HOW TO TREAT 27
ausdoc . com . au 6 DECEMBER 2024
HOW TO TREAT 27
Table 5 . Postabortion contraception recommendations from Faculty of Sexual and Reproductive Healthcare
Method Medical abortion Surgical abortion
Intrauterine contraception This can be safely used after an uncomplicated abortion Provides 5-10 years of contraceptive cover
The levonorgestrel-releasing intrauterine system may result in reduced uterine bleeding ; only immediately effective if inserted within the first five days after a surgical or medical abortion , or during the first seven days of the menstrual cycle .
The Cu-IUD is immediately effective
Progesterone-only implants Immediately effective when inserted within the first five days following a surgical or medical abortion ; proves three years of contraceptive cover
Progesterone-only injectables ( depomedroxyprogesterone acetate / DMPA ) Can be started immediately postabortion to provide 14 weeks of contraceptive cover
Progesterone-only pills Should be commenced immediately , or within five days , after surgical or medical abortion .
Combined hormonal contraception It is safe to start this immediately after abortion
Immediately effective provided it is started within five days of medical or surgical abortion
Barrier methods Male and female condoms and diaphragms can be used after first trimester abortion
Source : Faculty of Sexual and Reproductive Healthcare 39
1 . Which THREE statements regarding abortion are correct ? a The abortion rate in Australia has steadily been increasing over the past 10 years . b The proportion of medical abortions has risen since the introduction of mifepristone . c Unintended pregnancy is not synonymous with unwanted pregnancy . d Screening for domestic violence is important .
2 . Which THREE are features in the legal consideration of abortion in Australia ? a Provision of abortion in Australia varies across states and territories . b Understanding the laws in the jurisdiction where you work is vital . c There is no provision for conscientious objection . d If the clinician has a conscientious objection to abortion , they must refer the woman to another health practitioner who does not have a conscientious objection .
3 . Which TWO are advantages of medical over surgical abortion ? a Avoids a procedure . b Reduced risk of retained products of conception .
This can be inserted at any time after expulsion of the pregnancy
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Initiation of progestogen-releasing methods at the time of mifepristone does not appear to reduce the effectiveness of medical abortion
Insertion can occur at the time of prescribing and / or taking mifepristone
There may be a slightly higher risk of continuing pregnancy ( failed abortion ) if DMPA is started when mifepristone is administered
Start the day after misoprostol administration
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c Reduced need for follow-up . d Available via telehealth for medical abortion .
4 . Which THREE form part of culturally safe abortion care ? a Considering individual health literacy and different religious beliefs and cultural norms . b Using interpreters and multilingual resources when needed . c Referring to appropriate services and support networks . d Imposing one ’ s own social and religious context on the woman seeking an abortion .
5 . Which THREE statements regarding ultrasound are correct ? a A fetal pole or yolk sac within the gestational sac is usually visible before five weeks ’ gestation . b Aligning the ultrasound findings with a quantitative beta-hCG level can help determine the most likely cause of an empty sac . c Ultrasound is undertaken in many settings to confirm
MEDICAL AND SURGICAL ABORTION IN THE FIRST TRIMESTER
the gestational age of the pregnancy . d Provided a thorough history is taken , medical abortion without prior pelvic examination or ultrasound has been found to be a safe and effective option for pregnancy termination .
6 . Which THREE are relative contraindications to early medical abortion ? a Known or suspected ectopic pregnancy . b Chronic corticosteroid use . c Severe anaemia . d A known bleeding disorder or on anticoagulants .
7 . Which THREE medications are appropriate in medical abortion ? a Mifepristone 200mg orally followed 24-48 hours later by misoprostol 800μg . b Antinausea medication . c Anticoagulants . d NSAIDS and / or paracetamol with codeine .
8 . Which THREE are complications
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This can be inserted immediately after evacuation of the uterine cavity
The implant can be inserted under the skin of the upper inner arm at the time of a procedure
DMPA can be started at the time of a procedure
Start on the day of the abortion ; in practice this usually occurs the next day
PAGE 25 and depressed , with some forced to continue the pregnancy because of a lack of safe , available early abortion . 41 Women in such circumstances can present later for abortion when options are limited for those who cannot afford a private procedure or those with complex physical and / or mental health problems where a private facility is not the appropriate place .
