Information for Doctors referring women for Termination of Pregnancy
Services
- Counselling for women with unplanned pregnancy
- Consultation for termination of pregnancy including ultrasound scan
- Surgical termination of pregnancy up to 22 weeks gestation
- Medical termination of pregnancy up to 9 weeks (63 days) gestation using Mifepristone and Misoprostol
- Contraception, including emergency contraception
- Post-abortion checks
- Post-abortion counselling
Appointments
Telephone 8243 3999. The woman must confirm the appointment directly with the receptionist. Waiting time for appointments is usually 7 to 10 days.
- Women will generally be given a consultation appointment at which an appropriate operation appointment will be made for several days later. The Centre usually does procedures Monday - Wednesday and on Thursday morning.
- Special arrangements are made for country women and those women who are 15 or more weeks gestation.
- Women who are 9 weeks (63 days) gestation or less will be offered the option of a medical abortion. An appointment for consultation is made and the abortion will commence on that day if she is clear about her decision.
Referral
Not essential, but a letter is appreciated to facilitate contact with General Practitioners. It is useful if a copy of the woman’s blood group including Rhesus factor is made available. A reply will be made to all letters of referral.
If gestation is uncertain women may come to the PAC for a dating ultrasound scan and an appropriate appointment made after discussion of her options.
Admission Criteria
Women who have serious medical problems e.g. severe hypertension, poorly controlled asthma, diabetes or epilepsy, bleeding problems, anaemia (Hb <10.0), or are greater than 100 Kg in weight will be assessed at the PAC. Arrangements may need to be made for these women to have their operation done in hospital.
Surgical Procedures
- Dilatation of the cervix followed by suction extraction is used for pregnancies up to 14 weeks.
- Women of 12-15 weeks gestation have pre-treatment of the cervix using Misoprostol oral tablets to facilitate dilatation and reduce the risk of damage or blood loss.
- Women of 16 weeks gestation or more have pre-treatment of the cervix using Misoprostol and Laminaria Tents - a sterile kelp preparation which absorbs fluid and swells to gently dilate the cervix. These are inserted in the cervix following partial dilatation using local anaesthetic and sedation. IV antibiotic cover is provided for these two step procedures. Further dilatation and evacuation of the pregnancy is carried out up to 24 hours later.
- Transvaginal ultrasound scan is carried out at the end of the procedure to ensure the pregnancy has been removed and no tissue remains in the uterus.
Anaesthetic
A specialist anaesthetist is in attendance. Procedures are generally carried out using a combination of paracervical block and intravenous sedation. The level of anaesthesia being tailored according to the woman’s needs.
Women are required to fast from 3.00am on the day of operation.
Post operation
Women are ready for discharge from the Centre when they satisfy criteria covering orientation, blood loss, pain, vomiting, ingestion of fluids, etc. This is usually about 2 hours post-operatively. Most women spend 4-5 hours at the Centre, longer when their gestation is higher.
Medical Abortion
Women who are 9 weeks (63 days) pregnant or less can choose a medical abortion. Current studies show that Mifepristone is safe and effective up to 63 days gestation. Mifepristone blocks the action of progesterone so the endo metrium can no longer sustain the developing foetus. It also sensitises the uterus to the action of the prostaglandin, Misoprostol, facilitating the expulsion of the pregnancy from the uterus.
A small number of women may have bleeding or spotting after taking the Mifepristone but it is very unlikely that the pregnancy will abort after the Mifepristone alone. Most women start to experience pain and bleeding from 30 minutes to 2-3 hours after using the Misoprostol and lasting for 6-8 hours tapering off over the next 7-14 days.
For most women the bleeding will resemble a heavy period. For some it may be minimal, while a very small number will bleed extremely heavily. As with miscarriage the woman may identify pregnancy tissue. Cramping pain may range from minimal to severe labour-like pain. Women are provided with Panadol and Ibuprofen for analgesia and are encouraged to use it early so it is more effective. Other side effects occurring in a small number of women include headache, nausea, vomiting, fever, flushes, and chills.
Women can elect to be cared for at the Centre when they have the Misoprostol tablets, or they can use the tablets at home providing there is a responsible adult to support them during the time side effects are most marked.
Complications
Post-operative (surgical or medical) complications are infrequent. Women having problems with pain, bleeding etc. are encouraged to contact the Centre in the first instance. An after hours emergency telephone contact is staffed by the Medical Co-ordinator or a senior Clinical Nurse. Wherever possible post-operative complications are managed by the Centre. However, in some situations women may be referred to public hospital emergency departments.
Post Abortion Follow-up
Medical Check
Women are encouraged to attend for routine follow-up 2 weeks after operation either at the Pregnancy Advisory Centre or with their General Practitioner. The purposes of the check are:
- to ensure involution of the uterus and ascertain there is no infection or retained products
- to follow up any concerns about contraception
- to ascertain that any emotional issues about the abortion are being resolved.
Medical abortion follow up at the Pregnancy Advisoy Centre will be arranged at the time of consultation.
Counselling
Very few women need further counselling following abortion if they have come to a sound decision for themselves. If necessary they can be referred to the Social Workers at the Centre.
Management of Post-abortion Problems
Bleeding
Variable post-operative bleeding may continue for 2-3 weeks. It is generally less than a period. Some women have little or no bleeding. Bleeding may not commence until several days after the operation. It usually settles spontaneously.
If bleeding appears excessive (soaking a pad every 1-2 hours over 3-4 hours) and particularly if accompanied by pain which is not relieved by adequate oral analgesia (Panadol, Panadeine, Ponstan or Naprogesic) then it is likely some tissue or blood clot has been retained in the uterus. This can be managed by using Misoprostol 200mcg 3 times daily for 2 days causing the uterus to contract and expel the remaining tissue or clot. Analgesia may be needed for the cramping pain caused by this treatment. Misoprostol is available at the PAC and at some hospitals. If bleeding persists a D&C may need to be arranged to remove the tissue. This can be carried out at the PAC during regular operating sessions. At other times referral to hospital is required.
Infection
The incidence of post-abortion infection is very low. However, in women with persistent lower abdominal ache and tenderness, unusual bleeding or discharge, or unexplained fever infection should be suspected. Cervical swabs for bacterial culture and Chlamydia assay are recommended. Do not delay therapy pending swab results. Broad spectrum cover is provided by Azithromycin 2x500mg plus Tinidazole 4x500mg plus Augmentin/Amoxycillin 2x500mg.
Continuing Pregnancy
This is rare but may occur particularly when an abortion is performed at an early gestation - 6 weeks or less, or there is an anatomical variation of the uterus or cervix, or a twin pregnancy. For most women pregnancy symptoms subside rapidly after operation, usually 2-3 days, although they may be prolonged by taking the contraceptive pill. Persistent symptoms or concern about possible continuing pregnancy may require investigations with serial quantitative Beta-HCG or pelvic ultrasound scan.
Note: Urinary Beta-HCG will nearly always still be positive 2 weeks after successful abortion.
Further Information
For further information about services contact the Pregnancy Advisory Centre
Phone 8243 3999 9.00am - 4.00pm Monday to Friday.
The Centre appreciates feed-back about women with post-abortion problems as part of our on-going quality improvement program.
Other Services for Termination of Pregnancy
Numbers to phone for appointments
| Women's & Children's Hospital | 81617580 |
| Flinders Medical Centre | 82045197 |
| Lyell McEwin Health Service | 82821611 |
| Royal Adelaide Hospital | 82225587 |
| Noarlunga Health Service | 83849233 |
This information updated by Medical Officer, Dr Robin Willcourt
September 2009
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