ERPC, TOP

Question 1

ERPC/’Surgical management of miscarriage’: what are the two surgical management options for miscarriage? What are the indications for each?

Answer 1

1. Vacuum aspiration (suction curettage) - done under local anaesthetic as an outpatient
   
   • Indication: <14 weeks gestation
2. Surgical management in theatre/ dilation and evacuation - done in theatre under GA. Previously called ERPC (evacuation of retained products of conception).
   
   • Indication: >14 weeks gestation

Question 2

Describe vacuum aspiration ERPC.

Answer 2

1. Done under local or GA
2. Sublingual 400mcg misoprostol 1hr pre-treatment to enable cervical dilation (should be used in all >12 weeks TOPs)
3. Gentle dilation of cervix with graduated dilators (usually to size in mm that the uterus is in weeks’ gestation)
4. Gentle suction performed using:
   
   • MVA or
   • EVA
5. Prophylactic antibiotics periabortal (not necessary in medical abortion)

*sharp curettage should never be performed due to risk of perforation and intrauterine adhesions (Asherman’s syndrome)

Question 3

What is the difference between MVA and EVA in ERPC?

Answer 3

• MVA = manual vacuum aspiration
• EVA = electrical vacuum aspiration

There is little to choose between MVA and EVA. The MVA may be more practical and portable for use in the outpatient setting. The EVA gives a more constant suction.

Question 4

Describe dilation and evacuation ERPC.

Answer 4

1. Pre-procedure cervical dilation achieved by:
   
   1. Osmotic dilators - (hygroscopic sticks placed in the cervix several hours preprocedure that absorb fluid from surrounding tissues, causing them to swell and bring about cervical dilation) or
   2. Misoprostol (PV or SL) or
   3. Mifepristone (PO)
2. Surgical dilation using graduated dilators
3. Removal of tissue using aspiration and instruments
4. US to confirm complete evacuation
5. Prophylactic antibiotics periabortal

(This is used at >14 weeks’ gestation)

Question 5

How soon after ERPC can women attempt to concieve?

Answer 5

Immediately after next menstrual cycle

Question 6

What are the complications of ERPC/SMM?

Answer 6

Immediate:

• Heavy bleeding (1 in 200) - may need a blood transfusion (1 in 1000)
• Perforation of uterus (1 in 1000) and damage to nearby bladder/bowel requiring laparoscopy + overnight stay
• Retained tissue (5 in 100) - signs incl persistent bleeding >2 weeks

Short-term:

• Pain - like period pain for 1-2 days
• Infection (4 in 100) - signs incl offensive discharge, fever, malaise, heavy bleeding and pain.

Long-term:

Asherman’s syndrome - signs are amenorrhoea for 2-3 months post ERPC with pre-menstrual symptoms

Question 7

What advice should you giev following SMM?

Answer 7

GA side-effects - stay at home with someone overnight, do not drive, do not drink alcohol or tae sleeping tablets. No heavy lifting for 24 hours.

Pain - can be controlled with paracetamol/ibuprofen

Discharge - can last up to 2 weeks and be brown; might be heavier than normal period. Do not use tampons or have sex during this time.

Histology - ask for permission for tissue to be examined for molar pregnancy; does not give reason for miscarriage

Question 8

If the woman is rhesus negative, what should be given post ERPC?

Answer 8

Anti-D

Question 9

Give 3 reasons for why SMM might be preferred over other management options for miscarriage.

Answer 9

• Heavy bleeding or expected heavy bleeding
• Infection
• Patient choice

Question 10

What is the current law around abortion based on? How and when was it amended?

Answer 10

Based on the 1967 Abortion Act.

In 1990 the act was amended, reducing the upper limit from 28 weeks gestation to 24 weeks

Question 11

What are the grounds that need to be met for abortion to be carried out?

Answer 11

Two two registered medical practitioners must sign a legal document (in an emergency only one is needed) that _>_1 of these grounds are met:

A - continuing would risk life of woman and risk would be greater than if the pregnancy were terminated

B - termination necessary to prevent grave permanent injury to mental or physical health of woman

C - pregnancy not exceeded its 24th week + continuance would involve risk greater than if the pregnancy were terminated of injury to mental or physical health of the mother

D - same as C but risk greater than if the pregnancy were terminated of injury to the mental of pshsycial helath of any existing child or the family of the woman

E - substantial risk that the child would be seriously handicapped due to physical or mental abnormalities

F - save life of the pregnant woman

G - prevent grave permanent injury to the physical or mental health of the pregnant woman

Question 12

Which Abortion Act 1967 grounds are applicable in an emergency?

Answer 12

F and G

“…termination is immediately necessary…”

Question 13

Who can perform abortions and where?

Answer 13

Only a registered medical practitioner

Must be doen in a NHS hospital or licensed premise

Question 14

What is RU486?

Answer 14

This is the name that mifepristone may be referred to as

Mifepristone is an anti-progestogen

Question 15

Does the 24 week cut off still apply if there is evidence of extreme fetal abnormality?

