Termination of pregnancy

Claudine Domoney

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www.rcog.org.uk

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TOP in Britain
186 000 in England 99.8% in NHS
& Wales
11500 in Scotland
annually

1/3 women will

have in lifetime

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hospitals in Scotland

42% NHS hospitals

36% charitable
sector funded by
NHS
22% private

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Induced abortion
Surgical TOP

Medical TOP

7 weeks 24 weeks

Any gestation

Hysterotomy > 24
weeks

Pre 63 days
amenorrhoea
Post 63 days

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Certificate A legal
requirement

Statutory grounds for termination of pregnancy

Abortion is legal in Great Britain if two doctors decide in good faith that a particular
pregnancy is associated with factors that satisfy one or more of five grounds
specified in the Regulations of the Abortion Act14,16 and Section 37 of the Human
Fertilisation and Embryology Act 1990:15
A The continuance of the pregnancy would involve risk to the life of the
pregnant woman greater than if the pregnancy were terminated.
B The termination is necessary to prevent grave permanent injury to the
physical or mental health of the pregnant woman.
C The pregnancy has not exceeded its 24th week and the continuance of
the pregnancy would involve risk, greater than if the pregnancy were
terminated, of injury to the physical or mental health of the pregnant
woman.
D The pregnancy has not exceeded its 24th week and the continuance of
the pregnancy would involve risk, greater than if the pregnancy were terminated,
of injury to the physical or mental health of the existing child(ren) of the family of
the pregnant woman.
E There is a substantial risk that if the child were born it would suffer
from such physical or mental abnormalities as to be seriously handicapped.

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 The Regulations also permit abortion to be performed in an

emergency on the basis of the signature of the doctor performing the

procedure, which may be provided up to 24 hours after the
termination.
The emergency grounds are:
F To save the life of the pregnant woman.
G To prevent grave permanent injury to the physical or mental
health of the pregnant woman.

Most abortions are undertaken on grounds C or D: that the pregnancy

has not exceeded its 24th week and that continuance would involve
risk, greater than if the pregnancy were terminated, of injury to the
physical or mental health of the woman or of the existing children of
her family.
As an illustration, in England and Wales in 2002,
the vast majority (94%) of abortions were for Ground C
4% for D
1% A&B,
1% E

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Risks of surgical TOP

Haemorrhage
with gestation
1/1000 (0.88 <12
wks, 4>20 wks)

Cervical trauma
1/1000

Uterine perforation

Failed abortion
2/1000

Infection
Up to 10%
with screening
and prophylaxis

1-4/1000

Anaesthetic
NB use of cervical priming agents
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Psychological

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Many regimes MTOP

Mifepristone alone

Mifepristone and

Misoprostol alone

Mifepristone and

misoprostol

gemeprost

Methotrexate
Methotrexate and
misoprostol

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NB limited availability of
antiprogesterone

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Contraindications
Known allergy to misoprostol or

mifepristone or another prostaglandin

medicine in the past or any component of
the products
Chronic adrenal failure
Severe asthma not controlled by therapy
Inherited porphyria
Renal failure, hepatic failure or malnutrition
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Cautions
Patients with prosthetic heart valves or who have

had one previous episode of infective endocarditis

should receive chemoprophylaxis according to the
current UK recommendations.
Known ischaemic heart disease or other serious
cardiovascular disease, treatment for hypertension,
Significant bronchitis
Haemorrhagic disorders and anticoagulation therapy
Smokers aged over 35 years (increased risk of
cardiovascular disease)
Breastfeeding
Adrenal suppression Eg concurrent steroid therapy
may require corticosteroid
Diabetes

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Side effects with

misoprostol
Nausea 40 in 100
Vomiting 20 in 100
Diarrhoea 15 in 100
Headache 16 in 100
Dizziness 25 in 100
Flushes 25 in 100
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TOP Under 16s

Safer and less risk in this group with
MTOP
Assess Fraser competence
Ensure no abuse/ discuss with
colleagues/social services
Age of boyfriend
Contraception/safe sex advice
RGN/RN admin of meds?
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Fraser guidelines
Gillick competence
lawful for doctors to provide contraceptive advice and
treatment without parental consent providing certain
criteria are met

the young person will understand the professional's advice;

the young person cannot be persuaded to inform their parents;
the young person is likely to begin, or to continue having, sexual

intercourse with or without contraceptive treatment;

unless the young person receives contraceptive treatment, their
physical or mental health, or both, are likely to suffer;
the young person's best interests require them to receive
contraceptive advice or treatment with or without parental consent

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Other considerations
Follow up
Pregnancy test >3/52
Anti D
Contraception
Antibiotics
Analgesia
Counselling
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Case 1
Age 23
With partner
No contraception
Ambivalent
12 weeks pregnant

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Case 2
Age 44
Teenage children
5 weeks pregnant
BMI 35

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Case 3
Age 14
With older boyfriend
8 weeks pregnant

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