UBC Objectives: Care of Children + Adolescents, UBC Objectives: Maternity Care & UBC Objectives: Women's Health

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Demonstrate patient-centred counselling to the adolescent capable of making informed decisions on self-determination and reproductive choice
• Demonstrate an approach to women experiencing unwanted pregnancy
• Counsel women about options for pregnancy termination
• Explain fetal and maternal legal rights, and the medical and ethical issues surrounding termination of pregnancies

While currently on my Obstetrics & Gynecology rotation at St Paul's Hospital, I'm generally in the business of trying to promote healthy and safe pregnancies, among other issues related to supporting women's health. For women who do not want to carry forward a pregnancy, they would not be referred to our hospital service, although there are women who I have been consulted to assess in the emergency department who have had complications from abortions. In Vancouver, there are a handful of abortion clinics where women can go to receive comprehensive care if they wish to terminate a pregnancy. This has benefits because often not only do these clinics manage the medical side of things, but they also often link patients to resources for emotional and psychological support. As a primary care physician, it is important to be aware of the community resources available for a woman who wishes to terminate a pregnancy, and to provide the necessary medical care that is needed before referral and afterward in followup. Furthermore, many places in Canada will not have the option to refer patients to a local abortion clinic, simply because there aren't any near by, and as a result may need to manage most or all of the abortion process, or else the patient long distances away to get necessary medical care. Some physicians do not feel comfortable with this for moral reasons*, but it is legally required that these physicians refer the patient to another physician who will provide these services. We know that in places where safe abortions are not offered, women will proceed with unsafe abortions or try to do this themselves, leading to a much higher rate of morbidity and mortality. 

When a woman is determined to be pregnant, no matter her age, it is important to solicit whether or not the pregnancy was intentional and if not, if they want to continue to carry it forward or if they are considering terminating. It is important to address this early on, because if a woman wishes to terminate a pregnancy, this is much safer and arguably less traumatic when done early in pregnancy. That being said, it is important to provide appropriate and sufficient counselling so that a woman can make an informed decision that reflects her circumstances. If the patient chooses to terminate the pregnancy, then she has the option of doing so medically or surgically, depending on how far along she is. Medical abortion is typically provided until 49 days of gestation. That being said, it is critical to determine the gestational age as accurately as possible. There are pros and cons associated with each choice. Medical abortion is less invasive, and can be done at home, but can lead to discomfort over a number of days, and there is always the chance that it may not work and that surgical evacuation may be required. On the other hand, while surgical methods resolve the problem immediately and have less risk of failure, they are more invasive and have a higher risk of post-procedure infection. Performing an exam to assess pelvic size can help corroborate this, and unless ultrasound is inaccessible due to local resource limitations, accurate dating by ultrasound is the standard of care. If pregnancy is suspected based on the history and physical exam, confirming pregnancy is first done with a simple urine dip, and then the rest of the assessment would follow. Other investigations to obtain if proceeding with termination include determining the patient's Rh status and current hemoglobin level (if there is excess bleeding associated with the termination procedure, it is useful to have a baseline to compare to). STI screening should also be offered to all patients. 

In Vancouver, the preferred method for approaching a patient who wants an abortion is to refer to one of the comprehensive abortion clinics (see this website for a list of options), but if I find myself in a place where referral to such a clinic is not available, I can provide this service if indicated. The SOGC has an online course that is wonderful (I did this in medical school just for the learning) that equips health care providers with the knowledge and skills to provide medical abortions. And if I was in a place without Gynecological support, I could learn how to perform office-based aspiration/curettage procedures to meet this need. While medical management is generally effective, there are times when retained products of conception need to be mechanically evacuated. Heath care providers providing only medical abortion need to have a place they can send patients for surgical management if needed should the medical abortion be insufficient. 

Issues to address following the procedure itself include:

1. Ensuring women who are Rh+ receive Rh immune globulin immediately after the procedure
2. Counselling women on expected signs and symptoms associated with the abortion process, and what to look for to know whether or not they should seek prompt medical attention. Lower abdominal cramping and bleeding can be normal, but this should improve after a couple of days, and NSAIDs can be taken to help with the pain/discomfort. If the patient was having symptoms associated with pregnancy prior to abortion, these symptoms should dissipate and they should get a menstrual period by 6 weeks post-abortion if not starting a method of contraception that can alter menstruation. Fever, heavy bleeding that isn't decreasing over time, severe pain that is also not improving, and ongoing pregnancy-associated symptoms would be some signs and symptoms warranting close clinical followup.
3. In general, if patients tolerate the procedure well and aren't having complications, they do not necessarily need to follow up with a clinician in person right away. Instead, telephone follow up in 24 to 48 hours may be sufficient in a patient who is at low risk of immediate complications, to remind her of the worrisome symptoms to watch for, and to make sure she these are not occurring at present. She may have a lot going on at this time, and this may not be the best time for her to fit in another thing on the to-do list. If there are concerns identified by telephone follow-up, or if telephone follow-up isn't feasible, a short-term follow-up clinic appointment is indicated. Follow up in clinic may then be arranged 2-4 weeks following the termination to provide supportive care as needed. As the patient's primary care physician, this will be a priority for me as the process can be quite emotionally stressful for some, and it is my preference to check in with how they are coping in person to provide what I think is more supportive care. 
4. Contraception! Prevention is the best cure. 

*To learn more about fetal and maternal legal rights as they pertain to abortion, along with major ethical and moral arguments that fuel the pro-life and pro-choice movements, check out this article that provides a good an concise overview of these issues. To learn more about ethical and legal "hot topics" in the world of reproductive and sexual health, check out the University of Toronto Faculty of Law webpage, Ethical and Legal Issues in Reproductive and Sexual Health.