Termination of pregnancy

Question 1

What are the criteria to allow for termination?

Answer 1

1. Risk to mother’s life if pregnancy continues
2. Termination is necessary to prevent permanent grave injury to physical or mental health of the women
3. Continuance risks injury to physical/mental health of the women greater than if terminated (and fetus < 24 weeks)
4. Continuance risks injury to the physical/mental health of existing children of the women greater than if terminated (and fetus < 24 weeks)
5. There is substantial risk that if the child were born he/she would suffer such physical or mental abnormalities as to be seriously handicapped

Question 2

What are the time limits for each cause?

Answer 2

1,2,5 - no limit

3,4 - fetus 24 weeks

Question 3

What should be done before TOP?

Answer 3

Written and verbal counselling and support
US to confirm gestation and identify non-viable and ectopic pregnancy
Screen for chlamydia ± other STIs
Antibiotic prophylaxis to prevent pos-op infection - e.g. metronidazole 1g PR
Discuss contraception (IUCD)
If RhD-ve she needs anti-D

Bloods for Hb, ABO, RhD and antibodies ± hepatitis B/C, HIV and haemoglobinopathies

Question 4

How is medical termination carried out?

Answer 4

Antiprogestagens e.g. mifepristone to prime the cervix

Followed by prostaglandin e.e misoprostol (oral or vaginal)

Question 5

When can medical management be used?

Answer 5

Highly effective from 6+ weels

Also used for 2nd trimester terminations

Question 6

What should you do post TOP?

Answer 6

Give NSAID pain relief, narcotic analgesia

Arrange follow up 2 weeks after procedure if early TOP

Question 7

What are the methods of surgical management of TOP

Answer 7

Vacuum aspiration
Dilatation and Evacuation

Cervical dilatation to reduce difficulty with:
Misoprostol which can be used up to 18 weeks

Question 8

Describe vacuum aspiration. When is it used?

Answer 8

7-14 weeks
Local anaesthesia or GA
If < 7 weeks check for gestational sac aspirate, follow up with beta-hCG if nor seen
Access to US is desirable

Question 9

Describe dilatation and evacuation

Answer 9

Misoprostol for cervical dilatation
Surgical forceps may be used at 13+0 to 24+0 weeks
Real time US reduces uterine perforation rates

Question 10

How are early medical terminations carried out?

Answer 10

Mifepristone + misoprostol 24-38h later

If not successful give further misoprostol

Question 11

How are medical terminations at 9-13 weeks carried out?

Answer 11

Mifeprisonte PO + misoprostol vaginally 36-48h later

Max 4 further doses of misoprostol

Question 12

How are medical terminations 13-24 weeks carried out?

Answer 12

Mifepristone followed 36-48h later by misoprostol

Mifepristone can be repeated

Question 13

What feticide can be used and when?

Answer 13

21+6 weeks
3ml intracardiac 15% potassium chloride
Confirm systole with US

If born after 24 weeks, dead fetus is stillbirth and requires registering
If signs of life, death certification is required

Question 14

What are complications of TOP?

Answer 14

Failed tOP
Infection
HAemorrhage
Uterine perforation
Uterine rupture
Cervical trauma
Retained products of conception

Question 15

What should you consider after TOP?

Answer 15

Anti D if RhD-ve
Contraception arranged?
Letter with sufficient information for practitioners elsewhere to manage complication
Written an verbal information of symptoms
Offer follow-up
Emotional support
Misoprostol risks teratogenicity