Termination_of_Pregnancy_Flashcards
What is the legal basis for abortion in the UK?
Abortion in the UK is governed by the 1967 Abortion Act, amended in 1990, which allows termination up to 24 weeks under specific conditions with the approval of two medical practitioners.
What are the general requirements for performing an abortion?
Abortions must be performed by a registered medical practitioner in a NHS hospital or licensed premises. In emergencies, only one practitioner’s approval is needed.
What are the medical options for terminating a pregnancy?
Medical options include the administration of mifepristone followed by a prostaglandin like misoprostol to induce contractions. This is often done at home up to a certain gestation period.
What are the surgical options for terminating a pregnancy?
Surgical options include manual vacuum aspiration (MVA), electric vacuum aspiration (EVA), and dilatation and evacuation (D&E), with options for cervical priming and various forms of anaesthesia.
How does the choice of procedure change with gestation period?
Up to 23+6 weeks’ gestation, women are offered a choice between medical or surgical abortion. After 9 weeks, medical abortions become less common due to various factors including visibility of the conception products.
What are the stipulations of the 1967 Abortion Act regarding the reasons for abortion?
The Act allows abortion if the continuation of the pregnancy poses greater risk than termination to the woman’s physical or mental health, to prevent grave permanent injury, risk to the woman’s life, or if the child would be born with severe disabilities.
Termination of pregnancy summary
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.
A 22-year-old G1P0 woman presents to the abortion clinic requesting a termination 1 week after a positive urine pregnancy test. Her last menstrual period was 8 weeks ago. An ultrasound prior to her clinic visit showed evidence of an intrauterine pregnancy. She has type 1 diabetes but is otherwise well with no known allergies. Her blood group is A negative.
Observations and a physical examination are normal.
The woman wishes to avoid surgery and would prefer to be at home, so the specialist prescribes two medications to take when it is convenient.
What medication should she take first?
Levonorgestrel
Medical termination is contraindicated
Mifepristone
Misoprostol
Ulipristal acetate
Mifepristone
Medical abortions are undertaken using mifepristone followed by prostaglandins
The correct answer is mifepristone. This is a steroid-based medication that sensitises the myometrium to contractions induced by the subsequent prostaglandins and ripens the cervix. The mechanism of action primarily lies in its progesterone antagonist effects rather than the steroid effects. Mifepristone is taken 36-48 hours prior to prostaglandins (interval treatment), which then induces contractions to expel the products of conception. This treatment is less likely to result in ongoing pregnancy than simultaneous administration of both agents, and bleeding and pain may start later. She should be counselled that there may be some bleeding after taking mifepristone, but that bleeding and cramps are likely to start several hours after taking the misoprostol which should be 36-48 hours after the first tablet.
Levonorgestrel is incorrect because this is not used for early medical abortion; it can be used as emergency contraception if taken up to 72 hours after unprotected sexual intercourse. Its mechanism of action is to inhibit ovulation, thereby preventing pregnancy. This woman has an established pregnancy confirmed on ultrasound, and her last menstrual period was 8 weeks ago so she is not eligible for emergency contraception. Instead, a combination of mifepristone with misoprostol taken 36-48 hours later should be prescribed.
Medical termination is contraindicated is incorrect. This patient does not have any contraindications to mifepristone or misoprostol, and is less than 10 weeks gestation so early medical termination is appropriate and suitable. Medical termination can be carried out after 10 weeks gestation, but this should be carried out in a hospital for safety reasons. As long as this woman is capable of seeking prompt medical attention should there be any complications from her early medical abortion, she is eligible to take the tablets at home. This woman also has a blood group status that is Rhesus negative, however, she would not be offered Anti-D at a gestational age of less than 10 weeks.
Misoprostol is incorrect because this is a prostaglandin E1 analogue that should be taken as the second set of tablets in the medical termination of pregnancy. This stimulates myometrial contractions to expel the products of conception and causes cervical dilatation to allow them to pass. Interval treatment is recommended to reduce the risk of ongoing pregnancy, which involves taking misoprostol 1-2 days after mifepristone. Therefore, the correct answer is to take mifepristone first.
Ulipristal acetate is incorrect because this is not used for early medical abortion; it can be used as emergency contraception if taken up to 120 hours after unprotected sexual intercourse. Its mechanism of action is to inhibit ovulation, thereby preventing pregnancy. This woman has an established pregnancy confirmed on ultrasound, and her last menstrual period was 8 weeks ago so she is not eligible for emergency contraception. Instead, a combination of mifepristone with misoprostol taken 36-48 hours later should be prescribed.
