Dear editor,
We are going to discuss two proposed points to be considered in clinical practice, firstly the uterine assessment by sound before curettage and the second is the use of ultrasound for cavity assessment before IUD application in women with fibroids. Firstly, the uterine clinical assessment: we commonly encounter cases in daily practice that need dilatation and curettage or uterine evacuation. Some simple clinical safeguards are proposed. Uterine sound has a role to exclude uterine septum or even a bicornuate uterus especially if it is not diagnosed before the surgery. Furthermore, it can be missed on ultrasound before surgery. It can be used to assess the cavity by running the sound at the fundus from one side to the other to exclude any deformity inside the cavity especially if there is limited range of motion less than 45°. Forty-five degrees or more range of motion is reassuring and excluding perforation along with limited deapth of uterine sound. The detected pathology can be septum, uterine wall of bicornuate uterus, or bulging scar tissue of previous surgeries in the uterine cavity after atrophy of the myometrium especially postmenopausal women. If there are some contents in one of the cavity horns, it is better to evacuate them under ultrasound guidance as some contents can be missed and can lead to continuous bleeding or a delayed one or even a perforation can occur. These applications are beside the others of assessing the length and confirming the direction of the uterus. This method can be used in low resource countries with limited ultrasound-guided procedures. It is better to do curettage starting with the big curette after using the ovum forceps to remove as many contents as possible to limit perforation which is common with the small curette and missing big tissues. If one of the septum walls was not curetted, pathology may be missed, and the decidua can pass later as bleeding and the patient should be informed of that if done for pregnancy related problems. We consider this technique, of running the uterine fundus with the uterine sound to detect any irregularities so as to avoid perforation or under treatment, as good practical point.
Another technical point is in menopausal females; uterine adhesions are common in postmenopausal uterus especially at the fundus. They appear in the cavity due to the thinning of the endometrium and the myometrium. They can be felt as adherent tissues at fundus that should not be pulled out, as they can lead to perforation of the uterus. If they are encountered, it is better to do an ultrasound to check for residual tissues in the uterus [1, 2, 3].
Secondly, the ultrasound uterine assessment: ultrasound assessment of the uterine cavity before IUD application in patients with fibroid is important. Ultrasound before IUD application is essential also in cases of suspected uterine anomalies whether by history, examinations, previous ultrasound, or previous surgery. Ultrasound should assess the cavity; and the endometrial line should be scanned in the sagittal plane with scanning to the right and to the left side from the midline. Endometrial line is seen as a uniform regular uninterrupted line from the fundus to the cervix. If this is the case, we can proceed with the IUD application in the presence of fibroids. In cases in which the endometrial line is seen as an interrupted line on scanning from the cervix upwards (failure to trace from endocervix) or if there is non uniformity, non smooth tracing of the endometrial line or any masses distorting the cavity, then it should not be applied [3].
These are some clinical technical points that are proposed here to be considered in clinical practice.
Author Contribution
Ahmed El-Agwany did the work, collected the data, performed the analysis, and wrote the paper.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved from Alexandria University Faculty of Medicine Ethics Committee.
Informed Consent
Informed consent was obtained from the patients included in the study.
Footnotes
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References
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