Termination of Pregnancy

Question 1

What are the conditions under which a termination of pregnancy is legal? (5)

Answer 1

A- Death
B. Permanent injury
C. Likely future injury
D. wellbeing of dependents
E. Disability

A. Continuance of pregnancy carries a risk to the life of the pregnant women greater than that of the termination.

B. Termination is necessary to prevent grave permanent injury to physical or mental health of the pregnant women.

C. Pregnancy has not exceeded 24 weeks and continuance of the pregnancy would involve risk of injury to physical or mental health of pregnant women greater than the risk of termination. (Patient’s physical/mental health)

D. Pregnancy has not exceeded 24 weeks and continuance of the pregnancy would involve risk of injury to physical or mental health of the children or family of the pregnant women greater than the risk of termination. (Patient’s families physical/mental health)

E. There is substantial risk that if the child were born it would be seriously handicapped either physically or mentally

Question 2

How should you manage any women that is considering TOP, including investigations?

Answer 2

Initial support:
Should be given information re options.

Blood tests:

• Hb
• Group & save and antibodies
• If indicated HIV, HBV, HCV, haemaglobinopathies

USS:
Good practice as gives good indicator of gestation and identifies already non viable pregnancies and ectopics

Prevention of infection:
Screening for lower genital tract infections

Prophylaxis:
Metronidazole at time of TOP + doxycycline for 7 days

Anti D:
For all Rh-ve women within 72hrs of TOP

Question 3

What should be offered after a TOP?

Answer 3

Written patient information about what to expect.

Offer of psychological counselling

Follow up appointment at 2 weeks

Discussion regarding contraception

Question 4

What are the different surgical options of TOP and at what stage are they appropriate?

Answer 4

7-13 weeks
Conventional suction termination. Under local or general anaesthetic.

Greater than 13 weeks
Dilation and evacuation:

Misoprostol (prostoglandin analogue) is used to help dilate the cervix as well as osmotic dilatation sticks.

Under a GA a speculum is inserted to visualise the dilated cervix the pregnancy is then removed during forceps. Suction is then used to complete the evacuation.

Question 5

What are the different medical options for TOP?

Answer 5

Less than 9 weeks
Mifepristone 200mg plus a prostaglandin misoprostol/gemeprost

Can do medical TOP upto 10 weeks at home and 14 weeks in clinic
but increased incomplete procedure rates form 9 weeks onwards

Question 6

What are the contraindications to medical TOP?

Answer 6

HTN
DM
High cholesterol
Bleeding/anticoagulation disorders
Oral steroids

Breast feeding

Question 7

What are the potential complications of TOP?

Answer 7

Failure
Retained products of pregnancy

Haemorrhage
Uterine perforation (surgical)
Cervical trauma
Uterine rupture (medical mid trimester)

Genital tract infection
Medication s/e: N&V + diahorrea

Short term depression
Long term regret