Supporting patients with unplanned pregnancy

Unplanned pregnancy is common, with an estimated one third of women in Australia having an unexpected or unintended pregnancy at some point in their lifetime. Since the general practitioner is often the first place a woman turns to after finding out they are pregnant, it’s important to remain open-minded and non-judgemental when faced with this scenario.

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A confirmatory pregnancy test should be performed in the clinic as a first-line investigation. Over-the-counter pregnancy tests can provide inaccurate results, or the results may be interpreted incorrectly. It is important to remember that not all unplanned pregnancies are unwanted pregnancies.

It is then important to counsel women on their options, continuing the pregnancy or opting for termination. In either scenario, it is prudent to ascertain the gestation of the pregnancy. This can be calculated from the last menstrual period (LMP), provided the woman has a regular cycle and is not taking hormonal contraception.

A confirmatory ultrasound scan is usually performed to ascertain the location of the pregnancy, intrauterine or otherwise.

If termination of pregnancy is the preferred option, correct and non-judgemental advice should be given. In Australia, medical abortions can typically be performed up to nine weeks of pregnancy and can be initiated by the general practitioner where appropriate. Medical abortion packs, e.g., “MS-2 Step”, are available, which contain the required medications. Medical abortion in Australia involves the combination of mifepristone and misoprostol. Mifepristone is usually administered as an oral dose of 1 × 200 mg and acts as a progesterone receptor antagonist, inhibiting the progression of the pregnancy. Misoprostol is administered 24–48 hours later and is usually inserted into the vagina. This prostaglandin analogue induces contractions and leads to the expulsion of the pregnancy.

If the gestation is greater than nine weeks, prompt referral to secondary care for surgical termination of pregnancy is warranted. The legal limits for termination of pregnancy differ according to state, so it is important to understand the relevant regulations.

Following termination of pregnancy, the general practitioner plays a key role in the post-pregnancy period and the prevention of further unplanned pregnancies. Appropriate counselling about contraception, particularly long-acting reversible contraception, should take place. Many forms of contraception can be started immediately following termination of pregnancy. Some women may require counselling and emotional support following termination of pregnancy.

If the woman plans to continue with an unplanned pregnancy, it’s important to ascertain her knowledge regarding pregnancy and provide good education. Pregnancy is an ideal opportunity to discuss and explore lifestyle factors such as diet, smoking, alcohol intake and drug use. It is crucial to discuss these factors with specific reference to the effects on the pregnancy and to be able to signpost to support services where appropriate.

In addition, it is prudent to ensure women are aware of recommended vitamins – folic acid and vitamin D ­– and to discuss routine vaccinations such as seasonal influenza. It is also important to organise regular antenatal tests such as height, weight, urinalysis, blood pressure, and testing for sexually transmitted infections regardless of the gestation of the pregnancy.

In conclusion, managing unplanned pregnancies is a common scenario for general practitioners, and it should be approached with compassion and impartiality.

- Dr Samantha Miller, MBChB

References

1. Australian and New Zealand Journal of Public Health (2016). Prevalence and distribution of unintended pregnancy: the Understanding Fertility Management in Australia National Survey. https://pubmed.ncbi.nlm.nih.gov/26456762/
2. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (2019). Antenatal Care during Pregnancy. https://ranzcog.edu.au/womens-health/patient-information-resources/antenatal-care-during-pregnancy
3. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (2019). Routine Antenatal Care in the Absence of Pregnancy Complications. https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Routine-antenatal-assessment-in-the-absence-of-pregnancy-complications-(C-Obs-3b)_2.pdf?ext=.pdf
4. National Institute for Health and Care Excellence (2016). Antenatal care for uncomplicated pregnancies. https://www.nice.org.uk/guidance/cg62/resources/antenatal-care-for-uncomplicated-pregnancies-pdf-975564597445
5. The Australian Government Department of Health (2020). Clinical Practice Guidelines: Pregnancy Care. https://www.health.gov.au/resources/pregnancy-care-guidelines
6. The Australian Government Department of Health (2022). Abortion Procedures – Medication. https://www.betterhealth.vic.gov.au/health/healthyliving/abortion-procedures-medication