Termination of Pregnancy

Question 1

How are unplanned pregnancies managed?

Answer 1

• Early diagnosis of pregnancy is ideal (less complications, simpler treatment methods)
• Counselling is non directive & non judgemental (support their choices); enable woman to voice doubts and concerns. Women are not told what to do; support is provided in the decision process but they decide what they want.
• Explore options and provide information, e.g. Continue pregnancy and keep baby, Continue pregnancy and give baby for adoption, Abortion
• Domestic pressures to keep the pregnancy need to be considered.
• These are the key ideas covered in the clinic.

Question 2

What 6 methods of abortion are available depending on length of pregnancy (weeks)?

Answer 2

• Early medical abortion (MTOP) 9 +6 = medication for termination under 10 weeks
• Manual Vacuum Aspiration(MVA) 9 +6 = surgical, but under local block on the cervix (3 6 9 12 position). Performed in the clinic itself (don’t have to go to theatre).
• Suction Termination (STOP) up to 14 (patient is asleep during procedure)
• Dilatation & Evacuation 15 – 18. Higher gestations have D+E, where the cervix is dilated and the contents of the pregnancy is evacuated. Can’t use suction as the baby is much bigger.
• Mid-trimester medical abortion 14 – 24. Pregnancy is divided into 3 trimesters; the first trimester is 12 weeks and under, the second is 12 to 28 weeks, 28 to term is the third trimester. In the mid-trimester, medical abortion can be carried out where a miscarriage is induced. This group of women have to be admitted, whereas the early medical ones go home.
• Two stage surgical procedure 19 – 24. The surgical options are quite late. They come in, have some procedure and then come back later for the surgery. This is called the two stage surgical procedure
• There is a limit to when early medical can be carried out. It was kept to 9 weeks and six days. Once reached 10 weeks, they fall into other categories. This is the same with MVA, as they can be painful.
• Patients get a choice between these methods. Late gestation (surgical options) = restriction in choice of methods (have to be admitted)
• The vast majority of them come under 12 weeks.

Question 3

What method of abortion is the most popular?

Answer 3

• Increase in medical interventions since 2010 and a decrease in surgical.
• The earlier they come in, the less invasive their options are with fewer complications.

Question 4

How is early medical abortion carried out?

Answer 4

• Medical abortion using Mifepristone plus prostaglandin is an appropriate method at any gestation under 9 weeks
• Mifepristone 200mg PO
  24 – 36 hrs later
  Misoprostol 800mcg PV (per vaginal)
  Given for gestations between 9 and 12
  Can be given
• Mifepristone is a progesterone receptor antagonist. Everything works through receptors. The villi are attached to the decidua through the receptors. The baby is totally dependent through the cord into the placenta and the way it is attached to the mother’s womb is through the placenta (through the villi).
• Mifepristone competes with those receptors and the villi becomes detached. When the villi is detached, the placenta is separated. Therefore, the foetus in the uterus is not attached to the mother. First, mifepristone is given.
• Once the villi is separated, the foetus has to be expelled from the uterus. PGs are then administered to contract the uterus and dilate the cervix. Prostaglandins in the form of misoprostol is given = PGF2alpha contracts and PGE2 dilates the cervix.
• Medical treatment = mifepristone initially (200 mg), followed by PG misoprostol (800 mcg). This induces the abortion or miscarriage.
• Success rates are lower after 9 weeks and 6 days. If the gestation is higher (10+ weeks), the medical can still be carried out. Normally, the success rates are 97-99% in this group, but the failure rate will then increase to up to 8%. The pain and bleeding is also higher. This is why it goes to surgery.
• Physiologically, this is because the villi infiltrate into the muscle at 9-12 weeks to get more blood when the baby is growing faster. A large source of nutrition is required for the baby to grow. At 6 to 11 weeks, all of the organs in the body are being formed. Once passing 11 weeks, it is only size that grows (all of the organs are formed, so there is rapid growth from here and circulation is needed). The villi penetrate into the muscle, dissolves some places, creates big vascular spaces to allow blood exchange to take place. At this point, if mifepristone is given, there is less separation, failure rate is higher and bleeding/pain is increased as the attachment is very strong. Therefore, surgery is much better for removal. It can be given if the woman demands it but counselling is important (risks should be explained).

Question 5

What are the advantages of early medical abortion?

