TERMINATION OF PREGNANCY (TOP)

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TERMINATION OF PREGNANCY (TOP)

Gestational age is based on the estimated size of the uterus rather than dates. Ultrasound examination is more accurate and of value in identifying ectopic pregnancy, molar pregnancy or twins.

 

SUMMARY OF CHOICE OF TERMINATION OF PREGNANCY ACT

Women eligible

Up to 13 weeks: on request.

13+ to 20 weeks: If doctor is satisfied that pregnancy was from rape or incest, or there is risk of fetal abnormality or risk to mother’s physical or mental health or social or economic circumstances.

More than 20 weeks: Doctor and second doctor or registered midwife are satisfied that there is danger to the mothers’ life, severe fetal malformation or risk of fetal injury.

Venue

An accredited facility with staff trained in performing TOP, designated by the Member of Executive Council at provincial level.

Practitioner

Up to 13 weeks: doctor, midwife or registered nurse with appropriate training.

More than 13 weeks: doctor responsible for decision and prescription of medication. Registered nurse/midwife may administer medication according to prescription.

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Pre and post termination counselling is essential.

Consent of spouse/partner is not necessary.

Consent for TOP and related procedures e.g. laparotomy may be given by minors. Minors are encouraged to consult parents or others but consent is not mandatory.

 

Mentally retarded/unconscious patient

On request from spouse or guardian; doctor and second doctor or registered midwife must agree.

If indicated as for 13+ to 20 weeks (above), spouse/guardian cannot prevent TOP by withholding consent.

GESTATION UP TO 13 WEEKS 

GENERAL MEASURES

Counselling.

Outpatient procedure by nursing staff with specific training.

Manual vacuum aspiration of the uterus.

MEDICINE TREATMENT

Manual vacuum aspiration:

  1. Misoprostol, PV, 400 mcg 3 hours before routine vacuum aspiration of the uterus.

 

Routine analgesia for vacuum aspiration

  1. Pethidine, IM, 100 mg 30 minutes before aspiration procedure.

OR

  1. Morphine, IM, 10 mg 30 minutes before aspiration procedure.

Do not give intravenous benzodiazepines and parenteral opioid analgesics concurrently.

 

Alternatively, consider paracervical block.

 

Oral analgesia as required for 48 hours.

  1. Paracetamol, oral, 1 g 6 hourly. AND
  2. Ibuprofen, oral, 800 mg 8 hourly.

 

Women who decline MVA:

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An alternative is medical TOP with:

  1. Mifepristone, oral, immediately as a single dose.

o Up to 9 weeks gestation: 100–200 mg.

o 9– 13 weeks gestation: 200 mg.

 

Followed 24–48 hours later by:

  1. Misoprostol, PV, 800 mcg.

o If expulsion has not occurred 4 hours after misoprostol administration, a second dose of misoprostol 400 mcg oral/PV may be given.

o Review with ultrasound on day 7.

 

Note:

Bleeding may persist for up to 1 week.

 

After administration of mifepristone, start:

  1. Paracetamol, oral, 1 g 6 hourly.

ADD

After expulsion is complete:

  1. Ibuprofen, oral, 800 mg 8 hourly.

 

GESTATION 13+ TO 20 WEEKS 

Inpatient care in facilities with 24-hour service and facilities for general anaesthesia.

 

GENERAL MEASURES

Manual vacuum aspiration of the uterus, if expulsion of products of conception is not complete.

 

MEDICINE TREATMENT

 

The dose of misoprostol decreases with increasing gestational age because of the risk of uterine rupture.

 

  1. Mifepristone, oral, 200 mg, oral, immediately as a single dose.

 

Followed 24–48 hours later by:

  1. Misoprostol, PV, 400–800 mcg as a single dose.

o Then, misoprostol, oral, 400 mcg 3 hourly for 4 doses.

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If no response after 24 hours, consider adding mechanical cervical ripening.

Pass a Foley catheter with 30 mL bulb through cervix with sterile technique.

Inflate bulb with 50 mL water or sodium chloride 0.9%.

Tape catheter to thigh with light traction on catheter.

Attach sodium chloride 0.9% 1 L with giving set to catheter.

Infuse sodium chloride 0.9% at 50 mL/ hour through catheter into uterus.

 

Warning

Uterine rupture may occur in women with previous Caesarean sections.

Caution for this group and those of high parity: use 200 mcg misoprostol or alternative methods such as extra-amniotic 0.9 % saline infusion without misoprostol.

 

Analgesia

  1. Pethidine, IM, 100 mg 4 hourly as needed. OR
  2. Morphine, IM, 10 mg 4 hourly as needed.

 

If Rh-negative:

  1. Anti-D immunoglobulin, IM, 100 mcg as a single dose.

 

REFERRAL

On the following condition, please refer the patient to a specialist;

  1. Having a complicating medical conditions, e.g. cardiac failure, etc.
  2. Having a Failed procedure.
  3. When suspecting ectopic pregnancy.

REFRENCE

Standard treatment for South Africa

Edited by

Dr. Shuaib Omoko

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