termination of pregnancy

Early surgical under protocol < 7 Early medical abortion(MTOP) < 9 Manual Vacuum Aspiration < 9 Suction Termination (STOP) 7 - 14 (mostcommon) Dilatation & Evacuation 15 - 18 Mid-trimester medical abortion 14 - 24 Two stage surgical procedure 19 - 24

Medical abortion using Mifepristone plus prostaglandin is an appropriate method at any gestation under 9 weeks Mifepristone 200mg PO Admit 36 - 48hrs later Misoprostol 800mcg PV Given for gestations between 9 and 12 (unlicensed) Advantages of EMA: Seemed a more ‘natural’ experience No surgery or anaesthesia was needed It afforded more privacy Perceived to be less frightening and easier emotionally than a surgical abortion Required a shorter stay in hospital It was easier, simpler and faster

Suction termination of pregnancy should be avoided at gestations of < 7 weeks. No longer the case. Conventional suction termination is an appropriate method at gestations of 7 – 15 weeks Cervical preparation is beneficial prior to suction termination Suction termination may be safer under local anaesthesia than general - MVA

OPD setting LA Suitable for patient keen on the procedure Shorter stay in the hospital Needs skilled, training and awareness as patient is awake Needs committed staff to support the patient Saving money for the NHS

Immediate complications: Anaesthetic Uterine perforation - 0.8 / 1000 Cervical Tears Primary haemorrhage Uterine rupture Death - rare - 0.6 / 1,000,000 complications after discharge: Failed abortion Retained products of conception ~ 1 : 100 Secondary haemorrhage Ectopic pregnancy Pelvic infection

Screen all women Chlamydia/Gonorrhoea Treat positives Doxycycline/Azithromycin Contact tracing HIV Treatment

Tubal factor infertility Rhesus Iso-immunisation Psychological and psychosexual sequelae psychological complications: Regret and early distress common Adverse sequelae occur only in a minority Continuation of problems present before abortion Long term post abortion distress risk factors Unsupportive partner Ambivalence before abortion Prior psychiatric history Considers abortion wrong

Anti-D prophylaxis Written information Contact numbers Counselling services GUM follow up Contraception advice and provision Follow up appointment within 2 weeks

NICE guideline (2005) which highlights that if 7% of women switched from the contraceptive pill to Long Acting Reversible Contraceptive (LARC) methods (defined as the intrauterine device (IUD), hormonal injection, intrauterine system (IUS) and contraceptive implant) the NHS could save around £100 million through reducing unintended pregnancies by 73,000. In February, 08/09 the Public Health Minister, announced £26.8m new funding for from the Comprehensive Spending Review to improve access to contraception.

For abortions at 22 weeks or beyond, feticide is recommended prior to the evacuation of the uterus to stop the fetal heart. In 2012, of the 1,312 abortions performed at 22 weeks and over Complications: 278 cases in 2012, a rate of about one in every 700 abortions, the same as in 2011 and 41 per cent lower than in 2002 There were no deaths following abortion reported in 2012.