Abortion care / Unplanned preg

Question 1

The sites of uterine perforation at surgical TOP by % incidence

Answer 1

Anterior wall 40%
Cervical canal 36%
Lateral wall 38% (21% right lateral 17% left lateral)
Fundus 13%
Posterior wall 13%

Question 2

Pre-abortion assessment steps

Answer 2

Confirm pregnancy + gestation 
Pmhx and medication and allergies
O+G hx, STI risk assessment, cervical hx
social history + DV + safeguarding
discuss pregnancy options
Offer additional decision support
explain procure options and risks
Check patient fulfils abortion act criteria
CT test and HIV 
Rh status
contraception plan
consent
HSA1 x2 dr signatures

Question 3

Average CRL at 6/40

Answer 3

0.5cm

Question 4

Average CRL at 14 / 40

Answer 4

8cm

Question 5

Average CRL at 11/40

Answer 5

4cm

Question 6

At what gestations is early medical abortion carried out?

Answer 6

<10 weeks

Question 7

what type of medication is mifepristone

and how does it work?

Answer 7

Synthetic steroid and progesterone receptor antagonist.
Inhibits the normal action of progesterone on the uterus which maintains a pregnancy.
Sensitizes the uterus to respond to prostaglandins

Question 8

what type of medication is misoprostal

and how does it work?

Answer 8

Prostaglandin E1 analogue

Causes the uterus to contract and expel pregnancy tissues

Question 9

Procedure steps for early medical abortion

Answer 9

200mg mifepristone PO
24-48 hours later = 800mcg misoprostal PV (unlicensed)
Abortion occurs 4-6 hours later

Question 10

Common symptoms during medical abortion

Answer 10

Cramping pain and bleeding with passage of tissue

Nausea
Vomiting
Diarrhoea
Headache
Dizziness
Flushing / sweats

Question 11

At what gestations can MVA be performed?

Answer 11

<12 weeks

Question 12

Anesthetic options for MVA

Answer 12

none
local anaesthetic
conscious sedation
general anaesthetic

Question 13

when should cervical preparation be considered before surgical abortion?

Answer 13

In all cases

Misoprostal 400mcg in 1 hour before surgery if vaginal miso (3 hours if buccal)

or osmotic dilator (>14 weeks)

Question 14

Steps for performing MVA under LA

Answer 14

Bimanual ex
LA to anterior lip
Tenaculum anteriorly
Complete cervical block at 3, 6, 9 o’clock positions
Dilate cervix
Engage MVA to create vacuum
Introduce plastic cannula
Attach aspirator
Release vacuum
Slow rotation and in+out motion to evacuate products
Empty and repeat until complete (gritty sensation)

Question 15

At what gestations is dilation and evacuation STOP recommended

Answer 15

> 14 weeks

Question 16

Method of dilatation and evactuation STOP

Answer 16

Cervical preparation
General anesthetic
Cervical dilation upto 24mm
Crushing forceps and removal of fetus under ultrasound guidance
Suction curettage to ensure empty cavity

Question 17

Protocol commonly used for medical abortion 9-13 weeks

Answer 17

200mg mifepristone PO
36-48hours later
800mcg misoprostal PO or PV
3 hourly 400mcg misoprostal PO upto a maximum of 4 doses.
Analgesia PRN

Question 18

Protocol commonly used for medical abortion 14-24 weeks

Answer 18

Feticide if >21+6weeks

200mg mifepristone PO
36-48hours later
800mcg misoprostal PO or PV
3 hourly 400mcg misoprostal PO 
Overnight stay likely
Analgesia PRN

Question 19

Frequency of uterine perforation relating to STOP

Answer 19

1 in 1000

Question 20

Frequency of cervical trauma relating to STOP

Answer 20

<1 in 100

Question 21

Risk of severe haemorrhage related to medical abortion upto 13 weeks

Answer 21

< 1 in 1000

Question 22

Risk of requiring surgical removal of retained products following a medical abortion up to 13 weeks

Answer 22

7 in 100

will need surgery to empty RPOC

Question 23

Risk of sepsis related to medical abortion upto 13 weeks

Answer 23

<1 in 1000

Question 24

Risk of requiring surgical removal of retained products following a medical abortion >13 <24 weeks

Answer 24

13 in 100

Question 25

Risk of severe haemorrhage related to medical abortion at >13 <24 weeks

Answer 25

1-2 in 100

Question 26

Risk of sepsis related to medical abortion at >13 <24 weeks

Answer 26

4 in 100

Question 27

Risk of requiring repeat surgical procedure following a surgical abortion <13 weeks

