Termination of pregnancy

Question 1

What history is required from a woman requesting a TOP?

Answer 1

• How do you know you are pregnant
• LMP to estimate gestation
• Previous pregnancies and any complications
• Gynecology history
  - Any previous gynecology issues
  - Menstrual cycle –> duration, frequency, volume
  - Current sexual partners
  - Frequency of sexual intercourse
  - Contraception
• Support at home
• Reason for TOP –> try NOT to ask this

Question 2

What investigations are required for a woman requesting a TOP?

Answer 2

• Positive pregnancy test  urine or serum
• Antenatal booking bloods (no longer needed but can be offered) –> FBC, UCEs, RBC antibodies, blood group, rubella, syphilis, HIV, Hepatitis B
• USS –> assess gestation of pregnancy if unclear LMP or concern that the pregnancy is further along than expected
• PV swabs –> MC&S, chlamydia / gonorrhea / trichomonas NAAT swabs

Question 3

What are the different options for TOP?

Answer 3

Early medical abortion –> involves taking 2 medications. First take 200mg PO mifepristone and then 800mcg PO misoprostol 24-48 hours later. Heavy bleeding and cramping occurs usually 4-6 hours after taking the misoprostol

Early surgical abortion –> vacuum aspiration under GA or light sedation. A day surgical case that involves the patient arriving NBM and then being given misoprostol to soften and open the cervix. Once sedated the cervix is dilated and there is suction aspiration / curettage of the POC

Question 4

What are the benefits and risks of medical TOP?

Answer 4

Benefits
* Can be done at home
* No anesthetic or surgery required
* Easy to access

Complications
* Pain and cramping –> heavy bleeding can occur
* Less predictable course of events
* May need 2nd dose of misoprostol or surgical procedure if ongoing RPOC

Question 5

What are the benefits and risks of surgical TOP?

Answer 5

Benefits
* Less pain and bleeding
* Low risk of needing further intervention

Risks
* Poor access to services
* 1/100 risk of uterine perforation
* Anesthetic risks
* Damage to surrounding structures
* Cervical laceration
* Infection
* Heavy bleeding

Question 6

What additional aspects of management need to be discussed with a woman coming to request a TOP?

Answer 6

• Time off work
• Explain no effect on future fertility
• Future contraception –> offer LARC and advise on how to take PO contraceptives more effectively