Clinical overview
Termination of pregnancy (TOP) in South Africa operates under the Choice on Termination of Pregnancy Act (Act 92 of 1996, amended 2008), one of the most progressive abortion laws globally. The Act permits TOP on request up to 12 weeks of gestation, on broader grounds (medical, fetal abnormality, mental/social, rape/incest) from 13 to 20 weeks, and on restricted grounds (serious fetal abnormality, threat to maternal life) after 20 weeks. Despite this legal framework, access in practice is uneven — many designated facilities are not functional, conscientious objection is widespread, and the result is that unsafe abortion remains a leading cause of maternal mortality in South Africa, particularly among adolescents and women living in rural areas.
The registrar must be able to: (1) understand the legal framework and ethical considerations; (2) counsel a woman seeking TOP without bias; (3) describe medical and surgical methods by gestational age; (4) recognise and manage complications of safe and unsafe abortion; (5) provide post-abortion contraception. The chapter integrates with sa-og-law (the Act details) and spontaneous-miscarriage (since incomplete TOP and incomplete miscarriage are managed similarly).
Core knowledge
The Choice on Termination of Pregnancy Act in summary
- Up to and including 12 weeks: TOP on request of the woman. No spousal/parental consent required. Minors must be advised to consult parents but cannot be refused if they do not.
- 13–20 weeks: TOP on grounds of risk to maternal physical or mental health, substantial risk of serious fetal abnormality, pregnancy from rape/incest, or socioeconomic circumstances.
- >20 weeks: TOP only on grounds of serious fetal abnormality, threat to maternal life, or severe fetal malformation. Two doctors must agree.
- Service must be provided in a designated facility.
- The Act has a conscience clause — clinicians may decline to perform TOP but must refer to a non-objecting provider; refusing to refer is unlawful.
Methods — by gestational age
First trimester (≤12 weeks)
Medical TOP (regimen aligned with WHO 2022 and SA NDoH).
First-trimester medical TOP: mifepristone and misoprostol with the gestational sac, uterus, and cervix labelled.
- Mifepristone 200 mg PO, followed by misoprostol 800 mcg vaginally/buccally/sublingually 24–48 hours later.
- If mifepristone unavailable: misoprostol-only regimen — 800 mcg vaginally/sublingually every 3 hours for up to 3 doses; less effective than combination (~85% vs ~95–98%).
- Effectiveness: ~95–98% with combined regimen up to 9 weeks; ~90% at 10–12 weeks.
- Pain control: paracetamol, ibuprofen, opioids if needed.
- Provided as outpatient/home where appropriate; safer for the patient than waiting for surgical access.
- Follow-up: at 2 weeks with urine pregnancy test or ultrasound to confirm completion. A persistent positive urine test at 2 weeks → exclude ongoing pregnancy or retained products.
Surgical TOP (manual vacuum aspiration, MVA, or electric vacuum aspiration, EVA).
- Under local anaesthesia ± conscious sedation; outpatient.
- Cervical priming with misoprostol 400 mcg sublingual 1–3 hours before, especially for nulliparous and >9 weeks.
- Effectiveness ~98%.
- Complication rate <1% (perforation, retained products, infection).
- Antibiotic prophylaxis: doxycycline 100 mg PO 12-hourly × 5 days, or single-dose azithromycin 1 g.
Second trimester (13–24 weeks)
Medical TOP.
- Mifepristone 200 mg PO, followed by misoprostol 400 mcg vaginally/sublingually every 3 hours from 24–48 hours later, until expulsion.
- Effectiveness ~95%.
- Pain control: opioids commonly required; PCA in some centres.
- Hospital-based.
Dilatation and evacuation (D&E).
- Surgical evacuation under sedation or general anaesthesia.
- Cervical preparation with mifepristone 200 mg + misoprostol 400 mcg, or osmotic dilators (laminaria, Dilapan).
- Performed by experienced operators.
- Lower morbidity than medical induction in skilled hands; but D&E expertise is limited in SA public sector.
Third trimester (≥24 weeks)
- Restricted indications (serious fetal abnormality, threat to maternal life).
- Feticide before induction (intra-cardiac potassium chloride or intra-amniotic digoxin) to avoid live birth, after ~22 weeks (some guidelines, ~24 weeks).
- Medical induction with misoprostol or mifepristone-misoprostol regimens.
- Mandatory multidisciplinary management; psychological support critical.
Special situations
- Previous caesarean section: medical TOP is safe in first trimester. In second trimester, reduce misoprostol dose (200 mcg every 4–6 h) due to risk of uterine rupture. RCOG: rupture risk ~0.3% with appropriately reduced doses.
- IUD in situ: remove before TOP.
- Bleeding disorders / anticoagulants: discuss with haematology; surgical method preferred in some cases.
- HIV: standard regimens; integrate with HIV care; ensure ART continuation; postoperative contraception planning.
- Adolescents: confidentiality, counselling, contraception, screening for safeguarding.
