Performing Second and Third Trimester Abortions: A South African Obstetrician and Gynaecologist’s Experience and Perspective

Background:  

  • In 1996, during the first wave of laws by the post-Apartheid parliament, the Choice on Termination of Pregnancy (CTOP) Act was passed in South Africa.  

  • Considered one of the world’s most liberal abortion laws, patients can chose to end a pregnancy at 12 weeks gestational age without restrictions. Further, nurses, midwives, and physicians are able to perform abortions up to 12 weeks. 

  • At 12 weeks through 20 weeks, a patient can only elect to terminate pregnancy in cases of fetal anomaly, rape or incest, risk to maternal physical or mental health, or if the pregnancy would have a negative economic/social impact on the patient.  

  • After 20 weeks gestational age, patients can chose to terminate a pregnancy if it poses a risk to maternal physical or mental health, risk of injury to fetus, fetal anomaly, mental disability, or continuous unconsciousness.  

  • Abortion procedures at 12 weeks, 1 day and beyond must be performed by a physician. 

  • Many people believe that the law only allows for abortion up to 24 weeks, however, there is no upper age limit. 

Later Abortion Procedures at Tygerberg Hospital: 

  • The legal language used in the CTOP Act is vague and therefore subject to wide interpretation. 

  • The policies and practices vary from hospital to hospital.  

  • Since 2014, Tygerberg Hospital has the following policy in place for the termination of a late-term pregnancy for fetal anomaly: “Termination of pregnancy (TOP) must cause (and ensure) the death of the fetus as the desired outcome, either before delivery or very soon thereafter (for TOP at a potentially viable gestation this will usually require a feticide procedure, unless the condition is uniformly and unequivocally lethal in the very short term).” 

  • Definitions of viability are institution specific in South Africa 

  • At Tygerberg Hospital, for example, a fetus is considered viable if it is >27 weeks gestational age and weighing 800 grams. 

  • Surgical abortions are not readily available to patients seeking second or third trimester abortions in most South African Hospitals with few institutions like TBH performing D&E generally to 20 weeks.(14 weeks and beyond). The following regimens were used previously and in many institutions still being used: 

  • 14- 24 weeks (medication abortion): 400mcg misoprostol 4-6 hourly po, vaginally, SL X6 doses. Then rest for up to 24 hours then repeat. Extra-amniotic F2α: intracervical balloon catheter (30cc Foley catheter) with 5mg F2α in 20ml with 1-2ml injected extra-amniotically every hr). Extramniotic Saline infusion. 

  • >24 weeks (unmonitored induction): misoprostol 100mcg 4hourly X6 doses, then rest 24 hours and repeat 

  • > 26 weeks: Misoprostol (oral dose of 50µg 4-hourly x 24 hours) if no contra-indications 

  • If medical induction fails, or the situation is urgent, patients undergo hysterotomy or c-section. 

  • These medical induction practices have changed in some institutions with the availability of mifepristone. Mifepristone is on the essential drug list but not available in all provinces in SA. In my institution our regimes are in keeping with best practices (i.e. RCOG and WHO) 

  • Feticide is offered only in cases of “severe malformation”, which includes “any abnormality of body or function that will have a severe impact on the quality of life of the infant” and ‘severe’ needs to be ethically justified by medical professionals who act with integrity 

  • Performed by 2 fetal medicine team doctors. 

  • Requires pre- and post-procedure counselling by genetist, social worker, ultrasonographers, and medical officers. 

  • Performed with an intra umbilical artery inject of a muscle relaxant. Potassium chloride injections are not available. 

  • There is currently only one doctor performing D&E procedures at Tygerberg. Another provider comes in once a week to perform procedures but she is not a staff member 

Problems with Performing Dilation and Evacuation for Late Abortion: 

  • Lack of access to laminaria for cervical ripening. 

  • The use of mechanical dilation with Hegar dilators, and not tapered dilators. 

  • It is difficult to keep the fetus intact for genetist evaluation. 

  • There have been cases of fetal expulsion with laminaria and mifepristone without misoprostol.