Termination of Pregnancy (TOP)
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Consent for someone who cannot give consent
Who can perform a termination?
Where can a termination take place?
Counselling should accompany termination
CHOICE ON TERMINATION OF PREGNANCY ACT, 1996 (now modified)
The Act replaced the Abortion and Sterilization Act of 1976
- A pregnancy may be terminated upon request of a woman (no age restriction) during the first 12 weeks of gestation, or:
- From the 13th week up to & including the 20th week of gestation if a medical practitioner, on consultation with the pregnant woman, believes that the pregnancy:
- Would pose a risk to the women’s physical or mental health
- Would pose a risk to the fetus of physical or mental abnormality
- Resulted from rape or incest
- Would significantly affect the socio-economic circumstances of the woman
- After the 20th week two medical practitioners or a medical practitioner & a registered midwife agree that the continued pregnancy would:
- Endanger the woman’s life
- Result in a severe malformation of the fetus
- Pose a ‘risk of injury’ to the fetus
Consent
- TOP may only take place with informed consent from the woman
- Only the informed consent of the woman is required for TOP
- When patients sign consent, they do so not only for the TOP itself, but for any procedure that may arise as a result of complications, e.g. hysterectomy, bowel resection, tracheostomy etc.
Consent for a Minor
The medical practitioner or midwife ‘shall advise [such minor] to consult with parents, guardian, family members or friends before the pregnancy is terminated,’ but this remains at the discretion of the minor, & termination cannot be denied if this is not done. Consent given, as above is for any procedure. The issue of discussion with a parent/guardian should be discussed by medical staff & documented.
Consent for someone who cannot give consent
This is either a ‘severely mentally disabled person…incapable of understanding & appreciating the nature or concept of termination of pregnancy’ or a person
‘in a state of continuous unconsciousness’ with ‘no reasonable prospect of regaining consciousness in time to request consent to the termination of her pregnancy’. Such a person may undergo termination according to the Act within the first 20 weeks ‘upon the request of her natural guardian, spouse or legal guardian’ or ‘of her curator personae.’
Who can perform a termination?
A pregnancy may be terminated by a medical practitioner or, up to & including 12 weeks, by a registered nursing sister ‘who has completed the prescribed training course.’
Where can a termination take place?
The surgical termination of pregnancy may take place only in a facility designated by the Minister of Health.
Counselling should accompany termination
The State shall promote the provision of ‘non-mandatory’ counseling before & after termination.
First trimester terminations
First trimester terminations should be performed in a Primary care facility or designated clinic (within a hospital). A medically complicated patient will require first trimester TOP in 1 of the 3 central hospitals.
Management of first trimester TOP (<13 weeks)
The patient must be counseled fully about the procedure & possible complications as well as future contraceptive options. The gestational age MUST be confirmed by ultrasound first.
Misoprostol 800mcg (4 tablets) pv 4-6hrly up to 3 doses
If Mifepristone available:
- <9 weeks: Mifepristone 200mg PO then 24-48hrs later Misoprostol 800mcg PV
- 9-13 weeks: Mifepristone 200mg PO then 36-48hrs later Misoprostol 800mcg PV then 400mcg 3hrly PV (to a max of 4 doses)
NOTES
- The tablets will cause pain & bleeding. The fetus should be disposed of in the toilet. The most common side effects are shivering & diarrhea
- Analgesics should be prescribed
- The patient can be given tablets to be taken at home, the patient should then be advised to return with bleeding or at a prearranged time.
- When the patient is reviewed sonar may confirm
- The uterus is empty & no further treatment is necessary
- The fetus has been passed but products remain which requires MVA
- A viable pregnancy persists & tablets may need to be re-prescribed & repeated. Alternatively a single Misoprostol tablet (200mcg) can be placed sublingually and MVA performed after 1-2hrs if the cervix is open.
- Tablets can be inserted PV or taken orally. GIT side effects are more common when taken PO.
- If, on examination there is an obvious vaginal discharge, Doxycycline 100mg bd po & Metronidazole 400mg bd po can be prescribed for 5 days. Otherwise this is optional
Second trimester Termination
Second trimester TOP should take place as an inpatient in a hospital or medical facility under the care of a medical practitioner.
Management of second trimester TOP (13-20weeks)
Day 1
- Admission
- U&E, Hb, Rh group & sample held in lab
- Antibiotics as for first trimester TOPs if indicated, otherwise not
- Misoprostol 600mcg PV to be inserted by the patients as a “vaginal loading dose”
- Misoprostil 400mcg 3hrly either PV or Sublingual (to a MAX 5 doses)
- Consider stopping Misoprostol if severe pain/strong regular contractions
Day 2
- If abortion has occurred, book the patient on the next evacuation list or for MVA by the experienced, at <16 weeks
- If abortion has not occurred, insert Misoprostol as for Day 1 (provided more than 12hrs since last dose Misoprostol)
- If pain or bleeding occur, start oxytocin 20 units in 1L normal saline at 125 mL/hour 6 hours after the last Misoprostol insertion
Day 3
- If abortion has occurred, book on the next evacuation list, or MVA as described
- If abortion has not occurred, give prostaglandin E2 (Prepidil) gel 0.5 mg intracervically, or repeat Misoprostol and Oxytocin as for Day 1 & Day 2
Day 4
- If abortion has occurred, book on the next evacuation list
- If abortion has not occurred, book for hysterotomy or D&C on the evacuation list.
- Advise patients who have fundal hysterotomy that elective caesarean section will be mandatory in future successful pregnancies
If Mifepristone available: (13-20 weeks)
Mifepristone 200mg PO followed 36-48hrs after with Misoprostol 800mcg PV the Misoprostol 400ug PV 3hrly up to 5 doses.
Important points about TOP
- Doctors are not compelled to participate in the TOP service however it is an offence according to the CTOP Act to prevent or obstruct access to TOP.
- Conscientious objectors therefore are compelled to refer women who request TOP to doctors who do participate in the TOP service.
- All doctors are expected to participate in the management of emergencies, whether associated with TOP or not
- Use agents with caution in patients with uterine scar in 2nd trimester.
- Do not deviate from the protocol without first discussing with a consultant
- Unless hysterotomy is required, patients are managed under each successive gynaecology unit on intake (CHBAH)
- Use IV triple antibiotics (as for severe PID) if there is any suspicion of sepsis (pyrexia, offensive products) or if prolonged termination or many vaginal examinations
- Give anti-D to Rh negative patients within 72 hours of TOP
- 1st Trimester: 250 IU
- 2nd Trimester: 625 IU
- Patients should be referred to social worker in suspected cases of rape/domestic abuse
- Productions of conception maybe required to be kept as evidence in rape cases
- Contraceptive counseling is important in prevention of future unwanted pregnancies
- If TOP is unsuccessful, confirm again on ultrasound that the pregnancy is intrauterine