Contraception/abortion Flashcards
what percentage of pregnancies are unplanned?
30-50%
what poor outcomes may result from continuation of an unplanned pregnancy
later and less frequent antenatal care increased preterm birth and low birth weight increased postpartum depression reduced breastfeeding decreased bonding increased rates of neglect and abuse poorer long term developmental outcomes
how many unplanned pregnancies end in abortion
30-40%
what law allows for pregnancy termination in the UK
Abortion act 1967
recently NI extension to 11+6 wks and beyond 12wks in specific circumstances
what legal document is required for abortion and who needs to sign it
HSA1 - green form
2 doctors
what does clause C of the HSA1 allow
abortion allowed up to 23+6 weeks
continuance of pregnancy leads to greater risk than if it was terminated
what does clause E of the HSA 1 allow
abortion up to full term justified if there is risk the child born with a mental or physical abnormality leading to severe disability
true/false - in an emergency one doctor can sign a HSA1 form
true
healthcare professionals can refuse to participate in abortion care with select exceptions. what are these?
doesnt apply if emergency/life threatening
should not delay or prevent patient access to care
should not affect indirect tasks associated with abortion
what is the time aim from referral to initial termination consultation
5 days
what time aim is given between referral for termination and procedure
2 wks
methods of abortion?
medical
surgical
clinical assessment of gestation?
palpable uterus in >12wks
LMP and date of +ve UPT
USS assessment of gestation?
abdominal USS or transvaginal if <6wks
only given really for risk ie symptoms or risk of ectopic, uncertain dates or STOP
how may a MTOP be given <12 weeks
at home
mifepristone followed by misoprostol 24-48 hours later
in a patient who had MTOP <12 weeks with no bleed what do you do
<10wks - further dose of misoprostol if not bleeding within 4 hours
>10 wks to 11+6 - 3 further doses misoprostol
how long are MTOP available for
in scotland up to 19+6 before needing travel to england
theoretically in clause E to full term
to clause C - 23+6
what is an EMAH and what is contained in an EMAH pack
early medical abortion at home mifepristone misoprostol antiemitic analgesia Abx 6/12 POP patient info and contact info sheet LSUPT
how may MTOP be performed >12wks
inpatient procedure
dose mifepristone and repeated doses of PV misoprostol
how may STOP be performed <14 wks
electric vacuum aspiration under general anaesthetic
manual vacuum anaesthetic by local anaesthetic but only up to 10wks
how may STOP be performed >14 wks
dilatation of cervix and evacuation
complications of medical abortion
haemorrhage
failed/incomplete termination
infection
complications of STOP
haemorrhage failed/incomplete infection uterine perforation cervical trauma
in who is Abx prophylaxis given for termination and what is given
medical abortion at high STI risk
all those undergoing STOP
doxy 7 days
in who is rhesus iso-immunisation given and why
women at risk who are Rh-ve
anti-D Ig
abortion can be sensitising to lead to development of anti-D Ab
can cross placenta in future pregnancies and leaf to destruction of Rh+ve foetal cells
what is given as VTE prophylaxis and for how long
risk assess
if high risk then LMWH 1 week post abortion
if very high risk then LMWH before abortion and considered up to 6 weeks after
can contraception be started right after abortion?
yes
is contraception fully effective after abortion
yes, if started within 5 days, if not then will take 2 days for POP or 7 for CHC, DMPA, SDI, LNG-IUS
when would you avoid use of an intrauterine method of contraception following termination
post abortion sepsis
when can barrier methods be used following termination
any time
avoid FAM until regular periods
sterilise consider after time as there is risk of regret or failure
diaphragm cannot be used after 2nd trimester TOP
follow up following EMAH?
