Essay 361

(a)

I would offer genital swab screening for Chlamydia and treat with antibiotic such as azithromycin before the surgery to minimise the risk of ascending genital tract infection after instrumentation of the genital tract. This will allow contact tracing and treatment of her partner as well.

She should have adequate cervical preparation with prostaglandins to minimise difficult cervical dilatation and thus cervical trauma or uterine perforation.

If prior genital swabs are not done or results are not ready at time of surgery, prophylactic antibiotic should be given to minimise ascending genital tract infection. Examples of antibiotic regime include  azithromycin on the day of surgery and flagyl at time of termination, or flagyl at the time of termination followed by 7 days of oral doxycycline.

The operator should have adequate experience and training or perform the surgery under guidance of a senior. It is important to have proper technique of performing vaginal examination before instrumentation to check for pelvic anatomy as well as careful use of Hagar dilators to dilate the cervical os. This is to minimise the risk of uterine perforation. Also, it is important to ensure that the uterus is empty after the procedure to minimise the risk of retained products of conception (RPOC).

Suction curettage is preferred over sharp curettage as it is associated with less risk of haemorrhage.

Uterotonic agents should be used in times of uterine atony to minimise blood loss.

Curettage can be done under ultrasound guidance if there is suspicion of distorted pelvic anatomy to minimise RPOC.

In events of suspected perforation, the procedure should be stopped immediately, senior anaesthetist and gynaecologist informed. Laparoscopy should be performed to check for extent of perforation and bleeding. Laparotomy and bowel repair should be performed by the general surgeons if bowel injury is present.

The patient should be given verbal and written information before discharge on the expected duration of pain and bleeding; complications to look out for (such as severe abdominal pain, foul vaginal discharge, fever, heavy bleeding), and a 24 hour contact number to call if any complication arises for arrangement to see the doctor.

Anti-D immunoglobulin should be given to the patient before discharge if she is rhesus negative to minimise sensitization and problems in future pregnancies.

I would offer to refer her to the medical social worker for emotional support after the termination of pregnncy.

(b)

There are 2 kinds of progesterone-only injectable contraceptives : 12 weekly depot provera and 8 weekly norethisterone enantate. Both work by inhibiting ovulation.

Side effects include increase in weight; irregular menses and per vaginal spotting which may require additional medications. It can cause a decrease in bone mineral density which is a significant side effect at her age and there may be a delay in return in fertility up to 1 year. It does not confer any protection against sexually transmitted disease as well as condoms.

Benefits include amenorrhea after 1 year of use for 70% of users which may be beneficial if she has heavy periods. It is a reliable form of contraception with very low Pearl index and does not require as much compliance as contraceptive pills. It is also not affected by medications such as rifampicin or other liver enzyme inducers.

It can be started up to 5 days of termination of pregnancy and she can go to her GP for the regular injections.

She should see the GP immediately if there are any abnormal bleeding patterns or if she missed the date of injection and had unprotected sexual intercourse. Otherwise, if she is on continuous progesterone-only injectable contraception, follow up is required every 2 yearly to discuss the risks and benefits of continuing with the method.

I would offer other alternative forms of contraception with minimal impact on bone mineral density such as contraceptive pills, progesterone implant or IUCD. Written information in the form of leaflets will be given to her.  

a) She needs to be counselled about the termination (TOP) to prevent psychological morbidity as she may have feelings of regret leading to depression. She needs to be given written information regarding the procedure to avoid any anxiety. An ultrasound to confirm an intrauterine pregnacy before embarking on the TOP is mandatory to prevent an unecssary surgical evacuation (SEVAC) if it is an ectopic or pregnacy of unknown location. She needs to be starved at least 6 hours prior to the procedure to avoid the anaesthetic risk of aspiration leading to aspiration pneumonia. Pre-operatively she should have a group and save sent in case she bleeds heavily during the procedure or if there are any complications then cross match blood can be made available.  The cervix should be primed with Misoprostol 800mcg vaginally, especially if she is primiparous, to avoid a difficult dilatation and hence cervical lacerations. Intraveous antibiotics need to be administered such as IV Augmentin 1.2g and IV Metronidazole 500mg to reduce the risk of pelvic inflammatory disease. An experienced operator needs to perform the procedure or directly supervise a trainee to reduce the risk of uterine perforation. Intra-operatively, a suction aspiration currette should be used rather than a metal currette to reduce the risk of uterine perforation. If she is bleeding and the uterus is empty then syntocinon 5-10units bolus IV can be given to reduce the bleeding and hence prevent a blood transfusion. Her Rhesus status needs to be confirmed prior to discharge and anti D administered if she is rhesus negative with 72 hours to prevent future alloimmunization and hence the difficulty in future cross matching and psychological morbidity of a future pregnancy with haemolytic disease if she becomes sensitized. She needs to be counselled post procedure and debriefed to avoid anxiety.

B) She needs to be given written information regarding the progesterone only injectable and about her alternative choices. The progesterone only injectable can be give to an 18 year old if all the other methods of contraception are unsuitable, so she needs to be counselled about all her alternative methods with their advantages and disadvantages, e.g COCP, mini pill, patches, IUCD/IUS, and nexplanon. She should be told about the two forms of progesterone only injectables: Depomedroxyprogestogerone acetate (DMPA) given 12 weekly and Norethisterone (Noristerate) given 8 weekly. She needs to be told the most common is DMPA and after the initial review she needs to be reviewed on a 2 yearly basis. The advantage of this method is better compliance than any oral method and it is very effective. In addition it is not affected by liver enzyme inducing medications in case she requires antibiotics in the future. If she forgets to attend for her next injection she has a 2 week window period as DMPA is effective for up to 14 weeks.

The side effects with this method that she should be counselled about include irregular bleeding that can range from spotting to heavy and can be unpredictable. She can be given Mefenamic acid 500mg BD or TDS if this occurs or ethyloestradiol to control the bleeding. Some women will have amenorrhoea at 1 year so she needs to be aware of this. Progesterone side effects of breast tenderness, bloatness and gastrointestinal effects are common. There is a weight gain of 2-3kg at one year and a delay in return on fertility of up to 1 year from stopping the injections. There is a risk of bone mineral density loss which is reversible upon stopping the injection.

a)This woman will need evacuation of retained product of conception so she is at risks related to the procedure;Risk of infection,uterine perforation,over curretting and bleeding and risks related to anaethesia.

Risks related to anaethesia ,patient should be fasting for at least 8 hrs to prevent aspiration .

Regarding infection this patient need to be screened for any genital infection so high vaginal swab for culture&sensitivity need to be taken as well as endocervical swab for chlamidya and n.gonorrhea,any infection should be treated promptly,Prophylactic antibiotic  should be given to those pateints as well.Urine sample(urineanalysis) to be obtained to test for leukocyte and nitrate Midstream urine specimen for C/S to be sent  if tested positive for the above and treat by broad spectrum antibiotic untill awaiting result of culture.The use of septic technique during procedure and instrumentation.

This patient is at high risk of uetrine perforation which can appear  in order of 1 in 1000, priming of the cervix with prostaglandins pre- operatively can assist cervical dilatation and decrease risk of perforation and the trauma to the cervix during cervical dilatation using hegars dilators.The operator should be experienced and well trained in proper usage of instruments.

This patients is also at risk of over curretting which may lead to Asherman syndrome,endometrities and amenorrhea ,Usage of suuction evacuation is preferred to currette to minimize these risks.

This patrient is at risk of bleeding,taking full blood count, group and save and coagulation screen prior to the procedure and knowing her Hb beforehand may help in taking decision to blood transfuse her if she required,Usage of oxytocic (syntocinone) infusion may help to reduce blood loss.

Thromboprophylaxis is required only if other risk factors coexist ( eg Obesity,diabetis,hypertension,,,ect)

b)Explaination that Depot provera injection can be given every 12 weeks. She may experience breakthrough bleeding and spotting at the begining which should be resolved afterwards,patient should be warned of this as it affect her compliance to continue,Other patients may experience amenorrhea after few months of its usage ,she should also be warned of that as she may mistakenly interpret the cause as new pregnancy.explination that this method is long acting and reversible and she can regain her fertility the next cycle after cessation of use(3 months).She may experience usual side effect of contraception weight gain,bloating .GI symptoms.Explaination about the failure rate of this method is  1in 100 per women years.The other alternative method for this lady is Implanon (subdermal implant) which can stay in for 3 years or intra uterine device either copper T or Mirena coil which maybe not preferred at this age as she is nulliparous and insertion od the IUCD is anticipated to be difficult. Transdermal patches(evera) can be used but need to be changed on weekly basis for 3 weeks and she maybe less compliant to that option.Her wish should be respected and her choice should be taken into consideration and this should be recorded in her notes.

