Post-abortion investigations

If further tests are required to confirm a diagnosis of fetal abnormality, they should be discussed and verbal consent obtained. These may include fetal chromosome analysis. If a postmortem is considered necessary, informed consent from the woman must be obtained. The options of a limited or external examination by a perinatal pathologist or geneticist can be offered if a full postmortem examination is declined. Once consent for a postmortem has been given, there should be a “cooling off” period to allow the woman to change her mind within a specified time[2].

Rhesus antibody prophylaxis

The UK Royal College of Obstetricians and Gynaecologists (RCOG) recommends that anti-D immunoglobulin G (IgG) immunoprophylaxis should be given within 72 h of an induced abortion to all Rhesus (Rh)-negative women regardless of gestation unless they are already sensitized[3]. Whilst there is little evidence to support anti-D prophylaxis in the first trimester, some studies indicate that the volume of a fetomaternal hemorrhage is potentially sufficient to cause sensitization[4]. The UK RCOG therefore recommends anti-D prophylaxis as routine in the first trimester[3].

The recommended dose of anti-D IgG is 250 international units (IU) before 20 weeks’ gestation and 500 IU thereafter. For abortions undertaken after 20 weeks gestation, the volume of fetomaternal hemorrhage should be assessed. If the test indicates a fetomaternal hemorrhage of >4 mL, an additional 125 IU of anti-D IgG per mL should be administered[3].

Lactation suppression

Women undergoing an abortion from the second trimester onwards should be informed about the possibility that lactation may be initiated. Treatments such as the use of a support brassiere, application of ice packs to engorged breasts and simple analgesia may be effective, but some women will experience severe discomfort[5]. Dopamine agonists have been shown to suppress lactation. Carbegoline appears superior to bromocriptene as it has fewer side effects and is a once daily dosage[6]. Dopamine agonists are contraindicated in women with hypertension or pre-eclampsia. Estrogen is of unproven benefit and increases the risk of thromboembolism. A recent Cochrane review found that there is weak evidence that pharmacologic treatments are better than no treatment in the 1st week and no evidence that nonpharmacologic approaches are more effective than no treatment[7].

Fertility and contraception

Information about fertility and contraception should be offered to women. Ovulation may occur as early as 2 weeks after an abortion so they should be advised about the possibility they could conceive before their next period[8].

Contraceptive supplies should be provided if required. Intrauterine contraceptives can be inserted immediately following medical and surgical abortion at all gestations. A systematic review of the literature concluded that the provision of combined oral contraceptives immediately following surgical or medical abortion was safe[9]. Use of the combined oral contraceptive pill does not affect either duration or amount of vaginal bleeding or the complete abortion rate.

The World Health Organization recommends that progestogen-only contraceptive pills, implants and injectables can all be started immediately following induced abortion; if started on the day of the abortion, contraceptive protection is immediate[10].

Psychologic sequelae

A woman or couple’s emotional needs should be addressed immediately following an abortion for fetal abnormality.

Staff caring for women undergoing medical abortion for fetal abnormality must be sensitive to the fact that some women or couples may express a wish to see or hold the fetus. They should be made aware of the possible appearance of the fetus with respect to the gestational age and any structural abnormalities. They may wish to have mementoes, such as hand and footprints and photographs, and if not, staff should offer to store them securely in the case records for future access. Keeping such mementoes has not been associated with adverse outcomes and qualitative studies have shown that many couples value them highly[11].

Induced abortion for fetal abnormality can have significant psychologic consequences. In a longitudinal study, 4 months after abortion, 46% of 147 women showed pathologic levels of post-traumatic stress symptoms, decreasing to 20% after 16 months. Depression scores were 28% and 13% at 4 and 16 months, respectively. The most important predictor of persistent impaired psychologic outcome was outcome at 4 months; other predictors were low self-efficacy, high levels of doubt during decision making, lack of partner support, being religious and advanced gestational age. Strong feelings of regret for the decision were mentioned by only 2.7% of women[12].

