Abortion is never far from the news: the past 12 months has seen the United States Supreme Court overturn Roe v Wade and the introduction of buffer zones outside of abortion clinics in England and Wales. Regardless of each clinician's views or workplace, we will all encounter patients who need or who have had abortions. Globally, each year an estimated 25 million unsafe abortions take place, which is why the Royal College of Obstetricians and Gynaecologists (RCOG)‘s Centre for Women's Health has prioritised safe abortion through the Leading Safe Choices and Making Abortion Safe programmes. Although the legal framework will differ between countries, clinical guidelines can be found in the RCOG Best Practice Papers, in four different languages. Furthermore, The Obstetrician & Gynaecologist (TOG) has published numerous articles relevant to clinicians caring for people who have abortions. In this Spotlight, several have been identified to highlight some of the most relevant issues. Different methods can be used to induce abortion, depending on the gestation, skills of the provider and patient choice. In the UK, medical abortion with mifepristone and misoprostol is now the most common method. Medical abortion is described in detail in a comprehensive review of medical management of miscarriage – including the history and pharmacology of mifepristone, gemeprost and misoprostol (TOG 2014;16:79–85). In 2002, Potts and Campbell described how misoprostol is also used by women in settings where abortion is illegal or inaccessible, as a pragmatic alternative to unsafe abortion with traditional abortifacients or inserting a foreign body into the cervix (TOG 2002;4:130–4). Surgical abortion can be performed with an electric vacuum machine, usually in an operating theatre. Alternatively, manual vacuum aspiration (MVA) is a handheld syringe technique which can be employed for surgical evacuation of the uterus in the first trimester, including in low-resource and outpatient settings. A useful and practical guide to MVA was published in 2015 (TOG 2015;17:157–61). Complications of abortion, specifically ongoing pregnancy, were discussed in an early issue of TOG (TOG 2002;4:222–41). More recently, the complexities of multifetal pregnancy reduction and selective termination were explored (TOG 2020;22:284–9), which may be of particular interest to colleagues working in fetal medicine and reproductive medicine. Valid informed consent is vital for all gynaecological procedures, and abortion by whichever method is no different. Consent in clinical practice, including considerations for emergency situations and non-English speakers, was discussed in a 2015 issue (TOG 2015;17:251–5). However, later that year the Montgomery ruling updated the law so that doctors now have a legal as well as professional duty to inform patients of any material risks involved in a treatment, and TOG published a helpful guide the following year (TOG 2016;18:171–2). Obtaining consent from young people in accordance with the Fraser guidelines is covered in a 2006 TOG article, with reference to a fictional case of a 14 year old seeking an abortion (TOG 2006;8:235–9). We are reminded that the Fraser guidelines are for provision of sexual health advice or treatment and are quite separate from identifying child sexual exploitation (CSE), for which a checklist of potential risk factors is provided. However, the author wisely states establishing rapport is essential because ‘grilling teenagers rarely makes them open up’, and helpfully a more conversational approach to identifying CSE was published in 2017 (TOG 2017;19:205–10). In addition to young people, other groups who may require additional considerations or support when accessing abortion care include transgender patients (TOG 2019;21:11–20), victims of sexual assault (TOG 2018;20:87–93), women with drug and alcohol dependency (TOG 2014;16:269–71), asylum seekers and refugee women (TOG 2015;17:223–31). Specifically, TOG covered abortion and domestic violence in a 2009 article (TOG 2009;11:163–8), drawing particular attention to those women experiencing domestic violence who need abortions at later gestations, citing social isolation, coercion and controlling partners as barriers to accessing care. Although the landscape has since changed with the introduction of telemedicine during the pandemic, these factors have not been eliminated; a commentary considering the use of telemedicine in obstetrics and gynaecology was published in 2021 (TOG 2021;23:237–42). No discussion on abortion would be complete without reference to ongoing contraception, which is required from 5 days post-abortion. Post-pregnancy contraception was outlined in an excellent 2018 TOG article (TOG 2018;20:159–66), which although focuses on contraception post-childbirth has much relevant information for clinicians seeing women after abortion. Intrauterine contraception can be fitted at the time of surgical abortion and at any time after completion of the second part of a medical abortion. A 2021 article provides an informative guide to the numerous intrauterine devices now available in the UK (TOG 2021;23:187–95). Returning to young people, the contraceptive needs of under 16s, including promoting the additional use of condoms to prevent sexually transmitted infections, was highlighted in 2008 (TOG 2008;10:22–6).
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May 7, 2024
Farrukh T Shah + 6