Answer 5

• Seemed a more ‘natural’ experience
• No surgery or Anaesthesia was needed. Surgery itself has complications and causes worry
• It afforded more privacy
• Perceived to be less frightening and easier emotionally than a surgical abortion
• Required a shorter stay in hospital
• It was easier, simpler and faster
• The government has pushed for women requesting an abortion to have the option for an appointment within 5 working days and then the abortion (if wanted) should be carried out within the next 5 days. The earlier the gestational age, the more medical options are used. This occurred when the GP did not have to be seen first. A central booking system has been put in place instead, so the woman does not need a GP referral. They have access to all clinics in the region. They are then more likely to be able to use medical options. Hence, there has been an increase in medical numbers.
  There are also independent providers (still NHS care), so the hospital does not need to control it.

Question 6

What is the legislation around abortion?

Answer 6

• 28 December 2018 women in England, can take the second of the two abortion pills,Misoprostol, at home. Patients only have to visit once. They come in for an assessment, take mifepristone, go home with misoprostol. This made it easier for women who had to travel a long distance to reach a clinic. Sometimes, she would put the misoprostol in the vagina and start bleeding (miscarry) on her way home. They are given support, so they can ring someone or come to the hospital if there is a problem.
• This brought England and Wales in line with Scotland, which allowed the second pill to be taken at home from October 2017
• Due to COVID, they can now get it approved over the phone and then get the drug from the pharmacy. Both abortion medications, mifepristone and misoprostol at home, without the need to attend a hospital. Temporarily approved by the Secretary of State to limit transmission of coronavirus (COVID-19) from 30 March 2020.

Question 7

What is suction termiantion?

Answer 7

• Suction termination of pregnancy should be avoided at gestations of < 7 weeks. No longer the case.
• Conventional suction termination is an appropriate method at gestations of upto 14 weeks. Most hospitals will perform suction up to 12 weeks, but up to 14 weeks is acceptable. After this is too difficult and D+E is performed.
• The earlier the gestation, the vacuum is very simple to perform.
• Cervical preparation is beneficial prior to suction termination
• Removes placenta and foetus. Creates a negative pressure to empty the cavity.
• Suction termination may be safer under local anaesthesia than general = Manual Vacuum Aspiration (MVA). MVA is also a suction termination. The suction is manually performed, instead of using a pump. A 50 ml syringe is used and a canula is put inside the uterus. When the manual pump is pulled, it has a shoulder that comes out and stays there. This creates a negative pressure for the suction process to then be carried out. This can easily be created manually a few times until the cavity is empty. This can be carried out anywhere in the world without a power supply. Patients do not require anaesthetic (just a local block) and don’t need to be admitted. Must be gentle so they do not feel much pain.
• In parts of the world where access to theatre etc. is a problem, MVA is very beneficial as long as someone is trained to do it.

Question 8

What are the complications of the surgical procedures?

Answer 8

1) The drugs from a general anaesthetic can cause problems themselves or the intubation.
2) Dilating the cervix is blind (can’t see the top), so uterine perforation is possible (but rare = 0.8 / 1000). Without realising, the cannula can be put in beyond the uterus and the bowel can be sucked out instead. If you keep going in and there is no resistance, it is likely there has been perforation. Can leave the dilator there and put a laparoscope from the top to see the perforation from there. If you want to do it, do it under laparoscopic guidance (use laparoscope to suck it from uterus). If perforation is not realised, there will be a problem. It is very rare, but have to be cautious.
3) Cervical tears - If higher up, it can lead to incontinence. When she has a pregnancy later on, she may not be able to hold it. It is the internal os (internal opening) that holds the pregnancy in the cavity (not the external one). Damage of the external os will not do any harm. When there is an abnormal cervical smear and it is treated, it does not affect the internal os. It is weakness of the internal os that allows the baby to come down quicker, leading to premature labour or miscarriage.
4) When doing termination, the placenta separates quickly. There is a big area that can bleed and if the bleeding is not stopped quickly, then she can have primary haemorrhage.
5) Uterine rupture means she has a caesarean scar. During the termination, this scar can rupture.
6) Death is very rare (0.6 / 1,000,000 extremely rare event).
- Prior to legalisation of abortions, backstreet abortions were taking place. Infection rates were high, haemorrhage was high, death rate was high. Most parts of the world have changed, but there are still places in the world where women are dying because of abortion.
- Abortion services being legally approved prevents a lot of deaths.
- Infection and haemorrhage can lead to death
- Deaths caused by other underlying conditions (inherent causes), i.e. medical causes like heart disease

Question 9

What are the complications of the surgical procedures (induced abortion) after being discharged?

