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MTP
- 2. Definition •Deliberate termination ofpregnancy either by medical or by surgical method before the viability of the fetus. •Medical termination of pregnancy act 1971 •Enforced in year April 1972 •Revised in 1975
- 3. Provisions of MTP MTPact 1975 •The continuation of pregnancy would involve serious risk of life or grave injury to the physical and mental health of the pregnant women. •There is a substantial risk of the child being born with serious physical and mental abnormalities so as to be handicapped in life. •When the pregnancy is caused by rape, both in cases of major and minor girl and in mentally imbalanced women. •Pregnancy caused as a result of failure of contraceptives.
- 4. Recommendations • A registeredmedical practitioner is qualified to perform an MTP provided: 1.one has assisted in atleast 25 MTP in an authorised center and having a certificate. 2. One has got 6 months house surgeon training in OBG. 3. One has got diploma or degree in OBG • Termination can be performed in hospitals, established or maintained by govt. or places approved by govt. • Pregnancy can only be terminated on the written consent of the women. Husband's consent is not required • Termination in a minor girl or lunatic girl cannot be terminated without consent of parents or guardian
- 5. • Termination ispermitted upto 20 weeks • The abortion has to be performed confidentially and to be reported to DHS in the prescribed form
- 6. Indications •To save thelife of the mother. 1. Cardiac diseases grade iii and iv 2. Chronic Glomerulonephritis 3. Malignant Hypertension 4. Intractable Hyperemesis Gravidarum 5. Cervical or Breast Malignancy 6. DM with Retinopathy 7. Epilepsy or psychatric illness
- 7. • Eugenic 1. Structural(anencephaly) 2. Chromosomal (downs syndrome) 3. Genetic (haemophilia) 4. Action of teratogenic drugs 5. Radiation exposure 6. Rubella • Social indications 1. Parous women having unplanned pregnancy with low socio economic status. 2. Rape
- 9. Method of termination ⮚FIRSTTRIMESTER (UPTO 12 WKS) ❖MEDICAL METHODS 1. Mifepristone and misoprostol 2. Mifepristone 3. Methotrexate and misoprostol 4. Tamoxifen and misoprostol
- 10. Mifepristone and misoprostol •Mifepristone act as antagonist, blocking effect of natural progesterone • Effective upto 63 days, highly successful when used within 49days. • Day 1- 200 mg mifepristone • Day 3 - misoprostol 400mcg orally or transvaginally • Patient remain in clinic for 4 hrs during which expulsion of conceptus occur • Patient is reexamined for 10-14 days
- 11. Methotrexate and misoprostol •Methotrexate 50 mg/sq.m IM (56 days of gestation) followed by 7 days later misoprostol 800 mcg vaginally. • Less expensive • Takes longer time • Contraindications- Women above 35 years, heavy smokers, taking long corticosteroid
- 12. ❖SURGICAL METHODS 1. Menstrualregulations 2. Vaccum aspiration 3. Suction evacuation and curettage 4. Dilatation and evacuation Rapid method Slow method
- 13. Menstrual regulation • Itis the aspiration of the endometrial cavity within 14 days of missed period in a woman with previous normal cycle. • 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 anesthesiamay be employed. • After introducing the posterior vaginal speculum, the cervix is steadied with an Allis forceps.
- 14. • Cervix maybe 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.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. • The procedure is contraindicated in advanced pregnancy and in the presence of local pelvic inflammation.
- 16. Vaccum aspiration ● Doneupto12 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.
- 17. ● .Hand operateddouble valve plastic syringe is attached to a cannula. ● The cannula is inserted transcervicallyinto the uterus and the vacuum is activated.A negative pressure of 660 mm Hg is created. ● Aspiration of the products of conception is done
- 18. Suction evacuation andcurettage • 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. • Vaginal examination- size and position of uterus • Vaginal speculum • Anterior lip of cervix is grasped by allis forceps • Uterine sound is introduced • Cervix is dilated- metal dilators, laminaria tent • IV methergin 0.2 mg • Suction. • The vaccum should be broken before withdrawing cannula
- 20. Dilatation and evacuation •The operation consists of dilatation of the cervix and evacuation of the products of conception from the uterine cavity. • Rapid method- Dilatation of cervix and evacuation of the uterus are done in the same setting. • Slow method- slow dilatation of the cervix with introduction laminaria tent or lamicel sponges into cervical canal. This is followed by evacuation of uterus after 12 hrs. Vaginal misoprostol 400 mcg 3 hrs before surgery is also used in cervical ripening.
