Makindo Medical Notes.com

Related Subjects: |Misoprostol

All aspects of abortion care should be delivered in a respectful and sensitive manner that is person-centred and recognises women and pregnant people as the decision makers

About

• The Abortion Act 1967 (Gov.UK 1967) (amended by the Human Fertilisation and Embryology Act 1990 (Gov.UK 1990)) defines the grounds upon which a termination of pregnancy can take place legally. This Act covers England, Scotland and Wales but does not apply to Northern Ireland.
• Termination of pregnancy is an integral part of reproductive healthcare for women. Around 1 in 3 women will have a termination, and each year just under 200,000 women have a termination in England, Wales and Scotland
• Most terminations are carried out because the pregnancy was unintended, and the large majority of procedures are conducted in the first 9 weeks of pregnancy. 99% of TOP occur in the first 20 weeks

Legality in UK except Northern Ireland

• Less than 24 weeks and
  • Risk to the woman's life
  • Risk to mothers physical or mental health (commonest reason > 90%)
  • Risk to physical or mental health to mother's existing children
  • Serious risk baby will be physically or mentally handicapped
• At all times up to Birth
  • Real risk to the mother's life
  • Risk of grave or permanent injury to the mothers mental/physical health
  • Baby will have serious physical or mental handicap

Seek medicolegal advice if age < 16 years old or cognitive impaired

Contraindications to medical abortion

• Known or suspected ectopic pregnancy
• Previous allergic reaction to mifepristone or misoprostol
• Severe uncontrolled asthma, Chronic adrenal failure, Inherited porphyria

Counselling

• Ensure patient knows that they can change mind at any time. Has she thought through the implications. Has she family support. Non judgemental consult.
• Should be given time even a few day to consider all options. Support regardless of decision taken. GPs with ethical issues should refer quickly to others.

Medical Management Before 12 weeks of pregnancy

• Mifepristone is used with Misoprostol. Can be done at home in the first 12 weeks
• Day 0: Take Mifepristone 200mg orally light bleeding may occur
• Day 1-2: Take Misoprostol 800 micrograms taken by the vaginal or between cheek and gum or sublingual. It may cause strong, painful cramps and heavy bleeding. Use 4 tablets placed either in vagina or between your cheek and gum. If 4 hours have passed and vaginal bleeding has not started or is minimal (meaning only spotting or smearing - only seeing blood on a tissue when wiping with a tissue), use the additional 2 misoprostol tablets either inside the vagina or between the cheek and gums.
• Take codeine analgesia

Medical Management Before 12-24 weeks of pregnancy

• Usually in a medical facility. No evidence that medical abortion is unsafe elsewhere.
• Day 0:Take Mifepristone 200mg orally light bleeding may occur
• Day 1-2: Take Misoprostol 800 micrograms taken by the vaginal or between cheek and gum or sublingual. Take further 400 mcg every 3 hours until abortion occurs.

Medical Management After 24 weeks of pregnancy

• Usually in a medical facility. Lower doses of Misoprostol needed as pregnancy advances.
• Day 0:Take Mifepristone 200mg orally light bleeding may occur
• Day 1-2: Take Misoprostol 100-400 micrograms taken by the vaginal or between cheek and gum or sublingual. Take further 100-200 mcg every 3-6 hours until abortion occurs.

Important Information on Complications

• Infection is less than with a surgical termination. The usual cause is chlamydia. Chlamydia screening will take place at your clinic appointment. If necessary follow up treatment will be arranged for you and your partner at the Department of Genito Urinary Medicine.
• The termination might be ‘incomplete’. This means that some tissue has remained in your womb. In 1/100 terminations the womb is not completely emptied of its contents and further treatment may be needed. If the termination is incomplete you may continue to have heavy or prolonged bleeding, or you can develop signs of infection in the womb. If this happens an ultrasound scan will be performed to check whether the termination has been ‘complete’. Following the scan the next step will be discussed with you. This may be a small operation called Evacuation of Retained Products of Conception or Expectant management which is waiting a little longer for the remains of the pregnancy to be expelled naturally. You will be monitored during this time.
• Excessive bleeding. Some bleeding from the vagina is a normal part of either procedure and can continue for 10 to 14 days. This bleeding is usually heavier with a medical termination. Rarely, women bleed much more heavily, either at the time of the termination or later. If this happens, you might require a blood transfusion. You may also find that your next period might be heavier than usual.
• Your pregnancy may not be terminated. With medical termination (including those carried out after 7 weeks) different studies have come up with different rates of failure. Some have found that only one or two out of every 1000 medical terminations failed to end the pregnancy, while others have reported that up to 14 in every 1000 fail. It is necessary to provide a urine pregnancy test. You will be given a urine container. Please take the urine specimen to your GP surgery or local hospital to be sent for testing. IT IS ESSENTIAL THAT YOU COMPLETE THIS TEST. Please phone in 48 hours after you have provided the urine sample for the result

Surgical Management Before 14 weeks of pregnancy

• Surgical abortion before 14 weeks can be performed using vacuum aspiration (electrical (EVA) or manual (MVA)). Vacuum aspiration involves evacuation of the contents of the uterus through a plastic or metal cannula, attached to a vacuum source.
• Cervical preparation before surgical abortion before 12 weeks is mifepristone 200mg orally, 24–48 hours before the procedure, or misoprostol 400 micrograms sublingually, 1–2 hours before the procedure, or misoprostol 400 micrograms vaginally or buccally, 2–3 hours before the procedure

Surgical Management at 14–24 weeks of pregnancy

• Surgical abortion between 14 and 24 weeks can be performed using dilatation and evacuation (D&E). D&E requires preparation of the cervix using osmotic dilators or pharmacological agents, and evacuating the uterus using long forceps and vacuum aspiration with cannulas. It is the safest and most effective surgical technique after 14 weeks, as long as skilled, experienced providers are available. Vacuum aspiration can be used up to 15–16 weeks of pregnancy with larger bore suction tubing and cannulas up to 16mm in diameter
• Cervical preparation combination of mifepristone and misoprostol

Prevention of post-abortion infection

• Prophylactic antibiotics are not required for medical abortion but should be used for surgical abortion as they have been shown to reduce the risk of infection following the abortion. However, surgical abortion should not be delayed if antibiotics are not available.
• The optimal regimen is not known but nitroimidazoles (e.g. metronidazole), tetracyclines (e.g. doxycycline) and penicillins have been shown to be effective. The following regimen can be considered for surgical (or incomplete) abortion antibiotic prophylaxis:
• oral doxycycline 100mg twice a day for 3 to 7 days, starting within 2 hours of the procedure (there is evidence that a 3-day course is as effective as a 7-day course

Complications

• Infection
• Haemorrhage
• Uterine perforation
• Cervical trauma
• Failed procedure with ongoing pregnancy
• Psychological

Anti-D

• If available, anti-D should be offered to non-sensitised RhD-negative individuals from 12 weeks of pregnancy and provided within 72 hours of the abortion.

Contraception

• Should be started after the TOP - can use OCP/POP or IUCD/IUS

References

• Best practice in abortion care