Termination of Pregancy Flashcards
What are the 2 methods of abortion
Medical
Surgical
How is a medical abortion carried out
Take 2 pills to terminate the pregnancy
First pill (mifepristone) needs to be taken at the clinic
This medication causes degeneration of the endometrial lining (anti-progesterone)
2nd pill can be taken at home around 24-48 hrs later
This one causes uterine contractions to cause the foetal tissue to be expelled
What are the advantages of a medical abortion
Less invasive than the surgical abortion
Don’t have to be under anaesthetic
Can complete it at home if before 9+6 weeks
What are the risks of a medical abortion
At later stages in pregnancy the passing will be more traumatic (foetal tissue will look like a baby)
Heavier and more prolonged bleeding - occasionally need transfusion
More painful
Risk of incomplete or failed procedure
Infection
Pregnancies past 10 weeks must be done in hospital
Until what stage can a medical abortion be used
Up to 19+6 weeks in Scotland
Risk increases in second trimester so anyone past 10 weeks must have their abortion done in hospital
What are the 2 methods of surgical abortion
Suction and curette - done from 7 to 14+6 weeks
Dilatation and evacuation - done after 14 + 6weeks
What are the options for an unplanned pregnancy
Continue the pregnancy and keep the baby
Give baby up for adoption
Abortion
What percentage of pregnancies are unplanned
30-50% of pregnancies are unintended
What are the risks of continuing an unplanned pregnancy
A lack of planning is associated with poorer outcomes for mother and babies
Less risk factor prevention e.g. smoking, weight loss
Later initiation and less frequent visits of antenatal care
Poorer bonding with baby
Increased rates of child neglect and abuse
Poorer long-term developmental outcomes
What acts sets out the abortion laws in the UK
1967 Abortion Act
All abortions in UK have to be reported to the CMO via a yellow form
What are the 2 most common clauses that abortions are carried out under
Clause C = gestational limit of 24 weeks
Most common
Done to prevent injury or risk to mother or foetus (physical or mental)
Clause E - no limit
Those conducted for foetal abnormalities
Can healthcare workers object to abortions
Yes they have the right to refuse to participate in an abortion
Must refer the patient to another physician though
What are the exceptions to the conscientious objection rules
Does not apply in an emergency situation e.g. haemorrhage (until such time that a colleague is able to assist)
Should not delay or prevent a patient’s care e.g. GP surgery – refer on to see a colleague
Does not apply to ‘indirect’ tasks associated with abortion e.g. administrative tasks, supervision etc.
What is the most common gynaecological procedure in the UK
Abortion
How do you refer someone for abortion
Either through GP or Sexual Health Clinic.
In some areas, self-referral is available.
What age group has the highest rate of abortion
Highest rates seen in 20-24 age group.
Lowest rates in under 16s.
Which socio-economic group has the higher rate of abortion
The more deprived areas
Are most abortions surgical or medical
Medical - 86%
Vast majority are done before 9 weeks
How do you assess gestation
Clinical or USS
Clinical – based on last menstrual period and date of +ve urine pregnancy test (UPT); palpable uterus can only be felt after 12weeks of pregnancy.
USS – TVUSS if <6wks; or Abdominal USS
What are the 2 drugs used in medical abortions
Mifepristone = anti-progesterone which ends pregnancy
Misoprostol = prostaglandin which causes uterine contraction and
cervical dilation to expel pregnancy
How is misoprostol administered
Inserted into vagina - more effective
Or sublingually - can cause GI side effects e.g. cramps, diarrhoea
Given 36-48 hours after the mifepristone
How do you prep a woman for surgical abortion
Cervical priming with misoprostol - allows it to dilate
Primes cervix to make passage of instruments easier
Lowers risk of injury to the cervix
Osmotic dilators:
– softening of the cervix
What are the risks of abortion
Haemorrhage - worse with surgical
Failed/incomplete abortion - higher risk at early abortion
Infection
Uterine perforation
Is antibiotic prophylaxis needed for TOP
Required for those undergoing STOP
Those undergoing MTOP with increased risk of STI
Doxycycline BD 100mg 7 days or Azithromycin
When is rhesus immunisation needed
Only issue for women with Rhesus D -ve blood group.
