Coping with UK Abortion Law
University of Aberdeen, Scotland, UK
When the 1967 Abortion Act came into practice in England, Scotland and Wales, it was seen as a major step forward in Women’s Health. Now almost fifty years later, the Act’s evident limitations inhibit best practice in several respects. Abortion in the UK is illegal unless the conditions of the 1967 Act are met and confirmed by two doctors. In the majority of cases a woman requests an abortion and an abortion is justified because it is safer than having a baby, condition c states “that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated”. This may not be what the Act intended and is certainly not what the GMC now advises in recognising a person’s right to make decisions about her own healthcare.
Furthermore the advent of medical abortion particularly has highlighted the inadequacies of the current Act with regard to safe and effective service provision. Nurses are prohibited from sanctioning and performing abortions. The obverse interpretation of the Act which requires both mifepristone and misoprostol to be given in clinics makes abortion at home (the preferred option of the majority of eligible women) both more inconvenient and uncomfortable than necessary. Within the UK, abortion has now been devolved to Scotland, and although it has been made clear there will be no early attempt to amend current legislation, changes which improve service provision will be considered. This highlights the dilemma of those wishing to improve matters, namely whether to campaign to strike out the laws which make abortion illegal and so recognise a woman’s right to abortion, or whether to interpret and amend current laws to improve service provision, as was very nearly achieved in 2008.
Professor Allan Templeton, University of Aberdeen, United Kingdom
The formulation of the antiprogesterone drug mifepristone in the 1980s led to the development of safe and effective medical abortion as an alternative to surgery. Initially the regimens were used in the early first trimester and second trimester, and increasingly employed the prostaglandin E analogue misoprostol given by a variety of routes, including oral (swallowing), vaginal, sublingual and buccal.
About ten years ago this approach was also assessed for use in the late first trimester and as a result medical abortion is now used at all gestations, where preferred to surgery. This review will focus on 10 years experience of late first trimester medical abortion at one centre, including efficacy, side-effects and acceptability. It will also illustrate how frequent review has facilitated improvement and development of the regimens used.
Professor Allan Templeton, University of Aberdeen, United Kingdom
Most current regimens for second trimester medical abortion are based on the administration of sequential doses of the prostaglandin misoprostol to women pre-treated with mifepristone, where available. Mifepristone given 24-48 hours prior to the administration of the first dose of prostaglandin will shorten the induction-abortion interval, decrease the dose of prostaglandin required and hence reduce side-effects and analgesia use. Most women will abort within 15 hours, but if not, the regimen can be repeated next day, or surgery undertaken. A dose of mifepristone 200 mgs is sufficient throughout the second trimester.
The initial prostaglandin dose can be administered vaginally or sublingually and subsequent doses given orally if the uterus is contractile but abortion has not occurred. Completion of the abortion will require surgery (usually removal of placenta) in 5% of cases with experience. Comparison with surgery (D and E) has proven difficult, although minor complications are more frequent with medical abortion and patient preference favours surgery. On the other hand the risk of infrequent but serious injury is probably higher with surgery. A number of other issues pertinent to late second trimester and early third trimester abortion including feticide and abortion for fetal abnormality will be discussed in the light of recent RCOG reports.
New developments in medical abortion care at 9-13 weeks
Alan Templeton (Scotland)
University of Aberdeen, Scotland
After considerable experience of a mifepristone-misoprostol regimen for induced abortion in the early first trimester, pilot studies indicated the feasibility of using a similar regimen in the late first trimester. A randomised study was then carried out which demonstrated efficacy and acceptability compared with surgical abortion, and indicated that medical regimen was an effective alternative, acceptable to the majority of women. Subsequent review of experience indicated that approximately half of women will opt for medical abortion at 9-13 weeks gestation, if offered the choice. However acceptability is less than surgery, and decreases with gestation. Similarly the ongoing pregnancy rate is higher at higher gestations. Further randomised study has indicated the efficacy and acceptability of sublingually administered misoprostol at all first trimester gestations, even though the frequency of prostaglandin related side affects is higher. Further developments using the regimen will be reported at the meeting.
Medical methods at later gestations
Allan Templeton University of Aberdeen, Aberdeen, UK - firstname.lastname@example.org
Induced abortion is one of the most common medical interventions. Most abortions are carried out in the first trimester, but there is a continuing need to provide services for those presenting later, about 10% of the total, and including most abortions carried out for fetal abnormality and for medical reasons. Medical, rather than surgical, methods became safe and effective with the advent of prostaglandins and this approach was greatly facilitated with the introduction of mifepristone around thirty years ago. Regimens employing mifepristone and a prostaglandin, usually misoprostol given vaginally or sublingually, are now available at all gestations. From about nine weeks onwards it will be necessary to repeat the misoprostol dosage perhaps two or three times or more, usually at three hourly intervals. Misprostol alone can be used in this way, where mifepristone is unavailable, but the efficacy is much reduced, a higher total dose is needed, the abortion interval is increased and there are more side effects. With the combined regimen the overall incomplete abortion rate is around 5%, necessitating the removal of the placenta (usually) surgically. Trials comparing medical and surgical approaches are few, but point to a greater preference among women for surgical approaches, although a good number choose medical. Pain and bleeding is higher with medical abortion, but the risk of serious injury, although rare, may be higher following surgery. Infection screening and antibiotic policies should be as for early abortion, as should the offer of immediate long-acting contraception.