Qn:A healthy 18 year old woman has been counselled and accepted for surgical termination of an unwanted pregnancy at 8 weeks gestation. (a) Discuss the interventions that you will undertake to reduce the risk of morbidity and mortality in this woman [12 marks]. (b) She wishes to use progestogen-only injectable contraceptives. How would you counsel her? [8 marks]

a) I will take a history to see if she has any pre-existing medical problems e.g. asthma and refer her for an anaesthetic review if necessary. Optimising her medical problems and review by anaesthetist will reduce her anaesthetic risks. I will screen her for anaemia with a full blood count and correct underlying anaemia if required. Preoperatively I will also screen her for Chlamydia infection and prescribe her prophylactic antibiotics post procedure if she is at high risk of infection. This reduces the risk of disseminated infection, sepsis and pelvic inflammatory disease which may cause tubal scarring and future subfertility. Cervical priming with a prostaglandin analogue should be prescribed e.g. oral misoprostol, so that dilatation and instrumentation of the cervix will be technically easier and reduce the risk of cervical trauma, uterine perforation or creating a false passage.

Intraoperatively I will ensure that the operating surgeon is experienced and adequately trained or supervised for the procedure. Vaginal examination should be done before the procedure to estimate size and ascertain position of the cervix. Careful dilatation of the cervix with vaginal dilators and checking the length of uterine cavity with a uterine sound will further reduce the risk of perforation. Use of suction curettage will cause less bleeding and has less risk of perforation than sharp curettage. Gentle check curettage should be performed at the end of procedure to minimise risk of retained products of conception. Consider intravenous oxytocin to prevent excessive bleeding.

Postoperatively, analgesia should be prescribed and prophylactic antibiotics e.g. doxycycline given if she is at high risk of Chlamydia infection to reduce risk of sepsis as mentioned earlier. Anti-D immunoglobulin 250iu should be prescribed if she is Rhesus negative. Advice and follow up appointments should be given. Psychosocial support and postoperative counselling should be available to reduce risk of psychological morbidity. Contraceptive advice should be given to prevent future unwanted pregnancies.

b) I will tell her that progestogen-only injectable contraceptives are a reliable method of contraception. For DMPA (depo-provera), 3-monthly injections are required. Other advantages are that she does not need to remember to take a pill every day, hence it is less user dependent; it is also relatively cheap and easily available. Side effects include bloating, weight gain, irregular bleeding and amenorrhoea. There is also a delay in return of fertility up to a year after she discontinues this method. DMPA does not provide protection against sexually transmitted diseases; hence she should continue to use barrier methods - condoms as well. If she continues this contraceptive method for long-term use, there is a risk of bone mineral density loss.

Hence I will counsel her on alternative reliable contraceptive methods, including long acting contraceptives such as implants (Implanon) which can last for 3 years; levonorgestrel intrauterine devices which can last for 5 years. Combined hormonal oral contraceptive pills are also an alternative - with added non-contraceptive advantages of reducing menstrual loss and dysmenorrhoea if she has these symptoms. I will provide her with written information including leaflets and ultimately respect her wishes for choice of contraception.

A)

Sensitive and understanding counselling with adequate information given both verbally and wriiten may help to reduce the psychological morbidity associated with opting for a termination of pregnancy.

Initial interventions would include an ultrasound to ensure that she has an intra uterine pregnancy rather than a PUL or an ectopic. Her BMI should be assessed and if she is morbidity obese a medical termination may be more appropriate as it would avoid the risks associated with a GA.

If she were to proceed with a surgical procedure, as she is less than 25 years she is in an age group that is more at risk of STI’s therefore endocervival and high vaginal swabs should be taken and antibiotics given accordingly. If the results are unavailable on the day of the operation then azithromycin 1g stat should be given anyway in view of her risk. If a positive result is found she should be advised to contact the GUM clinic so that contacts can be also treated and this would reduce of risk of re-infection.

Prior to the operation she should be advised to not eat and drink for 6 hours before her operation to reduce the risk of aspiration. Cervical prostaglandins should be given a hour before the operation to reduce the risk of cervical trauma. An US scan should be used during the procedure if there is a cavity that is distorted eg by fibroids. Careful suction evacuation after dilation of the cervix should be carried out by a doctor that is skilled in the procedure. Curettage should be avoided as it may cause Ashermans syndrome. Care should be taken to ensure that the cavity is empty, retained products of conception are an infection risk. If uterine perforation is suspected the procedure should be abandoned and a laparoscopy carried out in order to identify if any visceral or bowel damage. Senior help and the surgeons should be called so that any damage can be repaired immediately.

Following the operation IM Anti-D  should be given within 72hrs if she is rhesus negative to minimise sensitization and problems in future pregnancies

B) I would explain that using a long acting contraceptive (LARCS) is a good idea as it means it means that she doesn’t have to remember to take something every day such as the pill and it is more reliable than othe methods such as condoms. I would clarify her understanding of other types of LARCS such as implanon and the mirena as well as what types of contraceptives she has used in the past.

I would explain the advantages of using injectable progesterone. It is effective reliable contraception that is given every 8 to 12 weeks depending on the preparation .It can reduce her menstrual blood flow or in some cause amenorrhea which maybe preferred by some women if they have heavy periods.

I would explain the disadvantages including break through bleeding, weight gain (3kg over 2 year use), acne, a delay in return of fertility for up to 1 year and reduced bone mineral density. I would explain the latter point makes it unsuitable for her age group and so not recommended however if she has tried alternatives and this is the only contraceptive that she is willing to use it could still be prescribed if she understood the risks. I would advise her that it could be given to her on the ward prior to discharge and repeat injections could be done at her local GP or family planning clinic.

A healthy 18 year old woman has been counselled and accepted for surgical termination of an unwanted pregnancy at 8 weeks gestation. (a) Discuss the interventions that you will undertake to reduce the risk of morbidity and mortality in this woman [12 marks]. (b) She wishes to use progestogen-only injectable contraceptives. How would you counsel her? [8 marks]

A history should be taken to establish if she has any medical conditions that might need optimising before the procedure. If she has any co-morbidities a pre-op assessment should take place and she should be reviewed by the anaesthetist. An obstetric history should be obtained with regards to any other pervious pregnancies and there outcomes. Her mental health status should be assess as if she has a past history she is at risk of relapse regardless of the pregnancy outcome. If she is high risk she should be referred to the mental health team. She should be screened for chlamydia, gonorrhoea and any other genital tract infections such as bacterial vaginosis. If the results of these are not back before the procedure or she declines screening then the procedure should be covered with peri-operative Metronidazole 1g and Azithromycin 1g to reduce the risk of genital tract sepsis. A discussion concerning contraception is vital and a plan made for how she is going to obtain the chosen method ie IUD inserted at the time of the procedure. 

An ultrasound scan should be performed to confirm the pregnancy is indeed an intrauterine pregnancy before the procedure and if there is no evidence of fetal pole then the products of conception should be sent for histology to rule out a molar pregnancy. She should have a FBC before to check haemaglobin level and a valid G&S incase of bleeding and to confirm the blood group as she will need 250IU anti-D post procedure if she is rhesus negative. She should be considered for cervical preparation pre-op to reduce the risk of cervical trauma. 

She should be informed that the injection can be given immediately after the procedure and there would be no need for additional contraception. It is over 99% effective but requires her to attend for an injection every 12 weeks. The side progestogenic side effects  should be discussed such as acne, bloating, labile mood and there is evidence of an increase in weight of 2-3kgs. The other main risk is that of osteoporosis. She should be aware of the association with long term use but she should be reviewed annually and if there are other risk factors for osteoporosis such as smoking or low BMI then an alternative should be considered. 

She should be advised about how it can effect the menstrual cycle and initially she may experience spotting but approximately 70% of women will be amenorrhaic by 1 year. Some women however will experience irregular bleeding. She should also be informed that it can take upto 1 year for fertility to return after stopping. She should be informed of the other options available to her and educated with regards to sexual health and informed that the injection will not protect her against STIs.

a)  A brief history would be essential to identify if she was on any contraception and why this has failed in order to guide the counselling for future contraception and prevent any unwanted pregnancies in the future that could increase her morbidity. In addition it is important to assess her risk of sexually transmitted infections and she should be offered genital swabs; 2 endocervcals and 1 high vaginal swab, to exclude Chlamydia, Gonnorhoea and Trichomonas respectively.  The patient should have antibiotics before or after her surgical termination like azythromycin and metronidazole in order to reduce her risk of developing any post-opertive infection or pelvic inflamatory disease. Misoprostol should be used to prime the cervix so that it can be easily dilated and minimise the risk of cervical trauma and its complication in future pregnancies (for example preterm labour or second trimester miscarriage). The use of a plastic suction curette should be used rather than sharp curettage as the latter has a higher risk of developing intrauterine adhesions that could lead to dysmenorrhoea and problems with conception in the future. Extreme caution is essential to avoid excessive suction/curettage as this can also increase the risk of intrauterine adhesions and also to avoid perforation of the uterus as this could cause intra-abdominal visceral damage and increased morbidity and mortality.  The operator needs to ensure that the uterus is empty so that there will be no products of conception left that could cause infection or bleeding after the operation. Finally, she should be offered follow-up after the termination to ensure taht appropriate contraception is used and to assess her well-being.If she has not developed any symptoms of regret she should be offered further counselling.

b) It is important to inform her that this method is very effective. Although progesterone only injectables  do not require daily compliance she should ensure that she has her inhjection every three months. She should be reassured that if she delayed her injection for few days up two 2 weeks she will still be protected but she should be encouraged to have her injections on time. It is important to inform her that her bleeding pattern is going to change with this method of contraception and although it will be intially irregular, about 70% of women become amenerrhoic within 12 months and this should not alert her that she may be pregnant. In addition, she should be informed that progesterone only injectables have been shown to slightly increase the risk of osteoporosis therefore, she should be advised about lifestyle changes like exercise, healthy diet and stopping smoking in order to reduce her risk.Finally she should be informed that her fertility may not return immediately after stoppig the injections but in the majority of the users it returns within one year.

