Podcast Beta
Questions and Answers
What is an initial step to take if perforation occurs during SFE using a dilator?
If a patient shows loss of resistance and severe abdominal pain during the use of KC, it's recommended to continue the procedure without informing anyone.
False
What equipment is required for Manual Vacuum Aspiration (MVA)?
MVA syringe and KC
During an episode of shock, the patient's _____ will typically show an increase in pulse rate and a decrease in blood pressure.
Signup and view all the answers
Match the following procedures with their characteristics:
Signup and view all the answers
What is the primary mechanism of action of Mifepristone?
Signup and view all the answers
Medical abortions using Mifepristone and Misoprostol can be performed safely up to 12 weeks of gestation.
Signup and view all the answers
What is the follow-up time after administering Mifepristone and Misoprostol to ensure complete abortion?
Signup and view all the answers
The drug _____ is used orally for medical abortion in the first trimester.
Signup and view all the answers
Match the following drugs with their primary purposes:
Signup and view all the answers
What is the most common site for a tubal abortion?
Signup and view all the answers
Cervicitis is a risk factor for ectopic pregnancy.
Signup and view all the answers
What is the highest risk factor for ectopic pregnancy?
Signup and view all the answers
The most common cause of ectopic pregnancy is __________.
Signup and view all the answers
Match the risk factors with their descriptions:
Signup and view all the answers
What is the recommended best method for medical termination of pregnancy between 9-12 weeks?
Signup and view all the answers
Patients with an Hb level of 9 g/dL require follow-up after the medical termination procedure.
Signup and view all the answers
What is the first step in the procedure for Suction & Evacuation?
Signup and view all the answers
After confirming the size and position of the uterus, the next step is to insert a triangular _______ after dilating the internal os.
Signup and view all the answers
Match the following complications with their corresponding criteria for follow-up:
Signup and view all the answers
What is the primary use of Karman's Cannula?
Signup and view all the answers
The maximum number of Karman's Cannula used for suction and evacuation is 12.
Signup and view all the answers
What is the pressure generated during suction and evacuation (SSE) using Karman's Cannula?
Signup and view all the answers
The injection site for the tenaculum is at the _____ o'clock position.
Signup and view all the answers
Match the instruments with their uses:
Signup and view all the answers
What is the maximum period for MTP in cases of congenital anomalies according to the 2021 amendments?
Signup and view all the answers
Only one doctor's approval is required for an MTP procedure up to 24 weeks.
Signup and view all the answers
What is required for patients under 18 years old to consent for an MTP?
Signup and view all the answers
MTP for severe congenital anomalies requires __________ from a medical board.
Signup and view all the answers
Match the MTP methods with their characteristics:
Signup and view all the answers
What is the most common cause of abortion-related complications?
Signup and view all the answers
Toxic shock syndrome can be caused by E. coli.
Signup and view all the answers
What are the symptoms of septic abortion?
Signup and view all the answers
The most effective management for septic abortion includes _____, Gentamycin, and metronidazole.
Signup and view all the answers
Match the grades of septic abortion with their descriptions:
Signup and view all the answers
What is the initial treatment for a patient with a history of thrombosis and abortion?
Signup and view all the answers
A threatened abortion requires immediate surgical intervention.
Signup and view all the answers
What is the standard time to restart anticoagulants after a vaginal delivery?
Signup and view all the answers
In the case of a complete abortion, the status of the uterus is typically _____ and will show no current bleeding.
Signup and view all the answers
Match the type of abortion with its appropriate management:
Signup and view all the answers
Which part of the fallopian tube is the most common site for ectopic pregnancies?
Signup and view all the answers
Progesterone levels in ectopic pregnancy are higher than in a non-pregnant state.
Signup and view all the answers
What is the least dangerous site of ectopic pregnancy?
Signup and view all the answers
The __________ is the most common non-tubal site for ectopic pregnancy.
Signup and view all the answers
Match each part of the fallopian tube with its characteristic:
Signup and view all the answers
Which drug is considered the best for medical abortion?
Signup and view all the answers
Blunt curettage should never be performed in a pregnant uterus.
Signup and view all the answers
What is the maximum number of doses of misoprostol that can be administered for medical abortion?
Signup and view all the answers
The most common surgical method for abortion is __________.
Signup and view all the answers
Match the following drugs with their associated risks or characteristics:
Signup and view all the answers
Study Notes
Perforation during SFE
- Perforation during SFE can occur when using a dilator or KC (likely a medical abbreviation).
