The indications for terminating pregnancy are based on legal constraints of various countries which medical personnel certifying and carrying out terminations of pregnancy must comply with. Termination of pregnancy rates per thousand estimated mean number of women aged 15-44 years vary in countries of low fertility from approximately 14.77 (England and Wales), 10.4 (Finland), 12.4 (France), 7.9 (Germany), 11.2 (Scotland), 22.9 (United States), 18.2 (New Zealand).
Table Risk factors and therapeutic score of the ectopic pregnancy.
|One previous ectopic pregnancy||2|
|Each additional ectopic pregnancy||1|
|Previous laparoscopic adhesiolysis||1|
|Previous tubal microsurgery||2|
|0-3 Laparoscopic conservative treatment|
|4 Laparoscopic salpingectomy|
|5 or mor Laparoscopic salpingectomy and contralateral sterilisation for future fertilityand In vitro fertilisation|
Table Regimens for cervical priming.
|Gemeprost||1 mg vaginally 3 hours prior to surgery|
|Misoprostol||400µh (2 x 200µh tablets) vaginally 3 hours prior to surgery|
|Mifepristone||200mg or as in data sheet|
Guidlines for termination
■ Medical termination of pregnancy has up to a 90 per cent success rate up to 83 days of gestation .
■ The dose of oral mifepristone (RU486) can be reduced from formerly 600mg to 200mg without any effect on the efficacy.
■ Misoprostol (800µg 36-48 hours later, administered vaginally) is cheaper and does not require special storage facilities compared to gemeprost as the type of prostaglandin to use in conjunction with mifepristone.
Table Regimens for early medical termination of pregnancy.
|Mifepristone 200mg in combination with a prostaglandin|
|Misoprostol (a prostaglandin E, analogue, given vaginally, is a cost-effective alternative for all abortion procedures for which the E, analogue gemeprost is given)|
|Alternative regimens for early medical TOP: mifepristone 600mg orally followed 36-48 hours later by gemeprost 1 mg vaginally.|
|Mifepristone 200mg orally followed 36-48 hours later by misoprostol 800µh (4 x 200µh tablets) vaginally|
|Mifepristone 200mg orally followed 36 hours later by gemeprost 0.5mg vaginally|
|Conventional suction TOP is an appropriate method of termination of pregnancy at gestations of 7-15 weeks. Cervical preparation is beneficial prior to suction termination and should be routine if the woman is aged under 18 years or the gestation >10 weeks.|
Table Methods of termination of pregnancy at more than 15 weeks’ gestation.
|Mifepristone 600mg orally followed 36-48 hours later by gemeprost 1 mg vaginally every 3 hours to a maximum of five pessaries|
|Mifepristone 200mg orally followed 36-48 hours later by misoprostol 800µh vaginally then misoprostol 400µh orally to a maximum of four doses|
|Mifepristone 200mg orally followed 36 hours later by gemeprost 1 mg vaginally every 6 hours|
Vaginal administration of misoprostol is associated with fewer side effects and improved efficacy.
■ At gestations up to 7 weeks, misoprostol appears to be as effective as gemeprost, but efficacy is reduced at 7-9 weeks’ gestation.
■ Termination usually occurs within 8 hours.
■ If a response has not occurred within 24 hours of misoprostol administration surgical termination may be offered. Alternatively, a repeat ultrasound scan could be done at 1 week. If there is doubt about the completeness of medical termination then a follow-up ultrasound scan vaginally should be done 10 days later.
■ As misoprostol is unlicensed for use in early TOP, qualified doctors are permitted by the EC Pharmaceutical Directive 89/349/EEC to use licensed medications for indications or in doses or routes of administration outside the recommendation given in the licence. Informed consent should be obtained.
Table Examples of prostaglandin administration protocols for evacuation of missed miscarriage and late fetal death in utero.
|Drug administration protocol||Vomiting(%)||Diarrhoea (%)||Expulsion time (hours) (mean or median)|
|Vaginal PGE, (misoprostol) 50-100µh/day||0||0||11.6|
|Vaginal PGE2 20mg every 3-6 hours||87||70||14.6|
|Vaginal PGE2 25mg single instillation + i.v. oxytocin after 15-20 hours||31||8||14.4|
|Vaginal 16,16-dimethyl-PGE,, 1 mg every 3 hours x 3 + i.v. oxytocin after 15-20 hours||15||10||14.2|
|Extra-amniotic PGE2 1-4µh/min infusion||29||0||10.0±|
|Intramuscular 16-phenoxy-PGE2 500µh every 4-6 hours||48||48||12.4|
|Intramuscular 15-methyl-PGF2„ 125-500µh every 2 hours||52||59||8.6|
|Intravenous 16-phenoxy-PGE2 1µh/min infusion||19||2||12.0|
|Intravenous 16-phenoxy-PGE2 3µh/min infusion||38||14||12.0|
|Intra-amniotic PGE2 5-10mg + i.v. oxytocin at 6 hours Intra-amniotic PGF2ct 25mg + 25mg every 6 hours Intra-amniotic 15-methyl-PGF2ct 2.5mg single injection|
Doxycycline for 7 days or azithromycin 1 g, which is more cost effective and ensures compliance. This covers bacterial vaginosis and chlamydial infection as opposed to screening and treatment of positive cases.
