Unwanted Pregnancy Flashcards
What are the laws surrounding termination of pregnancy
Legal up to 23+6 weeks
Abortion act 1967 - two registered medical practitioners agree
Clause A: <24w and risks to the physical and mental health of the woman or any children in her family are greater if the pregnancy were continued
Clause B: At any stage, necessary to prevent grave and permanent injury to the mother
Clause C: At any stage if continuing the pregnancy involves a greater risk to the life of the woman
Clause D: at any stage if there is substantial risk of serious physical or mental handicap
Describe foeticide
Termination of pregnancy after 21+6 weeks to reduce risk of live birth after abortion. Uses potassium chloride injections into the foetal heart to cease the heartbeat
Asystole should be observed for 2 mins -> if not -> repeat injection
USS to confirm demise 30-60s after
What is the pre-abortion management for TOP
- Confirm pregnancy with urine test and history
- Blood tests: Hb, Rhesus blood type, red cell alloantibodies, screen for haemoglobinopathies
- VTE risk assessment
- Cervical cytology screening
- Abx prophylaxis for chlamydia and anaerobes
- Doxycycline on the day of
- Metronidazole before or on the day of - STI screening: chlamydia, HIV, gonorrhoea, syphilis
What are the management options for TOP
Medical: vaginal misoprostol and oral mifepristone
Surgical: manual vacuum evacuation or evacuation
Describe the medical TOP >10 weeks
Oral Mifepristone -> 36-48 h -> 800microg misoprostol + repeat doses every 3h until expulsion (max 5 doses)
Must take misoprostol in clinic or hospital
Anti-D prophylaxis given
the uterus is more sensitive to misoprostol as pregnancy advances (misoprostol dose reduces and interval between doses increases)
Follow up
Pregnancy passes within 4-6h of the misoprostol
Bleeding follow for 2 weeks
Urine pregnancy test in 2-3 weeks
Describe medical TOP <10 weeks
Most successful <63 days (9 weeks)
200mg mifepristone and 24-48h later -> Vaginal/buccal/sublingual misoprostol 800mg
<49d: misoprostol 400microg
<63d: misoprostol 800microg
+ simple analgesia
Administered at home IF easy to follow up and understands safety netting
Follow up
Pregnancy passes within 4-6h of the misoprostol
Bleeding follow for 2 weeks
Urine pregnancy test in 2-3 weeks
What are the options for surgical management of TOP
<14 weeks: manual vacuum aspiration
>14 weeks: dilation and curettage
+ anti-D prophylaxis
What are the pre-surgical management preparations for TOP
Cervical priming
- reduces risk of incomplete abortion
- May cause bleeding and pain
<14w: Vaginal/sublingual misopristol before abortion
>14w: osmotic dilators OR misoprostol
Anaesthetic Options
- Local anaesthetic only
- Conscious IV sedation + local anaesthetic
- Deep sedation or general anaesthetic (IV propofol + fentanyl)
Describe manual vacuum aspiration for TOP
<14 weeks
Involves gently dilating the cervix and using vacuum suction to evacuate the uterine cavity
Can be performed under LA or GA
Takes 5-10 minutes to perform
Describe dilation and curettage for TOP
Contents of the uterus are extracted using aspiration (vacuum pump with suction curettage) and other instruments (e.g. grasping forceps to remove larger parts of foetal tissue)
This can be done under LA or GA
Continuous USS guidance is required during D+E
Takes 10-20 mins and might be able to go home the same day
+ cervical priming and prophylactic Abx
An USS must be done to confirm evacuation
NOTE: ideally this is not done < 7 weeks as the risk of perforation is higher
What is the follow up advice after TOP
No medical need for follow-up after uncomplicated abortion
Safety net
Provide ongoing contraception
In ALL TOP patients, discuss the insertion of long-acting reversible contraception (copper IUD, LNG- IUS, Nexplanon)
Women who have an early medical abortion at home, they should have a scheduled ultrasound to exclude ongoing pregnancy or a self-performed urine pregnancy test
Urine pregnancy test often remains positive for up to 4 weeks following termination. A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast
What are the complications of medical TOP
Failure to end pregnancy
Risk of excessive bleeding e.g. haemorrhage (changing pads consecutively within 2 hours)
Retained products
Infection
What are the complications of surgical TOP
Failure to end pregnancy
Perforation of uterus
Haemorrhage
Cervical damage
Infection - most common (10% of cases)
What are the referral options for TOP
Can be referred through:
Primary Care
Self-referral
Hospital
Local Independent Providers
What safety netting advice should be given after TOP
Can experience some discomfort and vaginal bleeding for up to 2 weeks
Return to clinic if heavy bleeding, severe pain, smelly vaginal discharge, fever or ongoing
signs of pregnancy such as nausea or sore breasts
Clinic gives 24 hour helpline for concerns
