2.3 Termination of pregnancy

Question 1

The legal limit for termination of pregnancy in Singapore is up to __________________ of gestation (ascertained by last menstrual period and clinical exam; confirmed by USS):
• Total of 10264 abortions were carried out in 2012 (90% in the 1st trimester)

Answer 1

24+0 weeks (means 24 weeks and 0 days)

Question 2

Medical indications for abortion

1) Foetal abnormalities
Results in an extremely poor quality of life for the foetus even if carried to full term and delivered:
• ____________ (absence of major portions of the brain, skull, or scalp → possibly unable to function)
• Presence of multiple foetal anomalies
• Genetic syndromes (e.g. Down’s syndrome, Edward’s syndrome → trisomy 18; often die during foetal life or experience severe defects and early mortality even if they survive past foetal life)

Maternal medical conditions: Results in danger to the mother (high risk of morbidity or mortality) if the foetus is carried to full term: 
• \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (increased risk of pulmonary embolism and sudden death in the first few days of postpartum → due to increased sensitivity to haemodynamic changes enhancing the R→L shunting and circulatory collapse) 
• Maternal rubella infection in 1st trimester (causes congenital rubella syndrome → foetal sight and hearing defects) •,
 Teratogenic medications (e.g. methotrexate, isotretinoin)

Answer 2

Anencephaly;

Eisenmenger syndrome;

Question 3

What is the relevant step to take before proceeding with TOP?

1. Comprehensive obstetric history: last menstrual period (LMP), __________ (number of times a woman has been pregnant) and _________ (number of times she has carried it to viable gestational age), past medical/surgical history, reason for TOP
2. Physical examination: whether the size of the uterus corresponds to LMP/gestation
3. Ultrasound: confirm _______________, viability, estimated ____________
4. Discussion: methods of TOP (risks and benefits), future contraception, consent

Answer 3

gravida;

parity;

intrauterine pregnancy;

gestation period

Question 4

What is the surgical method for 1st trimester abortion (7-12 weeks)?

Answer 4

Suction & curettage (S&C)

- Products of gestation are suctioned from the uterus under general anaesthesia (rarely regional)

Question 5

What is the surgical method for 2nd trimester abortion (12-24 weeks)?

Answer 5

Dilation & evacuation (D&E): Foetus is grasped and pulled out of the uterus under GA

Question 6

What is the medical method for 1st trimester abortion (up to 9 weeks)?

Answer 6

Mifepristone → 24 – 48h → single dose of prostaglandin (no need for surgical curettage thereafter):

Question 7

What is the medical method for late 1st - 2nd trimester abortion (9- 24 weeks)?

Answer 7

Mifepristone → 24 – 48h → multiple doses of prostaglandin (e.g. misoprostol or gemeprost) → surgical curettage of placenta left inside:

Question 8

The products of conception which were removed from the uterus are sent for histology to exclude _________________ (tumour growth in the uterus):
• Follow-up: review if menses have returned, assess for signs of bleeding/infection, reinforce future contraception needs and prevention of STIs
• Discuss contraceptive options (if the patient is keen): OCP, Depo-Provera® (progestin injections), Implanon® (prevention of ovulation), IUCD/IUS, sterilisation
• Rhesus-negative unsensitised women with Rhesus-positive partners should receive _____________) within 72 hours of abortion:
o Due to risk of haemolytic disease of the newborn (HDN) → foetus could have been Rh-positive → sensitise the mother during abortion

Answer 8

trophoblastic disease;

anti-D immunoglobulin (e.g. RhoGAM®

Question 9

Complications may arise from the abortion during the post-TOP phase → monitor patient: • Bleeding may last up to 2 weeks (blood transfusion rarely needed; 0.5%)
• Localised pelvic infection (3%)
• Uterus/cervix trauma (1%)/uterine perforation (0.76%) → laparoscopy/laparotomy
• Failure of TOP (very rare)
• Retained products of conception → requires _______________
• Asherman’s syndrome: intrauterine adhesions (scar tissues) → may follow curettage on recently pregnant uterus/pelvic infections/repeated curettage
o Presentation: __________
o Investigations: hysteroscopy, US pelvis, hysterosonography
o Management: _____________________

Answer 9

evacuation of uterus (1%);

reduced menstrual flow/amenorrhoea;

hysteroscopy resection of adhesions, IUCD and oestrogen after procedure to prevent recurrence