Termination Flashcards
What are your rights and obligations as a healthcare professional when it comes to termination of pregnancy?
any healthcare professional can decline to be directly involved but must refer women on to colleague where appropriate, and you must be able to understand and manage complications if they arise
Within what period of pregnancy is termination of pregnancy performed?
- Vast majority in first trimester
- Can in theory be performed at any gestation by medical or surgical methods
What does the usual medical termination of pregnancy involve?
Mifepristone and prostaglandins (normally misoprostol) then awaiting delivery
What type of method of TOP is most common?
medical, at all gestations, sometimes as outpatient
What does surgical termination of pregnancy (STOP) involve?
use of suction curette under GA
In addition to surgical and medical TOP, what is an additional method and what does it involve?
MVA: manual vacuum aspiration
generally performed with patient awake
Within what period of pregnancy is manual vacuum aspiration usually performed?
in first trimester (0-12 weeks) or ocasionalyl after 12-13 weeks
What is the method of TOP if gestation is later than 22 weeks and why?
feticide performed first as otherwise fetus may be delivered with signs of life
What is the upper limit for most terminations in England, Wales and Scotland?
24 weeks’ gestation
What are 5 things for you and the patient to take into account when deciding on method of TOP?
- What modes of TOP available locally
- How quickly they can usually be arranged
- If funding available on NHS
- What gestation
- Why it’s being performed
What follow up is essential after termination of pregnancy?
follow up or self-pregnancy test must be performed, to ensure pregnancy has been terminated
How do women tend to come to obs+gynaecology for a termination of pregnancy?
rapid referral from GP or from sexual health clinic
What usually happens during or immediately before a patient for TOP is seen in clinic?
pregnancy dated by ultrasound scan either by doctor in clinic or sonographer immediately prior to clinic
also identifies already non-viable or ectopic pregnancies
What are 11 things that should be done in clinic when seeing a patient for TOP, after the gestation has been determined from USS?
- Check personal/ contact details, who knows she’s here, how she’s happy to be contacted
- Establish O+G history, including previous pregnancies and outcomes, and cervical smear history
- Establish contraception history
- Establish relevant medical/surgical history
- Enquire as to whether sexual intercourse that led to conception was consensual and if any issues concerning woman’s safety
- Ask reason for termination - establish if case meets criteria for 1967 Abortion Act, and complete Certificate A (must be done by 2 doctors)
- Confirm woman sure of decision, help talk through it if not
- Obtain consent for proceure and make arrangements (home, ward or theatre)
- Prescribe relevant drugs (mifepristone, misoprostol, analgesia, antiemetics, prophylactic antibiotics and anti-D where needed)
- check FBC and group and save (baseline in case significant bleeding, and to check rhesus status for anti-D) and chalmydia/gonorrhoea self-swab
- give contraceptive advice and discuss plans
Why is it importnat to check a patient’s contact details/ how she wants to be contacted and who knows she’s there when attending for TOP?
don’t want to ring home phone and don’t know who in house knows she’s been to clinic
What legal requirements must be met for TOP and what is the documentation that must be completed?
- reason for termination must meet criteria of 1967 Abortion Act
- Complete Certificate A - by 2 doctors
What are 6 drugs that may need to be prescribed for a woman for TOP?
- Mifepristone
- Misoprostol
- Anti-emetics
- Analgesia
- Prophylactic antibiotics
- Anti-D (needed for every TOP)
What are 3 investigations that should be performed for a woman in the TOP clinic?
- FBC
- Group and save (baseline in case of bleeding, check rhesus status for anti-D)
- Chlamydia/ gonorrhoea self-swab
Why is it important to make absolutely sure the pregnancy for TOP is intrauterine on the USS?
need to be sure it’s not ectopic; pain from ruptured ectopic might be mistaken as pain from TOP possibly leading to hazardous delay in diagnosis
What should be readily available in the TOP clinic to discuss contraception with patients?
either clinic contraception checklists or UKMEC if these aren’t availabel
What is important to remember if a woman attends TOP clinic with a friend or partner?
important to ensure woman not being coerced into termination; need to see woman alone at some point even if only briefly (check local procedure)
Why is it important to make sure the TOP case meets Abortion Act criteria and document this?
actively cutting corners can put both termination service and your career at risk
What should be done if bleeding and pain following medical TOP is heavier than expected?
ensure woman stable and check no POC (products of conception) coming from os
if shock out of proportion with volume of bleeding, consider rare possibility of uterine rupture (rare in first trimester, uncommon but possible later) and check from scan this was definitely intrauterine pregnancy and not ruptured ectopic
What are the 5 categories of the Abortion Act of 1967 for which abortion is legal?
- A: continuance of pregnancy would involve risk to life of pregnant woman greater than if pregnancy terminated
- B: termination necessary to prevent grave permanent injury to physical or mental health of pregnant woman
- C: pregnancy has not exceeded 24th week and continuance would involve risk, greater than if were terminated, of injury to physical or mental health of pregnant woman
- D: pregnancy has not exceeded 24th week and continuance would involve risk, greater than if terminated, of injury to physical or mental health of any existing children of family of pregnant woman
- E: substantial risk that if child born it would suffer from such physical or mental abnormalities as to be seriously handicapped
What are the only 2 clauses of the Abortion Act 1967 that have a legal limit of gestation?
