Abortion Flashcards
How should abortion care be organised to improve women’s health outcomes? (From RANZCOG guideline) (7 headings)
- Prevention of unintended pregnancy
- Improving access to abortion services
- Provision of care
- Confidentiality and unprejudiced approach to care
- Well trained workforce
- Counselling and support
- Legislation:
- legislation to support the above recommendations
- Clinicians should be aware of the legislation in the area in which they practice
Define late abortion.
Abortion beyond 14 weeks or beyond 20 weeks gestation. (depends on jurisdiction)
What are some of the situations where late abortion may be deemed the most appropriate management of a pregnancy?
- Late diagnosis of significant fetal anomaly
- Selective fetocide in multiple pregnancy to benefit surviving twin (e.g. TRAPS, severe TTS)
- Psychosocial circumstances (e.g. rape, incest, sexual exploitation OR significant psychiatric deterioration in pregnancy such that it becomes a risk to mothers life)
- Maternal medical conditions - conditions diagnosed in pregnancy or exacerbated by pregnancy so that it poses a risk to mothers life (e.g. cancer)
What is the global health impact from prohibited or difficult access to abortion services?
Unsafe abortions lead to > 50,000 maternal deaths globally each year.
Abortion done by trained staff is very safe, there have been no maternal deaths associated in over 35 years of data collection in NZ.
Globally around 1/4 pregnancies are unplanned.
In countries where abortion is illegal or culturally inaccessible have similar rates of abortion.
Therefore access to safe abortion is critical.
The global estimated cost of managing complications as a result of unsafe abortion exceeds 550 million USD.
What factors affect the mode of abortion a woman receives?
- Woman’s wishes
- Gestation
- Woman’s medical/surgical history and presence of contraindications to either method
- Available options/services
- Experience and clinical judgement of clinician
Until what gestation can early medical and early surgical termination be offered?
early medical - up to 9+0 weeks (CRL >25mm)
early surgical - up to around 14 weeks - after this time it requires Dilation and Evacuation and overnight stay
Compare MVA to suction curettage.
Setting: MVA can be performed in outpatient setting; suction curettage requires theatre.
Anaesthesia: MVA done under cervical block +/-sedation - suction curettage often done under GA but can also be done under cervical block +/- sedation.
Benefits of MVA:
MVA is more comfortable, because the suction pressure reduces as products are pulled into the collection tube.
MVA is quieter, thus less distressing for the awake pt.
MVA is cheaper, more portable, easily sterilised.
Benefits of suction curettage:
Suction curettage provides faster recourse to laparoscopy if concerns re. uterine perforation as done in theatre.
Suction curettage under GA better for select patients as:
- MVA may be distressing due to cervical dilation, emotional stress of being aware of procedure, pre-existing vaginismus/vuvlodynia
- MVA is only appropriate up to 10 weeks, thereafter suction curettage or D&E is safer.
MVA and suction curettage have comparable rates of RPOC.
What are the risks/complications of suction curettage?
How does Dilation and Evacuation compare?
- Mild pain and bleeding post-op is common
- 2-3/1000 failure rate
- 1-2% cases require repeat procedure for RPOC
- 10% risk infection
- 1/250 - 1/1000 risk uterine perforation
- <2/1000 risk haemorrhage needing blood transfusion
- <1/1000 risk cervical injury
- <1/1000 risk asherman’s syndrome
- < 1/100,000 risk of maternal death
Complications for D&E are comparable, though increase with advancing gestation.
Risk of cervical trauma increases significantly.
Risk of uterine perforation mild increase.
Risk of haemorrhage needing blood transfusion doubles.
What are the long term risks of abortion?
- Preterm birth -repeat abortion (particularly surgical, and particularly in absence of misoprostol cervical priming) increases risk of cervical damage and future preterm birth
- Long term sequelae of surgical complications (e.g. bowel/bladder damage after perforation)
- PID and/or subfertility as result of disseminated pelvic infection at time of procedure (particularly with chlamydia, gonnorhea, BV)
No evidence that abortion increases risk of:
- psychological trauma
- infertility
- early miscarriage
- ectopic pregnancy
- cancers
- placenta praevia
What is the procedure for early medical abortion?
How does it work?
Eligible if <9 weeks
200mg mifepristone
36-48hours later - 800mcg misoprostol SL/buccal/PV
Pain and bleeding start within first few hours
Many have delivered by 6-8 hours
95% delivered by 24 hours
Needs careful follow-up and either second course EMA if still <9wks, or recourse to STOP
What are the advantages and disadvantages of early medical abortion?
Benefits:
- perceived as more natural
- Allows woman to do at home in a more private/comfortable setting
- avoids risks related to surgery of cervical damage or uterine perforation, anaesthetic risks
- Can be used in women for whom surgery would be challenging and have higher risk of complications (e.g. cavity distorted by fibroids, significant cervical stenosis)
Disadvantages:
- 3% failure rate
- Pain and bleeding can be very distressing and not managed at home
- Takes longer to work (1-3 days, if effective)
- Bleeding continues for longer after treatment
- Higher total blood loss than surgical Rx
- Less opportunity to arrange LARC after
Contraindication to EMA.
Absolute:
- Allergy to mifepristone or prostaglandins
- Chronic adrenal failure (mifepristone has antiglucocorticoid activity)
- Severe asthma and conditions requiring long term steroid use (mifepristone has antiglucocorticoid activity)
- Porphyria
Relative:
- Bleeding diathesis or anticoagulation
- Severe anaemia <80g/L
- Current steroid use
- Multiple uterine scars or high risk for uterine rupture and morbidly adherent placenta
What are the options for late abortion after 14 weeks?
Late medical
Late surgical - can be offered up to 20 weeks
What are the requirements and procedure for late surgical abortion?
- Can be done up to 20 weeks
- Cervical preparation (with misoprostol till 16 weeks, with osmotic dilators after 16 weeks)
- Must be done in theatre, under adequate anaesthesia
- IV abs prophylaxis and IV syntocin after
- Requires experienced practitioner
- Requires specific instrument, including: large dilators up to size 16, forceps to crush skull
- US in theatre
- Suction curettage to complete procedure
How is the cervix prepared for STOP >16wks?
2 step procedure over 1 days (16-18wks) or 2 days (>18 weeks)
Step 1:
Lamisil or dilapan rods are inserted into the cervix in theatre after dilating cervix up to H12
Absord water by osmosis and swell to manually dilate cervix
Effect takes 3-4 hours
IV abs prophylaxis should be charted
Step 2:
1 day procedure: misoprostol 400mcg PV then 400mcg hourly for 2-3 hours, then STOP preformed 4 hours post rod placement
2 day procedure: misoprosotl 600mcg ducally on day 2, and further 400mcg after 4hours. STOP performed once symptomatic or after 1000-1400mcg misoprostol
If >20 weeks:
Return to OT day 2 for rod removal, ARM and reinsertion of new rods.
Then misoprostol regime.
