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Essay 191 - TOP

Posted by Kishor S.
Surgical termination of pregnancy at less than 13 weeks carries risks of haemorrhage (<1 in 1000), uterine perforation (1-4 in 1000), cervical trauma (1%) and infection (upto 10%). 2 to 3 women in 1000 may have failed abortion necessitating further procedures. The problem of infection is more likely to manifest in 2 weeks after the abortion rather than at the time of the procedure itself.
General procedures for TOP will be followed in the following manner. Pre abortion assessment will be done within 5 days followed by the procedure in 2 days. Information leaflets information containing the abortion procedure and the possible risks will be made available, which she may take away and read before the procedure. In case she needs extra support, she will be given contact details of organization such as Family Planning Association, LONDON.
Pre abortion assessment begins with history related to general health, sexual behaviour and medical problems. Vaginal examination both speculum and digital will be performed to look for any infection including sexually transmitted diseases. Investigation will include Hb, ABO grouping and Rh typing. HIV and HBSAg will be done depending on the history. Cervical and vaginal swab for culture will be taken provided clinical examination warrants. In the event there is any infection, it should be treated prior to the procedure.
The procedure for surgical termination will be ?dilatation and suction evacuation? under local anaesthesia as a day care patient. Since by the time she undergoes the procedure, it will be 11 weeks, the cervix will be primed by gemeprost 1 mg vaginally 3 h before the procedure. Cervix will then be dilated upto Hegars 10. This will prevent the small increase in miscarriage and preterm labour. Electric suction evacuation will be done using plastic cannula no. 10. Completeness will be confirmed by blunt curette, not by sharp curette. Prophylactic antibiotics in the form of metronidazole I gm per rectal and doxycycline 100 mg orally for 7 days will be given from day of abortion.
Depending on her need, she will be prescribed paracetamol and/or diclofenac for post abortal analgesia for 3 to 4 days. If she is Rh negative, 250 IU Anti D in deltoid muscle IM will be given within 72 hrs.
Verbal as well as written account of symptoms of any complications e.g. excessive bleeding, fever, abdominal pain with nausea and vomiting, 24h help line in case of complications will be provided. Follow up appointment will be given within 2 wks and sufficient information will be included in the discharge slip so that any other practitioner understands the procedure in case of emergency.
Posted by Zaharuddin R.
History should be taken either the patient at high risk of sexual transmitted diseases (STD) such as multiple partners, no contraception used, previous history of STD, recent changing of partner or chronic unknown vaginal discharge. Screening should be offered such as pap smear, Hepatitis B and HIV screening and PCR for chlamydia DNA from first early morning urine sample or endocervical smear. As this is an elective procedure, awaiting for results is appropiate.

Past medical history should be taken either the patient has cardiac problem, medical illness such as hypertension or diabetes mellitus, previous complication of anaesthesia or history of allergy. Referral to appropiate specialists such as endocrinologist for poorly controlled diabetes mellitus is needed to optimized medical condition peri-operatively.

Physical examination should be done to exclude cardiac murmur, breath sound and uterus size. If the patient has respiratory infection, it should be treated first before the procedure and another elective date should be given.

Blood should be taken for full blood count as baseline haemoglobin level, blood for group, rhesus status, screened and hold. Intamuscular rhogum is needed after the procedure if rhesus negative.

As the patient is primigravida, most likely the cervical score is unfavourable. Cervical ripeneng by cervagem or antiprogesterone is needed to reduce cervical trauma or tear. Consent for the procedure should be taken after counseling.

Surgical TOP should be done under general anaesthesia and aseptic technique. The patient should be in lithotomy position, perineum cleaned and drapped. Urine should be catheterized in/out with metal catheter. Cervical os should be dilated gradually with Hager dilator up to size 8. Bigger size of Hager dilator may put the patient at higher risk of cervical trauma and incompetence in subsequent pregnancy.

The procedure should be done with suction apparatus as it is associated less trauma and bleeding compared to currettage per se. IM syntometrine should be given during the procedure if the patient is not hypertensive or has cardiac problem. This should reduce amount of blood loss. Gentle currettage should be done after suction to ensure complete evacuation. Product of conception should be sent for histopathological examination.

If the patient is at low risk of STD or screening was negative, there is no role of prophylaxis antibiotic as the risk of infection due to the procedure is same as general population about 5%. But if the screening is positive, appropiate antibiotics based on culture and sensitivity. If the patient has no screening but she is at high risk, prophylaxis antibiotics such oral metronidazole and doxycycline are appropiate.

