Induced Termination of Pregnancy (TOP)

What is an induced termination of pregnancy?

Induced termination of pregnancy (also called TOP or induced abortion) is the act of ending a pregnancy intentionally. It may be done with surgery or medicine. TOP prevents the live birth of a baby.

Dealing with an unplanned or unwanted pregnancy is very difficult. Talking with your partner, family, clergy, friends, and healthcare provider may help you decide what to do. You may choose to continue the pregnancy and raise the child yourself. Perhaps you will want to find someone to adopt the baby. You may decide to end the pregnancy by having a legal TOP.

What happens before a termination of pregnancy?

First you may talk with a specially trained counselor to explore choices and answer questions. The goal of counseling is to provide information that will help you make the best decision for you. Your healthcare provider will take a medical history and perform a physical exam, including a pelvic exam. Cells from your cervix (a Pap test) and urine and blood samples may be taken for lab tests. You may have an ultrasound exam to determine your stage of pregnancy. If you decide to have a TOP, your provider will tell you about any special steps you need to take before the procedure.

What types of procedures may be performed?

The type of procedure used for a TOP depends on the stage of pregnancy and the laws in the state in which you live.

• If it has been just 1 or 2 weeks since your period should have started, a menstrual extraction might be done. Medicine, such as the oral medicine mifepristone (Mifeprex, or RU 486), is another method that may be used within the first few weeks of pregnancy.
• If it has been less than 13 weeks since the first day of your last menstrual period, the most common procedure is vacuum curettage.
• The procedure most often used between the 13th and 21st weeks of pregnancy is a dilation and evacuation (D&E).
• For pregnancies after 16 weeks, medicines may be used to cause the uterus (womb) to contract and deliver the fetus and placenta (afterbirth).
• Be sure to discuss the possible side effects and complications of the type of procedure you have with your healthcare provider.

How are these procedures performed?

Menstrual extraction

Menstrual extraction is a procedure that can be done only very early in pregnancy. It can be performed in your healthcare provider's office.

For this procedure, your provider inserts a speculum into your vagina. A small tube is then placed into the womb through the cervix. (The cervix is the opening to the womb.) The tube is used to remove the pregnancy tissue from the womb with a syringe.

Medicines used early in pregnancy

Mifepristone (Mifeprex or RU 486) is a medicine you can take by mouth to cause a TOP. It is usually called the abortion pill. It may be used within 7 weeks of the first day of your last period. It ends the pregnancy by blocking one of the hormones you need to stay pregnant. The earlier in the pregnancy the medicine is taken, the more likely it is to be effective.

You will probably start having vaginal bleeding one or two days after you take mifepristone. Two days after taking the mifepristone you will take a medicine called misoprostol. This second medicine causes cramping of the uterus and helps empty the uterus.

After you have taken both medicines your healthcare provider may want you to have an ultrasound scan to make sure the TOP has occurred and all pregnancy tissue is gone.

For about every 100 women who use mifepristone, 1 woman has heavy bleeding. If you have heavy bleeding, you may need a surgical procedure called a D&C. The D&C is a scraping of the inside of the uterus. It removes any remaining pregnancy tissue and blood clots. It stops the heavy bleeding.

Mifepristone cannot be used if you have certain medical conditions. Discuss this with your healthcare provider.

Other combinations or types of medicines may be prescribed by your healthcare provider to end a pregnancy.

Vacuum curettage

A vacuum curettage is a surgical procedure performed in an operating room. It is also called a suction dilation and curettage, or suction D&C. Before the procedure you are given either local or general anesthesia. For local anesthesia you are given a shot deep inside the vagina into your cervix. The shot numbs your cervix. You may also be given a sedative through an IV to make you drowsy. If general anesthesia is used, you will be asleep during the procedure.

After the anesthetic has taken effect, your provider dilates, or opens, the cervix so a small plastic tube can be placed through it into the womb. This tube is attached to a vacuum pump. The pump suctions the pregnancy tissue from the womb. Your provider then uses a dull spoonlike instrument (a curette) to scrape the walls of the womb and be sure that all of the tissue has been removed. The procedure generally takes 10 to 20 minutes. You will then spend some time in the recovery room.

