Trial puncture in tubal pregnancy
Preparation of the operating field, ie, the external genitalia, the vagina and the vaginal part of the uterus, which is common for a vaginal operation. It is necessary only to observe great care when handling the vagina, so as not to disturb the integrity of the capsule and the fusion that separates the focus from the common abdominal cavity. Therefore, disinfection of the vagina is a careful wiping in the mirrors of the vaginal part of the uterus and the walls of the vagina with gauze or cotton wool tampers moistened with alcohol and lubricating with iodine tincture. Then the mirrors are replaced and the cervix is exposed. To avoid rupture of adhesions, in acute cases of the disease we prefer to perform puncture from the back of the vaginal vault, without grasping the posterior lip of the uterine throat with bullet forceps, as many do.
Our technique is as follows: with the back spoon of the mirror pulling down the back of the vagina, the front spoon is placed under the vaginal part of the uterus. Puncture is done by a long( not less than 8-10 cm) not too thin needle so that not only liquid blood can pass through it, but also the smallest blood clots. The needle is placed on a 10-gram syringe, which is then checked again. The puncture is done with the syringe fully inserted. The needle should be directed a little anteriorly, so as not to pierce the rectum, fixed to the sacrum. The danger of damage to the moving loops of the intestines, as mentioned repeatedly, is negligible, since the loops slip away from the needle. The needle is moved to the depth( usually 3-4 cm), until you get the feeling that the needle has fallen into the void. Then proceed to suction the contents of the cavity. Piston syringe pulling right hand, while the left firmly holds the needle in place of its attachment to the syringe. If liquid is not sucked, then the needle is very slowly removed, while continuing with the other hand to pull the piston. As soon as blood or other liquid is shown in the syringe, immediately remove the needle extraction. If the puncture does not give a result, then the needle is extracted and the puncture is repeated either to a greater depth, or the puncture is done slightly deviating from the place of the first puncture. If the first puncture that did not produce a result was made with a thin needle, then with a repeated puncture we take a thicker needle.
In the old days, many( including us) made a puncture not in the mirrors, but under the control of the fingers of the left hand inserted into the vagina( the right hand holds a syringe with a firmly inserted needle).With this method, it is easy to violate the rules of asepsis, which here has the same significance as in any abdominal operation. Therefore, preference should be given to punctures made under the control of the eye in the mirrors.
In those cases when a two-handed study of the fluid( blood) is determined in front of the uterus( with the infection of the posterior rectum-uterine cavity, with the placement of the pregnant uterine tube in front of the uterus, etc.), a test puncture can be performed through the anterior abdominal wall. A necessary condition for such a puncture is from our point of view the accumulation of fluid directly behind the abdominal wall. In the presence of a mobile tumor, which can be inflammatory, we do not make a trial puncture, as some authors recommend. If the application of such a puncture can be tolerated in a clinical setting, the top conditions of the district doctor's work should not be used. Immediately before the puncture, the urine should be lowered by a catheter. The place for a puncture is determined by percussion( muffling of the percussion sound over the bosom with a bladder emptied) and palpation( sensation of fluctuation).In these cases, the patient must be previously examined through the vagina. The study should be very thorough, as there have been cases when a normal pregnant womb was swallowed for a blood tumor. The puncture of the pregnant uterus made in this case can give complications.
For a test puncture through the anterior abdominal wall use a syringe with a needle attached to it. With a thin abdominal wall, use a conventional needle, used for subcutaneous or intramuscular injections. With a thick abdominal wall it is necessary to take a longer needle - 8-10 cm.
The correct evaluation of the puncture result is important for the diagnosis. If the blood obtained by puncture has a coffee color, and especially if it has dark grains, it means that it is old blood, and not caught in a syringe from a vessel of the vaginal wall, damaged by puncture.
In doubtful cases, you can recommend a water test according to Feigel. It consists in the following: typing even a small amount of blood into the syringe, another 3-4 cm3 of saline solution is poured into it and the contents of the syringe are poured into a glass cup filled with physiological solution. If the blood is really old, then at the bottom of the cup drop small blood clots( grains).This sample, according to the author, is valuable, especially in those cases when a syringe managed to gain only a small amount of blood. If the dark syringe is easily drawn into the syringe, the doubts disappear and the proposed sample is superfluous.
Having established in a doubtful case a test puncture, the presence of blood in the abdominal cavity, which in the vast majority of cases indicates an abortive ectopic pregnancy, should immediately proceed to the abdominal process.
A number of authors indicate a greater diagnostic value of posterior colpotomy compared with a trial puncture. Undoubtedly, trial colpotomy allows more accurate diagnosis than a trial puncture. But it is also undoubtedly that trial colpotomy is a surgical intervention requiring a certain experience in the technique of vaginal operations. And with this technique, many general surgeons and some gynecologists do not have sufficient knowledge. Therefore, in order to establish a differential diagnosis in a doubtful case in the presence of fluid accumulated in a small pelvis, it is first of all necessary to make a test puncture, and only in case of its failure to resort to trial colpotomy or even to a trial laparotomy.
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