Implementing Routine Procedural Transvaginal Ultrasound to Decrease Holdbacks: A Quality Improvement Initiative | BMC Women’s Health
This study highlights the successful implementation of a quality improvement process and protocol using transvaginal ultrasound during dilation and suction curettage to reduce retained products of conception and associated reoperation rates in a university educational institution. We also observed a tendency to decrease associated complications such as hemorrhage and endometritis; however, this did not reach statistical significance. It is important to note that we have not encountered an increased impact of quality improvement balancing measures (defined as when a positive change in one part of one system has a negative impact on another. ), or sequelae such as Asherman’s syndrome or uterine perforation after implementation.
The strengths of our study include the standardized definition of the design products selected to reduce observer bias. The POCs retained were defined both by symptoms which led to an ultrasound assessment revealing ultrasound results warranting medical or surgical intervention (heterogeneous and thickened endometrium with Doppler flow), and confirmed by a pathological and / or visual analysis of the products. retained. It is important to note that finding a thickened and irregular endometrium with low impedance Doppler flow after the procedure may be a normal variation in up to 32% of women one week after the procedure. . Therefore, a comprehensive clinical evaluation should be used in each case to determine the likelihood of retention of the products of conception before committing to the intervention. Finally, one of the strengths of our study was that our Olmstead County patient population had near-universal follow-up for postoperative miscarriage check-ups, making the determination of procedural complications and retreatment much more reliable.
Limitations of our study include the possibility of a Hawthorne effect in which surgeons alter their procedural performance and attention to detail when they learn that their results are being studied. We also attribute the increased diagnosis of incomplete abortions after implementation to improved documentation of case details such as preoperative bleeding or cervical dilation, a result of both surgeons’ awareness of the initiation of the l study, as well as the transition to a new electronic medical record and diagnostic codes. alongside the post-implementation phase. Other limitations include the quality improvement-based methodology, which allows for uniform implementation of the intervention without enrollment in a prospective cohort or randomized controlled trial. Fortunately, this methodology allows the continuation of the quality improvement process by tracking the retained product design rates in the future. In addition, our study had a small sample and small event size, precluding statistical adjustment for characteristic differences. However, despite these limitations, obvious statistical significance was found. Finally, we also recognize the factual basis for the safety of manual vacuum aspiration, which was temporarily not performed at our facility during this time. Indeed, previous authors have demonstrated equally low complication rates with MVA compared to VAS. [15,16,17], suggesting that inferences of the benefit of transvaginal ultrasound in this population can also be made.
Although we were able to obtain a significant reduction in retained conception products, the pre-intervention incidence of retained POCs in the present study was slightly higher than that reported in the literature, which may have biased our results towards significance. . This may have been representative of several factors, including almost complete patient follow-up to detect all cases, as well as the complexity of some patients referred to a tertiary referral center. We are encouraged that our results are consistent with the previous report by Debby et al., Who noted a decrease in the incidence of retained conception products during curettage to a goal of less or less endometrial thickness. equal to 8 mm . It is important to note that our study differed in two ways: first, in the design based on quality improvement with an emphasis on process-based improvement, and second, we allowed surgeon autonomy by not requiring an arbitrary cut of the thickness of the endometrium. Wong et al. found that the diagnosis of successful conception products based on an endometrial thickness greater than 8mm was found to have limited specificity of about 80% . Therefore, we advocated using the surgeon’s clinical experience to interpret the appearance of a patient’s endometrium on ultrasound, which resulted in no cases of retention of products of conception.
Our results suggest that transvaginal ultrasound can be used as an effective safety check to confirm complete evacuation of the uterus after dilation and suction curettage procedures. The addition to the procedure does not add any surgical risk to the patient, but reassures both the surgeon and the patient. Although we did not charge for our use of the bedside ultrasound during this quality improvement study, it could be done at the discretion of the providers. Finally, training residents in the use of transvaginal ultrasound is an important skill set for future independent practice, and scanning in this supervised setting increases their experience. Although our study focused on first trimester procedures, further studies should be conducted to evaluate the use of transvaginal ultrasound in second trimester dilation and evacuation procedures and in patients with abnormalities of the vagina. Muller. Previous studies have suggested curettage at objective endometrial thickness to ensure uterine evacuation ; However, we propose that larger multicenter studies are needed to validate the safety of this objective threshold-based approach and our subjective approaches.