In one line
Termination of pregnancy and early pregnancy loss are managed with the same small toolkit — mifepristone, misoprostol and uterine evacuation — and in South Africa the consultant's job is as much to make a legal, equitable, complication-light service work under the Choice on Termination of Pregnancy Act as it is to pick the right regimen; the single most important principle is that safe abortion is harm reduction, and obstructing access (through delay, conscientious objection without referral, or under-trained providers) is itself a cause of maternal death.
This chapter assumes the early-pregnancy groundwork — dating, the discriminatory zone, viability criteria — and addresses running and defending a service. The mechanics of medical evacuation overlap almost entirely between an induced abortion and a spontaneous miscarriage, so the two are covered together; where the management forks it is on consent and legality, not on pharmacology. Rhesus prophylaxis is covered in depth at Rhesus alloimmunisation and the haemorrhage pathway at Postpartum haemorrhage; recurrent loss has its own dedicated work-up and is not re-derived here.
Mechanism & pathophysiology
Two drugs and one piece of physiology underpin the whole toolkit: a pregnancy is maintained by progesterone acting on the decidua and myometrium, and the cervix is a collagen gatekeeper that must soften before the uterus can empty without trauma.
Mifepristone is a competitive antiprogestin. It binds the progesterone receptor with higher affinity than progesterone itself but produces no agonist signal, so the decidua loses its progesterone support, undergoes necrosis and detaches; the trophoblast separates, and prostaglandin-degrading enzyme activity falls. Two further effects matter clinically: mifepristone softens and ripens the cervix, and it up-regulates myometrial prostaglandin receptors and gap junctions, priming the uterus so that a subsequent prostaglandin produces stronger, better-coordinated contractions. This is why mifepristone is given first and then a deliberate interval is left before the prostaglandin — the pre-treatment is what converts a sluggish, painful misoprostol-only evacuation into an efficient one.
Misoprostol is a synthetic prostaglandin E1 analogue. It binds myometrial EP2/EP3 receptors to drive contractions and, independently, breaks down cervical collagen to ripen the cervix. It is heat-stable, cheap, orally/vaginally/sublingually/buccally active and needs no cold chain — the single most important drug in a low-resource abortion and post-abortion service. Route changes the pharmacokinetics: oral gives a fast, short peak (more GI side-effects), while vaginal, sublingual and buccal give a slower, sustained exposure with higher bioavailability and are preferred for evacuation. Given alone it works, but less reliably and more slowly than when the uterus has first been primed by mifepristone — the entire logic of the combination regimen.
The same physiology drives a spontaneous miscarriage: progesterone withdrawal (here from a failing trophoblast) triggers decidual breakdown and prostaglandin-mediated contractions. So a missed or incomplete miscarriage is, mechanistically, a pregnancy that has already begun the antiprogestin cascade on its own — which is exactly why the same drugs complete it, and why mifepristone pre-treatment helps a missed miscarriage just as it helps an induced abortion.
The South African legal framework
In an SA exit exam this topic is examined as much on the Choice on Termination of Pregnancy Act 92 of 1996 (as amended by Act 1 of 2008) as on clinical method. The Act is one of the most liberal abortion laws in the world, and a consultant must be able to state its thresholds precisely.
| Gestation | Grounds | Who may perform |
|---|---|---|
| Up to and including 12 weeks | On request — no reason required | Medical practitioner OR a registered midwife/nurse who has completed the prescribed CTOP training |
| 13–20 weeks | On a stated ground: risk to the woman's physical or mental health; substantial fetal abnormality; pregnancy from rape or incest; or substantial socio-economic impairment | Medical practitioner only |
| After 20 weeks | Restricted: continued pregnancy would endanger the woman's life, the fetus has a severe malformation, or there is risk of serious fetal injury | Medical practitioner only, in consultation with another medical practitioner or midwife |
Four provisions reliably generate the curveballs:
- Consent is the woman's alone. No spousal, partner or parental consent is required at any gestation. A husband cannot veto, and cannot demand, a termination.
- Minors. A girl of any age who has the capacity for informed consent may consent to her own termination without parental assistance — this is the CTOP Act read together with the Children's Act 38 of 2005 (which sets the general medical-consent floor at 12 years with capacity). She must be advised to consult her parents, guardian or family, but a termination may not be refused or delayed if she chooses not to involve them. "Bring your mother first" is unlawful gatekeeping.
- The grounds in 13–20 weeks are stated, not adjudicated. The woman states the ground (e.g. socio-economic circumstances); the provider does not sit as a tribunal investigating its truth. The rape ground in particular does not require a police report, a J88, or proof — demanding any of these as a precondition is both unlawful and a recognised access barrier.
- Conscientious objection. A provider may decline to perform a termination on grounds of conscience, but the right is narrow: it does not extend to refusing emergency care, does not cover pre- or post-abortion counselling and care, and — critically — carries a duty to refer the woman without delay to someone who will help. An objector who obstructs, stalls or fails to refer is not exercising a protected right; they are creating the delay that pushes a first-trimester request into the second trimester (or out of the legal service altogether), and that delay is the mechanism of harm. Conscientious objection and the woman's right of access are reconciled by the referral obligation — the objector steps aside but does not block the door.
The gap between this permissive law and the service reality is the central SA story: a minority of designated facilities actually provide terminations, second-trimester services are concentrated and often distant, and the consequence is that women present later, travel further, or use unregulated misoprostol bought informally. The unsafe-abortion deaths the CTOP Act was written to prevent persist not because the law is restrictive but because access is patchy — which reframes "manage TOP" as a service-delivery and equity problem, not only a prescribing one.
Assessment
The pre-procedure assessment is deliberately lean — over-investigating is itself a barrier — but a consultant must know what genuinely changes management.
- Confirm and date the pregnancy. Gestational age sets both the legal pathway and the regimen. Ultrasound dating is ideal but not mandatory for early medical abortion where dates are certain and there are no red flags — WHO is explicit that routine scanning is not a prerequisite, and insisting on it where it is unavailable simply delays care. A scan is warranted when gestation is uncertain, ectopic is plausible (pain, prior ectopic, IUCD, suspicious bleeding pattern), or molar disease is suspected.
- Exclude ectopic before attributing bleeding/pain to an intrauterine process. A misoprostol regimen will not treat — and may mask — an ectopic. Where the pregnancy is of unknown location, follow the ectopic pathway rather than presuming a miscarriage or proceeding to evacuation; advanced and non-tubal ectopics carry their own management considerations beyond the scope of this objective.
- Rhesus status — and the modern reframing. Determine blood group, but appreciate that the indication for anti-D in early pregnancy has narrowed sharply (developed in the trials section). It is no longer a reason to delay an early medical abortion.
- Bloods are minimal. Haemoglobin where anaemia or significant bleeding is likely; no routine baseline panel is required for uncomplicated early abortion. HIV testing is offered as part of SA care, but a result is not a gate to the procedure.
- Screen the context, not just the uterus. Contraceptive intentions (so a LARC can be placed at the same visit), intimate-partner violence and coercion (is this her choice?), and — for a minor or a disclosed rape — the safeguarding and forensic pathways. The clinical encounter is often the only contact point, so the assessment is also a screening opportunity.