Mid-gestational abortion for medical or genetic indications

Women who have major medical complications, such as cardiovascular conditions leading to cardiac, renal, or cerebral impairment, which interfere with their lifestyle or who have fetuses with major malformations or chromosomal abnormalities are eligible for pregnancy terminations before the fetus has reached a viable stage. Any method for uterine evacuation may be offered at any time if the woman's life is threatened or if the fetal chromosomal abnormality (e.g. triploidy) or malformation is considered to be definitely incompatible with life. Such malformations would include bilateral renal agenesis, anencephaly, lethal forms of chondrodysplasia, holoprosencephaly, and severe pulmonary hypoplasia. Prostaglandin vaginal suppository therapy is the primary method for cervical dilation and induction of uterine contractions at most perinatal centres. This therapy is particularly useful when a fetal abnormality is suspected, since the fetus is usually delivered intact for gross and histological evaluation. Postmortem findings are helpful to the parents and other family members for future childbearing and family history. Disadvantages of such therapy include side-effects from the medication, prolonged labour discomfort, and delivery of a viable rather than stillborn infant. A surgical dilation and evacuation of the uterus may be undertaken between 12 and 20 weeks' gestation for women with prior uterine surgery, contraindication to prostaglandin use, no future childbearing being desired, and a fetus having a known lethal chromosomal abnormality (e.g. trisomy 13 or 18). This form of therapy is rapid, less painful, and fetal blood and tissue may be gathered for analysis although complete morphological examination of the fetus is not possible. Instillation of hypertonic saline or urea is no longer widely used for pregnancy termination, although intra-amniotic urea may be used adjunctively. Prolonged instillation-to-evacuation times and potential metabolic concerns are limitations. This therapy may be particularly useful when a stillborn infant is desired or when prior prostaglandin therapy has been unsuccessful. Abdominal operations such as hysterectomy or hysterotomy are also unnecessary unless there is an accompanying gynaecological complication or unless other pregnancy termination methods have been unsuccessful or unavailable. Women experiencing mid-gestation pregnancy terminations undergo a grief process which involves disbelief, sadness, guilt, anger and acceptance before and after the pregnancy termination. This is common and understandable. Parental counselling is recommended both before the procedure and several weeks thereafter.