Pregnancy Choices

What do you need to know before your appointment

You can bring an adult of your choice for support at your appointment. We may need to see you on your own for some of your appointment. This is so we can talk to you about your feelings and options about your pregnancy.

Your options are:

• Continuing your pregnancy.
• Continuing your pregnancy and arranging fostering / adoption.
• Ending your pregnancy with a termination procedure.

Your options will be based on your personal and medical history. We will discuss your options with you at your appointment. There will be time for you to ask questions.
We will support you in your decision and understand if you change your mind at your appointment. We can arrange further appointments or support if you would like to discuss your options further.

Informed consent

This leaflet is provided to supplement verbal information that will be given to you by your healthcare provider prior to your procedure. Information sharing between you and the clinician is essential to ensure that your decision to consent is fully informed. You have a right to be involved in these decisions and should feel supported to do so.

Please take the time to consider what is important to you to ensure the information you receive is specific and individualised.

Choosing to have a termination of pregnancy

A termination of pregnancy is a procedure to end your pregnancy and is sometimes called an abortion.

A termination of pregnancy ends your pregnancy by you either taking medication (a medical termination), or by having a surgical procedure (a surgical termination).

If you chose a termination of pregnancy another appointment will be arranged for you to come back and start your treatment.

The termination may be completed within several hours but some patients will require a longer hospital stay to ensure safe care for significant health issues.

Formal written consent will be taken for the chosen method of ending the pregnancy. You will be offered the opportunity to have a copy of this signed form.

We respect your wishes for confidentiality. The healthcare professional that referred you to the clinic is usually updated to the plan made from your visit. Please tell us if you have any preference for correspondence to your GP, the person who referred you and yourself.

Additional specialists are sometimes required to be part of the treatment planning process. This will be discussed with you during the clinic visit. We are legally required to document our clinical consultation, and this is held within your electronic patient record. This is subject to our trust policy on clinical governance and your records are only accessed for relevant medical care. Our electronic patient record is a regional platform and assists with safer patient care across the region.

Consultation & medical assessment

History

We will ask questions to gain a deeper understanding of your current and previous medical conditions, previous pregnancies, date of the start of your last period and what surgeries you have undertaken in the past. We need to know the names and doses of the medications that you take. If you have allergies to medication we will ask for the name and the kind of allergic reaction that you experienced.

It would be useful to be aware of any teams and doctors who are providing specialist medical care for you as we may need to take their opinion or assistance for safely managing your care.

We will ask you some questions to help inform further support or referrals for safety e.g. mental health, abuse. Confidentiality is a main consideration.

Examination and investigation

It is important that we know the stage (or weeks) of pregnancy and to confirm the location of the pregnancy. This is usually done by way of an internal (trans-vaginal scan) and therefore we prefer that you have AN EMPTY BLADDER when you come to see us. There is no need to drink lots of fluid before your appointment.

We will arrange to check your blood count, blood group and Rhesus status as a minimum. Additional tests e.g. other blood tests, vaginal swabs to rule out infections, heart trace, heart or lung scan etc. are decided on a case by case basis.

Sexual health screens e.g. chlamydia, gonorrhoea, HIV testing may also be discussed. Should any sexual health screen be found to be positive it is unlikely to delay termination timing and we will involve you in the treatment plan.

Planning treatment

There are instances where the opinions of and support from other medical specialists are required. As such, commonly the termination process is NOT started at your original clinic visit and specific dates for termination (if this is your chosen path) cannot always be given at the time of your face-to-face consultation.

In order to let you know the plans it is important that we have an agreed contact method and details e.g. email, mobile / landline telephone.

Termination of pregnancy treatments

The options for termination of pregnancy treatments are broadly divided into medical or surgical. Not all methods of termination are suitable for everyone. We will discuss the treatments offered on an individual basis during your consultation. For additional assistance regarding choice of method you may wish to review NICE decision aids:

Medical termination

This unit can offer tablet medication to end a pregnancy up to 15 weeks and 6 days of pregnancy. Commonly, this requires two sets of medication – mifepristone and misoprostol. It is important to know that you may see the pregnancy as it is passed. The pregnancy tissue becomes more recognisable the further into the pregnancy you are, more-so over 9 weeks of pregnancy.

Mifepristone

Mifepristone is the first tablet that is taken. Almost all of our patients are required to take this tablet within the clinic or hospital setting and most persons will be able to go home shortly after. Mifepristone works by blocking one of the important pregnancy hormones (progesterone) and it stops the pregnancy from continuing. It can cause some cramping, nausea or vomiting or light bleeding but most commonly there are no symptoms.

