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MRCOG PART 2 SBAs and EMQs

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EMQ	1502
SBA	2115

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Essay 240 - TOP

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		Posted by Radhika A. Tue Jul 24, 2007 12:15 am
healthy17 year old woman attends the gynaecology clinic at 8 weeks gestation requesting termination of pregnancy. (a) Justify your clinical assessment [6 marks] (b) What will you tell her about medical termination of pregnancy? [7 marks]. (c) What will you tell her about surgical termination of pregnancy? [7 marks]. a)My clinical assessment of the 17 year old would be aimed at identifying reasons for her request for termination of the pregnancy, diagnosing any complicating factors like sytemic medical disease or local causes like acute infection which need to be taken care of first. Firstly going through the history I would like to assess her understanding of the procedure, her relationship with the partner,ask her detailed history for medical diseases like cardiac disease,diabetes or any history of medication or intake of any drugs. A specific question regarding the use of contraceptive, its knowledge would also be asked for.I would also like to ask her for any foul smelling discharge per vaginum, itching or any lesions in the vulval area. I would also like to do her physical examination to look for evidence of anemia, thyroid enlargement, cardiovascular and respiratory system and abdomen for any abnormality. I would like to do a speculum examination of vagina and cervix to rule out infection and any evidence of obvious abnormality of the cervix.A vaginal bimanual palpation to confirm the size of uterus and its direction including situations of acute anteversion and retroversion which could be a reason for perforation during a surgical procedure. b) I would like to tell her that there are medications to enable a termination of pregnancy but the efficacy of this method is best at about 97% chances of completion of pregnancy termination till 49 days (7 weeks) with two drugs. Thereafter the chances of complete evacuation fall to about 90% at 8 weeks pregnancy. The benefit of this method is that she doesnot need admission to the hospital though needs to remain in telephonic contact.The procedure causes cramping pain to occasionally acute abdominal pain followed by passage of the conception products. This usually occurs after few hours of starting the vaginal tablets ( which follow an oral tablet). The bleeding usually stops in about 2-3 days time though it may persist for upto 2 weeks. An USG is required to confirm the completion of abortion. About 3-5% paitents may require a surgical procedure to complete the evacuation procedure. c) I would like to inform her that the surgical procedure requires dilatation of the cervix followed by evacuation of products by suction. Though the produre is usually safe and not associated with complications there are small chances of perforation of the uterus, retention of products of conception necessitating a repeat evacuation, infection of the uterine cavity. Very rarely, too vigorous curettage could result in the adherence of the two walls of the uterus causing decreased menstrual bleed, infertility later. I would a;so like to inform her of the various contraceptives available in case she would like to avoid a pregnancy in the near future.
		Posted by Valerie T. Tue Jul 24, 2007 05:06 am
A healthy17 year old woman attends the gynaecology clinic at 8 weeks gestation requesting termination of pregnancy. (a) Justify your clinical assessment [6 marks] (b) What will you tell her about medical termination of pregnancy? [7 marks]. (c) What will you tell her about surgical termination of pregnancy? [7 marks]. a) First, I would speak with the patient and assess whether she is mentally competent and capable of understanding the procedures of termination of pregnancy, that is whether she is Gillick competent. I would find out her reasons for terminating the pregnancy. If she is unsure or upset I would offer counselling. I would take a history to determine wthere she has had previous terminations and if she has any medical conditions. I would do an ultrasound scan to determine the gestational age and whether it was a singleton pregnancy and for the presence of a heart beat. The gestational age will influence the type of dose of medication that can be administered in the medical termination of pregnancy. Also, if the pregnancy is more than 14 weeks, the termination will not be allowed. If there is no heart beat, then the diagnosis will be missed miscarriage and procedure will no longer be a termiantion of pregnancy but an evacuation of products. I would do a full blood count to identify anaemia. I would do group and save to determine her blood group since she would need Anti D if she was Rh negative. Also, the lab would have a specimen of blood, in case of excessive haemorrhage and the need for crossmatching and blood transfusion. I would take endocervical swabs for chlamydia and a high vaginal swab to identify infection that would need to be treated. b) First, I will tell her that a medical termination of pregnancy is a method of ending her pregnancy with the use of tablets. It is done in 2 parts. The first part, she will need to come to the ward to be given tablets to be taken by mouth. She will then be allowed to go home. Then the second part, she must return to the ward and will be given some more tablets. If, she\'s bleeding the tablets will be given orally but if she\'s not bleeding, the tablets will be given vaginally. On that day, she will need to remain in hospital overbnight. If she doesn\'t pass the fetus, then she will be given further dose of medication. If this is unsuccessful she has the choice of returning in 1 week for the medical termination to be repeated or she has the option of a surgical termination of pregnancy. During the procedure, she may have abdominal pain and will be given pain killers. The risks of medical termination of pregnancy include infection and bleeding. There is also a small failure rate. c) First, I will tell her that a surgical termination of pregnancy is an operation done in theatre, to end her pregnancy. It is performed under a general anaesthetic and she will be asleep during the operation. In theatre she will be lying on the theatre table with her legs in stirrups. One end of a plastic tube will be attached to a vacuum suction pump. The other end will be inserted into the cervix and the products of conception removed. I would tell her that the operation is associated with the risks of infection, bleeding and perforation of the uterus. There is also a small risk that the operation will be unsuccessful. The pregnancy may not be terminated or some tissue may remain. There are also anaesthetic risks. It can be done as a daycase, which means she should be able to go home the same day as long as she does not develop any problems. Antibiotics would be given. If her blood group is Rhesus negative, she will be given intramuscular Anti D. She should not drive home and should have someone accompany her home. She would be able to go back to work that week.
