Early Pregnancy (Termination of pregnancies)

Question 1

What is the most common cause of abortion after 20 weeks? [1]

What are others? [5]

Answer 1

Fetal anomaly

Question 2

Describe the legal framework of abortions [1]

Answer 2

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.

Question 3

An abortion can be performed at any time during a pregnancy in which circumstances? [3]

Answer 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

Question 4

What are the legal requirements for an abortion to proceed? [2]

Answer 4

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

Question 5

Since 2020, in England, which drugs can be sent for a home abortion? [1]

Answer 5

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.

Question 6

Under which clause are 98% of abortions under? [1]

Answer 6

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

Question 7

Descrine the difference in types of medical / surgical abortion offered depending on gestation time [4]

Answer 7

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

Question 8

In England & Wales - up to when can you have pills by post (early medical management)? [1]
In Scotland? [1]

Describe the medical management [2]

Answer 8

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.

Question 9

What are the MoAs of mifepristone and misoprostol? [2]

Answer 9

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.

Question 10

Describe what the symptoms are like for someone who has undergone medical abortion < 10 / 12 weeks [5]

Answer 10

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

Question 11

Describe the medical management for an abortion > 10/12 weeks? [2]

Answer 11

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

Question 12

How do you medically manage a pregnancy > 22 weeks? [2]

Answer 12

Feticide recommended from 22 weeks to avoid possibility of birth with signs of life
* Digoxin: intraamniotic, intrafetal, intracardiac
* Potassium chloride: intracardiac

Question 13

How do you perform vacuum aspiration - up to 14 weeks? [2]

Answer 13

• Dilation of cervix and aspiration of pregnancy tissue with electric or manual suction
• Local (manual suction) or general anaesthesia (electric) or conscious sedation

Question 14

Describe the surgical process from 14+ plus [3]

Answer 14

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

Question 15

Post-surgery, what medication do you need to consider / give? [2]

Answer 15

**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

Question 16

What is the most common complication from EMA? [1]

Answer 16

Question 17

How do you follow up an abortion? [1]

Answer 17

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

Question 18

When should a patient seek medical attention post-abortion? [5]

Answer 18

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

Question 19

Describe how retained products of contraception would present and how you would manage this complication of abortion

Answer 19

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

Question 20

What is another complication (aside from retained products), could occur from abortion? [1]
Describe the signs and symptoms [4]

Answer 20

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