Post operatively, simple analgesia either NSAIDS orally or rectally is appropiate. Vital signs such as BP, PR, pad chart and abdominal examination should be done in regular interval.

Upon discharge, contraception should be discussed. Option should be given. COCP may offer not only contraception but also regularize menses and reduce dysmenorrhea. However it does not prevent STD. Double Dutch regime, combined COCP with male condom may offer protection against STD. Wriiten information should be given regarding contraception.

The patient sholud be reviewed at Gynaecology ward to review histopathology result of POC and others screening results.
Posted by Remi A.
In this case,Informed consent is important,the nature of the procedure and associated risks like cervical trauma,risk of uterine perforation,[1/1000],with possible need for laparoscopy or laparatomy,Infection and Haemorrhage should be explained and documented.
Preoperatively,investigation should include a Full blood count for Hb,platelets.A group and Hold,and Rhesus status. Anaesthestist review as well.
The risk of cervical trauma during dilatation can be reduced by cervical priming with prostaglandins[eg cytotec 400-600mcg]3hrs pre-operatively.
The procedure should be performed by appropriately trained surgeon or a trainee under supervision. Suction curretage would be ideal for this gestation.
Anaesthestic risk can be reduced by performing the procedure under conscious sedation or regional anaesthesia.
She should either screen for Sexual transmitted infection or given empirical treatment [metronidazole 1g pr with Azithromycin 1g po stat] based on risk assessment.The advantage of scrreening is that it allows for contact tracing if results are positive.
In case of suspected perforation,senior personnel should be informed,and a laparoscopy should be performed as a minimum.
Postoperatively, She can be discharged on the same day ,if all are well,but there should clear follow-up instructions according local protocols.She should be asked to report excessive bleeding,abdomonal pain or fever.
The National institute of clinical excellence [NICE] guidelines states that there is no need to send products of conception for histopathology in induced miscarriage.
Anti-D should be administered if Rh neg. and unsentisised.
Adequate analgesia[mefenamic acid 500mg tid for 3-5 days]should be provided
Contraception should be discussed and oral contraception can be started immediately.
Contact details for support group for induced termination of pregnancy should be provided to minimise psychological morbidity
Posted by Vinayak B.
Dera dr paul
this is my first attempt. please guide me .
thanks






This young patient has procedure related morbidity such as hemorrhage perforation cervical trauma, pelvic infection leading to tubal block, cervical trauma and post procedure psychological morbidity. Pat ient also at risk of infectivemorbidity due to associated cervical vaginal infections

Prior to procedure consent should be taken from the patient. Hemoglobin should be checked prior to procedure with blood group and antibody titres. History of any vaginal discharge or pelvic infection recent or past should be enquired and chlymadia screen should be offered . if not prophylactic antibiotics given. If any recent history or evidence of pelvic infection , Gum clinic reference should be done prior to procedure . Hepatiis and HIv screening offered.

Preprocedures cervical priming donewith misoprostal or laminaria tent .Bladder should be emptied prior to procedure. Size & position of uterus confirmed.to avoid cervical trauma and perforation dilatation done gently and excessive force avoided. So as to prevent prevent future incompetent os and preterm labour .procedure done under aseptic precautions. If accidental perforation suspected procedure should be stopped senior help should be asked termination completed under laparoscopic guidance. Excessive curettage avoided as it will lead to asherman syndrome . To avoid excessive bleeding oxytocics are used .


Prophylactic antibodies done if prior chlymadial screening is not done. If patient is Rh negative non immunized Rh prophylaxis given . Patient should be adviced to come to hospital if pain excessive bleeding or fever. She should be asked to follow up after two weeks to reconfirm any problem or if she did not get period and to discuss about contraception . to avoid recurrent terminations and its sequele.If patient is rubella non immune rubella immunization given , with advice of avoiding pregnancy for three months
Posted by Srivas  P.
Surgical termination of an unwanted pregnancy can be emotionally debilitating for the woman, contributing to a feeling of guilt and associated psychological morbidity and fears about future fertility .She needs to be handled with care and sensitivity. It is essential that her consultations and subsequent follow ups are kept separate from other ANC consultations and it is best if her abortion can be performed ideally within 7 days and by maximum of 2 weeks time to minimize anxiety and apprehensions. Besides the complications are minimum if the procedure is done earlier in gestation which includes decreased risks of hemorrhage and risks of cervical trauma.

