24 HOW TO TREAT : MEDICAL AND SURGICAL ABORTION IN THE FIRST TRIMESTER
3270 RCOG Abortion guideline . qxd : 3270 RCOG Abortion guideline . qxd 11 / 11 / 11 14:13 Page 60
24 HOW TO TREAT : MEDICAL AND SURGICAL ABORTION IN THE FIRST TRIMESTER
6 DECEMBER 2024 ausdoc . com . au the need for laboratory testing . Informed consent requires the individuals to understand the concepts in box 5 . 27
Nausea and pain relief
Offer women undergoing medical abortion antinausea medication ( such as ondansetron ) and pain relief ( NSAIDS and / or paracetamol with codeine ) to take before the misoprostol tablets .
Offer women less than 14 weeks pregnant a single dose of ibuprofen 1600mg ( off-label use ), followed by ibuprofen 400mg to 600mg eighthourly . A maximum dose of ibuprofen 2400mg can be taken in 24 hours if pain persists . Optimise pain relief before 14 weeks by offering paracetamol ( 1000mg 4-6 hourly as required with a maximum 4000mg per 24 hours ) in addition to ibuprofen . The clinician may consider selective use of opiate analgesia . 14
Modes of delivery
Medical abortion can be delivered face to face , via telehealth or a combination of these . Face to face services offer women an appointment to do baseline investigations including serum beta-hCG and ultrasound , and provision of medications . Follow-up to review symptoms and confirm completion of the abortion with an adequately falling or negative urine or blood serum beta-hCG may be in person or via telehealth .
Abortion via telehealth often consists of three consultations ( via video and / or phone ) for the clinical assessment and to organise investigations , to organise provision of the medications and to follow-up to ensure completion . For medical abortions up to 10 + 0 weeks , offer expulsion of pregnancy at home based on patient preference , clinical need and access to timely urgent care . 14
Side effects and complications
The side effects of medial abortion include diarrhoea , headache , nausea and vomiting , dizziness , flushing and shivering or chills . Complications include bleeding , infection , incomplete abortion and continuing pregnancy .
During the abortion the patient will experience central pelvic pain and cramping accompanied by vaginal bleeding ; these symptoms are similar to those of a spontaneous miscarriage and will respond to simple analgesia .
Post-procedure
Most women pass the products of conception within 12 hours of taking the misoprostol and will experience moderately heavy vaginal bleeding for 3-5 days , and then lighter bleeding for up 9 – 12 days . 29 Offer follow-up to all women after early medical abortion to exclude an ongoing pregnancy and assess for complications . The clinical history alone ( for example , self-reported passing of the gestational sac , settling of bleeding , resolution of pregnancy symptoms ) is unreliable in excluding ongoing pregnancy . Arrange a consultation and serum or urine beta-hCG and ultrasound to detect a suspected ongoing pregnancy . 14
The RANZCOG abortion guidelines states : “ If using urine beta-hCG , ongoing pregnancy is excluded by a negative low-sensitivity urine pregnancy test at 14-21 days from mifepristone . If the test is positive or
Reproduced from : Royal College of Obstetricians and Gynaecologists . The Care of Women Requesting IndUced Abortion . London : RCOG , November 2011 , with the permission of the College .
4 5 6 7 8 9 10 �
11 �
12 13 14 15 16 17 18 19 20 21 22 23 24
Early vacuum� aspiration to strict� protocol a�
(< 49 days )
invalid , investigate further and manage as appropriate . If using serum beta-hCG , an ongoing pregnancy is excluded by a decrease in serum beta-hCG level of 80 % or more from
Electric or manual � vacuum aspiration b
Vacuum� aspiration ( large-� bore cannula ) c
ingestion of mifepristone ( if beta-hCG taken within 72 hours ) to 8-16 days afterwards . If less than 80 % decrease , investigate further and manage as appropriate .” 14
Dilatation and evacuation � ( 13 + 0 to 24 + 0 weeks ) d
Mifepristone and one � Mifepristone and multiple doses of misoprostol � dose of misoprostol � ( 64 days to 24 + 0 weeks ) f �
( ≤ 63 days ) e � �
� � a . Surgical abortion by means of vacuum aspiration at gestations below 7 weeks . To increase confidence
Figure 4 . Summary of abortion methods appropriate for use in abortion services in Great Britain by gestational age in weeks . that the gestation sac has been removed , protocols should include safeguards such as examination of the aspirate for the presence of the gestational sac and follow-up serum human chorionic gonadotrophin a . Surgical estimation abortion by if needed means of . vacuum aspiration at gestations below 7 weeks . To increase confidence that the gestation sac b . has Surgical been removed abortion , protocols using should electric include or manual safeguards vacuum such aspiration examination . The of uterus the aspirate is emptied for the presence using a of suction the gestational cannula sac . and Sharp follow-up curettage serum is not human recommended chorionic gonadotrophin . estimation if needed . b . Surgical c . Surgical abortion abortion using electric using or vacuum manual aspiration vacuum aspiration which . may The uterus require is emptied large-bore using suction a suction cannula cannula and . Sharp tubing . curettage d . Surgical is not abortion recommended using . a combination of vacuum aspiration and specialised forceps . e . Medical abortion using a single oral dose of the antiprogesterone mifepristone , followed by a single dose c . Surgical abortion using vacuum aspiration which may require large-bore suction cannula and tubing . of a prostaglandin analogue . d . Surgical abortion using a combination of vacuum aspiration and specialised forceps . f . Medical abortion using a single oral dose of the antiprogesterone mifepristone , followed by multiple e . Medical abortion using a single oral dose of the antiprogesterone mifepristone , followed by a single dose of doses of a prostaglandin analogue . a prostaglandin analogue .
f . Medical abortion using a single oral dose of the antiprogesterone mifepristone , followed by multiple doses of a prostaglandin weeks analogue .