A healthy 18 year old woman has been counselled and accepted for surgical termination of an unwanted pregnancy at 8 weeks gestation. (a) Discuss the interventions that you will undertake to reduce the risk of morbidity and mortality in this woman [12 marks]. (b) She wishes to use progestogen-only injectable contraceptives. How would you counsel her? [8 marks]

A)Preoperative investigationsi.e FBC  for Hb level,blood group and Rh status done ,including redcell antibodies are done.In case of bleeding crossmatched blood can be requested.Hemoglobinopathies tested and cervical screening  is done if it is due.

Infective morbidityis reduced by doing Chlamydia screening. If she tested positive treatment can be given and contact tracing is done so that she does not get reinfected by the partner.Referral  is made to test for other STIs and adequately treated.

She should also be assessed for the need of VTE

On the day of surgery she should be given Azithromycin 1g po/Doxycycline 100mg bid  with metronidazole 1g rectally or 800mg orally if she tested positive for Chlamydia or if she is negative she should be given metronidazole 1g  rectally / 800mg orally.

Intraoperative  complications  include hemorrhage ,perforation cervical trauma  and failed procedure known to cause morbidity,and these can be reduced by--

Appropriate  skills of surgeon is important for good outcome .Trainee may need supervision during the procedure.This  can be undertaken under local,general or regional anesthesia. If general anesthesia is used, she should be kept fasting for 6hrs, to prevent risk of aspiration.

Pelvic examination is done to asses the size and position  of the uterus before instrumentation and Vacuum Aspiration is preferred to sharp curettage.This  would reduce risk of perforation and hemorrhage.

Cervical priming with vaginal prostaglandins,mispprostol 400mcg 3hrs prior to surgery would also help in reducing the risk of cervical trauma and perforation.

Ultrasound assistance can be taken to ensure complete evacuation of uterus .If there is bleeding after evacuation syntocinon 5-10u iv may be given to prevent hemorrhage.

Anti  D should be given of she is Rh-ve.to prevent  woman getting sensitized.

On discharge she should be given a letter with sufficient in formation about the procedure.

She should be provided with sufficient verbal and written information about the symptoms she may experience,including those which need  medical consultation such as severe bleeding, abdominal pain and  fever.

B)She should be counseled that  long acting injectables act by preventing ovulation.There are 2 types.Depomedroxyprogesterone acetate-DMPA  and NET-EN. Pregnanacy rate is less than 0.4 in 100 over2yrs.DMPA is injected every 12wks,where as NET-EN needs to be injected every 8wks.Benefits are that it provides reliable  contraception especially in young people where compliance is issue.But this may not prevent her  from STIs, for which she would require use of condoms.Other side effects include irregular bleeding and weight gain,upto 2-3kg over a year.

Loss of bone mineral  density is  an important side effect in this young lady.but it largely recovers when DMPA is stopped.She may experience amenorrhea and this is more common with DMPA.She should also be couselled that there is delay in fertility of 6-8m after stopping the contraception.There is no evidence that DMPA has effect on depression,headache or acne.

She should be given written information  to be able to make informed choice.

a)

Pre-operative:

I would obtain an adequate history to exclude/identify the possibility of potentially serious pregnancy complications (i.e. ectopic pregnancy, molar pregnancy).  I would specifically ask whether she had any bleeding or abdominal pain, or excessive nausea and vomiting.  I would take a sexual history and assess risk for STI’s and then proceed to take genital swabs (triple swabs: HVS and endocervical).Bloods would be taken including an FBC, group & save, plus antibody screen.  Anti-D immunoglobulin would be requested and administered if Rh –ve.  Cervical ripening would be considered with prostaglandins to minimize the risk of trauma at cervical dilatation & insertion of the curette.

Intra-operative:

IV antibiotics would be provided at induction of anaesthesia.  Broad spectrum (i.e. cefuroxime and metronidazole if no allergies).  There should be full aseptic technique for the procedure.  This would include antiseptic cleaning solution (i.e. iodine based  prep), along with a sterile operative field.  During the procedure care must be taken for good lighting and the person performing the procedure should be appropriately skilled. Prior to cervical dilatation and curettage, the size and axis of the uterus should be ascertained.  This would ensure the correct angle for introducing instruments, decreasing the risk of perforation.  Suction curettage should be performed over sharp curettage as it is associated with a lower risk of trauma.  The use of uterotonics i.e. oxytocin (5-10IU)just after insertion of the curette would be used to assist myometrial contraction  for i) a lower chance of perforation ii) decreasing intra-operative blood loss.  Systematic quadrant curettage  should be performed without excessive force or over zealous curetting ( risk of perforation or Ashermans syndrome respectively).  The products of conception should be sent for histopathology to i) confirm POC ii) to exclude occult perforation (i.e. presence of ommental/other tissue in sample indicating perforation) iii) exclude molar pregnancy which would necessitate follow up +/- further treatment.If there are any concerns over excessive bleeding or injury then there should be no hesitation in calling for appropriate.  This may include consultant gynaecologist, consultant anaesthetist and consultant surgeon.  The patient may need to be prepped for a laparoscopy/laparotomy accordingly and all members of the theatre team should be informed and prepared.

Post-op:

Immediately post-op, observations for HR, BP, temperature, SaO2, PV loss and pain.   If any abnormality, appropriate investigations as necessary.  A prescription of antibiotics (TTO) to to cover against STI/PID (doxycycline 100mg bd for 14/7 plus metronidazole 400mg bd for 14/7) since young  patients requesting a TOP are at high risk.  Post-operative advice to be given which would include avoiding tampons, swimming and intercourse until post-operative bleeding settled.  Advice regarding medical review if increased/heavy/offensive PV loss, abdo pain or fever.  Finally appropriate contraceptive advice and follow up should be given.

b)

 The injectable progesterone contraceptive is an injection which is required every 12 weeks (DMPA)  for effective contraception.   It is an effective contraceptive and can be administered by the GP or family planning clinic.  However,  like all other non-barrier methods does not protect against STI’s and precautions for such should still be taken. 

It is beneficial if remembering daily pills is a problem or likely to be difficult with an erratic daily lifestyle. 

As a progestogen it does however have disadvantageous progestogenic side effects.  These include: weight gain (typically 2-6kgs), bloating/fluid retention and breast tenderness.   Irregular bleeding or amenorrhoea may also be problematic.  70% of women are amenorrhoeic at 1 year. 

There is a delay in return to fertility of up to 1 year after stopping the contraceptive. 

There is the risk of bone mineral density loss with long term use, although this tends to resolve after discontinuing.  Alternative long acting progestogen contraceptives that do not require a 12 weekly regime include the implanon or the Mirena IUS, both may be acceptable alternatives, obliterating the need for  regular quarterly appointments.  The Mirena may also have less systemic progestogenic side-effects but this should be weighed up against the small risks of insertion.

Medical review should be saught if any unusual bleeding patterns are experienced.  If the injection is forgotten and there has been unprotected intercourse, then medical review to exclude pregnancy would be required.

At the end of the consultation I would provide written leaflets on the injection, and also on the  alternative contraceptives available.

A healthy 18 year old woman has been counselled and accepted for surgical termination of an unwanted pregnancy at 8 weeks gestation. (a) Discuss the interventions that you will undertake to reduce the risk of morbidity and mortality in this woman [12 marks]. (b) She wishes to use progestogen-only injectable contraceptives. How would you counsel her? [8 marks]

a)  during the consultation obtain a previous medical history such as diabetes which will increase risk of infection, bleeding disorders which will increase the risk of bleeding and previous sexually transmitted infections such as chlamydia or gonorrhoea which will increase risk of endometritis and acute pelvic inflammatory disease affecting her future fertility.  Previous surgeries such as caesarean, surgical termination can increase her risk of uterine perforation.  Exclude any allergies to anaesthesia or opiods which can lead to an anaphalxis shock during intraoperatively.  assess her current contraception use to assess risk of future unwanted pregnancies.  assess her social factors which will influence her psychological response to the current pregnancy such as self harm, depression and suicide.  exclude the possible risk of gestational thromboplastic disease in this pregnancy which will increase risk of haemorrhage, dissemination of the disease and risk of choriocarnioma.

On clinical assessment calculate her BMI if raised will increase intraoperative complications such has haemorrhage, Thromboembolism, anaesthetic complications such as aspiration.  Assess her abdomen to identify size of uterus, lie of uterus and cervical dilatation.  intrauterine anomalies and space occupying lesions such as fibroids will increase chance of bleeding and uterine perforation intraoperatively.  cerival stenosis will increase chance of cervical laceration, create false passage or bleed therefore cervical preparation with misoprostol is beneficial. 