Potential complications should be verbally discussed with the woman supplemented with written patient information booklets which she can take home to read so that she can decide and give valid informed consent. Contraceptive advice should be given and her opinion taken and discussion on possible insertion of IUCD post abortion if she wishes should be discussed if she is not high risk for STD?s. Other contraceptive options like COC?s should be discussed and leaflet information should be given

The risk of hemorrhage is 1:1000 and is lesser if done in earlier gestations less than 13 weeks, 1-4/1000 risk of perforation ,<1/1000 risk for uterine rupture, 1/100 risk of cervical trauma and 2.3/1000 risk of failed abortion and continuing pregnancy. Other complications include risk of genital tract infection in 10 % cases and potential RH sensitization. She should ideally have Chlamydia and lower genital tract screening to minimize infective morbidity and if not possible should have prophylactic antibiotic cover against any infection . Other pre abortion assessments include FBC, ABO, Rh blood grouping, testing for HIV hepatitis B and Hepatitis C if she seems high risk.

At 10wks gestation period, suction termination is an appropriate procedure and it is safer under local anesthesia and can be done as a day case. As a primigravida she maybe too apprehensive and general anesthesia could be a valid option. Cervical preparation before suction termination helps decrease chances of cervical trauma by manual dilatation. This could be misoprostol 400 microgms intravaginally (unlicensed in UK) or gemeprost 1 mg I/V 3 hrs before surgery or mifepristone 600mg orally 36-48 hrs before surgery. The latter two are licensed for use as cervical prime in UK. Analgesics may be given depending on requirement of the woman. Surgical procedure should not be done with sharp curette.

To prevent Rh sensitization all Rh negative woman should be given 250 i.u Anti D immunoglobulin after surgical abortion at 10 wks and should be given preferably before 72 hrs.

Following abortion she should be given information on when to review- incase she has pain, bleeding, fever or dirty vaginal discharge. She should have follow up appointment in 2 weeks time. She should have 24 hrs helpline facilities to contact in emergencies.
Posted by adnan S.
The measures that would be taken to reduce morbidity and mortality when performing surgical termination of pregnancy at 10 wks include pre, intr and post operative measures. The risks &complications associated with surgical termination of pregnancy are haemorrhage, uterine perforation ,cervical trauma, failed abortion, post abortion infection and psychological sequelae.

Pre ? operative measures includes detailed history is obtained to assess general risk factors like diabetes ,heart disease ,respiratory illness and any bleeding disorders.Obstetric history is obtained previous termination of pregnancy ,method used and any complication like excessive bleeding and perforation .Sexual history is obtained regarding previous h/o sexually transmitted infections ,new partner more than one partner last year .Pre-operative investigations like FBC to check haemoglobin concentration ,ABO and rhesus blood groups with screening for red cell antibodies.HIV,hepatitis B and C screening is done if there is risk factors in history.Routine crossmatch is not cost effective
Infection ,especially by Chlamydia is the most important cause of acute and long term morbidity including risk of chronic PID ,ectopic pregnancy and sub fertility.Screening for Chlamydia infection and treating positive cases is effective in reducing risk of post-TOP PID and allows contact tracing .However ,the ELISA test has variable sensitivity and results may not be available at the time of TOP. PCR based testing has better sensitivity.Universal prophylactic antibiotic treatment allows prompt treatment but may be treated un-necessarily.Contact tracing is not possible and re-infection likely to occur.
Cervical trauma, haemorrhage and perforation are minimsed by cervical priming with gemiprost or misoprostol, 3 hrs before the procedure .Suction termination is safer under local aneasthesia than genral aneasthesia.During the suction termination the uterus should be emptied using the suction curette and blunt forcep if required only.THE Procedure should bnot be completed by sharp curettage.Operating time is shorter with electric aspiration.Out of the procedure is dependent on skill of the operator.
Following abortion woman must be given a written account of symptoms they experience like slight spotting and list of symptoms that needs urgent medical consultation like heavy bleeding ,sever abdominal pain and high temperature .She should be given a 24hr telephone helpline number if she feel worried about heavy bleeding abdominal pain and high temperature.On discharge she should be given a letter that include sufficient information about the procedure to allow another practitioner to deal if any complication .Follow up appointment should be offered and pos-termination counsslling as some woman regret the decision .Future contraception should discussed and contraceptive supplies should be offered if required .The chosen method of contraception should be initiated immediately following abortion.
Posted by Aroosha B.
Termination of pregnancy is associated with significant morbidity and risk of mortality of 1.4/100000. Although the women has been adequately counseled for TOP, she still require additional counseling, the facilities for it should be provided. The consent for TOP should be checked before procedure. Her blood group, Rhesus status, blood for antibodies and full blood count should be done. The risk associated with general anesthesia can be decreased by carrying out procedure under local anesthesia. If conscious sedation is given it should be by an experienced person. The procedure should be carried ideally with in one week of request or maximum of two weeks because a delay in procedure associated with increased risk and complications.

