12.1 Care before abortion


This chapter describes termination of pregnancy (ToP) for viable intrauterine pregnancies up to 12 to 14 weeks of gestation.

Beyond 14 weeks, the conditions for ending a pregnancy and the management are different, and are not described in this manual.

12.1.1 Information and counselling

The decision of ending a pregnancy belongs to the patient. Her choice should be respected, and there should be no judgment. The role of the health care staff is to allow her to make an informed choice, to provide safe care and confidential environment.

Prior to the abortion an interview has to be ensured:
– Listen to the patient: reason(s) underlying the ToP request, situation, needs and concerns.
– Discuss the possible alternative to ToP: keeping the baby or putting him up for adoption.
– Provide information on ToP methods: description, advantages and disadvantages, follow-up.
– Discuss contraception: available and suitable method after the ToP; see Chapter 11, Section 11.5.

The staff is required to respect the confidentiality of the interview, the examination and the procedure.

The patients’ consent for ToP needs to be clearly expressed.

12.1.2 History and examination

(including abdominal palpation, bimanual and speculum examinations)

– If necessary, perform a pregnancy test to confirm pregnancy.
– Estimate the gestational age (date of last menstrual period, fundal height); if necessary, determine the age of the foetus and its location by ultrasound.
– Look for current problems (and treat accordingly): sexually transmitted infection (e.g. abnormal vaginal discharge), vaginal bleeding, pelvic pain, fever, anaemia, etc.
– Take medical history (contra-indication to medical or surgical abortion method, contraindication to subsequent contraception methods).
– In rare cases where an intrauterine device is in place, it must be removed.

12.1.3 Choosing a method

There are two methods of abortion: medical and surgical. There are advantages and disadvantages to each method.

Table 12.1 - Comparison between medical and surgical abortion


Medical abortion

Surgical abortion

Advantages

Non-invasive method.
Low infectious risk.

Immediate result.
No absolute contraindication.
An intrauterine device can be inserted at the same time, at the end of the procedure.

Disadvantages

No immediate result; requires a follow-up visit to verify expulsion.
Heavy bleeding and cramping as the pregnancy is expelled.
Bleeding often lasts longer than after aspiration.
Aspiration required in case of failure*.

Invasive method.
(Low) risk of uterine perforation or cervical laceration.
Antibiotic prophylaxis required.

*  i.e. continuing viable pregnancy, in less than 1% of the cases with a combined mifepristone + misoprostol regimen.

Elements that need to be considered in choosing the method are: the patient’s preference, contextual constraints (e.g. possibility to return for follow-up visit), the specific contraindications for each method, and operator experience.