To avoid the misuse of induced abortions, most countries have enacted laws whereby only qualified Gynaecologists under conditions laid down can do abortions in clinics/hospitals that have been approved.

The Medical Termination of Pregnancy Act was enacted by the Indian Parliament in 1971 and came into force from 01 April, 1972. The MTP act was again revised in 1975.

The act was amended in 2003 to include the medical methods of abortion with two drugs Mifepristone (RU 486) and Misoprostol

Under the act pregnancy can be terminated upto 20 weeks of gestation.

The MTP Act lays down the condition under which a pregnancy can be terminated, the persons and the place to perform it.

The reasons, for which MTP is done, as interpreted from the Indian MTP Act, are:

(i)   where a pregnant woman has a serious medical disease and continuation of pregnancy could endanger her life like:

·        Heart diseases.

·        Severe rise in blood pressure.

·        Uncontrolled vomiting during pregnancy

·        Cervical/ Breast cancer.

·        Diabetes mellitus with eye complication (retinopathy).

·        Epilepsy.

·        Psychiatric illness.

(ii) Where the continuation of pregnancy could lead to substantial risk to the newborn leading to serious physical/ mental handicaps examples like

·        Chromosomal abnormalities.

·        Rubella (German measles) viral infection to mother in first three months.

·        If previous children have congenital abnormalities.

·        Rh iso-immunisation.

·        Exposure of the fetus to irradiation.

(iii) Pregnancy resulting of rape.

(iv)  Conditions where the socio-economic status of the mother (family) hampers the progress of a healthy pregnancy and the birth of a healthy child.

Failure of Contraceptive Device irrespective of the method used (natural methods/ barrier methods/ hormonal methods).

This condition is a unique feature of the Indian Law. All the pregnancies can be terminated using this criterion.

Consent:

·        If married--- her own written consent. Husband's consent not required.

·        If unmarried and above 1 8years ---her own written consent.

·        If below 18 years ---written consent of her guardian

·        If mentally unstable --- written consent of her guardian.

Consent assures the clinician performing the abortion that she has been informed of all her options and has been counseled about the procedure, its risks and how to care for herself after she has chosen the abortion of her own freewill.

Person or persons who can perform MTP

Physicians qualified to do MTP are:

·        Any qualified registered medical practitioner who has assisted in 25 MTPs.

·        A house surgeon who has done six months post in Obstetrics and Gynecology.

·        A person who has a diploma /degree in Obstetrics and Gynecology.

·        3 years of practice in Obstetrics and Gynecology for those doctors registered before the 1971 MTP Act was passed.

·        1 year of practice in Obstetrics and Gynecology for those doctors registered on or after the date of commencement of the Act.

·        Whenever the pregnancy exceeds 12 weeks but is below 20 weeks opinion of two registered medical practitioners is necessary.

Place where MTP can be performed:

Any institutions licensed by the Government to perform MTP. The certificate issued by the Government should be conspicuously displayed at a place easily visible to persons visiting the place.

DIAGNOSIS:

A.  Clinical diagnosis

·        A thorough history including date of LMP

·        An internal examination to confirm the duration of pregnancy.

·        GPE including blood pressure and weight

B.   Laboratory Diagnosis

·        Urine test for confirmation of pregnancy.

·        Routine urine analysis.

·        Routine blood counts including hemoglobin estimation.

·        Blood group and Rh factor.

·        Fasting Blood Sugar

·        HIV, HbsAg, HCV

·        For 2nd Trimester Abortions with Ethacridine - Renal function

C.   Radiological Diagnosis

·        Ultrasound may be required, If the client does not remember her LMP or there is disparity between period of amenorrhea and clinical examination

Methods of Induced Abortion:

Abortion can be induced by different methods depending on the weeks of pregnancy completed.

Methods of MTP

·        Upto 12 weeks of pregnancy

1.      MEDICAL METHOD

-  Mifépristone and Misoprostol

2.      SURGICAL METHOD

-  Suction evacuation/Vacuum aspiration!

Suction curettage

-Dilatation and Curettage(D&C)

1.   MEDICAL METHOD - By Mifepristone and Misoprostol

The termination of pregnancy by medical methods is allowed upto 7 weeks period of gestation (49 days from the first day of last menstrual period in a woman with a regular cycle of 28 days)

Mode of Action:

MIFEPRISTONE (RU-486)- It is a derivative of norethindrone and has antiprogestin action

-it binds to progesterone receptors at endometrium and decidua so leads to necrosis of placenta and detachment

-  it softens cervix

-  it causes uterine contractions

MISOPROSTOL - it binds to myometrial cells causing strong myometrial contractions and causes cervical softening and dilatation. This leads to expulsion of conceptus from the uterus

Contra indications:

Absolute:

