Abortion Care

Question 1

Which act gives doctors legal defense when preforming terminations?

Answer 1

1967 abortion act

Question 2

When are patients able to have an abortion at home?

Answer 2

Under 12 weeks in Scotland.
Under 10 weeks in England and Wales

Question 3

What act limits the time available for abortions?

Answer 3

The human fertilization and Embryology act 1990. Means patients can only have an abortion below 24 weeks gestation.

Question 4

What is the 1967 abortion act?

Answer 4

Makes an abortion legal if preformed by registered medical practitioner. Must be authorized by two doctors.

Question 5

What did the HFE Act 1990 do?

Answer 5

Remove time limit on abortions on a fetus with serious disability.
There is no set criteria for disability

Question 6

Important history questions to ask regarding abortions and periods

Answer 6

When was your last menstrual periods?
Was it a normal period (heavy and as long as normal)?
Are your cycles regular?

Question 6

What re the indications for an ultrasound before a termination?

Answer 6

IUD in situ,
LMP over 10 weeks,
Uncertainty around LMP,
Irregular/absent periods,
Ectopic pregnancy risk

Question 6

Describe features of induced abortions

Answer 6

Medical abortions:
- Medical termination of pregnancy (MTOP)
- Early medical abortion at Home (EMAH)
Surgical abortions:
- Surgical termination of pregnancy (STOP).
- Manual vacuum aspiration (MVA),
- Electric vacuum aspiration (EVA)
- Dilation and Evacuation (D&E)

Question 7

Describe features of spontaneous abortion

Answer 7

Usually referred to as a miscarriage and occurs before 24 weeks.

Question 8

Who should get screening for ectopic pregnancy?

Answer 8

Previous ectopic pregnancy,
Damaged fallopian tubes
IUD in place

Question 9

What are the symptoms of an ectopic pregnancy?

Answer 9

Non ruptures - Vaginal bleeding/spotting and abdominal pain.
Ruptured - Pain under ribs/shoulder tip pain, severe abdominal pain, signs of shock and rebound tenderness.

Question 10

WHat are the CI to medical abortion?

Answer 10

Allergy to mifepristone or misoprostol,
Chronic adrenal failure,
Severe uncontrolled asthma,
Inherited porphyria,
Known/suspected ectopic pregnancy.

Question 11

What are the CI to surgical abortions?

Answer 11

Inability to remove pregnancy through cervix.

Question 12

What are the examinations and investigations done prior to an abortion?

Answer 12

Examination - if surgical abortion then do BP, pulse, respirations, temp and BMI
Screen for STIs,
Rhesus status for abortions > 10-12 wks.
Hb if concerned for anaemia.
Selective other tests eg LFTs, UEs

Question 13

Explain the pharmacology of the drugs used in terminations

Answer 13

MiFepristone (F for first) - Antiprogesterone drug which causes decidual necrosis, detachment, cervical softening and dilation. Sensitization to prostaglandins.

MiSoprostol (S for second) - Prostaglandin-analogue. Softens and dilates the cervix. Causes uterine contractions and expulsion of the pregnancy.

Question 14

What is the regimens for medical abortions under 12 weeks?

Answer 14

MiFepristone 200mg taken orally.

Then 24-48 hours later

MiSoprostol 800 micrograms (four tables) taken vaginal, buccal or sublingual. Ideally vaginal!

Patients are also given cyclizine and dihydrocodine.

Question 15

How long does it take for a pregnancy test to turn negative after termination?

Answer 15

6 weeks for shop bought tests.
3 weeks for sandyford tests.

Question 16

What are the side effects of misoprostrol?

Answer 16

Hot flushes,
Dizziness,
Chills,
N+V,
Headaches
Diarrhoea.
Fewer GI side effects if taken vaginally.

Question 17

What should patients expect following a medical abortion?

Answer 17

Abdominal cramping (more painful than a periods)
Vaginal bleeding (heavier than period and does have clots)

Question 18

When should patients seek medical attention following termination?

Answer 18

Very heavy bleeding (soaking >2pads per hour),
Little or no bleeding 24 hours after misoprostrol.
Ongoing/new abdominal pain.
Fever and or unusual smelling or discoloured vaginal discharge.
Feeling generally unwell.
Ongoing bleeding after 4 weeks.

Question 19

What is the difference for medical abortions done >12 weeks?

Answer 19

Extra misoprostol 400 mcg is given every 3 hours until abortion occurs.
Feticide recommended from 22 weeks onwards to avoid possibility of a live birth (digoxin or potassium chloride)

Question 20

Describe features of vacuum adpiration

Answer 20

Done up to 13 weeks.
Misoprostrol is used to cause cervical dilations.
Local or general anesthesia.
Aspiration of pregnancy with electrical or manual suction.De

Question 21

Describe features of dilation and evacuation

Answer 21

It is done after 13 weeks.
Generally done under GA.
Cervical preperation then removal of pregnancy using forceps and vaccum aspiration

Question 22

What are the side effects following surgical abortion?

Answer 22

Abdominal cramping and vaginal bleeding. Avoid bathing, swimming, sex and tampons.

Question 23

When should you seek medical attention following surgical abortion?

Answer 23

Very heavy bleeding,
High fever or systemically unwell,
Persistent or worsening abdominal pain,
Unusual-smelling vaginal discharge,
Signs of ongoing pregnancy

Question 24

What are the complications of abortions?

Answer 24

Failure to end pregnancy,
Retained tissues,
Infections,
Haemorrhage,
Cervical tear,
Uterine perforation.

Question 25

Describe features of retained products of conception

Answer 25

Placental or fetal tissue left inside the uterus. This usually presents with persistent pain and or bleeding.
May have infection.
Usually clinical diagnosis but can do ultrasound

Question 26

How can you manage retained products of pregnancy?

Answer 26

Watchful waiting,
Medical - further dose of misoprostol.
Surgical - evacuation of retained products of conception.
Urgent evacuation if heavy bleeding/haemodynamically unstable/infection

Question 27

Describe features of endometritis

Answer 27

It is an infection of the lining of uterus which may extend to upper genital tract.
Presentation: lower abdominal pain/tenderness, pain with intercourse, persistent bleeding, offensive vaginal discharge, fever and cervical motion tenderness.
May occur in first few days after abortion

Question 28

How do you manage endometritis?

Answer 28

Give broad spectrum antibiotics and analgesia.
Admission to hospital for IV abx and fluids if systemically unwell.

Question 29

Describe features of uterine perforation

Answer 29

Usually recognized at time of procedure or presents 48hr later with severe pain +/- bleeding.
Do laparoscopy/laparotomy and repair.