Unplanned pregnancy

Question 1

What are the causes of unplanned pregnancy & wanting an abortion?

Answer 1

• Contraceptive problems - failure, non-use/incorrect/inconsistent use
• Other reasons = rape, lack of knowledge/planning, lack of motivation

Question 2

What are the 3 options someone has when they have an unplanned pregnancy ?

Answer 2

1. continue & keep the baby
2. Abortion
3. continue & have the baby adopted

Question 3

Termination of pregnancy (TOP) is highest in which age groups ?

Answer 3

20-24

Question 4

What is the abortion act 1967?

Answer 4

• An abortion can take place only if 2 registered medical practitioners are of the opinion, formed in good faith that an abortion is justified within the terms of the act
• Only registered medical practitioners can terminate a pregnancy
• ‘Any treatment for the termination of pregnancy’ must take place in an NHS hospital or approved premises

Note - NI now has the same abortion rules as the rest of the UK

Question 5

What forms must be completed with regards to TOP?

Answer 5

• Certificate A (HSA1 in england): 2 doctors are required to sign this form before an abortion is performed
• Certificate B (HSA2 in england): this is to be completed by the doctor within 24hrs of an emergency abortion being performed
• HSA4: this must be completed by the doctor & sent to the chief medical officer (CMO) within 7 days of the abortion taking place

Certificate A or B done & then HSA4 always done

Question 6

What are the legal limits for TOP and the limits for TOP done in scotland and tayside ?

Answer 6

Legal limit:

• For social termination of pregnancy – 23 weeks 6 days
• For fetal anomaly- any gestation

NHS Tayside -18 weeks and 6 days, In scotland no TOP is done past 20weeks after this you need to go down to london for TOP

Question 7

List the different grounds (both emergency & non-emergency) under which a TOP can be carried out

Answer 7

• A - Continuance of pregnancy would involve risk to life of pregnant woman greater than if pregnancy were terminated
• B -Termination necessary to prevent grave permanent injury to physical/mental health of woman
• C - Pregnancy has NOT exceeded its 24th week and continuance of pregnancy would involve risk, greater than if pregnancy terminated, of injury to physical or mental health of pregnant woman
• D - Pregnancy has NOT exceeded its 24th week and continuance would involve risk, greater than if pregnancy terminated, of injury to physical or mental health of existing child(ren)
• E - There is substantial risk that if the child were born it would suffer from physical or mental abnormalities as to be seriously handicapped
• F - It was necessary to save the life of the woman
• G - It was necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman

Question 8

Go over the important ethical aspects regarding TOP:

1. If women is < 16 then you need to assess Gilick competence
2. If you are worried about a young person (e.g. abuse) & feel like socail work should be informed then you should let the patient know that you dont have to have consent to speak to social work if you are worried
3. Conscientious objection

Question 9

What are the rules regarding conscientious objection and TOP?

Answer 9

GMC guidelines:

• If carrying out a particular procedure or giving advice about it conflicts with your religious or moral beliefs, and this conflict might affect the treatment or advice you provide, you must explain this to the patient and tell them they have the right to see another doctor.
• You must be satisfied that the patient has sufficient information to enable them to exercise that right. If it is not practical for a patient to arrange to see another doctor, you must ensure that arrangements are made for another suitably qualified colleague to take over your role
• Treatment in the event of an emergency may NOT be denied on the grounds of conscientious objection

Question 10

Describe the timeline from initial consultation to TOP

Answer 10

Initial consultation:

• Certainty to proceed/alternatives discussed
• USS to confirm pregnancy & determine gestational age
• Complete medical history taken
• Discussion of suitable methods of TOP

Referral for TOP to the TOP clinic is then made

At the TOP clinic plenty of opportunities to discuss options/decisions are provided

Referral is then made for TOP treatment (2 weeks long)

They then come onto the ward for TOP

Question 11

Alongside the treatment for TOP what else needs to be done ?

