12.1 Care before termination of pregnancy


This chapter describes termination of pregnancy (ToP) for intrauterine pregnancies up to 22 weeks LMP. 

12.1.1 Information and counselling

The decision to end a pregnancy belongs to the patient. Her decision 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 a confidential environment.

Prior to the ToP, ensure information and counselling:
– Listen to the patient: thoughts, feelings, situation, needs and concerns.
Discuss ToP methods: description, advantages and disadvantages, follow-up.
– Discuss post-abortion contraception options (Chapter 11, Section 11.5).
Staff are required to respect the confidentiality of the consultation, the examination and the procedure.
The patient's consent for ToP should be clearly expressed.

12.1.2 History and examination

– In case of doubt perform a pregnancy test. No other laboratory test is routinely required.
– Estimate the gestational age (date of last menstrual period and/or uterine size by bimanual examination or abdominal palpation); routine ultrasound is not recommended.
– Look for current problems and treat accordingly: sexually transmitted infection (e.g. abnormal vaginal discharge), signs of ectopic pregnancy, pelvic pain, fever, severe anaemia, etc.
– Take medical and obstetric history: look for contra-indication to ToP and/or subsequent contraception methods.
– In rare cases where an intrauterine device (IUD) is in place, it should be removed if possible.

12.1.3 Choosing a method

Before 13 weeks LMP

There are 2 methods: medication abortion and aspiration. Instrumental curettage must not be used.

Table 12.1 - Comparison between the 2 methods


Medication abortion

Aspiration

Advantages

• Non-invasive method.
• Can be done at home.
• No antibiotic prophylaxis required.

• Immediate result.
• No absolute contra-indications.
• An IUD can be inserted at the end of the procedure.

Disadvantages

• No immediate result (takes hours to days).
• Heavy bleeding and cramping as the pregnancy is expelled.
• Aspiration required in the event of failure.

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

The choice of the method depends on the woman's preference and the feasibility in a given context. In most cases, medication abortion is preferred. Aspiration is also a valid and safe method that should be used when medication abortion is contra-indicated (coagulation disorders) or has failed or, when in a given the context, medication abortion is not an option.

Between 13 and 22 weeks LMP

Only medication abortion can be provided.