ABORTION

DEFINITION- Abortion is the separation partial or

complete, with or without expulsion of the products of
conception, before viability i.e. termination of the
pregnancy before the fetus is sufficiently developed to
survives.
Abortion is the expulsion or extraction from its mother of
an embryo or fetus weighing 500 gm or less when it is
not capable of independent survival. This 500 gm of fetal
development is attained approximately at 22 weeks of
gestation. The expelled embryo or fetus is called abort
us. The term miscarriage, which is mostly used, is
synonymous with spontaneous abortion
 INCIDENCE
• The incidence of abortion is difficult to work
out but probably 10-20% of all clinical
pregnancies end in miscarriage and another
optimistic figure of 10% are induced illegally.
75% abortions occur before the 16th weeks and
of these, about 75% occur before the 8th weeks
of pregnancy.
ETIOLOGY OF SPONTANEOUS ABORTION
CAUSE OF EARLY ABORTION

1. Germ plasm (upto 50% cases)-

• Chromosomal abnormality- trisomy (eg. Down’s
syndrome) monosomy (eg. Turner XO), Polypliod
• Structural defect (deletions, ring chromosomes,
trance location.)
• Aging of gametes.
2. Defective intrauterine environment-which
interferes with development of the conceptus.
• Important causes include- IUCD with pregnancy,
fibroid with pregnancy, uterine septum.
3. Extra uterine factors-which disturb
pregnancy:
• Acute appendicitis or pyelonephritis, pelvic
inflammations, colitis, pelvic surgery.
4. Acute infectious fever, viral infections (eg
rubella)
5. Severe systematic disease (renal disease,
diabetes, TB etc.)
6. Alcohol tobacco
7. Luteal phase defects:
• Improper functioning of the corpus leuteum can
lead to –short luteal phase -Irregular levels of
progesterone which interfere with maintenance
of decidua, (endometrium of pregnancy) hence
can lead to both infertility and recurrent abortion.
8. Immunologocal causes-
• Autoimmue disorder- can cause miscarriage
usually in the second trimester. these patients form
antibodies against there own tissue and the
placenta.these antibodies ultimately cause
rejection of early pregnancy. antibodies
responsible are:
(a) Anti nuclear antibodies (ANAs)
(b) Antiphospholipid antibodies include lupus
anticogulation (LAC) and anti cardiolipin
antibodies (aCL). Placental thrombosis, infraction
and fetal hypoxia is the ultimate pathology to
cause abortion.
• Alloimmune diseases- Paternal antigens which
are foreign to the mother invoke a protective
blocking antibody response. These blocking
antibodies prevent maternal immune cells from
recognising thefetus as aforeign entity. there fore,
the fetal allogarft containing foreign paternal
antigen are not rejected by the mother. Paternal
human leukocyte antigen sharing with the mother
leads to iminished fetal maternal immunologic
intraction and ultimately fetal rejection.
CAUSE OF LATE (SECOND TRIMESTER)
ABORTION
1. Grem plasm defects which are less severe
• May manifest as congenital anomalies, growth
failure and late abortions
2. Systematic infection leading to fetal infections
• Syphilis, toxoplasmosis, listeria monocytogenes
3. Rh or ABO incompatibility
• In severecases, with severe fetal anemia and
development of hydrops fetalis, can cause late
abortion
4. Incompetent cervix
• Term used to describe cases where the internal os
of the cervix open up, usually after 12-14 weeks,
leading to spontaneous, retatively painless
expulsion of an immature live birth, usually with a
gush of amniotic fluid.
5. Alcohol, tobacoo
6. Other systemic disease
• Renal hypertention, diabetes, acute pyelonephritis,
cardiac, especially uncontrolled or cynotics.
TYPES OF ABORTION
There are number of type of spontaneous abortion-
1. Threatened abortion
2. Inevitable abortion
3. Complete abortion
4. Incomplete abortion
5. Missed abortion
6. Septic abortion
 THREATENED ABORTION
DEFINITION:
It is a clinical entity where the process of abortion has
started but has not progressed to a state from which
recovery is imposible.