Bloods sent for full blood count will identify base line haemoglobin and the need of iron replacement if anaemic.  Group and save sample will avoid delay in blood transfusion if active bleeding.  Rhesus status will identify the need for antiD if Rhesus negative to avoid seroconversion and antibody development which will affect future pregnancy.

Patient should be counselled by professionals to avoid dissapointment or regret of the desicion and make her aware of the options available and support available.  this will reduce her risk of depression and vulnerability.

The procedure should be done on an elective list with adequate staff and operating instruments for laparoscopy and laparotomy in the event of perforation to explore and repair.  there should be facility for Intensive care unit in the event of complication for intensive monitoring and managment.  Suction currettage is better thand currettage to reduce blood loss.  If the procedure is able to be done under local anaesthetic cervical block with sedation such as medazalam it has less side effects in comparison to general anaesthesia and less recovery time.  However the discomfort can be distressing to the patient and she might whish for general anaesthesia despite complications such as infection and aspiration.

Patient should be given antibiotics (metronidazole & azothioprine) preop if tripple swabs for chlamydia or gonorrhoea not done to reduce the risk of endometritis and pelvic infections.  appropriate size of the cannula will avoid unnessary trauma to the cervix and suction from in to outward direction will reduce risk of perforation.  Histology should be sent to identify fetal tissue and exclude GTD.  To minimise blood loss syntocinon 5iu im/iv should be administered to encourage uterine contraction.  At the end of the procedure assess the blood loss and estimate the blood loss to avoid poor recognition of blood loss.

Post operatively patient should be recovered in the recovery room with adequate staffing observing respiratory and cardiovascular suppor where patient is in high risk of hypoxia secondary to poor respiratoy effort.  Prior to discharge patient should be reviewed by the team to assess for pain of the abdomen to exclude signs of peritonism and distention which could be signs of uterine perforation.  Adequate analgesia should be given to patient to avoid pain.  Advice patient to seek attention if develop signs of infection or abodminal pain which could be secondary to endometritis, retain products or perforation. 

Contraception should be discussed with the patient to avoid recurrent termination which should not be used as a mode of contraception.  Advise to see the GP or family planning clinic for further information and long term contraception.

b)

Progesterone only injection is a long acting contraception.  It has the benefit of repeating every 3 months therefore no daily reminders required and compliance is better. The injection is free of charge.  The Depo has a very low failure rate therefore her chance of pregnancy is low.  There is an increased risk of sexual transmitted infections because the injection does not protect patients from sexually transmitted infections.  therefore regular sexual health check should be carried out.  The injection does not increase risk of venous thromboembolism therefore no contraindications for high risk patients such as previous DVT/PE, Thrombophillic disease or FH of Thrombosis.  The depo can develop menstrual disturbances which might affect compliance.  THe depo can give mood disturbances, headache and weight gain.  The depo can increase risk of osteophorosis on long term use in young age women. 

(a) Pre-operatively, I would screen her for sexually transmitted disease specifically looking for Chlamydia, gonorrhoea and bacterial vaginosis. I would treat her with the appropriate antibiotics if there is time before the operation, otherwise I will give her antibiotics post-operatively. I would do a full blood count to screen for anaemia and do a type and screen in the event she needs a blood transfusion. I would ask the anaesthetist to review her to discuss the forms of anaesthesia. Local anaesthesia or sedation can be considered to avoid the risk of general anaesthesia. She should be fasted before her operation to prevent aspiration of gastric contents during surgery. I would use prostaglandin either vaginally or orally pre-operatively for cervical priming in order to prevent traumatic dilation of the os during surgery to minimize the risk of perforation, and also to decrease blood loss intra-operatively.

The surgery should be done by a qualified surgeon who has experience with surgical termination of pregnancy to minimize complications. Suction curettage should be used to minimize blood loss and to decrease the operating time. Sharp curettage and over zealous curettage should be avoided to prevent the risk of Asherman’s syndrome. If there is evidence of uterine atony or increased blood loss, intravenous oxytocin bolus of 10 units should be given, or an oxytocin infusion if necessary. There should be a hospital protocol in place in the event of massive vaginal bleeding.

Rectal metronidazole of 1 gram can be given intra-operatively followed by oral doxycycline 100mg twice a day for 7 days post operatively to prevent infection. She should be given written information and contact number for assistance with the advice to return for medical attention if she develops fever, abdominal pain, offensive vaginal discharge or profuse vaginal bleeding. She should be referred to a counsellor early if needed if she requires psychological support.

(b) I would tell her that progestogen-only injectable contraception is a good form of contraception and the failure rate is very low, with the pregnancy rate of less than 4 per 1000 over 2 years. It works by inhibiting ovulation and altering the cervical mucus to prevent sperm penetration. The advantage is that the injection is given 3 monthly with depo-medroxyprogesterone and 2 monthly with norethisterone enanthate. It decreases the risk of ectopic pregnancy and pelvic inflammatory disease but barrier methods is still needed to prevent sexually transmitted disease. Non-contraceptive benefits include decreased menstrual pain and decreased menstrual flow. There is no evidence of teratogenicity if pregnancy occurs.

The disadvantages are that 50% of women will experience irregular menses or prolonged menstrual bleeding but it can be treated with mefenemic acid or COCP if necessary. 20% of women will experience amenorrhoea. There might be 2-3kg of weight gain over 2 years and more significant if her BMI is high. There might be a delay of return of fertility up to 1 year after stopping the contraception but it is not associated with permanent loss of fertility. It is associated with loss of bone mineral density but it is reversible on discontinuation.

The first dose can be given immediately after surgical termination of pregnancy. I would advice her to go for her repeat injections on time as delaying the injection by more than 2 weeks will result in a loss of contraceptive efficacy.  I will give her written information about the contraception and give her information about the other available options of contraception like pills, subdermal implants and intrauterine contraceptive devices.

1. At this age of group I would perform cervical swabs for Chlamydia screening as this is the most common STI and  untreated before uterine manipulation can lead to  PID with subsequent mobiditis like infertility, chronic pelvi pain. If the results of swabs are not available in day of surgery then empirical antibiotic treatment which covers Chlamydia should be given in line with unit protocol. Ceftriaxone 250 mg im stat dose or Azythromycine 1g stat dose can be given. I would chech her Rh status and give 250 iu Anti D if Rh – negative to prevent isoimmunisation. Procedure is performed by a trained surgeon or a trainee under direct supervision. Cervical preparation with misoprostol prior to surgery can minimise the force of cervical dilatation and subsequent cervical laceration. Procedure is performed with aspiration cannula rather than sharp curette and this leads to less risk of perforation and uterine adhesions ( Asherman syndrome). During the procedure early recognition of complications such as uterine perforation should trigger timely fashion action such informing the anesthetist to intubate patient if LMA has been used and to inform theatre staff and senior colleagues of the event and early recourse to laparoscopy/laparotomy to identify any active bleeding or damage to other organs. Specimen usually not sent to histopathology examination but if suspected molar pregnancy by seeing vesicles then histology should be performed. Before discharge I would counsel the patient  in regards to future contraception in order to avoid unwanted pregnancies.

B) It is an effective contraceptive method with a failure rate of less than .04% in 3 years. DMPA injections need to be repeated every 12 weeks. Up to 50% of users will have irregular and unpredictable bleeding and up to 40-50 % will be amennorheic after 3 injections. The rate of ectopic pregnancy is slightly highr than in COC users however it is less than non contraceptive users. It  can be associated with delay in fertility which can be up to two years. It can reduce the bone mineral density especially in very young patient but it recovers to pretreatment values after stopping the treatment.  The use of injectable is limitedc to two years. It may protect against PID as it changes the cervical mucosa but dosent protect against STI. 

A healthy 18 year old woman has been counselled and accepted for surgical termination of an unwanted pregnancy at 8 weeks gestation.

(a) Discuss the interventions that you will undertake to reduce the risk of morbidity and mortality in this woman.

At first I would offer screening for genital infections, as this will decrease the risk of further pelvic infections.

Proper explanations and instructions should be offered to her preoperatively, like what to expect, when to start being nil by mouth and any preoperative preparations.

The day of the procedure I would ensure that she is given Misoprostol (PG E2) preoperatively for cervical preparation and avoidance of cervical tears. I’d also review her before the surgery to ensure she is generally well and there are no acute health concerns that may put her at risk.

The procedure itself should be performed by an experience surgeon who can deal with its steps and its possible complications.

During the procedure we should make sure all steps are performed aseptically. Adequate cervical dilatation is necessary for proper evacuation of the uterus and avoidance of retained products.

Whether the procedure is done with a suction tube or curette, caution should be taken to avoid perforating or scarring the uterus. Syntocinon injection will help the uterus contract and prevent unnecessary bleeding.

If any complication is faced the we should act promptly towards the management. Hence, if uterine perforation is suspected then a diagnostic laparoscopy is mandatory. If the uterus goes into atony, then further uterotonics will be needed promptly.

