Termination of Pregnancy (TOP)

Synonym: 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.
Doctors may have strongly held personal beliefs concerning abortion. Current GMC guidance states¹:

Incidence

One third of all pregnancies are terminated worldwide. According to Department of Health statistics²:

• In 2006 193,700 abortions were performed, compared with 186,400 in 2005, a rise of 3.9%. This was equivalent to an age-standardised abortion rate of 18.3 per 1,000 resident women aged 15-44.
• The highest age-standardised abortion rate in 2006 was 35 per 1,000 women aged 19.
• The under 16 abortion rate in the same year was 3.9.
• The under 18 rate was 18.2.
• The NHS funded 87% of abortions in 2006; of these, just over half (55%) took place in the independent sector under NHS contract.
• 89% of abortions were carried out at under 13 weeks gestation; 68% were at under 10 weeks.
• Medical abortions accounted for 30% of the total compared with 24% in 2005.
• Only 1% of UK abortions conducted in 2006 were due to grounds of a risk of severe mental or physical handicap in the child.

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
• 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.³ Currently, the BMA does not favour a reduction in the gestational age limit for TOP.⁴
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% TOPs are performed after 20 weeks. This is usually following amniocentesis, or in very young girls who have concealed or not recognised the pregnancy.

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.⁵

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 can not consent to, or refuse termination).
Ideally, allow time for her to consider and bring her decision to a further consultation. However, remember that the 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% post-op salpingitis if untreated)
• Discuss future contraceptive needs (start pill next day or insert IUD)
• Check Rhesus status, if negative needs anti-D
• Offer follow-up, may be problems around time she would otherwise have delivered.

• All women should have access to a clinical assessment
• There should be arrangements to minimise delay, eg 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 women should wait longer than 3 weeks from initial referral to time of her abortion.

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

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 US 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

The most common complications are:

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

Uncommon complications are:

• Haemorrhage - 1.5/1000
• Perforation of uterus - 1-4/1000
• Failed termination - 2.3/1000 surgical, 6.0/1000 medical

No clear evidence to link abortion and breast cancer or subsequent infertility or pre-term delivery.
Neonatal death occurring after TOP. Very rare but does occur and can usually be attributed to deficiencies in clinical practice.⁹

Psychological effects

Only 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.

Ideally services should offer a choice of methods for the relevant gestational age.
Antibiotic prophylaxis⁶ and/or infection screening with treatment using metronidazole 1g rectally at 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.

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 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 preferable alternative using mifepristone 600 mg orally followed 36-48 hours later by gemeprost 1 mg vaginally every 3 hours to max 5 pessaries.

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 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 follow-up appointment within 2 weeks and further counselling for small number of women who experience long-term distress.