Medical termination of pregnancy (IMG)

What differentiates Medical Interruption of Pregnancy (or therapeutic abortion) fromAbortion : it is the absence of choice.

Framed by the Veil law n ° 75-17 of January 17, 1975 on the right to abortion, IMG or therapeutic abortion, tends to terminate a wanted and desired pregnancy for medical reasons. This is in the interest of the mother in the event of a dangerous pregnancy, or of the fetus suffering from a malformation or an incurable disease.

Prenatal diagnosis has become, since the Perruche judgment, a major issue for both mothers and health professionals. It is for not having been able to detect this risk of fetal malformation nor to give the mother the possibility of performing an IMG that the doctors saw their liability incurred for failure to comply with their information obligation.

The development of prenatal diagnosis and the specialization of physicians have enabled great progress in fetal medicine. The latter work in multidisciplinary centers for prenatal diagnosis created by decree n ° 97-578 of May 8, 1997.

These multidisciplinary centers (CPDNP) whose missions are framed by decree n ° 2006-1661 of December 22, 2006, have a center of clinical, ultrasound and biological skills, the aim of which is to promote access to antenatal screening.

They intervene in particular:

• In case of affection or suspicion of affection in an embryo or a fetus, or in cells taken from an embryo in vitro
• To provide theoretical and practical training for practitioners involved in prenatal diagnosis.
• To provide advisory opinions when requesting an IMG as well as attesting to the indication of an IMG.

Law n ° 94-653 of July 30, 1994 associates the specialist doctors of these centers with the IMG procedure under the conditions set out in article 2313-1 of the public health code.

Law n ° 2001-598 of July 2001 and decree n ° 2002-778 of May 3, 2002 modified the procedure to promote consultation and offer a more human framework to women confronted with IMG by allowing them to choose their doctor. , to be accompanied by psychologists, associations ...

The IMG can be performed for two reasons: The interest of the mother or that of the fetus. Hence the need to clearly distinguish the two applicable procedures.

The mother's interest

It is about ending a pregnancy that endangers the health and even the life of the mother.

The procedure

According to article R. 2213-1 of the public health code “ When a pregnant woman plans to have an IMG on the grounds that the continuation of her pregnancy seriously endangers her health, she requests it from a doctor specializing in gyneco-obstetrics (...) ».

It is therefore the mother who must make the request to an obstetrician gynecologist practicing in a public or private health establishment under the conditions of article L.2322-1 of the public health code.

The doctor contacted the team at the Multidisciplinary Prenatal Diagnosis Center (CPDNP) for an opinion. This team is made up of:

• A doctor specializing in obstetrical gynecology
• A doctor chosen by the woman
• A psychologist or social worker

Before the consultation, the parents or the mother can ask to be heard by one or more members of the team.

After the consultation, minutes of the meeting will be drawn up. If two doctors recognize that the continuation of the pregnancy seriously endangers the health of the woman, the multidisciplinary team will establish a certificate.

All these documents, the report, the certificate and all the examination reports will appear in the mother's medical file which will be kept by the CPDNP.

The IMG will be performed by medication or surgery at any time even after the 12th week of pregnancy and therefore, at a very advanced stage of pregnancy.

Fetal malformation

Framed by law n ° 94-653 of July 29, 1994 relating to respect for the human body, the IMG can only be considered if it exists " a high probability that the unborn child will have a particularly serious condition recognized as incurable at the time of diagnosis ».

The legal definition

Although there is no exhaustive list, the following will be retained as a particularly serious fetal condition:

Chromosomal abnormalities - Ultrasound malformations (for which treatment will be either palliative or impossible) - Disabled genetic diseases - Syndromes or sequences identified - Serious congenital infections - Pathologies of twin pregnancies (STT, etc.) - Environmental pathologies (drugs, alcohol, etc.)

Ultrasound malformations can affect all organs including: Malformations of the nervous system (anencephaly, spina bifida, etc.) - Malformations of the heart and large vessels - Malformations of the bilateral reno-urinary system - Malformations of muscles, bones, of the limbs - Malformations of the abdomen and walls - Edemas, hydrops, tumors of the soft parts - Malformations of the genitals - Extreme growth delays in utero (…)

To know :

IMG cannot be considered for malformations that can be operated on from birth.

The procedure

The request is made by the mother to the obstetrician gynecologist who follows her to forward it to the Multidisciplinary Center for Prenatal Diagnosis (CPDNP).

A prenatal diagnosis will be performed by two doctors, one of whom must be recognized as an expert by the Court of Appeal or the Court of Cassation.

Article R. 162-19 of the public health code specifies that the multidisciplinary team must include two doctors specializing in fetal diagnosis, that is to say: an obstetrician gynecologist, a sonographer, a geneticist or a pediatrician of the Center.

Several examinations can be carried out to establish the prognosis: These could be in utero procedures such as punctures of trophoblasts, amniocentesis (karyotype, FISH, search for pathogenic germs, etc.), fetal blood punctures, blood transfusions. utero… And depending on the fetal pathology, several other practitioners will be able to intervene: Cardiopediatricians, urologists, pediatric neurologists, “digestive” surgeons…

This involves establishing a precise diagnosis, explaining the pathology to the parents and, above all, discussing the prognosis.

It will then be up to the two designated specialist doctors (including the expert near the courts) to rule on the existence of high probabilities " that the unborn child has a particularly serious condition recognized as incurable at the time of diagnosis ».

They will establish a certificate including their names, their specialties, their membership in the multidisciplinary center and their signatures. A copy will be given to the parents and the original will be kept in the patient's medical file.

The multidisciplinary center keeps a medical file for each request including the report, opinions, conclusions, certificate, date of the IMG and the results of examinations.

To know :

Whether it is an IMG performed in the interest of the mother or for fetal malformation, the multidisciplinary team can give an unfavorable opinion if it is a question of disease or malformations that can be treated, corrected to birth such as cleft lip, extra fingers ...

Likewise, parents, although informed of the risks, may refuse the intervention. In this case, they will benefit from appropriate support during pregnancy but also after the birth of the child.

After the IMG, a new meeting is scheduled to inform the couple about the results of the examination carried out, or those to be done, to understand what from a genetic point of view was at the origin of the malformation or incurable disease of the fetus.

Likewise, psychological support can be put in place at any time to help the couple overcome this ordeal.

Pregnancy Medical Interruption: A right recognized and protected by the ECHR

The European Court of Human Rights in a judgment of March 20, 2007 (Tysiax v / Poland) held that a State has a positive obligation to protect the rights of its nationals to respect for their private life in the event of disagreement medical on their right to benefit from a therapeutic abortion

A Polish national suffering from severe myopia who was refused by doctors to perform a therapeutic abortion which risked aggravating her disability. But after giving birth, her condition worsened anyway.

She based her action on the violation of Articles 8 (right to respect for his private life, 3 (prohibition of inhuman and degrading treatment), 13 (right to appeal to a national body) and 14 (principle of non-discrimination) of the European Convention on Human Rights.

The ECHR condemned Poland on Article 8 of the ECHR, for not having put in place a medical procedure in the event of disagreement between a doctor and his patient, or between doctors to resolve the conflict.

To note :

The decision is based on Article 8 of the ECHR, as abortion legislation comes into the realm of privacy.

The right to privacy is a concept which includes in particular, physical and social identity, the right to autonomy and personal development, the right to establish and maintain relations with other human beings and outside world…