This document discusses the Pre-Natal Diagnostic Techniques (PNDT) Act and the Medical Termination of Pregnancy (MTP) Act of India. The PNDT Act was implemented in 1994 to ban sex-selective abortion and regulate pre-natal diagnostic techniques, while the MTP Act of 1971 allows abortion under certain conditions. Both acts specify procedures that can be performed, qualifications of those performing them, and where they can be done (e.g. registered clinics). Common abortion methods discussed include medication (mifepristone/misoprostol), manual vacuum aspiration, dilation and curettage, and use of prostaglandins. Complications are also outlined.

2.  Introduction
 Definition
 Objectives
 Salient features

3.  Pre natal diagnostic technique Act
Citation Act No.57 of 1994
Enacted by Parliment of India
Date of assented to 20 September 1994
Date of commence 1 January 1996
Amends The Pre-Conception and pre
natal Diagnostic Technique Act
in 2003

4.  An act to provide for the prohibition of sex
selection, after conception, and for regulation of
prenatal diagnostic techniques for the purposes
of detecting genetic abnormalites or metabolic
disorders or chromosomal abnormalites or
certain congenital malformations or sex linked
disorders and for the prevention of their misuse
for sex determination leading to female feticide.

5.  It is any act of identifying the sex of the foetus and
elimination of the foetus if it is of the unwanted sex.
Includes
 Procedure
 Technique
 Test
 Administration
 Prescription
 Provision of anything for the purpose of ensuring or
increasing the probability that an embryo will be of a
particular sex

6.  To ban the use of sex selection techniques
after conception and prevent the misuse of
prenatal diagnostic technique for sex
selective abortion.

7.  Includes
 Ultrasonography (USG)
 Test or analysis of
amniotic fluid
chronic villi
blood
any tissue
fluid

8. To detect
 Genetic abnormalities
 Metabolic disorders
 Chromosomal abnormalities
 Congenital malformations
 Sex linked disorders
 Haemoglobinopathies

9.  Pregnant women is above 35 years
 Pregnant women has undergone a spontaneous
abortion or foetal loss
 Pregnant women has been exposed to potentially
teratogenic agents such as drugs/ radiation/
infection/ chemicals.
 Pregnant women or her spouse has a family history
of mental retardation/ physical deformities such as
spasticity or any other genetic disease
 Any other condition specified by central supervisory
board

10. PND procedure will be conducted only after
 Explaining all known side and after effects of the
procedures to the pregnant women.
 Obtained her written consent to undergo the
procedures in the language which she
understands
 Copy of her written consent is given to the
pregnant women

11. In registered
 Diagnostic laboratories
 Genetic counselling centres
institute
hospital
Nursing home
 Genetic laboratories
 Genetic clinics
 Ultrasound clinics

12. QUALIFIED PERSONS LIKE
 Radiologist
 Sonologist
 Gynecologist
 Pediatrician
 Registered medical practitioner
 Medical geneticist
Note: should not conduct/ cause to be conducted/ or
aid in conducting by himself or through any other
person any other PNDT other than a registered
place

13.  PNDT Act ,1994 was amended in 2003 to the Pre
conception and Pre Natal Diagnostic Technique
Act (PCPNDT Act) to improve the technology
used in sex seection.

14. MTP ACT

15.  MTPACT was enforced to safeguard the health
of mother undergoing abortion and the interest
of the doctor performing the procedure on her.
 Medical Termination of Pregnancy Act
Enacted by Parliment of India
Date of assented to 1971
Date of commence 1 April 1972( J&K 1
Nov 1976)
Amends in December 2002 and
rules in June 2003

16. 1. The condition under which the pregnancy can
be terminated
2. The person or persons who can perform such
termination
3. The place where such termination can be
performed

17.  There are five conditions that have been
identified in the MTPAct
i. Therapeutic or medical indication: where
continuation of pregnancy might endanger the
mothers life or cause grave injury to her
physical or mental heath.
ii. Eugenic: where there is “substantial risk of the
child being born with serious physical or mental
abnormalities so as to be handicapped for life”.

