ABorto

Question 1

Def

Answer 1

• Termination of pregnancy before 20 weeks’ gestation calculated from date of onset of last menses (WHO).
• An alternative definition is delivery of a fetus (produto de expulsão) with a weight of <500 g.
• 24 weeks (fetal viability)
• Spontaneous or induced termination
• Legal abortion / illegal (unsafe abortion)

Question 2

Leis de aborto

Answer 2

• diferentes pelos paises
• Paises mais pobres tem leis mais restritas

a) This is the only way to eliminate the danger of death or serious and irreversible
injury to the body or the physical or mental health of the pregnant woman (without
limit)

b) It would avert a risk of death or serious damage to the physical or mental health of the mother, and the procedure was performed during the first 12 weeks of gestation
c) There are safety reasons to provide that the unborn child may suffer from an incurable form of a serious illness or congenital malformation, and is performed in the first 24 weeks of pregnancy, except for non-viable fetal situations, in which case the interruption may be practiced at any time;
d) Pregnancy is the result of a crime against liberty and sexual self-determination and is interrupted for the first 16 weeks of pregnancy;
e) On woman´s request - within the first 10 weeks

Question 3

Consentimento informado

Answer 3

• The circumstances supporting the termination of a pregnancy must be verified by a medical certificate, written and signed before the abortion, by a physician different from the one who is performing or supervising the abortion
• Informed consent in a document signed by her, or at her request and, when is possible, at least 3 days before the date of the abortion. Before delivering her consent, the woman must undergo a period of reflection lasting a minimum of 3 days
• If the woman is under 16 or is incompetent, the written consent may be provided, in order of priority, by a competent ascendant or descendant ,or in their absence , by any relative in the collateral line
• If the procedure must be performed as a matter of urgency, the physician may decide according to their conscience

Question 4

Metodos de aborto

Answer 4

• Cirurgico (idd gestacional mais precoce e até 12 semanas por aspiração manual ou eletrica e/ou dilatação e curetagem-> bloco com sedação)
• Medicamentoso- gestações mais precoces mas são a eleição para as >12 semanas
  o Mifepristone para preparar o colo e doses repetidas de misoprostol ou gemeprost
  o Pg vaginais (doses repetidas)
  o Soluções hipertonicas
  o Pg intra/extra-amnioticas

Question 5

Como escolher metodo

Answer 5

• Randomization (provavel pior forma)
• Women preferences
• Operating room
• Gestacional age
• Training and skills of providers
• Available medicines
• Follow- up facility
• Indications
• Contraindications

Question 6

Gestão pre-aborto

Answer 6

• Patient history and physical examination
  o Pregnancy should be confirmed by history and a reliable urine pregnancy test
• Laboratory testing:
  Determination of Rhesus blood status (Ig anti-d se Rh -)
• Ultrasound scanning
  o Gestational age should be confirmed by clinical evaluation or ultrasound
  o Before ultrasound is undertaken, women should be asked whether they would wish to see the image or not
• Prevention of infectious complications
  o Antibiotics
  . Surgical abortion: universal use is effective
  . Medical abortion: controversial

o Antibiotic choice should take into account the local epidemiology of genital tract infections, including sexually transmitted infections.

o If bacterial vaginosis or a sexually transmitted disease is identified preoperatively, treatment should be administered according to CDC sexually
transmitted disease treatment guidelines

• CHLC: Azitromicina, 1g oral route (surgical and medical abortion)

Question 7

CI de aborto medico

Answer 7

• Chronic adrenal failure- ação antiglucocorticoide
• Mifepristone, prostaglandines (intolerance ou allergy)
• Current long-term systemic corticosteroid therapy
• Porphyria (aumenta proto porfirias)
• Confirmed or suspected ectopic pregnancy (atua no utero)
• Intrauterine device in place (confirmar evacuação do DIU)
• Severe anemia, known coagulopathy or anticoagulant therapy

Question 8

Vantagens aborto medico

Answer 8

• High effective, safe and acceptded method (metodo eleição)
• Can be used for all gestacional ages
• Can replace surgical abortion
• Mefipristone (antiprogestogen) + Prostaglandin analogs E1 (misoprostol, 1-2 days after mifepristone) -> não deve ser usado na asma pois provoca contração mx liso
• Misoprostol alone (Prostaglandin )
• Methotrexate + misoprostol (ainda não aprovado em PT)

Question 9

Metodo cirurgico

Answer 9

1. Vacuum aspiration (standard method)
2. Dilatation and curettage
3. Dilatation and evacuation

• Electric vacuum aspiration (EVA) versus Manual vacuum aspiration (MVA):
  There were no differences in complications: cervical trauma, hemorrhage, infection, transfusion, fever, duration of procedure or women’s preferences
• Advantages of MVA: Portable, does not require electricity, cost effective for resource-poor settings, easy use at earlier gestational ages, the aspirated material can be examined por AP, less pain
• Preparação cervix

o Prostaglandin E1 analogs (Misoprostol orais ou vaginais 2h antes), antiprogesterone (mifepristone), rigid dilators, osmotic dilators

o Reduces complications:  
. Cervical trauma
. Uterine perfuration
. Bleeding
. Incomplete abortion

o Especially beneficial: cervical anomalies or previous surgery, nulliparous those with advanced pregnancies

Question 10

Gestão pos aborto

Answer 10

o Pain control (ibuprofeno, metamisol magnesico, paracetamol)

o Rhesus prophylaxis: Rh(D)-immune globulin (≥ 6 weeks), 50 mcg (até às 12 weeks)

o Discussion and offering of contraception

o Alarm signals: pain, hemorrhage, fever

o Follow-up (mandatory in medical abortion) -> pode ficar prod da conceção no medicamentoso

o Provision of post-abortion information (brochuras)

Question 11

Complicações

Answer 11

• Medicamentoso
  o Failed abortion (maior risco que no cirurgico) -> se aconceter passamos para o cirurgico

o Infection

o Incomplete abortion

o Hemorrhage

• Cirurgico:
  o Major complications (1%)

. Incomplete abortion

. Infection

. Failed abortion

. Hemorrhage/hematometra (produto evacuado mas houve trauma cervix e estenose com retenção sanguinea)

. Uterine perforation

Question 12

Contraceção pos aborto

Answer 12

• Ovulation- Dia 22 apos procedimento (mean), Dia 10 (earliest) (descrição do mais cedo)
• Medicamentoso:
  o Contraceção hormonal na altura do aborto
  o Contraceção intra uterina no follow-up de confirmação da liberdade da cavidade uterina OU apos 1 menstruação
• Cirurgico:
  o Contraceção hormonal na altura do aborto
  o Contraceção intra uterina na altura do aborto