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Termination of pregnancy

Specialties > Gynaecology

Background knowledge 🧠

Definition

  • Termination of pregnancy (TOP) refers to the deliberate medical or surgical ending of a pregnancy.
  • It is a legal and regulated procedure under UK law.
  • Commonly referred to as abortion in medical and legal contexts.

Epidemiology

  • In the UK, approximately 1 in 3 women will have an abortion by the age of 45.
  • The majority of terminations occur before 10 weeks of gestation.
  • Around 200,000 abortions are performed annually in England and Wales.
  • Rates have remained relatively stable over recent years.

Aetiology and Pathophysiology

  • Variety of reasons including fetal abnormality, maternal health risks, or socio-economic factors.
  • Pathophysiology varies depending on whether medical or surgical methods are used.
  • Medical TOP involves the use of drugs like mifepristone and misoprostol to induce uterine contractions and expulsion.
  • Surgical methods typically involve vacuum aspiration or dilation and curettage (D&C).

Types

  • Medical TOP: Involves the use of medication, usually up to 10 weeks of gestation.
  • Surgical TOP: Includes methods like vacuum aspiration (most common up to 15 weeks) and dilation and evacuation (D&E) for later gestations.
  • Late TOP: Usually after 20 weeks, often performed for severe fetal anomalies or maternal health reasons.

Clinical Features 🌡️

Symptoms

  • Vaginal bleeding: Common after medical TOP; may also occur post-surgical TOP.
  • Abdominal cramping: Typical after medical TOP, usually mild to moderate.
  • Nausea and vomiting: Can occur due to medications used.
  • Emotional distress: Varies depending on individual circumstances and support.

Signs

  • Pelvic tenderness: May be noted on examination post-TOP.
  • Fever: Suggests infection, a potential complication.
  • Incomplete TOP: Persistent bleeding, retained products of conception on ultrasound.

Investigations 🧪

Tests

  • Ultrasound: Confirms intrauterine pregnancy and gestational age; checks for retained products post-TOP.
  • Blood tests: hCG levels to confirm pregnancy status and assess completeness of TOP.
  • Infection screen: Swabs or blood cultures if infection is suspected post-TOP.
  • RhD status: To determine if anti-D immunoglobulin is needed in Rh-negative women.

Management 🥼

Management

  • Medical management: Mifepristone followed by misoprostol, usually for pregnancies up to 10 weeks.
  • Surgical management: Vacuum aspiration or D&E depending on gestational age and preference.
  • Supportive care: Includes pain management, emotional support, and follow-up.
  • Contraception: Discussed and offered post-TOP to prevent future unintended pregnancies.
  • Referral: To specialist services for complex cases or later gestations.

Complications

  • Infection: Risk reduced with prophylactic antibiotics but can occur.
  • Hemorrhage: Uncommon but can be severe, especially in later gestation TOP.
  • Incomplete TOP: Requires further medical or surgical management.
  • Psychological impact: Varies; support should be available for those who experience distress.
  • Uterine perforation: Rare complication of surgical TOP.

Prognosis

  • Generally excellent with appropriate management.
  • Fertility usually unaffected by uncomplicated TOP.
  • Important to address any psychological or emotional issues post-TOP.

Key Points

  • TOP is a safe, legal procedure with well-established guidelines in the UK.
  • Both medical and surgical options are available, with choice depending on gestational age and patient preference.
  • Post-TOP care is crucial to ensure physical and emotional well-being.
  • Early and appropriate referral and management reduce the risk of complications.

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Gynaecology