CLINICAL FEATURES:
The patient having symptoms suggestive of pregnancy,
complains of :
(1) Bleeding per vaginam: The bleeding is usually slight and
bright red in colour. On rare occasion, the bleeding may be
brisk and sharp, specially in the late second trimester,
suggestive of low implantation of placenta.the bleeding
usually spontaneously.
(2) Pain- Bleeding is usually painless but there may be mild
backache or dull pain in lower abdomen. Pain appears
usually haemorrhage.
Sign- Pelvic examination should be done gently to aviod trauma.
On per speculum examination bleeding may be seen and
sometimes cervival lession is seen on digital sometimes
cervical lesion is seen on digital examination closed cervical
os is felt, the size of uterus corresponds to period of
amenorrhea.
INVESTIGATION: Hb estmation, ABO and Rh
grouping, urine examinations.
Special investigations: A well formed gestational ring
with observation of fetal heart motion shows healthy
fetus on the other hand a blighted ovum is evidence by
crevated or irregular gestational sac, Small mean
gestational sac diameter, absent fetal echoes and absent
fetal cardiac movements.
Serum progesterone value of 25ng /ml or more
generally indicates a viable pregnancy in about 95% of
cases. Serial serum chorionic gonadotrophin (HCG)
level is helpful to assess the fetal well being. Normally
quantitative value of HCG should double by every 48
hours.
TREATMENT:
Rest: The patient should be in bed for few days until
bleeding stops. Prolonged restriction of activity
has got no therapeutic value.
Drugs: Sedation and relief of pain may be ensured by
phenobarbitone 30 mg or diazepa 5mg table
twice daily.
General measures:
(1) The patient is advised to preserve the vulval pads
and anythins expelled out per vaginam, for
inspection.
(2) To report if bleeding and / or pain become
aggravated.
(3) Routine note of pulse, temperature and vaginal
bleeding.
ADVICE ON DISCHARGE: The patient should limit
her activities for at least two weeks and avoid heavy
work. Coitus is contraindicated during this period. She
should be re-examined after one month to assess the
growth of the fetus,
PROGNOSIS: The prognosis is very unpredictable whatever
method of treatment is employed either in the hospital or at home.
In isolated spontaneous threatened abortion, the following events
may occur.
In about two- third, pregnancy continue s beyond 28 weeks.
In the rest, it terminates either in inevitable or missed abortion. If
the pregnancy continues, there is increased frequency of preterm
labour, placenta previa, intra uterine growth retardation of the
fetus and fetal anomalies.
 INVETABLE ABORTION
DEFINITION-
It is the clinical type of abortion where the changes
have progressed to a state from where continuation of
pregnancy is impossible.
CLINICAL FEATURES: The patient having the
feature of threatened abortion, develops the
following manifestations
1) Increased vaginal bleeding.
2) Aggravation of pain in the lower abdomen which
may be colicky in nature.
3) The general condition of the patient is
proportionate to the visible blood loss.
4) Internal examination reveals dilated internal os of
the cervix through which the product of
conception are felt.
Sign- On internal examination internal os is dilated and
products of conception can be felt through os.
MANAGEMENT- Excessive bleeding should be promptly
controlled by administering methargin 0.2 mg if the cervix
is dilated and the size of the uterus is less than 12 weeks.
The shock is corrected by intravenous fluid therapy and
blood transfusion.
ACTIVE TREATMENT-
BEFORE 12 WEEKS :
1. D & E followed by curettage of the uterine cavity by
blunt curette under general anaesthesia.
2. Alternatively, suction evacuation followed by
curettage is done.
AFTER 12 WEEKS:
The uterine contraction is accelerated by oxytocin drip (10
units in 500 ml of normal saline) 40-60 drops per minute. If
the fetus is expelled and the placenta is retained, it is
removed byovem forceps, if lying separated. If the placenta
is not separated, digital separation followed by its evacution
is to be done under general anaesthesia.
