The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes	336
EMQ	1502
SBA	2115

Do you realy want to delete this discussion?

Forum >>

ESSAY 278 - TOP

Page 1 of 1 [1]
		Posted by Srivas P. Fri Aug 22, 2008 07:05 pm
(a) An experienced surgeon and avoiding delay in performing TOP is crucial as perforations are lesser at lower gestations. The TOP should be ideally scheduled within 1 week of decision to do TOP and not longer than 2 weeks in any case. The suction termination is an appropriate procedure at this gestation. Cervical priming is effective in avoiding undue force at dilatation and hence perforation. The methods used are licensed regimes like mifepristone 600µg 36-48hrs prior to surgery or gemeprost 1 mg vaginally 3 hrs prior to surgery. Another regime is use of Misoprostol 400µg inserted vaginally 3hrs prior to surgery but is unlicensed in Uk and the woman should be informed about it. As far as possible termination should be completed using suction curette or a blunt curette and sharp curetting should be avoided to minimize perforation. An experienced surgeon who does these procedures routinely, should do TOP to minimize perforations. (b) All women undergoing TOP should have preliminary screening for Chlamydia and if sexual history suggests high likelihood for STD’s she should be screened for gonococcus also. She should be given periabortion antibiotic prophylaxis with metrogyl and doxycycline pending report and if that comes positive for genital infection, contact tracing and treatment of contacts is crucial in preventing reinfection. Referral to GUM clinic should be made for appropriate screening for other STD’s and tracing her sexual contacts. Prior to TOP a perspeculum examination should be done to look for vaginal discharge and if it suggests infection, tests to detect Bacterial vaginosis or trichomoniais should be done. These tests can be done in OPD setting—hanging drop preparation for motile trichomonas-can be seen with naked eye. For BV, the schiff’s test is rapid and along with presence of clue cells on microscopic examination can help diagnose Bacterial vaginosis using amsel’s criteria. Treatment preoperatively using single dose metrogyl can help decrease infective morbidity in both cases. If the woman’s pelvic examination suggests PID, TOP should be delayed until she receives atleast 2 days of antibiotics pre operatively. The TOP should be done under strict aseptic conditions in all cases to avoid infection. The TOP should be complete as incomplete procedures can cause infection. Meticulous follow up to look for continuing bleeding post operatively and USG can detect RPOC and reevacuation planned earliest if required. (c) I will explain that she may bleed slightly for 3-4 days but she should not be passing clots or bleeding profusely. Incase she has fever, abdominal pain or continuing vaginal bleeding, I would ask her to contact emergency numbers which I give her and she may require a visit to the hospital for check up. Sexual intercourse is preferably avoided for 10 days to avoid infections. If she has no complaints post operatively, I will ask her to review after 2weeks to look for any evidence of infection and also to review pre-operative screening reports. If it requires contact tracing the risk of reinfections should be explained to her as this increases her risks of infertility, ectopic gestations, and chronic PID later. I will enquire regarding her need for future contraception so as to avoid future unwanted pregnancy. If she has multiple sexual partners I will emphasize need to use condom and also use reliable contraceptive measures. The details of all contraceptic options I will discuss and start her on COC’s or DMPA or implant depending on her preferences.If they are started immediately post abortion, there would be no need to use any other contraceptive measures. IUD can also be inserted immediately post TOP. She may still need condom to prevent STD’s if she has multiple partners and risk of STD. I will arrange a review by social worker or her GP to assess her psychological well being as TOP’s often cause extreme psychological morbidity and she may require counseling. I will give information booklet and details of post abortion meet up groups if she has post TOP trauma.