It should be carried out as day procedure but if there is inadequate support at home, facilities for inpatient should be provided. The risk of hemorrhage is 1.5/1000 and should be controlled by uterotonics. The risk of infection is 8-10 percent and patient should be given either prophylactic antibiotic or alternatively by screening and treating the positive cases. The risk of perforation is 1-4/1000, which should be minimized by cervical ripening. If the perforation occur during dilatation than the procedure should be carried out under ultrasound guidance and antibiotic should be given. If the perforation occurs during suction curettage then significant damage to intra abdominal organ occurs. In this case laparoscopy should be a minimum and lapratomy should be done if there is bowel injury because it is difficult to realizes the whole bowel with laproscopy. Trauma to external cervical os occurs in 1 % cases. All these complications can be minimized if the procedure is done by an experienced surgeon. Failure to terminate occurs in 0.7/1000 and if there is failure to obtain products then the possibility of septate uterus should be considered and ultrasound scan should be done. Incomplete termination occurs in 3% cases but is less if the procedure is by an experienced person.

The mortality associated with the procedure occurs if there is unrecognized injury or trauma to the uterus and surrounding structure so very close and careful follow up should be done after procedure. If there is complain of pain, fever or delay in recovery than an early recourse to lapratomy should be done and senior?s help sought. The patient should be informed that there is no long term sequel with the procedure.

If the patient is Rh negative anti D should be given. Analgesia should be given if required. The patient should be given detailed oral and written information about the procedure, which she can take with her. Contraception should be discussed and provided and follow up visit should be arranged after 2 weeks. A letter should be given to her GP. The patient should be provided with information leaflets and support groups.
Posted by Ebeinheizer S.
Surgical termination of unwanted pregnancy is commonly performed in the UK. It carries more anaesthetic and surgical risk as opposed to medical termination. Known morbidity are haemorrhage, blood transfusion, uterine perforation, infection, cervical trauma, Rhesus iso-immunization (if Rhesus negative) and rarely laparotomy. However, overall morbidty is less than 1%.

First step to minimise morbidity would be informed consent. Proper counselling and explanation with written leaflets would greatly reduce anxiety, fear and worry. It gives the patient an insight of what to anticipate. Explanation about risks of procedure including anaesthetic risks should be given. Good communication is essential to minimise psychological and emotional morbidity.

Pre-operatively, patient need to be optimally prepared. Fasting for at least 4 hours prior to surgery reduces risk of aspiration pneumonia. Cervical priming using mifeprostone and/or misoprostol would reduce excessive force at cervical dilatation. This reduces the risk of cervical laceration, future cervical incompetance (though not proven) and risk of uterine perforation.
Having good intra-venous access with blood sent for group and save in advance would be very useful in the events of haemorrhagic emergencies.

Surgical procedure itself needs to be undertaken by an experienced operator. Learners should be directly/adequately supervised. Choosing the right technique (manual vacum aspiration, suction evacuation or suction curettage) would be dictated by local protocals and operator experience. Adequate vaginal and bimanual examination before instrumentation is vital. Suction evacuation has been shown in many studies to have less risk of uterine perforation compared to suction curettage. Even though some small studies suggest more incomplete evacuation by this technique, it is not substantiated by larger studies.

Swabs for chlamydial screening need to be taken prior to surgery to reduce the risk of chlamydial infection and future subfertility due to that. Patient would need treatment according to the swab results. If patient is Rhesus negative, IM anti-D 250i.u. need to be given within 72 hours post-procedure.