18. iii. Humanitarian: where pregnancy is the result
of rape
iv. Socio economic indication: where actual or
reasonably forceeable environment can lead to
risk of injury to the physical or mental health of
the mother.
v. When pregnant women is not mentally sound

19. i. MTP can only performed by a registered
medical practitioner with the certificate to do
MTP like
› Who has got a degree or DGO
› Who has done 6 months house job in obstetrics and
gynecology.
› Who has assisted in at least 25 MTPs in an authorized
center and has a certificate to do MTP.
› 3 years of practice in obstetrics or gynecology for the
doctors registered before the 1971 MTP act passed.

20. Approved by
the DHS or
CMO of
district

21.  Consent:
guardian concent- women under 18 years and
mentally disturbed women above 18 years.
 Period of gestation:
less than 12 weeks – single medical
practitioner
exceeds 12 weeks – 2 medical practitioners
opinion is requried.

22.  Medical disorders like heart disease
 Suspected ectopic pregnancy
 Chronic renal failure
 Hematological disorders
 Allergy to any drugs used

23.  Counselling
risk
reason
 Clinical assessment: it provides
1. Confirmation of pregnancy
2. Gestational age
3. Womens general health condition
4. Associated gynecological conditions
5. Associated medical conditions.

24.  Components of clinical assessment
History
General physical examination
Gynecological examination
Laboratory tests
 Investigation
Hemoglobin estimation
Urine examination
Blood group examination

27. 1. Mifepristone
2. Mifepristone(RU 486) and Misoprostol
3. Methotrexate and Misoprostol
4. Tamoxifen and Misoprostol
5. Misoprostol

28.  Mifepristone(RU 486) acts as a antagonist , blocking
the effect of natural progesterone.
 Addition of low dose prostaglandins (PGE1)
improves the efficency of the first trimester
abortion.
 Effective up to 63 days
 Successful when used within 49 days of gestation.

29.  protocol:
Day 1:
200mg of Mifepristone
Day 3:
Misoprostol 400µg orally or
800µg vaginally
After 10-14 days again re examined
Note
Oral 200mg of Mifepristone (1 tab) with vaginal
Misoprostol 800µg( 4 tab, 200µg each) after 6 to
48 hours is equally effective.

31.  Nausea
 Vomiting
 Diarrhea
 Headache
 Pain

32. Mifepristone should not be used in womens
Aged over 35 years
Heavy smokers
Those who on long term corticosteroids

33. 1. MENSTRUAL REGULATION/
ASPIRATION
Aspiration of the endometrial cavity, using a
flexible 5-6 mm Karman cannula and
syringe, within 6 weeks of amenorrhea has
been reffered to as MR.

34.  (A) Syringe
 (B) Plastic cannula with whistle tip used in
suction evacuation

35.  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 anesthesia may be employed.
 After introducing the posterior vaginal
speculum, the cervix is steadied with an Allis
forceps.
 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.

36.  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.

37. 2. VACUUM ASPIRATION (MVA/EVA)
 Done upto 12 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.
 The cannula is inserted transcervically into the uterus
and the vacuum is activated.
 A negative pressure of 660 mm Hg is created.
 Aspiration of the products of conception is done

41.  Acute vaginal, cervical or pelvic infections
 Suspection of ectopic pregnancy
 Suspection of perforation

42. 3. SUCTION EVACUATION AND/ OR
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.
Preliminaries:
1. General anaesthesia is usually not needed.
2. If the patient is apprehensive, intravenous
diazepam 5–10 mg (conscious sedation)
supplemented by paracervical block is quite
effective.
3. The patient is put on the table after she empties
her bladder.

43.  1. Vaginal examination is done to note the size
and position of the uterus and to note the state
of cervix. USG (TAS/TVS) should be performed
when there is any doubt about the gestational
age.
 2. Posterior vaginal speculum is introduced and
an assistant is asked to hold it.
 3. The anterior lip of the cervix is to be grasped
by an Allis forceps. An uterine sound is to be
introduced to note the length of the uterine
cavity and position of the uterus.

