Termination of Pregnancy Flashcards
Terminology
-Abortion: Interruption of pregnancy using either medications or surgery
=Induced Abortion
=Therapeutic Abortion
-Termination of Pregnancy or TOP (Surgical - STOP or Medical –MTOP)
-TOPFA (TOP for Foetal Anomaly)
-EMA – Early Medical Abortion
-MVA – Manual Vacuum Aspiration
-EVA – Electric Vacuum Aspiration
-D&E – Dilatation and Evacuation
Global statistics of TOP
-25% of pregnancies end in abortion each year globally
-Criminalising abortion just makes it unsafe
=Countries where prohibited: 37/1000
=Countries where available: 34/1000
-25 million unsafe abortions take place each year: almost all in developing countries
-Annually up to 13.2% of maternal deaths can be attributed to unsafe abortion
-Almost every abortion death and disability could be prevented through: sex education, effective contraception, provision of safe, legal induced abortion, timely care for complications
UK statistics of TOP
-Proportion of abortions performed using medical methods: Scotland higher than England
-200 000 abortions per year in UK= 75% conceived while using contraception
How has COVID changed legislation?
-COVID-19
=Temporary emergency changes to law in England and Wales allowing home use of mifepristone and misoprostol up to 10weeks
=Same change in Scotland but no time limit in law. Clinical guidelines advise up to 12 weeks (in line with WHO).
-Post-COVID-19
=These changes were made permanent
=This allows patients to have entirely remote care – with selective use of ultrasound
Grounds for abortion
-A: risk to life of pregnant women greater than if terminated
-B: prevent grave permanent injury to physical or mental health of pregnant woman
-C: not exceeded 24 weeks, involve risk of injury greater than termination (most common)
-D: C but to existing children of family
-E: baby would be seriously handicapped (2nd)
-F: to save the life of the pregnant woman
-G: To prevent grave permanent injury to pregnant woman
Why do people seek abortion?
-Contraceptive failure
-Financial instability
-Breakdown of relationship
-Family complete
-Majority of patients are certain
-Delays in care are unnecessary and unwanted
-Mandatory counselling is unhelpful for most patients
Pre-abortion care
-Non-judgemental approach
-Medical eligibility for method (rather than social eligibility for abortion)
-Safeguarding – vulnerable adults and children
-Introduce post abortion contraception and provide information to consider
Medical abortion
-Combination treatment
=Mifepristone – progesterone receptor antagonist (increases GAP junctions, soften of cervical tissues)
=Misoprostol – synthetic prostaglandin (increases contractility of myometrium, dilates cervix)
-Early Medical Abortion (up to 12 weeks)
=200mg Mifepristone PO STAT
=800microg Misoprostol SL/PV/BUC 24-48 hours later +400microg additional dose if needed
=At home
-Medical Abortion after 12 weeks
=Same as EMA but multiple doses of Misoprostol 400microg maybe required – usually more doses needed as gestation advances.
=Usually day case, sometimes overnight procedure
Indications and contraindications for EMA
-Preference, including treatment at home
-As early as possible and up to 12 weeks’ gestation
-Most patients eligible
-Contraindication
=Hypersensitivity to drugs used
=Severe, uncontrolled asthma
=Inherited porphyria
=Chronic adrenal failure
=Known/suspected ectopic
Cautions for EMA
-Long-term corticosteroids
-Haemorrhagic disorder
-Severe anaemia
-IUC in situ (remove before mifepristone)
How does mifepristone and misoprolol work?
-Synergistic effect on uterine contractility
=Stronger and more frequent contractions
-Mifepristone – progesterone receptor antagonist (increases GAP junctions, soften of cervical tissues)
-Misoprostol – synthetic prostaglandin (increases contractility of myometrium, dilates cervix)
Outcomes of medical abortion
-Incomplete abortion requiring surgery ~5%
-Ongoing pregnancy ~1%
-Sepsis 0.1%
-Haemorrhage (>1000ml) 0.1%
-Median duration bleeding (at 8 weeks’) 12 days
-Median blood loss (at 8 weeks’) 72.5ml
-Factors associated with greater pain =Advanced gestation
=Nulliparity
=Dysmenorrhoea
-Location of expulsion: Home or clinical facility
Surgical abortion methods
-Vacuum Aspiration
=Less than 14 weeks
=General or Local Anaesthesia
=Less than 10 minutes
=Broader range of practitioner
-Dilatation and Evacuation
=Over 14 weeks
=General Anaesthesia or sedation
=About 20-30 minutes
=More specialised skills
Which method to use for abortion?
-Equally Safe and Effective
-Low rate of complications
-Low rate of side effects
-Choice of method should be driven by patient preference
=NICE Abortion Care Guideline – decision aids to help patients and clinicians select option
Post-abortion contraception
-Most will ovulate in month post abortion
=> 50% have resumed sex by 2 weeks
=Pills, patches, rings, and injections can be commenced on day of mifepristone or misoprostol or STOP
-Progestogen-only subdermal implant
=Can insert on same day as mifepristone or STOP
=No effect on abortion efficacy
=Immediate insertion associated with (Better uptake, Reduced risk further unintended pregnancy)
-Intra-uterine contraception
=Insert once pregnancy passes after MTOP or evacuation of uterus at STOP
=Immediate insertion associated with: Higher insertion rates, Similar expulsion as interval, Low complication rate
