Epidemiology
Incidence
In Europe, 30% of all pregnancies are terminated.[2] In 2011, according to Department of Health statistics:[3]
The total number of abortions was 189,931.
The age-standardised abortion rate was 17.5 per 1,000 resident women aged 15-44.
The abortion rate was highest at 33 per 1,000, for women age 20.
The under-16 abortion rate was 3.4 and the under-18 rate was 15.0 per 1,000 women.
96% of abortions were funded by the NHS; of these, over 61% were in the independent sector under NHS contract.
91% of abortions were carried out at under 13 weeks of gestation; 78% were at under 10 weeks.
Medical abortions accounted for 47% of the total.
2,307 abortions (1%) were under ground E - risk that the child would be born handicapped.
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Legal requirements
The 1967 Abortion Act allows termination before 24 weeks of gestation if it:
reduces the risk to a woman's life; or
reduces the risk to her physical or mental health; or
reduces the risk to physical or mental health of her existing children; or
if the baby is at substantial risk of being seriously mentally or physically handicapped.
Most terminations are performed under the second of these criteria. There is a general debate in political and public circles currently that the upper gestational age limit ought to be reduced from 24 weeks to 22 or 20. This is due to the realisation that advances in neonatal care are improving the survival rates of some premature infants born around this time, setting up an environment of moral concern that babies that could survive are having their lives ended. 4-dimensional ultrasound also appears to show 20-week gestation fetuses displaying complex behaviours, prompting a call for a shift from viability as the main criterion, towards sentience.[4] Currently, the British Medical Association (BMA) does not favour a reduction in the gestational age limit for TOP.[5]
There is no upper limit on gestational time if there is:
Risk to the mother's life.
Risk of grave, permanent injury to the mother's physical/mental health (allowing for reasonably foreseeable circumstances).
Substantial risk that, if the child were born, it would suffer such physical or mental abnormalities as to be seriously handicapped. Such TOPs must be conducted in an NHS hospital.
<1% of TOPs are performed after 20 weeks. This is usually following amniocentesis, or in very young girls who have concealed or not recognised the pregnancy
Abortion in girls under 16 years
In girls aged under 16 years, form HSA1 must be signed by two doctors. GMC guidelines are that girls <16 years may be able to reach an informed decision depending on their capacity to comprehend everything involved in the procedure. However, in those cases where a competent underage girl refuses termination, it may be possible for a parent or guardian to authorise termination if it is in the girl's best interests - see separate article Consent to Treatment in Children (Mental Capacity and Mental Health Legislation). In Scotland, parental consent cannot be given if a competent girl has refused termination. In girls <16 years deemed unable to reach an informed decision, a parent or guardian may give consent to, or refuse, termination. However, you may ask a court to overrule if you believe that it is not in the child's best interests to consent to, or refuse, treatment.[1]
It is strongly recommended that you seek medico-legal advice from your medical indemnity organisation regarding your statutory and ethical duties, and the rights of patients and/or their parents, regarding TOP in girls aged <16 if you have any uncertainty.
Before termination
Confirm the patient is pregnant.
Counsel to help her reach the decision she will least regret.
Ask her to consider the alternatives (eg, adoption); ask about her partner (but note that the partner cannot consent to, or refuse, termination).
Ideally, allow time for her to consider and bring her decision to a further consultation. However, remember that the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines state that 'the earlier in pregnancy an abortion is performed, the lower the risk of complications. Services should therefore offer arrangements that minimise delay'.
If she chooses termination:
Screen for chlamydia (25% postoperative salpingitis if untreated).
Discuss future contraceptive needs (start the pill next day or insert an intrauterine contraceptive device (IUCD).
Check rhesus (Rh) status - if negative, anti-D is needed.
Offer follow-up - there may be problems around the time she would otherwise have delivered.
Royal College of Obstetricians and Gynaecologists guidelines[6]
All women should have access to a clinical assessment.
There should be a pathway to tertiary medical care for women with significant medical conditions.
There should be arrangements to minimise delay - eg, direct access from referral sources other than GPs.
Women who decide to continue their pregnancy should be referred for antenatal care immediately.
All women should be offered an assessment appointment within five working days of referral.
All women should undergo an abortion within five working days of the decision to proceed.
