Therapeutic Termination of a Pregnancy

Understanding the Medical Indications for Ending a Pregnancy

Midwife checking woman's pregnancy in hospital
What are some of the reasons for a therapeutic termination of pregnancy?. Hans Neleman/Stone/Getty Images

If you've been told by your doctor that you need to consider ending a pregnancy for health reasons—sometimes called therapeutic termination—you’re very likely struggling with the news. We'll review the reasons so you can make the best decision in this difficult situation.

Facing a Difficult Decision

Therapeutic termination is also known as medically indicated termination or medically indicated abortion.

It is only recommended in cases where:

  • The fetus has a medical condition which is certain to result in death either before or shortly after birth.
  • The mother is risking death by continuing the pregnancy.

The decision to go ahead with a termination is usually very painful for parents. There are many things to consider, from your personal moral beliefs, to religious laws, state laws, and insurance coverage. As always, the choice is personal, and your doctor should not pressure you into any decision you are uncomfortable with. In most cases, you can take your time to decide.

Therapeutic Termination of Pregnancy

Before any decisions can be made, most parents want to thoroughly understand the reason a termination is indicated. The reasons are best broken down into two types: problems with the developing fetus or problems associated with the pregnancy.

Problems with the Fetus

The process by which a fetus develops is complex and intricate.

Even tiny changes in the process can dramatically affect the health and well-being of a baby.

There are spectrums of severity for some conditions. For example, one baby with amniotic band syndrome may only have a minor malformation of the fingers or toes, while another baby’s amniotic bands might restrict the umbilical cord, which is potentially fatal.

Not every defect is life-threatening. But some conditions are fatal.

If your baby is diagnosed with any of these conditions during routine prenatal testing, you may be offered a therapeutic termination:

  • Anencephaly - Early in development of an embryo, a flaw in the formation of the neural tube (which eventually becomes the brain and spinal cord) can result in a failure of the brain, skull and scalp to develop, a condition called anencephaly. In a fetus with anencephaly, the forebrain and cerebrum do not develop, and the remaining parts of the brain may not be covered by bone or skin. Although babies with anencephaly may live to full-term and be born alive, only basic functions like breathing are possible. They will never be fully conscious. Most of these babies only survive a few hours or days after birth.
  • Chromosomal AbnormalitiesChromosomal abnormalities are the genetic changes which are responsible for the majority of miscarriages and many stillbirths. They are generally random and do not repeat in subsequent pregnancies. (This is true unless the father or mother is affected by a genetic disorder called balanced translocation, which can lead to unbalanced translocation in a developing fetus.) Chromosomal abnormalities are a frequent indication for therapeutic termination.
  • Hydrocephalus - Hydrocephalus, or "water on the brain' is a condition which occurs when cerebral spinal fluid cannot flow properly between the ventricles in the brain resulting in a build up of pressure. Hydrocephalus has a range of causes. Independently, it is not usually life threatening, but if your baby is found to have excess fluid in the brain on ultrasound, you should have further evaluation to look for the related condition ventriculomegaly, and its associated causes.
  • Meckel Gruber Syndrome - Meckel Gruber syndrome is a rare genetic disorder that only occurs when both parents carry the recessive gene for it. Meckel Gruber results in a combination of congenital malformations that include a too-large fontanel (soft spot) in the front of the skull, polycystic kidneys and polydactyly (too many fingers or toes). The liver and lung development is impaired in this disorder, and it is always fatal. This is an indication for a therapeutic termination.
  • Pentalogy of Cantrell – This is a rare genetic disorder with five possible malformations. Most affected fetuses do not have all five, but the condition can be life-threatening even without all of them. These defects include: omphalocele (a defect in the abdominal wall which allows intestines to protrude outside the body), anterior diaphragmatic hernia (an internal muscle defect which can allow lower organs to intrude into the chest cavity), sternal cleft (a groove or cleft in the sternum), ectopia cordis (where the heart may protrude outside the body) and intracardial defect (a hole or defect in one of the walls of the heart). An ultrasound diagnosis of any of the possible malformations should be referred to a perinatalogist for a complete assessment and to form a treatment plan.
  • Potter’s Syndrome – This term may refer to the characteristic appearance of a baby without adequate amniotic fluid (the fluid or "water" that surrounds the baby inside the uterus) during pregnancy. It is more specifically applied to a fetus with bilateral renal agenesis (BRA, failure of the kidneys to develop). In cases of BRA, the condition is lethal and may be an indication for a therapeutic termination.
  • Thanatophoric Dysplasia – A genetic disorder that causes severe skeletal malformations. The skull, long bones and torso are affected. Although there have been rare cases of affected people surviving into early childhood, the condition is still largely considered lethal. This disorder is an indication for a therapeutic termination.