Answer 15

No - the 24 week cut off does not apply if:

1. it is necessary to save the life of the woman, t
2. here is evidence of extreme fetal abnormality,
3. there is risk of serious physical or mental injury to the woman.

Question 16

Is there any medical need for 2 practitioners to be invovled in authorising an abortion?

Answer 16

No medical need for two doctors to be involved, and the British Medical Association Ethics Committee have argued that the law should be changed to reflect this

Question 17

Can a practitioner object to participate in abortion?

Answer 17

Any medical practitioner who has an objection to abortion is not required to participate in abortion services, unless the treatment is necessary to save the life of the pregnant woman.

However, a medical practitioner who conscientiously objects to abortion should still provide advice and refer a woman promptly to another doctor who does not hold such views.

Question 18

What preabortion investigations should be done?

Answer 18

Recommended:

• Gestation assessment by USS
• Rhesus status - anti-D required for non-immunised rhesus negative

Consider:

• STI testing - chlamydia, gonorrhoea, HIV, syphilis
• FBC - check for anaemia

Question 19

Which legal grounds are most abortions carried out on in the UK?

Answer 19

Ground C

1% are carried out for ground E (serious fetal abnormality)

Question 20

What is the 24 week abortion limit based on?

Answer 20

24 weeks (23 completed weeks) reflects fetal viability as a result of improvement in neonatal care

Question 21

Why deos RCOG recommend abortions not to be delayed unnecessarily?

Answer 21

At earlier gestations, medical methods can be used with greater efficacy and there is less pain and bleeding and lower risk of complications

Question 22

What are the options for TOP at different gestations?

Answer 22

<9 weeks - mifepristone (anti-progesterone) followed by prostaglandins (misoprostol) 48 hours later to stimulate intrauterine contractions

>9 weeks - same combination of mifepristone and misoprostol except misoprostol is administered every 3 hours until expulsion occurs

<13 weeks - surgical dilation and suction of uterine contents

>15 weeks - surgical dilation and evacuation of uterine contents or late medical abortion (induced ‘mini-labour’ )

Question 23

Describe the steps of medical abortion.

Answer 23

• Mifepristone orally given
• Misoprostol given 24-48 hours later to allow expulsion
• Simple oral analgesia (e.g. ibuprofen, dihydrocodeine) should be sufficient to provide pain relief
• At 9 weeks, expect to bleed for ~2 weeks which can be managed at home. After 9 weeks, shouls be managed in a clinical setting. At >12 weeks, average induction to abortion time from misoprostol dose is 7 hours.

Question 24

Does the fetus feel pain id aborted at <24 weeks?

Answer 24

No - neural pathways necessary to experience pain are not fully developed in the fetus until after 24 weeks

Question 25

What does RCOG reommend for medical abortion after 21 completed weeks (21 weeks and 6 days)?

Answer 25

Feticide to eliminate the possibility of the aborted fetus showing signs of life Done by: * intracardiac injection of potassium chloride OR * intrafetal or intraamniotic injection of digoxin

Question 26

Describe the steps of surgical abortion (vacuum aspiration).

Answer 26

* Used until 14 weeks * Involves gently dilating the cervix and using vacuum suction to evacuate the uterus * Can be performed under local or general anaesthetic * Cervix is usually pre-treated with misoprostol * Prophylactic antibiotics (metronidazole) can be given to reduce the risk of infection

Question 27

Describe the steps of surgical abortion (D&E)

Answer 27

* Dilation and evacuation is used over 14 weeks * Required good cervical dilatation to remove larger foetal parts (up to 20mm) * Misoprostol\* (3 hours pre-surgery, vaginal or sublingual) is used to ripen the cervix to allow easier dilatation * Contents of the uterus extracted using aspiration and other instruments (e.g. forceps) * Ultrasound is required to confirm evacuation \* alternatively osmotic dilators (hygroscopic sticks placed in the cervix several hours preprocedure that absorb fluid from surrounding tissues causing them to swell and cause cervical dilation) or mifepristone (oral)

Question 28

What are the complications of surgical TOP?

Answer 28

* Failure - ongoing pregnancy * Incomplete abortion - requiring evacuation * Infection * Haemorrhage * Exacerbation of mental health problems post-abortion or distress - higher risk if unsupported, ambivalent about the decision, feeling that abortion is morally wrong

Question 29

What does abortion not impact on (as sometimes believed)?

Answer 29

No impact on: * Future reproductive potential unless severe infection or operative complications * No association with infertility or ectopic pregnancy

Question 30

What follow-up is necessary post abortion?

Answer 30

Not if uncomplicated but must provide safety netting advice and access to 24 hour care should anything go wrong Confirming completion: * Scheduled ultrasound * Self-performed urine pregnancy * +/- a telephone call from the provider to determine the result of the pregnancy test + duration of bleeding/symptoms of pregnancy

Question 31

When is contraception necessary post-abortion?

Answer 31

Immediately after abortion - LARC is most effective at preventing future unintended pregnancies. Can be inserted at time of surgical abortion.