Medical termination of pregnancy can be performed using medication or surgically. Common medication methods include mifepristone with misoprostol or methotrexate with misoprostol. Surgical termination includes vacuum aspiration. The MTP Act of 1971 legalized abortion in India and established conditions for termination up to 20 weeks gestation. Termination requires consent and can be performed by qualified practitioners in approved facilities. The most effective and commonly used regimens include mifepristone followed by misoprostol 2-3 days later or methotrexate followed by misoprostol.

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