Be sure to discuss your diagnosis thoroughly with your physician. If possible, request to meet with a perinatalogist who has experience with your diagnosis.

It is important to know that none of these conditions requires you to have a therapeutic termination. Some women choose to carry a pregnancy as long as possible, potentially to full-term, and allow nature to take its course. You can choose palliative care at that time. If you decide to continue a pregnancy when your baby has a condition known to be fatal, you may want to seek out a program that specializes in palliative care for infants, and a consultation with a neonatologist who can explain your diagnosis fully.

Problems in the Pregnancy

Sometimes, during pregnancy, unexpected events threaten the life of the fetus or the mother. While these conditions do not always result in a pregnancy loss, there is a possibility that you will not want to, or be able to, continue your pregnancy.

  • Amniotic Bands – When strands of the amniotic sac detach from the sac, they can become wrapped around any part of a developing fetus. Complications can include amputations of fingers or toes, fused digits, clubbed feet and cleft lip. In more severe cases, amniotic bands can wrap around the head or umbilical cord and become life-threatening.
  • Maternal Conditions – Occasionally, women with severe medical problems become pregnant, and the biological stress of pregnancy would be dangerous, or deadly to her. These situations could include a woman with a severely compromised heart, or a new diagnosis of a dangerous cancer that requires immediate treatment. These cases are unusual and recommending a termination is not done lightly. Your doctor should thoroughly assess the risks and benefits of continuing your pregnancy, including your wishes, and work with you to choose a satisfactory treatment plan. It's important to note that it is possible for some women to receive chemotherapy during pregnancy, at least during the second and third trimester. If you are diagnosed with cancer during pregnancy it is important to work with both an obstetrician who specializes in high risk pregnancies, and an oncologist who is comfortable treating women who are pregnant.
  • Premature Rupture of Membranes - Premature rupture of membranes is a condition in which a woman's bag of waters (the amniotic sac) breaks before the pregnancy reaches full-term. There are many reasons why a woman’s bag of waters may break before the pregnancy reaches full-term. If it happens prior to 24 weeks gestational age, your physician may recommend a therapeutic termination because the lack of fluid will severely impair the normal development of your baby’s organs. There is also a high risk of infection for you, and if you become infected, ending your pregnancy may be the only cure.
  • Selective Reduction – In multiple pregnancies, there are circumstances where your doctor may recommend a selective reduction, or terminating one or more of the fetuses. This is intended to decrease risk to the other babies and/or the mother. For example, if in vitro fertilization is done and seven embryos implant, a woman may choose to "reduce" this to two or three in order to prevent the likely loss of all of the embryos.
  • Severe Pre-Eclampsia - Rarely, a woman can develop severe pre-eclampsia before a fetus is viable (can live outside the womb.") Because the only known “cure” for pre-eclampsia is delivery, it may be necessary to end your pregnancy to save your own life. Continuing a pregnancy with severe pre-eclampsia can lead to seizures, kidney failure, stroke, liver complications, and death.

Making a Decision About a Therapeutic Termination

After you understand the reasons why your doctor may recommend at termination, you may wish to review some of the pros and cons of ending a pregnancy for medical reasons or a poor prognosis.

As always, be sure you fully understand your situation and your treatment options, and if you have concerns, discuss them with your physician. A consultation with a perinatologist may help you make the right decision for you.

It's important to state again that there is not a right or wrong decision to make most of the time. The right decision is in fact the one that you feel most comfortable with after you fully understand your situation and have reviewed all of the possible options. This can be a deeply emotional time, especially if any of your loved ones have opinions that differ from yours or would make a different choice if they were in your shoes. You may have to firmly remind your friends and loved ones that you appreciate their thoughts and input, but that you must make the decision that both you and your partner feels are best for you.

When you make your decision, you will also need to decide who you will tell. Take some time to consider this decision thoughtfully. Know matter how caring and well meaning some friends may be, it is difficult to know what an individual would do in a situation such as yours unless they are forced to face it themselves. Many people have changed their thoughts about issues such as these when they themselves must face them.  If you do decide to share with others, choose those people who will be entirely non-judgemental of your choice, either way. At this time you need all the support your loved ones can share with you, not a discussion of what they may hypothetically do in a situation they have not faced.

Sources:

Cote-Arsenault, D., and E. Denney-Koelsch. ”Have No Regrets:” Parents’ Experiences and Developmental Tasks in Pregnancy with a Lethal Fetal Diagnosis. Social Science and Medicine. 2016. 154:100-9.

Creasy, Robert K. Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice. 7th Edition. Saunders. 2013. Print.

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