- 22. SECOND TRIMESTER TERMINATION MEDICALMETHODS •PROSTAGLANDINS AND THEIR ANALOGS 1. Misoprostol 2. Mifepristone and prostaglandins 3. Gemeprost 4. Dinoprostone 5. Prostaglandins F2α •OXYTOCIN
- 23. Misoprostol. PGE1 analog •400-800 mcg misoprostol given vaginally at an interval of 3-4 hrs Or • First dose of 600mcg misoprostol given vaginally, then 200 mcg orally every 3 hrs • Recently, 400 mcg misoprostol is given sublingually evry 3 hrs for a maximum of 5 doses • Successful method 100% • Mean induction abortion interval is 11-12 hrs.
- 24. Mifepristone and prostaglandin 1.Mifepristone 200 mg oral, followed 36-48 hrs later by misoprostol 800mcg vaginal, then misoprostol 400 mcg oral evry 3 hrs for 4 doses is used. 2. Success rate 97% 3. Mean induction abortion interval 6.5 hrs
- 25. Gemeprost PGE1 analog •1 mg vaginal pessary every 3-6 hrs for 5 doses in 24 hrs • 90% • 14-18 hrs Dinoprosrone PGE2 analog • 20 mg vaginal suppository every 3-4 hrs. • When used along with osmotic dilators, mean induction to abortion interval is 17 hrs • Thermolabile & expensive Prostaglandin F2a • Carboprost tromethamine 250 mcg IM every 3 hrs for a maximum of 10 doses. • Success rate 90% in 36 hrs • Side-effects - nausea, vomiting, dairrhea and pain • Contraindications - bronchial asthma
- 26. Oxytocin • High dosesingle agent. • Effective in 80% cases • It can be used with IV NS along with any of medication used either intra amniotic and extra amniotic space in an attempt to augment abortion. • Drip rate increased upto 59 milliunits or more per min • Currently 300 units in 500 ml dextrose saline is favoured.
- 27. SURGICAL METHODS • 13-15 WEEKS - Dilatation and evacuation • 16- 20 WEEKS - Intrauterine instillation of hyertonic solution Intra amniotic Extra amniotic • Hysterotomy
- 28. Intrauterine instillation ofhypertonic solution • Extra amniotic- 0.1 % ethacridine lactate is done transcervically through a Foley's catheter. • The catheter is passed up the cervical canal for about 10 cm above internal os between membranes and myometrium and ballon is inflated with saline. • It is removed after 4 hrs. • It can be used in cases contraindicated for saline instillation. 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.
- 29. • Intra amniotic-It is instilled through abdominal route. Amniocentesis is done Amount of saline to be instilled = no. of weeks of gestation * 10 ml Infused slowly at 10 ml/min • 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.
- 30. Hysterotomy 1. Operative procedureof extracting the products of conception out of the womb before 28 wks by cutting through anterior wall of uterus. 2. Abdominal route 3. Used when other methods fail, fibroids, placenta previa, uterine didelphys , septate uterus, cervical cancer, multiple CS
- 31. Complications • There isno universally safe and effective method which is applicable to all cases. • However, the complications are much less (5%) if termination is done before 8 weeks by MVA or suction evacuation/currette. • The complications are about five times more in mid-trimester termination. • Use of PG analogues and mifepristone has made second trimester MTP effective and safe. • The complications are either related to the methods employed or to the abortion process.
- 32. IMMEDIATE •Injury to cervix •Uterineperforation •Hemorrhage and shock •Thrombosis or embolism •Post abortal triad- Pain, bleeding, low grade fever
- 33. REMOTE •Gynecological i. Menstrual disturbances ii.Chronic pelvic inflammation iii. Infertility iv. Scar endometriosis v. Uterine synechiae •Obstetrical a. Recurrent midtrimester abortion b. Ectopic pregnancy c. Dysmaturity
- 34. d. Preterm labour e.Increased perinatal ploss f. Rupture uterus g. Rh- isoimmunisation h. Failed abortion and continued pregnancy
- 41. Reference • DC Duttatextbook of obstetrics. Pg no: 164-168 pgno:524- 528