Abortion care — structured SAQ (15 marks)

(a) Counselling and pre-abortion assessment (4 marks)

One mark per point, maximum four. ^[1][6]

• Counsel the options: medical versus surgical, with the alternative of continuing the pregnancy and ongoing antenatal care, and adoption; give real numbers (medical failure roughly 4 to 8 percent; surgical completion over 99 percent); describe the bleeding, pain and follow-up timeline and the warning signs that mean return (soaking bleeding, severe pain, fever, fainting).^[1]
• Structured history: last menstrual period and gestational estimate, prior caesarean or uterine surgery, allergies, anaemia, bleeding disorders, and contraception intentions.^[1]
• Screen privately for reproductive coercion and intimate partner violence — red flags are a partner dominating the consult, patient discomfort, disruption in contraception use; use telehealth and discreet signals, plan covert care where safety demands.^[6]
• Confirm gestational age (dates plus ultrasound where uncertain); note that routine haemoglobin and Rh D testing are not required before abortion up to 10 weeks, and that an asymptomatic woman with a confident gestational age does not need a confirmatory ultrasound (VEMA non-inferiority).^[1][2]

(b) The MS-2 Step regimen and gestational limits (4 marks)

One mark each for regimen, dose/route, interval, and the limits. ^[1]

• Regimen: mifepristone 200 mg orally, then misoprostol 800 micrograms (four 200 microgram tablets) — the MS-2 Step pack (Linepharma mifepristone plus GyMiso misoprostol).^[1]
• Route: buccal is the only approved route for misoprostol in Australia; sublingual and vaginal are alternatives in New Zealand.^[1]
• Interval: misoprostol is taken 24 to 48 hours after the mifepristone.^[1]
• Limits: licensed to 9 weeks (63 days) in Australia per TGA authorisation; used to 10 weeks (70 days) in Aotearoa New Zealand under jurisdictional protocols, with misoprostol off-label beyond 63 days.^[1]

(c) Analgesia and antibiotic plan (4 marks)

Two marks analgesia, two marks antibiotic, with method separation. ^[1][4]

• Medical abortion analgesia: ibuprofen with an antiemetic 30 minutes before misoprostol is the first-line backbone; NSAIDs are first line, opioids as needed.^[1]
• Surgical abortion analgesia: a multimodal bundle — buffered lidocaine paracervical block plus a preoperative NSAID (ibuprofen 600 mg lowers pain scores), with conscious or deep sedation or general anaesthesia for selected patients. Oral opioids do not reduce procedural pain.^[4][1]
• Antibiotic — surgical: antibiotic prophylaxis for every woman having a surgical abortion, regimen per local protocol.^[1][3]
• Antibiotic — medical: do not routinely give antibiotic prophylaxis for medical abortion up to 14 weeks (severe infection under 1 percent; over-use drives resistance); test-and-treat gonorrhoea and chlamydia on suspicion and screen those under 25.^[1][3]

(d) Anti-D decision and counterpoint (3 marks)

One mark for the decision, one for the gestational reasoning, one for the counterpoint. ^[1][5]

• At 7 weeks 4 days (under 10 weeks) in an Rh D-negative woman, routine anti-D is not required before the abortion, and routine Rh D testing is not required before 10 weeks for either medical or surgical abortion.^[1]
• Anti-D becomes recommended for abortion at 10 weeks or more in Rh D-negative women; below that there is no comparative evidence that it prevents sensitisation.^[1][5]
• Counterpoint she should be aware of: guidelines from 2022 onwards, including the World Health Organization, now recommend against anti-D for first-trimester abortion entirely — a position examiners may probe and that local ANZ practice is moving toward.^[5]