Once the procedure is completed we need to check the swabs and instruments are correct and estimate accurately the blood loss.

If the patient is rhesus negative she will need anti-D within 3 days of the procedure. Moreover, she will need antibiotics (doxycyclin and metronidazole) to be prescribed prior to her discharge.

Once the patient is fully awake a full debriefingshould be offered with an assessment if she cango home and possible contraceptive advice.

If the procedure was uncomplicated no follow up is indicated. However, I would offer her open access to the ward for the first few days post operatively.

(b) She wishes to use progestogen-only injectable contraceptives. How would you counsel her?

Progestogen-only injectable contraceptives are a very successful for of long acting reversible contraceptives (LARC). The do not require compliance and are administered intramuscularly every 8 or 12 weeks (depending on their type).

The failure rate is almost 1% and after a year’s time use up to 80% of women may be amenorrhoeic. So considering she has no active cardiac, thromboembolic or cerebrovascular condition there are no further contraindications.

On the other hand, they can be associated with the Progestogen-related side effects like headaches, breast tenderness, weight gain and irregular PV bleeds. Moreover, if she wishes to get pregnant, fertility may need up to 18 months to be restored after stopping this contraceptive method. A specific risk with Injectable LARCs is that of osteoporosis, as they are associated with deminrelisation of the bones; hence it is not advisable to use them continuously for more than 2 years. She should also know that she will not be protected from STIs or the risk of PID.

If she agrees with all that then she can have it within a week of the termination of pregnancy and she will need an additional barrier method for the first week of use.

1. She should be dealt with sensitive and supportive manner as termination of pregnancy have pshycological implication .Her privacy and confidentiality should be maintained all the time.

Mode of anaesthesia should be taken according to her wish local or general. It can be performed as a day care procedure .consent for the procedure should be taken .she should be screened for the Chlamydia as it is recommended before any uterine instrumentation, if result not available before procedure and she is at high risk of STI  like multiple sexual partner, recent change of sexual partner  then consideration to start pre procedure antibiotic should be given. Her preoperative investigation should include FBC and ABO rh typing and saving ,routinely crossmatching is not required unless her haemoglobin is low.

To minimize cervical trauma priming of the cervix should be done with the prostaglandin 2-3 hrs before procedure .  procedure should be done by the experienced and skill person or trainee under supervision. In the operation theatre complete aseptic technique should be practice . bladder should be emptied.

After giving anaesthesia she should be examined per vaginally to know the uterine size ,mobility, axis( anteverted or retroverted), adenexa .knowledge of the uterine axis will help to know the direction of the dilation. Cervix should be hold with valsellum or sponge holding forcep and it should be pulled gently to maintain the uterine axis straight. uterine sould should be introduced to know the uterocervical length .dilation should be done to start with smallest number with gradual increasing in number. dilation should not be done with force it should be introduced only to cross the internal os of the cervix, as forceful dilation will cause cervical trauma and perforation . dilation should be done as much as required and it should be able to pass suction cannula ,it usually achieved up to number 8  or 9 .As dilation up to higher number will cause cervical trauma and incompetence.

Suction curettage should be the method of choice as it has less blood loss ,less time taking and less pain after procedure. Routine curettage of the uterine cavity is not recommended. If any unexpected bleeding start the oxytocics should be given ,otherwise routine use of oxytocis is not recommended. Procedure should ensure that all the products of conception is removed ,if there is doubt then ultrasound can be done at the same time to ensure completeness.

If there is doubt about any complication like perforation any trauma the procedure should be stopped immediately and senior help should be sought. At the end of the procedure all instrument should be checked and counted and cervix should be checked to see any trauma by holding instrument. Product of conception should not be send for the histopathological examination if ultrasound suggest the fetal parts,if there is doubt it should be sent to rule out molar pregnancy.

The procedure should be documented in detail including and difficulty encountered.

She should be provided post procedure analgesia and antibiotic metronidazole  1gm rectal suppository and tablet doxycyclin 100mg twice daily for 5- 7 days.

Injection AntiD should be given to all RH  negative nonsensitise women with in 72 hrs of the procedure in dose 250 IU intramuscular.

She should be discharged with the contraceptive advice and safe sex  and discharge summary should be in detail of the procedure. she should be instructed to contact health care professional if she has fever, vaginal discharge, abdominal pain and excessive bleeding.

Her GP should be informed about her condition and contact detail of the support group should be given.

1. She should be given full information about injectable progesterone only contraception along with other long acting reversible contraception like IUCD,IMPLANT, LNG IUS..She should be also

given information regarding other combine hormonal contraception.

She should be told that progesterone only injectable contraception is long acting reversible contraception available in two form DMPA(deport medroxy progesterone acetate) and NET EN(Norethisterone enanthat) in uk ,Its DMPA more widely available and NET-EN only available after vasectomy to protect till complete clearance of the sperm from the semen.

Its mode of action is inhibition of ovulation. It can be started as quick start method after termination of pregnancy or as a bridging method. In her case if she will start with in 5 days of the procedure then she don’t have to take any additional precaution. If she will start later then she has to take additional precaution .its effect start immediately.

It is given  deep intramuscular at 12 week interval, delay to take another injection up to 14 days donot need any additional precaution. Its highly effective failure rate 3-4 /1000 in 2 yrs. Its cost effective. It is not influenced by hepatic enzyme inducing drugs.

Its associated with irregular bleeding and amenorrhea , which may not be acceptable to some women and may need to investigate if not subsided by 6 month or if women concerns. Women have concern for pregnancy during the period of amenorrhoea.

Its related to weight gain 2-3 kg over a period of one years, acne and other progestgenic side effect breast heaviness and tenderness.

It is related to loss of bone mineral density so prolong use over period of 2 years need to be reviewed. Although its reversible.

Return of fertility can be delayed up to 1 yr in some cases ,athough who don’t want pregnancy after stoppage should choose another suitable method of contraception.

It does not prevent against STI ,so she should use barrier method of contraception.

She should be given written information leaflets and ask to contact health care professional if she has any query and concern.

A)                                                                  Interventions to reduce mobidity and mortality

Pre operatively, FBC will be done to detect and treat anaemia if present. Blood group and save serum is done. Urine microscopy and culture is done to rule out urinary tract infection Anaesthetic assessment is done to assess fitness for anaesthesia and surgery. Screening is done for chlamydia, gonorrhoea and bacterial vaginosis. Antibiotic is prescribed for those who screen positive.In cases where screening is not done prophylactic antibiotic is given (Metronidazole 1 gram per rectum at the time of TOP and oral doxycycline 100 mg twice daily for 7 days started post operatively. Risk assessment for thromboprophylaxis is done and pre operative low molecular weight heparin given 2 hours before surgery in moderate risk cases to reduce the risk of venous thromboembolism. Cervical preparation with prostglandin pessary is done to reduce the risk of cervical trauma during surgery.

Intraoperative--Evacuation should be done by a trained surgeon or trainee under supervision. Size and position of the uterus should be assessed prior to evacuation. Avoid excessive force during dilatation. Suction evacuation should be used as it is associated with reduced blood loss and is faster. Avoid sharp curettage. Ensure evacuation is complete from the gritty sensation. In case perforation is suspected  call a senior colleague and do a laparoscopy to assess the site and size of perforation. Complete evacuation under direct vision and suture the perforation.

Post operative--Monitoring of vitals as per protocol. Injection Anti D 250 IU intramuscular given within 72 hours of evacuation if the woman is Rhesus D negative. Hydration is maintained and early mobilisation encouraged. Reassasment of thromboprophylaxis risk factors done and TED stocking and Heparin prescribed accordingly. Contraception is discussed so as to avoid further unplanned pregnancy.Contraception can be started immediately following evacuation. Referral to genito urinary clinic is advised for contact tracing if the screening tests for STD were positive. Follow up appointment is given for any further discussions.

B)                                                         Counselling  for Progestogen only injectable  

The woman is informed  regarding the 2 types of progetogen only injections. Medroxy progesterone acetate is the most commonly used and is given every 3 months. It is an effective long acting reversible contraceptive. Failure rate is low 0.4%. The efficacy is not reduced by hepatic enzyme inducing drugs. The progestogenic side effects like depression , acne and headache are also less.

However, MDPA injection is associated with irregular bleeding pattern which leads to discontinuation in 50% women. It may also cause amenorrhoea which may be unacceptable to her. It is associated with a weight gain of 2-3 kg in 1 year. There is a loss of bone mineral density also with prolonged use and hence not a contraceptive of choice in young women. There may also be a delay in return of fertility upto 1 year. However, another contraceptive is advised if this is discontinued and pregnancy is not desired.

Alternative methods of long acting reversible contraception like Mirena, Implanon and copper IUCD are discussed along with their failure rate and risks and benefits. Ultimately, informed decision is to be made by the woman . Written information is given. Follow up clinic appointment is given if she wants any future discussion.         

