Medical termination of pregnancy, MTP act, methods of termination

2. Definition
•Deliberate termination of pregnancy either by medical or by surgical
method before the viability of the fetus.
•Medical termination of pregnancy act 1971
•Enforced in year April 1972
•Revised in 1975

3. Provisions of MTP
MTP act 1975
•The continuation of pregnancy would involve serious risk of life or
grave injury to the physical and mental health of the pregnant
women.
•There is a substantial risk of the child being born with serious physical
and mental abnormalities so as to be handicapped in life.
•When the pregnancy is caused by rape, both in cases of major and
minor girl and in mentally imbalanced women.
•Pregnancy caused as a result of failure of contraceptives.

4. Recommendations
• A registered medical practitioner is qualified to perform an MTP
provided: 1.one has assisted in atleast 25 MTP in an authorised
center and having a certificate. 2. One has got 6 months house
surgeon training in OBG. 3. One has got diploma or degree in OBG
• Termination can be performed in hospitals, established or
maintained by govt. or places approved by govt.
• Pregnancy can only be terminated on the written consent of the
women. Husband's consent is not required
• Termination in a minor girl or lunatic girl cannot be terminated
without consent of parents or guardian

5. • Termination is permitted upto 20 weeks
• The abortion has to be performed confidentially and to be reported
to DHS in the prescribed form

6. Indications
•To save the life of the mother.
1. Cardiac diseases grade iii and iv
2. Chronic Glomerulonephritis
3. Malignant Hypertension
4. Intractable Hyperemesis Gravidarum
5. Cervical or Breast Malignancy
6. DM with Retinopathy
7. Epilepsy or psychatric illness

7. • Eugenic
1. Structural (anencephaly)
2. Chromosomal (downs syndrome)
3. Genetic (haemophilia)
4. Action of teratogenic drugs
5. Radiation exposure
6. Rubella
• Social indications
1. Parous women having unplanned pregnancy with low socio
economic status.
2. Rape

9. Method of termination
⮚FIRST TRIMESTER (UPTO 12 WKS)
❖MEDICAL METHODS
1. Mifepristone and misoprostol
2. Mifepristone
3. Methotrexate and misoprostol
4. Tamoxifen and misoprostol

10. Mifepristone and misoprostol
• Mifepristone act as antagonist, blocking effect of natural
progesterone
• Effective upto 63 days, highly successful when used within 49days.
• Day 1- 200 mg mifepristone
• Day 3 - misoprostol 400mcg orally or transvaginally
• Patient remain in clinic for 4 hrs during which expulsion of
conceptus occur
• Patient is reexamined for 10-14 days

11. Methotrexate and misoprostol
• Methotrexate 50 mg/sq.m IM (56 days of gestation) followed by 7
days later misoprostol 800 mcg vaginally.
• Less expensive
• Takes longer time
• Contraindications- Women above 35 years, heavy smokers, taking
long corticosteroid

12. ❖SURGICAL METHODS
1. Menstrual regulations
2. Vaccum aspiration
3. Suction evacuation and curettage
4. Dilatation and evacuation
Rapid method
Slow method

13. Menstrual regulation
• It is the aspiration of the endometrial cavity within 14 days of
missed period in a woman with previous normal cycle.
• The operation is done as an out patient or an office procedure.
• It is done with aseptic precautions and in apprehensive patients,
sedation or paracervical block anesthesiamay be employed.
• After introducing the posterior vaginal speculum, the cervix is
steadied with an Allis forceps.

14. • Cervix may be gently dilated using 4 or 5 mm size dilators.
• 5–6 mm suction cannula (Karman’s) is then inserted and attached
to the 50 mL syringe for suction.
• The cannula is rotated, pushed in and out with gentle strokes.The
operator should examine the aspirated tissue by floating it in a clear
plastic dish over a light source.
• Placental tissue appears fluffy and feathery when floats in normal
saline.
• This will help to detect failed abortion, molar pregnancy or ectopic
pregnancy.
• The procedure is contraindicated in advanced pregnancy and in the
presence of local pelvic inflammation.

16. Vaccum aspiration
● Done upto12 weeks with minimal cervical dilatation
● It is performed as an outpatient procedure using a plastic disposable
Karman’s cannula (up to 12 mm size) and a 60 mL plastic (double valve)
syringe.
● It is quicker (15 minutes), effective (98–100%), less traumatic and safer
than dilatation, evacuation and curettage.
● The procedure may be manual vacuum aspiration (MVA) or electric
vacuum aspiration (EVA).Hand operated double valve plastic syringe is
attached to a cannula.

