Unplanned pregnancy and abortion

Question 1

How common is unplanned pregnancy?

Answer 1

30-50%

Question 2

What are some outcomes of unintended pregnancy?

Answer 2

• Later initiation and less frequent antenatal care
• Increased preterm birth risk and low birthweight
• Increased postpartum depression and substance misuse
• Reduced breastfeeding rates
• Decreased bonding with infant
• Increased rates of child neglect and abuse
• Poorer long-term developmental outcomes§

Question 3

What percentage of unplanned pregnancies result in TOP?

Answer 3

30-40%

Question 4

How common is death in unsafe abortions

Answer 4

8 deaths per hour worldwide

Question 5

What act legalised abortion in Scotland, Wales and England?

Answer 5

Abortion act 1967

Question 6

How do Northern Irish abortion laws differ from the rest of the UK?

Answer 6

Only permitted to prevent serious harm or death up until 2019, but could travel to other parts of the UK

Question 7

What certificate is required to carry out an abortion?

Answer 7

HSA1 (Certificate A)

Question 8

What is required to certify an abortion?

Answer 8

HSA1 signed by 2 doctors
Emergency certificate signed by 1 doctor
Reporting to the chief medical officer

Question 9

What is the most common clause under which abortion is carried out in the UK?

Answer 9

Clause C:

Continuing the pregnancy would involve risk of injury to the physical or mental health of the pregnant woman or her existing children/family

Question 10

What is the gestational limit for abortion clause C?

Answer 10

24 weeks

Question 11

What is abortion clause E?

Answer 11

There is a substantial risk that if the child were worn, it would suffer from such a physical or mental abnormality as to be seriously handicapped

Question 12

What is the gestational limit for abortion clause E?

Answer 12

No gestational limit

Question 13

What is meant by conscientious objection?

Answer 13

HCPs have the right to refuse to participate in abortion care

Question 14

What are some limits of conscientious objection?

Answer 14

• Does not supply in emergency or life-threatening situations
• Should not delay or prevent a patients access to care
• Does not apply to indirect tasks associated with abortion such as administrative work or supervision of staff

Question 15

How common are abortions in the UK?

Answer 15

200,000 per year

Question 16

How are people referred to abortion services?

Answer 16

GP
Sexual and reproductive health clinic
Self-referral

Question 17

What factors determine method of abortion?

Answer 17

Local availability
Patient choice
Gestational period

Question 18

What are the 2 main categories of abortion methods?

Answer 18

Medical
Surgical

Question 19

What is the gestational limitation for medical termination?

Answer 19

24+6 weeks

Question 20

How are pregnancies dated prior to TOP?

Answer 20

Estimation using last menstrual period and date of positive UPT
Palpable uterus (>12 weeks)
USS if unsure

Question 21

What are the 2 drugs given for medical abortion?

Answer 21

Mifepristone 200mg PO
Misoprostol 800mcg PV (24-48 hours later)

Question 22

What is meant by EMAH in abortion?

Answer 22

Early Medical Abortion at Home - Use of medical abortion at home

Question 23

What is the gestational limit for EMAH?

Answer 23

11+6 weeks

Question 24

What are some benefits of EMAH?

Answer 24

More comfortable
Prevents bleeding or cramping en route from hospital

Question 25

What is contained in an EMAH pack?

Answer 25

- Mifepristone - Misprostol - Anti-emetic - Analgesia - Antibiotics - Contraception (6/12 POP) - Low-sensitivity pregnancy test

Question 26

What is given for EMAH if expulsion hasn't occurred within 4 hours?

Answer 26

2nd dose of 400mcg misoprostol

Question 27

What is the gestational limit for inpatient medical abortion?

Answer 27

23+6 weeks

Question 28

Describe the treatment regime for inpatient medical abortion

Answer 28

Repeated doses of PV misoprostol: 800mcg PV then 400mcg 3-hourly PV/PO/SL (Up to 4)

Question 29

Describe the availability of medical TOP in Scotland

Answer 29

MTOP available up to 19+6 weeks in most areas of Scotland; >20 weeks requires travel to England (BPAS)

Question 30

What are the 3 forms of surgical abortion?

Answer 30

Electrical vacuum aspiration Manual vacuum aspiration Dilatation and evacuation

Question 31

What is done prior to surgical TOP?

Answer 31

Cervical priming with msioprostol or osmotic dilators Local or general anaesthetic

Question 32

What is the gestational limit for electrical vacuum aspiration?

Answer 32

13+6 weeks

Question 33

What is the gestational limit for manual vacuum aspiration?

Answer 33

10 weeks

Question 34

What is the gestational limit for dilatation and evacuation?

Answer 34

≥14 weeks (No limit)

Question 35

Describe the availability of surgical TOP in Scotland?

Answer 35

Dilatation and evacuation is not available in Scotland, so patients must travel down to England

Question 36

What is required in a pre-abortion consultation?

Answer 36

- Confirm ID and check if safe - Feelings about pregnancy - Assessment of gestation - Gynae/Obstetric history - Medical, drug and social history - Exploring safeguarding issues (E.g. under 16s, vulnerable groups) - Discussions of available options - Risks of procedure and consent - STI risk assessment or testing - Contraception - Further arrangements and follow-up

Question 37

What are some possible complications of abortion?

Answer 37

- Continuing pregnancy (1-2%) - Infection - Severe bleeding requiring transfusion - Cervical injury - Uterine perforation - Uterine rupture

Question 38

What are some possible prophylactic requirements in TOP?

Answer 38

Antibiotic prophylaxis Rhesus iso-immunisation VTE prophylaxis

Question 39

Who is offered antibiotic prophylaxis in TOP?

Answer 39

Those undergoing STOP Those undergoing MTOP with increased STI risk

Question 40

What is the antibiotic prophylaxis regime for TOP?

Answer 40

7 days 100mg doxycycline BD

Question 41

Why may rhesus iso-immunisation be required in TOP?

Answer 41

This may be a sensitising event to D-negative women, leading to development of anti-D antibodies, which cross the placenta and cause haemolytic disease

Question 42

Who is given rhesus isoimmunisation

Answer 42

Rhesus D-negative women with STOP or MTOP ≥12 weeks

Question 43

How is high risk of VTE managed in abortion?

Answer 43

LMWH 1 week post-abortion

Question 44

How is very high-risk of VTE managed in abortion?

Answer 44

LMWH before abortion, continuing for 6 weeks

Question 45

How long after abortion does ovulation begin?

Answer 45

Ovulation occurs in >90% of women within 1 month and can start as early as 8 days after and so contraception is required

Question 46

How soon after abortion do contraceptives become immediately effective?

Answer 46

Up to 5 days

Question 47

Use of IUDs post-abortion

Answer 47

- Avoid in presence of post-abortion sepsis - Can be inserted immediately after STOp or after MTOP once expulsion of pregnancy is confirmed

Question 48

Use of hormonal contraception post-abortion?

Answer 48

Can be started anytime after MTOP/STOP including day of mife/miso

Question 49

Use of non-hormonal methods post-abortion?

Answer 49

- Barrier methods can be used anytime (Expect diaphragm after 2nd trimester TOP) - Sterilisation after some time has elapsed - Avoid FAM until regular periods resume

Question 50

How are patients followed up after EMAH?

Answer 50

- Low-sensitivity UPT performed at least 2 weeks after abortion (Not standard UPT) - Cut off equivalent to 1000 iu/L HCG (Normal is 25 iu/L) - This is to identify incomplete or failed procedures - Signposting to support services