Termination of Pregnancy

1
Termination of Pregnancy

• Kamal Ojha MRCOG
• Consultant Obstetrics and Gynaecology
• St. Georges Hospital

2
Induced Abortion

• Modern Law in the UK is based on 1803 Act,
• Abortion Bill 1967, and the 1992 HEFA Act
• In 1963- 23000 terminations were performed.
• In 1987- 198000 terminations were performed

3
Criteria for termination

• Risk to the life of the pregnant woman.
• Risk of injury to the mental and physical health
  of the pregnant woman

4
Criteria for termination

• Risk of injury to the mental and physical health
  of the pregnant woman and child(ren)
• Substantial risk of the baby being born suffering
  from a mental or physical abnormality or to be
  severely handicapped.

5

• Majority of the reasons fall into clause 2 or 3
  and the reasons are mental stress, too many
  children,Unwanted unplanned pregnancy, failed
  contraception and socio-economic factors
• Termination is generally performed upto
• 24 weeks and 0 days gestation
• However for congenital defects it can be
  performed at any gestation

6
Statistics

• Single 63
• Married 26
• Others 11

7
Statistics

• lt 9 weeks 33
• 9-12 weeks 54
• 13-18 weeks 11
• 19-24 weeks 2

8

• Increase is mainly due to increase in the number
  of woman aged 15- 44
• 70 of the patients are below the age of 30
• teenage pregnancy below the age of consent is
  seen more frequently

9
Counseling

• General Practitioner
• Family Planning Nurse
• Family Planning clinic staff
• Gynaecologist

10

• Non-directional counseling is essential to
  convert a negative situation ( TOP ) for positive
  and constructive advice.

11
Objectives of counseling

• Full medical,social, family and contraceptive
  history
• Information on methods of termination, their risk
  and benefits
• Discuss alternative course of action
• Adoption,Fostering and Continuing pregnancy
• Give factual advise and determine what the woman
  wishes
• Allow her to reach a decision

12
High Risk Groups

• Teenagers - Lack of parental support or parental
  interference.Inability in the very young to
  comprehend what is really needed and post TOP
  contraceptives
• Repeat terminations- problems with contraception,
  reasons for request and compliance for
  contraception after TOP

13

• Sexual abuse- women need extra counseling and
  support
• Late terminations ( 16- 20 )
• Extra counseling, Support and explanation
  regarding method of termination.

14
Methods of termination

• Surgical TOP
• More than 90 of cases
• Requires a short general anaesthetic
• Local anaesthesia can be used
• Day case
• Upto 12 weeks
• 18-20 weeks by D/E needs skill and special
  instruments. Medical methods equally good
• more safer.

15

• Hysterotomy
• Removal of uterine contents by a laparotomy and
  a uterine incision was a method practiced in
  1960s. Now rarely used because of medical methods

16
Medical methods

• Complete GI UTpain
  Ex.hge
• STOP 95-100 - -
  lt0.5
• RU486 61 0 0
  5.6
• PGS 94 55 56
  0
• 23 96 0 13
  0

17
Methods of medical TOP

• Upto 9 weeks
• Mifepristone(RU486) 200mg on D-1 and
• Misoprostol 800micogm PV on D-3
• 12 weeks onwards needs admission as misoprostol
  needs to be repeated at 3 hourly intervals till
  abortion occurs(max 5 doses)

18

• Intrauterine extra-amniotic prostaglandin's is
  given via Foley's catheter
• Other drugs Urea and hypertonic saline may be
  given intramniotic

19
Contraindications

• Adrenal Insuffiency
• Current Asthma
• Ectopic or multiple pregnancy
• Heart disease
• Caution for women gt35 and heavy smokers

20

• Customary for legal reasons to supervise for one
  hour after swallowing Mifepristone
• Misoprostol is not licensed although freely used

21
Complications

• Retained products of contraception varies from
  0.1 to 2.9.After second trimester TOP curettage
  should be performed routinely to avoid RPOC
• Blood loss increases with gestation
• 50ml at 8 weeks and 100ml at 12weeks.
• Loss in excess of 500ml is considered significant

22

• Causes of significant blood loss are uterine
  atony, RPOC,Cervical trauma and uterine
  perforation.
• Uterine perforation is generally rare.
• Small perforations go unnoticed and need no
  treatment
• Large perforations - The key to the management
  realising early and the site of injury

23

• Injury may be to the broad ligament involving the
  uterine vessels or the peritoneal cavity
  involving the bowels
• Exploratory laparotomy to repair the bowel if
  traumatised and repair of the uterine rent .
• Securing proper haemostasis in case of vascular
  injury. Rarely hysterectomy or bowel resection
  may be required

24

• If unrecognised it may be fatal because of severe
  internal haemorrhage or faecal peritonitis.
• Cervical trauma
• During dilatation and cervical traction. Can be
  avoided by proper cervical priming with
  misoprostol
• RH isoimmunisation- avoided by anti-D

25

• Cervical incompetence
• Prior to the era of cervical priming cervical
  incompetence has been reported
• Cervical softening with PGS more recently
  misoprostol has definitely decreased the
  incidence of cx incompetence

26
Conclusion

• Legalisation of abortion has dramatically reduced
  the maternal mortality especially due to illegal
  abortion.
• Mifepristone(RU486) and Misoprostol has made
  medical abortion very effective with minimal side
  effects.
• Surgical TOP is the most common method acceptable
  to the patient.

27

• Counseling is important to decide the method of
  TOP, future contraception and helps in reducing
  the incidence of guilt feeling after the
  procedure.
• Counseling should be Non-directional and must
  help them to come to a decision regarding TOP
• Teenagers,Late-TOPs,Repeat TOPs and following
  sexual abuse need more attention

28

• All rhesus negative patients should receive anti-
  D
• Screening for infection and treating both
  partners is essential to prevent PID and future
  prospects of fertility
• Cervical ripening with misoprostol is very cheap
  and effective. STOP without cervical ripening
  mounts to negligence.

29

• Uterine perforation if not recognised can be
  fatal
• TOP is the commonest day case procedure
• Proper counseling regarding complications is
  necessary to avoid Medicolegal problems
• Hysterectomy or bowel resections are very rarely
  needed.