MRCOG PART 2 SBAs and EMQs
| Course PAID | ||
| notes | 336 | |
| EMQ | 1502 | |
| SBA | 2115 | |
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ESSAY 133 - CONTRACEPTION
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Posted by vijaya L. |
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| Measures that are taken depends to some extent upon why in the first place she is undergoing a termination and why surgical termination (as medical termination is associated with less long term morbidity) followed by the general measures to be followed before during and after the termination to decrease the morbidity Heavy bleeding in early pregnancy requires termination. In this case resuscitation and fluid management are absolutely necessary to avoid mortality and morbidity. Gestational trophoblastic disease is terminated surgically and there is a higher risk of haemorrhage, infection and perforation in this case. Referral to specialist centers and follow up of serum levels of serum b-hcg is essential to prevent and treat neoplasia and persistent trophoblastic disease. If termination of pregnancy is chosen for underlying medical disorders then appropriate management pertaining to this disorder is necessary , medical induction is contraindicated in the renal and liver failure. Endocarditis prophylaxis is required for valvular heart disease. Any type loss of pregnancy is associated with psychological upset for the mother. Recognition and sympathetic counseling is important. Women should be provided with the information regarding the procedure and possible complications and implications for the future pregnancy. Rh negative women should receive 500iu of Anti-D to decrease the seroconversion Pre-op Hb should be known as 0.5 to 1% of cases can have severe haemorrhage. Pre-op ripening of the cervix with either 800micro grams of misoprostol inravaginally 2 hours earlier or intramuscular prostaglandin F 2 alpha injection an hour earlier decreases the cervical and future cervical incompetence during dilatation. Vacuum aspiration should be employed instead of curettage to decrease the risk of perforation Single dose of broad spectrum antibiotics reduces the infective morbidity which is especially important as about 1% of tubal block has been reported after first trimester miscarriage. In case of congenital uterine anomalies and fibroids distorting the cavity, ultrasound guided termination might be prudent. All the products obtained should be sent for the hiostological examination, so that partial moles are not missed Women should be told to return in case they notice excessive bleeding or fever after discharge. |
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Posted by Sarwat F. |
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| Various steps that may be taken to reduce the morbidity in this woman can be evaluated by dividing them into preoperative, operative and postoperative measures. Preoperatively detailed information should be provided to the woman regarding the procedure, information leaflets are provided to her and related abortion certificates are completed and signed. As the decision for surgical termination is already made, the procedure should be done as early as possible because of lower incidence of complications of termination at earlier gestational age. Preoperative assessment should include measurement of haemoglobin concentration, determination of ABO and rhesus blood group status and screening for red cell antibodies. In the light of clinical features any further investigation regarding hemoglobinopathies, hepatitis B and C and HIV are carried out. To minimize infective morbidity after the procedure, preoperative antibiotic prophylaxis is given in the form of metronidazole 1 gram rectally at the time of abortion and doxycycline 100 mg orally twice daily for seven days commencing on the day of abortion. Ideally services should offer testing for lower genital tract organisms with treatment of positive cases but this becomes difficult in actual clinical situation because of increase workload. Cervical cytology history should be assessed as an opportunity to offer cervical smear for women who have not had one within the interval recommended in the local programme. However this is beneficial only if the smear results are communicated to the woman acted on appropriately and recorded. Regarding operative measures, suction evacuation is the appropriate surgical method for termination of pregnancy at this gestation. During the procedure uterus should be emptied using suction curette and blunt forceps if required only. This has been proved by randomized controlled trials according to Royal College of Obstetricians and Gynaecologists guidelines. Procedure is safe under local anaesthesia and this option should be made available to the woman prior to the procedure. In case the procedure is carried out under conscious sedation it should be preferably done by trained personnel. After the surgical procedure the need for analgesia varies and oral and parenteral analgesia should be made available to the woman. As far as postoperative measures are concerned, anti-D immunoglobulin 250 i.u. should be given by injection into the deltoid muscle to all unsensitized Rh D negative women within 72 hours of termination of pregnancy. Following abortion women should be given written account of the symptoms they may experience and a telephone help line number to use for any complaint. Before discharge future contraception is discussed and contraceptive supplies are offered. An intrauterine device can be inserted immediately after the procedure.On discharge a letter should be given containing sufficient information regarding the procedure. In conclusion the available evidence from well conducted clinical studies suggests that if the above measures are followed morbidity after surgical termination of first trimester pregnancy can be reduced significantly. |
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Posted by uma M. |