		Posted by hoping .. Fri Aug 22, 2008 09:33 pm
A healthy 20 year old primigravida has been counselled and accepted for surgical termination of an unwanted pregnancy at 10 weeks gestation. (a) How will you minimise the risk of uterine perforation?[5 marks] Uterine perforation is a recognised complication of surgical termination and mostly avoidable. As this patient is nulliparous cervical dilation is likely to be difficult and thus use of prostaglandins like gemeprost, cervigem few hours before procedure reduce risk of perforation due to cervical dilatation. Prior to instrumentation uterine size and position should be confirmed as anteverted or retroverted uterus require direction of insertion according to cavity orientation. Cervix must be stabilised with vulsellem or tenaculum while any instrumentation to uterine cavity. Procedure should be done by surgeon with adequate expertise or supervision.If ultrasound undertaken to confirm intrauterine pregnancy revealed any uterine anamoly like bicornuate uterus, extreme caution must be undertaken. Ultrasound guided evacuation has lower risk of perforation but is not used routinely, may be justified when difficuly anticipated prior. (b) How will you minimise the risk of genital tract infection? [6 marks] Apart from risk of infection due to surgical procedure , patient may be at high risk of developing pelvic inflammatory disease due to preexisting infection like chlamydia , gonnorhea, bacterial vaginosis. Young women are at high risk of these infections thus screening should be offered. This included endocervical swabs for chlamydia , gonnorhea and high vaginal swab for other infections. Urine could be sent for chlamydia NAAT testing. Her risk assesment from sexual history regarding lenght of time with current partner, other sexual contacts in past year, previous sexually transmitted infection. If she is high risk, antibiotic prophylaxis with ofloxacin and metronidazole should be given as swab results may not be available prior to procedure or could be false negative and thus treatment ma be justified. Procedure should be done with aseptic technique. Vagina should be meticulosly cleaned with sterile antiseptic and procedure completed with notouch technique. Surgeon should be assured of complete evacuation to reduce risk of infection due to retained products. (c ) She should be briefed about procedure and detailed explanation if any complications occurred or additional procedures undertaken. If she requires anti-D for her rhesus negative status, she should be informed of benefit and given with informed consent. Her views regarding disposal of products should be obtained and documented. She should be informed that vaginal bleeding may continue for upto 3 weeks. If bleeding becomes heavy or offensive or she feels unwell, she should come in. She should be given contact number with 24 hour access prior to discharge. Method of communication if infection screening positive should be disussed and documented. If she is given antibiotics she should be advised to complete course and use barrier methods until screening results available. Contraception should be discussed taking into account her wishes and suitability and compliance and idealy prescribed before discharge. She can commence any suitable method as soon as possible. She should be informed of option of postcoital contraception to reduce risk of unwanted pregnancy due to non use or improper use of contraceptive method. Upto 10% women develop psychological sequale inspit of predecision counselling and thus continuous support provided and advised to seek help. She should be given discharge letter and if she consents letter should be sent to her GP. She should be informed that all terminations are reported centrally to aid in audit and improve health service but care is taken to preserve patients identity. She should be provided with written information on contraceptive methods.
		Posted by San S. Sat Aug 23, 2008 02:55 am
(a) How will you minimise the risk of uterine perforation?[5 marks] It is important check the scan report and with patient for any history or evidence of abnormal pelvic organ anatomy e.g. bicornuate uterus or uterus didelphys as a senior operator is needed in these cases to minimise complications. Ultrasound guided evacuation may be useful in these cases. Cervical priming with misoprostol would make cervical dilatation easier and decrease uterine perforation due to forceful cervical dilatation. Surgeon who carry out the procedure should be competent or have supervision if not achieve competence to perform the procedure independently. It is important to examine the patient prior to procedure to assess uterine size and if it is anteverted or retroverted. During the procedure, the largest possible size instruments i.e. suction curette should be used and a sharp curette should be avoided to check the cavity. (b) How will you minimise the risk of genital tract infection? [6 marks] It is recommended by NICE that patients are offer chlamydia screening and treated if indicated prior to uterine instrumentation. If this is not done, she should be given prophylactic treatment with azithromycin post procedure. Metronidazole prophylaxis is also recommended after TOP in case of gonorrhoea and bacterial vaginosis. During the procedure, meticulous aseptic techniques should be adapted including scrubbing, gowning by both medical and nursing staff. It is also important to make sure haemostasis after the procedure. Patient should be advised to avoid tampon after the procedure at least until resume of her next menstruation. Partner tracing is important if she is chlamydia or gonorrhoea positive on screening prior to procedure and they should avoid sexual intercourse until they are both fully treated and clear of infection. (c ) She has a surgical termination of pregnancy under general anaesthesia. Which information will you give her before discharge from hospital?[9 marks]. I would explain how the procedure went and that she may experience mild lower abdominal cramps and bleeding post procedure. Pain should settle in next 24 to 48 hours but bleeding maypersist for nest 2 to 3 weeks. She should be explained that the procedure would not affect her future fertility or pregnancy. She should report any severe abdominal pain, heavy bleeding or feeling unwell and feverish. Gynae emergency ward contact number should be given should these symptoms occur. She should be advice to use sanitary towel and avoid tampon to decrease risk of infection until resume of her next menstruation. It is also important to offer and counsel her regarding future contraception and treatment could be commence immediately. Long acting reversible contraception is very reliable if she has poor compliance in taking oral contraceptive pills. If there is STIs picked up prior to the procedure, she should be advised regarding contact tracing and avoid sexual intercourse until they are both fully treated.