		Posted by Saad A. Tue Jul 24, 2007 05:01 pm
Deatailed history is obtained including LMP, menstrual irregulaities and contraception, contraindications to OCPs. She is enquired for TOP whether she is requiring for any medical problem, physical illness or due to social problem so as to determine the certainity of her decision and can give her time for reviewing her decision if she is not certain of TOP. She should be given written information with accurate printed information. Her abortion certificate is completed and signed . To prevent post abortion infection screening for micro organisms is carried out during pelvic examination for uterine size. The patient blood grouping is also carried out. She is given option of medical or surgical TOP and her wishes should be obeyed. b. I will tell her that for medical TOP she will be given mifeprsterone(200 mg)orally followed by prosta glandin gemeprost( 1 mg vaginally) or misoprostol 800ug vaginally 36 hrs later. It is effective in 95% cases. As misoprostol is not liscenced her informed consent is obtained after providing information. I will tell her that bleeding will continue for 3 weeks after medical TOP and there is risk of surgical intervention if medical treatment is not complete .The benifit of medical TOP is that it is not associated with risk of infection but is associated with abdominal cramps. Written information backed up by leaflets is provided. c. I will tell her about the risks and benifits of surgical TOP. It is a day case procedure and can be carried out under general/regional/local anaesthesia. There may be need of cervical priming by cervicogram. I will explain the risk of anaesthesia and surgery like haemorrage, infection and retained POCs. I will take her written consent provide written information backed up by leaflets .Future contraception is discussed and follow up appointment given if furthur counselling is required.
		Posted by Mohammad H. Tue Jul 24, 2007 09:10 pm
A healthy17 year old woman attends the gynaecology clinic at 8 weeks gestation requesting termination of pregnancy. (a) Justify your clinical assessment [6 marks] (b) What will you tell her about medical termination of pregnancy? [7 marks]. (c) What will you tell her about surgical termination of pregnancy? [7 marks]. Clinical assessment will include history and clinical examination. The cause of requesting termination should be discuused with the patient and wheathter this is for medical cause (to be evaluated ) or for social cause and wheather the patient is sure of her decision. Menstrual history, and previous obstetric history should be taken.The presence of vaginal discharge ,previous episodes of PID and multiple sexual partners increases the risk of PID and subsequent effect on her fertility. Speculum examination to detect vaginitis or cervicitis. Bimanual examination to assess uterine size,adnexal masses andcervical motion tenderness.I will take swabs for infection screen as chlamydia is so ncommon in this age and it may lead to permenant subfertility and it is easily treatable . about the medical TOP I will tell her that drug (PG gel or tablets )is used locally first to ripe the cervix then another drugv (mefipristone ) is used to induce uterine contractions and expulsion of contents of pregnancy .The orocess is successful in over 90% of cases but if failed there will be a need for surgical evacuation. The procees may be accompanied with side effects as sever pain , bleeding and incomplete expulsion of contents that will need surgical interference . ,Medical TOP is suitable up to 9 weeks gestation so if the patient will undergo medical TOP ,it should be done within one week.I will inform the patient that if she is RH negative she will receive anti-D immunoglobulins. I will tell her that surgical TOP is a procedure that will need anaethesia .General or epidural anaethesia may be used and each process with its complications should be discussed with the patient .I will to her the procedure that is cervical preparation using PG gel or tablets followed by cevical dilataion and suction evacuation.The process is mostly successful and without cmoplications.However ,perforation of the uterus,infection leading to PID andincomplete evacuation with subsequent prolonged bleeding or infection may occur. Need for anti-D immunoglobulins should be discussed with her if she is RH negative . Information leaflets and enough should be given to the patient to decide about hte method of TOP. Counselling should be clearly documented in patient\'s hospital notes.
