Termination of Pregnancy

Question 1

Definition of termination of pregnancy

Answer 1

Involves an elective procedure to end a pregnancy

Question 2

What legal guidance exists for termination of pregnancy

Answer 2

• The 1967 Abortion Act states that abortion can be performed if two registered medical practitioners agree that the pregnancy should be terminated on one of the recognised legal groups.
• Most abortions are made on ground C.
• An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of the woman or existing children of the family.

Question 3

Pre-abortion investigations

Answer 3

• Gestation assessment (USS or clinical)
• Rhesus status (anti-D required if non-immunised RhD-negative)
• Consider STI testing (should offer antibiotic prophylaxis to women having a surgical abortion), FBC (determine if anaemic)

Question 4

When can TOP be carried out at any time

Answer 4

• Continuing the pregnancy is likely to risk the life of the woman
• Terminating the pregnancy will prevent ‘grave permanent injury’ to the physical or mental health of the woman
• There is substantial risk that the child would suffer mental or physical abnormalities making it seriously handicapped

Question 5

How can patients access TOP fascilities

Answer 5

• Abortion services can be accessed by self-referral or by GP, GUM or family planning clinic referral.
• Doctors who object to abortions should pass on to another doctor able to make the referral (duty of care).
• Many abortion services are accessed by self-referral, without the involvement of a GP or other doctor to make the referral
• Marie Stopes UK- a charity that provides abortion services. They offer remote service for women less than 10 weeks gestation, where consultations are held by telephone can medication are issued remotely or taken home

Question 6

Complications of TOP

Answer 6

• Women should be informed that abortion is a safe procedure for which major complication and mortality are rare at all gestations

Complications:
* Uterine rupture (1 in 1000), severe bleeding requiring transfusion (more common beyond 20 weeks), uterine perforation (surgical abortion only), cervical trauma (surgical abortion only)
* Failure (1 in 100) and risk of further intervention (5%)
* Post-abortion infection (reduced by prophylactic antibiotics)
* Small increased risk of preterm birth
* NO proven association between TOP and subsequent ectopic pregnancy, placenta praevia, infertility

Psychological sequalae: no more or less likely to suffer adverse psychological sequelae whether they have an abortion or continue with the pregnancy and have the baby (risk is increased in case of previous history of mental illness)

Question 7

Pre-abortion management

Answer 7

• Prior to referral, pregnancy should be confirmed by history and reliable urine pregnancy test
• Identification of those who require more support in the decision-making process HOWEVER, women who are certain of their decision should not be subjected to compulsory counselling
• FBC, rhesus blood status, haemaglobinopathy screen, VTE risk assessment
• Peri-abortion antibiotic prophylaxis: azithromycin 1 g orally on the day of abortion, plus metronidazole 1 g rectally or 800 mg orally prior to or at the time of abortion
  OR doxycycline + metronidazole
• All women should be screened for C. trachomatis and undergo a risk assessment for other STIs (for example, HIV, gonorrhoea, syphilis), and be screened for them if appropriate
• All appropriate methods of contraception should be discussed with women at the initial assessment and a **plan agreed for contraception after the abortion **
• Feticide should be performed before medical abortion after 21+6 weeks to ensure that there is no risk of live birth

Question 8

Medical methods of TOP

Answer 8

• The majority of women undergoing a TOP will choose medical abortion
• Involves a combination of Mifepristone (progesterone receptor modulator- halts pregnancy ad relaxes the cervix) followed by misoprostol (prostaglandin analogue- softens the cervix and stimulates uterine contractions)
• Oral mifepristone 200ug and oral misoprostol 800ug
• From 10 weeks gestation, additional misoprostol doses are required (every 3 hours- to a maximum of four further doses)
• It is safe and acceptable for women who wish to leave the abortion unit following misoprostol administration to complete the abortion at home (should be adequately safetynetted)
• Women should be routinely offered pain relief (NSAIDs) during medical abortion- oral paracetamol is not recommended

Question 9

Surgical methods of TOP

Answer 9

• Manual or electric vacuum aspiration is an appropriate method of surgical abortion up to 14 weeks gestation
• Vacuum aspiration under 7 weeks of gestation should be performed with appropriate safeguards to ensure complete abortion, including inspection of aspirated tissues
• CAN be performed up to 16 weeks, however large-bore cannulae and suction tubing may be required (may also require forceps)
• May be performed under local or general anaesthetic
• Dilatation and evacuation, preceded by cervical preparation is appropriate for pregnancies above 14 weeks gestation (should be guided by continuous USS)
• Up to 14 weeks of gestation: Misoprostol 400 micrograms administered vaginally 3 hours prior to surgery or sublingually 2–3 hours prior to surgery.
• Women should be offered pain relief using NSAIDs

Question 10

Post-abortion care

Answer 10

• Anti-D IgG should be given, by injection into the deltoid muscle, to all non-sensitised RhD negative women within 72 hours following abortion, whether by surgical or medical methods.
• Women should be advised that they may experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks after the procedure
• A urine pregnancy test should be performed 3 weeks after the abortion to confirm completion
• Contraception should be discussed and started where appropriate