- Signs of perforation include:
- Loss of resistance.
- KC going deep inside the uterus.
- Patient experiencing a rise in pulse rate and a drop in blood pressure, indicating shock.
- Patient complaining of severe abdominal pain.
- Management of perforation includes:
- Immediately stopping the procedure.
- Not removing the KC.
- Informing a senior consultant.
- Checking the patient's vital signs.
- If the patient is stable, a diagnostic laparoscopy is performed.
- If the patient is unstable, resuscitative measures are taken followed by a diagnostic laparotomy.
Manual Vacuum Aspiration (MVA) & Menstrual Regulation (MR)
- MVA is an alternative to suction and evacuation (S&E) in rural areas where electricity is not available.
- MR is considered outdated.
- MVA requires a specific syringe with two pinch valves and a KC, while MR requires a single pinch valve syringe.
Obstetric Complications Based on Gestational Age
T1
- Medical abortion options include:
- Mifepristone + Misoprostol.
- Suction evacuation.
- Manual vacuum aspiration (MVA).
T2
- Medical abortion options (require inpatient procedures) include:
- Prostaglandins: misoprostol/Carboprost/Dinoprostone.
- Oxytocin.
- Extra-amniotic Ethacridine instillation.
- Intra-amniotic saline.
- Other options for T2 complications include:
- Suction evacuation.
- Dilatation & Evacuation (D&E).
- Hysterotomy: A procedure to open the uterus to remove the products of conception.
1st Trimester Abortions: Medical Abortions
- Timing: Up to 9 weeks (63 days)
- Drugs used:
- Mifepristone: Oral
- Misoprostol: Oral/sublingual/per-vaginal/per-rectal.
- Mechanism of Action:
- Mifepristone (RU 486): Progesterone antagonist leading to detachment of the implanted embryo.
- Misoprostol: Promotes uterine contraction, cervical ripening and softening, leading to the expulsion of the detached embryo.
- Bleeding typically occurs after misoprostol.
- Protocol:
- Day 1: Tab.mifepristone 200mg - single tablet orally
- Day 3: Tab.misoprostol 800 mcg - Vaginal > Sublingual (OTC) >> Oral (ISE)
- Bleeding occurs within 14-6 hours
- Day 15: Follow-up to ensure complete abortion. USG in MTP - Not routinely required
- Indications:
- Patient uncertain of last menstrual period (LMP).
- Size of uterus doesn't match the gestational period.
- Patient experiencing pain/continuous spotting with the internal os open on day 15.
Outcome of Tubal Abortion and Tubal Rupture
- Tubal abortion: Occurs in the fimbrial end of the fallopian tube.
- Most common site: Ampulla.
- Tubal rupture: Occurs due to continuous growth of the ectopic pregnancy.
- Most common site: Isthmus.
Criteria for Various Sites of Ectopic Pregnancy
Site | Criteria |
---|---|
Cervical | Paalman (New), Rubin (Obsolete) |
1° Abdominal | Studdiform, Spiegelberg |
Ovarian | |
2° Abdominal | From fimbrial end |
Risk Factors and Clinical Features of Ectopic Pregnancy
Risk Factors
- PID/Salpingitis: most common.
- Previous history of ectopic/tubal surgeries - Highest risk.
- Cervicitis.
- Multiple partners.
- Smoking.
- Risk factors for PID.
- Previous history of C-section.
- Infertility & ART (Assisted reproductive techniques).
- Contraceptives: Increased risk of ectopic pregnancy.
- Lower absolute risk (chance of pregnancy).
- Higher relative risk (chance of ectopic pregnancy if pregnancy occurs).
- Highest risk is associated with:
- Tubal ligation > Progesterone IUD (mirena, progestasert) > Cu-IUD.
- POP > OCP (Progesterone - smooth muscle relaxant leading to decreased peristalsis).
Medical Termination of Pregnancy (MTP) Act & Methods
-
Amendments 2021:
- MTP for Congenital Anomalies: Up to 24 weeks.
- MTP for Contraceptive Failure: Up to 20 weeks.
- Severe Congenital Anomalies: No upper limit. Requires approval by a medical board.
-
Composition of Medical Board:
- Gynecologist.
- Radiologist.
- Paediatrician.
- Person assigned by the State.
-
Indications for MTP:
- Rape.
- Contraceptive Failure.
- Saving the life of the pregnant female.
- Preventing serious physical or mental injury to the mother.
- Preventing a fetus with physical or mental abnormalities from being born.
