Abortion(331)

ABORTION AND UNPLANNED PREGNANCY

Specific Outcomes and Teaching Strategies

  • At the end of the session, the students should be able to:

  • Define and Provide Possible Causes of Abortions and Unplanned Pregnancies

    • Demonstrate Knowledge on the Termination of Pregnancy (TOP) incorporating the Termination of Pregnancy Act of 1996.

    • Provide Health Education and Advocacy Skills on the TOP.

    • Discuss Different Types of Abortion.

    • Provide Accessible Referral to Patients Wanting Termination of Pregnancy.

    • Provide Counseling Before and After Abortion.

    • Prevent and Manage Complications of Unsafe Abortion.

Introduction to Abortion

  • Common Health Intervention:

    • Abortion is regarded as a common health intervention.

    • It is safe when performed by someone with necessary skills, using methods recommended by WHO, appropriate for the pregnancy duration.

  • Statistics on Unintended Pregnancies:

    • Six out of ten unintended pregnancies end in an induced abortion.

  • Unsafe Abortions:

    • Approximately 45% of all abortions conducted are unsafe.

    • Of these unsafe abortions, 97% occur in developing countries.

  • Consequences of Unsafe Abortions:

    • Unsafe abortion leads to maternal deaths and morbidities and can cause:

    • Physical complications

    • Mental health complications

    • Financial burdens on women

    • Burden on communities and health systems.

  • Access to Safe Abortion:

    • Lack of access to safe, timely, affordable, and respectful abortion care is a critical public health and human rights issue.

Definition of Termination of Pregnancy

  • Definition of TOP:

    • Termination of pregnancy refers to a woman's decision to end her pregnancy through medical intervention.

    • Specifically, it is the deliberate termination of pregnancy through the removal or expulsion of an embryo or fetus.

  • Timeframes Regulating TOP:

    • A woman can end her pregnancy without giving reasons if she is under 12 weeks pregnant.

    • Between 13 and 20 weeks:

    • Termination may occur under specific conditions.

    • After 20 weeks:

    • Termination is only permissible if the life of the woman or fetus is in danger or if there are likely to be severe birth defects.

Circumstances for Termination of Pregnancy

  • First 12 Weeks of Gestation:

    • A pregnancy may be terminated upon the woman's request.

  • 13 to 20 Weeks of Gestation:

    • Termination is allowed if the medical practitioner determines:

    • Continued pregnancy poses a risk to the woman's physical or mental health.

    • There exists a substantial risk of severe physical or mental abnormalities in the fetus.

    • The pregnancy resulted from rape or incest.

    • The continued pregnancy significantly affects the woman's social or economic circumstances.

  • After 20 Weeks of Gestation:

    • Termination can occur if:

    • The woman's life is endangered.

    • There would be a severe malformation of the fetus.

    • The continued pregnancy poses a risk of injury to the fetus.

Performance of Termination of Pregnancy

  • Qualified Personnel for TOP:

    • A registered midwife who has completed the prescribed training course can perform TOP during the first 12 weeks of pregnancy.

    • A medical practitioner is necessary for procedures from 13 weeks and up.

    • After 20 weeks, the procedure can only be conducted after consultation between the medical practitioner and another qualified healthcare professional.

Causes of Abortions and Unplanned Pregnancies

  • Common Causes Include:

    • Incomplete formal education.

    • Financial difficulties.

    • Failure of contraceptive methods.

    • Wrong timing for pregnancy.

    • Family size is complete.

    • The woman is unmarried.

    • Family spacing issues.

    • Problems relating to the partner.

Termination of Pregnancy (TOP) Act, 1996

  • Overview of the Act:

    • The Choice on Termination of Pregnancy Act in South Africa came into effect on February 1, 1997.

    • It allows abortions upon request during the first trimester, without requiring doctor's or magistrate's approval.

    • Minors (under 18) are advised to inform a parent or guardian but do not need their consent.

    • No documentation is required for victims of rape or incest to obtain an abortion.

    • For women between 13 and 20 weeks, abortions are allowed under specified conditions such as threats to health or socioeconomic consequences.

    • After 20 weeks, termination is permissible if health risks or severe fetal disabilities are present.

Types of Abortion

  • Two Main Types of Abortion:

    1. Medical Abortion

    2. Surgical Abortion:

    • Vacuum aspiration

    • Dilation and evacuation

Medical Termination of Pregnancy

  • Description:

    • Requires taking pills at different intervals and is applicable only in the first trimester (<12 weeks).