Post-operatively, adequate analgesia need to be prescribed to reduce morbidity due to pain which is usually negligible. Adequate hydration, early ambulation, TED stockings and heparin prophylaxis where necessary greatly reduces risk of mortality caused by deep vein thrombosis and pulmonary embolism. Massive haemorrhage is potentially fatal and would need early intervention with blood transfusion and other medical/surgical intervention. Infection/sepsis need appropriate treatment with antibiotics.
Posted by Raja kumar S.
Decision regarding termination of pregnancy are never trivial,thus it is of paramount importance that she be informed about alternative options and safety and risks of subsequent procedures.Ensure confidentiality and legel requirements (abortion act 1967 )are adhered to
TO lessen the psychological ,emotional(feeling of anger ,shame guilt,sadness) and physical morbidity that occurs in such situations.it is vital that;
She is provided a pre abortion counselling that is open ,understanding and non judgemental. Be sure that no decision has been made under duress or in haste without adequate time or information.Explore and mobilize familial and partner support.Post termination contraception must be emphasized.
She should also be screened. to uncover any serious medical(e. g cardiac /pulmonary diseases)or psychiatric conditions,as such conditions might put her at an increased risk and she should be better cared for in a regional centre .
An infective screen to rule out chlamydia and gonorrhea infec tion in the lower genital tract,and if suggestive also screen for HIV and HEP B AND C.If screen positive refer to the Genitourinary clinic for(counselling ,treatment and contact tracing) and provide antibiotcs. if screen negative
consider prophylactic antibiotics(metrnidazole /azithromycin)to reduce the infective morbidity such as endometritris and P.I.D,which may impair her future obstetric potential.
Routine investigations should include ,Hb levels, ABO blood grouping and rh status .Provide anti -D if rh negative post procedure.
Surgical termination (suction and evacuvation ) is appropriate at this gestational age ,but carries risks of bleeding ,trauma to the cervixs,uterine perforation,anesthetic risks, pain and infecton(febrile morbidity.Thus to reduce this risks .,ensure adequate cervical ripening (PGE OR MISOPROSTOL),procedure carried out by
an experienced operator,use regional anesthetic techniques(spinal,paracervical block)and provide prophylactic antibiotics and oxytocics post evacuations to reduce risks of bleeding.Products of conception should be examined and and if required sent for HPE .
Appropriate contraceptive counselling and provision,the method of her choice should be initiated after the procedure.Baring contraindications COCP can be started immediately after termination,is effective and has other beneifts e.g(reduce menorraghia and dysmennorhea) .
Iucd is also effective and provides reliable contraception,but asociated with a slight risk of infection ,expulsion and uterine perforation.Encourage use of barrier methods as it also provides protection against STD.
Ideally the procedure should be done in a day care setting ,and the patient allowed home(if well and no complications),provide written details of the actual procedure carried out ,and she should be advised to call if she experiences any pain,excessive bleeding or fever.
Provide clinic appointment ,so that she could be assesed for well being both physically and psychologically and to discuss any concerns and to follow up on her contraceptive usage.
In the event she requires admission .she should be cared in a
separate area in the gynae ward.
provide contact numbers of supporting social organaisations and self help groups to help her tide thru this trying times.
Posted by SWATI M.
Morbidity and mortality due to surgical TOP arises from the complications of the procedure such as haemorrhage, infection, injury, incomplete evacuation and psychological trauma..
The procedure should be performed at earliest ,preferably within a week of the decision being made to proceed ,as all the complications will be lower if performed at earlier gestation.This sometimes may not be possible due to the workload.
Proper pre-op selection of a patient for day case is important to rule out any medical , surgical , geographical contra-indication and also need adult to care for 24 hours after the procedure . If any contra-indication,it should be performed as inpatient as it is more safe but has cost implications and depends upon availability of beds.
Performing procedure under local anaesthesia minimizes complications arising from general anaesthesia but many women may not prefer it and may experience pain during cervical dilatation which is likely at10 weeks gestation.
Use of prostaglandins such as gemeprost / misoprostol prior to procedure minimizes risk of trauma to external os .It needs to be administered vaginally 3 hours prior to the procedure and some women may find it invasive.Side effects of the prostaglandins may be troublesome.
Proper clinical evaluation of uterine size, position is important to minimize risk of uterine perforation and haemorrhage.Clinical assessment of uterine size is subjective and may be difficult in obese woman.Risk of perforation also depends on surgical experience and may not be totally preventable.
