Abortion

Question 1

What is the upper limit of gestational age to which a woman can have an abortion?

Answer 1

Up to 24 weeks (23 completed).

Question 2

List the legal grounds of abortion according to the 1967 abortion act.

Answer 2

A. Continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated.

B. Termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnanc woman.

C. Pregnancy has not exceeded its 24th week and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or metnal health of the pregnant woman.

D. Pregnancy has not exceeded its 24th week and continuance would involve risk, greater than if the pregnancy were terminated, of injury to the physical or metnal health of any existing children of the family of the pregnant woman.

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

Question 3

What is the most common legal ground for abortion in the UK?

Answer 3

Ground C: Pregnancy has not exceeded its 24th week and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or metnal health of the pregnant woman. (>95%)

2% are based on Ground E, i.e. substantial risk of foetal disability/anomalies.

Question 4

Up to what week is medical abortion typically available?

Answer 4

Usually up to 9 weeks, but it can technically be used until much later.

RCOG says medical TOP can be performed up to 14 weeks’ gestation - may go with this in an SBA.

Question 5

What does a regimen of medical abortion consist of?

Answer 5

Medical abortion consists of:

• Mifepristone (progesterone receptor antagonist)
• Misoprostol (prostaglandin analogue) 24-48 hours later

Progesterone is involved in uterine quiescence, so mifepristone leads to increased uterine contractility. Mifepristone also sensitises the uterus to prostaglandins.

Misoprostol leads to slight opening of the cervix and to contraction of the uterus, and subsequent expulsion of the foetus.

In more advanced gestational age, it might be necessary to give several doses of mifepristone before giving misoprostol.

The woman can usually do this at home.

Question 6

Name and birefly explain the 2 most commonly used surgical abortion techniques.

Answer 6

Vacuum aspiration:

• Done up to 14 weeks
• The cervix is dilated and then gentle suction is used to evacuate the cavity (either manual or electrical aspiration)
• Procedure takes around 10 minutes
• Under local or general anaesthesia

Dilation and evacuation:

• After 14 weeks
• Cervix needs to be dilated pre procedure (e.g. misoprostol or mifepristone)
• Instruments and vaccum is used to evacuate the uterus

In all surgical terminations prophylactic antibiotics should be given.

Question 7

In the TOP (Termination of Pregnancy) clinic, what tests should be performed?

Answer 7

• FBC (looking if anaemic, as blood loss is common in all types of TOP)
• G&S (Rh D status - indicates requirement for anti-D IVIG)
• Chlamydia screen (aroudn 30% of patients in TOP clinic had 1-night-stands, so targeting high-risk population) + consider other STI checks
• USS for gestational age assessment
• Counselling (Determine reason for TOP/exclude coercion. Also counsel about contraception)
• Consultation with Gynaecologist (information about procedure)

Question 8

What are possible consequences of TOP (Termination of Pregnancy) ?

Answer 8

• Failure (continuing pregnancy)
• Retained products of conception
• Infection
• Haemorrhage
• Potential psychological consequences
• Very small chance of maternal mortality

All these risks are much lower than childbirth.

Question 9

What is the impact of TOP (Termination of Pregnancy) on future fertility?

Answer 9

TOP has no impact on future fertility and there is no association with ectopic pregnancies.

Question 10

How soon after abortion do women need to start using contraception?

Answer 10

Most women ovulate in the first month after the abortion, effective contraception should therefore be started immediately.

When counselling women at the time of TOP (Termination of Pregnancy) a LARC should be suggested, as these are associated with the lowest rates of unintended pregnancies.

Question 11

Which website can you refer women to if they want more information on different forms of TOP?

Answer 11

BPAS (british pregnancy advisory service).

This website offers advise around all issues regarding TOP, as well as miscarriage, foetal anomalies and contraception)

Question 12

How long after an abortion can a pregnancy test be positive?

Answer 12

A pregnancy test can still be positive for up to 4 weeks after the abortion. A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast.