|| POST ABORTION TRAUMA HEALING SERVICE
Breaking the silence - information, hope and healing after abortion
Newsletter Excerpts 2017
Changing Laws and Health Issues Around Abortion
The debate around changing the law risks confounding health perspectives.
Traditionally legalising abortion in most countries has centred on women’s rights agenda as part of a human rights initiative. This has effectively marginalised those impacted deleteriously by their abortion experiences.
The common view of abortion as a “right” embodies the precept of freedom to choose. However in reality, for many faced with an unplanned, unwanted or difficult pregnancy, abortion has become the solution of choice, and is not only offered but in many areas promoted as the best option or the only viable alternative, often at the expense of other alternatives being equally supported. In some situations women are pressured and co-erced to their detriment which can create more negative reactions afterwards. The layers of politico-legal and politico-medical considerations, potentially shroud the often deeper concerns and impacts for people after an abortion or termination experience.
The view that abortion is generally innocuous is a misnomer. Unlike other medical/surgical procedures such as appendectomy or tonsillectomy, abortion is a deeply human relational experience. The commonly taouted belief that abortion promotes wellbeing as it gets rid of the problem and allows a person to resume life, precludes the lived experience of numbers of women, men and family afterwards for whom abortion has been a turning point in their lives, has had unanticipated consequences and unwelcome effects on wellbeing and function.
Any pregnancy-baby loss has the potential for grief and trauma. This applies equally, or often more so, to abortion, which is an artificially- induced termination of a pregnancy. The context and complexity surrounding situations and decision making for those availing themselves of the procedure to end a pregnancy, can be difficult and stressful, and emotions can be intense, tumultuous and confusing. When a pregnancy is unplanned, unwanted or difficult, it can send a person into crisis mode, and decision-making becomes fraught. Thinking may be distorted, the ability to process both long and short term consequences is usually compromised, and the space to explore the ins and outs of what is happening, and to align a decision with personal values and beliefs, is often missing.
The reality of the experience and what it means for a person may only be discovered afterwards. Some adjust well from this life event and it has no obvious impact. However, the effect of utilising coping strategies, such as avoidance or rationalisation, to help hold the experience safely can alter a person all the same. There may be flow on effects on the person, their life and relationships, which even the person themselves may not recognise or acknowledge. Often in counselling women and men after abortion, the true effects only become apparent through the unpacking of the experience, attending to the emotions, and addressing conflicts and relational aspects in more depth.
For some women, and men, especially where there was ambivalence, or the decision was a pressured pragmatic response to the situation, or they had ad have inadequate internal and external supports and resources, this can be a significant event, sometimes life-altering.
Symptoms of depression and anxiety are hallmarks of negative abortion/termination reactions. It seems that depression and anxiety is becoming more prevalent in wider society, but being done to identify if there are possible correlates with depression and anxiety to a recent or past abortion/termination, particularly in women.
The failure to deal with the inherent grief associated with the experience, or the possible trauma incurred can mean feelings become suppressed and trauma material internalised, which can affect the person’s wellbeing and functioning, physically, mentally, emotionally, spiritually, relationally and socially. Avoidance of pain is a normal human response to challenging situations and psychological defences are used to keep painful memories at bay. This does not discount impacts from the experience, rather acknowledges the strategies employed to “maintain control” and endeavour to continue to function. Whether that functioning is at an optimum and whether the person is wholly healthy, or not, is another question.
The reality is, that many women, young and old, who have availed themselves of an abortion or termination, are irrevocably changed by the experience, and can struggle afterwards in silence, secrecy and shame. The abortion is not much talked about and those affected often go unheard.
P.A.T.H.S. continues to work to support those affected negatively by their abortion / termination experiences, and to be a voice to raise awareness around post abortion issues, so that more people who are impacted can come for help, and those in the community and health circles can respond openly and sensitively to them.
- Carolina Gnad
Medical Aspects of Ectopic Loss
by Sunny Martin
This article has been written to give a brief explanation about ectopic pregnancies and the general management of them. To better inform woman of what ectopic pregnancies are and equally to inform those supporting women who have had an ectopic pregnancy in how better to support and care for them. Ectopic pregnancies are not just a potential medical emergency, it is also a significant loss of a child.
Ectopic pregnancies are said to occur in 1% of all pregnancies in the developed world. The word ectopic comes from the Greek word meaning ‘out of place’. An ectopic pregnancy occurs when the fetus begins to grow out side of the womb (uterus).6 95% of ectopic pregnancies occur in the fallopian tube. Unfortunately, if left undetected, these pregnancies are not viable and because the fallopian tube can rupture and can endanger the life of the mother.
Awareness of ectopic pregnancy is important for any woman of child bearing age. The symptoms may be many or very few. Most women will begin the pregnancy with the same pregnancy symptoms as any other pregnancy. She may feel nauseated or have breast tenderness or an aversion to certain foods.5 There may be other symptoms such as dark red spotting, increasing abdominal pain, shoulder tip pain, nausea or vomiting, dizziness or faintness.4 If you are aware that you are pregnant and are not sure of your symptoms, seek medical advice.
There are a number of tools used to diagnose an ectopic pregnancy. A medical history will be required for anyone presenting with lower abdominal pain or vaginal bleeding. A physical assessment will also be undertaken.1 Taking blood to measure Human Chorionic Gonadotropin (HCG), which is the hormone the body produces when pregnant, will confirm a positive pregnancy. More than one blood test may be taken over a number of days to see the pattern. In the first trimester of an intra uterine pregnancy (where the embryo has implanted in the womb) HCG usually doubles every 48 hours. The pattern of HCG levels will help with a correct diagnosis.6
A highly accurate tool used is an ultrasound to see were the pregnancy is located.7 A transvaginal ultrasound can detect as early as 5.5 weeks gestation a small sac in an intrauterine pregnancy.3 If the pregnancy has been confirmed and the ultrasound image is showing an empty uterus the pregnancy must be found and an ectopic pregnancy must be ruled out.7 Further investigation around the ovaries and fallopian tubes may show a growth and/or free pelvic fluid may also be seen and this will increase the likelihood of an ectopic pregnancy.6 An ectopic pregnancy cannot be ruled out until the pregnancy has been located. A second ultrasound may be required on another day to rule out an ectopic pregnancy if no pregnancy has been found.7
As mentioned, sometimes a gestational sac cannot be located immediately. In this situation, doctors will watch and wait. They may monitor your blood HCG levels and see if they are falling which would indicate a spontaneous end of pregnancy, insure you are stable and not at risk of internal blood loss, or if there is an absence of a foetal heart beat.8 Sometimes, the ectopic pregnancy may resolve by itself and no intervention is needed. If symptoms persist or get worse, you will need to seek medical assistance straight away.
90% of women who have an ectopic pregnancy will need some intervention.7 The management of an ectopic pregnancy can also be done in different ways. Medical management using a particular drug can be taken to dissolve the pregnancy.5 This way the fallopian tube can be saved but usually only used before 6 weeks gestation. It is an effective course of treatment but has some side effects.1
The surgical management of ectopic pregnancy may be necessary if the medical management is not the best option for the mother. A specialist will conclude which is the best course of action for the mother with the best outcome. A laparotomy or a mini laparotomy is where the surgeon makes an incision along the woman’s bikini line to obtain access to the ectopic pregnancy. This is a much more invasive procedure and recovery time is longer.7
A much less invasive alternative is a laparoscopy is where a tube is inserted into the abdomen via small cuts. The recovery time is much quicker, less blood loss, less analgesics needed, shorter hospital stay and faster recover.6
The pregnancy must be removed and this reality may come with unfamiliar emotions and even grief. A salpingostomy is where the pregnancy is removed without the fallopian tube. This is a less invasive procedure but it can increase the risk of further ectopic pregnancies. A salpingectomy is where the fallopian tube is removed with the pregnancy. Although there is risk of adhesions or internal scarring it may be necessary if a woman has uncontrolled bleeding, recurrent ectopic pregnancy in the same tube or if the tubal gestational sac is greater than 5cm in diameter.7
Around 60% of women will go on to have a viable pregnancy after an ectopic pregnancy. It is imperative that a woman who does conceive after an ectopic pregnancy has an early scan to exclude a recurrent ectopic pregnancy.1 The risk of a recurrent ectopic pregnancy is about 5-20%.6