44.  4. The cervix may have to be dilated with smaller size
graduated metal dilators up to one size less than that of the
suction cannula. Feeling of “snap” of the endocervix
around the dilator is characteristic. Instead laminaria tent
12 hours before (osmotic dilator) or misoprostol (PGE1)
400 μg given vaginally 3 hours prior to surgery produces
effective dilatation.
 5. Intravenous methergin 0.2 mg is administered.
 6. The appropriate suction cannula is fitted to the suction
apparatus by a thick rubber or plastic tubing. The cannula is
then introduced into the uterus, the tip is to be placed in the
middle of the uterine cavity.

45.  7. The pressure of the suction is raised to 400–600
mm Hg. The cannula is moved up and down and
rotated within the uterine cavity (360°) with the
pressure on. The suction bottle is inspected for the
products of conception and blood loss. The suction
is regulated by a finger placed over a hole at the
base of the cannula.
 The end point of suction is denoted by:
(a) No more material is being sucked out
(b) Gripping of the cannula by the contracting smaller
size uterus
(c) Grating sensation
(d) Appearance of bubbles in the cannula or in the
transparent tubing.

46. 8. The vacuum should be broken before
withdrawing the cannula down through the
cervical canal to prevent injury to the internal
os.
9. It is better to curette the uterine cavity by a
small flushing curette at the end of suction and
the cannula is reintroduced to suck out any
remnants.
10. After being satisfied that the uterus is
remaining firm, and there is minimal vaginal
bleeding, the patient is brought down from the
table after placing a sterile vulval pad.

48.  Excessive haemorrhage
 Injury
 Shock
 Perforation
 Sepsis
 Hematometra may cause pain

49. 4. DILATATION AND EVACUATION (D+E):
The operation consists of dilatation of the cervix
and evacuation of the products of conception from
the uterine cavity.
The operation may be performed:
o One stage — Dilatation of the cervix and evacuation
of the uterus are done in the same sitting.
oTwo stages — a) First phase includes slow dilatation
of the cervix b) Second phase includes rapid
dilatation of the cervix and evacuation.

50. Steps:
1. If the cervix is not sufficiently dilated to admit the index finger (usually it
does), it should be dilated.
2. Sim’s posterior vaginal speculum is introduced and an assistant is asked to
hold it. The anterior lip of the cervix is grasped by an Allis forceps to steady
the cervix. Uterine sound is not to be introduced. Sounding provides no
information but risks perforation and bleeding.
3. The cervical canal is gradually dilated up to the desired extent by the
graduated metal dilators.
4. The products are removed by ovum forceps. The uterine cavity is finally
curetted gently by a flushing (blunt) curette. Injection methergin 0.2 mg is to
be administered intravenously during the procedure.
5. The speculum and the Allis forceps are to be removed. The uterus is to be
massaged bimanually with the help of the external hand and the internal
fingers, placed inside the vagina.
6. After being satisfied that the uterus is firm and the bleeding is minimal, the
vagina and perineum are toileted; a sterile vulval pad is placed and the
patient is sent back to her bed.

52.  Slow dilation of the cervix- inserting laminaria
tents into cervical canal.
 After 12 hr evacuation from the uterus is done.

53.  immediate:
same as d&c
 Late:
1. Pelvic inflammation
2. Infertility
3. Cervical incompetence
4. Uterine synechiae.

54.  PROSTAGLANDINS:
› They act on the cervix and the uterus.
› The PGE (dinoprostone, sulprostone,
gemeprost, misoprostol) and PGF
(carboprost) analogues are commonly
used
› PGEs are preferred as they have more
selective action on the myometrium and
less side effects.