		Posted by J P. Sat Aug 23, 2008 03:22 am
a.The risk of uterine perforation is 1-4 per 1000 procedures.In young nulliparous women preoperative cervical priming with gemeprost,cervagem will reduce the risk.The procedure will be suction evacuation ,if needed should be completed by blunt curette and not sharp curette whick increases the risk.General anaesthesia should be avoided fror the procedure to reduce the risk. Ultrasound guided evacuation will mininimise the risk if difficulty anticipitated.Adequate training and expertise needed which will reduce the risk. b.Genital tract infection ofvarying severity occurs in about 10 % patients due to suction evacuation.Screening for organisms like Chlamydia and gonorrhea should be done and treatment commenced in high risk patients [with multiple sexual partners,more than 2 partners changed in a year] without awaiting the result.The optimum therapy will be 1 gm metronidazole rectally and doxycyclin 100 mg bd for 14 days given during the procedure.Alternatively antibiotics can be started after results are available. Adequate sepsis will be maintained during procedure . c.I will tell that, patient may experience bleeding and mild abdominal discomfort for 10 days.The worrying signs for which she has to report are increasing pain or bleeding,rising temperature .Emergency 24 hr contact numbers and addresses are given. I will explain the need for Anti-D in case of Rh negative mother.I will explain repeated terminations of pregnancy are associated with PID,infertility,chronic pelvic pain.Hence all methods of contraception will be explained .IUCD can be fitted immediately after procedure and OCP can be started immediately after first trimester suction evacuation.If patient declines, advice regarding post coital contraception and information leaflets provided.Detailed explanation of the procedure with discharge letter will be handed over.Psycological mobidity including feeling of guilt is common hence adequate emotional support and counseling given.Next appointment will be 2 weeks later when need for contraception if declined will be discussed along with the screening results
		Posted by Manoj M. Sat Aug 23, 2008 03:36 am
A healthy 20 year old primigravida has been counselled and accepted for surgical termination of an unwanted pregnancy at 10 weeks gestation. (a) How will you minimise the risk of uterine perforation?[5 marks] (b) How will you minimise the risk of genital tract infection? [6 marks] (c ) She has a surgical termination of pregnancy under general anaesthesia. Which information will you give her before discharge from hospital?[9 marks]. (a) The surgical termination of pregnancy should be undertaken by trained professional gynaecologist or under supervision to minimise uterine perforation. Uterine perforation can be minimised by avoiding forceful dilatation of cervix for which cervical softening agents like gemeprost 1mg pessary inserted into posterior fornix 3 hours before the surgery could be used. Avoiding use of uterine sound in pregnanct uterus prior to termination will also prevent uterine perforation. Also avoiding sharp currette as check currette will minimise uterine perforation risk. If an intrauterine contraceptive device/system is used simultaneously for future contraception then a coil thread check should be organised in 4-6wks time to minimise the risk of uterine perforation. (b)She should be offered screening for chlamydia prior to the surgical procedure with swabs/urine testing and if positive treated with antibiotics to prevent any ascending infection with surgical termination procedure. If screen result not available or patient refuses then emperical treatment for chlamydia should be considered either with single dose azithromicin for the benefit of compliance or else with doxycycline. The role of intra-operative prophylactic antibiotics for surgical termination procedure is controversial in minimising the risk of genital tract infections. Sterile and meticulous approach in theatre with aseptic and antiseptic technique and good hand wash and hygiene will minimise genital tract infection. Allowing the patient to urinate herself prior to general anaesthesia and avoiding urinary catheterisation can minimise urinary tract infection which in turn minimise genital tract infection. Avoiding excess blood loss and hypothermia during the termination procedure can also minimise genital tract infection. Early discharge home when she is recovered from the procedure and when obsevations are stable will also minimise the risk of genital tract infections. (c)Information regarding risk of infection and bleeding on discharge should be explained and to seek medical help promptly. She should be given oral and written details of the ward contact details and telephone number or to approach her own GP if she has any concerns related to the procedue. If she is screen positive for chlamydia she should be advised and referred to genitourinary medicine consultation for further testing and management of sexually transmitted infection and ideally partner notification and contact tracing organised. She should be counselled and offered for definite contraception if not planning a pregnancy immediately and an immediate supply of short term contraception provided on discharge and advice to attend GP or family planning centres for long term contraception. She should be offered anti-D if she is rhesus negative prior to discharge. If she has some one to drive home after a general anaesthetic procedure she can be considered home the same day and ideally to have a responsible adult with her for the next 24hours to bring her back to hospital if she has any immediate complications during this time. She should be advised not to drive for atleast 24 hours after general anaesthesia for safety profile.
