Presention on Mtp

1. Medical Termination Of
Pregnancy
PREETY JHA
ROLL NO 172

2. Overview
 Introduction
 MTP act
 Methods of MTP
 Conclusion

3. Introduction
A medical abortion is brought about by taking
medications that will end a pregnancy, alternative is the
surgical abortion which ends a pregnancy by emptying
the uterus (womb) with special instruments
 .

4.  Hippocratic oath forbade physicians from
inducing elective abortions
 But, Aristotle held that abortion was ethical if
performed in the first trimester of pregnancy

5.  Before 1971:
- Abortion – purposely causing miscarriage
- 1860 IPC under British rule – induced
abortion is illegal
- Abortion practitioners would either be
incarcerated for 3yrs or fined or both
- Women could be imprisoned upto 7yrs & also
would be fined
- Only exception was abortion done to save
women life

6. MTP 1971
 Conditions under which a pregnancy can be
terminated
 Who can perform such terminations
 The place where such terminations can be
performed

7.  Conditions where pregnancy can be
terminated:
- Medical
- Eugenic
- Humanitarian
- Socio economic

8. Qualification to perform abortion
 Assistance of atleast 25 cases of MTP in
approved institution
 6months of Housemanship in OB&G
 A PG qualification in OB&G
 3yrs of practice in OBG for those doctors
registered before 1971 MTP act was passed

9. Place where MTP performed
 Place established and maintained by Govt.
 Non Govt institutions can perform provided
they obtain license from Chief Medical Officer
of the district.

10.  Consent
- Can only be terminated on a written informed
consent of the woman, husband consent not
required
- <18yr or lunatic – written consent of parent or
legal guardian.

11.  Termination is permitted upto 20wks of
pregnancy
 When pregnancy >12 week 2medical
practitioners opinion required
 The abortion has to be performed confidentially
and reported to Director of Health Services in
prescribed form

12. Methods of termination
1st trimester
 Medical - Mifepristone
- Mifepristone & Misoprostol
- Methotrexate & Misoprostol
- Tamoxifene & misoprostol
 Surgical – Vacuum aspiration
- suction evacuation & or curettage
- Dialatation and evacuation
Rapid Slow

13. 2nd trimester
 Prostaglandins – Misoprostol
- Carboprost
- Dinoprost
 Dilatation and evacuation – 13-14wks
 Intrauterine instillation of hypertonic solutions
 Oxytocin infusion
 Hysterectomy

14. Classification of drugs used in
MTP
CARBOPROST
SULPROSTONE
DINOPROSTONE
GEMEPROST
MISOPROSTOL
MIFEPRISTONE
LILOPRISTONE
ONAPRISTONE
ULIPRISTAL
METHOTREXATE

15. Mifepristone:
 Synthetic steroid
 antiprogesterone, antiglucocorticoid &
antiandrogen
 Partial agonist, competative antagonist in
presence of progesterone
 80-85% effective in causing abortion

16.  Blockage of the progesterone receptor results
in vascular damage, decidual necrosis and
bleeding

17. Mifepristone blocks progesterone receptors
Endometrial decidual degeneration
Trophoblast detachment
↓HCG from syncytiotrophoblast
Inturn ↓ progesterone by corpus luteum

18. Pharmacological actions
 Decidual breakdown by blockade of uterine PR
 Detachment of the blastocyst which decreases hCG
production
 Decrease in progesterone secretion from the corpus
luteum
 increase uterine PG levels
 sensitizes the myometrium to their contractile actions.
 Cervical softening, which facilitates expulsion of the
detached blastocyst

19. Pharmacokinetics
 Orally active with good bioavailability
 t1/2 of 20-40 hrs
 Bound by α 1-acid glycoprotein.
 Hepatic metabolism and enterohepatic
circulation
 Metabolic products are found predominantly in
the faeces

20. Contraindications:
 Ectopic prgnancy
 In presence of IUD
 Adrenal failure
 Hemorrhagic disorders
 Porphyria
 Patients on long term therapy with
corticosteroids

21. Misoprostol (PGE1)
 Synthetic prostaglandin E1
 Inexpensive and can be stored at room
temperature
MOA
 Binds to myometrial cells causes myometrial
contraction and expulsion of tissues
 Also causes ripening of cervix

22. PHARMACOKINETICS
 After oral administration, rapidly absorbed from the GI tract.
 t1/2 20-40 mins
 DOSE:400 μg oral misoprostol, the plasma misoprostol level
increases rapidly and peaks at about 30 minutes declines
rapidly by 120 minutes and remains low thereafter.
 ROUTES OF ADMINISTRATION : Oral, vaginal, sublingual,
buccal or rectal
 Mainly urinary excretion

23.  Protocol
200mg of mifepristone given orally on day1
On day 3 misoprostol 400mcg PO
Or 800mcg PV
Patient remains in hospital for 4hrs during which
expulsion occurs in 95% of cases

24. Mifepristone 200mg oral
36-48hrs later 800microgram misoprostol
vaginal
Then misoprostol 400microgram oral every
3hrs (4doses)
 Success rate is 97%

25. Gemeprost
 PGE1 analogue (16, 16-dimethyl-trans-d2- PGE1
methyl ester)
 Used as a vaginal pessary. Every 3-6hrs for 5 doses
in 24hrs
 Has got 90% success rates
 Used as a non-surgical method to dilate the cervix
before VA in late-first and early-second-trimester
abortion
SE : Vaginal bleeding, cramps, nausea, vomiting, diarrhea,
headache, muscle weakness , backache ,chest pain

