Dilemma: Late termination
A young woman presents to you in a busy surgery, and you calculate together that she is 26 weeks pregnant. She requests a termination. She is very distressed to find out that this is beyond the legal limit for termination. She states that if you do not help her to end the pregnancy that she will kill herself. She has a history of self harm. How do you proceed?
No decisions must be rushed, and she must be kept safe
Your first reaction to this might well be ‘nightmare scenario’. Mine certainly was and the important thing to acknowledge is that you will need to seek help. The issues here are psychiatric, obstetric and ethical.
It will be vital to take a thorough history, exploring the circumstances of the pregnancy, who the father is, what antenatal care she has received so far. What are her social and family support systems? Has she been in denial about the pregnancy? If she is under 16, there are child safeguarding issues and you will need to explore for evidence of any sexual abuse. Is she under a psychiatrist or CPN for mental health problems, and what is her history of self harm?
Once you have discussed the situation with her, it will be important to establish her dates accurately. An ultrasound scan as soon as possible will be helpful. You will need to discuss the difficulties with late terminations; the legal upper limit is 24 weeks but only a few specialised centres actually perform terminations after the first trimester. After 24 weeks, the decision to terminate involves further legal implications.
If you conclude that she is at serious risk of suicide, then the immediate referral will be to psychiatry. The on call psychiatry team can assess her risk on the same day and if necessary admit her. The obstetricians can then liaise on the ward.
If she can be persuaded to continue the pregnancy until term, one option would be for the baby to be adopted. No decisions must be rushed, and she must be kept safe, to ensure the best outcome for both mother and child.
Dr Fiona Cornish is a GP in Cambridge and president of the Medical Women’s Federation.
Double-check that she’s within the 24-week limit
This case may evoke emotions for the doctor: Why has she presented so late? Why was she not using any contraception? We need to consider how she might have got into that situation: was she trafficked? Is she in an abusive relationship so was not able to negotiate the pregnancy? Has her partner left her recently? Is she here in the UK illegally? Clearly there are psychosocial issues that might need addressing, whatever the outcome of the pregnancy.
Under UK law, abortion can only be performed within 24 weeks. It is important to ascertain the dates urgently by scan as it makes a huge difference what you can offer her. Your local abortion provider may be your first point of contact and may be able to arrange an urgent appointment. Other contingencies that need to be discussed include antenatal care, adoption and fostering.
Discuss risk of sexually transmitted infections and offer her a check; the tests can be self-sampled so it should not take much more of your time. This would also be a good opportunity to discuss future contraception including LARC; it may be enough to leave her with a range of leaflets if you are pushed for time.
This scenario highlights the risk of an already uncertain landscape of abortion provision in some parts of the UK. The NHS reform in England separates responsibility for contraception with Public Health England and local authorities but abortion commissioning is with CCGs. Thankfully late abortions are rare but these services should be available and easily accessible.
Dr Richard Ma is a GP in Islington, London, and former London sexual health champion.
If you have a conscientious objection, refer her on to a colleague without delay
The Abortion Act 1967 allows for abortion beyond 24 weeks if ‘it is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman or where the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated’ (Section 1 (b) and (c)).
The Act requires two medical practitioners to form an opinion in good faith that the termination is necessary, and an abortion must be undertaken by a registered medical practitioner.
You will need to discuss all the relevant options with the woman and, as the pregnancy is relatively far advanced, you may wish to refer the patient urgently to a pregnancy counselling service or local gynaecology department. Given her history of self harm, you may also want to consider referring her urgently for a psychiatric assessment in conjunction with advice from your local pregnancy service.
If you have a conscientious objection to abortion the GMC’s personal belief and medical practice guidance (2013) says you must tell the patient about her right to see another doctor, provide her with enough information to exercise that right, and not seek to impose your views on her. In this context, you should try to ensure she can see a colleague without delay.
This is a difficult dilemma and you may wish to seek advice from your medical defence organisation.
Dr Wendy Pugh is a medico-legal advisor to the MDU.