Synonyms: induced/therapeutic abortion, abortion is a widely used synonym amongst the general public

Termination of pregnancy (TOP) is a medically directed miscarriage prior to independent viability, using pharmacological or surgical means.

Epidemiology

Incidence

One fifth of all pregnancies are terminated worldwide.² In 2008, according to Department of Health statistics:³

• The total number of abortions was 195,296 - a fall of 1.6%.
• The age-standardised abortion rate was 18.2 per 1,000 resident women aged 15-44.
• The abortion rate was highest at 36 per 1,000, for women age 19.
• The under-16 abortion rate was 4.2 and the under-18 rate was 18.9 per 1,000 women.
• 91% of abortions were funded by the NHS; of these, 58% were in the independent sector under NHS contract.
• 90% of abortions were carried out at under 13 weeks' gestation; 73% were at under 10 weeks.
• Medical abortions accounted for 38% of the total.
• 1,988 abortions (1%) were under ground E, risk that the child would be born handicapped.

Legal requirements

The1967 Abortion Act allows termination before 24 weeks of gestation if it:

• reduces the risk to a woman's life, or
• reduces the risk to her physical or mental health, or
• reduces the risk to physical or mental health of her existing children, or
• if the baby is at substantial risk of being seriously mentally or physically handicapped

Most terminations are performed under the second of these criteria. There is a general debate in political and public circles currently that the upper gestational age limit ought to be reduced from 24 weeks to 22 or 20. This is due to the realisation that advances in neonatal care are improving the survival rates of some premature infants born around this time, setting up an environment of moral concern that babies that could survive are having their lives ended. 4-dimensional ultrasound also appears to show 20-week gestation fetuses displaying complex behaviours, prompting a call for a shift from viability as the main criterion, towards sentience.⁴ Currently, the British Medical Association (BMA) does not favour a reduction in the gestational age limit for termination of pregnancy (TOP).⁵

There is no upper limit on gestational time if there is:

• risk to the mother's life
• risk of grave, permanent injury to the mother's physical/mental health (allowing for reasonably foreseeable circumstances)
• substantial risk that, if the child were born, it would suffer such physical or mental abnormalities as to be seriously handicapped. Such TOPs must be conducted in an NHS hospital

<1% of TOPs are performed after 20 weeks. This is usually following amniocentesis, or in very young girls who have concealed or not recognised the pregnancy

Abortion in girls under 16 years

Form HSA1 must be signed by 2 doctors in girls under 16 years age. GMC guidelines are that girls <16 years may be able to reach an informed decision depending on their capacity to comprehend everything involved in the procedure. However, in those cases where a competent underage girl refuses termination, it may be possible for a parent or guardian to authorise termination if it is the girl's best interests - see consent to treatment. In Scotland, parental consent cannot be given if a competent girl has refused termination.
In girls <16 years deemed unable to reach an informed decision, a parent or guardian may give consent to or refuse termination. However, you may ask a court to overrule if you believe that it is not in child's best interests to consent to, or refuse, treatment.¹

Before termination

• Confirm the patient is pregnant.
• Counsel to help her reach the decision she will least regret.
• Ask her to consider the alternatives (e.g. adoption), ask about her partner (but note that the partner cannot consent to, or refuse, termination).
• Ideally, allow time for her to consider and bring her decision to a further consultation. However, remember that the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines state that 'the earlier in pregnancy an abortion is performed, the lower the risk of complications. Services should therefore offer arrangements that minimise delay'.

If she chooses termination:

• Screen for chlamydia (25% postoperative salpingitis if untreated)
• Discuss future contraceptive needs (start the pill next day or insert an intrauterine contraceptive device (IUCD)
• Check rhesus status - if negative, needs anti-D
• Offer follow-up - there may be problems around the time she would otherwise have delivered.

Royal College of Obstetricians and Gynaecologists guidelines⁶

• All women should have access to a clinical assessment
• There should be arrangements to minimise delay, e.g. direct access from referral sources other than GPs
• All women should be offered an assessment appointment within 2 weeks of referral (ideally within 5 days)
• All women should undergo an abortion within 2 weeks or the decision to proceed (ideally 7 days)
• No woman should wait longer than 3 weeks from initial referral to the time of her abortion.

Blood tests

Pre-abortion assessment should include:

• Measurement of haemoglobin level
• Determination of ABO and rhesus blood groups
• Screening for other conditions as clinically indicated, e.g. haemoglobinopathies, Hepatitis B virus, HIV
• Cervical screening

Ultrasound scanning

All services must have access to scanning, as it can be a necessary part of pre-abortion assessment, particularly where gestation is in doubt or where extrauterine pregnancy is suspected. However, ultrasound scanning is not considered to be an essential prerequisite of abortion in all cases,⁶ although there is some evidence to suggest routine transvaginal ultrasound would be beneficial⁷; where a woman may just be within the gestational age limit for a medical termination, accurate ultrasound dating may improve the range of options available.⁸When ultrasound scanning is undertaken, it should be in a setting and manner sensitive to the woman's situation. It is inappropriate for pre-abortion scanning to be undertaken in an antenatal department alongside women with wanted pregnancies.⁶

Complications of termination

The most common complications are:

• Infection: up to 10% of terminations are reduced by prophylactic antibiotics or pre-procedure screening for infection.
• Cervical trauma: 1%, lower when termination is performed early.