Misoprostol

Misoprostol is the second tablet(s) given. It is normally given 24-48 hours after mifepristone (first tablet). It makes the womb contract in order to expel the pregnancy. It is expected to cause vaginal bleeding, cramping and the loss of the pregnancy similar to a miscarriage. Occasionally it can have other side effects such as sickness, dizziness, fever (self- limiting) and loose stools.

Many people referred to our clinic will require an inpatient stay for their treatment with misoprostol. In most instances, we anticipate that the termination treatment is completed the same day but some people with complex medical backgrounds may need longer stays in hospital even after the termination is complete.

Medically eligible people who are at or under 9 weeks and 6 days may be able to take the second tablet at home 24-48 hours later. Additional tablets may be given to take at home if the bleeding has not started 3 hours after the initial misoprostol tablets.

Medically eligible people at or under 9 weeks + 0 days may be able to take the second tablet (misoprostol) at the same time as the first (mifepristone). This may be associated with a longer time for bleeding and pain to start and may increase the risk of on-going pregnancy. Additional tablets may be given to take at home if bleeding has not started after 48 hours.

Expected effects and risks of medical termination of pregnancy treatment

• Lower abdominal pain, cramping and vaginal bleeding (common). Pain medication such as paracetamol and ibuprofen may be helpful. Occasionally, a stronger pain medication is needed. The vaginal bleeding should become lighter after the termination is complete but may continue (including spotting) until your next period.
• Nausea, sickness, loose stool, headache, dizziness and fever / chills are common. If these symptoms continue more than 24 hours after the last tablet please contact the unit for advice.
• For many patients, the process is completed within 4-6 hours. However it can be an unpredictable time to the completion of the termination.
• Haemorrhage (excessive / very heavy bleeding) (1-2 in 1000).
• Infection (less than 1 in 100).
• Retained products of conception (pregnancy tissue left behind) (2 – 7 in 100).
• Undiagnosed ectopic pregnancy (2 in 1000).
• Continuing pregnancy (under 1 in 100). All patients are requested to take a urine pregnancy test three weeks after the procedure and contact the team if it is positive.
• Uterine rupture (less than 1 in 1000). The risk is highest for persons over 14 weeks and who have had a previous caesarean section.
• Regret or psychological problems.
• Death (under 1 in 100,000).

Additional procedures that may become necessary

• Surgical method for emptying the womb (1-2 in 100).
• Blood Transfusion (2 in 1000).
• Laparoscopy or Laparotomy (look inside the abdomen) or Hysterectomy (removal of womb) (2 -3 in 100,000).

What to expect during the medical termination

At home

It is common to experience some light, moderate or heavy bleeding and moderate to strong period-like pain during the termination. Consider using large sanitary towels to monitor your bleeding. It is not normal to have no bleeding or scant bleeding or flooding and we would not expect the clots to be larger than a tangerine or lemon. You can also use simple pain medication e.g. paracetamol, ibuprofen unless these are unsafe for you.

See the section ‘Contact details, how and when to seek further help’.

See the section ‘Management of pregnancy tissue – outpatient’ for information about the management of pregnancy tissue that passes at home.

In Hospital

You will be cared for on the ward. The nurses monitor your bleeding and offer pain relief. They will check any pregnancy tissue that passes and manage this tissue respectfully and according to your wishes.

See the section ‘Management of pregnancy tissue – inpatient’ for information about the management of pregnancy tissue.

Surgical termination

There are two methods of providing surgical termination.

Vacuum Aspiration / Manual Vacuum Aspiration

This removes the pregnancy with gentle suction and can be offered when the pregnancy is 11 weeks and 6 days or less. We provide strong pain medication, anti-sickness medication and misoprostol tablets (to soften the neck of the womb) one hour before the procedure. We also use some local anaesthesia into the neck of the womb and we can offer inhaled pain relief e.g. Penthrox®, Entonox®.

When compared to a similar procedure under general anaesthetic, manual vacuum aspiration provides a quicker recovery, quicker discharge and allowance to drive if needed. On average, there is also less bleeding and reduced risk of damage to the womb. Manual vacuum aspiration removes the added risk of the general anaesthetic.

We advise that you eat a light meal and drink as normal before manual vacuum aspiration. Mild bleeding and cramping may start before the procedure as a result of the pre-procedure medications and should not cause concern.

It is not necessary to empty your bladder before the procedure unless asked specifically to do so. We encourage you to chat with the team during the procedure and we can play music via a Bluetooth speaker as well if you wish.

You will be asked to rest on a couch that supports your legs. After the initial preparation, the procedure usually takes 5- 10 minutes. It is common to experience cramping period-like pain during the procedure and this intensifies briefly at the end of the procedure. We can also provide certain forms of contraception at the end of the procedure.