A 2023 Australian senate inquiry focused on barriers to universal access to sexual , maternity and reproductive healthcare , to end the ‘ postcode lottery ’ of service access . 42 Recommendations specific to abortion included universal public hospital surgical abortion services ; timely and affordable pathways to abortion care ; and a review of renumeration for practitioners delivering medical abortions . 42
Surgical or medical abortion well into the second trimester is not optimal . These procedures are potentially more difficult and complex , more emotionally difficult for the patient and staff , costly to the hospital , and time-consuming for all clinicians . Thus , improving access to first trimester medical and surgical abortion is vital .
of medical abortion ? a Bleeding . b Infection . c Uterine perforation . d Incomplete abortion .
9 . Which THREE are options for pain relief during early surgical abortion ? a NSAIDs alone . b Local anaesthetic plus
NSAIDs . c Procedural sedation with local anaesthesia plus NSAIDs . d Deep sedation or general anaesthesia plus NSAIDs .
10 . Which THREE statements regarding surgical abortion are correct ? a Cervical priming with misoprostol reduces both the need for additional cervical dilatation and the risk of incomplete abortion . b Treat all patients prophylactically with antibiotics for bacterial vaginosis and STIs before the procedure . c Provision of information on effective reversible contraception after abortion is key to integrated abortion care . d Major complications are uncommon in vacuum aspiration abortions before 14 weeks ’ gestation .
CASE STUDIES
Case study one
MARIA , 42 and G3P3 , has a son aged 22 and twin daughters aged 20 . She has been using the withdrawal method for contraception . Her periods have become less regular and she thinks she is becoming perimenopausal . After noticing breast tenderness , she does a urinary pregnancy test from the chemist , which is strongly positive . She requests an abortion . The GP orders an ultrasound that shows an intrauterine pregnancy with a single live fetus at seven weeks ’ gestation .
Maria is offered counselling ,
There is a huge disparity in access to abortion , with great swathes of rural and remote Australia considered abortion deserts .
which she declines . She is given a prescription for mifepristone and misoprostol that she starts on the Friday . On Sunday she has some bleeding and passes the jelly-like conceptus into the toilet . She has mild pelvic pain but does not require pain medications . The pain resolves after expulsion of the sac , and she has light bleeding for two days before it ceases completely . She returns to the GP two days later for an uneventful insertion of a hormonal IUD .
Case study two
Lola , 18 , presents requesting an abortion . She was diagnosed the year prior with polycystic ovarian syndrome after presenting with irregular heavy menses , acne and hirsutism . She used condoms for contraception and her GP suspected a pregnancy when she presented with delayed menses and nausea . An ultrasound examination shows an intrauterine gestation sac containing a single live fetus at 10 + 1 weeks ’ gestation .
The GP explains that Lola is beyond the gestation for medical abortion and requires a surgical abortion . At the time of the procedure , Lola consents to chlamydia and gonorrhoea testing and is given antibiotic prophylaxis . Having been counselled about contraceptive options , she chooses the oral contraceptive pill to regulate her cycle and improves her androgenic symptoms . The abortion is conducted under light sedation and is uncomplicated . She is discharged a few hours later .
RESOURCES
• Victorian Government ’ s Health Translations https :// bit . ly / 3XulpW6
• NSW Pregnancy Choices https :// bit . ly / 3XuEG9M — Helpline 1800 008 463
• Children by choice https :// bit . ly / 4g6u2NM — Multicultural Resources https :// bit . ly / 3Xgz1Tn — Easy English Resources https :// bit . ly / 3z8T5za — Inclusive language Guide https :// bit . ly / 3ThThTu
• Royal Women ’ s Hospital Melbourne : Principles of post early medical abortion care https :// bit . ly / 3ThTrKMf
References Available on request from howtotreat @ adg . com . au