Management of termination of pregnancy at primary health care level: gestation ≤ 12 weeks and 0 days

O04.9

GENERAL MEASURES

  • Confirm pregnancy with urine pregnancy test.
  • Determine gestational age with ultrasound. If ultrasound is unavailable, use dates (LMP) and bimanual (pelvic) examination:
  • If unsure of dates, or examination disagrees with dates, or uterus palpable abdominally, or the woman is obese or difficult to examine, arrange pre-procedure ultrasound.
  • Ultrasound is mandatory if suspected ectopic pregnancy – refer if uncertain
  • Counselling.
  • Outpatient procedure by nursing staff with specific training.
  • Screen for STIs (if treatment needed, do not delay TOP).
  • Arrange Pap smear if needed.
  • Check HIV status, Hb and blood group (Rh).
  • Counsel and start contraception post TOP, before leaving facility. Arrange contraception follow-up.

MEDICINE TREATMENT

Medical TOP - if gestation ≤ 9 weeks and 0 days:

  • Mifepristone, oral, 200 mg, immediately as a single dose.

LoEIII[6]

Followed 24–48 hours later by:

  • Misoprostol, SL, 800 mcg by self-administration
    • If expulsion does not occur within 4 hours of misoprostol administration, a second dose of misoprostol 400 mcg, oral/PV may be given.

LoEIII[7]

Note: Bleeding may persist for up to 1 week. If there is no bleeding after the second dose of misoprostol, the woman must return to the facility as soon as possible as there is a possibility of an incomplete procedure or ectopic pregnancy.

LoEIII[8]

For pain:
After administration of mifepristone, start:

  • Paracetamol, oral, 1 g 4–6 hourly when required.
    • Maximum dose: 15 mg/kg/dose.
    • Maximum dose: 4 g in 24 hours.

LoEIII[9]

ADD

After expulsion is complete:

  • Ibuprofen, oral, 400 mg 8 hourly with or after a meal.

LoEIII[10]

OR

TOP using manual vacuum aspiration (MVA) - if gestation ≤ 12 weeks and 0 days:

  • Misoprostol, PV, 400 mcg 3 hours before vacuum aspiration of the uterus.

LoEIII[11]

Routine analgesia for vacuum aspiration:

  • Morphine, IM, 0.1 mg/kg 30 minutes before aspiration procedure, to a maximum of 10 mg (Doctor prescribed).

LoEIII[12]

Alternatively, consider paracervical block if trained in technique.

Oral analgesia as required for 48 hours:

  • Paracetamol, oral, 1 g 4–6 hourly when required
    • Maximum dose: 15 mg/kg/dose.
    • Maximum dose: 4 g in 24 hours.

LoEIII[13]

AND

  • Ibuprofen, oral, 400 mg 8 hourly with or after a meal.

LoEIII[14]

For both medical and surgical TOPs (MVA):

In Rh-negative, non-sensitised women: (O36.0)

  • Anti-D immunoglobulin, IM, 50 mcg preferably within 72 hours but may be given up to 7 days following TOP.

LoEIII[15]

Contraception:

Counsel all women on effective contraception, especially long-acting reversible methods.

All methods can be given at the time of the procedure, with the exception of the IUCD at a medical TOP.

LoEIII[16]

Review all patients after 7 days: if bleeding persists, arrange urgent ultrasound.

REFERRAL

  • If gestation ≥12 weeks and 1 day.
  • If gestation uncertain.
  • If any signs or symptoms of ectopic pregnancy or other early pregnancy complications.
  • Co-morbid conditions (heart disease, asthma, diabetes, anaemia, clotting disorder, seizure disorder, substance abuse, hypertension).
  • Large fibroids (may interfere with determining gestation age and/or MVA).
  • Any signs of sepsis (tachycardia, hypotension, pyrexia, tachypnoea, offensive vaginal discharge).
  • If gestation ≥ 9 weeks and 1 day and MVA not available or declined, refer.