22 HOW TO TREAT : MEDICAL AND SURGICAL ABORTION IN THE FIRST TRIMESTER
22 HOW TO TREAT : MEDICAL AND SURGICAL ABORTION IN THE FIRST TRIMESTER
6 DECEMBER 2024 ausdoc . com . au
Northern Territory 2017 / 2021
• Lawful up to 24 weeks if one medical practitioner believes appropriate in the circumstances
• Greater than 24 weeks : consultation with two medical practitioners required
Abortion law across Australia
Queensland 2018
• Lawful 22 weeks or less on request
• Greater than 22 weeks if two medical practitioners believe appropriate in the circumstances
Source : MSI Australia Abortion Law in Australia 2024 13
Western Australia 2023
• Fully decriminalised if performed by a qualified practitioner
• Lawful at less than 23 weeks if performed by a medical practitioner
• 23 weeks or older if two medical practitioners believe appropriate in the circumstances
New South Wales 2019
• Lawful 22 weeks or less on request
• Greater than 22 weeks if two medical practitioners believe appropriate in the circumstances ; some conditions
South Australia 2021
• Lawful if 22 weeks and six days or less on request
• 23 weeks or more if two medical practitioners are of the view termination is necessary and meets certain criteria
Figure 1 . Abortion law across Australia .
Tasmania 2013
• Lawful under 16 weeks on request
• 16 weeks or greater if two medical practitioners agree that there is greater risk to woman of continuing pregnancy
Australian Capital Territory 1993
• Lawful by medical practitioner
• No gestational limits
Victoria 2008
• Lawful 24 weeks or less on request
• Greater than 24 weeks if two medical practitioners believe appropriate in the circumstances to decide about their own treatment and understand the implications of treatment ) is important for deciding on the right course of action .
LEGAL MATTERS
THERE are different legislative requirements across Australia ( see figure 1 ). These determine the gestation at which consultation with one or two doctors is required , the settings where abortion can be performed , the circumstances under which abortion can be performed , and the information that must be recorded for each procedure . It is crucial to understand these for your location .
The laws around conscientious objection ( the legal rights and decisions by health practitioners to refuse to provide , perform or take part in any activity related to their profession based on personal , moral or religious beliefs ) are provided in each of the state and territory laws . 12
These laws state that any health practitioner asked to advise a woman about abortion , or perform , direct , authorise or supervise an abortion , and who has a conscientious objection to abortion must inform the woman that they have this objection . 12
Most states and territories stipulate that the clinician must refer the woman to another health practitioner , in the same profession , who they know does not conscientiously object to abortion , and that non-compliance with this can lead to charges of professional misconduct .
TYPES OF ABORTION
TWO methods of abortion , medical and surgical , are available in Australia . Medical abortion involves the administration of medication to interrupt the pregnancy and facilitate expulsion of the products of conception . Medical
Box 2 . Culturally safe abortion care
This involves healthcare practitioners :
• Using respectful language and considering individual health literacy and different religious beliefs and cultural norms .
• Understanding the social and religious context of abortion in different cultures and communities .
• Using interpreters and multilingual resources when needed to communicate effectively and empathetically with people from diverse backgrounds .
• Being aware that some people may experience stigma , shame and fear around abortion , and providing them with a safe and confidential space to express their concerns and feelings .
• Recognising and addressing the potential for reproductive coercion , violence or discrimination that some may face from their partners , families or communities .
• Ensuring every person presenting for abortion receives comprehensive and unbiased information about their options , rights and risks , and supporting them to make informed and autonomous decisions .
• Referring to appropriate services and support networks , such as counselling , contraception , family planning , sexual and reproductive health , and migrant and refugee health .
Source : RANZCOG 2023 14 , Makleff S et al 2023 16
abortion comprises a combination of mifepristone ( a synthetic antiprogesterone ) followed 24-48 hours later by misoprostol ( a prostaglandin analogue ).
Surgical abortion is the interruption of a pregnancy via surgical means . In the first trimester , the preferred method is manual or electric suction curettage , generally performed in a day surgery clinic under sedation .
CLINICAL GUIDELINE
IN October 2023 , the Royal Australian and New Zealand College of Obstetricians and Gynaecologists ( RANZCOG ) launched its evidence-based Clinical Guideline For Abortion Care for Australia and New Zealand . 14
Principles of care
The key principles of abortion care include providing information and guidance in a manner responsive to the needs , preferences and values of each woman , and ensuring access to accurate information , quality services and support ( see box 2 ).
Women who obtain an abortion in a legal , safe and supportive environment , without coercion , have good psychological outcomes . 15
Providing comprehensive information
The information provided to individuals considering abortion should be culturally sensitive , comprehensive and non-judgemental . Discuss all options for the pregnancy , including abortion , continuing the pregnancy and continuing the pregnancy with a plan for adoption or kindship care , noting the advantages and disadvantages of each . Box 3 lists key issues to cover in the initial conversation . 14
Many have already arrived at a clear decision when presenting to
Box 3 . Key issues to cover in the initial conversation
• The tests that may be required before abortion .
• The types of abortion procedure available depending on the gestation of the pregnancy , medical history and local service availability and choice .
• The advantages and disadvantages of each option .
• The steps involved in the procedure and what to expect .
• What to expect if they choose to view pregnancy tissue following a medical or surgical abortion .
• The options for pregnancy tissue management after the abortion procedure ( acknowledging the cultural significance of this for many groups ).
• What to expect in terms of pain and bleeding , and options to manage this .
• The lack of association of abortion with increased risk of infertility , cancer or mental health issues .
• The options for psychological support , social services and local cultural support services and resources available after the abortion procedure , as required .
• Follow-up after abortion , if indicated , and signs of ongoing pregnancy .
• Possible short- and long-term complications associated with abortion procedures , including an explanation of expected increase in these risks based on the specific woman ’ s medical history ( for example , previous uterine surgery ): — Anaesthetic complications . — Severe bleeding ( see Royal Women ’ s Hospital Melbourne ‘ Principles of post early medical abortion care ’). 17 — Side effects of the medication . — Damage to the uterus . — Incomplete abortion . — Ongoing pregnancy . — Pelvic infection .
• Contraceptive options available and timing of initiation following abortion .
Source : RANZCOG 2023 18
abortion services , and it is important to recognise that unplanned pregnancy decision counselling is optional . To assist with the decision , counselling can explore the issues of relationship status and safety , family and social supports , and the financial implications of parenting .
CLINICAL ASSESSMENT
THIS includes confirming the gestation of the pregnancy , identifying any medical contraindications to either medical or surgical abortion , and screening for STIs .
Gestational age
Gestational age can be accurately assessed before medical abortion by taking a good history of the last menstrual cycle , including the date and bleeding pattern , contraceptive use , and by excluding symptoms and / or a history that may suggest ectopic pregnancy . 19 , 20 The current TGA product information recommends that ultrasound be used to assess gestation