		Posted by Sabahat S. Wed Jul 25, 2007 05:17 am
In a sensitive & nonjudgmental way I will try & explore the reasons for such a request. She will be assured that confidentiality will be strictly maintained.Her maturity & competence to understand the consequences of her decision (gillick competent) will be judged. Her menstrual history will be taken to estimate the gestational age. Results of PT if any will be seen. Although she is healthy, any previous H/O pelvic infections ( STI ) any previous pregnancies or pregnancy terminations is important. She will be asked about any systemic diseases e.g DM, thyroid disorders, anaemia , Br asthama ,bleeding tendencies. Her general examination, and fitness for anaesthesia is assessed. Per abdomen examination for any mass, any e/o of a suprapubically palpable uterus indicating a pregnancy larger than dates, is done. P/S examination to see for any unhealthy vaginal / cervical discharge any e/o cervcitis & opportunistic screening is done to for chylamydia, gonorrhorea, ( followed by appropriate treatment as applicable ). PV examination is done to assess the uterine size, whether or not it is corresponding to GA, version &mobility of the uterus, any adnexal tenderness or mass. A urine PT will be done if it has not already been done. MSU for dipstix will be done to rule out any infection FBC, Rh type, group & save is requested. Pelvic USG preferably vaginal scan is done to confirm the GA & viability. The opportunity should be utilized to elicit any H/O domestic violence (after assuring her confidentiality & developing sufficient rapport.) she will be given clear understandable written information & time to consider her decision. B) She will be told that she has the option of terminating her pregnancy by taking tablets orally & if required vaginally. She is that the success rate for medical TOP is 95 ? 97 % at 7 completed weeks of gestation & 90 ? 94 % at completed weeks. She will be given tablets orally ( Mifipristone 600 gm ), after which she is allowed to go home & requested to return after 36 ? 48 hours for vaginal tablets. During this duration she may experiences pain in abdomen, nausea, vomiting, diarrhea, bleeding per vaginum or expulsion of products. Fever is not expected normally. She will be given adequate analgesics & antiemetics & antidiarrhoeals as required. On coming to the clinic the second time she will be reasesed & if she has not passed any products , she will be given prostaglandin tablets (Misoprostol or gemeprost ) vaginally. She will be told that although misoprostol is not licensed for such use, there is wide clinical experience in its use for such an indication. Her informed consent will be required for such purpose. After the vaginal tablet she may expel the products over 4 ? 8 hours. The products should preferably be submitted for histopathology. Following expulsion of products of conception she may experience bleeding for 2 ?3 days to 2 weeks . a 24 hour helpline phone no is provided. A follow-up scan is done to confirm completion of the expulsion of products. She should be informed about 2 ?3 % risk of failure of medical TOP when surgical evacuation is required to complete the procedure. Anti ? D is given if Rh-negative. written information in simple understandable language is provided to her. C) In surgical termination of pregnancy, the cervical priming is done by inserting tablets vaginally to soften the cervix & allow easy dilatation. This may be done as a day case when the vaginal tablets are inserted the night prior to evacuation. The procedure involves general anaesthesia ( when she will sleep during the procedure & not feel any pain ) or regional anaesthesia, although it is possible to do it under paracervical block & sedation ( when she will be conscious but feel some abdominal discomfort during the procedure ) a metallic suction canula is inserted into the opening of the uterus & the products of conception are sucked out by vaccum aspiration.. There is a small risk of complication like excessive haemorrage, perforation , infection. In case of perforation by a suction canula, laparoscopy/ laparotomy will be required to rule out intestinal / omental injury ..She will be given adequate pain killers and if all goes well she may go home the same evening , but in case of any complication may require overnight admission for observation. Prophylactic antibiotics (1 gm flagyl PR ) is given . Anti-D will be given if she is Rh negative to prevent sensitization. The products of conception will be sent for histopathology. Further contraception will be discussed & avoiding high risk sexual practices will be stressed upon. Written information will be provided.