2. If bleeding is profuse with the cervix closed ( suggestive
of low implantation of placenta) – evacuation of the uterus
may have to be done by abdominal hysterotomy.
 COMPLETE ABORTION
DEFINITION-
Wen the product of conception are expelled en mass, it is
called complete abortion.
CLINICAL FEATURE: There is history of expulsion
of a fleshy mass vaginam followed by:
1. Subsidence of abdominal pain.
2. Vaginal bleeding become trace or absent
3. Internal examination reveals:
a) Uterus is smaller than the perio of
amenorrhoea and a little firmer.
b) Cervical os is closed.
c) bleeding trace
4. Examination of the expelled fleshy mass is
found intact.
MANGEMENT- The effect of blood loss, if any should be
assessed and treated. If there is doubt about complete
expulsion of the products uterine curratage should be done.
Transvaginal sonography is useful to prevent unnecessary
surgical procedure.
Rh-NEGATIVE WOMEN: A Rh-negative patient without
antibody in her system should be protected by Anti-D gamma
globulin- 50 microgram or 100 microram IM in cases of early
abortion or late abortion respectively within 72 hours.
However, Anti-D may not be required in a case with
complete miscarriage before 12 weeks gestation where no
instrumentation has been done.
 INCOMPLETE ABORTION
DEFINITION-
When the entire products of conception are not
expelled, instead a part of it is left inside the uterine
cavity, it is called incomplete abortion.
CLINICAL FEATURES: History of expulsion of a
fleshy mass per vaginam followed by
1. Continuation of pain lower abdomen colicky in
nature, although in diminished magnitude.
2. Persistence of vaginal bleeding of varying
magnitude.
3. Internal examination reveals –
a) uterus smaller than the period of amenorrhoea
b) patulous cervical os often admitting tip of the
finger and
c) varing amount of bleeding
4. On examination, the expelled mass is found
incomplete.
TERMINATION: The product left behind may lead to -
(a) Profuse bleeding
(b) Sepsis
(c) Placental polyp and
(d) Rarely choriocarcinoma
MANAGEMENT- In recent cases
Early abortion-dilatation and evacuation under general
anaesthesia is to be done.
Late abortion- The uterus is evacuated under general
anaesthesia and the products are removed by ovum forceps or
by blunt curette.
In late cases, dilatation and curettage operation is to be done to
remove the bits of tissues left behind. The removed materials
are subjected to a histological examination.
 MISSED ABORTION (SILENT MISCARRIAGE)
DEFINITION-
When the fetus is dead and retained inside the uterus for
a variable period, it is called missed abortion or silent
miscarriage or early fetal demise.
PATHOLOGY-
The cause of prolonged retention of the dead fetus in the
uterus is not clear. Beyond 12 weeks, the retained fetus
becomes macerated or mummified. The liquor amnii get
absorbed and the placenta become pale, thin and may be
adherent. Before 12 weeks, the pathological process
differs when the ovum is more or less completely
surrounded by the chorionic villi.
CLINICAL FEATURES-The patient usually presents with
feature of threatened abortion followed by:
I. persistence of brownish vaginal discharge.
II. subsidence of pregnancy symptoms.
III. retrogression of breast changes.
IV. Cessation of uterine growth which in fact become
smaller in size.
V. non audibility of the fetal heart sound even with doppler
cardioscope if it had been audible before.
VI. cervix feel firm.
VII. immunological test for pregnancy become negative.
VIII. real time USG reveal an empty sac early in the
pregnancy or the absence of fetal motion or fetal heart
movement later in the pregnancy.
COMPLICATIONS - The complication of the missed
abortion are those mentioned in intra uterine fetal death.
Blood cogulation disorders are less likely to occur in
missed abortion.
