Unplanned Pregnancy Flashcards
are the outcomes for mother and baby the same or worse in unplanned pregnancy compared to planned
worse:
o Later initiation and less frequent antenatal care
o Increased pre term birth and low birth weight
o Increases postpartum depression and substance misuse
o Reduced breastfeeding rates
o Poor bonding
o Increased neglect and abuse
o Poorer long term developmental outcomes
how many unplanned pregnancies end in abortions
30-40%
what is the risk of unplanned pregnancies in lower income countries
unsafe abortion
what is the legal documentation needed for abortions in uk
HSA1/ certificate A
needs to be signed by two doctors who dont need to have met patient but need to be familiarised with case
two emergency clauses that only need one doctor to sign
Most abortions in UK certified under clause C which has gestational limit of 24 weeks- risk/ injury to mental or physical health to mother/ her family greater than if the pregnancy were terminated. Next most common in clause E which has no gestational limit- mental or physical abnormalities causing the foetus to be severely handicapped.
do all abortions need to be reported
yes to CMO
can HCP abstain form abortion care
yes but not if:
- life threatening emergency
- if going to delay or prevent patients access to care
- indirect tasks associated with abortion (administration, supervision of staff)
how can you be referred for an abortion
GP
sexual + repro health
self referral (not in tayside yet)
what is the most common method of abortion
medical
what does the type of abortion chosen depend on
gestation
patient preference
what is available
how do you assess gestation
date of LMP and +ve UPT
palpable uterus means more than 12 weeks gestation
USS: abdominal or transvaginal (if <6 weeks)
what is the procedure for a medical abortion
- Mifepristone 200mg PO (antiprogesterone, enhances uterine contractility and increases prostaglandin receptors- acts as a priming agent)
- Misoprostol 800mcg PV/SL (24-48 hours) (4 200mg tablets inserted into vagina (better) or sublingually (can cause GI side effects) (Is a prostaglandin)
- If under 10 weeks gestation can do misoprostol at home
- > 10 weeks inpatient procedure, repeated doses of PV misoprostol: 800mcg PV then 400 mcg 3 hourly PV/PO/SL (up to four)
until what gestation can you have a medical abortion
19+6 weeks in scotland
if over 20 weeks referal to england
when can you have an early medical abortion at home (EMAH)
<10 week gestation
not recommended for <16s, those who live alone/ far away from hospital (misoprostol works quickly) or those at risk of complications
what are the methods of surgical abortions
cervical priming is done via misoprostol or osmotic dilators (relaxes and dilates cervix, reduces rate of complications- trauma to cervix or uterus)
- Under 14 weeks: o Electric vacuum aspiration (GA) o Manual vacuum aspiration (up to 10 weeks, LA) - >14 weeks o Dilatation and evacuation
what gestation can a surgical abortion be done up till
14 weeks in scotland
>14 weeks referral to england
what are the possible complications of an abortion
(Complications increase with increasing gestation)
haemorrhage (higher risk in surgical)
failed/ incomplete abortion (higher in medical)
infection
uterine perforation
cervical trauma
what will bleeding be like after a medical abortion
will start light and get heavier, like a heavy period lasting several hours, will have cramping pain, should stop within 2 weeks
who needs prophylactic antibiotics for an abortion
all surgical
MTOP with increased risk of STI (if screening not performed/ results not available
describe rhesus iso-immunisation
for women with rhesus D negative blood group an abortion can be a sensitising event (where fetal blood cells gain access to the maternal circulation)
this leads to development of anti-D antibodies which can cross placenta in future pregnancies and destroy Rh +ve fetal red cells
how can rhesus iso immunisation be prevented
Anti-D Ig given to all at risk Rhesus NEGATIVE women
who needs anti- D Ig
STOP or mid to late trimester MTOP
what VTE prophylaxis can be given for abortions
all patients should get risk assessment (BMI, smoking, previous VTE event)
if high risk consider LMWH for a week after abortion
if very high risk start LMWH before abortions and continue it for longer after
what should be included in a pre abortion consultation
- Feeling about pregnancy
- Assessment of gestation
- Gynae/ obstetric history
- Medical, drug and social history
- Safeguarding issues: under 16s, vulnerable groups
- Discuss available options
- Risks of procedure and consent
- STI risk assessment +/- testing
- Contraception
- Further arrangements and follow up
- Women should be gibven enough time to discuss options and concerns
- Info should be given in balanced way in a way that is appropriate to them
- Women should be seen alone for a least part of the consultation
when does fertility return after an abortion
- Ovulation occurs in >90% within 1st month (as early as 8 days after medical)
- At least 50% of women resume sexual activity within 2 weeks of abortion
when can contraception be started after an abortion
almost all can be started day of/ soon after
immediate provision of long acting reversible contraception (IUD/IUS)- avoid in post abortion sepsis. can be inserted immedialey noth STOP and MTOP (after expulsion)
hormonal methods can be started at any time including day of STOP/MTOP
avoid FAM until periods regular
barrier methods used any time, except diaphragm after 2nd trimester TOP (need anatomy to go back to normal)
sterilisation can be done after some time has relapsed (regret. failure common)
what follow up is needed after an abortion
nothing after surgical/ in patient medical abortion where passage of products of conception has been confirmed
after EMAH do low sensitivity (as hCG takes while to come down) at least 2 weeks after abortion to identify failed/ incomplete abortion
if +ve then USS
if retained tissue then Tx is either conservative with antibiotics or surgical
signpost to support services
when can you get abortions till in scotkand
surgical 12 weeks
medical 19+6 weeks
after this referral to england
what are the anaesthesia options in surgical abortion
general anaesthesia (anxious or for dilatation and evacuation), deep sedation (will be unconscious), conscious sedation with local anaesthesia (less time in hospital)
vacuum aspiration can be done under any type
what antibiotics can be offered for prophylaxis in abortion
7-days 100mg doxycycline BD* OR 1 g oral azithromycin +500 mg daily for 2 days