1.      Inherited porphyria

2.      Allergy to drugs Relative:

1.      Anemia (Hb<8gm%)

2.      Suspected/confirmed ectopic pregnancy

3.      Female on anticoagulant therapy

4.      Chronic adrenal failure

5.      Current use of systemic corticosteroids

6.      Uncontrolled Hypertension with BP 160/100

7.      Cardiovascular disease as angina, valvular disease

8.      Severe renal, liver or respiratory distress

9.      Uncontrolled seizure disorder

Medical abortion need to be done cautiously in:

·        Pregnancy with IUCD in situ (remove IUCD first)

·        Pregnancy with fiBPoids

·        Pregnancy with scarred uterus

·        Bronchial asthma

Pre-abortion counseling:

·        Patient should be told that she will have to come for minimum three follow-up visits

·        Family support

·        Side effects of drugs

·        Easy access to health care facility

·        D & C will be needed in case of failure

·        Risk of congenital malformation in case of continuation of pregnancy

·        Contraceptive advice Consent: Is must (Form C)

Dosage Schedule:

DAY 1 -Mifepristone 200m stat is to be given

·        Give her lnj Anti-D, if pregnancy> 6 weeks

·        Back-up facility address and phone numbers should be given where she can contact in case of emergency

·        She must return to clinic after 24-48 hrs

·        She should be told that bleeding may occur with mifepristone alone also

DAY 2-3 - Misoprosfol 400µg (2 tablets of 200pgecich) to be given orally or kept in posterior vaginal fornix

·        Ask for H/O bleeding or side-effects if any

·        Observe the woman in clinic/hospital for 4 hours

·        Give pain relief if required (Paracetamol 500 mg)

·        No need to give antibiotics routinely

·        Advise her adequate rest and to avoid going out of station

·        She should report in case of excessive bleeding/pain( she should be told that soaking two pads per hour for 2 hours in a row is all right at the time of peak cramping which is often the case when the pregnancy expulsion occurs)

·        She should avoid intercourse or use condoms or oral pill fill next visit

DAY15-

•                          Ask for clinical history (regarding the expulsion of products of conception and bleeding) to ensure abortion is complete

•                          P/V exam (to confirm complete abortion)

•                          USG-if needed. The clinician must understand that during medical abortion, once the

gestational sac is expelled, the uterus will normally contain blood, blood clots and decidua, which appear as hyper echoic tissue on USG and may be interpreted as incomplete abortion. In the absence of excessive bleeding, these patients should be followed conservatively

•                          Contraceptive advice (very important)

•                          Inform her that next period may be delayed

A written statement signed by the woman must be kept on record if surgical treatment is refused in case of failure

Side-effects:

·        Pain

·        Bleeding (average 9-11days)

·        Nausea

·        Vomiting

·        Diarrhea

·        Headache

·        Chills

·        Feeling of warmth

·        Dizziness & fatigue

These will subside with passage of time and rarely need medication Efficacy:

·        A combination of Mifepristone and misoprostol has a success rate of 95-99% for pregnancies up to 7 weeks

·        Approximately 1 % woman may require surgical evacuation for heavy bleeding

•    1 % may fail to abort

·        Abortion may be incomplete in 2-3% requiring surgical evacuation Failure:

·        Failure with medical abortion is a term when a surgical curettage is performed for any reason

·        True drug failure is defined as presence of cardiac activity 2 weeks following mifeprestone and misoprostol administration

Prevention and Patient Education

·        Encourage to come for follow-up when periods resume

·        Offer contraception to all seeking medical abortion

·        Oral pills/DMPA- stated on day 15 if abortion complete

·        Oral pill may be started on day of misoprostal administration as it does not interfere with abortion process

·        Cu T – after next periods

·        Condoms – preferably intercourse should be avoided till day 15 but can be used if woman has intercourse before that

·        Tubal ligation- prefer surgical termination or after next cycle

·        Inform about emergency contraception

·        Counsel regarding HIV/AIDS

Advantages:

·        Abortion possible at early gestation

·        Feasible with minimal assistance

·        Less complication rate

·        More privacy

·        Less invasive

·        No instruments used

·        No anesthesia needed

·        No effect on future fertility

Disadvantages:

·        Patient needs at least 3 visits

·        Bleeding is prolonged (9-11 days)

·        Drug side-effect may occur

·        Failure in small percentage i.e. 2-3%

·        Potential risk of congenital malformation it fails to cause abortion

Record keeping

·        All medical practitioners or institution heads should maintain admission register for medical abortion (a combined register can be maintained for medical & surgical abortion)

·        The register should include serial no., date of registration, name of patient and name of her husband/father/guardian, address, education, age, religion, marital status, reason for termination, obstetrical history, any significant past/surgical history, findings of GPE and pelvic examination and relevant investigations done

·        The prescribed drug protocol should be written clearly, indicating date & time, dose and route of administration

