MedicalJOBS HOW TO TREAT 23 before medical abortion , and if this is not performed , extra caution should be exercised . 21
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MedicalJOBS HOW TO TREAT 23 before medical abortion , and if this is not performed , extra caution should be exercised . 21
RANZCOG advises that “ the gestational age of the pregnancy should be determined prior to an abortion ; this could be by clinical means ( history , including last menstrual period , with or without examination ) or by ultrasound scan .” 14
In Australia , a transvaginal or transabdominal ultrasound is routinely undertaken before surgical abortion to ensure the pregnancy is intrauterine and that the gestational age of the pregnancy is appropriate for the planned procedure .
Last normal menstrual period
Take a menstrual history , documenting the first day of the last normal menstrual period ( LNMP ) and how confident the woman is of the date , and whether the period was entirely consistent with previous cycles in terms of timing and duration . Record recent use of any hormonal contraception ( pill , injection , intrauterine or implant ).
Pregnancy symptoms
Asking about pregnancy symptoms , including those potentially identifying early pregnancy complications such as pain and bleeding , may help to clarify the gestation of the pregnancy or point to a potential history of threatened miscarriage or ectopic pregnancy .
Physical examination
Limited physical examination , such as checking blood pressure , pulse and examining for signs of anaemia if there is a history of heavy menstrual bleeding , may be required before first trimester abortion .
Ultrasound
Ultrasound is undertaken in many settings to confirm the gestational age of the pregnancy . However , there is mounting evidence that ultrasound can be used selectively , and a 2023 systematic review concluded that medical abortion performed without prior pelvic examination or ultrasound is a safe and effective option for pregnancy termination . 22
RANZCOG says : “ An ultrasound is recommended prior to abortion up to 14 weeks pregnant if there is uncertainty about gestational age by clinical means , or if there are symptoms or signs suspicious for ectopic pregnancy or other clinical concerns . Where gestational age has been established by clinical means , the decision about ultrasound prior to abortion should be made according to patient preferences and access to services .” 14
The confirmation of a viable intrauterine pregnancy requires the visualisation of either the fetal pole or yolk sac within the gestational sac ( see table 1 and figure 2 ).
These structures are usually not visible before five weeks ’ gestation . Reasons for lack of visualisation include the pregnancy being too early ( most common reason ), an ectopic pregnancy , and the sac being a collection of blood / pseudosac , or the pregnancy not being viable .
Aligning the ultrasound findings with a quantitative beta-hCG level can help determine the most likely cause of an empty sac . If the beta-hCG is less than 1500 IU / L , then the pregnancy is possibly too early to visualise the fetal pole .
Figure 2 . A 5.5-week yolk sac plus fetus .
Serum beta-hCG levels
Serum beta-hCG is a poor predictor of gestation age ( see figure 3 ). However , it is vital to measure a baseline quantitative level before medical abortion to compare it with serum beta-hCG measurement 8-16 days after the mifepristone is taken .
Medical and surgical history
Take a focused medical history that identifies any contraindications to abortion medication , anaesthetic and complication risks . The contraindications to medical abortion are discussed later .
There are no absolute contraindications to surgical abortion , but suggest to those with a complicated medical or surgical history that the procedure be performed in a hospital rather than a community service .
Medical and surgical abortion in the first and second trimester appears safe in women with prior caesarean section . However , advise women about the potential risks of uterine rupture , the need for surgical intervention , and haemorrhage from undiagnosed placenta accreta .
Blood group
The RANZCOG guideline recommends that anti-D is administered in rhesus negative ( anti-D negative ) women undergoing surgical or medical abortion after 10 weeks ’ gestation . 14
At this gestation , the dose is 250 IU / mL as a slow , deep intramuscular injection . GPs are unikley to be involved in abortion procedures after 10 weeks ’ gestation .
STI screen
The RANZCOG guidelines recommend that routine sexually transmitted infection ( STI ) screening is offered to all women having medical or surgical abortion . 14 STI screening should not cause a delay to providing timely abortion care . Treat the women and partner / s per local sexual health guidelines .
Routine use of antibiotic prophylaxis for women having medical abortion up to 14 weeks pregnant is not recommended , as the likelihood of severe infection is very low .
Other
Haemoglobin measurement may be recommended if there are risk factors for anaemia ( coeliac disease , vegetarian diet , heavy menstrual bleeding , advanced gestation ), but routine testing is not required . 14
CHOICE OF ABORTION
IDEALLY , women are able to choose a surgical or medical abortion .
A summary of abortion methods appropriate for use in abortion services in Great Britain by gestational age in weeks appears in figure 4 . 23
However , availability will depend on the gestational age , the location and access to services .
RANZCOG recommends offering the woman a choice of medical or surgical abortion up to 14 weeks pregnant , as both methods are safe , effective and acceptable . 14
The advantages and disadvantages of each method are documented in table 2 , and the complications of each are documented in table 3 .
MEDICAL ABORTION
RANZCOG recommends mifepristone 200mg orally followed 24-48 hours later by misoprostol 800μg by buccal ( see figure 5 ), sublingual or vaginal route for early medical abortion up to 10 weeks ’ gestation , 14 although the Therapeutic Goods Administration allows the regimen only up to
25 , 26
63 days .
The regimen induces the miscarriage of an intrauterine pregnancy . Mifepristone blocks progesterone support of the pregnancy , as well as softening and dilating the cervix . The misoprostol also softens and dilates the cervix , and increases uterine contractility to expel the products of conception .
The TGA recently lifted the requirement for special certification in order to prescribe this regimen ; it can now be prescribed by any practitioner with appropriate qualifications and training . The TGA includes nurse practitioners , but this is subject to statebased regulations .
Before prescribing this regimen , determine the gestational age ; assess for contraindications ( see box 4 ); provide patient-centred counselling on the management options , side effects and complications ; and assess
Expected values for normal pregnancy Gestational age from LMP
Range in IU / L 4 weeks 16-160 4-5 weeks 100-5000 5-6 weeks 1000-30,000 6-7 weeks 2500-80,000 7-8 weeks 23,000-150,000 8-9 weeks 27,000-230,000 9-13 weeks 21,000-290,000 2nd trimester 6000-100,000 3rd trimester 3000- 80,000 Non-pregnant female Less than 5 Figure 3 . Beta-hCG and gestational age .
Table 1 . Ultrasound images at various gestational ages
Gestational age
Week 0
Milestone
Last menstrual period
Ultrasound
Nil visible
Week 2 Conception occurs Nil visible Week 4.5-5
Week 5-5.5
Week 6-7
Gestational sac
Yolk sac
Yolk sac plus fetus
7-8 weeks Fetal spine
8 weeks Head flexes on body Limbs appear
8-10 weeks A cystic space in the brain is always seen ( rhombencephalon )
Ultrasound images from Ultrasound Care , Sydney , NSW .
Beta-hCG — IU / L
300,000 275,000 250,000 225,000 200,000 175,000 150,000 100,000 75,000
50,000 25,000
High
Low
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Gestational age — weeks
The reference limits , kindly supplied by Douglass Hanly Moir , are applied to Douglass Hanly Moir reports for BhCG results obtained by the Abbott method on both its Architect and Alinity analyser platforms .