		Posted by Shahla K. Wed Jul 25, 2007 07:36 am
a)She should be seen in early pregnency assessment unit,because it provide quick availability of expertise ,cost effective assessment and investigation. Parity should be asked,reason for termination of pregnancy documented. If reason is unwanted pregnancy ,offer alternative option to continue pregnancy for adoption. Identification of women who at risk of psychological sequelae, so that psychiatric followup can be arrange. examination exclude presence of anemia relevant examination if history suggest any medical disorder to judge severity. investigation include complete blood picture, blood group and Rh factor, if Rh negative then antiD to be given avoid isoimonization.In the presence of anemia blood should be crossmatch and arrange. termination of pregnancy provide opportunity to screne for sexualy transmited diseases (Chlamydia, HIV ,HBV) if infection identified then contact tracing can be done,therefore appropriate treatment and reinfection can be prevented. ultrasound should be done if any suspicion of ectopic arise clinically. Methods of termination discuss. Inform consent taken ,verbal information supported by written material provided,contact number of support group should be given. b)medical termination is overwhelmingly effective choice of termination of pregnancy.it involve antiprogesterone that is .Mifiprostone which is given orally then 36-48 hour later prostaglandin pervaginaly administer,it can be sucessfuly to evacuate in 95% of women ,it is a prolonge process take more then 2 days,there is 5%chance of retention of products and therefore surgical evacuation. c)surgical options are Vacume aspiration and diatation curettage. It is done under general anaesthesia,need fasting for 6 hour,termination complete in few minute. Dialatation and curettage require ripening of cervix with prostaglandin incomplete evacuation is usually very rare in this procedure(2/1000) ,there is less risk of perforation in vacume aspiration.perforation if happen then it need laproscopy .it is most commonly perform procedure,it involve ripening of cervix then under GA catheter of 12mm introduce into uterus through cervix, Risk of haemorrhage 1.5/1000 which is less if done in early gestation
		Posted by Dr Mamta D. Wed Jul 25, 2007 04:13 pm
a) First of all, I will access that the woman is certain of her request of termination of pregnancy. I will access whether she is gillick competent or requires support in decision-making process. I would find the cause (social or medical) for her request, about the relationship with partner and partner stability. I would take her menstrual history, LMP and menstrual regularity to ascertain her gestational age. I would take her medical history to rule out any cardiac or respiratory problem. I would take her sexual history (use of contraception, stability with partner, history of STI, vaginal discharge, pelvic pain) and her cervical smear history. I would do speculam examination to assess the cervical status, take a cervical smear if not done with her local screening programme. I would do bi manual pelvic examination to assess the uterine size and to rule out any adnexal mass or tenderness. In the investigations, I would advise her blood group / Rh typing, Hemoglobin estimation, screening for red cell antibodies and screening forh aemoglobinopathies,HIV and Hepatitis B (if indicated on clinical grounds). Routine ultrasound examination is not advised but if doubt about her gestational age or if adnexal mass or tenderness is present, it is advised. b) I will tell her medical abortion is done with medicines (given orally and vaginally), is a safe and effective method. She does not require hospitalization or anaesthesia. I will tell her that one of the regimen for medical abortions is to use tablet mifepristone 200 mg orally followed 36-48 hours later by tablet misoprost 800 mcg vaginaly or 1 mgm gameprost vaginal pessary. I will tell her that following medical abortion by this method, abortion is complete in 95% cases and in 5% cases may be retained placental or fetal tissue, which may require surgical abortion. I will tell her that there may be a risk of heavy bleeding for which she should be compliant and report to the hospital immediately and contact number should be provided. She may experience side effects like abdominal cramps, nausea and vomiting. I will tell her that abortion occurs within 2-4 days after medicines are given but slight bleeding may continue till 2 weeks. A check ultrasound pelvis after 2 weeks may be required to ascertain the completeness of abortion. I will explain her that absolute contraindication for medical abortion are asthma and adrenal insufficiency. After a medical abortion. I would advise her contraceptive options (Tablets, Injectable & implants) and Injection Anti D if she is Rh Negative, non immunized. I would advise her follow up appointment after 2 weeks. I would provide written information backed up by leaflets. c) I will tell her that surgical abortion at 8 weeks will be done by vacuum aspiration technique. which requires general anaesthesia but may be done under local anaesthesia. It is done as the day case procedure in operation theater and she will need hospitalization. I will explain that the procedure involves dilating the mouth of uterus (cervix) and passing a curette (8 mm ) in the uterine cavity and contents are aspirated using a mechanical pump. I will tell her that pre operative cervical preparation with gameprost or misoprost vaginal pessary will be beneficial in her to minimise cervical trauma. I will tell her that complications due to surgical abortion are rare but may include persistence of placental or fetal tissue (less common than medical abortion ) , heamorrage (1.5 / 1000) , uterine perforation (1 ? 4 / 1000), genital tract infection ( 1%). I would advise her screening for genital tract infection (chlamydia & gonorrhoea). I would obtained written informed consent before the procure . I would provide written information backed up by leaflets. After the surgical abortion, I would give her contraceptive advise and Injection Anti D if she is Rh Negative, non immunized. I would advise follow up appointment after 2 weeks.