Figure 7.1 Summary � of abortion methods appropriate for use in abortion services in Great Britain by gestational age in
Table 2 . What abortion methods entail from Best Practice in Abortion Care Medical abortion
A
• Avoids surgery .
• Mimics miscarriage .
• May take place at home ( depending on stage of pregnancy ).
• Takes time ( hours to days ) to complete and the timing may not be predictable .
• The medications can cause nausea , vomiting , diarrhoea , chills and fever ( 1 in 10 ).
• Will experience abdominal cramping and bleeding while passing the pregnancy ( worse than during a period ).
• Abdominal cramping can last , on and off , for a week and bleeding for 2-3 weeks .
• May see the pregnancy as it passes .
• Serious complications are uncommon .
• All contraceptive methods can be started at the time of the medical abortion , except intrauterine devices ( IUDs ), which can be inserted immediately after the pregnancy is expelled .
Surgical abortion
• Takes place in a healthcare facility .
• Will experience some discomfort during procedures conducted with sedation and / or local anaesthetic .
• Will experience no discomfort during procedures conducted under general anaesthetic .
• The medications used to prepare the cervix cause cramps and bleeding and can cause nausea , vomiting , diarrhoea , chills and fever ( 1 in 10 ).
• Will experience some pain and bleeding for 1-2 weeks afterwards .
• Will not usually see the pregnancy , unless patient wishes to do so .
• Requires a pelvic examination and insertion of surgical instruments into the uterus .
• Serious complications are uncommon ( see table 3 ).
• All contraceptive methods can be started at the time of the procedure , including the IUD .
Source : RANZCOG 2022 24 Adapted from the WHO ( 2014 ) Clinical Practice Handbook for Safe Abortion and the NICE ( 2019 ) patient decision aids published with the Abortion Care guideline .
Figure 5 . Buccal application of medication .
Management of common complications
Bleeding after medical abortion is expected . It may sometimes be difficult to determine whether this indicates retained products of conception ( RPOC ). RPOC after medical abortion is fairly common and presents with heavy or prolonged bleeding and / or abdominal pain . According to the Royal Women ’ s Hospital ( Melbourne ) guideline , “ routine ultrasound scanning after a medical abortion is NOT recommended , as blood clot , debris or thickened endometrium are commonly found and are not likely to be clinically relevant ”. 30 Box 6 outlines when RPOC are suspected and ultrasound is recommended . 17
A good transvaginal ultrasound examination may show an empty uterus with some blood but no RPOC , or it may show retained products of conception ( see figure 6 ). The options for management of RPOC appear in table 4 . Asymptomatic or incidental findings of RPOC do not routinely require management . Expectant
Box 4 . Contraindications to medical abortion
• Contraindications to mifepristone and misoprostol : — Chronic adrenal failure . — Severe disease requiring steroid administration . — Hypocoagulation diseases . — Anticoagulation therapy . — Allergy to mifepristone , misoprostol or other prostaglandin .
• Consider any conditions in which medical termination is not recommended ( eg , anaemia , renal failure , hepatic impairment , malnutrition or cardiovascular disease ).
�
Source : NPS Medicine Wise 2015 28
Box 5 . Informed consent for medical abortion
• Bleeding and pain are associated with medical abortion .
• Normal activities can continue before the misoprostol . Advise the woman that once she has taken it , she should rest at home , with access to pain relief and medical facilities .
• Complications are uncommon but women need to know when they should seek help ( see box 6 ).
• Advise women to have a support person with them after taking misoprostol in case emergency care is required .
• Once the medical abortion process is started , it should be completed as misoprostol is a known teratogen .
• Follow-up is required to ensure the abortion is complete and there is no ongoing pregnancy .
Source : Therapeutic Guidelines 2023 27
Box 6 . When to suspect RPOC
• At seven days : — Bleeding is heavier than the normal menstrual period or contains clots . — Persistent cramps . — Bleeding that waxes and wanes and has been as heavy as a normal period for at least the past 24 hours .
• At 14 days : — Bleeding is heavy and persistent . — Bleeding that has not markedly reduced .
• At 4-5 weeks : — Bleeding is ongoing after next menstrual period .
• At any time : — Heavy bleeding is considered two ( or more ) saturated sanitary pads per hour for two consecutive hours or passing large clots ; woman feels faint or perceives the bleeding as heavy .
Source : Royal Women ’ s Hospital Melbourne 2020 17
management , medical or surgical options may be appropriate according to clinical indicators and patient ’ s preference .
SURGICAL ABORTION
Surgical abortion up to 14 weeks
IN surgical abortion the contents of the uterus are evacuated through