Other medications required
■ Anti-D at the time of termination.
Table Complications of TOP.
|Haemorrhage||1.5 per 1000|
|1.2 per 1000 at <13 weeks|
|8.5 per 1000 at >30 weeks|
|Uterine perforation||1.4 per 1000 (rate is lower the earlier the gestation)|
|Cervical trauma||<1% (rate is lower the earlier the gestation)|
|Failed termination of pregnancy requiring a further procedure|
|Surgical||2.3 per 1000|
|Medical||6 per 1000|
|Infection||Up to 10% of cases. Risk is reduced|
|– pelvic inflammatory disease||with prophylactic antibiotics or when lower genital tract infection has been excluded by bacteriological screening|
|Future reproductive outcome||No proven association between induced abortion and subsequent infertility or preterm delivery|
■ Human immunodeficiency virus rate in women attending for TOP in inner-city London in an anonymous survey in 1994 was 1 in 160.
■ Future contraceptive plans need to be established.
■ Up to 70 per cent require no analgesia. Co-proxamol may be needed in up to 25 per cent. Less than 5 per cent require intramuscular opioid analgesia. Increasing analgesic requirements are associated with increasing gestational age.
Side effects of TOP
- ■ In developed countries the safety of both medical and surgical TOP is well established – mortality <1 in 100000 with surgical TOP.
- ■ Ongoing pregnancy rate is approximately 3 per 1000.
- ■ Incomplete TOP rate is 2 per cent.
- ■ Vomiting occurs in 25 per cent and diarrhoea in 13 per cent undergoing medical TOP.
- ■ Mean blood loss is <100ml. A clinically significant blood loss occurs in 1 per cent.
- ■ Transfusion rate is 1 in 2000. After termination of pregnancy:
- ■ Anti-D immunoglobulin should be given to all non-sensitised PvhD-negative women following termination of pregnancy whether surgical or medical methods are used, regardless of gestational age (see above for anti-D regimens).
- ■ A follow-up visit should occur at 2 weeks and adequate contraception supplied. An intrauterine device may be inserted at the time of termination of pregnancy.
Mid-trimester termination of pregnancy
Under aseptic condition the self-retained 14- or 16-gauge Foley’s catheter is introduced through the cervical canal. The balloon is distended with 20-50 ml of sterile isotonic saline. The catheter is connected to an infusion pump. Prostaglandin E2 (PGE2) solution is infused into the extra-amniotic space at 20-150 µh/hour with 10 µg/hour incremental increases at 15-minute intervals as necessary using a solution concentration of 1.5-5 µh/ml. The infusion is maintained until the catheter is naturally expelled into the vagina when labour has caused cervical dilatation. Oxytocin augmentation is started 3 hours or more after discontinuing the prostaglandin infusion. It is preferable not to rupture the membranes because of the risk of ascending infection.
Alternatively, a single bolus injection of prostaglandin may be given using a disposable polyethylene catheter introduced into the extra-amniotic space. PGE2 (240-500 µh in 7-10 ml of viscous gel) is injected and the catheter withdrawn. Oxytocin is commenced as previously once labour has commenced.
The optimal treatment protocol for a mid-trimester termination of pregnancy has not been established. Examples may be seen in Tables 2.18 and 2.19. Clotting status should be made if fetal death has occurred 3 weeks previously. Adequate analgesia should be provided. Ergometrine or intramuscular prostaglandin analogues should be given to enhance uterine contractility following delivery to reduce the chances of excessive haemorrhage.
Intra-amniotic protocols have been used for terminations beyond 15 weeks’ gestation. Many protocols have been developed over the past 20 years and involve either single instillation of prostaglandins at amniocentesis or repeated injections through an indwelling trans-abdominal intra-amniotic catheter inserted through a Tuohy needle at the time of amniocentesis. An additional 200 ml of hypotonic saline solution is inserted to ensure fetal demise before delivery.
Alternatively, 10 ml of air into the umbilical cord under ultrasound for pregnancies smaller than 24 weeks’ gestation. Embolisation procedures are better done with prostaglandins given vaginally, since the myometrium is increasingly sensitive as the gestation advances. Vaginal pessaries of prostaglandins offer a relatively non-invasive method which can be enhanced by subsequent intravenous infusion of oxytocin. The oral administration of the anti-progestational agent epostane, a 3β-hydroxy steroid dehydrogenase inhibitor, or mifepri-stone (RU486), the progesterone-receptive blocker, 200 mg 24-72 hours prior to prostaglandin treatment, reduces the induction to TOP interval by up to 60 per cent, thus lowering the dose of prostaglandins needed with a decreased incidence of gastrointestinal side effects and the need for analgesia.
The placenta should deliver within 2 hours of TOP. The longer the delay before surgical removal the greater the rate of excessive bleeding.
Ergometrine (0.5 mg intramuscularly) should be given at the time of termination of pregnancy, to reduce excessive blood loss (>500ml).