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Abortion care

Abortion act 1967 provides the legal basis of abortion – applicable in Scotland , England and Wales 
○ amended by the Human Fertilisation and Embryology Act 1990 and regulations made under that act – currently
○ Abortion Regulations 1991

Abortion Act regulates when and where the abortions can happen lawfully.
 Guidance in relation to requirements of the Abortion Act 1967- a guidance was issued in May 2014 this has information for on organizing and running abortion services
 Patients must give consent for abortion. If an adult patient lacks capacity then ” best interests” should form the basis of decision making in England , N Ireland and Wales and ” benefit ” in Scotland
 People aged less than 16 can give consent if they are deemed competent. If the young person lacks capacity then parents can consent to treatment in their best interests
 Personal consciousness ( of health care professional ) and abortion – BMA acknowledges this and states that ” unless abortion is necessary to save women’s life or prevent grave permanent injury , doctors in England , Scotland and Wales have a right of conscientious objection under Abortion Act. At the same time , patients have a right to receive objective and non-judgmental care. Doctors with a conscientious objections should inform patients as soon as possible , and make appropriate arrangements for referral “
 Two signatures are required -two registered medical practitioners on the HSA1 form which confirms that in their opinion made in good faith , the term of abortion act have been satisfied. The BMA informs that the regulation published in 1991 requires that the two doctors would agree on the same grounds and if a woman’s request meet more than one of the grounds the doctors must agree which of them to specify in the HSA1 form
 Sex-selective abortion – is unlawful in the UK

 

Under the section 1 (1 ) (a) of the abortion act a pregnancy can only be terminated only if it has not exceeded 24 weeks BMA has quoted in its report that currently the standard medical threshold of viability is understood to be around 24 weeks gestation

 

The services carrying out abortion would provide for the below mentioned measures and you would not be expected as a GP to issue them. It is never-the less important to known them as you may still be questioned about these by women who may contact you for further advice.

 

Anti-D prophylaxis -for rhesus negative women who are having an abortion after 10 + 0 weeks for women who are rhesus negative and are having a surgical abortion up to and including 10 +0 weeks of gestation

 

Antibiotic prophylaxis-routine antibiotic prophylaxis is not required in medical abortions for women undergoing surgical abortions antibiotic prophylaxis is indicated if considering Doxycycline in medical or surgical abortion the dose should be
100 mg bd x 3 days if metronidazole is used it should not be routinely given in combination with another broad spectrum antibiotic such as doxycycline

 

Venous thromboembolism prophylaxis-women who need VTE thromboprophylaxis consider starting LMWH for atleast 1 week post-abortion women who are at a higher risk- consider starting before the abortion and giving for longer

 

Information -address general concerns – inform about the choices ie medical and surgical be non-judgmental and use easy to understand information reassure that abortion is not known to be linked to increased risk of infertility , breast cancer or mental health issues explain the process and what to expect – find leaflets under links and resources discuss contraception how to check to ensure that the pregnancy has ended when and how to seek medical help if they develop signs and symptoms suggestive of a complication inform that major complications and mortality rate are rare at all gestations

 

Medical abortion – this involves taking Misoprostol or and Mifepristone Usually a tablet of mifepristone followed by misoprostol taken vaginally 
as pessaries , sub-lingual or buccal Mifepristone ( also known as RU-486 ) is a potent synthetic steroidal antiprogesterone which can be used as a single dose or in combination with Misoprostol ( a prostaglandin analogue )
Mifepristone sensitizes the myometrium to prostaglandin induced contractions and ripens the cervix ( BNF ) Misoprostol ( also called cytotect or glefos ) is an organic compound of the class prostaglandins and related compounds- also used to reduce the risk of NSAID induced ulcers , prevent post-partum haemorrhage . Misoprostol can also be taken in the clinic or hospital , it causes the womb to expel the embryo / fetus within 4-6 hrs It is common practice to offer ultrasonography to ascertain gestational age particularly when physical exam and LMP are substantially discordant

 

if taking mifepristone for medical abortion – offer expulsion at home after they have taken misoprostol. Misoprostol can be taken in the clinic or hospital

 