		Posted by Idris O. Thu Jul 26, 2007 04:11 am
a) This consultation must be provided in a very sensitive manner to be able to address the need of this patient while at the same time maintainig confidentiality. The history would include enquiring about her last menstrual period, regularity of the cycles, symptoms of pregnancy with the aim of determining the GA of the pregnancy. Determine if had pregnancy test that was positive. Determine the reasons for the request like unplanned pregnancy or failed contraception. Assess risk of STI if pregnancy was for a new partner . Enquire about her past obstetric history, number of children or previous TOP. Previous pregnancies may make cervical primming unnnecessary at this gestation.Determine if any previous pelvic operation like caesarean section which increases the risk of surgical TOP. Determine if this was coercion or have support from partner or family member. Provide pre and post TOP counselling because of possible guilt feeling after the procedure. . Determine GA of the pregancy by USS to be able to counsel about appropriate method of TOP. Perform screening for chlamydia and offer azithromycin and contact tracing before TOP if positive. Obtain FBC and blood group because would require anti-D if negative. Information leaflet on TOP methods and help line after the procedure would be provided if any complaints or concerns after the procedure, b) Explain medical TOP involves using medications to bring about miscarriage. This is usually effective if the pregnancy is 9weeks or below . She would be given mifepristone orally and would go home and 36-48h after would be admitted and given misoprostol per vaginam and orally until the miscarriage. She may miscarry at home . There would be bleeding and pain. She may require mild analgesia but no risk of surgery or anaesthesia. No risk of infection.The draw back is there is no tissue for histological diagnosis and she may still require surgical TOP if retained products of conception. c) Surgical TOP is a procedure of suction currettage of the products of conception under conscious sedation or GA. It is quick and very effective . Provides tissue for histological diagnosis. It is associated with pain and bleeding as well as anaesthetic and surgical risk of cervical trauma, perforation of the uterus, infection and injury to the bowel or bladder. Small risk of reatined products and need for a second evacuation. She would be offered anti-D if negative after any of the procedure, advised on safer sex, offered contraception like the pill and condom or implanon if desired and post TOP counselling and follow up should be arranged.
		Posted by Natalie P C. Thu Jul 26, 2007 08:04 am
Natalie A My first step is to assess the mental condition of this girl and offer her counselling if she needs it. I would assess her reasons for termination ensuring that it meets the criteria of the Abortion Act. I would assess her risk of STDs and high risk behaviour. I will try to ascertain that she is sure that this is what she wants and find out her reasons and ensure that she has considered all her options. I would also assess her contraception and assist her in preventing another unplanned pregnancy. I would next examine her. I would do endocervical swabs for Chlamydia with her consent as we may instrument her uterus and exacerbate PID and contribute to future infertility. I would do an USS to check her dates as options available and the risks of these would change if she is more than 12 weeks and criteria for TOP change at 24 weeks. I would also want to rule out a molar pregnancy as suction TOP would then be the recommended option to prevent vascular embolisation of molar tissue. I would do a Full bout count so we have a baseline haemoglobin and a group and save as she may bleed and need blood and because if she is RH negative then she needs anti-D. B I would start by explaining the procedure; that we start with oral Mifepristone then 48hours later vaginal prostaglandin 800mgs and a repeat dose 3-6 hrs later. I would explain the side effects and risks such as bleeding, blood transfusion, fever, nausea, vomiting, diarrhoea, incomplete requiring ERPOC. Benefits include avoiding surgery with its anaesthetic and surgical risks. It can be done in hospital or at home. I will explain that bleeding starts quite light then gets heavier as she passes tissue then it settles to quite light for up to 1-2weeks. We would rescan her if bleeding does not settle by 2 weeks and she needs to come into hospital if bleeding is more than a period. C I would explain the procedure ? usually general anaethetic. Medication pre operative in vagina softens cervix to make dilatation less traumatic then dilatation and suction curettage. Risks include anaesthetic risks, bleeding, blood transfusion, infection, uterine perforation with risk of laparoscopy or laparotomy and incomplete requiring a repeat procedure. I would tell her that benefits to her would be that it is dealt with at once and so she does not have to wait for it to happen.
