Written by Dr Ryan Lee, Consultant obstetrician and Gynaecologist Specialist

Discontinuation of pregnancy can be performed by either Medical Termination of Pregnancy (MTOP) or surgical evacuation of the uterus. MTOP involves ingesting two types of tablets that expel pregnancy tissues through the vagina.  Home MTOP, combined with mifepristone and misoprostol, is a safe, acceptable, and feasible process. This combined regimen has a high success rate, offering women an alternative method to surgical TOP, avoiding the associated complications, anaesthetic risks, and costs of the surgical option.

Termination of a pregnancy spanning longer than 24 weeks cannot be carried out unless it is necessary to save the life or prevent grave permanent injury to the physical or mental health of the pregnant woman. The termination of a pregnancy must be at the request of the pregnant woman and with her consent.

Women eligible to undergo TOP in Singapore include:

• A Singapore citizen or the wife of a Singapore citizen
• A work pass holder or the wife of a work pass holder, issued under the Employment of Foreign Manpower Act
• A person who has been a resident in Singapore for at least four months immediately preceding the date TOP is to be performed, unless it is immediately necessary to save the life of the pregnant woman

What does it involve?

• Mandatory TOP counselling

Under Singapore law, you must attend mandatory counselling before and after MTOP. A 48-hour “cooling-off” period after the counselling is required before the medications are given to you. You may change your mind at any time before the medications are ingested.

• Medications

You will be given TWO types of tablets for MTOP:

1. Mifepristone – It works by blocking the effect of progesterone, a hormone required for pregnancy to continue. Mifepristone alone can induce abortion in some patients (1%). You must return to take another dose if you vomit within ONE hour of taking mifepristone.
2. Misoprostol – It works by causing contractions of the womb and relaxation of the cervix which helps push the pregnancy contents out.

You will be given additional medications, which may include:

Antibiotics – They reduce your risk of an infection after MTOP. You should complete the course of antibiotics prescribed for you.

Painkillers – It relieves abdominal cramps. You may take this medication 30 minutes before misoprostol and as required.

Anti-D (Rhogam®) – If you have a Rhesus negative blood group, you may be given a prescription. You should get the injection within 72 hours of expulsion of the pregnancy tissues. This prevents you from forming antibodies that can affect the foetus in your future pregnancies.

Feticide – It should be performed in advanced pregnancies after 21+6 weeks of gestation (except for lethal foetal abnormalities) before the commencement of MTOP to ensure no risk of live birth.

Lactation suppression (oral cabergoline 1mg tablet one dose) – It should be given to women carrying pregnancies after 20+0 weeks of gestation, and discussed from the 16+0 week.

Women should be informed that if any of these complications occur, further treatment in the form of blood transfusion, laparoscopy, laparotomy or hysterectomy may be required. Women should be given information on follow-up plans, contraception, sexually transmitted infection (STI) screening, cervical cancer screening, and emotional and social support, where appropriate. 

Things to expect during MTOP include the following:

• Vaginal Bleeding

You can expect to experience vaginal bleeding within 4 hours of taking misoprostol. Bleeding can range from light to heavy and is usually heavier than a normal period. It should decrease after the pregnancy has been expelled. It lasts an average of  8 to 10 days.

• Abdominal Cramps

You can expect to experience abdominal cramps within 4 hours of taking misoprostol. Cramping can range from mild to severe and is usually more than a normal period. This should be reduced after the pregnancy has been expelled and may continue for the next few days.  Painkillers, massages and ample rest may help to relieve the pain.

• You may experience other common side effects like fever, nausea, vomiting, diarrhoea and dizziness.

What happens if the MTOP fails?

About 5-6 in 100 women who had an MTOP may not completely empty the pregnancy tissues from their womb. You may be given another dose of 600mcg misoprostol, or undergo a surgical procedure called ‘evacuation of uterus’ to remove the pregnancy tissues from your womb.

What happens after MTOP?

You should continue to use sanitary pads and not tampons. You should also avoid sexual intercourse until the bleeding stops to reduce the risk of infection.

Please seek immediate medical attention if you experience the following signs and symptoms:

• Fever more than 37.5▫C after 48 hours of misoprostol
• Foul smelling vaginal discharge
• Excessive bleeding i.e. soaking TWO pads an hour for TWO consecutive hours
• Excessive abdominal pain which is not relieved by painkillers given to you
• Feeling generally unwell

Each authorised medical practitioner shall provide post-abortion counselling to a woman who has had her pregnancy terminated.

Discussion about various contraception methods will be made if they are not ready for another pregnancy.

You will be given a follow-up appointment around 3 weeks after your MTOP. Please make sure to attend this appointment. It is important to confirm that the pregnancy tissues have been completely expelled during this follow-up appointment.

Features of medical and surgical TOP