		Posted by Farkhanda A. Sat Aug 23, 2008 08:18 pm
A---How will you minimise risk of perforation. The risk factor for perforation in this patient is prigravidity. Any patient who delivered vaginally is at less risk. To minimise the risk of perforation, there is need for cervix prepration to make it soft and easy dilatation. One passary of anti progesterone either gemiprost or mifipristone can be inserted 1-2 hours before procedure. It is expensive, so alternative-800 microgram misoprostol can be used vaginally or orally (less effective). Evacuation should be done by suction aspiration rather by blunt curettage. The surgeon should be experienced to do termination. Any previous procedure on uterus like hystrotomy should be accounted as previous caesarean section and be mors careful during the procedure. B---how will you minimise risk of perforation. There is 1 in 10 risk of infection after termination of pregnancy. In consultation clinic which is usually in a week after referral at least her screening for Chlamydia trchomatus shoud be done. If it is not done at least profylactically Azithromycin 1000mg per rectum can be given peri operation . She can be given doxycyclin200 mg twice a day for 7 days. If there is risk of other sexual transmitted infection as suspected from history, she should be referred to gynae uro medicine. If as a routine ultrasound scan is performed to confirm complete evacuation at the end of procedure, then risk due to retained products can be prevented. . C---what information can be given before discharged. Tell her about the procedure. Give her information about duration of bleeding , it may be 10 to 14 days. I will tell her about the signs and symptoms of infection in case if she developed it , so she can promptly get treatment from her family doctor. I will warn her that delay of few days to start treatment can lead to endometritis, salpingitis, parametritis, oophoritis and long term consequences will be infertility, ectopic pregnancy and chronic pelvic pain. I will advised the patient to avoid intercourse until all bleeding and blood stained discharge stopped and use sanitary towels instead of tampons for bleeding. I will give her information about all contraceptive methods supported by written leaflets. If she is not sure what method she will use, then I will counsel her at least about medroxyprogesteron depo provera injection and if she is agreed I will give her one injection before discharge .At least she will be covered for 12-13 weeks which is enough time to decide for regular method of contraception. I will give her contact number of support groups for termination of pregnancy. I will make an appointment in a 4-6 weeks time to make sure that every thing is alright. If routine scan after the procedure is not performed then I will do pregnancy test to make sure she had complete termination as there is a risk of 2 per 1000 continuation of pregnancy even after the suction method.
		Posted by g.b. D. Sat Aug 23, 2008 10:06 pm
gb a) I will give prostaglandins like PGE2 to be inserted 3hours before the procedure.this will ripen the cervix and prevent perforation during cervical dilatation. I will ensure that the termination is done by a person with adequate training.adequate relaxation of patient with proper anesthesia is essential.i will empty the bladder at the start of procedure and do a bimanual examination to check the size and position of uterus whether it is anteverted ot retroverted.i will use gradual dilatation starting with the smaller dilators and gradually increasing the size. I will take caution not to go far beyond the internal os during dilatation.i will use suction with a flexible karmans canula for emptying the uterus and avoid curettage. B) I will take swabs for chlamydia , gonococci and bacterial vaginosis to identify the preexisting infection in the clinic at the time of deciding for termination of pregnancy. I will check the reports and give appropriate antibiotics to treat the infection before instrumentaion. Aseptic precautions will be taken in the operation theatre at the time of scrubbing, painting the perineum , draping and catheterizing the bladder. All the instruments and gowns should be properly steralised. I will use a disposible suction canula. Shaving of perineum is better avoided and clipping should be recommended. Prophylactic antibiotic should be used at the time of induction of anesthesia according to local protocol to reduce any genital infection. c) I will give her that there will be mild bleeding for a week. and will give her mild angesics like mefenamic acid for the same.i will tell her to follow with the gp after 2 weeks to check the histopathology report of products of conception. I will tell her to report to the hospital if she has symptoms of increasing pelvic pain, fever, foulsmelling vaginal discharge or excessive bleeding. I will counsel her regarding further contraceptive advise and start a pill if she wishes so. I will tell her to avoid pregnancy for atleast 3 months till she recovers physical and mentally. I will advise her regarding preconception folic acid for 3 months before next pregnancy.i will tell her that she should expect a period in 28 days from now and to report if dosent have it. I will tell her that there is no need for complete bed rest and she can resume all her activities including sexual intercourse by 1 week.
		Posted by Sam M. Sat Aug 23, 2008 11:12 pm
She has a nulliparous cervical os so cervical dilatation with dilators can cause cervical damage and and forceful dilatation could result in uterine performation.I will like to do cervical ripening before procedure.Cervical ripening with gemeprost I mg vaginally 3 hours before surgery will soften cervix and minimise risk of perforation..Mifepristone 36 to 48 hours before surgery is also effective for cervical ripening. A product like misoprostol is also effective but are not licenced to use in U.K .i will do a bimmanual pelvic examination. Bimannual pelvic examination preferably with empty bladder before procedure give rough estimate of size and position of uterus whether anteverted or retroverted. These are helpful in reducing uterine perforation At this gestation recommended and safe procedure is suction curettage either by electric suction or manual aspiration . I will sure that complete evacuation is done and would only use suction curette or blind forceps and will avoid sharp curette . Antibiotic prophyalxis with metronidazole and doxycyclin is recommended and will be used . Speculum examination before procedure will be done and looked for any abnormal findings or discharge so that treatment of infection before carrying out termination of pregnancy will be done. .Endocervical specimen for chlymedial screening will be taken and also for bacterial vaginosis .If she has STD then referral to GUM clinic for contact tracing and treatment will be required .Procedure will be done under aseptic conditions .I will make sure that complete evacuation with no residual tissue is done. c.She will be provided written information about procedure and care provided .If she consult other physician then this information should be sufficient. I will make sure that she had anit D prophylaxis if she is non immune Rh D negative .she will be explained that she will have some amount of bleeding and pain after the procedure .she will be provided with analgesics .she will be given a 24 hrs contact number in case she feels un well ,had excessive bleeding or abnormal discharge or severe pain to discuss and access accident and emergency services .She will be told that her next cycle will start in 2to 4 weeks time period but she needs contraception from now .Importance of emergency contraception ,types and her choice of either hormonal preparations or placement of intrauterine contraceptive device will be discussed. She could develop feeling of guilt so full psychological support and help of social services if she needed will be provided .A follow up appointment after 2 weeks will be arranged. Specimen if send for histopathology ,the results could be discussed.