		Posted by Fahima A. Thu Jul 26, 2007 04:46 pm
a) First of all an enquiry should be made about the reason behind the decision of the TOP. Her mental status should be assessed & if any doubt the procedure should be deferred. Further appoinment should be given for counselling. History should be taken about the regularity of menstrual cycle and LMP. In case of any uncertainties an ultrasound scan is to be done to exclude ectopic pregnancy. She should be asked whether this is her first TOP or not. Advice for future contraception should be given to her. If she has any child & needs social support arrangement should be made for it. A STI screening should be done & if she is chlamydia positive she should be treated with doxycycline & metronidazole . She should be referred to GUM clinic for contact tracing. If she is confirmed about her decision informed written consent should be taken and an appointment for the procedure should be given within 7 days of consent. b) Medical TOP is done with mifepristone , an anti progesterone & prostaglandin. There are two regimen. First one is that she will be given mifepristone 600 mg orally and she will go home. She will come back 36 hours later when she willbe given gemeprost 1 mg vaginally. Another regimen is not licensed but widely used and cheaper. This regimen includes mifepristone 200mg orally followed by misoprostol 800 micrograms vaginally 36 hours later. The benefits of medical TOP are that it is simple, easy and cheaper. There are no requirements of anaesthesia and no instrumentation. Therefore chances of infection are less. However there are risk of increased haemorrhage, pain and requirements of analgesia. Rarely medical TOP may be incomplete and further surgical procedure will be needed to complete it. c) Surgical TOP is done with suction curette. It is done under anaesthesia either local or general depending on the protocol. Cervical ripening is done with 1 mg gemeprost vaginally 3 hours before the procedure. The benefits of surgical TOP are less bleeding, less pain. However it is associated with anaesthetic risk, cervical trauma, uterine perforation and over curettage leads to Asherman syndrome. Anti D injection will be given to the lady in both Medical & surgical TOP if she rhesus negative. Patient can go home on the same day in both the cases. She should be given 24 hours helpline in case of bleeding, pain or any other problem. A follow up appoinments should be given after 2 weeks. Proper documentation should be made and information leaflet should be given to her so that she can make a decision regarding the procedure.
		Posted by Jancy V. Sun Jul 29, 2007 12:54 am
(a) I would give the woman an opportunity to discuss in confidence the reason for her request for termination of pregnancy. If she wishes I would involve her partner or her parent in the discussion. However if she doesn?t want a third person to be involved, I would respect her wish. I would ask her obstetric history, regarding previous pregnancies, delivery or termination of pregnancy, LMP of her present pregnancy, details of any ultrasound scan done to confirm the gestational age and to know if the pregnancy is viable and intrauterine. I would also ask if she has any medical illnesses which might influence the method of termination, any previous uterine surgery and complications, any medication being used and regarding substance abuse. I would also assess her current and future contraceptive plans and provide necessary advice for the same. I would take a brief social history to rule our domestic violence, lack of support at home to assess if she needs additional support in decision making and access to social security. I would do a pelvic examination for uterine size and transvaginal ultrasound for confirmation of gestational age. In view of her age, I would also assess if she is mentally capable of giving consent to the procedure requested. I would do lab tests- Hb, blood group and screening for hemoglobinopathies and HIV. (b) I would tell her that medical termination of pregnancy is the most safe and effective method of termination of pregnancy until 9 weeks. An informed written consent would be taken from her prior to prescribing the drugs. She has to take one tablet of 200 mg mifepristone orally and 1-3 days later, she has to take 4 tablets (800 mcg) of misorostol vaginally. She can apply the vaginal tablet herself or seek the help of the clinician for it. I would inform her that though misoprostol is not a licensed drug in UK, it is permitted to be given for abortion. She would have vaginal bleeding for 7 to 10 days following this and 99% of medical abortions are successful. 