Termination of Pregnancy by 132Healthwise

Termination of pregnancyTermination of pregnancyClaudine DomoneyClaudine Domoney

Pregnancy Termination – Read More

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TOP in BritainTOP in Britain• 186 000 in England 186 000 in England

& Wales& Wales• 11500 in Scotland 11500 in Scotland

annuallyannually

• 1/3 women will 1/3 women will have in lifetimehave in lifetime

• 99.8% in NHS 99.8% in NHS hospitals in Scotlandhospitals in Scotland

• 42% NHS hospitals42% NHS hospitals• 36% charitable 36% charitable

sector funded by sector funded by NHSNHS

• 22% private22% private







Induced abortionInduced abortion• Surgical TOPSurgical TOP

– 7 ½ weeks – 24 weeks7 ½ weeks – 24 weeks

– Hysterotomy > 24 Hysterotomy > 24 weeksweeks

• Medical TOPMedical TOP

– Any gestationAny gestation

– Pre 63 days Pre 63 days amenorrhoeaamenorrhoea

– Post 63 days Post 63 days




Certificate A –legal requirementStatutory 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.




• 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




Risks of surgical TOPRisks of surgical TOP• HaemorrhageHaemorrhage

– ↑ ↑ with gestationwith gestation– 1/1000 (0.88 <12 1/1000 (0.88 <12

wks, 4>20 wks)wks, 4>20 wks)• Cervical traumaCervical trauma

– 1/10001/1000• Uterine perforationUterine perforation

– 1-4/10001-4/1000• AnaestheticAnaesthetic

• Failed abortionFailed abortion– 2/10002/1000

• InfectionInfection– Up to 10%Up to 10%– ↓↓with screening with screening

and prophylaxisand prophylaxis

• PsychologicalPsychologicalNB use of cervical priming agents







Many regimes MTOPMany regimes MTOP• Mifepristone aloneMifepristone alone

• Misoprostol aloneMisoprostol alone

• MethotrexateMethotrexate

• Methotrexate and Methotrexate and misoprostolmisoprostol

• Mifepristone and Mifepristone and misoprostolmisoprostol

• Mifepristone and Mifepristone and gemeprostgemeprost

NB limited availability of NB limited availability of antiprogesteroneantiprogesterone










ContraindicationsContraindications• Known allergy to misoprostol or Known allergy to misoprostol or

mifepristone or another prostaglandin mifepristone or another prostaglandin medicine in the past or any component of medicine in the past or any component of the productsthe products

• Chronic adrenal failure Chronic adrenal failure • Severe asthma not controlled by therapy Severe asthma not controlled by therapy • Inherited porphyriaInherited porphyria• Renal failure, hepatic failure or malnutritionRenal failure, hepatic failure or malnutrition




CautionsCautions• Patients with prosthetic heart valves or who have Patients with prosthetic heart valves or who have

had one previous episode of infective endocarditis had one previous episode of infective endocarditis should receive chemoprophylaxis according to the should receive chemoprophylaxis according to the current UK recommendations. current UK recommendations.

• Known ischaemic heart disease or other serious Known ischaemic heart disease or other serious cardiovascular disease, treatment for hypertension, cardiovascular disease, treatment for hypertension,

• Significant bronchitisSignificant bronchitis• Haemorrhagic disorders and anticoagulation therapyHaemorrhagic disorders and anticoagulation therapy• Smokers aged over 35 years (increased risk of Smokers aged over 35 years (increased risk of

cardiovascular disease)cardiovascular disease)• Breastfeeding Breastfeeding • Adrenal suppression Eg concurrent steroid therapy – Adrenal suppression Eg concurrent steroid therapy –

may require corticosteroidmay require corticosteroid• DiabetesDiabetes




Side effects with Side effects with misoprostolmisoprostol• Nausea 40 in 100Nausea 40 in 100• Vomiting 20 in 100Vomiting 20 in 100• Diarrhoea 15 in 100Diarrhoea 15 in 100• Headache 16 in 100Headache 16 in 100• Dizziness 25 in 100Dizziness 25 in 100• Flushes 25 in 100Flushes 25 in 100




TOP Under 16sTOP Under 16s• Safer and less risk in this group with Safer and less risk in this group with

MTOPMTOP• Assess Fraser competenceAssess Fraser competence• Ensure no abuse/ discuss with Ensure no abuse/ discuss with

colleagues/social servicescolleagues/social services• Age of boyfriendAge of boyfriend• Contraception/safe sex adviceContraception/safe sex advice• RGN/RN admin of meds?RGN/RN admin of meds?




Fraser guidelinesFraser guidelines• Gillick competenceGillick competence• lawful for doctors to provide contraceptive advice and lawful for doctors to provide contraceptive advice and

treatment without parental consent providing certain treatment without parental consent providing certain criteria are metcriteria are met

• the young person will understand the professional's advice;the young person will understand the professional's advice;• the young person cannot be persuaded to inform their parents;the young person cannot be persuaded to inform their parents;• the young person is likely to begin, or to continue having, sexual the young person is likely to begin, or to continue having, sexual

intercourse with or without contraceptive treatment;intercourse with or without contraceptive treatment;• unless the young person receives contraceptive treatment, their unless the young person receives contraceptive treatment, their

physical or mental health, or both, are likely to suffer;physical or mental health, or both, are likely to suffer;• the young person's best interests require them to receive the young person's best interests require them to receive

contraceptive advice or treatment with or without parental consentcontraceptive advice or treatment with or without parental consent



Other considerationsOther considerations• Follow upFollow up• Pregnancy test >3/52Pregnancy test >3/52• Anti DAnti D• Contraception Contraception • AntibioticsAntibiotics• AnalgesiaAnalgesia• CounsellingCounselling


Case 1Case 1• Age 23Age 23• With partnerWith partner• No contraceptionNo contraception• AmbivalentAmbivalent• 12 weeks pregnant12 weeks pregnant


Case 2 Case 2 • Age 44Age 44• Teenage childrenTeenage children• 5 weeks pregnant5 weeks pregnant• BMI 35BMI 35


Case 3Case 3• Age 14Age 14• With older boyfriendWith older boyfriend• 8 weeks pregnant8 weeks pregnant


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Termination of Pregnancy by 132Healthwise