INTRODUCTION
Induced abortion is a controversial topic that ignites complex and emotional debate. Unintended pregnancy is a problem that may never be fully resolved, and women who do not wish to continue a pregnancy will often seek out termination by any means, regardless of safety. This document is not meant to support either side of the abortion debate. Rather, it is intended to assist physicians to present their patients with available options appropriate to their circumstances,  to develop a quality management program, based on available evidence, of the current methods for pregnancy termination, and to provide this service safely and effectively.

All patients choosing abortion are entitled to quality care by practitioners who are qualified to perform procedures and to identify and manage complications.

These clinical guidelines were prepared with the best available evidence and professional consensus on induced abortions.

COUNSELLING

Every woman seeking abortion should receive supportive and compassionate counselling on all the options available, including continuing the pregnancy and having the child adopted or seeking assistance should she wish to parent.

Counselling should take place early enough to avoid any delays in the event the woman chooses to terminate the pregnancy. The counsellor should be free of personal bias and responsive to the woman’s circumstances.

If the woman chooses to terminate the pregnancy she must have the opportunity to fully understand the nature of the proposed procedure including the type of anaesthesia, safety, potential immediate and long-term complications, and side effects.

The patient needs to know that her care is completely confidential unless she is below the age of consent.

Contraceptive counselling,  including risk behaviour and risk reduction strategies (including those to prevent sexually transmitted infections), before and after the termination is imperative to reduce the risk of recurrent unintended pregnancy. The advantages and disadvantages of available contraceptive methods that fit the individual woman’s needs, as well as when and how the method of choice will be initiated, should be explained. The physician must assure the patient of the availability of post-abortion counselling.

ABORTION FACILITY

Experience has shown that first trimester and second trimester terminations, up to a gestational age of 16 weeks, can be safely performed by experienced personnel in clinics or physicians’ offices. (II-2A) In Canada, the proportion of terminations performed in hospitals has declined since the early 1990s, and the proportion of clinic terminations has increased. A hospital where access to emergency facilities is immediately available is safer for patients with certain health problems (bleeding disorders,  major cardiac conditions, etc.)  or for those who require a late second trimester termination.

INFORMED CONSENT

It is essential to obtain the patient’s written consent for both medical and surgical methods of pregnancy termination.

The physician must make sure that the woman understands the nature and the potential complications of the procedure and that she has the necessary information to make an informed decision.

If a minor presents for abortion accompanied by a parent, it is important to ensure the youth was not coerced and the decision is voluntary.  In Canadian common law and in some provinces “age of consent”  follows the “mature minor” rule: the legal right to make health care decisions depends on decision-making ability rather than age; in other provinces the age of consent is consistent with the age of majority. The key element is the minor’s competence and capacity to understand the consequences of the procedure and the potential for complications, not her chronological age. In provinces that have not adopted the mature minor rule, health care providers can treat minors when appropriate without parental involvement, as common law invariably overrides local legislation. However, there should be documentation that the health care provider discussed the importance of involving parents in health decisions, and there must also be a reasonable impression that the intervention is in the best interests of the minor. It is imperative that health care providers be aware of the laws of the province in which they work.

EVALUATION

Pregnancy diagnosis and accurate estimation of gestational age (GA) are integral aspects of abortion care. Only with this knowledge can appropriate options be discussed and abortion-related complications minimized. Accurate gestational dating will also assist in the diagnosis and management of abnormal pregnancies.

Preprocedural History and Physical Examination
1. Confirm the diagnosis of pregnancy by urinary or serum βhCG assay.

2. Determine gestational age by: (a) bimanual pelvic examination to ensure the uterine size is consistent with dates; and (b) ultrasound when the GA is questionable or an intra-uterine gestation is uncertain, and in all cases of second trimester procedures.

3.  Identify all pre-existing conditions, e.g., malignant hyperthermia, coagulation disorder, cardiorespiratory disease.

4.  Determine any factors that could influence the choice of procedure, anaesthesia, or preoperative or postoperative management.

Investigations
Preprocedural tests of hemoglobin and Rh factor are recommended. All unsensitized Rh-negative women require Rh immune globulin following termination. The hemoglobin serves as a baseline for comparison in the event of hemorrhage during or after the procedure.

Investigations should also be performed for rubella immunity (with immunization if susceptible), sexually transmitted infections, cervical cytology (if necessary), and sickle cell disease.

If bacterial vaginosis (BV) is suspected, screening may be prudent. In a randomized study of 231 abortion patients with BV, women treated with metronidazole before the abortion had a significantly lower rate of postoperative pelvic inflammatory disease than those given placebo.7(IA)

 

 

Summary of Recommendations

REFERENCES

Victoria Jane Davis, MD
These guidelines were reviewed by the Clinical
Practice - Gynaecology Committee and the Social and Sexual
Issues Committee and approved by the Executive and Council of
the Society of Obstetricians and Gynaecologists of Canada.