A) 1st high vaginal swabs and endo cervical swab should be done to exclude any infection that will complicate surgical procedure and  effective antibiotics should be given

prostaglandines can be given before operation to ribing cervix decreasing by this cervical trauma resulting from dilatation and bleeding.

uterine size should be measure first by uterine soul to avoid deep curretage and uterine perforation

sucton evacuation is perferable to curretage and it associated with less chance of uterine perforation.

sharp currtage should be avoided to minimise perforation  mand over curretage should be also avoided to minimise complication such as asherman syndrome,

anti D should be given if pt is rhesus negative.

written iformation should be given to the pt regarding operation .

B) injectable progesterone include depoprovera given every 3 months, medroxeprogestrone acetate given every 2 months.

pt should be inform about benefit of injection as it is strong and reversible types of contracepion, and it is associated with low risk of VTE than COCP.

Injectable progestrone also associated with low risk of ovarian,cervical,and colon cancer, lower risk of fibroid ,less dysmenorrhea

she should know that it may be associated with long peroid of amenorrhea and intermenstural bleeding.

It is also associated with delay in  regain to fertility up to one year.

First of all, I would check any investigations carried out in the pre-operative period. This may include swabs and blood investigations; If there were any concerns regarding blood loss an FBC should be taken to check haemoglobin concentration and serum should be sent for group and save. I would also check rhesus status.

The risk of VTE risk should be assessed and documented during admission and reviewed again postoperatively. It is unlikely that this young woman will need any VTE thromboprophylaxis.

This woman should be given cervical preparation three hours preoperatively. Misoprostol 400mcg given vaginally would be a suitable dose. This is associated with the least side effects and would be particularly beneficial in this case because of he young. This will help reduce cervical trauma and reduce the risk of perforation during dilatation.

She should be offered antibiotic prophylaxis against Chlamydia and anerobes, a suitable regime would be azithromycin 1g orally on the day of the termination and metronidazole 1g rectally at the time of the abortion. This is effective in preventing PID.

The uterus should be evacuated using suction cannula and blunt forceps only. This reduces the operating time and is associated with less blood loss. It also reduces the intraoperative risk of perforation and of adhesions following surgery. I do not use US routinely but know it can obviate the need for sharp curettage, reduce the risk of perforation and leaving large amounts of tissue in the uterus.

If bleeding is heavy, I would ask the anaesthetist to administer ergometrine 500mcg IV to induce uterine contraction to reduce the blood loss.

Following the procedure if the woman was rhesus negative, I would make arrangenments for her to have  500iu of anti-D within 72 hours.  

On discharge, the woman should have a discharge summary providing sufficient information to allow another practitioner elsewhere to manage any complications.

The woman herself should be aware of symptoms which necessitate return to the ward and she should know where to come back to and have a 24 hour contact telephone number.

To protect against further unwanted pregnancies, I would ensure that her chosen method of contraception is started immediately.

I would explain that the the most commonly used progestesterone injectable is called depo provera (DMPA) and it works by inhibiting ovulation and making the mucus in her cervix thicker.

 I would tell her it is an effective form of contraception which can be given to her as an intramuscular injection prior to discharge form her termination and will be effective immediately. I would explain that the failure rate is very low (4:1000)

She should be told the injections are repeated every 12 weeks and that it is not affected by antibiotics. She should also be aware that she may experience changes in her bleeding pattern. She may infact not have any periods at all.

She needs to know that depo provera is associated with some weight gain and when she stops it may take up to 1 year for her to get pregnant. She also needs to know that long term use, especially in an 18 year old is associated with a reduction in bone mineral density. To review this she should be reviewed by her GP after 2 years of use.

Finally she should be aware that while dep provera is an effective contraception, it does not protect against STI and if she does have irregular bleeding she should be screened for Chlamydia in particular.

All information given should be backed up with written information.

Make sure transvaginal scan is being done, and it was confirmed intrauterine viable pregnancy.  If any concern about location of pregnancy, patient should be reviewed and followed up at the early pregnancy assessment unit.   Repeated unwanted pregnancy is high risk of morbidity.  So, check with the patient whether she is already on any contraception and the compliance.  To assess her for any new long term contraception and associated risks, we need to check her menstrual cycle regularity, any previous pregnancy, previous termination, miscarriage, previous delivery, weight, BMI, breast examination, history of smoking and thrombosis history, taking enzyme inducing drugs.  This helps to assess the suitability for combined contraceptive pills.  In low BMI, avoid Depo-provera, as there is risk of reduced bone density.  The next, she needs, screening for chlamydial infection before the surgical procedure, in view of inserting intra uterine devices as contraception, to avoid long term consequences because of this mainly future fertility risk.  We need to check her Rhesus status and give her anti D injection if it is negative with antibodies to protect future pregnancies.  Consider cervical preparation with misoprostol or cervaginum pessaries before the surgery, if the patient never had any vaginal deliveries to avoid forced cervical dilatation which could be at risk for perforation.  She may need anesthetic assessment, if she has any known medical problem with regular medication, as surgical termination would be done under general anesthesia.  Assess her psychological status and arrange counseling if necessary, make sure it is her decision, she is not forced into this decision, any possibility of domestic violence, partner’s age may be important, whether it is a consequence of rape.  Arrange HIV, Hepatitis B, C and syphilis screening if there is suspicion of risk.  While doing the surgery, avoid too much vigorous curetting which may lead to asherman’s syndrome which will affect future fertility.  Meanwhile, take precautions to avoid incomplete curetting which may lead to increased bleeding, retained products, infection risk.  Counsel the patient, to avoid using tampon, bubble bath and sexual intercourse immediately following the procedure as there is increased risk of infection.

Inform her risk of irregular per vaginal bleed with progesterone contraception, risk of weight gain.  Her weight should be measured before each injection which would be given at the interval of 11 to 13 weeks regularly.  It will be given as a deep intramuscular injection at the gluteal muscle region.  It could be painful.  History of breast tenderness is one of the complications.  Ideally it should be avoided if her BMI is very low or very strong family history of osteoporosis.  Otherwise it can be given maximum 2years continuously, then we need arrange Dexa scan to check the bone density.  Failure rate with regular injection is less than 1% while on for 2years time.  The first dose can be given immediately after the surgery before she leaves hospital.  It suppresses the ovulation and also makes the cervical mucous would become thick, the return of fertility would be delayed on stopping the injection, it could be more than a year.  Considering the risk of sexually transmitted infection, use condoms should be promoted in addition to the injections.  Patient should be taught to do breast self examination, timing and how to do it.  Her blood pressure needs to checked before each injection.  Inform her, if she has needle phobia, she would not be suitable candidate for this.

A healthy 18 year old woman has been counselled and accepted for surgical termination of an unwanted pregnancy at 8 weeks gestation. (a) Discuss the interventions that you will undertake to reduce the risk of morbidity and mortality in this woman [12 marks]. (b) She wishes to use progestogen-only injectable contraceptives. How would you counsel her? [8 marks]

a)

Sensitivty and understanding that this may have been a diffcult decision for patient to come to terms with and to help cope with the psychological stress of undergoing a termination.  A written leaftet regarding the procedure and where she could seek help (counselling services) from after would be useful.

As she is also 18 years old I would screen for sexually transmitted infections in particular chlamydia and gonorrhoea as they are prevalent in this age group and pose a risk at surgery for ascending PID (if are present).  I would also endure that a full blood count to check her heamoglobin before the procedure was sent and that a group, save and antibody screen thad also been to sent to check for Rhesus status and atypical antibodies. At pre-assessment it would also be important to establish if she has any medical problems for which she takes regular medication, allergies to any medication and past history of surgcal procedures to the abdomen e.g. appendicectomy.  I would aslo wish to establish about her prior Obstetric history, period history and current form of contraception.  It would also be useful to establish if she has been treated previuosly for STI's.  It would aslo be necessary to ensure that the patient knew that they needed to fast for >6hrs before the operation.

A pelvic USS should be perfomed before the procedure to ensure that it is a confirmed intrauterine pregnancy and no ectopic or PULwas found.  This will also be able to determine the gestation of the fetus and therefore allow the correct size instrument to be used at the time of the operation.

I would also ensure that somebody who is competant to do the procedure obtained the consent for the operation.  The consent would need to explain the procedure and that risks associated with the procedure such as infection, bleeding, and a small risk of perforation of the uterus  (in a languauge that was understood by the patient). This complication is rare and happens 1:100.  It also be necessary to explain to the patient that if there were any complications then a laparoscopy/laparotomy may be required but these are very rare.  If she bled then a blood transfusion may also be required.  I would inform the woman that it is a person who is trained to do the operation that will be undertaking the operation and that if the person is learning to do the procedure then appropriate supervision from someone who is competant to do the procedure.

The patient would also need to see the anaesthetist before the operation to ensure that the patient was able to have an anaesthetic and to ensure that they had been adequately starved for more than 6 hours to decrease the risk of gastric content aspiration.

Before the operation it is recommended that the patient has cevical preparation to aid dilatation of the cervix and help prevent unneccessary trauma to the cervix.  This could be with either misoprostol 800mchg PV or gemprost.  Both of these are given 1-2 before the operation.