Dilation and evacuation (D&E)

A D&E is a surgical procedure performed if you are 13 to 21 weeks pregnant. Because the fetus is larger, the cervix needs to be opened more than for a vacuum curettage. To do this safely, the cervix may need to be prepared 24 to 48 hours before the procedure. At the office your provider will gently place some sticks into your cervix. The sticks are usually made from a type of seaweed called laminaria. The sticks absorb water from the body and cause the cervix to open up. After placement of the sticks, you usually go home. Your cervix will be examined the next day. If it has opened enough, the D&E will be performed. If not, a second set of sticks may be inserted and the D&E may be done the following day.

The D&E is performed in an operating room. General anesthesia is usually used, so you are asleep during the procedure. The procedure is similar to a suction curettage. After the sticks are removed, the cervix may be gently opened more with metal rods. The pregnancy tissue is removed with instruments and suction. You are given medicine through an IV to contract the uterus. The uterus is scraped to be sure the tissue has been removed. The procedure takes about 30 minutes. Afterward you will spend time in the recovery room.

Medicines and saline used for second-trimester TOPs

Certain medicines may be used for TOPs after the 14th to 16th weeks of pregnancy. These medicines cause contractions that lead to labor and delivery. Medically induced TOPs are usually done in the hospital.

The medicine used most often is prostaglandin E2 (also called PGE2 or prostin). Your provider places a suppository of the medicine in your vagina. The side effects of the medicine may be nausea, fever, and diarrhea. These side effects are temporary and can be controlled with other medicines.

A less commonly used procedure is a saline TOP (also called a saline abortion), which, like PGE2, causes labor and delivery. With this procedure the skin on your abdomen over the womb is numbed with a local anesthetic. Then saline (a salt solution) or another medicine is injected through the skin of your abdomen and into the amniotic fluid in the womb. This starts contractions leading to labor.

After the fetus is delivered by any of these procedures, you may need to have a dilation and curettage (D&C) to remove any pregnancy tissue remaining in the womb.

What happens after the procedure?

After each of these procedures, you are observed for 1 or more hours to check for complications. The length of time in recovery depends on the type of procedure you had and the method of anesthesia. In general, you may be observed for about 2 hours after a suction curettage, 4 hours after a dilation and evacuation, and 6 hours after a medically induced second-trimester TOP. If your blood is Rh negative, you will need a shot of RhoGAM. It will help prevent problems with future pregnancies.

When your healthcare provider determines that you are ready to go home, you may be given an antibiotic to prevent infection and a drug to contract the uterus. Your provider will tell you how long to wait until you may have intercourse again. You may discuss ways to prevent pregnancy, and your provider may prescribe a method for you. Someone should drive you home.

It is normal to have some cramping for a few days after the TOP while the uterus contracts to its normal size. It is also normal to have some small amounts of bleeding for several days. Other possible side effects from a medical TOP are:

• headaches
• nausea and vomiting
• feeling warm or having chills
• dizziness
• tiredness

Most women are able to return to their normal daily activities within a day or so after the TOP if there are no complications.

Make sure you follow all of your provider's instructions for care after the TOP, including a follow-up appointment.

What are the possible complications of a TOP?

TOPs performed by licensed healthcare providers are generally safe. The rate of complications from TOPs done by licensed providers is very low. Possible complications include:

• perforation (a tear that may happen if a surgical tool goes through the wall of the uterus), and possible injury to another nearby organ, which would require more surgery
• infection
• excessive bleeding
• failure to end the pregnancy
• psychological problems after the TOP
• scar tissue inside the uterus
• trouble becoming pregnant after several TOPs or after complicated TOPs
• problems with the development of the fetus if a medical TOP fails and the pregnancy continues

Report any of the following symptoms of possible complications to your healthcare provider promptly:

• severe abdominal pain
• fever over 100°F (37.8°C)
• dizziness or fainting
• foul-smelling discharge from the vagina
• bleeding that is more than a heavy period or consists of large blood clots
• signs of continued pregnancy such as breast tenderness, fatigue, and nausea

Some women become depressed after having a TOP. This may occur right after the TOP or weeks or months later. If you are feeling depressed, contact your provider to help you find support and counseling.