medical termination of pregnancy act

1. MTP ACT

2. MTP Act
• Liberalisation of MTP Act was approved by parliament in the
year 1971
• By law,MTP in India is permitted upto 20 weeks of gestation

3. GROUNDS FOR PERFORMING MTP
MEDICAL
•The continuance of pregnancy would involve risk to
the life of the pregnant women or of grave injury to
her physical or mental health.
EUGENIC GROUNDS
•Risk to the child if born,it would suffer from physical
or mental abnormalites.

4. SOCIAL GROUND
Pregnancy occured after rape
The pregnancy occurs as result of failure of any device
or method used by any married woman or husband for
the purpose of limiting the number of childrens.

5. consent
• Written consent of the patient on a special form is necessary
• If the women is less than 18yrs of age or she is mentally
abnormal written consent of the legal guardian should be
obtained

6. Who can perform MTP?
• A registered medical practitioner having
postgraduate training in obstetrics and gynecology
•Having special training in MTP
•For termination upto 12 weeks of gestation opinion
of one medical practitioner is enough
•In case of second trimester MTP opinion of 2 medical
practitioners is essential

7. Where is MTP performed
• According to the act MTP is performed only in a hospital
established and maintained by government
• Place recognised and approved by the government for this
purpose

8. First trimester MTP
Prerequisites
1. Ascertain pregnancy by pregnancy test and bimanual examination
2. Assess gestational age
3. Ultrasound to rule out ectopic gestation
4. Local infection to be treated
5. Cvs and other systems to be checked
6. Routine blood examination for Hb and blood grouping and urine
analysis
7. Information about the contraception and explain the procedure
8. Written informed consent

9. MEDICAL ABORTION
1) MIFEPRISTONE (RU 486) AND MISOPROSTOL
Action
▪Mifepristone is a progesterone antagonist and blocks
progesterone receptors in the endometrium causing
disruption of the embryo and release of prostaglandins
▪This causes a decrease in HCG and a withdrawal of support
from corpus luteum
▪ shorter the duration of pregnancy the more the chance of
success

10. ▪Mifepristone is also showing promise in the field of
contraception as an emergency contraceptive ,a monthly
pill and a daily pill
▪Accepted Regimen
▪The currently accepted regimen with least side effects and
cost but equal efficacy is a combination of
200 mg mifepristone followed 48 hours later by vaginal
administration of 800 micrograms of misprostol
If the women is RH negative,anti-D should be given on first
day itself

11. ▪Patient remains in the clinic for 4 hours during which
expulsion of conceptus often occurs
▪Patient is re-examined on day 15 and a scan is taken
to ensure completeness.
▪Complete abortion is observed in 95%, incomplete in
about 4% and about 1% do not respond at all
▪If there are retained products surgical evacuation is
done

12. 2) PROSTAGLANDIN ALONE
▪In early gestation, a single dose of 800 micrograms
has been found to effective
▪ in late first trimester abortion, 800micrograms daily
for 3 days
3)METHOTREXATE AND MISOPROSTOL
Oral methotrexate25-50 mg followed by 800
micrograms of misoprostol vaginally after 1 week
(because methotrexate takes longer to act )
Methotrexate is teratogenic hence in case of failure,
surgical evacuation must be performed else infants
may present mobius syndrome,equinovarus etc

13. Advantage:
•Avoids hospitalisation
•No interference with privacy
•More acceptable to woman
•Non surgical
•No specific training needed and can be given by any
healthcare provider

14. Disadvantage:
•Bleeding and cramping
•Cost of drugs
•Repeat visit to ensure completeness

15. SURGICAL METHOD
1. MENSTRUAL REGULATION
▪It was previously used widely but not very popular now
▪A Karman cannula is attached to a 50 ml syringe and a
vacuum is created .
▪Advantage is that no prior dilation of the cervix is necessary.
▪Anasthesia is not required.
▪Main disadvantage is that incomplete evacuation is very
common.
▪if done very early the conceptus may be missed completely
leading to continuation of pregnancy

17. 2.Manual vaccum aspiration (MVA)
▪Is done up to 12 weeks with minimal cervical
dilatation .
▪There is an aspirator(volume 60cc) and cannulae
have adaptors which are color coded according to
size
▪The green corresponds to 5 mm,blue to 6mm,brown
to 7mm and white to 8mm

18. Advantages:
•cannula is made up of plastic and is flexible, cervical trauma is
less.
•controlled suction therefore less bleeding.
•No electric suction is used
•perforation is less.
•No anaesthesia
Disadvantages:
•incomplete abortion is more, especially after 10 weeks.