And if they’ve had a sensitising event = potential for foetal blood cells to access mother’s circulation
Recommeded if abortion was after 9+6 weeks’ gestation or if abortion was surgical
Due to risk to future foetus
Give them anti-D
What VTE prophylaxis is needed after abortion
If high-risk patient (e.g. obesity, previous VTE, smoking, hypertension), consider LMWH in week after abortion, until coagulation has normalised.
If very high-risk, considering starting earlier (before abortion), and for a longer period ~6weeks
What is covered in the pre-abortion consultation
See the woman alone STI risk assessment +/- testing Contraception Future fertility intentions Discussion of options Feelings about pregnancy Medical, drug and social history Safeguarding issues Discuss risks and get consent
How is fertility affected by abortion
Ovulation occurs in >90% of women within 1st month following abortion
Should be fine unless there is a serious complication
How soon after abortion can contraception be started and is effective
Most methods can be started during, or soon after abortion
Method is immediately effective if started within 5 days
After this its the standard efficacy for each type
What type of contraception is the only one to reduce rate of repeat abortions
Long-acting reversible methods
What must you check post-abortion before fitting a coil
Need to make sure pregnancy has passed following MTOP
What follow up is required after an abortion
Routine clinical review or USS for most women
MTOP in hospital doesn’t need follow up - passage is confirmed by Drs at the time
At home MTOP they need to take a pregnancy test 2 weeks after abortion
After MTOP, not required until any complications
How long can a pregnancy test remain positive after an abortion
Can still be positive 4-6weeks after abortion
Takes ages for it to fall to 0
What happens if a woman has a positive pregnancy test after an abortion
They are invited back for a scan
How can you manage retained pregnancy tissue following an abortion
antibiotics or possibly a surgical procedure
Which medical conditions in PMH might you worry about in TOP
Bleeding disorders Severe asthma - due to use of prostaglandins Cardiac disease - anaesthetic Porphyria Allergic reactions Adrenal failure Anaemia Crohns Hepatic/renal failure.
What questions are important to ask in a TOP consultation
Last menstrual period and cycle Previous pregnancies and outcomes Any pregnancy symptoms/pain/bleeding Contraception – need to know if coil in situ and also post procedure plan Past medical history/meds/allergies Circumstances surrounding pregnancy How she feels Social history
What investigations are carried out prior to TOP
USS – confirm intrauterine pregnancy/exclude ectopic
Bloods – Risk assess for HIV/Syphillis FBC/G&S and check rhesus status
Swabs – Chlamydia/gonnorhoea
What are the options for an unwanted pregnancy if they are past 24 weeks
Only adoption
Will need robust psychological support
What is a EMAH
Early Medical Abortion at Home
This is when the patient takes the misoprostol - second medication - at home and completes the abortion there
Offered before 10 weeks
What follow up is required for an Early Medical Abortion at Home
Patient will need to take a self urine pregnancy test 2 weeks later
If positive they have to come back to the clinic
Also need advice on what to do if symptoms become severe - safety net
What are the 7 legal reasons for abortion in the UK
A - continuing pregnancy would risk the life of the mother more than termination
B - termination will prevent grave permanent injury to woman’s physical or mental health
C- continuing pregnancy would involve greater risk to the physical/mental health of the woman than termination
D - continuing pregnancy would involve greater risk to the physical/mental health of existing children/family of the woman
E - There is substantial risk that the baby suffer from such physical or mental
abnormalities as to be seriously handicapped
In emergencies
F - to save the life of the pregnant woman
G - to prevent grave permanent injury to the
physical or mental health of the pregnant woman.
In what situations can abortion be carried out past 24 weeks
If the woman’s life is in danger
If there is a severe foetal abnormality
If the woman is at risk of grave physical and mental injury.
EMAH are offerd up to which gestation
Up to 10 weeks
Past 10 weeks the abortion must be carried out in hospital
Why must those over 10 weeks gestation have their abortion in hopsital
Better to have monitoring as the risks associated with abortion increase with advancing gestation
Multiple doses of misoprostol may be required
What is the maximum number of misoprostol doses that can be given for a medical abortion
maximum of 5 doses in 24 hours
