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.
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