W13 Termination of Pregnancy- for info not heavily assessed (GW) Flashcards
Female reproductive system (for info)
Foetus/ baby grows in the uterus
Cervix is the entrance to the uterus
Baby is delivered through the vagina (usually)
Normal length of pregnancy is 40 weeks (‘full term’)
Number of weeks along is referred to as gestation
Termination of Pregnancy (TOP)- what does this mean?
Also known as an abortion
Way of ending a pregnancy either through the use of drugs or through a surgical procedure
It’s considered a safe procedure, with complications being uncommon
The earlier in the pregnancy the TOP is had, the safer it is
Highly divisive and emotionally charged topic in society
TOP: Legal Considerations
Tightly regulated area of healthcare
UK law (Abortion Act 1967):
Allowed up until week 24 of pregnancy
Must be agreed by TWO doctors
Only allowed if continuing the pregnancy would cause more damage to physical and mental health of the patient than the termination
This law applies to Great Britain; Northern Ireland has more restrictions
Patients have a right to confidentiality when seeking TOP
Hospital or clinic aren’t required to inform GP
Don’t need partner’s agreement to have an abortion
NB TOP may be allowed after week 24 if mum’s health/life at risk
Buffer zones (for info)
Buffer zones will come into force around abortion clinics in England and Wales from 31 October.
It will make it illegal to hand out anti-abortion leaflets within the buffer zone or obstruct anyone using or working at an abortion clinic.
The protection zones, which will prohibit protest, will extend to a 150-metre radius around abortion services and those convicted of breaking the new law will face an unlimited fine
TOP: Legal Considerations
Children under 16 years of age:
What competency applies here?
Should parents be told?
Social services?
- Gillick competency applies here
-Children aged 13-16 years can consent to abortion treatment if deemed to have capacity - Will be encouraged to tell and involve parents, but not a legal requirement to get parental consent
- If under 13 / concerns re sexual abuse, MUST report to social services as it’s a child protection issue
-As per Fraser guidelines – repeated TOPs in young people could be sign of sexual abuse
-Gillick competence – children under 13 deemed too young to have capacity
TOP: Moral and Ethical Considerations
Moral:
Doctor or nurse can refuse to take part in abortion on the grounds of conscience BUT they must refer patient to another who will be able to help
GMC: Must ensure that personal beliefs do not prejudice patient care
Ethical
4 pillars of medical ethics:
1. Beneficence (do good)
2. Non-maleficence (do no harm)
3. Autonomy (giving the patient the right to choose freely, where able)
4. Justice (ensuring fairness)
* Refusing abortions / not referring to others goes against each pillar
TOP: Patient Considerations
Why might a patient want a TOP? (4)
- Highly emotional situation and a decision not made lightly
- May feel ashamed, upset, indifferent, embarrassed, guilty
- Scans have detected a foetal abnormality which would lead to serious physical or mental disability in the child
- Tests have detected a genetic abnormality which would lead to serious disability in the child (e.g. Trisomy 21)
- Pregnancy is a result of crime or abuse
- Social reasons, e.g. poverty, unable to cope with having a child, mother doesn’t want a child
As HCPs, we should:
-Respect the patient’s decision
-Treat the patient with dignity and compassion
-Speak plainly and directly, rather than skirting around terminology
TOP: Foetal Considerations (for info)
Up to what age will the foetus not experience the TOP?
Does an unborn foetus have legal rights?
- Cut off of 24 weeks for abortion has been decided based on neuroanatomical and physiological evidence
- Connections between periphery and cortex are not intact before 24 weeks of gestation
- Means that the foetus cannot experience pain sensations and does not have awareness at this stage – will not be able to experience the TOP
Note: UK law does not give legal rights to an unborn foetus.
“The foetus cannot […] have any rights of its own at least until it is born and has a separate existence from the mother”
HOWEVER- very grey area of the law
“the foetus is not a person, but this doesn’t mean it’s nothing”
“if the foetus has no rights, then there would be no need to regulate abortion and restrict it. This […] shows a consensus that the foetus has some kind of rights.”
3 main ways to get abortion on the NHS?
- Self-refer by contacting abortion provider directly
-e.g. British Pregnancy Advisory Service (BPAS) - Speak to GP
-They can refer to an abortion service - Contact sexual health clinic / GUM clinic / family planning clinic
-They can refer to abortion service
- Waiting times vary from geographical location, but whole process from referral to appointment to abortion should be within 2 weeks.
- Private hospitals and specialist clinics are also available, but patients will need to pay fees.
- These centres must be licensed and inspected by the Healthcare Commission and approved by the Department of Health
What are the methods of TOP? (2)
When are they used?
Which is preferred?
- Medical or Surgical
- Both can be used at any stage of pregnancy
- Medical is preferred for gestations of less than 7 weeks (more likely to be effective)
Medical Termination of Pregnancy:
What 2 drugs are used?
- Attend clinic or hospital to receive medication
- Same drugs used regardless of gestation: mifepristone and misoprostol
Up to 10 weeks’ gestation:
* Usually take first drug on premises, then can either return for second drug or take it at home.
* Faster process, with pregnancy usually terminated 4-6 hours after second medication taken
After 10 weeks’ gestation:
* Will likely need to stay in hospital for duration of process as can be complex and risk of complications, with drug doses potentially repeated
* Abortion process likely to take longer and be more painful
MIFEPRISTONE
Drug class?
Dose?
Common SE?
Interactions?
- Type of antiprogestogenic steroid
- Used to block pregnancy hormones
- Also sensitises the myometrium to prostaglandin-induced contractions and ripens the cervix – prepares to expel foetus
- Will usually only need one dose
- Usual dose: 600mg orally
Common s/e: abdominal cramps, n+v, vaginal bleeding
Interactions: drug levels reduced by enzyme inducers (e.g. antiepileptics).
Will only be supplied to NHS hospitals and premises approved under the Abortion Act 1967.
MISOPROSTOL
Drug class?
Dose?
Common SE?
Interactions?
- To be taken 48 hours after mifepristone
- Type of synthetic prostaglandin analogue
- Acts as a potent uterine stimulant that induces uterine contractions, so that the womb expels the pregnancy
-Takes 4-6 hours to work - Dose can be given orally, intra-vaginally, buccally or sublingually
- Dose varies depending on gestation
- Can give repeated doses to induce effects (max stated under specific indications in BNF; further doses may be via different routes)
Common s/e: Chills, constipations, n+v, diarrhoea, headache
Interactions: oxytocin (not relevant for this indication)
After taking the medication:
How long are patients monitored for?
- Patient will be observed for at least 3 hours
- May be observed for longer – until bleeding and pain at an acceptable level
- Follow-up visit will be required within 2 weeks to verify complete expulsion and to assess vaginal bleeding
-i.e. pregnancy test needed to confirm procedure successful - Patient should be advised to seek emotional support if needed, and how to access it.
- Some patients may wish to see the foetus, hold it, name it or arrange a funeral for it (only possible with medical termination)
- Others may choose not to.
Surgical Termination of Pregnancy
What are the different types?
Up to 7 weeks’ gestation
* Early surgical termination consisting of vacuum aspiration
From 7 to 15 weeks’ gestation
* Suction termination used
* May be done under local or general anaesthetic, or conscious sedation
* Cervix stretched and opened, with suction tube inserted to remove the uterus contents
* May insert misoprostol tablet into vagina beforehand to soften cervix
Over 15 weeks’ gestation
* Surgical dilatation and evacuation
* Done under general anaesthetic
* Pregnancy removed in fragments with a suction tube and forceps
* May use ultrasound scanner to ensure all pregnancy contents removed