		Posted by Latha H. Sun Aug 24, 2008 01:56 am
MKP As the gestation is 10 weeks at the moment,surgical termination should be done preferably within 1 week, or maximum 2 weeks toavoid complication like perforation. Any knowledge of bicornuate uterus, any other uterine abnormality, or history of severe endoometriosis with fixed uterus or chronic PID should be found so that one can be vigilant during the procedure.. In such cases the procedure to be done by consultant or expert. Being nulli, cervical dilation during procedure may be difficult, hence prior priming of the cervix by prostaglandins, gemeprost or mefipristone may be helpful. Surgical evacuation to be done by experienced surgeon or under supetrvision. Intraopertive, one should do bi manual pervaginal examination to determine whether the uterus is anteverted or retroverted, so that the directions of the instrument can be guided accordingly. b) Detailed sexual history as regarsd partners, prior history of genital tract infections, chronic PID, infections in contacts should be sought.All patients scheduled to undergo surgical evaqcuation, should undergo screening for chlamydia, the most common cause of PID. Also if high risk one can check for gonococcal infection also. Bacterial vaginosis being the commonesdt vaginal infection, one should check for that also and traet accordingly. Prophylactic antibiotic may be given (Metronidazole and doxycycline) as results of tests may not be available at the time of surgery. Strict aseptic techniques to be followed during the procedure to minimize infection. One should be sure that the evacuation is complete as retained products of conception are nidus for infection. Post operative antibiotics to be completed. c) Before discharge the patient should be explained in detail about the procedure and if any additional procedures were undertaken intraop. She should be explained that she may bleed for a week or two and that it should be like periods. Any excessive bleeding with clots or passage of pieces(products) warrants immediate reporting as this may be due to incomplete evacuation. Any symptomsof infection like fever, foul discharge pervaginum abdominalpain to be reported. Contact numbers to be given and written information about the procedure details to be given to her. Although a voluntary decision for termination of pregnancy was taken by the patient, she may still feel guilty or emotional about it, therefore may need support. Counselling to be done and support group information to be given. As this was an unwanted pregnancy, avoidance of a similar situation by using appropriate contraception should be counselled.She should also be taught about emergency contraception. Follow up to be arranged to assess her cgeneral condition and reports of her infection screening are to be discussed.
		Posted by Mandeep S. Sun Aug 24, 2008 04:29 am
Perforation of uterus during surgical termination of pregnancy can be reduced if this procedure is performed by an experienced surgeon competent in performing procedure independently. I will perform this procedure by using plastic suction canulla as opposed to metallic canulla of appropriate size. If I suspect any uterine anomaly I will perform procedure using trans abdominal ultrasound under direct vision using gentle rotatory hand movements. Before performing procedure I will ensure that the cervix is primed by inserting Misoprostol 400 mcg 2 hours before the scheduled surgery. This will make cervical dilatation easy and reduce risk of injury to uterus. I will perform a thorough per vaginum examination and determine the exact position of uterus (anteverted/ retroverted) before using cervical dilators. Suction of the products of conception will be performed by gentle rotatory movements of cannula till grating sensation is achieved. These measures will minimise risk of uterine perforation. All women undergoing uterine instrumentation should be screened for chylamadia infection asking patient to perform a self-assessment smear. Antibiotics like Azithromycin 1 gram single does or doxycycline 200 mgs twice daily for 5 days should be given after procedure. I will perform procedure under thorough surgical asepsis at place approved for performing surgical procedures. If there is any evidence of vaginal infection additional smears can be taken before performing procedure. Antibiotics can be changed or prescribed if the organism is subsequently reported as resistant. Each unit should have an audit of infection following surgical procedure as this will help in making subsequent improvements and reduce infection. I will review the patient before discharge and assure that she has recovered fully form the effect of general anaesthetic. I will make sure that a responsible adult drives her home. I will review her blood group and if this is Rh negative I will prescribe 250 IU of anti D injection before discharge. I will review her consent regarding histology examination and method of disposal of products of conception. I will inform her that she may have spotting after the procedure and may have period like pain for one to two days and will give her analgesics to take home. I will provide her with contact number of hospital and advice her to contact if she experiences heavy pv bleeding, severe pain in abdomen, distention of abdomen, vomiting, fever, fouls smelling pv discharge. I will inform her that she should expect her next period in 4-6 weeks and should report if she does not have a period. I will explore her wishes regarding future contraception and advice her regarding the same if this has not been discussed at initial consultations. I will also provide contact details of family planning clinic if she wishes to seek any help regarding contraception.
