A nulliparous 15-year-old single girl presents to you in the clinic at 8 weeks’ amenorrhoea, requesting for pregnancy termination. Discuss the management of this patient.

Unwanted teenage pregnancies and abortions have serious implications for the patient’s physical and psychological health. It is important to listen to the patient’s reasons for wanting to terminate the pregnancy, to provide counseling and a careful assessment of her health status before acquiescing in her request. In consideration of the patient’s vulnerabilities and distress at this moment in time, the interview should be conducted in sensitive, non-intimidating and non-judgmental manner that will put the patient at ease and comfort. 

I would first tell her that termination of pregnancy is a serious matter and she needs to give herself some time to ponder over her decision and other possible options and of the necessity of taking a detailed history from her. 

History

1.	Current pregnancy:
-	How did she discover her pregnancy?
-	Who is the father?
-	How did she get pregnant: consensual unprotected sex or rape. 
-	Reasons for terminating the pregnancy.
-	Knowledge / prior discussion of her decision by her partner and family.
-	How did she feel about the matter and was she coping well?
-	Symptoms of pregnancy: breast engorgement, nausea and vomiting.
-	Any abnormal signs: lower abdominal pain, PV bleeding. 

2.	Past obstetric history of pregnancies, termination of pregnancies, miscarriages, stillbirths and ectopic pregnancies.

3.	Menstrual history:
-	Age of menarche.
-	Menstrual pattern: duration and length of each period.
-	Flow volume and dysmenorrhoea.
-	Last menstrual date.

4.	Sexual history:
-	Age of first intercourse.
-	Number of sexual partners.
-	Use of contraception.
-	Attitude, beliefs and values regarding sex. 

5.	Medical and surgical history:
-	Signs and symptoms of STDs: fever, discharge, etc.
-	Other medical problems: asthma, IDDM etc.
-	Previous operations, especially abdomino-pelvic. 
-	Drug allergies. 

6.	Family and social history:
-	Occupations and financial status of her family and that of her partner: to assess their capability of supporting the baby if delivered.
-	Likely reaction and level of support from family members towards her pregnancy. 
-	Is she studying or working now?
-	Does she smoke or drink?

Physical examination

1.	Vital signs: heart rate, blood pressure, temperature.

2.	Peripherals:
-	Pallor, cyanosis, jaundice.
-	Hands: pulse and nailbed pallor.
-	Legs: edema, varicose veins.

3.	Breasts.

4.	Cardio-respiratory system.

5.	Vaginal examination:
-	Uterus: position and size.
-	Extrauterine abnormalities.
-	Cervical smear. 

6.	Abdomen (unlikely to yield much findings if the fetus is really at 8 weeks gestation, but an examination is still necessary as patient may remember LMP wrongly).
-	Distension: symmetry and site.
-	Umbilicus: flushed or everted.
-	Cutaneous signs of pregnancy.
-	Scars.
-	Fetal movements.
-	Symphysis-fundal height.
-	Singleton fetus?
-	Lie.
-	Presentation.
-	Fetal back. 

Investigations

1.	Confirmation of pregnancy by a pregnancy test.

2.	Infection screen for Chlamydia, gonorrhoea, hepatitis B or HIV if the woman has a vaginal discharge, is a rape victim or in a high-risk category.

3.	Haemoglobin and blood group.

4.	Ultrasound to confirm presence of intrauterine gestational sac. estimation of gestational age and to assess fetal growth and viability. 

I would next offer the patient pre-abortion counseling to offer adequate information and explanation to allow her to make an informed choice. 

The following areas should be discussed in the counseling process:

1.	Alternatives to abortion: continuing the pregnancy and either keeping the baby or having it adopted.

2.	The way in which the abortion will be carried out.

3.	The risks of the procedure.

4.	Her relationship with the partner and his attitude to the pregnancy.

5.	Ensuring adequate support for the woman both before and after the abortion.

6.	Offer of post-termination support counseling.

7.	Contraception after the abortion.

8.	Arrangements for follow-up.

If the patient is still adamant on the abortion after the counseling session, I would advise her on the Abortion Law and Regulation in Singapore and the proper channels she need to go through to get a termination of pregnancy legally:

1.	In Singapore, pregnancy should be terminated by an authorized medical practitioner acting on the request of a pregnant woman and with her consent in an approved institution. The patient is offered an institution where the TOP will be done.

2.	As she is below 16 years of age, she will need to have counseling at the Health Promotion Board. A Certificate of Attendance (COA) will be issued to her. No TOP can be performed unless she produces the COA.

3.	Counseling will be provided to her on the day of TOP. 

Method of TOP

If the gestational age is indeed 8 weeks, misoprostol is used to induce the abortion. 800ug is to be inserted into the vagina, followed by 400ug every 3 hours. 

I would see her for follow-up around two weeks later to:
-	Ensure that the abortion is complete.
-	Exclude an ongoing pregnancy.
-	Check for possible pelvic infection.
-	Offer advice on contraception and sexual health.
-	Assess the woman’s emotional state.