3 Removal of a large fetal part, usually the caput or vertebral
column, with a forceps. To avoid perforation or grabbing the uterine
wall the forceps may be steered by ultrasound scan
monitoring. [chapter 9]
4 In the case of selective abortion in multiple pregnancy, a
narrow canula of the Karman type can be steered into the chosen
gestational sac which is then slowly and carefully aspirated under
ultrasound scan monitoring.
Ultrasound scan is also valuable for final checking if the uterus
is empty after the procedure. This is particularly useful in advanced
pregnancies where there is a danger of retained fetal parts. After
successful aspiration the uterus is empty, but the irregular inner
cavity may give false echo's so that the ultrasound scan image may
resemble soft tissue retention This phenomenon has led in a few cases
to perforation if the surgeon fervently keeps trying to remove
retained tissues. A few minutes after removal of a young pregnancy the scan becomes less valuable . Fluid and blood may make the view unclear.
4. ANAMNESIS (medical history)
There are very few diseases which form a contraindication for a
termination, and few sicknesses may complicate the procedure or
require certain measures.
1. Epilepsy - No contraindication, give diazepam 10 mg I.V.for
premedication.
2. Diabetes - If the patient must be starved for general
anaesthesia she must be advised to take half her usual dose of
insulin. Keep glucose for injection ready to control hypoglycemia. Do
not use drugs that may elevate the bloodpressure, as vessels are
often in a bad condition and may rupture is e.g. epinephrine is
administered
3 Anticoagulant treatment and use of salicylates - The patient
must be advised to discontinue her medication 24 hours before the
procedure.
4. Marked anaemia - Refuse to terminate advanced pregnancy. This
may only be done if a blood transfusion is available.
5. Sickle cell disease - Check Hb. Refuse advanced pregnancy if
Hb is low. patient should take a prolonged rest for the intervention
and drink >1 liter of water.
6. Hypertension - Administration of prostaglandins or ergometrine
may lead to an acute crisis. Also avoid (nor-)adrenalin in the local
anaesthetic.
In a clinic in den Haag a patient got a cerebral
haemorrhage after administration of a local anaesthetic with
noradrenalin resulting in a stroke and permanent hemiparesis.
7. Acute infections with fever - Advise her to come back after
antibiotic treatment. Allergy for local anaesthetic - The termination
can be done without local anaesthesia under heavy sedation and
analgesics.
8. Asthma - If she uses a spray she should keep this with her
during the procedure. Do not use morphinomimetics in premedication.
Blood group of patient and her partner to consider the
administration of anti-D-immunoglobulin after termination
[Chapter 14]
During anamnesis ask for the above mentioned diseases or their
symptoms. Best is to use a checklist which covers all possibilities.
The specific gynaecological hystory must include operations, the
existence of fibromata or other tumours, recent or current
gynaecological treatment, former terminations including
unprofessional abortions. Appendix 9 gives a suggestion for an
anamnesis form.