·        The follow-up visits should be recorded with comments

·        Admission register is a secret document and the particulars of the pregnant woman should not be disclosed to any person except appropriate authority

·        Entries made in case sheet, OT register, follow-up card or any other document should not disclose indentify of pregnant woman in any way

·        Destination of admission register and other papers: as per MTP regulations 1975 are to be followed

Record of complications and failures

A record of complications especially pertaining to heavy bleeding necessitating I/V fluids, blood transfusion or curettage, sepsis, incomplete abortion, continuation of pregnancy, adverse drug reactions should be maintained

Reporting to authorities

·        Every Head of hospital/institution or practitioner should send a monthly record of abortions with Mifepristone & Misoprostol to CMO of the state as per MYP Act

·        This report should include the name and address of the practitioner/ Head of institution who provided medical abortion with completed consent forms and any drug reactions noted

·        Confidentiality should be maintained

2. SURGICAL METHOD-

A)  Vacuum Aspiration (Also k.a. Suction Evacuation/Suction Curettage)

B)  Dilatation & Curettage (D&C)

A)   Vacuum Aspiration

·        Vacuum aspiration, manual or electric is the preferred method of choice for the first trimester surgical abortion

·        Manual vacuum aspiration and electrical vacuum aspiration are both equally effective

·        According to FIGO Suction Evacuation is the most effective method of 1st

trimester abortion

·        Counseling is very important, regarding method, follow-up and contraceptive advice

Cervical ripening: (if preg. ˃8wks)

1 Misoprostal sublingual or intravaginal 400µg is given3-4 hours before the procedure)

Anesthesia

Paracervical block General Anesthesia

Pre-op procedure:

History/GPE

Routine investigations Fasting- 6 hrs

Mild sedation

Procedure:

1.      Evacuate bladder

2.      Lithotomy position

3.      Clean and drape (sponge holding forceps)

4.      P/V exam (confirm findings)

5.      Retract the posterior vaginal wall (Sims speculum)

6.      Hold anterior lip of cervix (Volsellum)

7.      Clean cervix (antiseptic- Povidone iodine)

8.      Give paracervical block (if not under GA)

9.      Do cervical dilatation (fully not reqd) Cervical dilator

10.  Karman's cannula inserted (by no touch technique)

11.  Electronic    suction    machine    or    MVA    syringe    (Manual Vacuum Aspiration) is used to do suction evacuation

12.  Pressure created is 600mm of Hg

13.  Routine curettage is done in the end to check completion of procedure

14.  lnj. Anti-D is given in case of Rh-ye mother Indications for completion of procedure:

-            No more uterine contents coming

-            Blood stained froth starts coming

-            There is grating feeling

-            There is gripping of cannula at the level of internal as

•            Methergin 0.2mg given IN slowly (may not be needed if priming already done with misoprostol)

•            Check the material obtained

•            Clean the vagina and instill povidone-iodine If no tissue obtained: the reason may be

-  Failure to interrupt pregnancy

-  Incomplete abortion

-  Ectopic pregnancy

-  Patient may not have been pregnant at all Follow-up:

-  Observe patient for 2-4 hrs

-  Give antibiotics and pain killers

-  Contraceptive advice

-  Abstinence for 10-14 days

-   Immediately report to the doctor in case of acute pain lower abdomen, excessive bleeding, raised temperature or if symptoms of pregnancy persist

Complications: occur in <2% of cases

•    Uterine hemorrhage

•    Pelvic infection

•    Uterine perforation

•    Retained products of conception

•    Continuation of pregnancy

•    Failure rate- <1%

•    Mortality rate is < 2/lac

Late sequelae or long term complications:

-  Infertility caused by tubal blockade

-  Incompetent as following trauma to cervix

-  Asherman's syndrome

-  Ectopic pregnancy

-  Rh-isoimmunisation

-  Psychiatric disorders

B)   Dilatation & Curettage (D & C) - FOGSI recommends against the routine use of D &C in first trimester terminations

•            As in suction evacuation dilatation is done by increasing number of cervical dilators

•            I/V Methergin 0.2 mg is given as a routine

•            The contents of the uterine cavity are removed with ovum forceps

•            Curettage is done to check that the cavity is empty

•            The rest of the steps are same as in suction evacuation The disadvantages are:

•                   bleeding is more

•                   It takes more time

•                   Chances of incomplete evacuation are more

•                   Complication rate is more between 12 - 20 weeks of pregnancy

1.               MEDICAL METHODS

A)     Extra-amniotic instillation of Ethacridine lactate

B)      lntra-amniotic instillation of hypertonic saline

C)      Mifepristone and Misoprostol

2.               SURGICAL METHODS

A)             Dilatation and Evacuation (D&E)