Antibiotics would be recommended in this patient.  A stat dose of azithromycin 1g orally could be given before the operation or after the operation to cover for any ascending sepsis from PID.  At the operation a dose of 1g metronidazole PR could aslo be given again to help prevent infection.

During the operation it would be recommended to only use suction with the appropriate sized suction curette applicable to the gestation, e.g. if 8 weeks pregnenat then use a size 8 suction curette.  It is recommended not use a metal sharp curette as this increases the risk of perforation.  If there is any oconcern over the cavity or fibroids are present then the procedure could be done under USS guidance.

5units syntocinon could be given once evacuation is complete to aid contraction of the uterus.  The products would be sent to histopathology to confirm the pregnancy.

Post operatively Rh status needs to be checked to see if anti D is required (if Rh negative).  The patient needs to know how to get her results from her swabs so that if contact tracing is required it can be organised by the GUM clinic.  Debrief the patient regarding any complications in the operation.

B)

There are 2 types of injectable progesterone contraceptives.  One is norethisterone based and has to be given every 8 weeks.  The other is medroxyprogsterone based (depo-Provera)and is given every 12 weeks.  Both are effective forms of contraception.  The failure rate is <1 per 100 woman years and can be used for a significant period of time.  They are given as an Im injection itno the gluteus muscle and the first dose can be given before discharge from hospital.

The side-effects with both types are weight gain, acne , bone loss, and mestrual disturbance such as amenorrhoea or irregular bleeding.  Fertility also may take up to 18 months to return to normal after stopping the injectables.

They can both be used for a period of 5yrs and after this time a bone scan should be arranged to ensure that the bones have not become oeteoporotic.

The one that contains norethisterone has more andogenic properties and may give more acne.

Both of them have good compliance as it is only 1 injection every 2-3 months (depending upon type) and there are no pills to forget.  The efficacy is not reduced with vomiting.diarrhoea and no extra contraception is required during that time.

A)The patient need to be assesed at Early Pregnancy Assessment Unit (EPAU) , which is a dedicated unit so as to reduce the risk of morbidity and mortality. She should be provided with dedicated care and support at EPAU. She should be sensitively counselled of the pros and cons of ERPC in adolescent age. TVS should be performed to locate the gestational sac and know the size of GS and confirm if pregnancy is not of unknown location. FBC must be done pre-operatively so as to know her Hb, and  do group & save, transfuse blood  if she is anaemic .Adolescent pregnancies may  present  with excess bleeding during ERPC, so blood & oxytocics must be kept ready.

Written information leaflets must be provided to the patient.Written informed consent must be taken. Rh status is detrermined and if patient is Rh negative, anti D immunoglobulin must be administered after evacuation to prevent the sensitisation. She should be screened of ‘Chlamydia trachomatis’ and if clinical indications exist of bacterial vaginosis ; as surgical evacuation in presence of genital infections may lead to PID. Antibiotic prophylaxis must be administered before the evacuation.(doxycycline 100mg for 14 days and metronidazole 400mg for 7 days)

The procedure must be performed in OT with full asepsis under general anaesthesia. Good lightning and position of patient must be maintained. Surgeon must be trained .ERPC must be performed with suction curettage and sharp curette should not be used as it may lead to uterine perforation, haemorrhage, and later synaechie. Prior to vacuum aspiration, oral/vaginal misoprostol must be administered to dilate and soften the cervix. This manuever decrease the risk of uterine, cervical trauma, force and hemorrhage. Hegars dilators are then used successively so as to dilate the cervix to required size. Oxytocin in infusion started; 20 units in500ml Ringer lactate.

One must be gentle while doing the vacuum aspiration.  Signs of completion of the procedure must be looked into carefully. Air-bubbles, grating on all uterine walls, gripping sensation on the karman’s cannula at external os ,all signifies completion of the procedure and so avoid over-curettage. Injection methergin is given i.m/i.v (if Rh +)after  completion of the procedure.

She should be discharged on oral  antibiotics, painkillers, antiemetics and methergin. Explain of persistence of bleeding for 10-14 days is normal. She should be explained of the warning signs of excess bleeding, pain abdomen, unable to pass flatus, fever. If she perceive such symptoms, she should report to EPAU immediately and there should be 24 hr telephone access  and admission services on emergency. TVS must be performed after 12 hr of the procedure to confirm the completion. Counsel her and provide ‘ Informed Cafeteria Choice ‘ of the contraceptives, which suits her most.

B) She should be counselled of the risks and benefits of Progestogen injectable contraceptives. Explain her that these are of two types, DMPA is most commonly used, 150 mg need to be administered every 3 monthly, NET-EN 200 mg every 2 monthly. Compliance is good and can be administered immediately, post evacuation. It does not interfere with the intercourse. She should be explained of the advantages, it lowers the incidence of endometrial cancer. Failure rate is low.

Light need to be thrown on disadvantages as well as it is a long list. Explain her of menstrual irregularities in form of breakthrough bleeding, amenorrhea after 1^st dose seen in 35% of patients and after 1 year in 70% .This is the most common cause of discontinuation and being adolescent this may not be desirable to her . Return of fertility is delayed by 1 year after the last dose. Loss of bone mineral density and osteoporosis makes it unsuitable for the adolescents. It does not provide protection against STD’s. She should be counselled that it may lead to weight gain, bloating, nausea, acne and over and above all osteoporosis ; so is unsuitable for her. After knowing all the implications  and considering her age, she should decide.

Offer her other reliable contraceptives which suits her age like COC, condoms.

A healthy 18 year old woman has been counselled and accepted for surgical termination of an unwanted pregnancy at 8 weeks gestation. (a) Discuss the interventions that you will undertake to reduce the risk of morbidity and mortality in this woman [12 marks]. (b) She wishes to use progestogen-only injectable contraceptives. How would you counsel her? [8 marks]

A)

Pre-operative interventions include a pelvic examination to determine the uterine size and position (anteverted or retroverted). Blood investigations including a complete blood count and blood group provide a baseline haemoglobin concentration and white cell count. If rhesus negative then at least 250iu of anti-D would be given within 72 hours of termination of pregnancy(TOP) to rduce the risk of iso-immunisation. I would arrange an anaesthetic review by a senior resident to discuss the optimal mode of anaesthesia with the patient. She should be kept fated for at least 8 hours pre-operatively to reduce the risk of aspiration during induction of general anaesthesia. The cervix would be ripened with 800 micrograms of misoprostol placed vaginally at least 3 hours pre-operatively. Cervical ripening reduces the risk of uterine perforation, cervical injury and retained products of conception (RPOC) by enabling cervical dilation prior to uterine evacuation. Psychological morbidity is reduced by offering counseling services and ensuring confidentiality.

Morbidity/mortality is reduced by ensuring that the surgeon is experienced with TOP. An aseptic technique should be used, performed in the operating theatre, with the patient under general anaesthesia in the lithotomy position. The cervix is visualized with the aid of a weighted speculum and its anterior lip graspd with a tinaculum. The length of the endometrial cavity is determined by insertion of a uterine sound. The risk of Uterine perforation is reduced by avoiding insertion of instruments beyond this length. The cervix is gradually dilated with hagar dilators. Suction is used to evacuated the uterus. Sharp curettage is avoided to reduce the risk of RPOC, uterine perforation and intra uterine synaechiae. The suction cannula is advanced to a mid uterine position. The suction is then turned on and continued until the grittiness of the uterine wall is felt. This indicates an empty contracted uterus. Real time ultrasound can be used to ensure complete evacuation. Excessive bleeding is controlled with oxytocics. Examine the products obtained.

If at any point during the procedure uterine perforation is suspected (fat seen amongst products, or insertion of instruments beyond length of cavity) laparoscopic examination of the abdomen and pelvis should be done to confirm uterine perforation and inspect other viscera for injury. A swab and instrument count should be done post operatively and ensured to be correct and blood loss estimated.

Metronidazole 1gram inserted rectally and azithromycin 1gram given orally post operatively reduces risk of pelvic infection.

Operative notes should detail operative technique with the aid of diagrams. Prior to discharge offer the patient written advice regarding contraception and a discharge summary. Offer a 24 hour help line service and advise to return urgently if she has a high temperature, abdominal pain or heavy vaginal bleeding. Offer review in 2 weeks where a clinical assessment is done and the histological findings are reviewed-to confirm products of conception and exclude a molar pregnancy.

B)

Inform her that 2 preparations exist. Depot Medroxy Progesterone Acetate (depot MPA) used 12weekly and Norethisterone Enanthate used 8 weekly.in form her that they inhibit ovulation, thicken cervical mucus and prevent endometrial implantation.

 Favourable characteristics include good contraceptive efficacy (failure of depot MPA <4 in 1000 after 2 years usage.). There is a reduced incidence of ectopic pregnancies compared to progesterone only pill users and of pelvic inflammatory disease. Contraceptive failure because of missed pills is avoided. Injectable progestogens can be started immediately. There is also a decreased incidence of endometrial cancer in users.

However, injectable progestogens offer no protection against sexually transmitted diseases. They are associated with menstrual abnormalities-50% of users will discontinue after 1 year of usage because of irregular vaginal bleeding, 35% will become amenorrhoeic  after 1 dose and 70% after 1year of use. Injectable progestogens are associated with weight gain of 3-6kg particularly if BMI>30kg/m2.

