Vaginal delivery will continue to be the main method of delivery and will continue to generate a low incidence of pelvic floor morbidity. The management of injury to the anal sphincter is facilitated by close co-operation between obstetricians and colorectal surgeons.
Key message points l Mifepristone followed 48 hours later by administration of misoprostol is an effective regimen for medical termination of pregnancy but is inflexible. l A regimen whereby misoprostol is given at varying times up to 72 hours after mifepristone appears to work well in a district general hospital setting, whilst being more convenient for patients and staff.
IntroductionMifepristone, followed 48 hours later by administration of misoprostol, is well established for medical termination of pregnancy (TOP).1 Initially offered for pregnancies of up to 63 days' gestation, 1 medical TOP has since been used throughout the first trimester 2 and extended to secondtrimester pregnancies. 3 We have found that the inflexibility of the standard regimen is inconvenient for patients and may be difficult to arrange on an outpatient basis.A study by Schaff et al. demonstrated that when misoprostol was given either 24 or 72 hours after mifepristone it was as effective as the 48-hour regimen, whilst at the same time being more convenient for patients and staff. 4 This study only included gestations up to 56 days. A study by Creinin et al. showed a lower success rate when mifepristone and misoprostol were administered at the same time. 5 The aim of our study was to ascertain whether misoprostol was effective when administered 24, 48 or 72 hours after oral mifepristone for gestations up to 83 days.
MethodIn the Women's Health Care Department at the Royal Bolton Hospital, medical TOP has been offered since 1992. The vast majority of terminations in our practice are performed medically and over 300 procedures are performed annually. The Women's Health Care outpatient department is open on Mondays to Fridays (0830-1700 hours) and has facilities to care for a maximum of three women per day undergoing this procedure.Following referral, an ultrasound scan is performed on all women requesting TOP to confirm a viable intrauterine pregnancy and to ascertain the gestational age. After counselling, medical terminations of pregnancy are offered up to 83 days' gestation. A high vaginal swab and an endocervical swab for Chlamydia trachomatis are routinely taken and a discussion with the specialised nurses regarding future contraception is arranged. Rhesusnegative women receive anti-D immunoglobulin at the time of the misoprostol administration.Mifepristone 200 mg orally was administered on the day of referral, or on a day that was convenient for the patient and the unit. The patient returned to the unit 24-72 hours following mifepristone administration. The women were informed that the success rates of administration of misoprostol either 24 or 72 hours later was not as well documented as that following a 48-hour interval.On their return to the unit, and after nursing assessment to ascertain that abortion had not already occurred, the first dose of misoprostol 600 mg was administered at 0900 hours. Vaginal administration was encouraged although some women opted for oral therapy. A second dose of misoprostol 600 mg was routinely admi...
The incidence of anal incontinence following repair of a third degree tear was not high and it is unlikely that we are missing a hidden pool of symptomatic women. No major change in management policy is required. The routine assessment of anal function in women who had sustained a third degree tear was appreciated by the women and enabled us to identify the small portion of women with significant symptoms.
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