Answer 11

• Written consent for procedure and fetal remains
• Bloods obtained (FBC/G&S +/-BBV) – mainly for grouping and saving for future, also Rh status, Hb conc & haemoglobinopathy screening
• Optional screening for STI
• Prophylaxis – when undergoing STOP or MTOP and at an increased risk of STI give 7 days doxycyline or 2 days azithromycin
• Counselling re: ongoing contraception (discussed at every opportunity)

Question 12

What are the 2 main methods used for TOP and what are the gestational limits for their use ?

Answer 12

1. Surgical termination up to < 12 weeks
2. Medical termination up to 18 weeks and 6 days (other parts of scotland its done upto 19+6 weeks)

Question 13

What are the 3 subclassifications based on timing of TOP?

Answer 13

• Early = up to 9 weeks
• Late = 9-12 weeks
• Mid-trimester = 12-24 weeks

Question 14

Describe the process of a medical TOP

Answer 14

1. Given oral Mifepristone (an anti-progesterone) then 24-48hrs they come back to the ward
2. 24-48hrs later they are given vaginal (or oral) prostaglandin e.g. misoprostol, gameprost. This can be given upto 5 doses 3hrs apart, abortions > 12 weeks (mid-term) often require > 1 dose

If < 10 weeks gestation then can self-adminster misoprostol at home (not recommended if < 16yrs old) if > 10 weeks then done on the ward

Question 15

What may a failed medical TOP require ?

Answer 15

Surgical intervention

Question 16

What are the 2 different methods of surgical TOP?

Answer 16

1. Vacuum aspiration carried out between < 14 weeks
2. Dilatation and evacuation carried out between > 14 weeks (not available in Scotland)

Question 17

Describe the process of vacuum aspiration TOP

Answer 17

• The patient is given a vaginal prostagladin for cervical ‘priming’ 3hrs prior to the procedure.
• Following this electric vacuum aspiration is then carried out

Question 18

What can be done at the same time as carrying out electric vacuum aspiration?

Answer 18

A LARC can also be fitted if the patient would like

Question 19

What vacuum aspiration technique can be used in resource poor settings/ developing countries and what gestation can it be done up until ?

Answer 19

Manual vacuum aspiration - it can be done upto 9 weeks gestation

Question 20

What are the potential complications of TOP?

Answer 20

• Pain
• Haemorrhage (increases with gestation)
• Infection
• Incomplete/failed procedure
• Uterine perforation* 1to 4/1000
• Cervical trauma* 1 in 100
• Anaesthetic complications
• Ongoing pregnancy
• Uterine rupture

Perforation, trauma & rupture mainly apply to surgical TOP

Question 21

What aftercare is required following TOP?

Answer 21

• Anti-D IgG given to all non-sensitised rhesus -ve women
• Info on when/where to seek help & 24hr contact info
• Info on the risk of ongoing pregnancy & its symptoms
• Should be able to provide all methods of contraception, this should be initiated prior to discharge (most can be started immediately) - may require follow-up at the SRH/GP
• VTE prophylaxis if high risk then give 1/52 following, if very high risk start before and continue longer
• Counselling regarding chosen contraception method, additional barrier contraception & emergency contraception
• May experience emotions such as saddness, depression etc so if needed appropriate referal to mental health services required

Question 22

When can the different contraceptive options be initiated following TOP?

Answer 22

Intrauterine methods (LNG-IUS, CU-IUD):

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

Hormonal methods (CHC, SDI, DMPA, POP):

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

Non-hormonal methods:

• Barrier methods can be used anytime (except diaphragm after 2nd trim TOP)
• Sterilisation after some time has elapsed; risk of regret/failure
  *

Question 23

When are the different contraceptive options effective after initiation following TOP?

