Medical termination of pregnancy (IMG), or therapeutic abortion, consists of terminating a pregnancy for medical reasons. It can be performed at any time during pregnancy, by the decision of the parents or of the pregnant woman alone.
When and why to perform an IMG?
Medical termination of pregnancy can be performed, regardless of the expected delivery date:
- if the pregnancy seriously endangers the health of the pregnant woman (10 to 20% of cases, depending on Health Insurance – source 1);
- if there is a high probability that the unborn child will have a particularly serious condition recognized as incurable at the time of diagnosis.
“There is no exhaustive list of pathologies, but they must be particularly serious and recognized as incurable at the time of diagnosis”, explains Laurence Pavie, a midwife at the Maternity of the Diaconesses (Paris).
It can be practiced until the end of pregnancy, at the request of the couple or the pregnant woman, but authorization must be issued by a multidisciplinary team. “The medical team is required to inform the parents beforehand of the consequences of the pathology on the baby and of the alternatives to IMG so that they can make their decision in an informed way”, adds the midwife. The couple (or the pregnant woman) can ask for several medical opinions to help him in his decision-making.
IMG: a difficult time for reflection, but essential
Depending on the maternity hospitals and the level of training of doctors and midwives, the information given is not always complete. And the parents, shocked by the announcement of the diagnosis, are not necessarily able to assimilate them.
“Excluding a medical emergency, a period of eight days is theoretically expected between the time of the announcement of the diagnosis and that of the IMG, with an interview between the two where the entire protocol is explained to them. This time is important so that they have time to think, to ask all the questions they wish, possibly to contact associations and, through them, parents who have been there “, specifies the midwife.
A time when they can also prepare for welcoming the baby: will they want to see him after childbirth? Take him in their arms? Dress him up? Take a picture of it? Have they planned a first name? Do they want to take care of the funeral? “None of these acts is imposed, but all seem necessary to me, because they humanize the birth, underlines Fabienne Sardis, psychoanalyst psychologist at the maternity of the Deaconesses. Otherwise, the parents risk feeling guilty after the fact, without ever being able to go back”
What is the procedure for obtaining a medical certificate from IMG?
Once the wish for an IMG has been formulated by the mother or by the couple, the obstetrician-gynecologist who follows the pregnancy submits the request to a multidisciplinary medical team.
If the IMG is performed to preserve the health of the woman
When the IMG is requested to preserve the safety of the pregnant woman, the request is reviewed by a multidisciplinary team comprising at least four people :
- a doctor qualified in obstetric gynecology, member of a multidisciplinary prenatal diagnosis center,
- a doctor chosen by the pregnant woman,
- a psychologist or a social worker bound by professional secrecy
- and one or more practitioners specializing in the condition from which the woman is affected.
Of Additional tests are carried out to establish the seriousness of the situation.
IF the IMG is performed due to a fetal malformation
If the unborn child has a serious condition that requires an IMG, the patient is sent to a multidisciplinary prenatal diagnosis center (CPDPN). It is supported by a medical team made up of at least:
- an obstetrician-gynecologist who has to work in a health establishment,
- a doctor specializing in neonatal pediatrics,
- a doctor specializing in fetal ultrasound
- and one (or more) specialist in medical genetics.
Of Additional tests can be done to confirm the diagnosis of fetal malformation.
How is the decision made?
At the request of the parents of the pregnant woman, the decision to medically terminate (or not) a pregnancy is taken by the multidisciplinary team. After consultation, if they consider that the risks are justified, the professionals establish a medical certificate allowing to practice the IMG.
“The voluntary termination of a pregnancy can, at any time, be practiced if two doctors who are members of a multidisciplinary team certify, after this team issued its advisory opinion, either that the continuation of the pregnancy seriously endangers the health of the woman, either there is a high probability that the unborn child will have a particularly serious condition recognized as incurable at the time of diagnosis “, specifies Article L2213-1 of the Public Health Code (source 2).
Note: the pregnant woman (alone or in a couple) can ask to be heard beforehand by the members of the team.
There are two methods of medical termination of pregnancy
Medical termination of pregnancy requires hospital treatment.
Most of the time, the medical termination of pregnancy is carried out by initiating childbirth by natural means (which avoids weakening the uterus by a surgical gesture). Different drugs can be combined, in varying ways, depending on the term of pregnancy, the woman’s state of health, her gynecological and obstetrical history, and any contraindications (source 3).
“These drugs trigger contractions and the procedure can be quite painful “, underlines Laurence Pavie. epidural anesthesia can therefore be scheduled (it is preceded by a pre-anesthetic consultation).
A surgical technique of IMG can also be considered by the medical team: curettage (aspiration), even cesarean section.
“When the pregnancy exceeds 22 to 24 weeks of gestation (no rules), a fetic anesthesia is recommended before the onset of childbirth, in view of knowledge about pain in the fetus “, indicates Health Insurance (source 3). Protocols vary from one team to another. Most often, it consists of to be injected into the umbilical cord a numbing or pain-relieving drug then a feticide drug (causing the fetal heart to stop, in utero).
What procedure after a therapeutic abortion?
- First, a injection of anti-rhesus serum is performed for all women whose blood group is rh negative and who had a fetus with a rh positive blood group.
- An autopsy and additional examinations on the placenta are offered after the IMG to find or confirm the causes of fetal abnormality, but the decision to perform them or not is up to the parents.
- For pregnancies over 15 weeks of gestation (13 weeks pregnant), treatment may be prescribed to facilitate the aftermath of childbirth and prevent the flow of milk.
- Psychological follow-up is systematically offered.
Parents need to be supported and accompanied
The mourning process is gradually settling in: “Intense at the beginning, the pain, the guilt, the loss of appetite and sleep, the anxieties, are dulled as the parents move towards other investments, other projects”, reassures Fabienne Sardis. Do you need to be accompanied by a shrink?
“I think that after an IMG, at least one interview is necessary if only to know what perinatal bereavement is and to find benchmarks in this situation where we have none”.
What parents need most is a strong support from loved ones. Perhaps the most difficult thing for those around them is to dare to talk about it with their parents. “But to dodge the subject, as if it were taboo, can also be very awkward, says Laurence Pavie. leave space for the couple to speak (especially the mother), and to tell them, by small gestures, small attentions, like a kind word on the anniversary date of his birth, that their child has not been forgotten “.
One thing is certain, there is a before and an after IMG: “It is terrible parenthood to decide to interrupt the life of your child, insists Fabienne Sardis. An ordeal that changes a woman, a couple, forever.”
(1) Understanding the medical interruption of pregnancy, Health Insurance
(2) Article L2213-1, Public health code, Légifrance
(3) Progress of a medical interruption of pregnancy (IMG), Health Insurance