Early Pregnancy (Termination of pregnancies) Flashcards
What is the most common cause of abortion after 20 weeks? [1]
What are others? [5]
Fetal anomaly
Describe the legal framework of abortions [1]
The legal framework for a termination of pregnancy is the 1967 Abortion Act.
The 1990 Human Fertilisation and Embryology Act altered and expanded the criteria for an abortion, and reduced the latest gestational age where an abortion is legal from 28 weeks to 24 weeks.
An abortion can be performed at any time during a pregnancy in which circumstances? [3]
Continuing the pregnancy is likely to risk the life of the woman
Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
What are the legal requirements for an abortion to proceed? [2]
Two registered medical practitioners must sign to agree abortion is indicated - have to be doctors. Sign an HSA1 form
- Form retained for 7 years in the notes
It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
Since 2020, in England, which drugs can be sent for a home abortion? [1]
Until 2019, misoprostol had to be taken in clinic, causing pain and misery on the way home. Now the pregnant person’s home is deemed in law to be a permitted place for early medical abortion.
Under which clause are 98% of abortions under? [1]
Clause C:
- carrying a pregnancy to term is physically more dangerous than having an abortion
- if dont want a pregnancy - then this clause protects their mental health
Descrine the difference in types of medical / surgical abortion offered depending on gestation time [4]
Medical
* < 12 weeks: early medical abortions: at home or clinical facility
* >12 weeks: have to be at a clinic
Surgical
* < 14 weeks: manual or electic aspiration
* > 14 weeks: dilatation or evacuation
In England & Wales - up to when can you have pills by post (early medical management)? [1]
In Scotland? [1]
Describe the medical management [2]
England & Wales: < 10 weeks
Scotland: < 12 weeks
Medication:
- MiFepristone - First drug @ home or in clinic. Ends the pregnancy but doesn’t cause the pregnancy to pass. Therefore 24-48 hrs later..
- MiSoprostol - Second drug. Acts to cause contractions that pass the pregnancy, at home or clinic.
What are the MoAs of mifepristone and misoprostol? [2]
Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix.
Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions. From 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion.
Describe what the symptoms are like for someone who has undergone medical abortion < 10 / 12 weeks [5]
Symptoms typically start 2-3 hours after starting misoprostol (second medication)
* Vaginal bleeding - gestational age correlates to bleeding amount
* Heavy with clots
* Some bleeding up to 2-3 weeks - normal
* Lower abdominal pain - stronger than period pain
Bad period-like cramping pain
* Most complete within 6-8 hours, almost all by 24 hours
Since telemedicine, EMA can be provided in many circumstances without the need for a scan
Describe the medical management for an abortion > 10/12 weeks? [2]
Mifepristone 200 mg orally
* Repeated doses of misoprostol at 3 hour intervals starting 24 hours post mifepristone - because pregnancy is more developed and larger
* In patient
How do you medically manage a pregnancy > 22 weeks? [2]
Feticide recommended from 22 weeks to avoid possibility of birth with signs of life
* Digoxin: intraamniotic, intrafetal, intracardiac
* Potassium chloride: intracardiac
How do you perform vacuum aspiration - up to 14 weeks? [2]
- Dilation of cervix and aspiration of pregnancy tissue with electric or manual suction
- Local (manual suction) or general anaesthesia (electric) or conscious sedation
Describe the surgical process from 14+ plus [3]
Dilatation and evacuation (D&E)
Typically from 14-24 weeks
* Cervical preparation with mifepristone / misoprostol (or both) / osmotic dilators inserted into cervical os; absorb fluid and then dilate cervix
* Cervical dilation and removal of fetus and placenta using forceps and vacuum aspiration
Post-surgery, what medication do you need to consider / give? [2]
Antibiotic prophylaxis
* Not required for early medical abortion
* Surgical: doxycycline 100mg bd for 3 days (or Azithromycin 1g oral)
Anti-D
* Not required for early medical abortion
* Prophylactic anti-D for all Rh negative, non-sensitised women undergoing surgical abortion
* Administer within 72 hours of abortion
What is the most common complication from EMA? [1]
How do you follow up an abortion? [1]
Important to do low sensitivity PT 3 weeks after medical abortion
- Low sensitivity because the high street ones are too sensitive and would detect a +ve result even though levels are appriopriate post abortion
When should a patient seek medical attention post-abortion? [5]
Very heavy bleeding
* If soaking more than two pads per hour for two consecutive hours
* Symptoms of anaemia e.g. dizziness, SOB, palpitations, fatigue
Persistent bleeding or pain (more than a week)
Offensive vaginal discharge
High fever or feeling systemically unwell
Also should contact abortion service if persistent bleeding >3 weeks or positive low sensitivity pregnancy test at 3 weeks post EMA
Describe how retained products of contraception would present and how you would manage this complication of abortion
Placental or fetal tissue left inside uterus:
* Usually presents with persistent pain and/or bleeding
* Can be associated with infection
* Clinical diagnosis however patients will usually have an ultrasound scan
What is another complication (aside from retained products), could occur from abortion? [1]
Describe the signs and symptoms [4]
Infection of the lining of uterus, may extend to upper genital tract
Signs and symptoms:
* Persistent lower abdominal pain / tenderness
* Pain with intercourse (deep dyspareunia)
* Persistent bleeding
* Unusual vaginal discharge
* Fever
* Cervical motion tenderness
