Pregnancy Termination

Question 1

in the US in 2008, what % of pregnancies were unintended and what % were terminated

Answer 1

50% unintended

19% terminated

Question 2

in what age groups are abortion rates highest

Answer 2

ages 20-24 and ages 25-29

Question 3

what should preoperative counselling contain when discussing pregnancy termination

Answer 3

thorough discussion of various types of pregnancy termination procedures, risks, benefits and expected outcomes of each

a non directive discussion of alternatives (continuing pregnancy, adoption)

signed informed consent form

Question 4

prior to pregnancy termination, when should you order an U/S

Answer 4

if GA is questionable

if an intrauterine gestation is uncertain

in ALL cases of second trimester procedures

Question 5

why do we care about gestational age in pre-abortion care

Answer 5

guides choices regarding the type of procedure, including medical versus surgical

Question 6

up until what day of gestation is mifepristone and misoprostol well established as effective for abortion

Answer 6

up to 49 days gestation

Question 7

up until what gestational age can you typically evacuate pregnancies with suction D and C

Answer 7

up to 14 weeks

Question 8

what do you have to do with gestations above 14 weeks

Answer 8

initial use of suction curretage followed by extraction forceps

Question 9

what lab tests should be done before abortion procedure is done

Answer 9

hemoglobin
Rh status
fibrinogen (if there has been IUFD)
screen for STI pathogens and treat prior to procedure (only some people do this)

Question 10

what type of abortion can be done in gestations below 8 weeks

Answer 10

medical–> methotrexate with misoprostol, misoprostol or mifepristone (not avail in canada)

surgical–> manual vacuum aspiration can be done as an office procedure if less than 10 weeks

Question 11

describe the advantages of manual vacuum aspiration for pregnancy termination prior to 10 weeks

Answer 11

office procedure

can be performed without delay, with early relief from undesirable symptoms of pregnancy

only local anesthetic needed usually

private

early detection of ectopic

cost effective

safe

Question 12

what dose of methotrexate combined with misoprostol should be used for medical abortion

Answer 12

before 8 weeks

methotrexate 50 mg/m2 IM followed 5-7 days later with misoprostol 800 mcg vaginally
*90-95% effective if before 49 days

Question 13

what is the dosing of misoprostol alone that can be used for medical abortion before 8 weeks

Answer 13

800 mcg vaginally q24 or 48 hours up to 3 applications (2400 mcg) or until termination occurs

Question 14

what is the dosing of mifepristone that can be used for medical abortion before 8 weeks

Answer 14

not available in canada

600 mg PO followed 2 days later with misoprostol 400 mcg orally/vaginally
*about 97% effective if before 49 days

Question 15

describe the process for vacuum aspiration for abortion in less that 13 weeks GA

Answer 15

in hospital or free standing clinic with LOCAL anesthesia

administer 400 mcg of misoprostol orally or vaginally 4-12 hours prior to first trimester surgical abortion–> provides cervical dilation and softening similar to osmotic dilators like laminaria

Question 16

name the two types of osmotic cervical dilators available in canada

Answer 16

laminaria osmotic dilators (seaweed)

synthetic polyacrylonitrile osmotic dilator (Dilapan)

Question 17

why do we recommend antibiotic prophylaxis before surgical abortion

Answer 17

post-abortal endometritis occurs in 5-20% of women not given antibiotics

Question 18

list the sequelae of postabortal infection

Answer 18

infertility

ectopic pregnancy

chronic pelvic pain

Question 19

describe the procecss of postop care after surgical abortion

Answer 19

observe for at least 30 minutes to monitor for vaginal hemorrhage or change in vitals suggestive of intraabdominal bleeding

give 300 mcg of rhoGAM following the procedures for unsensitized Rh - women (50 mcg is enough for procedures in the first trimester)

methylergonovine maleate (0.2 mg orally q4 hrs for as many as 5 doses) is given by some providers to decrease postabortal bleeding resulting from uterine atony and help present development of hematometra

Question 20

what is the rate of uterine perforation in first and second trimester abortion procedures

Answer 20

less than 0.6%

Question 21

what two factors are associated with a decreased risk of perforation

Answer 21

performance by an experienced surgeon and use of preoperative cervical dilation with osmotic dilators

Question 22

what is hematometra

Answer 22

uterine distension syndrome or postabortal syndrome

usually presents with complaints of dull, aching lower abdo pain, sometimes with tachy, diaphoresis, nausea

onset usually first hour after completion of the procedure

pelvic exam reveals large midline globular uterus that is tense and tender

Question 23

what is the treatment of hematometra

Answer 23

immediate uterine evacuation, permitting the uterus to retract back to normal post procedural size

administration of methylergonovine maleat (0.2mg PO) then given to ensure continued contraction of the uterus

Question 24

list the potential complications of abortion

Answer 24

infection

retained tissue, failed abortion, ectopic pregnancy

hemorrhage

uterine injury (1/1000)

post abortal syndrome (hematometra)

DIC

psychological sequelae

death (1/100 000… continuing with pregnancy has a risk of 7-10/100 000)