low sensitivity UPT at least 2 weeks after
most effective emergency contraceptive? terms of use
copper IUD
fit within 5 days of early possible day ovulation or 5 days after single episode of sex
true/false - oral methods of contraception are not affected by liver induding drugs
false- they are affected by them
mechanism of action of levonorgestrel, terms of use
large dose progestogen to inhibit ovulation
need double dose if >70kg
best if in 24hrs but up to 72
good for needing quickstart contraceptive
mechanism of action of ulipristal acetate, terms of use and caveat of use for POP
progesterone receptor modulator to block progesterone receptor
5 days post unprotected sex
prevents LH surge
licensed for 5 days
POP cannot be used 5 days before or after
what forms of contraception prevent ovulation
most hormone methods except hormone coil
suppress FSH/LH
emergency to delay
what forms of contraception prevent fertilisation
condom, diaphragm, spermicide, sterilisation, IUS/IUD
what forms of contraception prevent implantation
hormonal
IUD as a secondary
copper coil as emergency
risk of pregnancy in withdrawal method in 1y
20%
factors to consider in contraception use
experience age child protection consent frequency/sex relationship status pregnancy risk and STI future plans lifestyle and compliance weight blood pressure PMHx breastfeeding SHx side effects procedure non hormonal effect?? migraine
what child protection concerns may arise with contraceptive advice
sex <13
age gap >2yrs in <18
power imbalance
drug/alcohol use or grooming
non-contraceptive benefits of hormonal contraception
period pain heavy bleed irregular bleed ovulation pain PMS cyclical breast tenderness cysts endometriosis ovarian cancer acne/hirsutism
reasons for condom failure
too late wrong lube wrong technique wrong size inconsistent use wrong storage damage on opening expired
reasons for diaphragm failure
too late removed early wrong technique inconsistent no damage check
reasons for CHC, POP, DMPA failure
inconsistent use late injection wrong storage late replacement drug interaction
reasons for iatrogenic contraception failure
poor counselling no extra precaution recommended drug interaction malposition or expulsion incorrect insertion
how long does IUD/IUS last
3-10 years
complications of IUD/IUS insertion
perforation, PID, expulsion
invasive and pain
how long can copper coil be used
up to 10yrs
if inserted >40 then can be kept up to menopause
what is the only method of contraceptive that mahy be reliable post breast cancer
copper IUD
side effects of copper IUD
can make periods longer, heavier and more painful esp in first 3m
true/false - hormonal IUS is more effective than copper coil
true
side effects of IUS
irreg spotting, bleeding in first few months then side effects low
alternative indication for mirena coil
heavy periods, HRT, hyperplasia or endometriosis
what is the most effective contraceptive
SCI
how long does SCI last
3yrs
how long does SCI take to work
7 days
what side effect can happen with SCI
prolonged bleeding
what score category can be used for contraceptive eligbility
UKMEC
how does CHC act, what are the failure rates
prevent ovulation
0.3% perfect use, user failure 8%
how to take CHC
start if first 5 days period or any time when not pregnant and use condoms for 7 days
take 21 days with 7 day break
can tricycle with 7 days off after
or take continuously until bleed, come off 4 days and start
factors affecting effectiveness of CHC
impaired absorption in GI conditions
increased metabolism, liver enzyme induction, drug interaction
compliance
risks associated with CHC
venous or arterial thrombosis adverse effect cancers systemic HTN migraine with aura age >35 breast and cervical cancer
benefits associated with CHC
reduced ovarian and endometrial cancer benefit on acne reduced PCOS lesser PMS lesser intense bleeding
side effects of CHC
breakthrough bleed breast tenderness worsening acne nausea all major risks
risks of cervical cancer with CHC
increased after 5 years
reduced after 10yrs
condom use and HPV vaccination
cervical screens
risks of breast cancer with CHC
increased but reduces 10 years off
risk of age >35 with CHC
UKMEC 2
risk but benefit outweighs
consider other risks as they can be contraindication
risk of systolic HTN and management with CHC
small increase
check 3m
needs to be <140/90
risk of arterial thrombosis with CHC
increased risk MI or stroke
particularly in smoking or HTN
risk of venous thrombosis with CHC
depends on dosage
prescribe with lowest risk involved
discuss signs and symptoms
risks of migraine with aura and CHC
ABSOLUTE CONTRAINDICATION
UKMEC 4
increases stroke risk
need to establish true aura - change 5-20 mins before headache
scotoma, altered sensation, taste, smell or hemiparesis
types of POP and mechanism
desogestrel, non-desogestrel
desogestrel acts to inhibit ovulation and all others thicken cervical mucus
how to take POP
taken day 1-5 period or any time if not pregnant and use condoms 7 days
absolute contraindication for POP
breast cancer
side effects POP
headache
bleeding
nausea
acne
missed POP?
take at same time
if late only matters if >12hrs
if >12hrs then wont work for 2 days
how does depot provera or sayana press work
lowers oestradiol and suppresses FSH
isnt affected by enzyme affecting drugs so good for epilepsy
side effect sayana press/ DMPA
weight gain nausea acne headache bleeding
discuss bone health and depot
can cause issues with peak bone age if given in teens
can be given if absolutely necessary but avoid
cannot be used in poor Ca absorption or strong FHx
try to avoid in menopause
how to use diaphragm/cap
use spermicide
put in before sex and take out after 6 hours
uses of diaphragm/cap
not wanting UID
family spacing
not good for absolute avoidance
71-88% effective
true/false - female sterilisation works better than male sterilisation
false
how effective is natural family planning
76%
only really if wanting something natural
counselling for vasectomy
weight up risk and benefit
regret?
consider other options
effectiveness of male sterilisation?
very low failure, very effective and can be hard to reverse
complications of vasectomy
pain anaesthetic infection bleeding haematoma failure - semen analysis needed
