLICATIONS

 Asherman’s Syndrome
-pathological condition of intrauterine adhesions
that can cause secondary amenorrhea, other
menstrual irregularities, infertility, or recurrent
abortion
 Untreated acute pelvic infection (endometritis,
salpingitis)
 Coagulopathy
 Possible fetal viability (except for elective

termination)
 Patient refusal
CONTRAINDICATIONS
 Surgical management of miscarriage or partially retained
placenta after delivery
 Consent should be taken after thorough explanation
 Patients should be advised to have pelvic rest for 1-2

weeks following this procedure. ( NO intercourse, NO
tampons)
 Cramping is the most common side effect NSAIDs are

generally most helpful for this discomfort.
 Patient should be told to come again if there is uncontrolled

pain, fever, chills, or continued heavy vaginal bleeding or
foul-smelling vaginal discharge
TAKE HOME NOTES

 Magowan, B.A, Owen P., Thomson A. Termination of
pregnancy. Clinical Obstetrics and Gynaecology. 3rd Edition.
2014
 Yancey. J.D, Scioscia E.A. Dilation And Curettage with
Suction. Edited August 8,2016. Assessed via
www.medscape.com
 Consent Advice No.10. RCOG Guideline for Surgical
Evacuation of the Uterus for Early Pregnancy Loss. June
2010
 Gynaecology Patient Information. ERPC. NHS Foundation
Trust. October 2017. Assessed via
www.royalberkshire.nhs.uk
 Letchuman,R., Dass,R.H.Doctrina perpetua. Guides on
Osbterics and Gynaecology. 2015.
REFERENCES
THANK YOU

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Evacuation of Retained

Sharon Jesicca Stephen

 Surgical management of miscarriage or

 Performed under a general anesthesia

PREPARATION FOR ERPOC

 Blood test (FBC)

 Preop Prophylaxis Antibiotics

 Treatment for miscarriage, retained

DILATATION & CURETTAGE

Missed miscarriage Molar pregnancy

5. Prepare the patient's vulva, perineum, and

6. Perform urine catheterization.

7. Drape the patient under sterile precautions

8. Place a sterile speculum (operative or deep

11. Uterine sound may be performed to confirm

13. Curette is inserted into

14. Rotate the curette 360 º continuously until no

*Avoid jerking movements to decrease risk of perforation.

16. Remove the tenaculum from the anterior lip of

17. Remove speculum. Complete course of

 Complete course of prophylactic antibiotics

 Administer RhoGAM within 72 hours after

< 13 weeks gestation 13 weeks gestation or more

IM 50 mcg x 1 used IM 300 mcg x 1 is used

RISKS & COMPLICATIONS

 Possible fetal viability (except for elective

 Consent should be taken after thorough explanation

 Patients should be advised to have pelvic rest for 1-2

 Cramping is the most common side effect NSAIDs are

 Patient should be told to come again if there is uncontrolled

TAKE HOME NOTES

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