[12] Termination Of Pregnancy Flashcards
What is termination of pregnancy?
A medically directed miscarriage prior to independent viability, using pharmacological or surgical means
What is termination of pregnancy commonly referred to as?
Abortion
What is the standardised abortion rate for women aged 15-44 in the UK?
16/1000 women
What % of abortions in the UK are carried out at under 13 weeks gestation?
92%
What % of abortions in the UK are carried out under 10 weeks?
80%
What % of abortions carried out in the UK were medical?
51%
What law governs abortions in England, Scotland, and Wales?
The 1967 Abortion Act
What is the age limit for abortion under the 1967 abortion act?
24 weeks
What are the requirements for abortion under the 1967 abortion act?
Can only be performed when;
- Reduces risk to woman’s life
- Reduces risk to her physical or mental health
- Reduces risk to physical or mental health of her existing children
- Baby is at substantial risk of being seriously mentally or physically handicapped
How is it confirmed that the criteria for abortion is met under the 1967 abortion act?
2 medical practitioners must certify in good faith by signing from HSA1 that at least 1 of these criteria apply
Under which of the criteria of the 1967 abortion act are most abortions performed?
Criteria 2 (risk to physical or mental health)
When is there no upper limit on gestation under the 1967 abortion act?
- Risk to mother’s life
- Risk of grave, permanent injury to mothers physical/mental health
- Substantial risk that, if the child were born, it would have such physical or mental abnormalities as to be seriously handicapped
What are the usual scenarios for abortion after 20 weeks?
- Following amniocentesis
- In very young girls who have concealed or not recognised the pregnancy
How does the abortion law differ in Northern Ireland?
Abortion is unlawful other than in restricted circumstances
What do the GMC guidelines state regarding girls under 16 requesting an abortion?
Girls under 16 may be able to make an informed decision without parental consent if they are deemed to have the capacity to do so
When do GMC guidelines state that abortions can be provided to girls under 16 without parental knowledge?
- The girl understands all aspects of the advice and its implications
- You cannot persuade her to tell her parents, or to allow you to tell them
- It is in the best interests of the young person to receive the advice and treatment without parental knowledge and consent
Can the consent of a girl under 16 override parental refusal to allow abortion?
Yes, if they are competent
When can someone with parental responsibility consent for abortion on a girls behalf?
If they lack capacity
What should be done if someone is parental responsibility is consenting to abortion because the young person lacks capacity?
The views of the young person should be heard and taken into consideration
What should be considered in a person presenting for abortion when they are unable to consent?
Should consider possibility of sexual abuse - if young person does not have capacity to consent to abortion, do they have capacity to consent to sexual intercourse?
What is strongly advised regarding terminations in girls aged <16?
You should seek medico-legal advice if you have any uncertainty
What steps should be taken before termination of pregnancy?
- Confirm patient is pregnant
- Counsel her to help her reach the decision she will least regret
- Most clinics provide optional counselling - encourage to utilise this if she would find it helpful
- Discuss methods of abortion and choices available
- Ask her to consider alternatives
- Ask about her partner
- Ideally, allow her time to consider her decision
What is the main alternative to abortion?
Adoption
Can the woman’s partner consent to, or refuse, TOP?
No
What should be considered when allowing a woman time to consider her decision to abort?
The earlier the termination is performed, the lower the risk of complications
What should be done if the patient decides on TOP?
- Screen for chlamydia
- Risk assessment for other STIs, and screen if indicated
- Discuss further contraceptive needs
- Check rhesus status
- Assess risk of VTE
- Establish if smear is due
What % of women attending abortion services screen positive for chlamydia?
10-13%
What % of women with chlamydia would get post-operative salpingitis if untreated?
25%
When can contraception be started after abortion?
Can start pill next day, or insert IUD at time
Why is it important to check rhesus status before TOP?
If negative, she needs anti-D
What should be done if smear is due in a patient presenting for TOP?
Can offer within abortion service, or give advice about when and where it can be done
How long after the decision to proceed should a woman undergo abortion?
Within 5 days
What is the maximum waiting time between initial referral for TOP to time of abortion?
3 weeks
How can infection be prevented in abortion?
Antibiotic prophylaxis and/or infection screening
Why is antibiotic prophylaxis recommended with TOP?
Because 10% of women will develop genital tract infection after abortion
What is the antibiotic of choice for prophylaxis in abortion?
Metronidazole
What are the options for surgical abortion?
- Vacuum aspiration
- Dilation and evacuation
What is given alongside surgical abortion in cases of less than 14 weeks gestation?
Vaginal or sublingual misoprostol 400mcg 3 hours before surgery
When is vacuum aspiration a suitable management option for abortion?
Up to 14 weeks gestation
What should be followed when vacuum aspiration is performed before 7 weeks gestation?
Strict protocols to ensure the gestational sac has been fully removed
How is it ensured that the gestational sac has been fully removed when vacuum aspiration is performed before 7 weeks gestation?
- Examination of aspirate
- Follow up blood tests for hCG
What gestation is dilation and evacuation a suitable management option?
14-24 weeks gestation
What is recommended for dilation and evacuation for TOP, in terms of the procedure?
Ultrasound guidance
What are the options for anaesthesia for surgical abortions?
- Local anaesthesia
- General anaesthesia
- Conscious sedation
What analgesia should be offered for surgical abortions?
NSAID should be routinely offered
How is medical abortion performed?
Regimens using 200mg oral mifepristone followed by misoprostol
How is misoprostol administered in medical abortion?
Can be vaginal, buccal, or sublingual
At what gestation is medical abortion a suitable management option?
Any gestation
What should be performed before any medical abortion after 21+6?
Feticide
What analgesia is recommended for medical abortions?
Analgesic such as NSAID, but stronger analgesia may be required in some cases
Why is paracetamol not recommended for analgesia in medical abortion?
It is ineffective for this indication
When should anti-D be given in TOP?
In all non-sensitised RhD-negative women
What aftercare should be provided after abortion?
- Discuss contraception, and supply if accepted
- Provide list of possible symptoms, highlighting those that need urgent medical attention
- If abortion confirmed at time of procedure, no need for follow up
- Arrange further counselling for women who experience long-term distress
When can intrauterine contraceptives be inserted immediately after an abortion?
When successful abortion has been confirmed
Is TOP a safe procedure?
Yes, considered a safe procedure, and complications are rare
What are the most common complications of TOP?
- Infection
- Cervical trauma
- Failed TOP
What % of terminations are complicated by infection?
Up to 10%
How can the infection rate in TOP be reduced?
Prophylactic antibiotics or pre-procedure scanning for antibiotics
What is the risk of cervical trauma from TOP?
1%, lower if performed early
Is cervical trauma a risk in all types of TOP?
No, only a risk in surgical abortion
What is the risk of failed TOP?
Less than 1%
What are the uncommon complications of TOP?
- Haemorrhage
- Perforation of uterus
- Psychological problems
What is the risk of haemorrhage from TOP in the first trimester?
1 in 1000
What is the risk of haemorrhage from TOP in the second trimester?
4 in 1000
What is the risk of perforation of uterus in TOP?
1-4 in 1000
Is perforation of the uterus a risk of all types of TOP?
No, surgical abortion only
Do many women having an abortion experience long-term psychological sequlae?
No, only a small proportion
What psychological effect is common with abortion?
Early distress
Is termination of pregnancy more likely to be associated with poor mental health outcomes than if pregnancy is continued?
No
What might have serious consequences on a woman’s mental health, or that of her families?
Denial of, or lack of, legal abortion services