Uncommon complications are:

• Haemorrhage - 1.5/1,000
• Perforation of uterus - 1-4/1,000
• Failed termination - 2.3/1,000 surgical, 6/1,000 medical

There is no clear evidence to link abortion and breast cancer or subsequent infertility or preterm delivery.
Neonatal death occurring after termination of pregnancy (TOP) - very rare but does occur and can usually be attributed to deficiencies in clinical practice.⁹

Psychological effects

Only a small proportion of women experience long-term adverse psychological sequelae. Although early distress is common it is usually a continuation of the symptoms present before the abortion. There is also evidence of the negative effects on both the mother and the child where abortion has been denied.

The abortion procedure

Ideally services should offer a choice of methods for the relevant gestational age.
Antibiotic prophylaxis and/or infection screening with treatment using metronidazole 1 g rectally at the time of abortion, plus doxycycline 100 mg bd for 7 days starting post-abortion, or metronidazole 1 g rectally at the time of abortion plus azithromycin 1 g orally on the day of abortion.⁶

At under 7 weeks' gestation

• Avoid conventional suction termination.
• Medical abortion using mifepristone plus prostaglandin is appropriate, e.g. mifepristone 600 mg orally followed 36-48 hours by gemeprost 1 mg vaginally.
• This has been found to be safe, effective and with no adverse outcomes for subsequent pregnancies.¹⁰
• Early surgical abortion using rigorous published protocol may be appropriate.

At 7-15 weeks' gestation

• Medical abortion is appropriate as described above between 7 and 9 weeks.
• Conventional suction termination is appropriate at 7-15 weeks, although medical abortion may be preferable above 12 weeks.
• Local anaesthesia for suction termination may be safer than general anaesthesia.
• Cervical priming using gemeprost or mifepristone is beneficial in surgical termination and should be used routinely in women <18 years age or at gestation >10 weeks.
• Surgical evacuation of the uterus is only necessary if there is clinical evidence of incomplete abortion.

Terminations at greater than 15 weeks' gestation

• Dilatation and evacuation, preceded by preparation, is safe and effective when undertaken by expert hands.
• Medical abortion may be a preferable alternative using mifepristone 600 mg orally followed 36-48 hours later by gemeprost 1 mg vaginally every 3 hours to maximum 5 pessaries.

Aftercare

Medical

Anti-D IgG to all non-sensitised RhD-negative women.
Discuss contraception and supply if accepted.

Written

List of possible symptoms highlighting those that need urgent medical attention with a 24-hour number where it can be obtained.
Also, a letter with enough details to allow another doctor to be able to deal with any complications.
Arrange a follow-up appointment within 2 weeks and further counselling for the small number of women who experience long-term distress.

Document references

1. GMC. Personal beliefs and medical practice - guidance for doctors March 2008
2. Facts on Induced Abortion Worldwide, Guttmacher Institute (on WHO website) 2007
3. Department of Health. Abortion Statistics, England and Wales: 2008.
4. Savell K; Life and death before birth: 4D ultrasound and the shifting frontiers of the abortion debate. J Law Med. 2007 Aug;15(1):103-16. [abstract]
5. BMA. Abortion time limits. A briefing paper available on website.; May 2005
6. RCOG. The Care of Women Requesting Induced Abortion. Evidence-based Clinical Guideline Number 7; September 2004
7. Sinha P, Pradhan A, Chowdhury V; Value of routine transvaginal ultrasound scan in women requesting early termination of pregnancy. J Obstet Gynaecol. 2004 Jun;24(4):426-8. [abstract]
8. Blanchard K, Cooper D, Dickson K, et al; A comparison of women's, providers' and ultrasound assessments of pregnancy duration among termination of pregnancy clients in South Africa. BJOG. 2007 May;114(5):569-75. [abstract]
9. Vadeyar S, Johnston TA, Sidebotham M, et al; Neonatal death following termination of pregnancy. BJOG. 2005 Aug;112(8):1159-62. [abstract]
10. Virk J, Zhang J, Olsen J; Medical abortion and the risk of subsequent adverse pregnancy outcomes. N Engl J Med. 2007 Aug 16;357(7):648-53. [abstract]

Internet and further reading

• Marie Stopes International. UK Resource page for women considering abortion
• Gaufberg S; Abortion, complications. eMedicine, December 2008.
• James D, Roche NE; Therapeutic Abortion. eMedicine, November 2009.
• Department of Health. Conscious sedation in termination of pregnancy. Expert Group; September 2002

Acknowledgements