Conditions and Treatments

Medical Termination of Pregnancy (TOP) - What it is

What is Medical Termination of Pregnancy (TOP)?
Medical TOP is a procedure which involves taking medication that will end your pregnancy. This can be done at any gestation up to 23 weeks and 6 days, dated by ultrasound scan.

Abortion at 24 weeks or beyond is prohibited by law in Singapore.

What does Medical TOP involve?

Mandatory TOP counselling
You will need to attend a mandatory counselling before the TOP. A 48-hour cooling off period is required by the Singapore law before the TOP is performed.
Medications
This involves two parts, taking two types of medication, 24-48 hours apart. The first part involves swallowing a medication, mifepristone, in the clinic. This medication blocks the effects of progesterone, a hormone that is required for a pregnancy to continue.

Mifepristone alone can induce abortion in some patients (1%). You need to take another dose if you vomit within ONE hour of taking mifepristone. There is a risk of adverse effects on fetal development and growth if pregnancy is continued after taking mifepristone.

The second part involves placing a second set of tablets, called misoprostol, 24-48 hours after taking mifepristone, inside your mouth beside the cheek and teeth, under your tongue or into the vagina. These tablets cause contractions of the womb and relaxation of the cervix which help push the pregnancy tissues out.

If you are carrying a pregnancy of less than 10 weeks, you will be given up to TWO doses of misoprostol tablets, four hours apart. Approximately 95-96% of women will pass out the pregnancy tissues within 4-6 hours of taking misoprostol tablets.

If you are carrying a pregnancy of more than 10 weeks, you will be given misoprostol tablets every 3-4 hours, up to 10 doses, until the pregnancy is expelled. Most women will spend 1-2 nights in the hospital. Majority of the pregnancies (more than 90%) will abort after these medications.

You will be asked to use bedpans when you go to the toilet so that any pregnancy tissues can be observed by the nursing staff. If the pregnancy has not been expelled, your doctor will discuss other options with you.
Expulsion of fetus / pregnancy tissue
Once the fetus / pregnancy tissue is expelled, you will be assessed to determine if some parts of the pregnancy (e.g. placental tissues) are still left inside the womb. Should there be any, you may sometimes require a minor surgery under anaesthesia to remove the retained parts. A separate consent for the procedure (evacuation of uterus) will be taken.
Feticide
This is only advised if your pregnancy is more than 22 weeks gestation and is performed before misoprostol tablets are given to you as per our hospital guidelines. This procedure is carried out in a scan room. Under ultrasound guidance, the doctor will administer an injection into the fetal heart to stop the heartbeat. This is to avoid the risk of the fetus being born with signs of life.

What if I have had a womb surgery?
If you have had a previous caesarean section or surgery to the womb, such as fibroid removal surgery, you are at higher risk of experiencing rupture of the scar on your womb during the procedure (1%). You will be sent to the High Dependency Unit (HDU) during the abortion process for closer monitoring.

What should I expect?

Abdominal cramps
You can expect to experience abdominal cramps even within 4 hours of taking misoprostol tablets. Cramping can range from mild to severe. Average pain score reported on a pain scale is between 3-5 out of 10. This should reduce after the pregnancy has been expelled and may continue for the next few days. You may ask for painkillers in tablet form or injection in the ward should you require them.
Vaginal bleeding
You can expect to have vaginal bleeding even within 4 hours of taking misoprostol tablets. It may be heavier than a period and should decrease after the pregnancy has expelled. Excessive bleeding is uncommon (<1%) but may rarely require a blood transfusion.
Other common side effects
You may experience fever, nausea, vomiting, diarrhoea, and dizziness during the process. These are side effects of misoprostol tablets. These will usually settle after a few hours.

When should I seek medical attention?
Medical TOP is generally safe. However, complications such as retained pregnancy tissues and infection can still happen. If you experience any of the below symptoms, you should return to the hospital for medical assessment:

Excessive vaginal bleeding
If you experience heavy bleeding (TWO pads an hour for TWO consecutive hours)
Abdominal pain
If you experience severe lower abdominal pain not relieved by painkillers prescribed
Fever
Foul-smelling vaginal discharge
Feeling generally unwell

Additional Information
Your doctor will also prescribe additional medication:

Antibiotics
Up to 1 in 10 women will get an infection after a medical TOP. Taking antibiotics can reduce your risk of getting infection. You should complete the course of antibiotics prescribed to you.
Painkillers
You will be given some painkillers, to be taken as required for abdominal cramps.
Cabergoline
You may be prescribed cabergoline tablets to stop breast milk production if your pregnancy is more than 20 weeks gestation.

You should continue to use sanitary pads (not tampons) until your next period.

Your doctor will discuss with you about various contraception methods to prevent an unplanned pregnancy. You may refer to to the contraceptive leaflet for more information. Most contraceptive methods can be started immediately after an abortion.

A blood test will be done to determine your blood group before the TOP and you may be given an anti-D immunoglobulin injection if you have Rhesus negative blood group. This injection is given within 72 hours of the abortion.

Some women may experience long-term emotional problems after TOP. This includes feeling of sadness, guilt or regret. You should talk to your doctor about these feelings.