ABORTION CARE

Question 1

How common is abortion?

Answer 1

Over 20,000 procedures are performed each year in GB and at least 1/3rd of British women will have had an abortion by age 45

Question 2

How do women access abortion services?

Answer 2

They can self-refer or see a HCP

Question 3

Why are earlier abortions better?

Answer 3

They are safer overall
Ensures the women have access to more abortion options
Decreases adverse events
Improves the woman’s experience
Costs saved for NHS as more medical rather than surgical management

Question 4

Guidelines on how quickly an abortion should occur after woman has been referred?

Answer 4

Referral to an abortion provider, if not directly, should be made within 2 working days
These services must offer assessment within 5 working days
And then the services must offer women the abortion procedure within 5 working days of the decision to proceed
I..e total time from seeing the abortion provider to the procedure is <10 days

Question 5

Complications of abortion?

Answer 5

Uterine rupture if abortion at late gestation (risk <1 in 1000)
Severe bleeding requiring transfusion <1 in 1000 if done <20 weeks
Cervical trauma <1 in 100
Failure and requiring another procedure 7 in 100
Infection/sepsis 1 in 1000

Question 6

How is the infection risk post-surgical-abortion reduced?

Answer 6

Antibiotic use and bacterial screening for lower genital tract infection is done

Question 7

How does abortion affect future reproductive outcomes?

Answer 7

No proven associations with ectopics, placenta praevias or infertility
Very small increase in the risk of a subsequent preterm birth

Question 8

Pre-abortion assessment?

Answer 8

Bloods for determining rhesus blood status

May also include determining blood group with screening for red cell antibodies, measuring Hb concentrating and testing for haemoglobinopathies

VTE risk assessment
If not had cervical cytology screening then this should be be offered
Screening for C.trachomatis and undergo risk assessment for other STIs and screen for them if appropriate
Contraception should be discussed.

Question 9

What is Marie Stopes UK?

Answer 9

A charity that provides abortion services. They offer a remote service for women less than 10 weeks gestation where consultations are held by telephone and medications are issued remotely to be taken at home

Question 10

How is medical abortion done?

Answer 10

oral mifepirstone
24-48 hours followed by misoprostol (vaginal, buccal or sublingual)

(From 9 weeks gestation = additional doses of misoprostol will be given until expulsion)

Question 11

When can medical abortion be done?

Answer 11

Any gestation up to 24 weeks

Question 12

How do mifepristone and misoprostol work for a medical abortion?

Answer 12

Mifepristone is an anti-progestogen that halts the pregnancy and relaxes the cervix
Misoprostol is a prostaglandin that stimulates uterine contractions

Question 13

What must be done after a medical abortion and when?

Answer 13

A multi-level pregnancy test (i.e. detects hCG level) 2 weeks after to confirm the pregnancy has ended

Question 14

What are the surgical abortion options?

Answer 14

Manual vacuum aspiration
Electric vacuum aspiration
Dilatation and evacuation

Question 15

When can vacuum aspiration for abortion be done?

Answer 15

Usually up to 14 weeks

Question 16

When can dilatation and evacuation for abortion be done?

Answer 16

Usually above 14 weeks gestation

Question 17

What happens in vacuum aspiration termination of pregnancy?

Answer 17

A tube is inserted into the womb through the cervix and the pregnancy is removed using suction.
Takes 5-10 mins and women can go home a few hours later

Question 18

What happens in dilatation and evacuation termination of pregnancy?

Answer 18

Involves inserting forceps through the cervix and womb to remove the pregnancy
Carried out under sedation or GA
Takes 10-20 mins and women can go home thr same day

Question 19

What is done before any surgical termination of pregnancy?

Answer 19

Cervical priming with misoprostol 3 hours before surgery
Or osmotic dilators (devices inserted into the cervix that gradually expand as they absorb fluid, opening the cervical canal)

Question 20

Side effects of misoprostol?