    • The process typically involves:

    • Administering mifepristone to halt pregnancy development.

    • Administering misoprostol to trigger the uterus to expel contents.

  • Procedure Details:

    • For first trimester:

    • Home use of misoprostol after mifepristone improves privacy, convenience, and service acceptability.

    • Common dosage is 200 milligrams of mifepristone followed by misoprostol no more than 24-48 hours later.

    • Misoprostol can be taken orally, sublingually, or vaginally.

  • Experience and Effects:

    • May experience cramping and bleeding similar to a heavy period, varying in intensity.

Risks and Complications of Medical Abortion

  • Risks Include:

    • Nausea

    • Heavy vaginal bleeding

    • Dizziness

    • Fatigue

    • Diarrhea

    • Mild fever

  • Potential Complications:

    • Failed termination

    • Incomplete expulsion leading to excessive bleeding and potential need for surgery

    • Infection requiring antibiotics

Surgical Termination of Pregnancy

  • Description:

    • Uses trans-cervical procedures like vacuum aspiration and dilation and evacuation (D&E).

  • Vacuum Aspiration:

    • Recommended for pregnancies up to 14 weeks and consists of:

    • Insertion of a speculum into the vagina followed by cervical dilation.

    • Removal of tissue by suction.

  • Advantages and Disadvantages of Vacuum Aspiration:

    • Advantages:

    • Quick procedure (5-10 minutes).

    • Patient comfort (often minimizes pain).

    • No general anesthesia required.

    • Disadvantages:

    • Not available for second-trimester procedures.

Dilation and Evacuation (D&E)

  • Description:

    • Common in the second trimester (≥12 weeks + 1 day).

    • Process includes cervical dilation followed by removal of pregnancy tissue using forceps and suction.

  • Advantages of D&E:

    • Available during second trimester and considered safe.

  • Risks After D&E:

    • Infection

    • Heavy bleeding

    • Injury to the uterus (less than 1 in 1000 risk).

Counseling Related to Termination of Pregnancy

  • Decision-Making Counseling:

    • Given to individuals who have not made a final decision.

    • Focus on ensuring that decisions are made based on accurate, non-directive information.

  • Pre-TOP Counseling:

    • Discuss methods, pain management, contraception needs, and available services like HIV counseling and testing.

  • Post-TOP Counseling:

    • Provide clear instructions for follow-up care, managing complications, and addressing normal activities post-procedure.

Assessment Before Termination of Pregnancy

  • Medical History Taking Includes:

    • Personal and family history, obstetric and gynecological history, bleeding tendencies, allergies, and violence assessment.

  • Physical Assessment May Include:

    • Pregnancy confirmation, abdominal and pelvic examination, potential referral if ectopic pregnancy suspected.

Investigations and Management Before TOP

  • Suggested laboratory investigations include:

    • Hemoglobin testing for suspected anemia.

    • Rhesus factor testing for Rh-negative women.

    • STD screening and cervical cancer screening.

  • Pain Management Considerations:

    • Administer analgesics and sedatives as indicated before the TOP procedure.

Post-Procedure Management and Follow-Up Care

  • Recovery Management:

    • Patients should remain monitored for several hours to a couple of days depending on individual health status.

  • Crisis Indicators:

    • Severe pain, high fever, heavy bleeding post-procedure, or prolonged feeling unwell should prompt immediate care.

Management of Incomplete TOP

  • Conditions Indicating Incomplete TOP:

    • Vaginal bleeding or abdominal pain with an open cervical os and visible removals inconsistent with pregnancy duration.

  • Management Options Include:

    • Uterine evacuation or repeated administration of misoprostol.

Special Situations in Abortion Care

  • Management of Unsafe TOP Indicators:

    • Infections leading to septic complications.

    • Uterine rupture and retained products post-abortion.

  • Clinical Policies for Management:

    • Active surveillance and intervention for signs of shock or hemorrhage. Documentation and care decisions are crucial.

References

  • National Clinical Guidelines for the implementation of the Choice on Termination of Pregnancy Act (1st edition, 2019). Department of Health, Republic of South Africa.

  • Steyn, C., Govender, I., & Ndimande, J. V. (2018). An exploration of reasons women select legal termination of pregnancy at Soshanguve Community Health Centre, Pretoria, South Africa. South African Family Practice, 60(4), 126-131.