Long term use is associated with decreased bone mineral density especially if less than eighteen years old where maximum bone density has not yet been attained. Therefore, in this regard injectable progestogens is not ideal. I will offer the combined oral contraceptive pill but respect her desires for contraception after she has been appropriately counseled.

Advise cervical smears from age 25.

This patient will need discussion of the implications  of the procedure and will require psychological support .

Pre- assessment should include measurement of haemoglobin concentration

determination of ABO and rhesus blood groups and red cell antibody screening.

it would be ideal to have a blood bank on site and  the most cost effective strategy would be to initiate cross matching  if blood transfusion is required.

 Vaginal examination is performed to assess  pelvic anatomy  and uterine size.

Speculum examination to look at the cervix to exclude any cervical masses such as polyps or any scarring that could cause difficulty in evacuation of the uterus.

Screening for genital tract infections is carried out followed by contact tracing and treatment if positive. This would minimise the infectious morbidity.

as a minimum, antibiotic prophylaxis effective against both C. trachomatis and bacterial vaginosis is offered to women undergoing surgical termination of pregnancy.

metronidazole 1 g rectally at the time of abortion plus doxycycline 100 mg orally twice daily for 7 days, commencing on the day of the procedure would be a suitable regimen.

The procedure need to be performed by an experienced clinician to minimize the risks associated.

suction evacuation is performed under general anesthesia although it can be performed under local anaesthesia.

Risk of cervical trauma is minimized by cervical preparation with prostaglandins .

misoprostol 400 micrograms (2 x 200-microgram tablets) administered vaginally 3 hours prior to surgery is an accepted regimen.

The risk of uterine perforation would be minimised by cervical preparation  with prostaglandins , guarding of dilators and gentle evacuation of uterine contents using appropriate surgical technique

By quadrant wise evacuation of the uterus and by avoiding excessive scraping .gritty sensation would alert that the uterus is empty.

Use of suction curettage and uterine evacuation under ultrasound visualization would further help to reduce the risk of uterine perforation.

there is  a small risk of failure to terminate the pregnancy and  thus necessitating a further procedure. this risk is minimised by operative skill and ensuring that  uterus is empty after the procedure.

Uterotonic agents may be used to reduce bleeding .

Anti-D immunoglobulin G 250 iu should be given  to the patient if she is  non-sensitised RhD negative, within 72 hours following abortion.

 Following abortion, would give a written account of the symptoms she may experience and a list of those that would make an urgent medical consultation necessary.

 Urgent clinical assessment and emergency gynaecology admission must be available when necessary. 

A follow-up appointment is offered.

On discharge, written information about the procedure is given to the patient to allow another practitioner elsewhere to deal with any complications.

Before she is discharged  future contraception is discussd and contraceptive supplies are offered if required.

The chosen method of contraception is initiated immediately following termination.

Intrauterine contraception is inserted immediately.

b) two types of progestogen only injectable contraceptives are available .

Depo-medroxyprogesterone acetate 150mg (depo-provera) is given every 12 weeks.

Norethisterone oenanthate 200mg (noristerat, given every 8 weeks).

They act by inhibiting ovulation. In addition, thickening of cervical mucous prevents sperm penetration and changes to the endometrium make it an unfavourable environment for implantation.

They have good efficacy with failure rate as follows

Pearl index

0.25-0.5 / 100 women years (depo-provera)

0.4-2.0 / 100 women years (noristerat)

they form  an effective method of contraception,associated with lower  risk of ectopic pregnancy compared to progesterone only pills .

lower risk of pelvic inflammatory disease and endometrial cancer.

common disadvantages of injectable progestogens are  Menstrual irregularities .

Amenorrhoea becomes more likely with repeated doses,  35% after 1st dose, 70% by 1 year.

 50% of users  discontinue after 1 year because of irregular bleeding patterns.

return of fertility can be delayed for up to 1 – 2 years after last injection.

associated with weight gain of up to 3 kg at 2 years.

Those with higher BMI > 30 are more likely to gain more weight.

This patient need to be counselled that injectable progestogens do not offer protection against STI s and she may need additional barrier contraception for this purpose.

In this young patient  Depo-provera should only be used after other methods have been considered and found to be unsuitable  as there is evidence that depot causes a reduction in bone mineral density. Reduction appears to be partly reversible after discontinuation and resumption of ovarian activity. There is no evidence on long term fracture risk.

This risk of osteoporosis must be explained to the patient before she embarks on this mode of contraception.

A) Interventions to reduce mortality and mortality can be divided into pre, intra and post operative. Prior to the procedure I will take endocervical swab to rule out Chlamydia. If operation is going to be done before swab results are available, I would give her prophylactic Azithromycin 1 gram PR at the time of termination. I would also give her either cervegam 1mg or misoprostol 800 mcg per vaginum. This will not only soften the cervix and make dilataion easy but will also prevent any inadvertent tears to cervix. operatively I will discuss effective contraception with her and discuss long term reversible contraception depending on her preference and previous experience and advice that she can start them straight ater the procedure.

She should be nil by mouth ideally overnight or at least for 6 hours or more and antacid given to reduce risk of gastric aspiration. Prior to procedure I will also ensure that blood tests including full blood count and group and save have been taken and sent. This is to ensure that she is not anaemic and also to know her rhesus status. During procedure I will ensure that excessive dilatation and sharp curettage is avoided. This is to prevent any damage to cervical tissue fibres and prevent risk of Asherman syndrome. I will also request 5 IU oxytocin to minimise blood loss during procedure. I will also request antibiotics at the time of induction to reduce risk of infection. Aseptic technique should be followed to reduce this risk further. Post operatively I will discuss effective contraception with her and ensure that this has been provided with or arrangments have been made for its provision. I will give her contact numbers and out of hours emergency contact if she feels unwell, has signs and symptoms of infection or excessive bleeding. I will also ensure that she has psychological support and contact numbers to contact if she feels upset or depressed.

b) I would take detailed contraceptive history enquiring about previous contraception used,any failure associated with its use, method of use and compliance. I would enquire why she has preference for injectable contraception. I would explain to her regarding other contraceptive methods including contraceptive pills, implants and mirena intrauterine system. I will explain that injectable contraceptive has pros and cons. Pros willl include lower contraceptive failure 0.1/1000. It is given every 3 months and have window period of 2 weeks. So the injection can be given up to14 weeks. It is discreet. No one will know that she is using contraceptive. The pros include irreversible loss of bone mineral density with prolonged use. She is at greater risk as her bones have not been mineralized fully, however, doing bone density scan to assess or follow that up is not recommended. She will need review in 2 years and would advise her to change to alternative contraceptive methods then. Irregular bleeding pattern is the most frequent risk and leads to its discontinuation in 30% of people. However, more than 3 months of use will lead to amenorrhoea in around 70% of people. Return of fertility can be delayed up to a year in long term users and she will need to keep this in mind when planning for pregnancy. Howver, it does not affect the long term fertility. Other frequent risks include bloading, breat tenderness, acne mood swings and gain of weight. There is gain of 2-4 kg of weight per every year of usage.  

A.

Sexual history to identify risk of sexual transmitted infections, drug allergy should be also enquired. BMI should be determined possible thromboprophylxis.

FBC for Hb level, blood group and Rhesus status done , including red cell antibodies to be done. She should be offered genital swabs; 2 endocervicals and 1 high vaginal swab, to exclude Chlamydia, Gonnorhoea and Trichomonas respectively.  The patient should have antibiotics before her surgical termination like doxycycline 100 mg 12 houry and metronidazole 400 mg 12 hourly for one week if screening positive.

Cervical priming with vaginal denoprostone 3mg or misoprostol 400 mcg 3-4 hrs prior to surgery would also help in reducing the risk of cervical trauma and perforation. Metronidazole 1g rectally and Azithromycin 1g orally should be given to reduce the risk of genital tract sepsis if screening for STIs not done.

Pelvic examination under anaesthesia [EUA] should be done to assess the size and position of the uterus before suction evacuation that is preferable to dilatation and curettage.  

The patient should be given verbal and written information before discharge on the expected duration of pain and bleeding; complications to look out for (such as severe abdominal pain, foul vaginal discharge, fever, heavy bleeding), and a 24 hour contact number to call if any complication arises for arrangement to see the doctor.

B.

DepoMedroxy progesterone acetate does not require compliance as much as contraceptive pills as it given deeply in intragluteal muscle every 8 – 12 weeks according preparation dosage. It is effective form of long acting revisable contraceptive with very low Pearl index. DMPA reduces but does not prevent her from STIs. On long term, it causes amenorrhoea so it is beneficial for women with heavy menstrual blood loss.

She should be counselled about irregular (breakthrough) bleeding that either vaginal spotting or unpredictable heavy bleeding. There is a weight gain of 2-3kg over one year and a delay in return on fertility of 6 to 18 months after cessation of it. There is a risk of osteoporosis on prolonged use which is reversible after discontinuation.