Guidelines for terminating pregnancy to prevent unsafe abortions

Guidelines for Termination of Pregnancy to Prevent Unsafe AbortionRoyal Thai College of Obstetricians and Gynecologists

Pregnant women who need to receive termination of pregnancy services should be cared for by a multidisciplinary team consisting of knowledgeable and skilled medical and public health personnel. They should have the ability to listen and provide appropriate counseling so that the service recipients, meaning the pregnant woman and/or her husband and family, can jointly consider the necessity, options, and various forms of assistance.

Medical termination of pregnancy is a medical treatment to ensure safe and standardized termination of pregnancy, in compliance with the Penal Code, Section 305, and the Medical Council’s regulations on the criteria for medical termination of pregnancy according to Section 305 of the Penal Code, B.E. 2548, as follows:

Consider termination of pregnancy in the following cases:

1. Physical health problems of the pregnant woman, where the pregnancy may pose a danger.

2. Mental health problems of the pregnant woman, which must be certified or approved by a medical practitioner who is not the one performing the termination, at least one person.

3. Pregnancy resulting from sexual offenses in 3 cases:

3.1 Rape (Section 276)

3.2 Sexual intercourse with a child under 15 years old (Section 277), even if the pregnancy resulted from consensual intercourse, but termination must have parental consent.

3.3 Pregnancy resulting from being exploited for the sexual gratification of others, which may involve being procured, lured, or taken, even with the woman’s consent, or being procured, lured, or taken by deceit, threat, force, domination, or coercion (Sections 282, 283, 284).

Places that can provide termination of pregnancy services:

1. In cases where the gestational age is not more than 12 weeks, termination services can be provided at a clinic.

2. In cases where the gestational age is more than 12 weeks, services must be provided in a hospital only.

Precautions before termination of pregnancy:

1. Know the gestational age.

2. It is a normal intrauterine pregnancy.

Methods of Termination of Pregnancy:

1. Medical termination should be the first choice as it is safe and convenient.

1.1 Gestational age before 9 weeks (63 days) after the last menstrual period
Take mifepristone 200 mg, 1 tablet, then 24-48 hours later use misoprostol 800 mcg (200 mcg, 4 tablets) sublingually, in the buccal cavity, or vaginally. The complete abortion rate within two weeks is 95%.

1.1.1 Suspected incomplete abortion

• No vaginal bleeding
• Pregnancy symptoms persist

Consider the following actions:

• Repeat the medication as per the above regimen (if the gestational age is still not more than 9 weeks) or

1.1.2 Suspected incomplete abortion within two weeks Consider the following actions:

• In cases of minimal bleeding, use misoprostol 800 mcg (200 mcg, 4 tablets) vaginally, sublingually, or in the buccal cavity, or perform MVA.

1.2 Gestational age 9-12 weeks
Take mifepristone 200 mg, then 36-48 hours later use misoprostol 800 mcg (200 mcg, 4 tablets) vaginally. If not aborted, use misoprostol 400 mcg (200 mcg, 2 tablets) sublingually, in the buccal cavity, or vaginally every 3 hours until abortion, not exceeding 5 times.

In cases of no abortion, refer to an obstetrician or consider performing MVA.

1.3 Gestational age more than 12-24 weeks
Take mifepristone 200 mg, then 38-48 hours later use misoprostol 800 mcg (200 mcg, 4 tablets) vaginally. If not aborted, use misoprostol 400 mcg (200 mcg, 2 tablets) sublingually, in the buccal cavity, or vaginally every 3 hours until abortion, not exceeding 5 times.

In cases of no abortion, refer to an obstetrician.

Summary Table of Guidelines for Using Medication to Terminate Pregnancy

Contraindications for Using the Above Medication Regimen for Termination of Pregnancy

1. Chronic adrenal failure

2. History of allergy or hypersensitivity to mifepristone or misoprostol

3. History of allergy to prostaglandins

4. Severe asthma that cannot be controlled with medication

5. Inherited porphyria

6. Ectopic pregnancy or suspected ectopic pregnancy

2. Surgical Termination of Pregnancy

2.1 Can be performed up to 12-14 weeks of gestation, depending on the provider’s expertise.

2.2 MVA should be chosen for termination due to its high safety, and in the MVA process, it is not necessary to use a curette to confirm complete abortion.

Considerations for Providing Termination of Pregnancy Services
1. Medical termination of pregnancy before 9 weeks of gestation may result in spotting for 1-2 weeks without harm to the patient.
2. Misoprostol may cause side effects such as fever, chills, abdominal pain, vomiting, diarrhea.
3. Contraceptive services should be recommended immediately after successful termination with MVA or immediately after the patient starts using misoprostol, as the patient may not follow up after treatment.
4. Antibiotics are recommended in all cases of surgical termination, with doxycycline 100 mg taken 1 tablet 1 hour before the procedure and 2 tablets after the procedure. If allergic to doxycycline, use metronidazole 500 mg, 1 tablet twice a day for 5 days.
5. Since the prevalence of Rh-negative blood group in the Thai population is about 0.3%, consideration of Rh blood group testing should be case-by-case.

References
World Health Organization. Clinical practice handbook for Safe abortion. Geneva: WHO press;2014.