Termination of Pregnancy - Induced abortion Flashcards
Definition of induced abortion
Termination of pregnancy before 24th week
Indications for TOP
- Maternal diseases
- Cardiac, malignancy, renal, sepsis - Fetal diseases
- Genetic conditions
- Fetal anomalies - Social reasons (MOST common)
Pre-TOP assessment
- History taking
- Gynae code
- Previous deliveries, previous miscarriages/TOP
- LMP, cycle regularity
- Symptoms of pregnancy
- Sexual history
- Past medical hx (bleeding disorders)
- Past surgical hx (uterine surg)
- Drug allergy
- When was pregnancy test taken
- REASON for TOP - Physical examination
- General inspection: Gravid uterus, linea nigra
- Abdo exam: SFH - Confirm intrauterine pregnancy with transabodminal U/S scan
- Determine week of gestation
- Determine viability (presence of fetal heart)
a. If NO fetal heart: pregnancy of unknown viability
-> come back for rescan 1-2 weeks later
i. If fetal heart +ve -> must go for mandatory counselling
ii. If fetal heart -ve -> list for surgery ASAP - Bloods
- FBC (Hb) and blood group (rhesus status) - Offer screening for chlamydia and gonorrhoea for high risk patients (<21yo, single ladies)
- Mandatory TOP counselling
- >48h before procedure
How long is cooling down-time post counselling before initiating TOP therapy
48h
TOP methods - Medical
- Mifepristone
- Anti-progestogen
- Causes decidual necrosis and cervical softening
- Increases uterine contractility
- Increases sensitivity to prostaglandins (prepping womb for misoprostol) - Misoprostol
- Prostaglandin E1 analogue
- Cause contraction of uterus and relaxation of cervix
- Combined regime with mifepristone
- Cheap, stable in room temp, easy to store and handle - Gemeprost (cervagem)
- Prostaglandin E1 analogue
- Used for cervical priming (softens cervix)
- More expensive and requires refrigeration
Administration of mifepristone is _____ _____ therapy
direct observed therapy
Early medical TOP regime for <10 weeks gestation
PO mifepristone 200mg
= 48h after (can go home)=
PV/BC/SL misoprostol 800mcg
= 4h after (if no abortion) =
PV/BC/SL misoprostol 400mcg
Medical TOP regime for >10 weeks gestation
PO mifepristone 200mg
= 48h after =
PV/BC/SL misoprostol 800mcg
= 4h after (if no abortion) =
PV/BC/SL misoprostol 400mcg
Give every 4 hourly until fetus expelled
If >22 weeks of gestation, may admit HDU
Medical TOP regime for women with uterine scar
Admit HDU during course - increased risk of scar rupture
Consider 1/2 dose misoprostol
Consider lengthening dosing interval
Medical TOP: Contraindications
- Confirmed or suspected ectopic pregnancy
- IUCD in place
- Known coagulopathy/anticoagulant therapy
- Intolerance/allergy to the meds
- Uncontrolled HTN or CVS disease (angina, valvular disease, arrhythmia, HF)
- Unable/unwilling to adhere to care instructions
Specific contraindications to mifepristone use
Severe liver, renal, respiratory disease
Long term systemic corticosteroids use
Chronic adrenal failure
Inherited porphyria
Medical TOP: Precautions
Must do inpatient TOP:
Septic abortion
Severe anemia
Uncontrolled asthma
Medial TOP: fetocide
- Performed if planned for termination from 22 weeks onwards
- Injection of pharmacological agent into fetus or amniotic fluid to cause fetal asystole
- Techniques: intracardiac, intra-amniotic, intra-umbilical
- Routes: Transvaginal or transabdominal
- Agents: potassium chloride, digoxin, lidocaine
Usually transabdominal intracardiac KCL
Benefits of medical TOP
- Highly effective
- Non-invasive (avoids risk of surgical TOP)
- Can be performed at any week of gestation
- Reduce waiting time for available OT slot
Risks of medical TOP
- Common: abdominal cramps, vaginal bleeding, infection, fever, N/V, diarrhoea
- Failure to terminate pregnancy, incomplete abortion
- Heavy bleeding requiring blood transfusion
- Severe infection – toxic shock syndrome
- Uterine rupture in scarred uterus
- Sadness, guilt, REGRET