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| TOP is a common procedure performed in UK, carries significant morbiditydue to complications. these include haemorrhage,uterine perforation,cervical trauma, failed abortion, post abortal infection,and psychological sequelae. Before TOP, confirm GA from LMP, US. confirm gestation is intrauterine.Examine the patient to exclude any risk for anaesthesia and procodure. Pre procedure councelling regarding possible complications, sequlae of TOP explained. Obtain conset.Give information leaf lets& give further information if pt require for desision making.Investigations pre procedure include HB,ABO ,SCREENING ANTIBODIES ,Rh, HIV ,HBsAG. nO NEED FOR X_MATCHING AS ONLY0.2%REQUIRE BLOOD TRANSFUSION Screen for chlamydia befor e uterine instrumentation. Abortion care to minimise infective complications include screening for lower genital tract infections and treat if positiveor antibiotic prophylaxis plus doxy 100mg bd for 7 days,metrogyl 1 gm rectally at time of abortion. Advice women regarding alternatives of surgical TOP.Medical abortion with mifepristone &misoprostol can be tried at this gestation. conventional suction termination is an appropriate method at this gestation. Suction termination is safer under LA than GA.cervical preparation is better with misoprostol 400mcg or gemiprost 1mgvaginally. to reduse cervical trauma, and risk of perforation of uterus. in event of intraop blood loss oxytocin should be used.in cases of suspected uterine perforation early resort to laparoscopy isinvestigation of choice. After abortion if rh _ve,nonsensitised Anti D Ig should be given. At discharge patient is provided with written informationregarding likely symptomsshe might experience, give her a 24 hr help line number, .follow up appointment should be given.Future contraception discussed before discharge. On discharge a letter is to be given to each patient about the procedure to allow another practioner to deal with any complications if they occur. If women experience post abortion distress arrange councelling. |
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Posted by Nibedita R. |
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| The measures that would be taken to reduce morbidity when performing a surgical termination of pregnancy in a young woman at 8 weeks of gestation include pre, intra and post operative measures. Timing of the termination is important. Early termination is associated with a lower risk of complications. Those women who need more support in decision making should be identified and counselled before the procedure and access to social services should be made available if required to reduce long term psychological sequelae. Adequate history to identify risk factors should be obtained. General risk factors like diabetes, hypertension, asthma, heart disease, past history of thromboembolism and hereditary thrombophilia must be found out. Preoperative investigations like chest x-ray, ECG, echocardiography, clotting factor screening and blood sugar may be required. Joint care should be provided in consultation with physician or cardiologist. Obstetric history regarding LMP, parity, reason behind termination, history of any previous termination with gestational age, method of termination and any complication like excessive bleeding or perforation. Past history of any molar pregnancy. Chlamydia is the commonest cause of post operative infection and sepsis, subsequent tubal damage and its sequelae ectopic pregnancy and infertility. Routine screening by PCR (more sensitive than ELISA) and treatment of positive cases is more appropriate than treating all cases without screening. This will help in contact tracing and treatment of partner will minimise risk of reinfection. Recommended antibiotic doxycycline/ ofloxacin/azithromycin for 7-14 days in chlamydia positive cases and routine use of 1 gm rectal metronidazole will reduce subsequent infection which is more evident within 21days of instrumentation. Determine haemoglobin concentration before the procedure and group (ABO and Rhesus) and save blood if necessary. Routine transvaginal ultrasound before the procedure to confirm intrauterine gestational sac and to determine gestational age as well as exclude molar and ectopic pregnancy. Cervical priming with gemiprost 1mg or 400microgram misoprostol (although not licensed in UK) vaginally 2 hour before the procedure will reduce risk of perforation and cervical trauma. The procedure can be undertaken under GA or local paracervical block (no evidence that one is superior to another). Outcome of the procedure is dependent on skill of the operator. Assessment of uterine size and position prior to instrumentation and suction evacuation compared to sharp curettage will minimise the risk of perforation. Ensure complete evacuation has been done else it will lead to irregular bleeding and infection. In case of suspected uterine perforation during the procedure a laparoscopy should be preformed and subsequently a laparatomy if necessary. Use oxytocic to reduce blood loss during the procedure. Product of conception should be sent for histopathological examination because a partial mole may be missed. administer anti D immunoglobulin if Rhesus negative to reduce isoimmunisation. Post operative cramp like pain, which is common, would be minimised by analgesics like diclofenac or paracetamol. She should be told that slight spotting is common for several days and she should return back if heavy bleeding is noticed. Discuss with the patient regarding different methods of contraception and agree on future contraceptive plan. Contraceptive supply should be offered if required. Arrangement for a follow up appointment with her GP at 4-6 weeks and additional counselling if required. |
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Posted by Vaijayanti R. |
