Termination Of Pregnancy

Question 1

What is a termination of pregnancy (TOP)?

Answer 1

A termination of pregnancy (TOP), or abortion, involves an elective procedure to end a pregnancy.

Question 2

Briefly describe the legal requirements for an abortion

Answer 2

The legal framework for a termination of pregnancy is the 1967 Abortion Act. The 1990 Human Fertilisation and Embryology Act altered and expanded the criteria for an abortion, and reduced the latest gestational age where an abortion is legal from 28 weeks to 24 weeks.

The legal requirements for an abortion are:

• Two registered medical practitioners must sign to agree abortion is indicated
• It must be carried out by a registered medical practitioner in an NHS hospital or approved premise

Question 3

What criteria must be met for an abortion occuring before 24 weeks?

Answer 3

There are specific criteria required to justify the decision to proceed with an abortion. The following is a simplified version of the criteria. An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of:

• The woman
• Existing children of the family

The threshold for when the risk of continuing the pregnancy outweighs the risk of terminating the pregnancy is a matter of clinical judgement and opinion of the medical practitioners.

Question 4

What criteria must be met for an abortion to occur at any point of the pregnancy?

Answer 4

An abortion can be performed at any time during the pregnancy if:

• Continuing the pregnancy is likely to risk the life of the woman
• Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
• There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped

Question 5

Briefly describe the pre-abortion care following an abortion

Answer 5

Abortion services can be accessed by self-referral or by GP, GUM or family planning clinic referral. Doctors who object to abortions should pass on to another doctor able to make the referral. Many abortion services are accessed by self-referral, without the involvement of a GP or other doctor to make the referral.

Marie Stopes UK is a charity that provides abortion services. They offer a remote service for women less than 10 weeks gestation, where consultations are held by telephone and medication are issued remotely to be taken at home.

Women should be offered counselling and information to help decision making from a trained practitioner. Informed consent is essential.

Question 6

Briefly describe a medical abortion

Answer 6

A medical abortion is most appropriate earlier in pregnancy, but can be used at any gestation. It involves two treatments:

• Mifepristone (anti-progestogen)
• Misoprostol (prostaglandin analogue) 1 – 2 day later
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Question 7

What is the mechanism of action of mifepristone? How does this lead to termination of pregnancy?

Answer 7

Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix.

Question 8

What is the mechanism of action of misoprostol? How does this lead to termination of pregnancy?

Answer 8

Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions. From 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion.

Question 9

When is anti-D prophylaxis required in a termination of pregnancy?

Answer 9

Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis.

Rhesus negative women having a surgical TOP should have anti-D prophylaxis. The NICE guidelines (2019) say it should be considered in women less than 10 weeks gestation.

Question 10

Briefly describe a surgical abortion

Answer 10

Surgical abortion can be performed, depending on preference and gestational age, under:

• Local anaesthetic
• Local anaesthetic plus sedation
• General anaesthetic

Prior to surgical abortion, medications are used for cervical priming. This involves softening and dilating the cervix with misoprostol, mifepristone or osmotic dilators. Osmotic dilators are devices inserted into the cervix, that gradually expand as they absorb fluid, opening the cervical canal.

There are two options for surgical abortion:

• Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)
• Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)

Question 11

Briefly describe the post-abortion care following an abortion

Answer 11

Women may experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks after the procedure. A urine pregnancy test is performed 3 weeks after the abortion to confirm it is complete. Contraception is discussed and started where appropriate. Support and counselling is offered.

Question 12

What are the complications of an abortion?

Answer 12

• Bleeding
• Pain
• Infection
• Failure of the abortion (pregnancy continues)
• Damage to the cervix, uterus or other structures