Abortion Care Flashcards
(24 cards)
England and Wales Law
Governed by abortion Act 1967 and amended by human fertilisation and embryology act 1991
Legal abortion must be:
Registered medical practitioner.
Performed accepting emergency, at NHS hospital or in a place approved for the purpose of the act.
Certified by 2 registered medical practitioners and justified by one or more following statutory grounds (except under emergency conditions where one signature needed for F and G)
A risk to life of woman
B risk permanent grave injury physical/mental health of women
C <24 risk injury physical/mental health of pregnant woman
D <24 risk of injury physical/mental health of existing children
E Fetal abnormality -> seriously handicapped
Emergency grounds for abortion (England and Wales)
F save life of woman
G prevent grave permanent injury to physical/mental health of women
Abortion in Northern Ireland
Decriminalised 2019
New framework: Abortion regulations 2020 
Up to 12 weeks (no conditions required. Just 1 medical practitioner).
Up to 24 weeks: clause C (risk mental/physical injury to woman)
No time limit but needs 2 signatures:
Clause A and B (risk to life/of grave permanent injury physical/mental health)
Clause E Fetal abnormality
No time limit, just 1 signature
Clauses F & G save life or prevent grace permanent injury physical/mental health
Abortion law in ROI
Legal up to 12 weeks
> 12 weeks if:
- risk of serious harm/life of pregnant person
- Fatal fetal anomaly
Regulated by Regulation of Termination of Pregnancy Bill 2018
HSA4 form
Legal requirement to report to CMO to DHSC
To be completed by practitioner terminating pregnancy.
To be done within 14 days
HSA1 form
Completed by 2 doctors for routine TOP
Applicable clauses A - E
Signed before TOP
Kept for 3 years
HSA2 form
For emergency TOP
Signed by 1 doctor
Used for clause F & G
Sign before or by 24 hours after TOP
For three years
Information collected on HSA4 form
– Practitioner details
– pt details
– Details of those signing HSA one
– treatment details location, funding, fetcide info
– Gestation
– grounds inc med conditions and fetal abnormality
Selective termination for multiple pregnancy
– screening
– complications
– Death
Contraindications to medical TOP
–? Ectopic pregnancy
– previous allergic reaction to mife or miso
– severe uncontrolled asthma
– chronic adrenal failure
– inherited porphyria
Cautions
- long-term steroid use (mife = glucocorticoid receptor antagonist)
– anticoagulation after
– bleeding disorder 
– Symptomatic anaemia
IUD in place
Medical abortion medications <12/40
Can be at home <10/40 England <12/40 Scotland
Mifepristone 200mg PO
Competitive progesterone receptor antagonist
Inhibits effects on Endo and myometrium = degeneration
Cervical softening and dilatation
Sensitises myometrium to PG induced contractions
24-48’ later
Misoprostol 800mcg PV/SL/buccal
PGE1 and PGE2 receptor agonist
Soften/dilate cervix
Uterine contractions
Further 400mcg if not passed after 4 hours
Allergy to mifepristone
800mcg misoprostol then 400mcg every 3 hours till passed
Medical abortion 12-24 weeks
Medical setting
Mifepriston 200mg
24-48’ later 800mcg misoprostol then 400mcg every 3 hours till abortion
If mifepristone allergy or none, same regime
800mcg misoprostol PV/SL/buccal then 400mcg every 3’ till abortion
When to scan before TOP
– Unsure gestation (irregular periods, conceived on HC or EC used)
– RF ectopic (previous ectopic, surgery, PID, IUC)
– previous GTD
– symptoms of ectopic
– if they want to scan
Contraindications and cautions for surgical abortion
– Contraindicated if cervical obstruction
Caution:
– bleeding disorders
– abnormal placentation
– Anticoagulation medication
– severe cardiac/pulmonary disease
– very raise BMI
– distortion of cavity
– previous cervical surgery
– FGM grade 3
Medical abortion >24/40
Uterus more sensitive to misoprostol as pregnancy advances
Same dose mife
24-25 400mcg misoprostol every 3 hours
25+1-28 200mcg misoprostol every 4 hours
> 28 weeks 100mcg misoprostol every 6 hours
Cervical prep for Surgical TOP
Reduces risk of incomplete TOP, makes dilation easier, may cause pain or bleeding
<14/40
Mifepristone 200mg PO 24-48 hours pre-op
Misoprostol 400mcg PV 3 hours pre-op or
Misoprostol 400mcg SL 1 hour pre-op
>14/40
Mife or miso as above
Osmotic dilators
If 19+1 onwards consider mife + osmotic dilators
Surgical termination <14 weeks
MVA or EVA (higher suction pressure)
Paracervical block recommend
Can be done under concious sedation
4-12mm cannula
Forceps if required
Surgical termination 14-24 weeks
More robust cervical dilatation
Long forceps + vacuum aspiration
Usually US guided
When is anti-D prophylaxis required?
- Rh-ve
- if having TOP after >10/40
- consider in surgical TOP <10/40
When are prophylactic antibiotics given?
For surgical TOP within 2 hours
- Doxy 100mg BD 3/7
- metronidazole 1g stat PR
If using metro don’t use with any other broad spec abx (like doxy)
Complications of abortion
Failure (EMA 1 in 100, surgical 1 in 1000)
Retained POC (EMA 3 in 100, surgical 1 in 100)
infection < 1 in 100
Haemorrhage 1 in 1000
Cervical tear 1 in 100
Perforation 1 in 1000
Can DMPA be given at the time of TOP?
Yes
But possibly reduces efficacy of mifepristone, therefore may increase risk of ongoing pregnancy but risk is low 
Complications of TOP
Amniotic embolism (systemic inflammation; disseminated intravascular coagulation), collapse, hypoxia, hypotension, coagulopathy) -> CPR & ITU
Haemorrhage (tone, tissue, trauma, thrombin)
Need for transfusion
Management
- bimanual compression
- Uterotonic (oxytocin, misoprostol, carbeprost)
- empty uterus
- intrauterine tamponade
Endometritis - persistent pain, days - weeks, offensive discharge, -ve PT, fever. Treat PID +/- ERPC
Asherman’s syndrome
Scar within uterus (light/amenorrhoea, infertility, miscarriage)
Managing incomplete abortion (no infection)
<14 week size
Misoprostol 400mcg PV or 400mcg 600mcg PO
Or surgical + abx
>14 week size
Misoprostol 400mcg PV every 3 hours
For missed abortion, non viable fetid, 200mg mifepristone 24-48 before
Contraindication to medical abortion?
- ? Ectopic
- allergy
- severe uncontrolled asthma *
- Chronic adrenal failure *
- Inherited porphyria *
- cant use mife but can use just misoprostol instead