Answer 9

• After discharge complications are rare
• Previously, it was the complications happening in theatre that were outlined. These are the complications that occur at home.
• Retained products of conception, e.g. placenta ~ 1 : 100. From the pregnancy being removed, there are bits of placenta left over. They come back with bleeding. They are scanned and left over products can be seen, so a second procedure is carried out to remove these products.
• Secondary haemorrhage is caused by infection (remnants have caused bleeding). Primary haemorrhage is during surgery, while secondary haemorrhage is after 24 hours.
• Pelvic infection is also caused by products leftover and causing infection. Depends on technique.
• All women who undergo termination can be given erythromycin, mainly for chlamydia, and metronidazole for anaerobic infection (preventative). Chlamydia is an organism that is sexually transmitted. If a termination is carried out when the woman has chlamydia, it will ascend into the uterus and, more importantly, into the tube. The tubes have cilia that can be damaged and cause secondary infertility. To prevent this, women are screened (tested) for chlamydia. As the result doesn’t come back very quickly and the procedure has to be carried out quickly, they are given erythromycin. If they turned out to be positive, they are traced with their partners, their partners are tested and they’re both treated.
• If they were not scanned, there could be an ectopic pregnancy.
• The incidence is low, but there is a chance.
• Failed abortion

Question 10

Why is there a focus on STIs in abortion care?

Answer 10

• Incidence is low, but they are a high risk group. They are having unprotected intercourse and they are likely to have infection. They are possibly not in a relationship or having multiple partners. The situation is not known, so the test is offered with an opt out policy.
• The incidence of HIV is 1 in 1000. Some patients already know that they have HIV, but sometimes there is a new case. Chlamydia is higher in the younger age group, gonorrhoea is coming up in some situations, syphilis is also coming up (slight rise in gonorrhoea and syphilis cases). The positives are treated, contact traced to partners, partners are treated if they are also infected.
• Treats the patient, the partner and the community
• This will help with impact on their health and future fertility (in case they want a pregnancy later on). These women who are having abortions may want a pregnancy later on and will regret not being able to have one.

Question 11

Complications and prevention of induced abortion.

Answer 11

• These are late complications
  1) Tubal factor infertility
  2) Screening and Antibiotics - prevention
  3) Iso-immunisation means that a pregnant woman’s blood proteins are incompatible with the baby’s
• If a mother is rhesus negative (A-), it means that she does not have the rhesus factor. If the baby is A+, because the partner is positive, then the baby has red blood cells with the rhesus factor. Those red blood cells will go into the mother. This will stimulate the mother’s immune system to produce antibodies. It takes some time to do this. If antibody injections (antiD administration) are given, then the mother will not produce antibodies as it will negate the red blood cells which have got the rhesus factor from the foetus. Anyone who has A- is given antiD (since the baby’s blood group is not known). The antiD prevents the mother from developing an iso-immunisation (an immunisation to the baby’s rhesus factor). If this is not done, once the mother has been stimulated to produce antibodies, they will be there for life. If the mother has a baby who is negative in the future, these antibodies will travel from the mother into the baby and destroy the red blood cells in the baby. The baby will get anaemia within the mother’s womb. Therefore, iso-immunisation can be harmful to the baby in future pregnancies (not in this pregnancy) and preventing this antibody formation will help. AntiD administration prevents it.
• During pregnancy, whenever there is bleeding, they are given antiD. Routinely, however, they are given around 28 to 32 weeks. Also, at term/delivery. At delivery, the baby’s blood group is checked. In this way, iso-immunisation in pregnancy is prevented. This applies to terminations. Miscarriages are different in terms of having no blood supply.
  4) Psychological and psychosexual sequelae
  5) Counselling support and options to patients

Question 12

What are the psychological sequelae with induced abortion?

Answer 12

• Regret and early distress common. Many women feel guilt or regret at first. With time, they get over it.
• Adverse sequelae occur only in a minority. Generally due to other factors in the background. A very small group have it just because of the termination.
• Continuation of problems present before abortion
• Long term post abortion distress risk factors
  1) Unsupportive partner. High risk of distress when the partner is unsupportive, when the woman is not sure about the decision (will not be carried out if the woman is not certain), previous history of psychiatric problems and when people are against abortion but want to carry one out anyway.
  2) Ambivalence before abortion
  3) Prior psychiatric history
  4) Considers abortion wrong

Question 13

Aftercare of induced abortion (preventing reoccurrence).

Answer 13

• Anti-D prophylaxis
• Written information
• Contact numbers for support
• Counselling services
• STI services follow up. There should be services for follow up if STI screening comes back positive.
• Contraception advice and provision aims to prevent them from coming back for another abortion
• Follow up appointment within 2 weeks optional (for their reassurance). They are not followed up but there is the option, so they feel reassured that they can come back if they have a problem.