17. ● .Hand operated double
valve plastic syringe is
attached to a cannula.
● The cannula is inserted
transcervicallyinto the
uterus and the vacuum is
activated.A negative
pressure of 660 mm Hg is
created.
● Aspiration of the
products of conception is
done

18. Suction evacuation and curettage
• It is a procedure in which the products of conception are sucked out
from the uterus with the help of a cannula fitted to a suction
apparatus.
• Vaginal examination- size and position of uterus
• Vaginal speculum
• Anterior lip of cervix is grasped by allis forceps
• Uterine sound is introduced
• Cervix is dilated- metal dilators, laminaria tent
• IV methergin 0.2 mg
• Suction.
• The vaccum should be broken before withdrawing cannula

20. Dilatation and evacuation
• The operation consists of dilatation of the cervix and evacuation of
the products of conception from the uterine cavity.
• Rapid method- Dilatation of cervix and evacuation of the uterus are
done in the same setting.
• Slow method- slow dilatation of the cervix with introduction
laminaria tent or lamicel sponges into cervical canal. This is followed
by evacuation of uterus after 12 hrs. Vaginal misoprostol 400 mcg 3
hrs before surgery is also used in cervical ripening.

22. SECOND TRIMESTER TERMINATION
MEDICAL METHODS
•PROSTAGLANDINS AND THEIR ANALOGS
1. Misoprostol
2. Mifepristone and prostaglandins
3. Gemeprost
4. Dinoprostone
5. Prostaglandins F2α
•OXYTOCIN

23. Misoprostol. PGE1 analog
• 400-800 mcg misoprostol given vaginally at an interval of 3-4 hrs
Or
• First dose of 600mcg misoprostol given vaginally, then 200 mcg
orally every 3 hrs
• Recently, 400 mcg misoprostol is given sublingually evry 3 hrs for a
maximum of 5 doses
• Successful method 100%
• Mean induction abortion interval is 11-12 hrs.

24. Mifepristone and prostaglandin
1. Mifepristone 200 mg oral, followed 36-48 hrs later by misoprostol
800mcg vaginal, then misoprostol 400 mcg oral evry 3 hrs for 4
doses is used.
2. Success rate 97%
3. Mean induction abortion interval 6.5 hrs

25. Gemeprost PGE1 analog
• 1 mg vaginal pessary every 3-6
hrs for 5 doses in 24 hrs
• 90%
• 14-18 hrs
Dinoprosrone PGE2 analog
• 20 mg vaginal suppository
every 3-4 hrs.
• When used along with osmotic
dilators, mean induction to
abortion interval is 17 hrs
• Thermolabile & expensive
Prostaglandin F2a
• Carboprost tromethamine 250
mcg IM every 3 hrs for a
maximum of 10 doses.
• Success rate 90% in 36 hrs
• Side-effects - nausea, vomiting,
dairrhea and pain
• Contraindications - bronchial
asthma

26. Oxytocin
• High dose single agent.
• Effective in 80% cases
• It can be used with IV NS along with any of medication used either
intra amniotic and extra amniotic space in an attempt to augment
abortion.
• Drip rate increased upto 59 milliunits or more per min
• Currently 300 units in 500 ml dextrose saline is favoured.

27. SURGICAL METHODS
• 13- 15 WEEKS - Dilatation and evacuation
• 16- 20 WEEKS - Intrauterine instillation of hyertonic solution
Intra amniotic
Extra amniotic
• Hysterotomy

28. Intrauterine instillation of hypertonic solution
• Extra amniotic- 0.1 % ethacridine lactate is done transcervically
through a Foley's catheter.
• The catheter is passed up the cervical canal for about 10 cm above
internal os between membranes and myometrium and ballon is
inflated with saline.
• It is removed after 4 hrs.
• It can be used in cases contraindicated for saline instillation.
Stripping the membranes with liberation of prostaglandins from the
decidua and dilatation of the cervix by the catheter are some of the
known factors for initiation of the abortion.

29. • Intra amniotic- It is instilled through abdominal route.
Amniocentesis is done
Amount of saline to be instilled = no. of weeks of gestation * 10 ml
Infused slowly at 10 ml/min
• Action- There is liberation of prostaglandins following necrosis of
the amniotic epithelium and the decidua. This in turn excites
uterine contraction and results in the expulsion of the fetus.

30. Hysterotomy
1. Operative procedure of extracting the products of conception out
of the womb before 28 wks by cutting through anterior wall of
uterus.
2. Abdominal route
3. Used when other methods fail, fibroids, placenta previa, uterine
didelphys , septate uterus, cervical cancer, multiple CS

31. Complications
• There is no universally safe and effective method which is applicable to
all cases.
• However, the complications are much less (5%) if termination is done
before 8 weeks by MVA or suction evacuation/currette.
• The complications are about five times more in mid-trimester
termination.
• Use of PG analogues and mifepristone has made second trimester MTP
effective and safe.
• The complications are either related to the methods employed or to the
abortion process.

32. IMMEDIATE
•Injury to cervix
•Uterine perforation
•Hemorrhage and shock
•Thrombosis or embolism
•Post abortal triad- Pain, bleeding, low grade fever

33. REMOTE
•Gynecological
i. Menstrual disturbances
ii. Chronic pelvic inflammation
iii. Infertility
iv. Scar endometriosis
v. Uterine synechiae
•Obstetrical
a. Recurrent midtrimester abortion
b. Ectopic pregnancy
c. Dysmaturity

34. d. Preterm labour
e. Increased perinatal ploss
f. Rupture uterus
g. Rh- isoimmunisation
h. Failed abortion and continued pregnancy

41. Reference
• DC Dutta textbook of obstetrics. Pg no: 164-168 pgno:524- 528