Termination of pregnancy

Question 1

Lawful termination of pregnancy in South Australia

Answer 1

Termination of pregnancy is not a criminal offence within 28 weeks of conception in the circumstances that 2 legally qualified medical practitioners are in the opinion that continuance of the pregnancy involves a greater risk to the life, physical or mental health of the woman than if the pregnancy were terminated
OR
if child was born, would suffer physical or mental abnormalities as to be seriously handicapped
AND
the woman has resided in SA for at least 2 months (unless life-saving)

Question 2

First trimester termination of pregnancy definition

Answer 2

Refers to all pregnancies ended before 12+6 weeks gestation

Question 3

Proportion of pregnancies that end in termination

Answer 3

20% globally (29% in Australia)

Question 4

Medical termination of pregnancy can be used up to what gestational age

Answer 4

Up to 7 week (49 days) PBS listed

Question 5

Contraindications to medical termination of pregnancy

Answer 5

Bleeding conditions or use of anticoagulants
Inherited porphyria
Adrenal failure
Chronic corticosteroid use (mifepristone suppresses adrenal function for 3-4 days)
Allergy to mifepristone/mispoprostol
Intrauterine device in situ
Pelvic infection
Known or suspected ectopic pregnancy

Question 6

Things that must be done in assessment of woman prior to termination of pregnacy

Answer 6

History: LNMP, pregnancy test, course of pregnancy, symptoms of pain/bleeding, previous O&G history, medical conditions, allergies
ASSESS ON HER OWN TO ENSURE NO COERCION
Provide contraception for use immediately after completion of VTOP - all should be started on day of misoprostol administration if medical termiantion (excepd IUCD - 2w later to ensure complete expulsion of products)
Inx: USS (site and gestation), serial quantitative bHCG, blood type

Question 7

Complications of medical termination of pregnancy

Answer 7

Haemorrhage (severe in 0.1%)
Continuation of pregnancy (4%) - must ensure f/u with USS
Retained products of conception
Infection 0.2% (often related to retained products)
Congenital malformations
Fertility RETURNS ALMOST IMMEDIATELY AFTER MEDICAL TEMRMINATION
Trauma to genital tract (more likely in surgery)

Question 8

Medications given in medical termination of pregnancy

Answer 8

Mifepristone and misoprostol

Question 9

Mechanism of misoprostol

Answer 9

Prostaglandin E1 analogue
Causes:
- uterine contractions
- cervical dilatation and ripening

Question 10

Mechanism of mifepristone in termination of pregnancy

Answer 10

Progesterone antagonist - binds to progesterone and glucocorticoid receptors - prevents effects of progesterone in uterus - interferes with implantation and placental development - feotal demise

Also increases uterine sensitivity to prostaglandins and softens and dilates the cervix

Question 11

Procedure of medical termination of pregnancy

Answer 11

200mg mifepristone orally
D/c woman with oral anti-emetic
24-48 hours later: woman premedicates with an anti-emetic and an NSAID (e.g. metoclopramine and ibuprofen/diclofenac)
Woman returns to hospital/clinic and administered 4x200mcg misoprotol buccal or S/L
Oral analgesics given
250 IU anti D if Rh negative
Can expect to pass products within next few hours, bleeding usually continues for several weeks

Follow up USS to ensure pregnancy is terminated

Question 12

Indicators of successful termination of pregnancy

Answer 12

Pregnancy symptoms subside
Next menstrual period expected within 5 weeks (unless implanon or Depo method used)
Falling b-hCG
Negative urine b-hCG (may remain positive for at least 4 weeks)

Question 13

Indications for first trimester surgical termination of pregnancy

Answer 13

Women seeking terminatin of pregnancy at gestational age 12w or less

Question 14

Procedure of first trimester surgical termination of pregnancy

Answer 14

Obtain written consent
Complete provision of contraception (Implanon or IUCD ready to insert at time of termination)
Fast for 6 hours
Administer pre-op oral misoprostol 3h prior (or S/L 30min prior)
Abdominal or TVUS to confirm gestation
Lithotomy position
Wash pubic area
Local anaesthetic to cervix
Dilation of cervix appropriate for gestation and parity
Suction curette applied in circular motion while slowly withdrawing until uterus empty
Administer misoprostol into posterior fornix of vagina
Indomethacin PR for analgesia
AntiD 250 if Rh neg

Question 15

Rationale for pre-operative oral misoprostol before surgical termination of pregnancy

Answer 15

Reduces need for mechanical dilation as well as risk of an incomplete evacuation
(Dose is dependent on gestational age)