Termination_of_Pregnancy Flashcards
What is the basis of the current law surrounding abortion?
The current law surrounding 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.
What are the key points of the 1967 Abortion Act?
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 an NHS hospital or licensed premise.
What general issue is addressed regarding anti-D prophylaxis?
Anti-D prophylaxis should be given to women who are rhesus D negative and are having an abortion after 10+0 weeks’ gestation.
What are the medical options for termination of pregnancy?
Mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins (e.g. misoprostol) to stimulate uterine contractions. This may be done at home depending on the gestation. Takes time (hours to days) to complete and the timing may not be predictable. A pregnancy test is required in 2 weeks to confirm that the pregnancy has ended.
What are the surgical options for termination of pregnancy?
Use of transcervical procedures to end a pregnancy, including manual vacuum aspiration (MVA), electric vacuum aspiration (EVA), and dilatation and evacuation (D&E). Cervical priming with misoprostol +/- mifepristone is used before procedures. Women are generally offered local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation or general anaesthesia. Following a surgical abortion, an intrauterine contraceptive can be inserted immediately after evacuation of the uterine cavity.
What is the choice of procedure recommendation by NICE?
NICE recommend that women are offered a choice between medical or surgical abortion up to and including 23+6 weeks’ gestation. Patient decision aids are usually given to allow women to make an informed decision. After 9 weeks medical abortions become less common. Before 10 weeks medical abortions are usually done at home.
What does the 1967 Abortion Act state regarding the termination of pregnancy?
Subject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith, that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
Summarise TOP
Termination of pregnancy
The current law surrounding 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*
Key points
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
General issues
anti-D prophylaxis should be given to women who are rhesus D negative and are having an abortion after 10+0 weeks’ gestation
Medical options
mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins (e.g. misoprostol) to stimulate uterine contractions
patient decision aids often refer to this as mimicking a miscarriage
this may be done at home depending on the gestation
takes time (hours to days) to complete and the timing may not be predictable
a pregnancy test is required in 2 weeks to confirm that the pregnancy has ended. This should detect the level of hCG (rather than just be positive or negative) and is termed a multi-level pregnancy test
Surgical options
use of transcervical procedures to end a pregnancy, including manual
vacuum aspiration (MVA), electric vacuum aspiration (EVA) and dilatation and evacuation (D&E)
cervical priming with misoprostol +/- mifepristone is used before procedures
women are generally offered local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation or general anaesthesia
following a surgical abortion, an intrauterine contraceptive can be inserted immediately after evacuation of the uterine cavity
Choice of procedure
NICE recommend that women are offered a choice between medical or surgical abortion up to and including 23+6 weeks’ gestation
patient decision aids are usually given to allow women to make an informed decision
after 9 weeks medical abortions become less common. Factors include increased likelihood of women seeing products of conception pass and decreased success rate
before 10 weeks medical abortions are usually done at home
1967 Abortion Act
Subject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith
that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or
that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
*these limits do not apply in cases where it is necessary to save the life of the woman, there is evidence of extreme fetal abnormality, or there is risk of serious physical or mental injury to the woman.
Textbooks
Links
NICE40
2019 Abortion care guidelines
Royal College of Obstetricians and Gynaecologists25
2011 The Care of Women Requesting Induced Abortion
A 35-year-old woman has an unplanned and unwanted pregnancy. Her obstetric history includes a miscarriage 5 years ago, an ectopic pregnancy 7 years ago, and she currently has 2 children who are healthy and well. She has no other medical history.
An ultrasound scan is performed and shows an intrauterine pregnancy and her estimated gestation is 8 weeks. She has been counselled on her options and she would like a medical termination of pregnancy.
What treatment is she most likely to be offered?
IM methotrexate and vaginal misoprostol
IM methotrexate only
Oral mifepristone and IM carboprost
Oral mifepristone and vaginal misoprostol
Oral mifepristone only
Oral mifepristone and vaginal misoprostol
Medical abortions are undertaken using mifepristone followed by prostaglandins
Oral mifepristone and vaginal misoprostol is correct. Since this patient is 8 weeks pregnant, a medical termination of pregnancy is preferred over a surgical option as it has a higher success rate and avoids the unnecessary risks associated with surgery (such as infection or bleeding). For the medical termination of pregnancy, oral mifepristone (an anti-progestogen, also known as RU486) is given followed by vaginal misoprostol, which stimulates uterine contractions and facilitates the passage of pregnancy tissue. This is often described as mimicking a miscarriage. A pregnancy test is then performed in 2 weeks to confirm the pregnancy has ended.
IM methotrexate and vaginal misoprostol is incorrect as methotrexate is not used in the medical termination of a pregnancy in the UK. It is instead used in the medical management of ectopic pregnancies. Although this patient has a history of ectopic pregnancy, their current pregnancy is not ectopic, as an ultrasound scan confirms that it is intrauterine. As mentioned above, misoprostol stimulates uterine contractions and facilitates the passage of pregnancy tissue.
IM methotrexate only is incorrect as methotrexate is not used in the medical termination of a pregnancy in the UK. It is instead used in the medical management of ectopic pregnancies. Although this patient has a history of ectopic pregnancy, their current pregnancy is not ectopic, as an ultrasound scan confirms that it is intrauterine.
Oral mifepristone and IM carboprost is incorrect as although oral mifepristone is used in the medical termination of pregnancy, carboprost is not indicated for this use. It is instead used in postpartum haemorrhage due to uterine atony where oxytocin and ergometrine are ineffective or inappropriate.
Oral mifepristone only is incorrect as prostaglandins (e.g. misoprostol) are given to stimulate uterine contractions and facilitate the passage of pregnancy tissue through the vagina. There is nothing in this patient’s history contraindicating misoprostol, therefore, it should be given as well as oral mifepristone.