MANAGEMENT-
Uterine is less than 12 weeks: vaginal evacution can be
carried out without delay. This can be effectively done by
suction evacuation or slow dilatation of the cervix by
laminaria tent followed by dilatation and evacuation (D &
E) of the uterus under general anaesthesia. The risk of
damage to the uterine walls and brisk haemorrhage during
the operation should be kept in mind.
Uterus more than 12 weeks: The same principles of the
management as advocated in the intrauterine fetal death are to
be followed. Induction is done by the following methods:
Oxytocin-to start with 10-20 units of oxytocin in 500 ml
normal saline at 30 drops per minuts. If fails, escalating dose
of oxytocin to the maximum of 200 mlU/min, may be used
with monitoring.
Prostglandins are more effective than oxytocin in such cases.
the methods used are:
(a) prostaglandin E1 analogue (misoprostol) 200ug tablet is
inserted into the posterior vaginal fornix every 4 hours
for a maximum of 5 such.
(b) IM administration of 15 methyl PGF 2a (carboprost
tromethamine) 250 ug at three hourly intervals for a
maximum of 10 such.
 SEPTIC ABORTION
DEFINITION-
Any thing associated with clinical evidences of
infection of the uterus and its contents is called septic
abortion.
Abortion is usually considered septic when there are:
1. Rise of temperature of at least 100.4 f (38 C) for 24
hours or more;
2. Offensive or purulent vaginal discharge and
3. Other evidence of pelvic infection such as lower
abdominal pain tenderness
MODE OF INFECTION: The microorganism involved in
the sepsis are usually those normally present in the
vagina. The microorganism are
(a) Anaerobic- bacteriodes group (fragilis), anaerobic
streptococci, Cl.welchii, and tetanus bacillus
(b) Aerobic- Escherichia coli (E.coli), Klebisella,
staphylococcus, Pseudomonas and haemolytic
streptococcus (usually exogenous). Mixed infection is
more common.
1. The increased association of sepsis in illegal induced
abortion is due to the fact that: Proper antiseptic and
asepsis are not take,
2. Incomplete evacuation and
3. Inadvertent injury to the geniatal organs and adjacent
structures, particularly the gut.
CLINICAL FEATURES: Depending upon the severity
and the extent of infection, the clinical picture varies
widely. History of illegal termination by an unathorised
person is mostly concealed.
Pyrexia is an important clinical manifestation. Associated
chills and rigors suggest blood stream spread of infection.
However, if hypothermia is present, it is an ominous
feature of endotoxic shock.
Pain abdomen of varying degree is almost a constant
feature.
Arising pulse rate of 100-120/minute or more is a
significant finding than even pyrexia. It indicates spread if
infection beyond the uterus.
Variable systemic and abdominal findings depending upon
the spread of infection.
Internal examination reveals offensive purulent vaginal
discharge or a tender uterus usually with patulous os or
a boggy feel of the uterus associated with variables
pelvic finding s depending upon the spread of infection.
Grade-1 The infection is localised in the uterus.
Grade-2 The infection spread beyond the uterus to the
parametrium, tubes and ovaries or pelvic
peritoneum.
Grade-3 Generalised peritonitis and /or endotoxin shock or
jaundice or acute renal failure.
Investigations: Routine investigation include:
(1) Cervical or high vaginal swab is taken prior to internal
examination for-
a) Culture in aerobic media to find out the
dominant micro-organisms,
b) Sensivity of the micro-organism to antibiotic
and
c) Smear for gram stain. Gram negative
organism are – E.coli, Cl. Tetani etc.
(2) Blood for haemoglobin estimation, total and
differential count of white cells, ABO and Rh
grouping.
(3) Urine analysis including culture.
Special investigation:
(1) USG pelvics and abdomen to detect intrauterine
retained products of conception, physometra, foreign
body- intrauterine or intra-abdominal, free fluid in
the peritonial cavity or in the pouch of douglas.
(2) blood
(a) Culture- if associated with spell of chills and rigors,
(b) Cerum electrolytes as an adjunct to the management
protocol of endotoxin shock.
