Top: Management of pregnancies ≤14 weeks of gestation

O04.9

GENERAL MEASURES

Counselling.
Outpatient procedure by nursing staff with specific training.
Discuss TOP options with patient: Manual vacuum aspiration of the uterus or medical TOP.

LoEIII [20]

MEDICINE TREATMENT

Manual vacuum aspiration:

  • Misoprostol, PV, 400 mcg 3 hours before routine vacuum aspiration of the uterus.

Routine analgesia for vacuum aspiration:

  • Morphine, IM, 0.1 mg/kg 30 minutes before aspiration procedure, to a maximum of 10 mg.

LoEIII [21]

Do not give intravenous benzodiazepines and parenteral opioid analgesics concurrently.


Conscious sedation - see Sedation.

Alternatively, consider paracervical block:

  • Use Lidocaine 1%.
    • Draw up lidocaine 1% in a 20 mL syringe.
    • Attach a 20-gauge spinal needle. Inject 2 mL superficially in the cervix at 12h00 and immediately grab the cervix with a tenaculum at 12h00 to stabilise cervix.
    • Inject remaining 18 mL slowly over 60 seconds into the cervicovaginal junction in four equal doses of 4–5mL at 2, 4, 8, and 10 o’clock (see diagram below).
    • This injection is continuous from superficial to deep (a depth of 3 cm) and again to superficial (injecting with insertion and withdrawal).
    • Manual vacuum aspiration can start after 3 minutes.

Paracervical Block.png

LoEI [22]

Oral analgesia as required for 48 hours:

  • Paracetamol, oral, 1 g 4–6 hourly when required.
    • Maximum dose: 15 mg/kg/dose.
    • Maximum daily dose: 4g in 24 hours.

AND

  • NSAID, e.g.:
  • Ibuprofen, oral, 400 mg 8 hourly with meals.

Medical TOP:

Up to 12 weeks and 0 days:

  • Mifepristone, oral, 200 mg, immediately as a single dose.

LoEI [23]

Followed 1-2 days later by:

  • Misoprostol, PV/SL 800 mcg or buccal by self-administration
    • If expulsion has not occurred 4 hours after misoprostol administration, a second dose of misoprostol 400 mcg may be given.

Note: Bleeding may persist for up to 1 week. If there is no bleeding after the second dose of misoprostol, the woman must return to the facility as soon as possible as there is a possibility of an incomplete procedure or ectopic pregnancy.

LoEIII [24]

For pain:

  • Paracetamol, oral, 1 g 4–6 hourly when required.
    • Maximum dose: 15 mg/kg/dose.
    • Maximum daily dose: 4 g in 24 hours.

ADD

After expulsion is complete:

  • NSAID, e.g.:
  • Ibuprofen, oral, 400 mg 8 hourly with or after a meal.