Medical Abortion (Termination of Pregnancy) 

Introduction

Termination of pregnancy (TOP) is a legally regulated procedure in Zambia under the Termination of Pregnancy Act, 1972 (Cap 304). It refers to the induced abortion of a pregnancy carried out by a registered medical practitioner, in consultation with at least two other registered medical practitioners, one of whom must be specialized in the relevant medical field necessary for assessment.

TOP is an essential reproductive health service that must be performed safely, respecting the legal framework and clinical guidelines to minimize morbidity and mortality.

Legal and Ethical Framework

• Lawful grounds for TOP in Zambia:

  1. Risk to the life of the pregnant woman.

  2. Risk of injury to the physical or mental health of the pregnant woman.

  3. Risk of injury to the existing children of the pregnant woman greater than the risk if the pregnancy were terminated.

  4. Substantial risk that the child would be seriously handicapped if born.

• Key ethical considerations:

  • Consent from the woman is mandatory.

  • If under 18 years, parental or legal guardian consent is required, but the best interest of the minor prevails.

  • Woman’s decision overrides that of the spouse/partner in cases of disagreement.

  • All services should be offered confidentially and with respect to the woman’s autonomy.

Eligibility Criteria

Women are eligible based on gestational age:

1. ≤12 weeks gestation – eligible if:

   • Pregnancy resulted from rape or incest

   • Substantial risk of severe foetal abnormality

   • Continued pregnancy poses a risk to maternal physical or mental health

   • Continued pregnancy significantly affects social or economic circumstances

2. ≥12 weeks gestation – eligible if:

   • Continued pregnancy endangers the mother’s life

   • Risk of foetal injury or severe malformation

Setting and Facility Requirements

• Public health facilities are legally obligated to provide abortion services.

• Private health facilities registered with the Health Professions Council of Zambia (HPCZ) offering reproductive health services may provide TOP.

• All procedures must be conducted in hygienic environments by skilled and trained personnel (doctors, midwives).

General Measures Before TOP

1. Certificate of opinion (A or B) completed within 24 hours (certificate B).

2. Pre- and post-termination counselling provided.

3. Informed consent for TOP and related procedures (MVA, laparotomy).

4. Medical history and examination, including bimanual pelvic examination.

5. Anti-D immunoglobulin offered to Rh-negative, non-immunized women after expulsion.

6. Contraception counselling and provision post-TOP.

7. Screen for ectopic pregnancy in women with positive pregnancy test and bleeding/pelvic pain.

   • Investigations: urine pregnancy test, Hb if anaemic, ultrasound to confirm gestation/foetal viability/ectopic pregnancy.

Uterine Evacuation Procedures

1. First-Trimester (<12 weeks)

• Surgical: Manual Vacuum Aspiration (MVA), Electric Vacuum Aspiration

• Medical:

  • Mifepristone 200 mg PO → Misoprostol 800 μg PV/SL 24–48 hours later

  • If no expulsion within 4 hours: second Misoprostol dose 400 μg PO or PV

2. Second Trimester (>12 weeks)

• Preferred methods: Medical abortion or Dilatation & Evacuation (D&E) after cervical priming

• Cervical preparation:

  • Misoprostol 400 μg PV 1–3 hrs before MVA or D&E

  • Osmotic dilators ± Mifepristone for 1–2 days if cervix stenotic or patient <18 years

• Analgesia: Paracervical block if trained, or oral analgesia (Paracetamol 1 g PO 4–6 hrly, Ibuprofen 400 mg PO 8 hrly)

Drug Protocols

Mifepristone + Misoprostol (Recommended)

Misoprostol-Only Protocol (If Mifepristone unavailable)

• Similar dosing schedules with Misoprostol, adjusted by gestational age and route.

• Notes:

  • Vaginal bleeding: avoid PV route

  • Home use allowed ≤12 weeks with counselling

  • Facility-based care recommended >12 weeks

Pain Management

• After Mifepristone: Paracetamol 1 g PO 4–6 hrly (max 4 doses/24 hr)

• After expulsion: Ibuprofen 400 mg PO 8 hrly with/after meals

• Analgesia and para-cervical block during MVA as indicated

Post-TOP Care

1. Anti-D immunoglobulin for Rh-negative women:

   • <12 weeks: 50 μg IM

   • ≥12 weeks: 100 μg IM

   • Preferably within 72 hrs (up to 7 days acceptable)

2. Contraceptive counselling and initiation before discharge

3. Follow-up: 7 days post-TOP; urgent ultrasound if bleeding persists

4. Emergency access: 24-hour contact and referral system

Referral Criteria

• Gestation ≥12 weeks or uncertain

• Suspected ectopic pregnancy or early pregnancy complications

• Comorbidities: heart disease, asthma, diabetes, clotting disorders, seizure disorders, hypertension

• Large fibroids affecting gestational assessment or procedure

• Signs of sepsis: tachycardia, hypotension, fever, offensive vaginal discharge

• MVA unavailable or patient declines

Late Second-Trimester Terminations

• Must be performed in hospital obstetrics/gynecology units

• Requires hospitalization, clear evidence-based protocols, and bereavement counselling

• Patient counselling must include:

  • Possibility of surgical intervention if medical methods fail

  • Risk of expulsion of live foetus

Summary / Key Points

1. Legal, safe, and timely access to TOP reduces maternal morbidity/mortality.

2. Eligibility depends on gestation, maternal health, and fetal condition.

3. Medical abortion preferred in early gestation; MVA/D&E preferred in later gestation.

4. Pain management, counselling, and follow-up are essential.

5. Referral and emergency protocols must be in place for complications.

6. Post-TOP contraception is critical to prevent unintended pregnancies.