(c) coagulation profile
COMPLICATION:
IMMEDIATE- Most of the fetal complications are associated
with illegally induced abortion of grade-3 type.
1. Haemorrrhage related due to abortion process and also
due to the injury inflicted during the interference.
2. Injury may occure to the uterus and also to the adjacent
structure particularly gut.
3. Spread to infection leads to
a) generalise peritonitis- The infection reaches through
I. The uterine tubes
II. Perforation of the uterus
III. Bursting of the microabscess in the uterine wall and
IV. Injury to the gut.
b) Endotoxin shock mostly due to e. coli or Cl. welchii
infection.
c) Acute renal faliure- multiple factors are involved
producing patchy cortical necrosis or acute tubular
necrosis. it is common in infection with Cl. welchii
d) Thrombophlebitis
REMOTE: The remote complication include:
a) Chronic debility
b) Chronic pelvic pain and backache
c) Dyspareunia
d) Ectopic pregnancy
e) Secondary infertility due to tubal blockage and
f) Emotional depression
MANAGEMENT
GENERAL MANAGEMENT- Hospitalization is essential
for all cases of septic abortion. The patient is kept in
isolation.
To take high vaginal or cervical swab for culture, drug
sensitivity test and gram stain.
Vaginal examination is done to note the state of the
abortion process and extension of the infection. If the
products are found loosely lying in the cervix, it is
removed by an ovum forceps.
Over all assessment of the case is to be done and the
patient is leveled in accordance with the clinical grading.
Investigation protocols as outlined before are done.
Principles of management are-
a) To control sepsis
b) To remove the source of infection
c) To give supportive therapy to bring back the normal
homeostatic and cellular metabolism
d) To assess the response of treatment.
GRADE 1: DRUGS
1. Antibiotics
2. Prophylactic anti gas gangrene serum of 800 units
and 3000 units of antitatanus serum IM are given if
there is a history of interference.
3. Analgesic and sedatives, as required are to be
prescribed.
4. Blood transfusion is given to improve anaemia and
body resitance.
5. Evacuation of the uterus-As abortion is often
incomplete, evacuation should be performed at a
convenient time within 24 hours following
antibiotic therapy.
GRADE 2: Drugs:
Antibiotics Mixed infections including gram positive, gram
negative and anarobic organisms are common ideal
antibiotic regimens should cover all of them.
FOR GRAM POSOTIVE AEROBES
a. Aqueous penicillin G5 million units I.V. every 6
hours,
b. Ampicillin 0.5 -1 gm I.V. every 6 hours
GRAM NEGATIVE AEROBES-
I. Gentamycin 1.5 mg/ kg I.V. every 8 hours
II. Ceftriaxone I.G. I.V. every 12 hours
III. FOR ANAEROBES Metronidazole 500 mg I.V.
every 8 hours or Clindamycin 600 mg I.V. everu
6 hours.
IV. Analgesic and sedatives, as required are to be
prescribed.
V. Blood transfusion is given to improve anaemia
and body resitance.
Surgery:
(1) Evacuation of the uterus-Evacuation should be
withheld for at least 48 hours when the infection is
controlled as is localised, the only exception being
excessive bleeding.
(2) Posterior colpotomy- When the infection is
localised in the pouch of dougles pelvic abscess is
formed. It is evidenced by spiky rise of temperature,
rectal tensmus (Frequent loose stool with mucus)
and boggy mass felt trough the posterior fornix.
Posterior colpotomy and drainage of the pus relieve
the symptoms and improve the general outlook of
the patient.
GRADE 3
Antibiotics are discussed above.
Clinical monitoring : to note vital sign, urinary output,
progression of the pain, tenderness and mass in lower
abdomen.
Supportive therapy is directed to treat generalised peritonitis
by gastric suction and intervention saline infusion.
Management of endotoxin shock or renal failure, if present,
is to be conducted .