B)             Aspirotomy

C)              Hysterotomy

MEDICAL METHODS

A)  Extra-amniotic instillation of Ethacridine lactate

Procedure: Involves instillation of 0.1% ethacridine lactate, on oxyfocic, through a Foley's catheter inserted transcervically, in an extra-amniotic space

Steps:

a)    After holding cervix with sponge holding forceps, No 16 Foley's catheter is introduced via cervix into uterus, in extra-amniotic space

b)  Bulb is inflated with 30cc of normal saline and pulled down so that it snugly fits over internal as

c)   Ethacridine is instilled through other channel, either by syringe or drip method

d)  Volume to be instilled is POG in weeks X 10 but not more than 150 cc

e)  Catheter is wrapped to medial aspect of thigh

f)     To expedite the procedure, ethacridine can be combined with prostaglandins or oxytocin

g)  Induction abortion interval ranges between 10-30 hours

h)  Gentle curettage may be required after expulsion of products

B)  Intra-amniotic instillation of hypertonic saline

·        Procedure involves trans-abdominal instillation of 20% hypertonic saline by needle introduced in intra-amniotic space, either blindly with prior USG or under USG guidance

·        Few deaths because of hypernatremia have been reported so not used these days

·        Apart from saline, urea and prostaglandins can be instilled intra-amniotically

C)  Mifepristone and Misoprostol

·        With the advent of mifepristone and misoprostol use of induction methods have declined. But it must be remembered that use of medical method using mifepristone and misoprostol is not approved in India for second trimester abortions

·        Recommended Dose: Mifeprisfone 200 mg stat followed after 36-48 hours by 400 micrograms of oral, sublingual or vaginal misoprostol every 3-6 hours up to doses

2.  SURGICAL METHODS

a)  Dilatation and Evacuation

·        It is mainly employed between 13-16 weeks

·        Prior priming is done by using either laminaria tents or misoprostol (preferred)

·        This is followed by suction evacuation by larger cannula or evacuation by ovum forceps of the products

·        May be associated with many complications like failure of complete evacuation, uterine perforation, cervical lacerations etc.

·        Not preferred

B)  Aspirotomy

·        The procedure is performed to undertake termination of pregnancy beyond 14-20 weeks

·        The procedure involves initial slow dilatation with either laminaria tents or misoprostol followed by rapid dilatation during procedure by metal dilators up to no. 14-16

·        Then by introducing 14-16 no cannula, membranes are ruptured and amniotic fluid aspirated

·        Aspirotomy forceps is introduced and fetal parts are grasped crushed and extracted bit by bit and arranged outside to make sure that no fetal parts are left behind

·        An oxytocin drip is started to ensure good uterine contractions, ensure complete evacuation and reduce bleeding

·        It is technically difficult, requires proper set up, training and skill and has much higher complication rate, thus not a preferred method for second trimester abortions

C)  Hysterotomy

·        Abdominal Hysterotomy or mini caesarean section maybe required as method of termination in the following cases:

1.   Women with previous two caesarean sections or other uterine scars

2.     Placenta praevia with risk of severe bleeding by trans-vaginal methods

3.      Where other methods of medical termination have failed or contraindicated

4.   Rarely women have vascular cervical lesion or cancer cervix with risk of massive hemorrhage with vaginal methods

Summary:

Though literature has proved efficacy of misoprostol with or without mifepristone as a safe and effective method of second trimester abortion, it is not an approved method in India. Extra-amniotic instillation of ethacridine lactate remains the method of choice in most cases of second trimester abortions

References:

1.      The medical termination of pregnancy act, 1971 (act no. 34 of 1971) (10th August, 1971)

2.      Amendment to MTP Rules: (Ref. GSR 485(E) notified on 30th June, 2003)

3.      Guidelines for Early Medical Abortion in India using Mifepristone and Misoprostol. Prepared by WHO-CCR in Human Reproduction, Department of Obstetrics & Gynecology, AIIMS New Delhi in collaboration with Ministry of Health and Family Welfare GOl 2007

4.      FOGSI FOCUS January 2012 by the Federation of Obstetric and Gynecological Societies of India

FORM C

(See rule 8)

I _____________________________________ daughter/wife of _____________________________________ aged about______________years (here state the permanent address) at present residing at _____________________________________ do hereby give my consent to the termination of pregnancy at _____________________________________ (State the name of place where the pregnancy is to be terminated)

Place:

Date:                                                                                                  Signature

(To be filled in by guardian where the woman is a mentally ill person or minor)

I_____________________________________ son/daughter/wife of_____________________________________ aged about __________ years of _____________________________________ at present residing at (Permanent address)_____________________________________ do hereby give my consent to the termination of the pregnancy of my ward _____________________________________ who is a minor/lunatic at_____________________________________ (place of termination of my pregnancy)

Place:

Date:                                                                                                  Signature