Most patients will be able to be discharged within 30-60 minutes of the procedure but please plan to be with us for half the day.

Electric Vacuum Aspiration under general anaesthesia

You will be given instructions for fasting (no food or drink) and the location, date and time for your admission in preparation for your surgery.

The team will confirm your choices with you before you are taken into theatre. You are free to change your mind at any point.

We offer misoprostol 1 -2 hours before the surgery to reduce the risk of damage to the womb and cervix. Mild bleeding and cramping may start before the operation takes place and should not cause concern.

There is no need to empty your bladder before the operation.

We can provide certain forms of contraception at the end of the procedure.
After the operation, you will be offered something to eat and drink when it is safe to do so.

Some patients are suitable to be discharged on the same day. Another adult will need to accompany you home and remain with you for at least 24 hours after the anaesthetic. You should not drive or operate machinery during this time.

Expected effects and risks of surgical termination of pregnancy treatment

Frequently occurring risks include

• Common side effects of misoprostol (if given to prepare the cervix) include nausea, loose stool, chills/fever, cramping, bleeding (usually mild may start before the surgery), headache, dizziness.
• Bleeding is expected during and after the surgical procedure. It can be heavier than a normal period and should reduce in heaviness in the days following and be associated with small clots. It can last for a couple of weeks.
• Pain (period cramping) is common during manual vacuum aspiration in the awake patient and after the surgical procedure is expected but will be less intense.

Serious risks include

• Excessive bleeding (haemorrhage) may affect 1-2 in 1000 patients.
• Infection (less than 1 in 100). Serious infection (sepsis) is uncommon less than 1 in 1000.
• Retained pregnancy tissue (less than 5 in 100). Sometimes further treatment is required.
• Uterine perforation (womb pierced by the instruments) affects less than 1 in 1000 patients. The risk increases with how far along you are in the pregnancy. Internal organs may be damaged.
• Laparoscopy (keyhole surgery) or Laparotomy (larger cut into abdomen) in less than 1 in 1000 patients. e.g. to assess or repair internal damage. Should this occur, admission to hospital is required.
• Cervical damage affects less than 1 in 100 persons and can often be repaired during the procedure.
• Continuing pregnancy (1 in 1000) is uncommon as we use ultrasound guidance.
• Ectopic pregnancy (pregnancy developed outside the womb) that was not recognised / visible during the planning process. This is uncommon and may occur in about 2 in 1000 persons.
• Regret and psychological problems.
• Anaesthetic risks related to the general anaesthetic, local anaesthetic or tablet treatments including unexpected allergic reactions.
• Hysterectomy is rare and only for life-threatening concern. This would affect the ability to carry future pregnancies.
• Death (under 1 in 100,000).

After surgery

• It is common to experience some light, moderate bleeding and mild to moderate cramping for about a week or so after the procedure. This should improve day by day.
• We would not expect the clots to be larger than a tangerine or lemon. You can also use hot water bottles or simple pain medication e.g. paracetamol, ibuprofen unless these are unsafe for you.

See the section ‘Contact details, how and when to seek further help’.

Management of pregnancy tissue – outpatient

After you pass the pregnancy at home there may be recognisable pregnancy tissue. Several options are open to you and this can be explored further within the clinic setting.

You may wish to flush this tissue down the lavatory or wrap the tissue in a small plastic bag and place in the dustbin.

Some persons may wish to bury the pregnancy remains in the garden in a pot with a plant. Burial in the garden or other private land is not unlawful but certain conditions need to be upheld e.g. consent from the owner of the freehold. The Planning and Environmental Health Office at your local City Council will be able to inform you of any by-laws or local regulations that may affect the burial.

There are a number of recommendations and points to be considered when thinking about where to bury the pregnancy remains. These include:

• There should be no danger to others.
• It should not interfere with any rights that others have on the land.
• There should be no danger to water supplies or water courses.
• There must be no chance of fluids leaking into or onto adjoining land.
• Burial should be at a depth greater than 24 inches or 60 cm.
• Permissions should be gained from the landowner before the burial.
• Consider whether to include that pregnancy remains are buried in the garden is included in the property deeds. This may affect the value of the property but may be important information for the new owners of the property.
• What would the patient wish to happen to the pregnancy tissue should they move house or if the land were to be used for a new purpose?
• Alternatives to garden burial include burial in a planted pot. This may be able to move with the patient should they move.
• It is important to keep the pregnancy tissue cold until burial. It should not be stored alongside food or in a place where foodstuff is usually kept.

You may wish to bring the pregnancy tissue back to the hospital where we can arrange either a group cremation or a respectful incineration with your consent.