ACTIVE SURGERY: Along to the antibiotic therapy and the
resuscitation of the patient with the fluid and electrolyte, the
patient should be assessed as to whether active surgery is
needed. The indications of active surgery are:
1. Injury to the uterus.
2. Suspected injury to bowel
3. Presence of foreign body in the abdomen as
evidenced by the sonography or X-ray or felt through
the fornix on bimanual examination
4. Unresponsive peritonitis suggestive or collection of
pus.
5. Septic shock or oliguria not responding to the
conservative treatment.
6. Uterus too big to be safely evacuted per vaginam.
The leprotomy should be done by experienced surgeon with
a skilled anesthesiat. Removal of the uterus should be done
irrespective of parity. Adnexa is to be removed or preserved
according to the pathology found. Even when nothing is
found on laprotomy, simple drainage of the pus is effective.
 RECURRENT MISCURRIAGE
DEFINITION-
Recurrent miscurriage is define as a sequence of three or
more consecutive spontaneous abortion before 20 weeks.
INCIDENCE- This distressing problem is affecting
approximately 1% of all women of reproductive age. The
risk increase with each succesive abortion reaching over
30% after three consecutive losses.
ETIOLOGY
FIRST TRIMESTER ABORTION
a. Genetic factors
b. Endocrine and metabolic
c. Infection
d. Inherited thrombophilia
e. Immunological cause- Autoimmunity, Alloimmunity
f. unexplained
SECOND TRIMESTER ABORTION
1. Anatomical abnormalities are responsible for 10-
15% of recurrent abortion. The cause may be
congenital or acquried.
2. Congenital anomalies may be due to defect in the
mullerain duct fusion or resorption eg.unicornuate,
bicornuate, septal or double uterus. Congenital
cervical incompetense is rare.
3. Acquried anomalies are intrauterine adhesion,
uterine fibriods and endometrosis and cervical
incompetence.
CERVICAL INCOMPETENCE 20%
Causes : The retentive power of the cervix (internal os)
may be impaired functionally and anatomaically due to the
following condition.
(A) Cogenital –rare
(B) Acquired –common following
I. D+C operation
II. Induced abortion by D+E (10%)
III. Vaginal operative delivery through an undilated
cervix
IV. Amputation of the cervix or cone biopsy.
DIAGNOSIS BASED ON THE FOLLOWING
CRITERIA
• HISTORY- Repeated mid trimeter abortions abortion
without apparent cause, starting with escape of liquor
amnii following by painless expulsion of the products
of conception is very much suggestive.
• INTERNAL EXAMINATION
• Interconceptional period- Bimanual examination
reveals presence of unilateral or bilateral tear and
gapping of the cervix upto the internal os.
• During pregnancy- periodic inspection of the cervix
through speculum from 10th weeks onwards at
weekly intervals is to be done.
• INVESTIGATION
• Interconceptional period- The following procedure
may be adop for confirmation of the diagnosis.
• Passage No. 6-8 Hegar dilator beyond the internal os
any resistence and pain and absence of internal os
withdrawal specially in prementural period indicate
• Premenstural hystro-cervicography show funnel
shadow.the internal os is supposed to be action of
progesterone during this cycle. Similar funnel
shaped shadow may be found if hysterography is
done in the proliferative phase with a competent
cervix..
• During pregnancy: Ultrasonographic findings of
cervix length less than 3cm. funnelling of upper and
which of internal os more than 1.5 cm in first
trimester with or without bulging of the
membranesuggestive.
• CHRONIC MATERNAL ILLNESS - such as
uncontrolled diabetes with atriosclerotic change
binopathies, chronic renal disease. Inflammatory
bowel disease, system lupus erythematous.
• INFECTION – syphillis, toxoplasmosis and
listerosis may be responsible in some cases.
• UNEXPLAINED.
INVESTIGATIONS
I. Careful history taking should include
II. The nature of previous abortion process.
III. Histology of the placenta
IV. Any chronic illness.
DIAGNOSIS TEST
1. Blood glucose (FBS & PPBS),VDRL, Thyriod function
test. Blood grouping. Toxoplasmosis antibiotics IgG, &
IgM.