1 to 14 per 1000 cases fail and few cases require surgical evacuation. Anti D injection 250 IU would be required within 72 hrs of abortion if she is Rh negative. She will be given an appointment 2 weeks after the medication to check completeness of the abortion .She would have access to a 24 hour helpline in case of need for information or psychological support, and can attend the clinic in case of any complications. I would also give her written information to take home so that she can read and make decision. (c) Regarding surgical termination of pregnancy , I would inform her that it involves evacuation of the uterus with a suction curette. She would need screening for Chlamydia and cervical cytology if not done recently. Blood tests- Hb and blood group are to be done prior to the procedure. An informed written consent would be taken from her prior to the procedure. Cervical preparation may be needed using vaginal tablets (400 mcg of misoprostol or 1mg gemeprost) 3 hours prior to the evacuation. This can be applied by the woman herself or by the clinician. Suction evacuation can be done under local anesthesia on a day case basis, however general anesthesia may be given if the woman requests. She would be given a local anesthesia which involves injecting the anesthetic drug near the cervix (paracervical block) to make the procedure painless. Some clinicians prefer to give IV sedation with opioids perform the procedure. I would inform her of the potential complications of suction evacuation. 1 in 1000 women have excessive bleeding, 1-4 in 1000 have uterine perforation, 1 in 100 have trauma to cervix, and 2 per 1000 continue the pregnancy and may need re evacuation. However surgical termination is not associated with infertility or increased risk of cancers. If she is Rh negative, anti D injection 250 IU would be given intramuscular. She would be discharged home the same day if everything goes well and no complications occur. Before being discharged, the clinician would discuss with her the contraceptive to be used and provide necessary information. If she wishes to have IUCD inserted, it can be done along with the procedure after evacuation. If she request tubal ligation, she may be advised to postpone it and use effective contraception, because it carries high regret rate if done in the same sitting as abortion. In case of psychological upset, a helpline number is provided ,so that she can access social support anytime she needs it.
		Posted by Parveen Q. Mon Jul 30, 2007 08:37 am
I will deal with her in a sensitive and nonjudgemental way. I will see that confidentiality is ensured . I would like to know the reason for her request for TOP, if it was a unplanned pregnancy, i will ensure that she gets appropriate contraception with TOP. Further history about her menstrual cycles, LMP, previous pregnancies, previous TOP, or any surgical procedures will be enquired. social history, partner support, educational difficulty will be ascertained. history of allergy to any medication in the past will be noted down . Her psycological status , if she was tearsome, or found be pressuried will guide me provide her with counsellor support . I will check her B.P , pulse, and examine her abdominally for any mass, tenderness, or surgical scars. Vaginal examination for uterine size, position, tenderness, adnexal mass or tenderness noted down. Endocervical swab for clamydia taken as those having induced abortion are increased risk for PID. I will tell her that medical termination of pregnancy is effective in upto 96% of cases. It gives high level of satisfaction to her as patients feel they are in control. It avoids the risk of anasthesia and surgery.It can be performed in outpatient basis, she will be given mifepristone tablet followed 36hours later by misoprostol or gemeprost. there will be increase in pain and bleeding pv with the medical methods. She will be provided with 24hours helpline and report if there is increase bleeding pv. There is a failure rate of 1%, , of incomplete misscarriage or ongoing pregnancy , she will need to be followed up. Bleeding may continue for upto 3weeks following medidal termination. There is no increase in pelvic infection or any adverse effects on future fertility.If she miscarry at home and admitted in hospital should bring the tissue passed for histopathological examination to rule out trophoblastic disease. She will be given anti-D if Rh negative. All the information given will be documented in her notes, and leaflets will be given. I will tell her that the surgical procedure is done under day case basis in the operationg theatre, under general anasthesia. if she wishes, it can be done under local or under sedation. suction curettage is the procedure, sometimes cervical or vaginal prostaglandins given before procedure to avoid cervical trauma , to reduce the dilational force. She can discharged on the same day. Prophylactic arenot necessary. She will be given a single dose of azithromycin to prevent clamydial infection. There are anasthetic complications and surgical complications like, hemorrhage, uterine perforation, cervical tear, infection and intrauterine adhesions. She can have IUCD inserted at the time of surgical evacuation if she prefers. She will be will provided with leaflets and name of support groups given. If she is Rh negative, she will be given anti-D.