Termination of pregnancy

Overview

•Two registered medical practitioners must certify in good faith that a ground applies (one suffices in a genuine emergency)
•Must be performed in a licensed NHS hospital or independent sector clinic
Ground
Indication
Gestational limit
A (social)
Continuing pregnancy poses greater risk to physical/mental health of woman or existing children than termination
Up to 24 weeks
B (grave injury)
Necessary to prevent grave permanent injury to physical/mental health of woman
No limit
C (risk to life)
Continuing pregnancy poses greater risk to life of woman than termination
No limit
D (fetal abnormality)
Substantial risk child would be seriously handicapped
No limit
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Ground A accounts for the vast majority of UK terminations. Grounds B, C, D - no upper gestational limit - are the grounds most likely in exam vignettes involving late termination or fetal anomaly.
•Conscientious objection is permitted (Section 4) but the practitioner must refer the woman to a willing colleague and must provide emergency care if her life is at risk

Management

•Confirm gestation by ultrasound before proceeding; offer impartial counselling on all options (continuation, adoption, termination) and discuss contraception
•Medical TOP - sequential regimen (simultaneous administration not recommended):
•Step 1 - mifepristone 200 mg orally (progesterone receptor antagonist - decidual breakdown, cervical priming, myometrial sensitisation)
•Step 2 - misoprostol 24-48 hours later (prostaglandin E1 analogue - uterine contractions, expulsion)
•≤10 weeks: misoprostol can be taken at home after in-clinic mifepristone
•10-24 weeks: managed in clinic/day-case unit
•From ~22 weeks: feticide (intracardiac potassium chloride) required before induction to prevent live birth
•Surgical TOP:
•Vacuum aspiration - up to ~14 weeks, outpatient under local anaesthetic
•D&E - 14-24 weeks, theatre under GA; cervical priming with misoprostol or osmotic dilators beforehand

Prophylaxis

•Anti-D: offer anti-D immunoglobulin to all rhesus-D negative women from 10 weeks gestation onwards (both MTOP and STOP); also consider for surgical abortion before 10 weeks
•Antibiotic prophylaxis: all women - doxycycline or metronidazole per local protocol (reduces post-abortion infection/PID risk)
•VTE prophylaxis: enoxaparin (LMWH) for at least 7 days post-procedure in high-risk women

Follow-up

•Urine pregnancy test at 3 weeks post-procedure - if positive, review to exclude RPOC or ongoing pregnancy
•Contraception can be commenced immediately after TOP

Complications

•Incomplete termination - RPOC after MTOP; more common with medical than surgical method; requires surgical evacuation
•Haemorrhage - both methods; uterine atony/vessel injury with surgical TOP
•Infection - PID/endometritis, especially with RPOC; reduced by antibiotic prophylaxis
•Uterine perforation - rare; surgical TOP (D&E), higher risk with advancing gestation
•Failed termination - ongoing pregnancy; repeat procedure required

Medical vs Surgical Termination

Medical vs surgical termination of pregnancy
FeatureMedical (MTOP)Surgical (STOP)
MethodMifepristone then misoprostolVacuum aspiration (≤14 wks) or D&E (14-24 wks)
Gestational rangeUp to 24 weeksUp to 24 weeks
SettingHome (≤10 wks); clinic/day-case (10-24 wks)Outpatient LA (vacuum) or theatre GA (D&E)
Key complicationIncomplete expulsion - RPOC requiring surgical evacuationUterine perforation, cervical injury