|
|
|
Methods of TOP
Depending on where a woman lives in New Zealand, she may or may not have the choice to have a medical termination of pregnancy (MTOP) instead of a surgical termination of pregnancy (STOP). Have a look at the map provided on abortion.org.nz to find out which regions have access to TOP services and which offer MTOPs. Does the region where you are doing your attachment offer TOPs? If so, are both types available?
Medical terminations of pregnancy can be performed up to 9 weeks of pregnancy and surgical terminations are offered in most places up until 12-13 weeks of pregnancy. Options for second trimester terminations are the same, but medical terminations are preferred after 16 weeks. Your textbook can provide more detail on this.
EDU in Auckland provides this comparison table for women of the two methods (link here):
Abortion option | Medical | Surgical |
Method | Uses medication 24-48 hours apart to induce abortion | Removes pregnancy tissue with a suction procedure under sedation |
When | Can be done earlier at 5-9 weeks gestation by scan | Can be performed at 7-13 weeks gestation by scan |
Who performs it | The woman takes the tablets | A doctor performs the procedure |
Where | Occurs in the privacy of home | Occurs at the hospital clinic |
How long does the abortion take | 4-6 hours | 5-10 minutes |
Requirements | In case of emergency you must have:
| Cannot drive for 24 hours after sedation medication |
Visits to clinic | Usually two visits | Usually 2 visits |
Additional medication | Oral pain relief and medication for nausea if needed | Local sedation or general anaesthetic Oral pain relief |
Bleeding | More difficult to predict and control | Same blood loss but fewer days of bleeding |
Side effects | Cramp-like pain, nausea, vomiting, and diarrhoea | Cramp-like pain, nausea, vomiting, and diarrhoea |
Complications |
|
|
Follow up | Must have follow up blood test 2-7 days after second tablet to ensure completion GP review at 1-2 weeks | Must have follow up blood test 2-7 days after second tablet to ensure completion GP review at 1-2 weeks |
Contraception | Effective method needed immediately IUCD must be inserted later, at 2 weeks, but all other methods suitable | Effective method needed immediately Can start any method, including IUCD (which can be inserted at the time of the procedure) |
Risk to fertility | Very rare- same as miscarriage | Rare |
Success rate | >95% | 99% |
We learnt in module 3 that some procedures involving the cervix increase the risk of preterm birth. Women should also be counselled that they do have an increased risk of preterm birth after one second trimester TOP or three first trimester surgical TOPs due to the cervical dilatation involved.
Surgical termination of pregnancy
Most DHBs will offer this under local analgesia and sedation, although in some it is carried out under general anaesthetic - check what is available for your area.
Written consent is obtained by the surgeon. Misoprostol 400mcg is given orally or buccally to soften the cervix and increase uterine tone- this decreases the risk of uterine perforation and reduces blood loss. Other premedications include a hypnotic such as midazolam and mild analgesia such as paracetomol or a non steroidal analgesic.
One to 3 hours after premedication, under narcotic analgesia, usually Fentanyl intravenously and paracervical block anaesthesia the cervix is dilated to 8-10 mm with instruments, and the uterus emptied by suction evacuation using a soft plastic suction catheter. The operation is carried out on a day stay basis and women are able to go home after the procedure.
Serious complications are very rare. All forms of hormonal contraception can be started immediately after 1st trimester TOP and an IUD can be also inserted immediately following the procedure. Follow up of all women is recommended 14 days after the termination to assess physical and emotional recovery and contraceptive usage.
The EDU brochure for women about STOP can be found here.
Medical termination of pregnancy
MTOP also involves the use of misoprostol. It is a two-step process. A medication called mifepristone (mifegynae) 200mg orally is given first, and this sensitises the uterus to the effects of prostaglandins and softens the cervix. It also blocks progesterone release. 24-48 hours later 800mcg of misoprostol is given vaginally or buccally to induce uterine contractions and cervical dilation. A prescription is also given for analgesia and antiemetics if these are required.
Most women will pass the pregnancy tissue within 4-6 hours of the medication. Bleeding and cramping are usually present, and women need to know that they need to present to hospital if they have very heavy bleeding or severe pain. Severe bleeding requiring transfusion or emergency surgery is rare- it occurs in 1/100 MTOPs.
After the pregnancy tissue has passed women can have light bleeding for up to three weeks. A follow up visit is recommended with the GP or Family Planning at 14 days. Women can get pregnant immediately after a MTOP and so contraception is recommended at the time of a TOP. All contraception except an IUCD can be used immediately. Women must wait 2 weeks after a MTOP to have an IUCD fitted.
Women also need a follow up blood test to ensure that their ßhCG levels have fallen appropriately.
The EDU brochure on MTOP can be found here.
After care
- If women are Rh negative then they should have a dose of anti-D at the time of their TOP
- Women are advised to avoid intercourse for 2 weeks after a TOP to reduce the risk of infection and to not go into a swimming pool or spa until the bleeding has stopped
- Safety advice is also given, including advice to seek medical advice for: heavy bleeding, dizziness, severe abdominal pain, fever, malaise, smelly vaginal discharge, still feeling pregnant within 1 week after the procedure
- Women may feel a range of emotions after a TOP and counselling is available to them if they wish to access it.
EDU brochure on surgical aftercare here
EDU brochure on medical aftercare here
Complications
Abortions are generally very safe procedures- 95% of women have no complications. Side effects from the use of misoprostol are common- 20% of women have nausea and vomiting and 2% have diarrhoea (misoprostol is a prostaglandin analogue so it has effects on the stomach and bowel, not just the uterus).
The most common complications are:
- Retained products of conception (may require a surgical procedure to be removed)
- Ongoing bleeding
- Infection
Rare complications include:
- Uterine perforation or cervical laceration (with STOP)
- Excessive bleeding requiring transfusion (with STOP and MTOP)
- Continuation of the pregnancy with need for another procedure (with STOP and MTOP)
| « Legal issues | Summary » |