Use of suction evacuation and avoiding sharp curretage is preferable as risk of haemorrhage, uterine perforation and intra-uterine adhesions is low but it depends upon the surgical experience of the person performing it.
Performing procedure by appropriately trained person / by trainee under supervision minimizes complications .Some complications can still occur in trained hands and not totally preventable.The trained person needs to be available in day theatre .
Prophylactic antibiotics should be used to prevent ascending infections and its sequaelae.Screening and treating positive cases is scientific, contact tracing can be done for positive cases but the results may not be available at the time of TOP. If antibiotics are used universally for all cases,it is not possible to do contact tracing and woman may have reinfection .Many women receive antibiotics unnecessarily,increasing cost and may cause antibiotic resistance in future .Screen all and universal use of antibiotics with contact tracing of positive cases may be an alternative but has cost implications.
Counselling by a trained counselor before and after TOP may minimize psychological trauma but still some women may suffer especially one who took time and needed additional support to make decision of TOP.Trained counselor needs to be available.
Posted by Aroosha B.
Dear Dr Paul
u have answered the questions of those candidates who answered after me kindly check my answer
thanks
Dr Aroosha
Posted by Aroosha B.
Dear Dr Paul
thank u very much Ihave seen the answer actually i tried to find the name of support group but i could not find
kindlt please tell the names one which I know is family planning association
thanks
Dr Aroosha
Posted by SANGEETA P.
Measures to reduce the risk of morbidity and mortality for a woman going for surgical termination of pregnancy will start from preoperative period, through intraopearative measures and will continue in postoperative pahase and until the follow up.
Preoperatively she should be councelled by an person experienced of such condition in a sympathetic manner and with provision of all the information sheets and maintaining the privacy.She should be screened for sexually transmitted infections and should be treated preoperatively should there be need to reduce the risk of infection.Blood should be checked for Hb to make sure that she is not anaemic, Rhesus status and serum should be saved in case of a serious event of haemorrhage requiring blood transfusion.
She should have an oppurtunity to see the anaesthetist to discuss the anaethesia.she can have general or spinal anaesthesia .Most hospitals practice general anaethesia for this procedure.
Prostaglandin analogues ,Misoprostol 400-800 mcg should be given(provided there are no containdication to the drug like allergy or severe asthmatic and certain cardiac conditions) 3-4 hour preoperatively to avoid injuries to the cervix and easy dilatation and to prevent uterine haemorrhage.
She should be consented for the procedure and explained thoroughly regarding the risks associated with the surgery and anaesthtic risks.
Surgical risks involve risk of serious haemorrhage requiring blood transfusion,which may require the syntocinon/syntometrine or occassionally syntocinon infusion.
Risk of infection can be prevented by preop screening and treatment or prophylactic antibiotics.
Pregnant uterus is at high risk of perforation which can be avoided by using suction and evacuation,avoiding using uterine sound or any other metallic instrument like currette or using the currette very very carefully.Junior staff need direct supervision while training.
Post operatively she should be watched for unaccepted per vaginal loss and should have a repeat full blood count to check her Hb status if she has had big blood loss in theatre.If she is Rhesus negative should be given 250 IU of anti D immunoglobulin.
Contraception should be discussed to avoid future unwanted pregnancy and she should be followed up in the clinic to discuss further.
Posted by Samir A.
Surgical termination of pregnancy carries the risks of anaesthesia complications, pevic infection, crevial laceration,uterine perforation and Rh isoimmunisation in Rh -ve patients.
Pelvic infection could be minmised by universally giving 1 G metronidazole rectally at induction plus 100 mg bid Vibramycine for 7 days post operatively.This is shown to reduce post abortion PID by 50% as demonstrated by RCTs. Another approach is pre-abortion screening for N.gonorrhoea, C.trachomatis and Bacterial vaginosis followed by treatment and notification of the partner if gono.or clmydia positive cases.However this approach was not compared by RCTs. A third approach iis a combination of universal prophylaxis plus screening which combines the benefits but is more expensive.This approach has not yet evaluated by means of RCTs.
Cervical priming by PGE2 3 h before surgery reduces the risks cervical injuries and uterine perforation as shown by RCTs.Local anaeasthesia reduces morbidity and mortality especially uterine perforation if compared by general anaesthesia as shown also by RCTs. Also I\'ll do uterine sounding before embarking on cervical dilatation which reduces the risk of perforation. If she is Rh-ve I\'ll give 250 mg Anti D post abortion.
I\'ll encourage the patient to commence contarception (COCP or IUCD) before discarge.I\'ll give 2 weeks follow up appointment as well as letter giving sufficient information about the procedure on discharge