Unplanned pregnancy and abortion Flashcards
How common is unplanned pregnancy?
30-50%
What are some outcomes of unintended pregnancy?
- Later initiation and less frequent antenatal care
- Increased preterm birth risk and low birthweight
- Increased postpartum depression and substance misuse
- Reduced breastfeeding rates
- Decreased bonding with infant
- Increased rates of child neglect and abuse
- Poorer long-term developmental outcomes§
What percentage of unplanned pregnancies result in TOP?
30-40%
How common is death in unsafe abortions
8 deaths per hour worldwide
What act legalised abortion in Scotland, Wales and England?
Abortion act 1967
How do Northern Irish abortion laws differ from the rest of the UK?
Only permitted to prevent serious harm or death up until 2019, but could travel to other parts of the UK
What certificate is required to carry out an abortion?
HSA1 (Certificate A)
What is required to certify an abortion?
HSA1 signed by 2 doctors
Emergency certificate signed by 1 doctor
Reporting to the chief medical officer
What is the most common clause under which abortion is carried out in the UK?
Clause C:
Continuing the pregnancy would involve risk of injury to the physical or mental health of the pregnant woman or her existing children/family
What is the gestational limit for abortion clause C?
24 weeks
What is abortion clause E?
There is a substantial risk that if the child were worn, it would suffer from such a physical or mental abnormality as to be seriously handicapped
What is the gestational limit for abortion clause E?
No gestational limit
What is meant by conscientious objection?
HCPs have the right to refuse to participate in abortion care
What are some limits of conscientious objection?
- Does not supply in emergency or life-threatening situations
- Should not delay or prevent a patients access to care
- Does not apply to indirect tasks associated with abortion such as administrative work or supervision of staff
How common are abortions in the UK?
200,000 per year
How are people referred to abortion services?
GP
Sexual and reproductive health clinic
Self-referral
What factors determine method of abortion?
Local availability
Patient choice
Gestational period
What are the 2 main categories of abortion methods?
Medical
Surgical
What is the gestational limitation for medical termination?
24+6 weeks
How are pregnancies dated prior to TOP?
Estimation using last menstrual period and date of positive UPT
Palpable uterus (>12 weeks)
USS if unsure
What are the 2 drugs given for medical abortion?
Mifepristone 200mg PO
Misoprostol 800mcg PV (24-48 hours later)
What is meant by EMAH in abortion?
Early Medical Abortion at Home - Use of medical abortion at home
What is the gestational limit for EMAH?
11+6 weeks
What are some benefits of EMAH?
More comfortable
Prevents bleeding or cramping en route from hospital
What is contained in an EMAH pack?
- Mifepristone
- Misprostol
- Anti-emetic
- Analgesia
- Antibiotics
- Contraception (6/12 POP)
- Low-sensitivity pregnancy test
What is given for EMAH if expulsion hasn’t occurred within 4 hours?
2nd dose of 400mcg misoprostol
What is the gestational limit for inpatient medical abortion?
23+6 weeks
Describe the treatment regime for inpatient medical abortion
Repeated doses of PV misoprostol: 800mcg PV then 400mcg 3-hourly PV/PO/SL (Up to 4)
Describe the availability of medical TOP in Scotland
MTOP available up to 19+6 weeks in most areas of Scotland; >20 weeks requires travel to England (BPAS)
What are the 3 forms of surgical abortion?
Electrical vacuum aspiration
Manual vacuum aspiration
Dilatation and evacuation
What is done prior to surgical TOP?
Cervical priming with msioprostol or osmotic dilators
Local or general anaesthetic
What is the gestational limit for electrical vacuum aspiration?
13+6 weeks
What is the gestational limit for manual vacuum aspiration?
10 weeks
What is the gestational limit for dilatation and evacuation?
≥14 weeks (No limit)
Describe the availability of surgical TOP in Scotland?
Dilatation and evacuation is not available in Scotland, so patients must travel down to England
What is required in a pre-abortion consultation?
- Confirm ID and check if safe
- Feelings about pregnancy
- Assessment of gestation
- Gynae/Obstetric history
- Medical, drug and social history
- Exploring safeguarding issues (E.g. under 16s, vulnerable groups)
- Discussions of available options
- Risks of procedure and consent
- STI risk assessment or testing
- Contraception
- Further arrangements and follow-up
What are some possible complications of abortion?
- Continuing pregnancy (1-2%)
- Infection
- Severe bleeding requiring transfusion
- Cervical injury
- Uterine perforation
- Uterine rupture
What are some possible prophylactic requirements in TOP?
Antibiotic prophylaxis
Rhesus iso-immunisation
VTE prophylaxis
Who is offered antibiotic prophylaxis in TOP?
Those undergoing STOP
Those undergoing MTOP with increased STI risk
What is the antibiotic prophylaxis regime for TOP?
7 days 100mg doxycycline BD
Why may rhesus iso-immunisation be required in TOP?
This may be a sensitising event to D-negative women, leading to development of anti-D antibodies, which cross the placenta and cause haemolytic disease
Who is given rhesus isoimmunisation
Rhesus D-negative women with STOP or MTOP ≥12 weeks
How is high risk of VTE managed in abortion?
LMWH 1 week post-abortion
How is very high-risk of VTE managed in abortion?
LMWH before abortion, continuing for 6 weeks
How long after abortion does ovulation begin?
Ovulation occurs in >90% of women within 1 month and can start as early as 8 days after and so contraception is required
How soon after abortion do contraceptives become immediately effective?
Up to 5 days
Use of IUDs post-abortion
- Avoid in presence of post-abortion sepsis
- Can be inserted immediately after STOp or after MTOP once expulsion of pregnancy is confirmed
Use of hormonal contraception post-abortion?
Can be started anytime after MTOP/STOP including day of mife/miso
Use of non-hormonal methods post-abortion?
- Barrier methods can be used anytime (Expect diaphragm after 2nd trimester TOP)
- Sterilisation after some time has elapsed
- Avoid FAM until regular periods resume
How are patients followed up after EMAH?
- Low-sensitivity UPT performed at least 2 weeks after abortion (Not standard UPT) - Cut off equivalent to 1000 iu/L HCG (Normal is 25 iu/L)
- This is to identify incomplete or failed procedures
- Signposting to support services
