Abortion care / Unplanned preg Flashcards
The sites of uterine perforation at surgical TOP by % incidence
Anterior wall 40% Cervical canal 36% Lateral wall 38% (21% right lateral 17% left lateral) Fundus 13% Posterior wall 13%
Pre-abortion assessment steps
Confirm pregnancy + gestation Pmhx and medication and allergies O+G hx, STI risk assessment, cervical hx social history + DV + safeguarding discuss pregnancy options Offer additional decision support explain procure options and risks Check patient fulfils abortion act criteria CT test and HIV Rh status contraception plan consent HSA1 x2 dr signatures
Average CRL at 6/40
0.5cm
Average CRL at 14 / 40
8cm
Average CRL at 11/40
4cm
At what gestations is early medical abortion carried out?
<10 weeks
what type of medication is mifepristone
and how does it work?
Synthetic steroid and progesterone receptor antagonist.
Inhibits the normal action of progesterone on the uterus which maintains a pregnancy.
Sensitizes the uterus to respond to prostaglandins
what type of medication is misoprostal
and how does it work?
Prostaglandin E1 analogue
Causes the uterus to contract and expel pregnancy tissues
Procedure steps for early medical abortion
200mg mifepristone PO
24-48 hours later = 800mcg misoprostal PV (unlicensed)
Abortion occurs 4-6 hours later
Common symptoms during medical abortion
Cramping pain and bleeding with passage of tissue
Nausea Vomiting Diarrhoea Headache Dizziness Flushing / sweats
At what gestations can MVA be performed?
<12 weeks
Anesthetic options for MVA
none
local anaesthetic
conscious sedation
general anaesthetic
when should cervical preparation be considered before surgical abortion?
In all cases
Misoprostal 400mcg in 1 hour before surgery if vaginal miso (3 hours if buccal)
or osmotic dilator (>14 weeks)
Steps for performing MVA under LA
Bimanual ex
LA to anterior lip
Tenaculum anteriorly
Complete cervical block at 3, 6, 9 o’clock positions
Dilate cervix
Engage MVA to create vacuum
Introduce plastic cannula
Attach aspirator
Release vacuum
Slow rotation and in+out motion to evacuate products
Empty and repeat until complete (gritty sensation)
At what gestations is dilation and evacuation STOP recommended
> 14 weeks
Method of dilatation and evactuation STOP
Cervical preparation General anesthetic Cervical dilation upto 24mm Crushing forceps and removal of fetus under ultrasound guidance Suction curettage to ensure empty cavity
Protocol commonly used for medical abortion 9-13 weeks
200mg mifepristone PO 36-48hours later 800mcg misoprostal PO or PV 3 hourly 400mcg misoprostal PO upto a maximum of 4 doses. Analgesia PRN
Protocol commonly used for medical abortion 14-24 weeks
Feticide if >21+6weeks
200mg mifepristone PO 36-48hours later 800mcg misoprostal PO or PV 3 hourly 400mcg misoprostal PO Overnight stay likely Analgesia PRN
Frequency of uterine perforation relating to STOP
1 in 1000
Frequency of cervical trauma relating to STOP
<1 in 100
Risk of severe haemorrhage related to medical abortion upto 13 weeks
< 1 in 1000
Risk of requiring surgical removal of retained products following a medical abortion up to 13 weeks
7 in 100
will need surgery to empty RPOC
Risk of sepsis related to medical abortion upto 13 weeks
<1 in 1000
Risk of requiring surgical removal of retained products following a medical abortion >13 <24 weeks
13 in 100
Risk of severe haemorrhage related to medical abortion at >13 <24 weeks
1-2 in 100
Risk of sepsis related to medical abortion at >13 <24 weeks
4 in 100
Risk of requiring repeat surgical procedure following a surgical abortion <13 weeks
3 -4 per 100
Risk of haemorrhage related to surgical abortion <13 weeks
1 in 1000
Risk of sepsis related to surgical abortion <13 weeks
1 in 1000
Risk of requiring repeat surgical procedure following a surgical abortion >13 <24 weeks
2-3 in 100
Risk of haemorrhage related to surgical abortion >13 <24 weeks
7 in 100 have haemorrhage requiring transfusion
Risk of sepsis related to surgical abortion >13 <24 weeks
< 1 in 100 women will develop sepsis
Risk of uterine rupture in women undergoing medical abortion at >13 <24 weeks
< 1 in 100 experience uterine rupture
(usually only occurs in the context of previous
caesarean section)
Possible perceived benefits of a medical abortion
Avoids need for surgery
Avoids an anaesthetic
The woman is awake and aware of the process which may enable them a sense of control
May feel more of a natural process than surgery to some women
Depending on gestation may be able to pass products at home
If performed in a clinic/ hospital = day case
May be considered more private
May be able to be accompanied
Possible perceived benefits of a surgical abortion
Can be performed under anesthetic or sedation
Avoids the woman seeing the pregnancy unless she requests to
Quick - Usually day case + home the same day
Usually reduced days of bleeding
May reduce duration and severity of cramping pain
Timing and duration is fixed
Can have contraception started / fitted at time of surgery
may require less repeat attendances
Possible perceived disadvantages of a surgical abortion
The woman will usually need
someone to accompany her home - if she
had sedation or GA
Overnight stay may be required
Must occur in hospital / clinic setting
Includes risks of uterine perforation or injury to the cervix
May be considered less private as requires more staff to be present
Usually cannot be accompanied during the procedure
Possible perceived disadvantages of a medical abortion
Increased pain and bleeding amount and duration
Timeframe for completing the abortion is more unpredictable
May require a follow up pregnancy test or ultrasound
May require more return visits than a surgical procedure
Can see the passage of blood and POC
Risk of uterine rupture if previous CS
Cannot have IUS / IUD inserted immediately if completed at home
What additional information may be needed for a woman having a termination because of fetal anomaly?
May be provided in the maternity setting or need referral to a separate termination service.
Confirm they have sufficient information about the anomaly
Explain that the fetus may not look abnormal despite there being a fetal anomaly
What other agencies should a TOP service have links with
gynaecology / EPAU for non-vibiable IUP or ectopic AN services Social care Adult safeguarding Child safeguarding DV support Sexual abuse support Alcohol and drug support community SRH GUM
What are the grounds for abortion
A-G
A - continuance of the pregnancy would involve risk to the life of the pregnant woman greater than termination
B - termination necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
C - pregnancy not >24 weeks and continuance would involve risk, greater than termination, of injury to physical / mental health of the woman
D - pregnancy not >24 weeks and continuance o would involve risk, greater than termination, of injury to the physical / mental health of any existing child(ren) of the family of the pregnant woman
E - a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped:
In an emergency if a termination is immediately necessary:
F - to save the life of the pregnant woman
G - to prevent grave permanent injury to the physical or mental health of the pregnant woman
WHO definition of unsafe abortion
WHO defines unsafe abortion as
“a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both”.
Risk of continuing pregnancy after surgical abortion
Continuing pregnancy after surgical abortion occurs in
0.2% of procedures at 12 weeks or less.
What factors may increase the risk of an ongoing pregnancy after surgical termination?
Procedure in a multiparous woman Conducted at six weeks’ gestation or less, When small suction cannulae are used, Performed by inexperienced surgeons Women with uterine abnormalities
Risk of continuing pregnancy after medical abortion
ongoing pregnancy rate for early medical abortion with recommended mifepristone-misoprostol regimens is
0.5 - 0.7%
More common with oral or lower doses of misoprostol.
vacuum aspiration is the treatment of choice because another dose of misoprostol is effective in <40%