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| The complications following surgical termination of pregnancy are procedure related as well as psychological.Measures to reduce morbidity must address the same. Pre procedure counseling should give verbal as well as written information regarding the procedure, and alternatives available { medical termination using Mifepristone and Prostaglandin E analogues}. Access to support groups and social services are initiaed if necessary. A detailed History would reveal any comorbid conditions which may affect the planned procedure { prostaglandins contraindicated in bronchial asthma, anesthetic risk in cardiac disease} , as well as the risk for sexually transmitted disease. Baseline hematocrit,ABO grouping, Rh Typing and screening for RBC antibodies will assess the risk for Isoimmunization.Infection { especially chlamydia, HIV, HBV and HCV} and hemoglobinoapthies screen is offered based on local prevalence and individual risk factors. As this is not cost effective, antibiotic prophylaxis is now considered routine with Termination of Pregnancy.Recommended regime is Metronidazole 1 g rectally at the time of procedure, followed by oral Doxycycline 100 mg 12th hrly x 7 days.The disadvantage of this is that any form of contact tracing will be lost in the absence of a positive screening test. The size and position of the uterus is assessed by pelvic examination. Preoperative instructions should ask her to come in on an empty stomach, to reduce the risk of aspiration { Mendelsons Syndrome} She should also be accompanied by a responsible adult to take her home post procedure.Test dose for the local anesthetic should be adminstered to identify hypersensitivity. Emptying bladder before positioning in lithotomy position will reduce the need for catheterization. Pain is usually well controlled with the Local anesthesia{ para cervical block}, however if she is very anxious , consious sedation/ Ga can be adminstered by a Specialist. Surgical termination at 8 weeks is best done by Suction Evacuation. Electric aspiration is preferred as the operating time is shorter, than with manual methods. Cervical trauma is avoided by gentle dilatation, without using excessive force.If necessary, priming of the cervix may be done with vaginal prostaglandins{ 1mg Gemeprost 3 hrs prior to procedure} Uterine perforation may be prevented by inserting the dilators as well as the suction cannula only upto the lower uterine segment. Plastic cannulas are used and sharp curettage should be avoided. The curettings are examined to conform the presence of chorionic tissue. It is advisable to send the products for histopathological examination to rule out any form of Gestational Trophoblastic Disease{ especially partial mole} Oxytocics may be used if there is excessive hemorrhage. She is observed for atleast 2 hrs post procedure,to identify and treat other immediate complications such as Acute Hematometra. Post procedure counselling should give verbal and written information regarding symptoms that would require emergency consultation{ excessive bleeding pv. pain abdomen, fever}A 24 hr help line access is ensured. Discussion is initiated regarding future contraception, and supplies are offered. Psychological counselling is organized if necessary.A follow up appointment is arranged within 2 weeks of the procedure. |
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Posted by narmin B. |
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| Evaluate the measures that may be taken to reduce morbidity in a 25 year old woman who is undergoing surgical termination of pregnancy at 8 weeks gestation. In the UK the most common method of termination of pregnancy at 8 weeks is suction curettage under general anaesthetic. Although this method is generally safe, but it can cause morbidity due to surgery and in rare occasions because of general anaesthetic. Morbidity which is related to surgery includes, cervical incompetence following to dilatation of cervix or cervical tear, hysterectomy because of significant damage to the uterus or uncontrollable haemorrhage, bowel resection and colostomy due to severe damage to small intestine or colon, Asher man?s syndrome following to aggressive sharp curettage of the uterus. Also spread of lower genital tract infection, especially due to Chlamydia trachomatis, to the upper genital organs can be seen. This is the reason for subsequent morbidity in the form of pelvic inflammatory diseases, pelvic pain, pelvic adhesions and sub fertility. Morbidity due to anaesthesia is rare and may be seen in the form of aspiration of the gastric contents and damage to the lungs and cerebral damage due to severe hypoxemia during general anaesthetic. Moreover psychological morbidity may be presented as depression and anxiety disorders after termination of pregnancy. However, morbidity can be minimized by taking appropriate steps. To reduce morbidity due to surgery taking the following measures are useful. Since dilatation of the cervix is required before termination, intravaginal administration of a prostaglandin such as gemprost or prostaglandin analogues (misoprostol) softens the cervix and reduces damage to the cervix during dilatation. Also this procedure should be performed by an experienced practitioner as this reduces significantly the risk of perforation of the uterus and damage to the bowel. In case of any difficulty in performing the procedure, senior help should be requested as this prevents further damages. Additionally aggressive sharp curettage must be avoided because it may cause Asher man?s syndrome subsequently. Intraoperative administration of an oxitocic agent such as syntocinon is effective in reducing the amount of blood loss should heavy bleeding occurs during the procedure. The next appropriate step is administration of one gram of metronidazoloe suppository after termination and continuing with doxycylin 100 mg twice a day for one week which covers most of the genital infections and reduces the rate of pelvic inflammatory diseases. With regard to anaesthetic morbidity appropriate preparation of the patient before anaesthesia is important .The following measures help to prevent regurgitation and aspiration of gastric contents and serious damage to the lungs. The patient should avoid eating and drinking 6 hours before the surgery. Also administration of ranitidine 150 mg orally before termination reduces gastric acidity. Intra tracheal intubation and adequate oxygenation during anaesthesia, prevents hypoxemia and cerebral damage. Another useful measure is adequate counselling of the patient before termination which minimizes the risk of psychological problems after the termination such as regret and depression. It should be ensured that the patient is sure about her decision and is aware of the all aspects and complications of the procedure. Even it may be necessary to refer her to a social worker for further counselling and help. |
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Posted by narmin B. |
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| Dear paul, When the question asks about morbidity do we need to write about complications? My impression is that morbidity and complication are different conditions.Complications may or may not lead to morbidity. Many thanks Narmin |
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