Termination of Pregnancy

Introduction

Termination of pregnancy (abortion) is a common procedure: around a quarter of pregnancies in England and Wales end in termination, making it one of the most frequently performed procedures in reproductive healthcare.¹ Care is provided predominantly by specialist services (both NHS-commissioned and independent sector providers such as BPAS and MSI Reproductive Choices), but every clinician should understand the legal framework, the available methods, and their duty regarding referral and conscientious objection, since patients may raise the topic in any setting.

In Northern Ireland, abortion was decriminalised in 2019 and is now governed by separate regulations rather than the Abortion Act 1967, with service provision that has developed differently from the rest of the UK; this article describes the framework in England, Scotland and Wales.²

Legal framework

The Abortion Act 1967, as amended by the Human Fertilisation and Embryology Act 1990, makes termination lawful only when two registered medical practitioners agree, in good faith, that the pregnancy meets one of the Act's specified grounds.³ The great majority of terminations are authorised under Ground C (continuing the pregnancy would involve greater risk to the physical or mental health of the pregnant woman than terminating it) or the equivalent Ground D accounting for existing children, both of which apply up to 24 weeks' gestation and are interpreted broadly in practice.

Other grounds have no gestational time limit, including where continuing the pregnancy would risk the woman's life, where there is a substantial risk of severe fetal abnormality, or to prevent grave permanent injury to the woman's physical or mental health.

The requirement for two doctors' signatures (HSA1 form) and treatment in an approved place are procedural safeguards under the Act; they do not require the woman to justify her decision beyond the clinical assessment made by the doctors against the relevant ground.

Assessment before termination

Assessment confirms gestational age (by last menstrual period and, where there is uncertainty or a discrepancy, ultrasound), explores the woman's decision-making without judgement, and screens for factors relevant to method choice and safety: medical history, current medications, allergies, and a sexual history including STI risk, since chlamydia screening (and treatment if positive) is routinely offered around the time of a surgical procedure to reduce the risk of post-procedure infection.¹

Counselling about the decision is offered but not mandatory, and must be non-directive - the clinician's role is to support an informed decision, not to steer the woman toward continuing or ending the pregnancy. Blood group and RhD status should be checked, since RhD-negative women require anti-D prophylaxis around the time of the procedure.

Medical termination

Medical termination uses mifepristone, a progesterone receptor antagonist that sensitises the uterus to prostaglandins and softens the cervix, followed 24-48 hours later by misoprostol, a prostaglandin E1 analogue that induces uterine contractions and cervical dilation to expel the pregnancy.⁴ This is the most common method for early gestations and is effective and safe across a wide gestational range with an appropriately adjusted misoprostol regimen for later gestations.

For pregnancies up to 10 weeks' gestation, both stages can typically be managed at home following a remote consultation, an approach ('telemedicine' or 'pills by post') introduced during the COVID-19 pandemic and subsequently made permanent in England, Scotland and Wales, having been shown to be safe, effective and preferred by many women.⁵ Bleeding and cramping are expected and can be significant; the woman is given clear safety-netting advice about when to seek urgent review, including heavy bleeding or signs of infection.

Surgical termination

Vacuum (suction) aspiration is used up to around 14-15 weeks' gestation, performed under local anaesthetic, conscious sedation or general anaesthesia, using gentle suction to evacuate the uterine contents through a cannula, usually after cervical preparation with misoprostol or osmotic dilators.

Dilatation and evacuation (D&E) is used for later gestations, requiring greater cervical dilation (again usually achieved with preparatory agents) before mechanical evacuation of the uterus, and is generally performed by practitioners with specific training in later gestation procedures.

Both surgical methods carry small risks of haemorrhage, infection, uterine perforation and, rarely, retained products of conception requiring further treatment. Anti-D prophylaxis is given to RhD-negative women having a surgical procedure (and to those having a medical termination beyond 10 weeks), because instrumentation of the uterus carries a risk of fetomaternal haemorrhage.

Choosing between methods

Medical and surgical methods have broadly similar success and complication rates in early pregnancy, and the choice is usually driven by patient preference, gestational age, and local service availability, rather than clinical superiority of one method over the other.⁴ Medical termination avoids anaesthesia and instrumentation but involves a period of bleeding and cramping managed largely by the woman herself, at home in most early cases, while surgical termination is typically completed in a single visit under sedation or anaesthesia but carries the (small) procedural risks of any uterine instrumentation.

Conscientious objection

Section 4 of the Abortion Act 1967 allows a healthcare professional to decline to participate in the treatment authorising or performing a termination on grounds of conscience, and this right is also reflected in GMC guidance.⁶ It does not extend to emergency treatment necessary to save the woman's life or prevent grave permanent injury, and it does not permit a clinician to obstruct or delay a woman's access to care - anyone exercising conscientious objection must ensure the woman is referred promptly to a colleague or service that will provide the care she needs, without judgement or delay.

Complications

Serious complications from termination of pregnancy are uncommon: haemorrhage requiring transfusion, infection, retained products of conception, and (specific to surgical methods) uterine or cervical trauma. Rates of complication rise with increasing gestational age, which is one reason earlier access to care generally carries a better safety profile, alongside being less invasive.

Red flags

Aftercare

A follow-up plan should confirm the termination is complete (by symptoms, low-sensitivity urine pregnancy testing at an appropriate interval, or ultrasound if there is any doubt) and address ongoing contraception, since fertility can return within as little as 2 weeks of a termination. Every termination consultation is an opportunity to start effective, ideally long-acting, contraception if desired, and this should be discussed and, where possible, provided at the same visit rather than left to a future appointment.