Termination of Pregnancy Flashcards
What is the upper limit for when a TOP can occur?
The current law surround abortion is based on the 1967 Abortion Act. In 1990 the act was amended, reducing the upper limit from 28 weeks gestation to 24 weeks.
Who can authorize a TOP and who can perform one?
- Two registered medical practitioners must sign a legal document (in an emergency only one is needed)
- Only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise
What are the indications for a TOP?
- There is a risk to the mother’s life if it continues
- TOP is necessary to prevent serious physical or mental harm to the mother
- Continuation would cause greater harm than if terminated
- Continuation could harm existing children in some way
- If born the child would suffer with serious physical or mental abnormalities
What methods can be used to induce a TOP?
Medical
Up to 9 weeks gestation: mifepristone orally (an anti-progestogen, often referred to as RU486) followed 24-48 hours later by prostaglandins orally (misoprostol) to stimulate uterine contractions – can be given orally or vaginally. If not successful 4 hours later then give another dose of misoprostol.
9-24 weeks gestation: mifepristone orally (an anti-progestogen, often referred to as RU486) followed 36-48 hours later by prostaglandins vaginally (misoprostol) to stimulate uterine contractions – can be given orally or vaginally. If not successful 4 hours a maximums of 4 further doses can be given.
Surgical
Less than 14 weeks: Manual vacuum aspiration/surgical dilation and suction of uterine contents, done under local or GA. Should not be done under 7 weeks.
More than 14 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’). Uses surgical forceps. Should be done under real time USS to reduce risk of uterine perforation.
In surgical TOP which drugs should you consider giving to aid the process and what analgesics should be given prior to all types of TOP?
For Surgical TOP consider misoprostol vaginally 3 hours before surgery in all women to reduce difficulty (especially in women >10weeks and young women <18yrs)
NSAID pain relief during TOP – Paracetamol usually ineffective but good as a placebo.
Rhesus negative mothers will require Anti-D
What should you consider discussing with the woman after a TOP.
Should discuss contraception following TOP
May need referral to emotional support/mental health services
What other consideration needs to be made in TOP if the pregnancy is later than 21+6 weeks?
If later than 21+6 weeks then it is essential the foetus is born dead. This is achieved using 3mL of intracardiac 15% potassium chloride. Asystole confirmed using US. Sometimes muscle relaxant or anaesthetic given to stop foetal movement beforehand.
What are the complications following a TOP?
- Infection can happen in up to 10% of TOP cases. Antibiotics are given (metronidazole and Azithromycin) to reduce the risk of infection. Signs and symptoms of an infection are unlikely to occur so soon after the procedure.
- Retained tissue pregnancy occurs in less than 1% of cases.
- Haemorrhage occurs in less than 1% of cases but is more likely to occur in pregnancies greater than 20 weeks gestation.
- Uterine rupture <4:1000
- Uterine perforation – surgical termination only 1-4:1000
- Failure occurs in less than 1% of cases.
- Injury to the cervix occurs in less than 1% of cases.
What should you warn the woman about pregnancy tests post TOP?
Following termination of pregnancy, HCG decreases by about 50% every two days. It is therefore normal for HCG to remain positive for a number of weeks.
The trend in HCG levels shows an initial steep decrease in the first two weeks and then a gradual decline over a further two weeks. In most women, without continuing pregnancy, the HCG levels will have returned to normal within four weeks at which point it is reliable to take a pregnancy test.