		Posted by Farina A. Sun Aug 24, 2008 05:41 am
A) Surgery should be perform by sufficiently experienced surgeon or supervised by an experienced surgeon. Correct estimation of uterine size by bimanual examination with empty bladder, preferably under general anaesthesia is advisable. Pre-op cervical ripening by prostaglandins or misoprostol can reduce the undue force and the use of dilators required to open cervical canal. Pre-op sonographic assessement of size of uterus and location of pregnancy can be helpful. Suction evacuation is the method of choice. Gentle handling of tissues and avoidance of sharp instruments like uterine sound is wise. B) In order to minimize the risk of genital tract infection, unhealthy sexual behavior should be inquired for. History of foul smelling vaginal discharge or previous history of sexually transmitted diseases and PID are important to know. The type of contraceptive she uses is important as male and female condoms significantly reduces the incidence of STIs. Chlamydia screening, high vaginal swabs and partner tracing is beneficial. Routine treatment for chlamydia without screening is one of the options however the opportunity of contact tracing is lost and the patient is at a risk of re-infection. Pre-op course of vibramycin and metronidazole can be given. C) Patient should be informed about the procedure, the operative findings and complications if any. It is important for her to know about the persistence of mild bleeding for three to four weeks however she can seek advise any time she suffers from heavy bleeding pain or if the bleeding does not stop after four weeks. There is no effect of the surgery on her future conception. If the cervix has been dilated by dilators, there is a small increase in risk of future second trimester miscarriage and pre-term birth. That the tissues has been sent for histopathology and the report will be available, which she should collect and visit OPD after six weeks. She can start contraceptive measures soon after surgery. The preferred choice can be an IUCD with male condoms as she has had an unwanted pregnancy which indicates that her compliance to other modes of contraception is questionable and male condoms will protect her from STIs. She should be provided with written information, contacts of social services and support groups.
		Posted by Ephia Y. Sun Aug 24, 2008 09:26 pm
A healthy 20 year old primigravida has been counselled and accepted for surgical termination of an unwanted pregnancy at 10 weeks gestation. (a) How will you minimise the risk of uterine perforation?[5 marks] To minimise risk of perforation, First of all there should be minimal delay between counselling and decision and performing procedure, ideally less than 1 week. A pelvic ultrasound will be performed to calculate gestation if not performed already. Misoprostol is used vaginally prior to procedure to soften cervix and ease cervical dilatation. At the time of procedure, bladder is evacuated and bimanual examination performed to assess size and position of uterus. Gentle dilatation is performed guarding the dilator. Right size cannula is selected and signs of emptying noted. Procedure is performed by trained individual or under supervision. (b) How will you minimise the risk of genital tract infection? [6 marks] In order to minimise infection, history is taken to evaluate risk. History of PID, STI including Chlamydia, multiple or recent change of partner elicited. Screening is performed with high vaginal and endocervical swabs are taken and any discharge noted. In absence of swab results prophylactic antibiotics are used according to local protocol. During the procedure care is taken to effect complete evacuation and retained tissue may aid infection. After evacuation, tissue is inspected. After the procedure she is advised to avoid using tampons and avoid intercourse till bleeding stops. Barrier methods (condoms) advised. (c ) She has a surgical termination of pregnancy under general anaesthesia. Which information will you give her before discharge from hospital?[9 marks]. She is informed how the procedure went. It is recognised that she might be upset and psychological support is provided. Long term psychological morbidity is uncommon. She is advised about expected symptoms such as bleeding which should reduce and stop in about 7 to 14 days. Pain and abdominal cramps may be experienced and she is provided with analgesics. As she had GA she is advised not to drive or operate machinery for 24 hours. She should have someone at home to care for her during this time. She should report any heavy bleeding, increasing pain, unusual vaginal discharge and smell, fever, diarrhoea, bleeding in stool, absent or scanty periods in 6 weeks. If pregnancy test is positive 2-3 weeks after procedure, it should be reported. She is advised to avoid wearing tampons after the procedure and abstain from intercourse till bleeding stops. Written information and telephone numbers are provided. Her contraception needs are identified and advise given. She can start Oral contraception pills from the next day. If she wishes long term reversible contraception, she can have IUCD or LNG-IUS can be inserted after the procedure. She is advised about use of condoms to minimise risk of STI. A termination normally does not affect future fertility. Follow up appointment is arranged in 2-3 weeks where sreening results can be discussed and need for GU medicine referral identified and discussed. Further discussion on contraception can take place at this appointment.