Answer 27

3 -4 per 100

Question 28

Risk of haemorrhage related to surgical abortion <13 weeks

Answer 28

1 in 1000

Question 29

Risk of sepsis related to surgical abortion <13 weeks

Answer 29

1 in 1000

Question 30

Risk of requiring repeat surgical procedure following a surgical abortion >13 <24 weeks

Answer 30

2-3 in 100

Question 31

Risk of haemorrhage related to surgical abortion >13 <24 weeks

Answer 31

7 in 100 have haemorrhage requiring transfusion

Question 32

Risk of sepsis related to surgical abortion >13 <24 weeks

Answer 32

< 1 in 100 women will develop sepsis

Question 33

Risk of uterine rupture in women undergoing medical abortion at >13 <24 weeks

Answer 33

< 1 in 100 experience uterine rupture (usually only occurs in the context of previous caesarean section)

Question 34

Possible perceived benefits of a medical abortion

Answer 34

Avoids need for surgery Avoids an anaesthetic The woman is awake and aware of the process which may enable them a sense of control May feel more of a natural process than surgery to some women Depending on gestation may be able to pass products at home If performed in a clinic/ hospital = day case May be considered more private May be able to be accompanied

Question 35

Possible perceived benefits of a surgical abortion

Answer 35

Can be performed under anesthetic or sedation Avoids the woman seeing the pregnancy unless she requests to Quick - Usually day case + home the same day Usually reduced days of bleeding May reduce duration and severity of cramping pain Timing and duration is fixed Can have contraception started / fitted at time of surgery may require less repeat attendances

Question 36

Possible perceived disadvantages of a surgical abortion

Answer 36

The woman will usually need someone to accompany her home - if she had sedation or GA Overnight stay may be required Must occur in hospital / clinic setting Includes risks of uterine perforation or injury to the cervix May be considered less private as requires more staff to be present Usually cannot be accompanied during the procedure

Question 37

Possible perceived disadvantages of a medical abortion

Answer 37

Increased pain and bleeding amount and duration Timeframe for completing the abortion is more unpredictable May require a follow up pregnancy test or ultrasound May require more return visits than a surgical procedure Can see the passage of blood and POC Risk of uterine rupture if previous CS Cannot have IUS / IUD inserted immediately if completed at home

Question 38

What additional information may be needed for a woman having a termination because of fetal anomaly?

Answer 38

May be provided in the maternity setting or need referral to a separate termination service. Confirm they have sufficient information about the anomaly Explain that the fetus may not look abnormal despite there being a fetal anomaly

Question 39

What other agencies should a TOP service have links with

Answer 39

``` gynaecology / EPAU for non-vibiable IUP or ectopic AN services Social care Adult safeguarding Child safeguarding DV support Sexual abuse support Alcohol and drug support community SRH GUM ```

Question 40

What are the grounds for abortion | A-G

Answer 40

A - continuance of the pregnancy would involve risk to the life of the pregnant woman greater than termination B - termination necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman C - pregnancy not >24 weeks and continuance would involve risk, greater than termination, of injury to physical / mental health of the woman D - pregnancy not >24 weeks and continuance o would involve risk, greater than termination, of injury to the physical / mental health of any existing child(ren) of the family of the pregnant woman E - a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped: In an emergency if a termination is immediately necessary: F - to save the life of the pregnant woman G - to prevent grave permanent injury to the physical or mental health of the pregnant woman

Question 41

WHO definition of unsafe abortion

Answer 41

WHO defines unsafe abortion as "a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both".

Question 42

Risk of continuing pregnancy after surgical abortion

Answer 42

Continuing pregnancy after surgical abortion occurs in | 0.2% of procedures at 12 weeks or less.

Question 43

What factors may increase the risk of an ongoing pregnancy after surgical termination?

Answer 43

``` Procedure in a multiparous woman Conducted at six weeks’ gestation or less, When small suction cannulae are used, Performed by inexperienced surgeons Women with uterine abnormalities ```

Question 44

Risk of continuing pregnancy after medical abortion

Answer 44

ongoing pregnancy rate for early medical abortion with recommended mifepristone-misoprostol regimens is 0.5 - 0.7% More common with oral or lower doses of misoprostol. vacuum aspiration is the treatment of choice because another dose of misoprostol is effective in <40%