Answer 23

Almost all methods can be started at/soon after abortion

They are immediately effective if started day of abortion (or within 5 days)

If started after 5 days, efficacy depends on method (2 days for POP; 7 days for CHC/DMPA/SDI/LNG-IUS) - i.e. the hormonals

Immediate provision of Long-Acting Reversible Contraception (LARC):

• Removes need to attend/arrange additional appointments
• Higher long-term continuation compared to other methods
• Decreased rate of further unintended pregnancy

Question 24

What follow-up is needed after a TOP?

Answer 24

A low sensitivity urine pregnancy test is needed 2-3 weeks later (low sensitivity urine test used not a ordinary preg test as they are more sensitive and the beta-HCG levels slowly decrease following TOP so it may still show as +ve on reg preg tests)

Question 25

What are the indications for emergency contraception (EC)?

Answer 25

For women who do not wish to concieve after UPSI that has taken place on any day of a natural menstrual cycle For women who do not wish to concieve after: * UPSI occuring after day 21 following childbirth (unless lactational amenorrhoeic) * UPSI after day 5 following abortion, misscariage, ectopic pregnancy, or uterine evacuation for gestational trophoblastic disease (GTD) And for women not wishing to concieve after UPSI if their regular contraception has been compromised or incorrectly used

Question 26

Go over these common examples of EC being required: * If more than one COC missed * If patch/ ring has been off/ out more than 48 hrs * If implant fitted out with first 5 days of cycle and UPSI within first 7 days of use

Question 27

Where can you get EC?

Answer 27

* local pharmacies * SRH clinic * GP * GAU

Question 28

What are the 3 methods of EC available in the UK?

Answer 28

* Copper-IUD * LNG-EC * UPA-EC

Question 29

What is the mode of action and cautions of LNG and UPA EC?

Answer 29

Question 30

What is the effectiveness of LNG and UPA EC and when can either of them be used up until ?

Answer 30

Question 31

In terms of the menstrual cycle when does LNG and UPA EC work up until?

Answer 31

* LNG-EC works until just before LH surge * UPA-EC can work during LH surge but not after peak Neither work after ovulation

Question 32

What are the contraindications to copper-IUD use as a EC?

Answer 32

The same as regular copper-IUD use

Question 33

What are the contraindications for UPA-EC use ?

Answer 33

* If wishing to “quick-start” hormonal contraception as progesterone reduces its effectiveness * You must delay ongoing contraception for 5 days after use * If hormonal contraception has been used in past 7 days (again progesterone reduces its effectivness) * If patient has acute severe asthma uncontrolled by oral steroids (think this is an enzyme inducer)

Question 34

What is the effectivness of LNG & UPA-EC reduced by?

Answer 34

Enzyme inducers

Question 35

What is the effectiveness of copper-IUD compared to oral EC?

Answer 35

It is 10x's more effective

Question 36

What is the mode of action of copper-IUD as a EC?

Answer 36

Same as its regular action (toxic to sperm ==\> anti-implantation)

Question 37

What needs to be done prior to copper-IUD insertion?

Answer 37

Screen +/- treat high-risk women for STI prior to insertion

Question 38

When can a copper-IUD be used as a EC?

Answer 38

* Up to 120 hours post-UPSI (5-7 days) * Up to 5 days after earliest expected date of ovulation (5-7 days)

Question 39

Why can a copper-IUD be used as EC Up to 5 days after earliest expected date of ovulation (5-7 days) ?

Answer 39

* Because it prevents implantation of the fertilised egg and implantation does not occur during the first 5 days following fertilisation during a pregnancy * 84% implant at 8-10 days post fertilisation * Earliest likely is at 6 days * Hence Cu IUD can be fitted up to 5 days post UPSI OR after 5 days after likely ovulation

Question 40

What are the 1st and 2nd line options then for EC?

Answer 40

* 1st line = copper-IUD, all women should be offered if appropriate as it is the most effective method * 2nd line = oral EHC, with UPA as 1st line (although LNG is as effective in the first 24hrs following UPSI, so if within this time period then LNG as it is cheaper)