-
Consent Requirements for MTP:
- For patients under 18 years old: Guardian required.
- For patients with mental instability: Guardian required.
-
Approval Requirements for MTP:
- Up to 20 weeks: Single doctor's approval.
- 20-24 weeks: Approval required from two doctors.
-
Records Required for MTP:
- Marriage proof (Not required).
- FIR report of rape (Not required).
-
Qualifications for Performing MTP:
- MD/MS/DGO/DNB in Obstetrics & Gynaecology (OBG).
- Registered medical practitioner.
- Assisted in 25 MTPs + primary surgeon in 5 of them.
- House job in OBG x 6 months.
- Worked in the OBG department of a multispecialty hospital for 1 year.
-
Methods of MTP Based on Technique:
Medical Abortion Surgical Abortion Advantages * Non-invasive * Surgical expertise not required * No surgical/anaesthetic complications * Fast procedure * One time completion * One step procedure Disadvantages * Surgical option on failure * Multiple step, longer procedure * Invasive * Surgical & anaesthetic complications
Types of Abortion
Type | c/o | Height of uterus P/A | Internal OS | USG | Management |
---|---|---|---|---|---|
Threatened abortion | Spotting P/v. | Equal to POG | Closed | Cardiac activity + | Reassurance. Advice to avoid intercourse. |
Inevitable abortion | Bleeding P/v. | Equal to POG | Open | Cardiac activity absent | Expedite abortion process by medical abortion/suction & evacuation. |
Incomplete abortion | Bleeding + Pain abdomen + H/o expelled POC | < POG | Open + POC seen coming | Incomplete POC | Maintain vitals if in shock. Expedite abortion. |
Complete abortion | H/o bleeding + POC expelled with no current bleeding | < POG | Closed | Empty uterus | Reassurance. Anti-D if Rh +ve. |
-
Abbreviations:
- POC: Products of conception.
- POG: Period of gestation.
- UPI: Unexplained Pregnancy Issue.
- UPT: Urine Pregnancy Test.
- LSCS: Lower Segment Cesarean Section.
- APS: Antiphospholipid Syndrome.
Missed Abortion
Type | c/o | Height of uterus P/A | Internal OS | USG | Management |
---|---|---|---|---|---|
Missed abortion: USG based diagnosis | No symptoms; may have brown discharge | ≤ POG | Closed | mean sac diameter ≥25 mm + no fetal pole; OR Crown rump length 27mm + Absent cardiac activity; OR Cardiac activity present earlier, absent now | Medical abortion; OR Suction evacuation |
Abortion + Features of Shock
- Most common cause: Septic abortion > Incomplete abortion.
- History of abortion + ↑ APTT: APLA syndrome.
Septic Abortion
- Septic foci in any abortion.
- Symptoms:
- Fever, chills.
- Abdominal pain.
- Diarrhea, vomiting.
Grading of Septic Abortion
Grade | Description |
---|---|
1 | Infection limited to uterus. |
2 | Infection spreads to pelvic organs. |
3 | Peritonitis/shock/renal failure. |
- Note: TSS (Toxic Shock Syndrome) is never caused by E.coli.
Management of Septic Abortion
- Features of septic abortion include:
- Purulent vaginal discharge.
- May present as shock (Toxic shock syndrome).
- Management includes:
- Ampicillin + Gentamycin + metronidazole.
Medical Abortion in Second Trimester
- Drugs: Prostaglandins (Best)
- i. misoprostol (PGE1) - Best
- ii. Dinoprostone (PGE2)
- iii. Carboprost (PGF2α)
- Dose: misoprostol 400mcg every 3 hours
- Maximum doses: 5 doses
- Patient admission: Required.
- Potential Complications: Patient may experience miniature labor. Products of conception are expelled out.
- Note: Mifepristone should not be used in second trimester pregnancy.
Surgical Abortion in Second Trimester
- Methods:
- Dilatation & Evacuation (D&E):
- Most common method.
- Instruments used:
- Ovum forceps/Sponge holding forceps.
- After procedure: Blunt curettage.
- Spoon-shaped forceps (with ratchet locks).
- Dilatation & Evacuation (D&E):
- Additional Note:
- Always perform blunt curettage in a pregnant uterus.
- Exception: After severe molar pregnancy or failed medical abortion using misoprostol.
- Misoprostol (Teratogenic) → Moebius Syndrome.
- Pregnancy will likely not continue.
Management of Certain Conditions
- If history of thrombosis or abortion: Heparin + Aspirin.
- If history of preterm labor (due to UPI): Aspirin.
