Abortion — structured SAQ (15 marks)

(a) Immediate management — first ten minutes (5 marks)

One mark per point, maximum five. ^[1]

• Recognise sepsis with retained products and call for help — senior gynaecologist, anaesthetics, nursing coordinator; activate the sepsis and massive-haemorrhage pathways as indicated; assign a scribe.^[1]
• Resuscitate: high-flow oxygen, two large-bore cannulae, intravenous fluids and blood pressure support; crossmatch and send FBC, coagulation, lactate, blood cultures before antibiotics.^[1]
• Broad-spectrum intravenous antibiotics early — for example ampicillin with gentamicin and clindamycin or metronidazole per local protocol, within the first hour; do not wait for culture results.^[1][3]
• Assess for retained tissue — speculum and bimanual examination, bedside ultrasound if available; the retained tissue is both the haemorrhage and the sepsis source.^[1]
• Plan urgent source control — examination under anaesthesia with suction evacuation; intensive-care escalation for organ dysfunction.^[1]

(b) The four complications (4 marks)

One mark per complication with the discriminating feature. ^[1][2]

• Infection — fever, foul discharge, pain, rising inflammatory markers; may progress to septic shock.
• Haemorrhage — soaking bleeding (more than two pads an hour for two hours), haemodynamic compromise; transfusion-requiring haemorrhage is a 0.1-percent-or-fewer major complication.^[2]
• Retained tissue (incomplete abortion) — persistent bleeding, visible tissue, ultrasound evidence of retained products; the commonest driver of the first two.^[1]
• Uterine perforation — sudden loss of resistance at instrumentation, visualised bowel or fat, visceral pain, haemodynamic change; needs visceral inspection and repair.^[1][2]

(c) Definitive management (4 marks)

One mark per point. ^[1][3]

• Source control by suction evacuation (manual or electric vacuum aspiration) under anaesthesia to remove retained products — the single intervention that addresses the haemorrhage and the sepsis.^[1]
• Uterotonics for haemorrhage: oxytocin, ergometrine 0.5 mg intramuscularly (not in hypertension), misoprostol 800 micrograms per rectum; activate massive transfusion if unstable, targeting fibrinogen and platelets.^[1]
• Continue broad-spectrum antibiotics and intensive-care support; monitor lactate clearance, urine output and serial observations.^[1][3]
• For incomplete abortion managed medically rather than surgically, the regimen is misoprostol 800 micrograms buccally followed by 400 micrograms after four hours if tissue has not passed; ultrasound is not required beforehand.^[1]

(d) Anti-D, counselling and conscientious objection (2 marks)

Half a mark each, up to two. ^[1][5]

• Anti-D: as she is beyond 10 weeks and Rh D negative, give anti-D (Rh D immunoglobulin) per the guideline; note that the WHO 2022 guideline recommends against anti-D for first-trimester abortion, a position local practice is moving toward.^[1]
• Counselling: debrief gently, screen for reproductive coercion in private, arrange contraception (a long-acting method can be placed now), and offer psychological follow-up.^[1]
• Conscientious-objection duty: a clinician who objects may decline to provide the abortion but must disclose the objection and refer the woman to the closest provider within a clinically reasonable time, without imposing delay, distress or harm; refusal without referral fails the duty.^[1][5]