55.  1. Misoprostol (PGE1 analogue)
400–800 μg of misoprostol - vaginally at an
interval of 3–4 hours.
Alternatively, first dose of 600 μg misoprostol-
vaginally-200 μg orally every 3 hours
Recently 400 μg misoprostol is given sublingually
every 3 hours for a maximum of five doses.
 2. Gemeprost (PGE1 analogue):
1 mg vaginal pessary every 3–6 hours for five
doses in 24 hours.

56.  Mifepristone and prostaglandins:
Mifepristone 200 mg oral, followed 36–48 hours later
by misoprostol o 800 μg vaginal; then misoprostol
400 μg oral every 3 hours for 4 doses is used.
 4. Dinoprostone (PGE2 analogue):
20 mg is used as a vaginal suppository every 3–4
hours (maximum for 4–6 doses).
When used along with osmotic dilators, the mean
induction to abortion interval is 17 hours.
 5. Prostaglandin F2 (PGF2α),
carboprost tromethamine— o 250 μg IM every 3
hours for a maximum 10 doses can be used.

57.  OXYTOCIN:
› High dose oxytocin as a single agent can be used
for second trimester abortion.
› It is effective in 80% of cases.
› It can be used with intravenous normal saline
along with any of the medications used either
intra-amniotic or extra-amniotic space in an
attempt to augment the abortion process.

58.  Between 13 and 15 weeks
Dilatation and Evacuation

61.  Between 16 and 20 weeks:
► INTRAUTERINE INSTILLATION OF HYPERTONIC
SOLUTION
o Intra-amniotic
o Extra-amniotic
Intra-amniotic:
Intra-amniotic instillation of hypertonic saline (20%) is less
commonly used now. It is instilled through the abdominal route.
Mode of 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.
Procedure:
Preliminary amniocentesis is done by a 15 cm 18 gauge
needle. The amount of saline to be instilled is calculated as
number of weeks of gestation multiplied by 10 mL. The
amount is to be infused slowly at the rate of 10 mL/min.

62.  Intra-amniotic instillation of hyperosmotic urea:
Intra-amniotic instillation of 40% urea solution (80 g of
urea in 200 mL distilled water) along with syntocinon
drip is effective with less complications.
 Extra-amniotic:
Extra-amniotic instillation of 0.1% ethacrydine lactate
done transcervically through a number 16 Foley‘s
catheter
The catheter is passed up the cervical canal for about
10 cm above the internal os between the
membranes and myometrium and the balloon is
inflated (10 mL) with saline.
It is removed after 4 hours.

63.  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

64.  Hysterotomy is an operative procedure of extracting the
products of conception out of the womb before 28th week by
cutting through the anterior wall of the uterus.
 The operation is usually done through the abdominal route.
The operation is rarely done these days for the purpose of
MTP.
 Complications: Immediate: I. Hemorrhage and shock II.
Anesthetic complications III. Peritonitis IV. Intestinal
obstruction.

65. IMMEDIATE:
 Injury to the cervix (cervical lacerations)
 uterine perforation during D and E
 Haemorrhage and shock
 Thrombosis or embolism
 Postabortal triad of pain, bleeding

66.  REMOTE:
o Gynecological
o Obstetrical
Gynecological complications
› menstrual disturbances
› chronic pelvic inflammation
› infertility due to cornual block
› scar endometriosis (1%)
› uterine synechiae leading tosecondary amenorrhea

67.  Obstetrical complications
› recurrent midtrimester abortion due to cervical
incompetence
› ectopic pregnancy (three-fold increase)
› preterm labour
› dysmaturity,
› increased perinatal loss
› rupture uterus
› Rh isoimmunization in Rh-negative women, if
not prophylactically protected with
immunoglobulin
› failed abortion and continued pregnancy.

68. First trimester:
 The maternal death is lowest (about 0.6/100,000
procedures) in first trimester termination specially
with MVA and suction evacuation.
Midtrimester:
 The mortality rate increases 5–6 times to that of first
trimester.
 Contrary to the result of the advanced countries, the
mortality from saline method has been found much
higher in India compared to termination by abdominal
hysterotomy with tubectomy.