- Aspirin started when intrauterine pregnancy is diagnosed (UPT +ve).
- Heparin started once intrauterine pregnancy confirmed.
- Anticoagulants are stopped intrapartum.
- Continued post-partum:
- a. 6 hours after vaginal delivery.
- b. 12 hours after LSCS.
- APS in non-pregnant female with history of thrombosis: Warfarin (DOC).
Role of Progesterone & Basics of Ectopic Pregnancy
- Role of Progesterone:
- Corpus luteum secretes progesterone.
- Progesterone levels are higher in ectopic pregnancy compared to the non-pregnant state, but lower than in intrauterine pregnancy.
- Decidualization of the endometrium:
- USG - Pseudogestational sac.
- Decidua vera +: Not differentiated into decidua basalis/capsularis/parietalis.
- Anatomy of fallopian tube:
- Parts (medial to lateral): Interstitium (Intramural) > Isthmus > Ampulla > Infundibulum.
- Narrowest part: Interstitium > Isthmus.
- Sphincters:
- Anatomical: Interstitium.
- Physiological: Isthmus.
- Duration of Ectopic pregnancy:
- Lasts longest: Interstitium (due to myometrial support).
- Most dangerous site of ectopic pregnancy (↑ bleeding): Interstitium.
- Ends earliest: Isthmus.
- Site of Ectopic pregnancy:
- Fallopian tube: most common.
- Most common part: Ampulla (a site of fertilization, maximum number of plicae (mucosal folds)).
- Non-tubal sites:
- Most common non-tubal site: ovary.
- Less common: C-section scar > Cervical ectopic > Abdominal ectopic (lasts longest; derives blood supply from adjacent organs).
- Fallopian tube: most common.
- Other details:
- Decidual cast +/- (Shedding of decidua).
- Placenta.
Instrument Details (Suction and Evacuation)
- Karman's Cannula:
- Description: Plastic cannula with triangular openings.
- Number: No. of the cannula = Diameter of cannula (in mm).
- Size: Size = Period of gestation (Or 1 less).
- Uses: Suction & Evacuation (SEE).
- Other Instruments/Procedures:
- Vulsellum: Hold the cervix.
- Sponge Holding Forceps: Hold the cervix.
- Paracervical Block: Anesthesia for SSE.
- Uterine Sound: Measures uterocervical length and confirms the position of the uterus. Acts as a first dilator.
- Olive Tipped Calibrated Uterine Sound: Measures uterocervical length.
- Hegar's Dilator: Used to dilate the internal os.
- Injection Sites:
- 12 o'clock position: Site to hold cervix (and 2, 4, 8, 10 o'clock positions).
- Not given: 3 & 9 o'clock.
- Injection site for tenaculum: 12 o'clock.
- Injection Sites (Other): 2, 4, 8, 10 o'clock.
- Anesthesia: Paracervical block with 1% lignocaine.
- Maximum number of KC used for SSE: 16.
- Pressure Generated during SSE: ≥ 600 mmHg.
- End Point: Blood loss, Air bubbles in KC, Grating sensation over uterus, Internal os starts closing → Gripping sensation over the KC.
- Possible Complications: Incomplete abortion, missed abortion, endometrial biopsy.
Treatment of Absent Cardiac Activity
- Repeat 400-800 mcg misoprostol after 7 days.
- Follow up with a medical professional.
Suction & Evacuation (S&E)
- Best method of medical termination of pregnancy (MTP): Between 9-12 weeks.
- Performed until 16 weeks.
Pre-requisites for Suction & Evacuation (S&E)
- ABO/Rh grouping.
- Pregnancy test (if not done with Nischay card).
- Confirm Size & Position (Anteverted):
- Empty bladder.
- Pelvic examination in lithotomy position.
- Posterior vaginal wall: Sim's speculum.
- Anterior vaginal wall: Anterior vaginal wall retractor.
Procedure for Suction & Evacuation (S&E)
- Empty bladder.
- Pelvic/Vaginal (P/V) examination in lithotomy position (confirm size & position - anteverted/retroverted).
- Retract vaginal walls.
- Use Hegar's dilators to dilate the internal os.
- Insert a triangular Karman's Cannula.
- Attach to a suction machine to evacuate products of conception.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
This quiz covers critical knowledge on managing perforation during SFE, including signs, immediate actions, and further procedures. Additionally, it explores the Manual Vacuum Aspiration (MVA) method and its relevance compared to menstrual regulation. Test your understanding of these important medical practices.