Pre-abortion counselling and assessment
History taking
It is important to explore the circumstances leading to the unintended pregnancy and the reason(s) why contraceptive failure has occurred. A properly taken contraceptive history forms the basis for further education and counselling on proper family planning and safe sex in future.
A social history of the woman and preferably that of her partner(s) should be obtained. The menstrual history aids in determining the dating of her gestation. The past obstetric and gynaecological history, sexual history, as well as past medical history need to be noted as these may have relevance to the subsequent management of the pregnancy, be it continued or terminated.The counselling process
The aim of counselling is to help the woman (or the couple) make an informed decision on the management of the unintended pregnancy. The interview should be conducted in adequate privacy, with confidentiality respected and emphasized. The counsellor should demonstrate an understanding, empathetic, and non-judgemental attitude, with care taken in the counselling process not to imply accusation of the woman being immoral, sexually irresponsible, or to induce guilt feeling. Alternatives to terminating the pregnancy, including continuation of the pregnancy and rearing the child or having the baby adopted, should be discussed. Support from partners and family should be explored, and yet the autonomy of the woman on her final decision should be maintained. Any suggestion that the woman has been a victim of sexual abuse or been coerced to make a decision either way should be tactfully attended to. Social security aids may
be explored in cases of financial difficulties. Referral to professional counsellors or social workers may be indicated in case of undue ambivalence or adverse social circumstances being identified.
When the woman or couple makes an informed decision for termination of pregnancy, the decision should be respected. The woman should then be informed of the details of the abortion procedure, including the logistics, treatment method, risks, and long-term complications. A future contraceptive plan needs to be formulated.
Pre-abortion medical assessment and preparation
After an informed decision for induced abortion is made, a careful clinical assessment should be carried out as follows:
1. A proper medical, drug, and allergy history should be taken and documented. This may have influence on the choice of the abortion method.
2. A pregnancy test should be performed, if not yet done, to confirm pregnancy state.
3. Testing for haemoglobin level may be done to exclude pre- existing anaemia, although the evidence is inconsistent as for whether it improves health outcomes (3)
4. Testing for rhesus type should be performed in women undergoing medical abortion after 10 weeks of gestation or surgical abortion, in order that rhesus-negative women are given anti-D immunoglobulin prophylaxis postabortion.
5. Prevention of infective complications: screening for sexually transmitted infections or empirical antibiotic prophylaxis for sexually transmitted infections should be offered. Postabortion infection is usually caused by pre-existing lower genital tract infection, the risk of which can be significantly reduced either by bacterial screening or administration of antibiotic prophylaxis. Either universal antibiotic prophylaxis, or universal screening and treatment of positive cases (the ‘screen-and-treat’ approach), or both, can be adopted for prevention of infective complications.
Various prophylactic antibiotic regimens have been recommended around the world. Although it remains unclear which regimen is the most optimal, it should be one that covers against Chlamydia trachomatis and anaerobes. The following regimens are recommended by the United Kingdom Royal College of Obstetricians and Gynaecologists (RCOG) (3):
• Azithromycin 1 g orally on the day of abortion plus metronidazole 800 mg orally or 1 g rectally prior to or during the abortion procedure, or
• Doxycycline 100 mg orally twice daily for 7 days starting on the day of abortion plus metronidazole 800 mg orally or 1 g rectally prior to or during the abortion procedure, or
• Metronidazole 800 mg orally or 1 g rectally prior to or during the abortion procedure in women who have been tested negative for chlamydial infection.
The single-dose regimen has the advantage of minimizing compliance problems. There are inconsistent opinions on whether prophylactic antibiotics should be applicable similarly for medical abortion, although the RCOG recommends this regardless of the abortion method in the context of service delivery in the United Kingdom. In the new UK NICE Guideline (2019), metronidazole is not routinely recommended together with another broad-spectrum antibiotic, and antibiotic prophylaxis is only indicated for medical abortion in women with increased risk of sexually transmitted infections. Further research is needed to explore for the best regimen.
While routine universal antibiotic prophylaxis is one acceptable approach, some suggested that the ‘screen-and-treat’ approach is more economical and appropriate. The RCOG actually recommends screening for C. trachomatis for all women undergoing induced abortion (3). Such a ‘belt and braces’ approach (i.e. combining both universal antibiotic prophylaxis and universal screening), if resources allow, would minimize the possibility of missing the diagnosis of infected women and hence the opportunity of initiating contact tracing and treatment in such cases. Screening for other sexually transmitted infections including HIV should also be considered as appropriate when risk factors are identified in the history.
With regard to treatment, uncomplicated chlamydial infection can be treated with azithromycin 1 g single oral dose or doxycycline 100 mg twice daily for 7 days, whereas bacterial vaginosis can be treated with metronidazole 2 g single oral dose or 400 mg twice daily for 5-7 days (3).
6. Dating of gestational age: gestational age should be determined by menstrual history and pelvic examination. A Cochrane review did suggest that routine ultrasonography improves gestational dating in early pregnancy (4), and yet it would add to the costs and may pose a limitation to the delivery of the abortion service, especially in lower-resources settings. Moreover, a small discrepancy may not alter the clinical outcome of treatment (5, 6). Therefore, pre-abortion pelvic ultrasound scanning is not recommended by RCOG as a routine (3), although it should be available for selected cases to ascertain the gestational age, fetal viability, and location of pregnancy when clinically indicated, for instance, when there is significant discrepancy between menstrual date and uterine size or when the woman reports vaginal bleeding or abdominal pain to exclude conditions such as miscarriage, hydatidiform moles, or ectopic pregnancies. When ultrasound scanning is performed, a systematic review (7) considered it acceptable to allow the woman to see the pre-abortion ultrasound image if it is opted for.
7. Women who are indicated for cervical screening but have not had one within the recommended interval should be provided with the screening opportunity or be reminded of it.