More than 100,000 women in England have early medical abortions / year Most are medical ~ 65 % Most happen at home but women have been required to administer the medication within licensed premises before they go home taking the medication in the privacy of own home is considered safe and effective studies have shown no difference in effectiveness or satisfaction between women who chose home based medical abortion and those who returned to the clinic and stayed for few hours after taking misoprostol safe and effective – avoids surgery and offers women more active participation and control over the process

 

Medical abortion – can be offered up to and after 23 weeks -the specifics of each situation differs based on the duration of pregnancy , indication , expertise and available facilities – detailed guidance for UK can be found in the NICE guidance NG 140 published in September 2019 regimens may vary between countries contraindications to the use of medical abortion with mifepristone – misoprostol include
◘ chronic adrenal failure
◘ inherited porphyria
◘ previous allergic reactions to mifepristone or misoprostol
◘ known or suspected ectopic pregnancy.

 

Surgical abortion – most common method is vacuum aspiration in the first trimester electric or manual vacuum device can be used drugs can be used to soften and dilate the cervix 2-3 hrs before the procedure
 dilatation and evacuation is used from 14-15 weeks of gestation cervix can be prepared by misoprostol or osmotic dilators
 surgical abortion – the process is generally quick , can be done under a general anesthetic with low risk of complications

 

Complications  damage to cervix uterine perforation bleeding allergic reaction to anesthetic / anaesthetic risks incomplete evacuation – term used is retained products of conception risk infection

 

Discussion complications – Complication depend upon
- gestational age
- method of abortion Younger the gestational age the lower the risk of complications Overall complication rate for medical abortions is about 2 % , 1.3 % for 1st trimester abortion and 1.5 % for 2nd trimester or later abortions SEs of medical abortion include pain , bleeding which arise from the abortion process and SEs related to medications as nausea , vomiting , diarrhoea , wrmths and chills. Failed abortion is seen more with early gestational age and women may present with symptoms of continuing pregnancy Septic abortion poses the highest risk of death It is controversial if abortion is a traumatic stressor and this argument is used by both sides who oppose or favor abortion rights. Psychological impact of abortion is often described as ‘ Post abortion syndrome ‘ ( PAS ) Further work is needed to identify women who are at greater risk and may benefit from pre-abortion and post-abortion counselling

 

Undertake an assessment Establish facts – positive pregnancy test and relevant history – gestational age , gravidity and parity Obstetric history circumstances Previous terminations – method Past medical history Medications / Allergies Contraceptive history. Discuss options and explain what happens , provide written information and further useful links as BPAS website.

 

Give the abortion care leaflet from RCOG – find that under links and fill the HSA1 form.

The HSA1 form can be downloaded fromhttps://www.bpas.org/media/1197/hsa1-form.pdf

Give her written information where to ring for e.g BPAS and to seek advice if she faces any problems

Patient information

RCOG abortion care leaflet https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-abortion-care.pdf

BPAS considering abortion https://www.bpas.org/abortion-care/considering-abortion/?gclid=CjwKCAjw74b7BRA_EiwAF8yHFMOvnitRvqf3Ljz-D7I9o4fRGbfUKWxqgQW8heBIT53EYsc1wxwAYhoCAEkQAvD_BwE

NHS information page on abortion https://www.nhs.uk/conditions/abortion/

References

RCOG Abortion Care via https://www.nice.org.uk/guidance/ng140/resources/abortion-care-pdf-66141773098693 RCOG Termination of Pregnancy for Fetal Abnormality in England Scotland and Wales May 2010 BMA The law and ethics of abortion November 2014 updated October 2018 Pubchem misoproltol via https://pubchem.ncbi.nlm.nih.gov/compound/Misoprostol Abortion BMJ 2014 ; 348 : f7553 HSA1 form via https://www.bpas.org/media/1197/hsa1-form.pdf RCOG Clinical Guidelines for Early Medical Abortion at Home England via https://www.rcog.org.uk/globalassets/documents/guidelines/early-medical-abortion-at-home-guideline-england.pdf Management of side effects and complications in medical abortion Beth Kruse et al AJOG Volume 183 , Issue 2 , Supplement , S65-S75 , August 01 , 2000 ( Abstract ) Sajadi-Ernazarova KR, Martinez CL. Abortion Complications. [Updated 2020 May 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK430793/ The abortion and mental health controversy: A comprehensive literature review of common ground agreements , disagreements , actionable recommendations and research opportunities SAGE Open Med . 2018 ; 6 :2050312118807624

 

 

 

 

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