Termination of pregnancy

Question 1

Definition

Answer 1

AKA Abortion = removal of the products of conception from the uterus.

Question 2

Legal requirements

Answer 2

• Defined in the 1967 Abortion act - altered in the 1990 Human Fertilisation and Embryology Act
  = Gestation before 24 weeks: Continuing the pregnancy poses greater risk to the physical or mental health of the women or existing children in the family than TOP
  = Gestation at any time:
  1. Risk to the life of the women
  2. Risk of “grave permanent injury” to the physical or mental health of the women
  3. Substantial risk of serious handicap to the children due to physical or mental abnormalities

Question 3

How is a TOP approved?

Answer 3

Must be agreed by two registered medical practitioners and undertaken in the NHS hospital or approved premise by a registered medical practitioner

Question 4

Diagnosis

Answer 4

TOP can be accessed by self-referral, GP or GUM clinic.
Doctors who conscientiously object to TOP should ensure a woman has access to services through another doctor or self-referral.
FIRST LINE:
- Pregnancy test: urinary or serum beta-hCG
- USS: to confirm the location of and to date the pregnancy.

Question 5

Medical Treatment

Answer 5

Oral Mifepristone: an anti-progesterone medication given first. This stops the pregnancy and relaxes the cervix
Vaginal Misoprostol:
- This is given 24-28 hours after mifepristone
- It is a prostoglandin analogue
- It causes uterine contractions to expel the products of conception and softening of the cervix
- This regimen is used for medical abortions up to 10 weeks of gestation
- From 10 weeks onwards additional misoprostol doses are given until complete expulsion.
Anti-D prophylaxis: given in rhesus negative women having a medical TOP from 10 weeks gestation onwards.

Question 6

Surgical treatment

Answer 6

Cervical priming: cervix softened and dilated prior to surgical TOP:
= misoprostol
= mifepristone
= osmotic dilators
Vacuum aspiration: performed under local or general, usually up to 12-14 weeks of gestation, pregnancy removed via suction
Dilation and curettage: used between 14-24 weeks gestation
Anti-D prophylaxis: given in rhesus -ve women having a surgical TOP from 10 weeks gestation onwards, considered in those less than 10 weeks

Question 7

Confirmation

Answer 7

A urine pregnancy test should be performed at 3 weeks to confirm complete TOP

Question 8

Complications

Answer 8

• Physical complications:
  = Pain, heavy bleeding, infection and incomplete abortion. Recovery is typically within days to weeks
  = May also be damage to the cervix or uterus
• Emotional or psychological challenges to a woman. Support and counselling should be offered.
• All women should be given contraceptive advice.