26. CARBOPROST
 Carboprost tromethamine PGF2α analogue
 First analogue to be tested clinically on a large scale
for the termination of second trimester pregnancy.
 MOA- It acts on the corpus luteum to cause
luteolysis, forming a corpus albicans and stopping the
production of progesterone

27. Dose: IM 100-200 µg
 Post partum haemorrhage
ADR: diarrhoea (most common)
 fever chills vomiting
 Cardiovascular collapse, Postural
hypotension

28. DINOPROSTONE
 Synthetic derivative of PGE2
 ROUTE OF ADMINISTRATION : vaginal/ oral
 Intravaginal suppository 20mg 3-5 hrs repeated. (17hrs)
 Half life 2.5-5 mins. Excreted in urine
 Induction abortion in second trimester/ early abortion
 Cervical ripening-10mg tab / 0.5 mg gel 6 hrly
 SE- Prolonged vaginal bleeding, Severe menstrual cramps ,GI
toxicity.

29. Methotrexate
 MTX is an antifolate belonging to the
antimetabolite class of antineoplastic agent.
 MTX is a cell cycle specific chemotherapeutic
agents that acts on S-phase &
 thus inhibit DNA synthesis

31. Pharmacokinetics
Readily absorbed from the GI tract at doses of <25 mg/m2
 7-hydroxy-methotrexate NEPHROTOXIC
 t ½ 8 hrs IM
 50% of methotrexate binds to plasma proteins
 Up to 90% of a given dose is excreted unchanged in the
urine within 48 hours
 Retained in the form of polyglutamates for long periods
 Weeks in the kidneys and for several months in the liver

32. Methotrexate/Misoprostol Regimens
 Methotrexate: 50 mg/m2 IM or 50 mg PO
 Misoprostol: 800 µg PV 3–7 days later
 Efficacy decreases after 49 days’ gestation
 Initial follow-up ~1 week after methotrexate
 Subsequent care based on results of
physical exam, ultrasonography
 If HCG has fallen by >80% over 7days,procedure was
successful

34. Contraindications
 Anemia (Hgb < 10 g/dL)/ leucopenia/thrombocytoenia
 Known coagulopathy
 Active renal or liver disease
 Uncontrolled seizure disorder
 Acute inflammatory bowel disease
 Intrauterine device in situ
 High intial hcg concentration >5000mU/ml
 Ectopic pregnancy > 4cm in size as in TVS

35. Regimens for medical abortion and
their effectiveness
Regimens Effectiveness
Use
upto
Mifepristone + misoprostol
or mifepristone +
gemeprost
>96% 9 weeks from last
menstrual period
Misoprostol alone >83% 12 weeks from last
menstrual period
Methotrexate + misoprostol >90% 9 weeks from last
menstrual period

36. Older methods
 Hystrecotomy (sectio parva)
 Intra-amniotic injection of hypertonic saline/hyperosmolar
urea
 Intra- or extra-amniotic administration of ethacryidine
lactate (Rivanol)
 Parenteral/intra-amniotic / extra-amniotic administration
of prostaglandin (PG) analogues
 I.V / i.m. administration of oxytocin

37. ETHACRIDINE LACTATE
 Ethacridine lactate/Rivanol is a yellow dye with antiseptic
properties
 MOA: Stimulates endogenous PG and thromboxane
production, promoting cervical priming and initiating labour
 DOSE:0.1%-solution of ethacridine lactate - extra-amniotic
space through a sterile catheter at a dose of 10 mL per
gestational week
 20-40 hrs mini labour
 Maximum of 150 ml

38. Hypertonic Saline
One of the first described instillation methods
 When used alone, intra-amniotic hypertonic saline
has a long latent period until the onset of
contractions
 Time to abortion of 30 hours
Addition of oxytocin to this
regimen improves the efficacy
and expulsion time

39. Use of concentrations exceeding 20%.
 Coagulopathy
 Hemorrhage
 Cervical laceration
 Maternal hypernatremia
SIDE
EFFECTS

40. IV OXYTOCIN
 First described by Winkler and associates
 100 units per 500 mL of DNS, is infused over 3
hours
 The dose is increased 50 units per 500 mL of
DNS until delivery is achieved
 Maximum of 300 units
 Mean time to delivery of 8.2 hours

41. UREA
 Rapidly traverses cell membranes
 Has a long instillation to abortion interval when
used alone
 Intra-amniotic urea, 80 to 90 g, with intravenous
oxytocin
 Average time to expulsion of 19 to 29 hours

43. Bibliography
 Goodmann and Gilman’s The pharmacological basis of therapeutics
12th edition
 Text Book of Obstetrics; D.C Dutta 4th edition
 Preventive and Social Medicine 21st Edition
 Udaykumar P. Medical Pharmacology. 4th ed. New Delhi: CBS Publishers;
2013.
 Sharma HL, Sharma KK. Principles of Pharmacology. 2nd ed. New Delhi:
Paras Medical Publishers; 2011.
 Uptodate.com
 Ashok PW, Templeton AA. Non-surgical mid-trimester termination of
pregnancy: a review of 500 consecutive cases. Br J Obstet Gynaecol
1999;106:706
 Stubblefield PG, Carr-Ellis S, Borgatta L.Methods for induced abortion.
Obstet Gynecol2004;104:174-85