Answer 20

Chills and shivering
Constipation and diarrhoea
Nausea and vomiting
Abdominal pain
Flatulence
Menstrual irregularities

Question 21

Side efefcts of mifepristone?

Answer 21

Abdominal cramps
Diarrhoea
Nauseaand vomiting
PID or infection
Uterine disorders
Vaginal haemorrhage

Question 22

After an abortion, who should recieve anti-D IgG?

Answer 22

All RhD negative women within 72 hours following abortion after 10+0 weeks gestation
Consider in those with a gestation <10 weeks if surgical

Question 23

When can medical abortions be done at home?

Answer 23

If its less than 10 weeks gestation and medical termination of pregnancy

Question 24

What is the Abortion Act 1967?

Answer 24

An act of Parliament of the Uk that legalised abortion in Great Britain on certain grounds by registered practitioners
The act made it lawful to have an abortion up to the 28th week if 2 registered medical practitioners believed in good faith that the continuation of the pregnancy would involve risk to the life of the pregnant woman or harm her physical/mental health, or that of any of her family members

Question 25

Changes to the Abortion Act 1967?

Answer 25

The Human fertilisation and Embryology Act 1990 made changes so that the time limits for abortion were lowered from 28 weeks to 24 weeks on the grounds that medical technology had advanced sufficiency to justify the change

Question 26

What are the statutory grounds for termination of pregnancy?

Answer 26

The continuance of pregnancy would involve risk to life of the pregnant woman greater than if the pregnancy was terminated
The termination is necessary to prevent grave permenant injury to the physical or mental health of the pregnant woman
The pregnancy has not exceeded its 24th weeks and the continuance of the pregnancy would involve risk, greater than if the pregnancy was termination, of injury to the physical or mental health of the pregnant woman, or to any existing children of the family of the pregnant woman
There is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped

Question 27

What are the statutory rules for permitting an emergency abortion?

Answer 27

To save the life of a pregnant woman
To prevent grave permenant injury to the physical/mental health of the pregnant woman

Question 28

What is the most common statutory ground that abortions are carried out on?

Answer 28

97%: pregnancy has not exceeded 24th week and continuance would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the woman

Question 29

Role of doctors in termination of pregnancy?

Answer 29

Make the care of your patient your first concern
Protect and promote the health of patients and the public
Provide a good standard of practice and care - help professional knowledge and skills up to date, work within levels of competence and work with colleagues to best serve pt interests
Treat patients as individuals and respect their dignity - polite, considerate and respect confidentiality
Work in partnership with patients - listen, respect pt right to reach decision, support pt in caring for themselves
Be honest and open, and act with integrity e.g. never discriminate unfairly

Question 30

What is the conscientious objection clause for abortion?

Answer 30

Permits doctors to refuse to participate in any treatment authorised by the abortion act if it conflicts with their religious or moral beliefs
Note: this does NOT apply where it is necessary to save lives or prevent grave permenant injury to the woman’s physical or mental health

Question 31

What should you do if abortion conflicts your religious or moral beliefs?

Answer 31

If the conflict might affect the treatment or advice you provide, you must explain this to the patient and tell them they have the right to see another doctor. You should make sure information about alternative services is readily available to patients.
You must support them through this

Question 32

Disposal of foetal tissue?

Answer 32

Foetal tissue must be treated with dignity and respect
In general it is incinerated. Some women may choose to use the local crematorium or burial services.
Women may decide to arrange disposal themselves and are free to do so

If a woman has a medical abortion at home then you should make them aware that if they wish they can return the products of conception to the provider for disposal

After 24 weeks then this is a stillbirth and by law the body needs to be buried or cremated

Question 33

The rights of the partner/spouse in the abortion?

Answer 33

The decision to have an abortion rests with the woman and her doctors
Legally the woman’s spouse has no right to demand or refuse an abortion

Question 34

How many medical practitioners must sign the legal document for termination of pregnancy?

Answer 34

2 registered medical practitioners
In an emergency only 1 is needed