		Posted by H P. Mon Aug 25, 2008 04:29 am
H (a) The procedure should be carried out by sufficiently trained practioner or under senior supervision. The termination should be carried out as soon as possible as increasing gestational age increases risk of perforation. Cervical priming by vaginal gemeprost 3mg 2-3 hours before procedure reduces the need for undue force during dilatation. Misoprostol 400ug can also be used but it is not licensed for use. Patient should be adequately relaxed under local/ general anaesthesia. I will empty the bladder before the procedure. I will check uterine size and determine position (anteverted/ retroverted) prior to instrumentation to orient the direction of dilators. Cervix should be held steady during instrumentation. Suction curettage done by correct size canula according to uterine size. I will avoid the use of sharp curettage after procedure. (b) I will offer her Chlamydia screening in the clinic by endocervical swabs and urine testing and if positive, treat her before procedure. If she has history of vaginal discharge or high risk sexual behavior like multiple partners, she should be offered screening for bacterial vaginosis and gonorrhoea and treated accordingly. If the results are not available before procedure or if she refuses screening, antibiotic prophylaxis is given with metronidazole 1gm rectally at the time of procedure. This is followed by Azithromycin 1gm orally single dose post procedure or oral doxycycline 10mg twice daily for 7 days. She should be asked to empty her bladder before procedure to avoid catherisation. After proper hand hygiene, sterile gown should be worn. The procedure carried out in a certified place. Strict aseptic technique is followed during the whole procedure. I will ensure complete evacuation as retained products act as nidus for infection. If her screen results are positive, she should be referred to GUM clinic for contact tracing and treatment to prevent further infection. She should be asked to avoid intercourse/ use barrier till she and her partner are completely treated. I will ask her to not use tampons immediately after procedure. (c) I will explain the details of the procedure and give her a letter regarding it. I will tell her that termination is not associated with increased risk of ectopic, placenta previa, infertility or breast cancer but may slightly increase her risk of miscarriage or preterm labour. If she is Rh-negative, I will inform her and give her intramuscular 250 IU of inj Anti-D in her deltoid muscle. I will tell her that products are sent for histopathological examination (HPE). Disposal of products should be done according to her wishes. I will tell her that the bleeding may continue for upto 2-3 weeks. She may also experience abdominal pain for few days. I will prescribe analgesics and ask her to complete her course of antibiotics. However, in case of heavy bleeding, foul smelling vaginal discharge, severe abdominal pain or fever she should immediately contact her GP or abortion clinic. I will give her written information about the symptoms and provide her contact details and 24 hour telephone helpline number. If she wishes, a letter regarding the procedure could be sent to her GP. I will give her contraceptive advice backed up with information leaflets and provide her contraception according to her choice. I will offer her some short term contraception if she wishes. I will give her an early follow up appointment for discussing her screen results (if not available) or else at 4-6 weeks to ensure her periods are regularized, to inform her report of HPE and discuss future contraception. I will refer her to GUM clinic if she has any STI to ensure contact tracing and complete treatment. I will offer to refer her for further counselling if she experiences post abortion distress. She can be offered rubella vaccination if she is susceptible.
		Posted by Atashi S. Mon Aug 25, 2008 11:27 am
a) To minimize the risk of perforation termination is to be done as early as possible to avoid advanced gestation age. Cervical priming with prostaglandin to facilitate dilatation will reduce the risk of perforation. Pelvic anatomy should be assessed appropriately. Procedure should be performed by appropriately trained surgeon or under appropriate supervision .Thorough evacuation is to be done using suction catheter rather than a sharp curette. b) Infection is an important cause of physical morbidity. Causing acute endometritis / PID, chronic PID, sub fertility and subsequent ectopic pregnancy. Measure to prevent infection will therefore be the most valuable. Most valuable approach is to screen infection. This allows contact tracing. Screen program should use PCR based test as ELISA based test have low sensitivity. Universal prophylactic treatment is an alternative but most women will be treated unnecessarily and contact tracing will not be available. Proper aseptic and antiseptic techniques in the operation theatre should be maintained . All person including anaesthetist should take hand washing and should use anti bacterial gel. Patient should be properly counselled before discharge regarding maintenance of personal hygiene. She should be advised not to use tampon as it may lead to infection. c) She should be advised to maintain abstinence from coitus for 2 weeks. There may be mild to moderate vaginal bleeding for 2 to 3 weeks. I will take 4 to 6 weeks to have normal menstrual period.. She should not use tampon as it may precipitate infection. She will have to use contraception to prevent further unwanted pregnancy. Merit and demerit of different type of contraceptive should be discussed with her. She should contact with the hospital or general practitioner If heavy or prolonged bleeding, offensive discharge and feeling unwell. She is allowed to do her normal job and activity . She should be ensured that her confidentiality should be maintained. Appropriate post TOP counselling is to be done. Follow up appointment is to be given after 2 weeks. Post TOP written information with contact details should be provided.