- Rape/incest: ensure forensic examination if recent, PEP HIV prophylaxis, STI screening, contraception planning, psychological support, mandatory reporting (Sexual Offences Act).
- Hyperemesis / severe maternal illness: hospital-based TOP, MDT input.
Complications
Of safe abortion (rare):
- Incomplete abortion (retained products) — manage with repeat misoprostol or surgical evacuation.
- Haemorrhage — uterotonics, evacuation if products retained, transfusion if severe.
- Infection / endometritis — antibiotics, evacuation if retained products.
- Uterine perforation (surgical method) — observe, laparoscopy if bleeding or visceral injury.
- Cervical injury (surgical method) — repair.
- Failed abortion / ongoing pregnancy — repeat procedure; counsel about future fertility.
Of unsafe abortion (still common in SA):
- Severe haemorrhage.
- Septic shock (E. coli, Clostridium perfringens, Group A strep).
- Uterine perforation with bowel injury.
- Tetanus.
- Acute kidney injury (sepsis or haemolysis).
- Long-term: infertility (tubal), chronic pelvic pain, Asherman's syndrome.
Septic abortion is a medical-surgical emergency. Management is per septic miscarriage section plus aggressive source control: IV broad-spectrum antibiotics, surgical evacuation of any retained products, urgent ICU input, sometimes hysterectomy.
Assessment
Counselling consultation
A non-directive, supportive consultation is essential. Bias — pushing the woman toward or away from TOP — is unethical.
- Confirm pregnancy (β-hCG + ultrasound for dating).
- Explore decision: is she certain? What's prompting this? Any pressure from partner or family?
- Explain options: continue pregnancy, adoption, TOP. Present each with respect.
- For TOP: explain methods, what to expect, risks, recovery, follow-up.
- Discuss contraception for after — initiate at the time of TOP where possible.
- Screen for STI, HIV, anaemia.
- Confirm she is not being coerced — particularly in adolescents and women in abusive relationships (gender-based-violence).
- Allow time; do not push the same-day decision.
Investigations
- Confirm pregnancy and gestational age (LMP + ultrasound).
- Rh status — anti-D for Rh-negative women per local protocol.
- HIV, syphilis, hepatitis screening.
- FBC.
- STI screen (chlamydia/gonorrhoea) — pre-procedure or treat empirically with prophylactic antibiotics.
Management
Pre-procedure
- Informed consent: discuss method, success rate, complications, what to expect.
- Antibiotic prophylaxis.
- Anti-D for Rh-negative.
- Choose method based on gestation, patient preference, comorbidities, access.
During procedure
- Adequate analgesia.
- Monitor for haemorrhage, pain, vital signs.
- Surgical: confirm complete evacuation (suction contents, ultrasound if needed).
- Medical: counsel that bleeding may be heavy; ensure clear instructions on when to seek help.
Post-procedure
- Discharge with contraception initiated.
- Clear written instructions: expected bleeding, warning signs (heavy bleeding > 2 pads/hour for >2 h, fever, foul discharge, severe pain).
- Follow-up at 1–2 weeks: confirm completion, address contraception adherence.
- Address mood: TOP is not associated with increased depression risk (large evidence base), but for individuals it can be emotionally complex; offer support.
Post-abortion contraception
- All methods can be started immediately.
- LARC (IUD, implant) ideal — insertion at the time of TOP (or immediately after for medical TOP at the follow-up visit).
- Combined pill, progestogen-only pill, injectables — start day 1 if confirmed not pregnant.
- Sterilisation (laparoscopic or hysteroscopic) can be offered with appropriate counselling.
- See contraceptive-modalities for full discussion.
Red flags / pitfalls
- Conscientious objection without referral — unlawful in SA.
- Refusing TOP to a minor — the Act permits this; do not require parental consent.
- Inadequate cervical priming in surgical TOP > 9 weeks — increases perforation risk.
- Misoprostol full dose in previous CS women in second trimester — reduce dose.
- Missing septic abortion — fever + retained products + tender uterus = emergency.
- Discharging without contraception — repeat TOP rates high without proactive contraception planning.
- Not screening for HIV/STI — missed opportunity.
- Failing to recognise coercion — explore "decision-making process" carefully.
- Forgetting safeguarding in adolescents.
- Inadequate analgesia in second-trimester medical TOP — opioids commonly needed.
Evidence anchors
- South African Choice on Termination of Pregnancy Act, 1996 (Act 92 of 1996, amended 2008).
- South African National Department of Health, Clinical Guidelines for Implementation of the Choice on TOP Act (latest edition).
- WHO Abortion Care Guideline (2022) — comprehensive global standard.
- WHO Safe Abortion: Technical and Policy Guidance for Health Systems (3rd ed.).
- RCOG/FSRH/BASHH Best Practice in Abortion Care (2022).
- ACOG Practice Bulletin No. 225 — Medication Abortion Up to 70 Days of Gestation.
- Ipas — Manual Vacuum Aspiration training materials.
- Cochrane Review: Medical methods for first-trimester abortion (Kulier, von Hertzen et al.).