A woman’s physical treatment and healing process may take some weeks to recover from after an ectopic pregnancy. However, it is important to be aware of the emotional and mental recovery that may take much longer. For health professionals and others who support the woman after an ectopic pregnancy, it is imperative to acknowledge the loss to the woman. The grief process is often complicated; a lot has been lost in such a short time. A couple may have only recently learnt of their pregnancy and now have to come to terms with the loss of it. There may be grief not only associated with the loss of a child but also loss of fertility and the unknown future.5
A follow up visit should be offered to all women who have experienced an ectopic pregnancy, whether they take up the offer or not. A choice of location should also be offered, her relationship with her GP may be better and more conducive to effective communication and recovery than to see an unknown specialist in the hospital where she lost her child, for instance. There are a lot of questions that may not come up whilst a woman is in hospital, but later, once reality has sunk in. Allow a woman to ask those questions in a non-judgmental way, allowing her to ask the questions even if there are no answers.9
Every woman may react very differently to her loss but must always be treated with dignity and respect. Her partner or husband may also be feeling deeply grieved by the loss also. Women who have had an ectopic pregnancy have experienced a loss of a child different from a woman who has miscarried and this distinction and understanding should be used when giving individual and appropriate support.9
Women who have endured a deep loss must be given time to emotionally and physically heal. They need to be supported and assured that it is ok and healthy to grieve. Encouraging them to talk about their grief or suggesting they write their thoughts and feelings down on paper. It is important to be aware that depression, anxiety and Post Traumatic Stress Disorder may not present immediately after the loss, but some weeks or months later.10 Woman and their partners should be given helpline numbers, brochures and web sites to be able to access support and help if she chooses to. Places to contact for support would be SANDS (Stillbirth and Neonatal Death Society) www.sands.org.nz or P.A.T.H.S. (Post Abortion Trauma Healing Service)
Women with an ectopic pregnancy undergo a traumatic experience, with the tests, the unknown, the potential treatment and surgery and further monitoring. They also experience a very real loss of a child. A woman with an ectopic pregnancy should be treated with care, respect and dignity. Her treatment should be carefully considered and fit to her symptoms and condition.
Health professionals and all those supporting the woman and her partner/husband should be aware of the physical as well as the emotional and mental impact this will have on her at the present time and further into the future.
1. National Women’s Health Clinical Guideline/Recommended Best Practise. Ectopic Pregnancy. 2012. Retrieved from, nationalwomenshealth.adhb.govt.nz
2. The New Zealand Pocket Oxford Dictionary. 2nd Edition, 1997
3. Histed, S. N., Deshmukh, M., Masamed, R., Jude, C.M., Mohammad, s., Patel, M.K. Ectopic Pregnancy: A Trainee’s Guide to Making the Right Call. RadioGraphics. 2016;36:2236-2237. Retrieved from, http://pubs.rsna.org/doi/pdf/10.1148/rg.2016160080
4. Capital and Coast District Health Board. Expectant management of an ectopic pregnancy: Patient information. 2015. Retrieved from https://www.healthpoint.co.nz/public/obstetric-and-gynaecology/capital-coast-dhb-womens-health-gynaecology/ectopic-pregnancy/
5. Hinton, C. What is an ectopic pregnancy?. 2002. Retrieved from http://www.silentgrief.com/articles/index.cgi?view_records=1&Category=Miscarriage&ID=55
6 Sivalingam, V.N., Duncan, W.C., Kirk, E., Shephard, L.A., Horne, A. W. Diagnosis and management of ectopic pregnancy. Journal of Family Planning and Reproductive Health Care. 2011;37:231-240. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3213855/
7 Murray, H., Baakdah, H., Bardell, T., Tulandi, T. Diagnosis and treatment of ectopic pregnancy. Canadian Medical Association Journal. 2005;173:905-912. Retrieved from, http://www.cmaj.ca/content/173/8/905.full
8 Canterbury District Health Board. Ectopic pregnancy: Health info Canterbury/Waitaha. 2014;59482:1-2
9 National Collaborating Centre for Women’s and Children’s Health. Ectopic pregnancy and miscarriage: Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage. 2012. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK132775/pdf/Bookshelf_NBK132775.pdf
10 Farren, J., Jalmbrant, M., Ameye, L., Joash, K., Mitchell-Jones, N., Tapp, S., Timmerman, D., Bourne, T. Post-traumatic stress, anxiety and depression following miscarriage or ectopic pregnancy: a prospective cohort study. British Medical Journal. 2016;6:eO11864. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5129128/
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