		Posted by H H. Mon Aug 25, 2008 03:04 pm
please sir, If I did for the patient say FBC in the first part of the question ,should this be enough for other parts of the question ,that is to say no need to repeat it. At the end it is the same patient. obliged
		Posted by N K. Wed Aug 27, 2008 05:41 pm
N (a) How will you minimise the risk of uterine perforation?[5 marks] It will be helpful to have prior knowledge from the history about any uterine anomaly or cervical treatment. Risk of uterine perforation can be reduced by cervical priming by prostoglandins (PGF2 alpha) such as misoprstol or gemprost . Surgery should be done by trainee appropriately trained or under supervision or by the consultant. A vaginal assessment prior to starting the procedure is essential to assess uterine position, size and presence of any anomalies if possible. Careful tissue handling and avoidance of usage of unnecessary force or uterine instrumentation such uterine sound or checking the cavity with sharp curette will prevent damage to uterus. (b) How will you minimise the risk of genital tract infection? [6 marks] Screening for Chlamydia and other sexually transmitted infections such as Gonorrhoea, by clinical suspicion or by prevalence is essential. Counselling before and after the test if positive is also essential. If positive for any infection, after treating the patient I will refer the patient to GUM clinic for partner treatment and contact tracing. If screening declined, will offer prophylactic treatment with Azithromycin or doxycylin. Screening and treatment of vaginal infections are also known to be beneficial. During the procedure strict adherence to aseptic technique by all the professionals involved in her care, especially the surgeon will reduce the chance of infection. Treatment with prophylactic antibiotics such as PR metronodazole will reduce infection rate. I will advice the patient on general hygiene measures and to report any sign of infection after the procedure and treat it promptly. (c ) She has a surgical termination of pregnancy under general anaesthesia. Which information will you give her before discharge from hospital?[9 marks]. A sensitive and non-judgemental approach is essential. This may be psychologically distressing experience for the women and if so, I will offer further counselling. I will explain the procedure and any additional measures done, for example to control bleeding or any difficulties encountered. I will explain the possible duration of bleeding and pain and provide her with adequate pain medications. I will advice her to report any excessive bleeding or sings of infection such as offensive discharge or fever which will need prompt treatment. A 24 hour contact telephone number will be provided. I will advice her to avoid intercourse until she stops bleeding and use clean sanitary pads to reduce infection. Future contraception needs to be discussed at this point – a long acting reliable method will be suitable for her. Any questions or doubts needs to be cleared. I will arrange for a follow up appointment with GP in 2 weeks time and provide her with written information and support groups.
		Posted by Drxyz A. Thu Aug 28, 2008 02:01 am
DRXYZ a) Risk of uterine perforation will be minimized by priming the cervix before surgical evacuation. Priming can be done by Mifespristone 600 µg 36-48 hours before or Gameprost 1 mg 3 hours before the evacuation. Mesoprostol 400 µg vaginally can be placed 3 hours before but is not licensed in UK. Senior obstetrician who has experience to do such procedures must undertake the procedure. Uterus position should be assessed, either antiverted or retroverted, before starting procedure. Dilatation of the cervix should be done carefully so dilator will only go into cervical canal. b) History about sexually transmitted diseases should be taken. If history is suggestive of STD then the swabs will be taken from endo-cervix, high vaginal and urethral. IV antibiotics should be given before procedure. The partner of the patient should be screened and asked to consult genito-urinary physician. If patient will go for evacuation, endo-cervical swab should be taken for Chlamydia. Procedure’s technique should be aseptic and bladder should be empty by the patient before undertaking the procedure. Then antibiotics should be given before the procedure. If the partner’s STD results are +ve then patient should be counselled for barrier method. c) Patient will be explained about the procedure. She will be explained that she can have mild vaginal bleeding and spotting uptill 2-3 weeks post evacuation. She will be provided with the contact numbers for the emergency room if she has heavy bleeding or abdominal pain or fever. She will be given follow-up appointment to see the results of STD and treatment for both patient and partner if needed. She will be explained the contraceptive methods to prevent unwanted pregnancy. If patient is psychologically disturbed by the procedure, she will be given information about how to get psychological support. Written information about the procedure and post operative care will be provided.
		Posted by Mandeep S. Sun Aug 31, 2008 11:45 pm
You were asked the question in three parts. However, you have written 4 paragraphs. Do not expect the examiner to help you and decide which paragraph is your answer to part (a) or (b). The least you should have done is label your paragraphs you have not checked my answer, is that becuause of not labelling the answer correctely. Will this be done by MRCOG examiners.