Counselling and procedure choice may well dominate the pre-assessment consultation, but it does provide an opportunity to screen for any pre-existing conditions that may require cross-specialty liaison and, despite the sensitivities of abortion, it is unusual for a woman to withhold her permission for such cross-consultation. It should be noted that for serious medical conditions, the risks of abortion are always lower than the risks of continued pregnancy. This visit also provides an opportunity for enquiry about previous use of contraception and discussion about intended use of contraception in an integrated manner.
Body mass index and blood pressure are checked at pre-assessment for all patients, and physical examination would be limited to auscultation of chest and heart for patients opting for general-anaesthetic surgical termination. An idea of gestational age will have been gained from the menstrual history, but given the inaccuracies of menstrual recall and limitations of bimanual pelvic examination, gestation is more accurately determined by ultrasound scan, either abdominal or vaginal, as relevant to the anticipated gestation. Viability and pregnancy location are also confirmed. This scan is undertaken in a sensitive setting and manner and the patient is advised that it is not necessary for her to watch the ultrasound examination in progress.
A full blood count can be useful to screen for anaemia and also acts as a baseline for comparison in the event of any substantial blood loss associated with the termination. This is also a useful opportunity to confirm immunity to rubella and to offer subsequent immunization if not immune. All patients have blood sent for confirmation of ABO and rhesus status with antibody screening. All unsensitized rhesus-negative women should be given anti-D immunoglobulin. Some centres offer testing for human immunodeficiency virus and hepatitis B and C at this time, but unless a policy for routine screening has been adopted and accepted, additional counselling would be required; in the meantime, such testing remains on a selective basis. Although not essential to abortion care, it is also an opportunity to check that cervical screening is up to date, and if it is not, opportunistic screening can be offered, ensuring that the result can be communicated to the women and appropriate action taken on any abnormal results.
Screening for genital tract infection helps to identify pathogens that increase the risk for post-abortion infection and pelvic inflammatory disease, as well as long-term sequelae of tubal infertility and ectopic pregnancy. The most important of these are Chlamydia trachomatis and Neisseria gonorrhoeae. A full screen, including for sexually transmitted infections (STI), allows for follow-up and partner notification and treatment to avoid re-infection. Some advocate antibiotic prophylaxis at the time of abortion, but prophylactic antibiotics alone do not allow for contact tracing and therefore leave women at risk from re-infection.
Some advocate the ‘belt-and-braces’ policy of a prophylactic regimen against chlamydia and bacterial vaginosis, along with a full STI screen. This is the approach in our own unit, where a prophylactic regimen of azithromycin 1 g orally and metronidazole 1 g rectally is offered to all women under 25 with a full screen offered to all women coming through the service.