C and D have limit of 24 weeks
What does the GMC say about TOP?
- doctors must ensure personal beliefs do not prejudice patient care
- drs have right to refuse to participate in TOPs on grounds of conscientious objection; if so must always refer patient to another dr who will help
What is the GMC ruling about patients for TOP aged under 16?
should be encouraged to involve their parents, but provided they are considered to be Fraser competent, can give own consent
What are the 2 overall methods for termination of pregnancy?
- Surgical
- Medical
What is the guidance about surgical termination of pregnancy before 7 weeks?
conventional suction termination should be avoided
What is the guidance about surgical TOP for 7-13 weeks gestation?
conventional suction termination appropriate, but in some settings skill and experience of practitioner may make medical TOP more appropriate at gestations >12 weeks
What is the recommendation for surgical TOP at gestation >13 weeks?
dilatation and evacuation following cervical preparation should be performed
What is needed to perform dilatation and evacuation for TOP at >13 weeks?
requires skilled practitioners with necessary instruments and sufficiently large case load to maintain skills
What factor increases the risks of dilataiton and evacuation for TOP and what are the risks (3)?
- greater gestation
- bleeding
- incomplete evacuation
- perforation
What are 2 reasons why cervical preparation before dilatation and evacuation for TOP is highly beneficial?
- Reduces difficulties with cervical dilatation
- Particularly if patient <18 years or gestation is >10 weeks
What are 3 possible regimes to achieve cervical preparation in advance of surgical dilatation and evacuation for TOP?
- Misprostol 400mcg PV 3h prior to surgery
- Gemeprost 1mg PV 3h prior to surgery
- Mifepristone 600mg PO 36-48h prior to surgery
To summarise what are the 3 gestation ranges to consider when looking at surgical TOP?
- <7 weeks: suction termination shuold be avoided
- 7-13 weeks: conventional suction appropriate
- >13 weeks: cervical preparation then dilatation and evacuation
What is the suggested medical management for TOP at <9 weeks gestation?
mifepristone priming plus prostaglandin regime most effective
mifepristone PO then misoprostol PV 48hr later
What is the suggested management for TOP at 9-13 weeks gestation?
medical TOP appropriate, safe and effective alternative to surgery (incomplete procedure rates increase after 9 weeks)
What is the suggested management for TOP at 13-24 weeks gestation?
medical TOP appropriate and safe in this group
What is generally considered about the method of TOP in advanced gestations i.e. >24 weeks?
feticide should be considered
How can the medical management of TOP be broken down in gestation ranges?
- <9 weeks: mifepristone + prostaglandin most effective method (over surgery)
- 9 - 13 weeks: medical TOP appropriate
- 13 - 24 weeks: medical TOP appropriate
How does mifepristone work for medical TOP?
antiprogesterone given 24-48h prior to prostaglandins
results in uterine contractions, bleeding from the placental bed, and sensitisation of uterus to prostaglandins
How much prior to use of misoprostol for medical TOP should mifepristone be given?
24-48 hours prior (passmed says 48hrs)
How does misoprostol work for medical TOP?
prostaglandin E1 analogue used off-licence in medical TOP and for cervical preparation prior to surgical TOP
stimaulates uterine contractions
What type of medication is germeprost and what 2 things is it used for?
prostglandin E1 analogue
licensed for
- softening and dilatation of cervix before surgical TOP in first trimester +
- therapeutic TOP in the second trimester
What are 3 reasons to perform an ultrasound initially when a patient attends TOP clinic?
- Date pregnancy - what gestation
- Identify already non-viable pregnancies
- Identify ectopic pregnancies
What are 2 aspects of minimising risk of post-abortion infection?
- Screening for lower genital tract infections such as chlamydia
- Prophylactic antibiotic regimes
What are 2 options for prophylactic antibiotic regimes used for TOP?
- Metronidazole 1g PR at time of TOP plus doxycycline 100mg PO BD for 7 days, commencing on day of TOP
- Metronidazole 1g PR at time of TOP, plus azithromycin 1g PO on day of TOP
What are 5 aspects of follow-up of TOP?
- Anti-D given to all Rh negative women undergoing medical or surgical TOP
- Provide written patient information - symptoms that may be experienced, symptoms requiring further medical attention, contact numbers
- Follow-up within 2 weeks of TOP
- Refer for further counselling if required
- Discuss and prescribe/provide ongoing contraception
Within what time frame should follow up after TOP be performed?
within 2 weeks
What dose of anti-D is given following TOP to rhesus negative women at 20 weeks gestation or less?
250 IU
What dose of anti-D is given to all rhesus negative women who have undergone TOP at over 20 weeks gestation?
500 IU
What are 10 possible complications of TOP?
- Significant bleeding
- Genital tract infection
- Uterine perforation (surgical)
- Uterine rupture (mid-trimester medical)
- Cervical trauma (surgical)
- Failured TOP
- Retained products of conception
- Nausea, vomiting, diarhoea due to PGs
- Psychological sequelae e.g. anxiety, depressed mood
- Long-term regret and concern about future fertility
