Termination of Pregnancy (TOP)
185,000 TOPs are carried out per annum in England and Wales, with 12,500 a year in Scotland. The highest rate of termination of pregnancy is among women 18-24 years old.
60% terminations are before 9 weeks, 13% carried out in second trimester.
The Abortion Act 1967 (1991)
This act states that termination of pregnancy may be carried out if:
- the continuance of the pregnancy would involve risk to the life of the pregnant woman
- the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
- the pregnancy has not exceeded its 24th week and continuing the pregnancy would involve risk of injury to the physical or mental health of the pregnant woman
- the pregnancy has not exceeded its 24th week and continuing it would involve risk of injury to the physical or mental health of the existing child(ren) of the family of the pregnant women
- there is a substantial risk that if the child were born it would suffer from such phsical or mental abnormalities as to be seriously handicapped.
95% of terminations of pregnancy are carried out under clause C ((3) above). Two doctors are required to agree that the pregnancy should be terminated.
Counselling before termination
Counselling process can help to identify women who will have coping problems and distress and can help identify what went wrong and led to the pregnancy.
Timely referral to a social worker should be available.
- Blood tests: Hb, ABO and Rh blood grouping. Rh –ve women need anti-D injection after the abortion. HIV, haemoglobinopathy and other tests can be performed as indicated.
- Estimation of gestation: performed by either clinical examination or ultrasound.
- Prevention of infection: infection can occur in about 10% of women after abortion, reduced with use of antibiotics. Some clinics give everyone prophylactic metronidazole and azithromycin.
- Cervical cytology required if a woman is due a smear.
- Provision of information: types available, risks and complications, who to contact if there are any problems.
Methods of termination
- Medical abortion – if less than 12 weeks, give mifepristone (blocks action of progesterone), allow woman home, returns in 48 hours, admitted for prostaglandin pv. Bleeding starts within a few hours and usually continues for 10 days. Mid-trimester medical abortion (13-24 weeks) requires mifepristone + multiple misopristol doses +/- feticide intervention if >22w.
- Early surgical abortion – below 7 weeks, use a narrow suction curette of 4-5mm, inserted into uterus under local paracervical block. 50ml syringe used to aspirate the pregnancy.
- Surgical abortion between 7-14 weeks use suction or vacuum aspiration – flexible suction curette and a mechanical/electrical pump. Curette inserted into uterus after cervical dilatation and contents are aspirated. Usually under general anaesthesia. Misoprostol 400ug vaginally is often given 3 hours before surgery. Complications increase with increased gestation – some doctors do not offer surgical termination after 12 weeks.
- Late surgical abortion (15-24 weeks) – cervical prep followed by dilatation and evacuation (D&E). Offered by limited amount of doctors in the UK. May be necessary to dilate cervix up to 20mm. Advantage is that women are unaware of procedure – however many medical personnel find the process disturbing.
- Retained products of conception (5%) more common after medical abortion.
- Failure of abortion 2.3/1000 in surgical abortion and 1-14/1000 women having medical termination, therefore it is critical to advise women of importance of follow-up.
- Post-abortion infection: pelvic infection can occur in up to 10% after termination – halved with pre-abortion STI screening and prophylactic antibiotics.
- Haemorrhage – 1/1000 cases of significant bleeding at time of termination.
- Trauma to genital tract – perforated uterus 1/1000, cervical trauma 1/100, small risk of uterine rupture.
- Future fertility – may be a slight increase in subsequent miscarriage and preterm delivery with later abortion
- Psychological sequelae – no evidence of lasting psychological harm to women undergoing abortion.