Termination of pregnancy in the UK is undertaken under the terms of the Abortion Act 1967, with over 200,000 induced abortion procedures occurring each year. For the consideration of anaesthetic procedures and potential problems, patients presenting for a termination of pregnancy broadly fall into two groups:
1. The presence of a maternal problem, the most commonly stated reason being danger to the mental or physical health of the mother. This accounts for up to 98% of terminations and may occur up to 24 weeks’ gestation, but usually before 15 weeks.
2. Severe fetal congenital abnormality or early fetal death, two-thirds of which occur before 20 weeks’ gestation.
Problems and special considerations
When caring for women who are to undergo a termination of pregnancy, it is important to consider the physiological changes of pregnancy, the psychological state of the woman and the need for routine preoperative assessment of the patient.
Those women in the first group above are usually scheduled to have termination of pregnancy on a gynaecological operating list. Patients in the second group are often looked after in the maternity unit.
Some members of staff may express conscientious objection to performing or being involved in termination of pregnancy, and this must be respected. They cannot be made to participate in such procedures, although they do have a duty to find other staff who will, if that is the patient’s wish.
Management options
Termination for maternal indications
Surgical termination of pregnancy is usually a day-case procedure. Assessment should be conducted sympathetically, as these women are often very distressed. Vacuum aspiration may be performed up to 15 weeks’ gestation; patients and clinicians are more used to this being performed under general anaesthesia in the UK, although it can be performed with systemic analgesia, local anaesthesia or conscious sedation. After 15 weeks’ gestation, dilatation and evacuation (D&E) is necessary, which is also usually performed under general anaesthesia.
As most terminations for maternal indications occur before 15 weeks, these women can usually be regarded as non-pregnant with respect to gastric emptying and acid aspiration unless they have symptoms of reflux.
An anaesthetic technique suitable for day-case anaesthesia should be employed, such as induction with propofol and maintenance with propofol or a volatile anaesthetic agent. There has been concern about concentrations of volatile anaesthetic agents greater than 1 MAC causing uterine relaxation unresponsive to oxytocics. For a termination of pregnancy at less than 15 weeks, standard concentrations of volatile anaesthetic agents do not appear to pose a risk and may be used to maintain anaesthesia. Analgesia may be provided by intravenous fentanyl or alfentanil, with rectal diclofenac (100 mg) at the end of the procedure.
The gynaecologist may request that 5-10 U oxytocin is administered to aid uterine contraction. There is no clear evidence that this is helpful at this stage of pregnancy, and it is not recommended by the Royal College of Obstetricians and Gynaecologists (RCOG).
Termination for fetal abnormality or death
Women who present for termination of pregnancy because of fetal abnormality or intrauterine death present a difficult clinical problem. A medical termination with vaginal delivery is often aimed for at later gestations, partly because this offers the opportunity for pathological examination of an intact fetus, but also because of limited access to D&E within the NHS. Induction of labour is usually required, and this may be a long and tedious process involving the use of prostaglandin pessaries and oxytocin infusion. The RCOG currently recommends feticide for terminations over 21+6 weeks. A discussion regarding analgesic options should be offered, including parenteral opioids and epidural analgesia (see Chapter 76, Intrauterine death). It must be remembered that as gestational age increases, the risks associated with termination, including complications such as haemorrhage, uterine perforation and infection, increase.
Termination of a pregnancy at less than 28 weeks is often associated with the retention of products of conception, for which surgical evacuation and anaesthesia are required (see Chapter 5, Evacuation of retained products of conception). Either regional or general anaesthesia may be offered to the woman, balancing the risks and benefits of each depending on the clinical condition and whether epidural analgesia is already in place. Rapid-sequence induction and tracheal intubation may be appropriate.
Key points
• Women may present for termination of pregnancy for maternal reasons or because of fetal abnormality or death.
• Such women are distressed and should be dealt with sympathetically.
• Early termination is usually performed as a day-case general anaesthetic procedure.
• Issues surrounding late terminations are as for intrauterine death.
Further reading
Royal College of Obstetricians and Gynaecologists. Termination of Pregnancy for Fetal Abnormality in England, Scotland and Wales: Report of a Working Party. London: RCOG, 2010. www .rcog.org.uk/en/guidelines-research-services/guidelines/termination-of-pregnancy-for-fetal-ab normality-in-england-scotland-and-wales (accessed December 2018).
Royal College of Obstetricians and Gynaecologists. The Care of Women Requesting an Induced Abortion. Evidence-Based Clinical Guideline 7. London: RCOG, 2011. www.rcog.org.uk/en/guide lines-research-services/guidelines/the-care-of-women-requesting-induced-abortion (accessed December 2018).