You also have the right to arrange a private individual cremation or burial. LTHT patient information leaflet LN005152: ‘Taking pregnancy tissue home’ can provide more information. Click on the link below:

Management of pregnancy tissue – inpatient

We will discuss the options of pregnancy tissue disposal with you during your clinic visit or on the ward.

For pregnancy tissue 13 weeks and 6 days and under, the options for pregnancy tissue disposal are

• Group cremation in Leeds arranged by Leeds Teaching Hospitals Trust. You will be unable to attend the cremation and ashes will be scattered in the crematorium’s baby garden.
• Respectful incineration arranged by Leeds Teaching Hospitals Trust
• Private individual cremation or burial at your expense. Tissue should be collected within 4 weeks of signing the consent form from the Mortuary or Bereavement Office at St James’s University Hospital.
• Return of the pregnancy remains to you in order for you to make your own arrangements. There is a separate LTHT patient information leaflet LN005152 available: ‘Taking pregnancy tissue home’.

Click on the link below:

For pregnancy tissue 14 weeks and over, the options for pregnancy tissue disposal are:

• Cremation arranged by Leeds Teaching Hospitals. If you wish to attend or receive the ashes you need to inform the bereavement office on 0113 206 4162 within 4 weeks of signing the consent form.
• Burial in a group plot arranged by Leeds Teaching Hospitals. If you wish to arrange
  an individual burial or to attend you need to inform the bereavement office on
  0113 206 4162 within 4 weeks of signing the consent form.
• You can arrange your own private funeral within 4 weeks of signing the consent form. After 4 weeks Leeds Teaching Hospitals will arrange cremation of the pregnancy tissue.

Anti D and venous thromboembolism assessment

If you are Rhesus negative, there may be a risk of developing antibodies if there is a mixture of your and baby’s blood. In a future pregnancy these antibodies may be able to attack the baby’s oxygen carrying cells in the blood. In severe cases this can be associated with pregnancy loss or still birth, or in other cases the baby may need to receive blood whilst still in the womb, be delivered quite early or need treatment for jaundice.

In order to reduce these risks, Anti D injection is given within 72 hours of treatment for all patients who are undergoing surgical termination of pregnancy and for patients receiving medical termination of pregnancy at 10 weeks pregnant and over.

Pregnancy increases the risk of clots in the legs and in the lungs. A risk assessment is performed for all patients and you will be advised on methods required to reduce your risk. Common reduction measures include being out of bed, mobilising and maintaining good hydration. Some patients will require additional treatments e.g. TED stockings, low molecular weight heparin (blood thinning injections) before and/or after the medical or surgical procedure.

Contraceptive options

We will offer to discuss contraceptive options that may be suitable for you and aim to provide or arrange provision of your chosen method at the time of the termination or shortly thereafter.

You can find further information about contraceptive options at:

After care

A responsible adult who is aware that you have had a general anaesthetic needs to be in the house with you overnight.

You should not drive, drink alcohol, go to work or make important decisions for 24 hours if you have had a general anaesthetic.

It is common to have cramps for a few of days /up to about a week after the termination. Common pain medication e.g. paracetamol, ibuprofen may be useful

Bleeding can last up to 3 weeks.

There is no specific guidance about tampon use or sex, but many patients avoid both until after the next normal period.

Periods are likely to resume within 6 weeks. It is possible to get pregnant before your next period, so contraception uptake is encouraged.

Contact details, how & when to seek further help

Seek further help with these signs and symptoms:

• Soaking through two or more maxi-sized sanitary towels per hour for two hours in a row (GATU or consider Accident and Emergency attendance).
• If it has been 24 – 48 hours since you have taken the misoprostol tablet and have had no bleeding or only mild spotting (Gynaecology secretary or Gynaecology clinic).
• If you develop an unusual or unpleasant smelling vaginal discharge (GATU).
• If you develop a fever or flu-like symptoms after more than 24 hours from taking the misoprostol tablets. (GATU).
• Feel unwell at any stage (consider Accident and Emergency).
• If you develop worsening pain particularly lower tummy pain on one side, pain under the ribs or shoulder tip pain (consider GATU or Accident and Emergency).
• If you have a positive urine pregnancy test 3 weeks after the procedure (Gynaecology Secretary or Gynaecology clinic).

Counselling service

Feelings before and after termination of pregnancy can vary and may include relief, sadness, confusion, anger. If you have been referred from external providers e.g. MSI, BPAS, NUPAS you will be able to access counselling through their services. If you have been referred by other means, we are able to access counselling (especially before the procedure) from our clinical psychology team. If you require this after your procedure please contact our secretary, the Gynaecology clinic or the Gynaecology Assessment and Treatment Unit so we can raise a referral.

Other useful addresses and information

Further patient information on termination

Contraception

Mental Health Mind

Benefits

Maternity

Termination Services