It is also associated with long-lasting consequences for a substantial number of women. A cross-sectional study of 254 women, 2–7 years after induced abortion for fetal abnormality under 24 weeks of gestation, showed that women generally adapted well to grief. However, a substantial number of the participants (17.3%) had high scores for post-traumatic stress. Women who experienced little support from their partners and were low educated had the most unfavorable psychologic outcome. Advanced gestational age at the time of abortion was associated with higher levels of grief, and post-traumatic stress symptoms and long-term psychologic morbidity were rare with abortions before 14 weeks of gestation[13].

Women’s emotional and psychologic needs must therefore be addressed both immediately after the abortion and in the longer term. Referral should be available to any woman who may require additional support, including the possibility of self-referral.

There should also be an awareness that partners may experience adverse psychologic sequelae, such as extreme grief reactions and post-traumatic stress disorder[11].

Sensitive disposal of fetal tissue

All fetal tissue under 24 weeks of gestation, whether resulting from miscarriage or induced abortion, must be treated with dignity and respect[14]. Local policies should reflect the Human Tissue Authorities Code of Practice 5, “Disposal of human tissue for fetuses born dead at or before 24 weeks of gestation”[15]. Whilst fetal tissue from a pregnancy under 24 weeks may be incinerated, by the year 2000 this practice was felt to be unacceptable by health professionals working within this area[14]. Most UK National Health Service hospital trusts therefore developed policies and practices for the sensitive disposal of fetal tissue under 24 weeks of gestation[16].

A woman or couple should be informed about the options for disposal. This information must be freely available, taking into account any particular needs of the woman or couple, such as literacy skills and language. Verbal and written information should be provided by trained health professionals. The information should specify who a woman or couple should contact if they would like to request a particular option and in what timescale[17]. Many hospitals have specific staff, such as bereavement support officers, to fulfill this role.

Staff should be sensitive to the values and beliefs of a wide range of cultures and religions, particularly those of their local community. However, they should be aware that each decision is one for the individual concerned. A hospital should ensure that the necessary training and support is given so that staff are equipped to identify and meet the widest possible range of needs and wishes[14].

Some women or couples may not wish to receive information about, or take part in, the disposal of the fetal tissue. Provided that they have been made aware that the information is available, these wishes should be respected. It should be clearly documented in the woman’s medical notes whether information has been requested or not and, if so, whether it has been given[17].

It is acknowledged that sometimes parents do not recognize their loss at the time, but may return months or even years later to enquire about disposal arrangements. It is therefore important that there is a well-documented audit trail to provide those details if needed at a later date[14]. Confidentiality must be ensured and it should not be possible to identify any individual from the information held by a crematorium or place of burial.

The hospital is responsible for the disposal of fetal remains. Both burial and cremation should be available to allow for cultural and religious differences. Hospital disposal usually involves communal cremation and burial. The hospital provides funding and makes the arrangements. The woman or couple should be informed and involved as appropriate and they and their family can choose whether to attend or not. In Scotland, there is an issue of whether multiple cremation and burial is allowed. Local policies may preclude it and if problems are encountered, advice can be sought from the Institute of Cemetery and Crematorium Management [14].

The woman or couple should be made aware that they can arrange a private burial or cremation themselves if they wish but that they may have to incur some or all of the costs. The UK Royal College of Nursing guidance for nurses and midwives on Sensitive Disposal of All Fetal Remains (2007) looks at the options[14]. The hospital should facilitate the arrangements and provide the necessary documentation. The woman or couple may wish to involve members of their religious community. There is no legal prohibition to burial outside a cemetery but certain requirements must be met. For instance, it must not cause a danger to the public, risk contamination of water supplies and must be buried to a depth of at least 45 cm.

Many hospitals provide a book of remembrance that is kept in a significant place, usually the hospital chapel. Parents should be informed of this and be aware that they can arrange for an entry to be placed in the book at any time. It is becoming commonplace to offer a regular service of remembrance to which couples are invited to attend. The format of this service should reflect the cultural, spiritual and diverse needs of the community the hospital serves.

Some units have developed a checklist to ensure that all the necessary information has been discussed. Timing is important in discussing issues about disposal arrangements. Guidance should be taken from experienced staff as to the most appropriate time. Many hospitals are looking at the issue of consent for disposal; some are including it on the consent form for the procedure or on a consent form for histologic examination[14].