Termination of Pregancy

Question 1

What are the 2 methods of abortion

Answer 1

Medical

Surgical

Question 2

How is a medical abortion carried out

Answer 2

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

Question 3

What are the advantages of a medical abortion

Answer 3

Less invasive than the surgical abortion
Don’t have to be under anaesthetic
Can complete it at home if before 9+6 weeks

Question 4

What are the risks of a medical abortion

Answer 4

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

Question 5

Until what stage can a medical abortion be used

Answer 5

Up to 19+6 weeks in Scotland

Risk increases in second trimester so anyone past 10 weeks must have their abortion done in hospital

Question 6

What are the 2 methods of surgical abortion

Answer 6

Suction and curette - done from 7 to 14+6 weeks

Dilatation and evacuation - done after 14 + 6weeks

Question 7

What are the options for an unplanned pregnancy

Answer 7

Continue the pregnancy and keep the baby
Give baby up for adoption
Abortion

Question 8

What percentage of pregnancies are unplanned

Answer 8

30-50% of pregnancies are unintended

Question 9

What are the risks of continuing an unplanned pregnancy

Answer 9

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

Question 10

What acts sets out the abortion laws in the UK

Answer 10

1967 Abortion Act

All abortions in UK have to be reported to the CMO via a yellow form

Question 11

What are the 2 most common clauses that abortions are carried out under

Answer 11

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

Question 12

Can healthcare workers object to abortions

Answer 12

Yes they have the right to refuse to participate in an abortion
Must refer the patient to another physician though

Question 13

What are the exceptions to the conscientious objection rules

Answer 13

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.

Question 14

What is the most common gynaecological procedure in the UK

Answer 14

Abortion

Question 15

How do you refer someone for abortion

Answer 15

Either through GP or Sexual Health Clinic.

In some areas, self-referral is available.

Question 16

What age group has the highest rate of abortion

Answer 16

Highest rates seen in 20-24 age group.

Lowest rates in under 16s.

Question 17

Which socio-economic group has the higher rate of abortion

Answer 17

The more deprived areas

Question 18

Are most abortions surgical or medical

Answer 18

Medical - 86%

Vast majority are done before 9 weeks

Question 19

How do you assess gestation

Answer 19

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

Question 20

What are the 2 drugs used in medical abortions

Answer 20

Mifepristone = anti-progesterone which ends pregnancy

Misoprostol = prostaglandin which causes uterine contraction and
cervical dilation to expel pregnancy

Question 21

How is misoprostol administered

Answer 21

Inserted into vagina - more effective
Or sublingually - can cause GI side effects e.g. cramps, diarrhoea

Given 36-48 hours after the mifepristone

Question 22

How do you prep a woman for surgical abortion

Answer 22

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

Question 23

What are the risks of abortion

Answer 23

Haemorrhage - worse with surgical
Failed/incomplete abortion - higher risk at early abortion
Infection
Uterine perforation

Question 24

Is antibiotic prophylaxis needed for TOP

Answer 24

Required for those undergoing STOP
Those undergoing MTOP with increased risk of STI
Doxycycline BD 100mg 7 days or Azithromycin

Question 25

When is rhesus immunisation needed

Answer 25

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

Question 26

What VTE prophylaxis is needed after abortion

Answer 26

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

Question 27

What is covered in the pre-abortion consultation

Answer 27

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

Question 28

How is fertility affected by abortion

Answer 28

Ovulation occurs in >90% of women within 1st month following abortion
Should be fine unless there is a serious complication

Question 29

How soon after abortion can contraception be started and is effective

Answer 29

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

Question 30

What type of contraception is the only one to reduce rate of repeat abortions

Answer 30

Long-acting reversible methods

Question 31

What must you check post-abortion before fitting a coil

Answer 31

Need to make sure pregnancy has passed following MTOP

Question 32

What follow up is required after an abortion

Answer 32

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

Question 33

How long can a pregnancy test remain positive after an abortion

Answer 33

Can still be positive 4-6weeks after abortion

Takes ages for it to fall to 0

Question 34

What happens if a woman has a positive pregnancy test after an abortion

Answer 34

They are invited back for a scan

Question 35

How can you manage retained pregnancy tissue following an abortion

Answer 35

antibiotics or possibly a surgical procedure

Question 36

Which medical conditions in PMH might you worry about in TOP

Answer 36

Bleeding disorders 
Severe asthma - due to use of prostaglandins
Cardiac disease - anaesthetic  
Porphyria
Allergic reactions
Adrenal failure
Anaemia
Crohns
Hepatic/renal failure.

Question 37

What questions are important to ask in a TOP consultation

Answer 37

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

Question 38

What investigations are carried out prior to TOP

Answer 38

USS – confirm intrauterine pregnancy/exclude ectopic

Bloods – Risk assess for HIV/Syphillis FBC/G&S and check rhesus status

Swabs – Chlamydia/gonnorhoea

Question 39

What are the options for an unwanted pregnancy if they are past 24 weeks

Answer 39

Only adoption

Will need robust psychological support

Question 40

What is a EMAH

Answer 40

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

Question 41

What follow up is required for an Early Medical Abortion at Home

Answer 41

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

Question 42

What are the 7 legal reasons for abortion in the UK

Answer 42

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.

Question 43

In what situations can abortion be carried out past 24 weeks

Answer 43

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.

Question 44

EMAH are offerd up to which gestation

Answer 44

Up to 10 weeks

Past 10 weeks the abortion must be carried out in hospital

Question 45

Why must those over 10 weeks gestation have their abortion in hopsital

Answer 45

Better to have monitoring as the risks associated with abortion increase with advancing gestation

Multiple doses of misoprostol may be required

Question 46

What is the maximum number of misoprostol doses that can be given for a medical abortion

Answer 46

maximum of 5 doses in 24 hours