No woman should wait longer than three weeks from initial referral to the time of her abortion.
Blood tests
Pre-abortion assessment should include:
Measurement of haemoglobin level.
Determination of ABO and Rh blood groups.
Screening for other conditions as clinically indicated - eg, haemoglobinopathies, hepatitis B virus, HIV.
Cervical screening.
Ultrasound scanning
All services must have access to scanning, as it can be a necessary part of pre-abortion assessment, particularly where gestation is in doubt or where extrauterine pregnancy is suspected. When ultrasound scanning is undertaken, it should be in a setting and manner sensitive to the woman's situation. It is inappropriate for pre-abortion scanning to be undertaken in an antenatal department alongside women with wanted pregnancies.
However, ultrasound scanning is no longer considered to be an essential prerequisite of abortion in all cases.[6] This is because medical TOP is now used at all gestations, so accurate dating of the pregnancy within the first trimester is no longer essential.
The abortion procedure
Ideally, services should offer a choice of methods for the relevant gestational age.
Antibiotic prophylaxis and/or infection screening with treatment should be offered. Regimens include metronidazole 1 g rectally at the time of abortion, plus doxycycline 100 mg bd for seven days starting post-abortion, or metronidazole 1 g rectally at the time of abortion plus azithromycin 1 g orally on the day of abortion.[6]
At under 7 weeks of gestation
Avoid conventional suction termination.
Medical abortion using mifepristone plus prostaglandin is appropriate - eg, mifepristone 200 mg orally followed 36-48 hours later by misoprostol 800 micrograms vaginally buccally or sublingually.
A further dose of misoprostol (the dose varies with gestation) may be given, if required, after four hours.
This has been found to be safe, effective and with no adverse outcomes for subsequent pregnancies.[7]
Early surgical abortion using rigorous published protocol (to include visual inspection of tissue) may be appropriate.
At 7-15 weeks of gestation
Medical abortion is now considered appropriate at any gestation. The regime is initially as outlined above. Repeat doses of misoprostol (400 micrograms) are given, if required at 3- to 4-hourly intervals.
Conventional suction termination is appropriate at 7-15 weeks, although medical abortion may be preferable above 12 weeks.
The uterus should only be emptied with suction cannula and blunt forceps.
Local anaesthesia for suction termination may be safer than general anaesthesia.
Cervical priming should be considered in all cases having surgical procedure, but should be routinely used where gestation is >10 weeks or the woman is under 18 years of age. Mifepristone can be used, but osmotic dilators are superior after 14 weeks of gestation.
Surgical evacuation of the uterus is only necessary if there is clinical evidence of incomplete abortion.
Terminations at greater than 15 weeks of gestation
Dilatation and evacuation, preceded by preparation, are safe and effective when undertaken by expert hands.
Medical abortion may be a preferable alternative using mifepristone 200 mg orally followed 36-48 hours later by misoprostol 800 micrograms vaginally every three hours to maximum of four further doses.
Feticide should be performed before medical abortion after 21 weeks and 6 days of gestation.
Aftercare
Medical
Anti-D IgG to all non-sensitised RhD-negative women. Discuss contraception and supply if accepted.
Written
Provide a list of possible symptoms, highlighting those that need urgent medical attention, with a 24-hour number where it can be obtained. Also, a letter with enough details to allow another doctor to be able to deal with any complications. Arrange a follow-up appointment for within two weeks and further counselling for the small number of women who experience long-term distress.
Complications of abortion
The most common complications are:
Infection: up to 10% of terminations are reduced by prophylactic antibiotics or pre-procedure screening for infection.
Cervical trauma: 1%, lower when termination is performed early.
Uncommon complications are:[6]
Haemorrhage (severe requiring transfusion) - 1/1,000 (1st trimester) - 4/1,000 (beyond 20 weeks).
Perforation of uterus - 1-4/1,000.
Failed termination - 2.3/1,000 surgical, 6/1,000 medical.
There is no clear evidence to link abortion and breast cancer, preterm delivery or subsequent infertility.
Psychological effects
Only a small proportion of women experience long-term adverse psychological sequelae. Although early distress is common, it is usually a continuation of the symptoms present before the abortion. There is also evidence of the negative effects on both the mother and the child where abortion has been denied.
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