19. Vacuum Aspiration or vaccum curettage or suction
evacuation
•most widely used techniquefor first trimester abortion
•Dilation of cervix followed by vacuum aspiration
•Usually a combination of intravenous sedation and
paracervical block is employed
•Cervical dilation is accomplished by vaginal
misoprostol 400microgram kept about 4hrs prior to
procedure

20. procedure
• Length of uterine cavity is measured by a uterine sound
• Cannula is inserted and connected to a vacuum suction
apparatus
• A negative pressure of 50-70 mmHg assures rapid
evacuation
• Cannula tip is advanced to uterine cavity rotated first
clockwise and then counterclockwise
• Some prefer to ascertain completeness by a sharp curette

22. Dilation and evacuation
•Dilation is done and ovum foreceps is then used to
evacuate uterus
•A gentle curettage is done with a sharp curette

23. 2nd trimester abortion
MEDICAL METHODS
1. PROSTAGLANDINS
▪Natural PG and PG analogues are used.
▪Recently very good success rates obtained by the use of
PGE1 analogue Misoprostol.
▪It is given as 400microgram vaginally, 3 doses and 3 hours
apart.
▪Before the use of misoprostol, prostaglandins F2alpha
was used.
▪Nausea, vomiting, diarrhoea are associated with
prostaglandins.

24. 2. MIFEPRISTONE AND MISOPROSTOL.
•200 mg Oral mifepristone followed 36 -48 hours later by
600micrograms of vaginal misoprostol and then
400micrograms of misoprostol every 3 hourly with
maximum of 5 doses or 200-600 mcg of vaginal misoprostol
every 12 hourly for a maximum of 5 doses is also used.
•The currently used first line methods for 2nd trimester
abortion are misoprostol alone or with mifepristone.
•But a combination of both gives a higher success rate than
misoprostol alone.

25. 3. ETHACRIDINE LACTATE OR EMCRIDIL.
• It works by the release of prostaglandins from the
decidua.
• 10 mL of 0.1% ethacridine is used for each gestational
week up to a maximum of 150 mL. It is introduced
extraamniotically by means of a Foley catheter. Oxytocin
can be used for augmentation and to reduce the
induction delivery interval.
• The side effects are minimum

26. 4. HYPERTONIC SALINE AND UREA.
• These were being used intraamniotically previously.
• Hypertonic saline was associated with maternal death
therby has been largely abandoned in most countries.
• The complication of saline are heamorrhage, infection
and hypernatremia.
• Disseminatied intravascular coagulation also associated
with hypertonic saline and urea.

27. SURGICAL METHOD
1. DILATATION AND EVACUATION
▪MTP up to 16 weeks is carried out by a slow and deliberate
dilation of the cervix with the use of laminaria tents,
prostaglandin gel before the evacuation of the uterine
contents using either vacuum aspiration or aspirotomy with
ovum forceps.
▪The cervical trauma, uterine perforation, incomplete
evacuation, haemmorrhage and infection are more common
in 2nd trimester MTP.

28. 2. HYSTEROTOMY
▪This involves removal of the fetus through an incision in
the lower segment as in caesarean section. After opening
the abdomen, the uterovescical fold of peritoneum is
divided and the bladder pushed down. The fetus is
removed and the incision closed in 2 layers.
▪Hysterectomy is almost never performed as a primary
procedure, but only when all other methods have failed

29. Late sequel of MTP
• Pelvic inflammatory disease
• Infertility caused by tubal infection and blockage
• Incompetent os following trauma to cervix
• Adherent placenta in subsequent pregnancy
• Asherman syndrome
• IUGR
• Rh-isoimmunisation if anti-D has not been administered
• Cervical ectopic pregnancy as a result of PID

30. THANKYOU