Hypertension

• Mild to moderate hypertension is not a contraindication; referral for treatment may be required as needed.
• Symptomatic and/or severe hypertension (>160/110 mm/Hg) should be treated prior to procedure or referred for additional management
• Ergometrine should be avoided for patients with hypertension

Seizure disorder

• Anti-seizure medicines should be taken as prescribed on day of early surgical abortion and resumed as usual following procedure
• There is no contraindication to receiving procedural benzodiazepines or opiates
• Uncontrolled seizure disorder or seizure in last two weeks is a contraindication to out of hospital (community) abortion
• Some anti-seizure medicine interact with hormonal contraception; options should be reviewed for medical eligibility

Anaemias

• If recent history or symptoms, check pre-procedure haemoglobin. If < 100 g/L, refer to hospital setting or be prepared to manage bleeding appropriately.

Blood-clotting disorders

• For active clotting disorders, early surgical abortion can be performed in outpatient setting with appropriate preparation (i.e. IV access, available uterotonics)
• Anticoagulation medicines can be continued with relatively low risk of additional blood loss up to 12 weeks

Insulin-dependent disorders

• No changes in diet or medicines are recommended for early surgical abortion, but consider scheduling the procedure for early in the day
• Low glucose levels require dextrose or food prior to procedure
• High glucose levels are not a contraindication, but levels ≥ 15 mmol/L warrant evaluation for diabetic ketoacidosis; this requires treatment or referral prior to procedure

Heart disease

• If symptomatic underlying heart disease, or severe disease, early surgical abortion may be performed in operating room with monitoring by an anaesthetist

Asthma

• Patients with mild asthma may have a routine early surgical abortion. Advise taking routine asthma medicines before the procedure and bringing these medicines along to the clinic.
• Patients with acute or poorly controlled asthma may need to delay abortion care until better controlled
• Misoprostol is safe for use in patients with asthma

Active respiratory infection

• Consider delaying the procedure. If unable, consider personal protective equipment (PPE) for both the patient and staff.
• In the context of COVID-19 community transmission, recommend PPE that assumes infection if status is unknown

Cervical stenosis

• Consider use of an Os finder, or perform early surgical abortion under ultrasound guidance
• A cervical preparation agent such as misoprostol or mifepristone may be helpful
• Medical abortion may be offered

Uterine fibroids

• Fibroids may inhibit ability to complete early surgical abortion depending on size and location in relation to pregnancy. Ultrasound guidance may be a helpful adjunct.
• Consider referral to a hospital care with an experienced provider
• Medical abortion may be considered as an alternative

Previous caesarean delivery

• Patient may be at increased risk of haemorrhage. Ensure uterotonic medicines are readily accessible. Consider performing with ultrasound guidance.
• Additional rare risk of uterine scar pregnancy if multiple previous caesarean deliveries; consider ultrasound and/or referral to hospital with experienced provider

Alcohol or substance use disorders

• Alcohol use disorder – may need larger benzodiazepine doses due to tolerance
• Opiate use disorder – may need larger opiate doses due to tolerance