2. Autoimmune screening anticogulant anticardiolipin
antibodies.
3. Serum LH on D2/D3 of the cycle
4. USG detect congenital malformation of the uterus,
polycystic overies and uterine fibroid.
5. Hysterosalphingography the scretory phase to detect
cervical incompetence, uterine synechiae and uterine
malformation
6. is supported by hysteroscopy and or laparoscopy.
7. Karyotyping (husband & wife)
8. Endocervical to detect chlamydia, mycoplasm and bacterial
vaginosis.
TREATMENT
INTRCONCEPTUAL PERIOD-
• To alleviate anxiety and to improve the psychology-
While counselling the couple, they should be assured
that even after 3 consecutive misarriages, the chance of
a successful pregnacy is high.however, the success rate
depends on the underlying etiology as well as the age of
the women.
• Hysteroscopic resection of uterine septa, synechae,
submucous, myomas improve the pregnancy outcome.
Uterine unification operation is done for cases with
bicornuate uterus.
• Chromosomal anomalies-If chromosomal abnormalities
is detected in the couple or in the abortus, genetic
counselling is under taken.
• Hypersecretion of LH as seen in PCOD cases, is
suppressed with GnRH analogue therapy.
Susequently ovulation induction with gonadotropins
improve the pregnancy outcome.
• Endocrine dysfunction: control of diabetes and
thyroid disorders are done.
• Genital tract infection are treated appropriately
following cultural of cervical and vaginal discharge.
Treatment with doxicycline or erythromycin is cost
effective.
INDUCTION OF ABORTION
DEFINITION- Deliberate termination of pregnancy before
the viability of the fetus is called induction of abortion.
In India, the abortion was legalised by ‘ medical termination of
pregnancy Act’ of 1971, and has been enforced in the year
april 1972. The provisions of the act have been revised in
1975.
MEDICAL TERMINATION OF PREGNANCY (MTP)
Since legislation of abortion in India, deberate induction of
abortion by a registered medical practitioner in the interest of
mother’s health and life is protected under the MTP act.
The following provisions are laid down:
• The continution 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 imbalance
women.
• Pregnancy caused as a result of failure of a
contraceptive.
INDICATION
TO SAVE THE LIFE OF MOTHER :
 Cardic disease
 Chronic glomerulonephritis
 Malignent hypertention
 Intractable hyperemesis graviderum
 Cervical and breast malignancy
 DM with retinopathy
 Epilepsy or psychiatric illness with the advice of a
psychiatrist
SOCIAL INDICATION
 80% Unplanned pregnancy with low socio economic
status
 Pregnancy caused by rape or unwanted pregnancy
caused due to failure of any contraceptive device also
falls in this category (20%)
EUGENIC: This done under the provision of substantial risk
of the child being born with serious physical and mental
abnormalities so as be handicapped in life.
 Structural chromosomal or genetic abnormalities of the
fetus.
 Rubella, a viral infection affecting in the forst trimester,
is an indication for termination
MTP Act 1971 and 2002 amendment
LEGAL ABORTIONS:
• Termination done for conditions and with in the
gestation prescribed by the act with the consent of
women.
• Termination done by a medical practitioner approved
by the act.
• Termination done at a place approved under the act.
• Other requirements of the rules and regulations with
the act are complied.
GESTATIONAL AGE
• Upto 20 weeks of gestation, with the consent of the
women, if the women is below 18 years or is mentally
ill, then with consent of a guardian.
• The opinion of a RMP has been formed in good faith,
under certain circumferances.
• Opinion of two RMPs required for termination of
pregnancy between 12 and 20 weeks.
EXPERIENCE:
• A registered medical practitioner is qualified to
perform an MTP provided
• One has assisted in at least 25 MTP in an authorised
centre and having a certificate.
• Experience in the practice of gynaecology and
obstetrics for period of not less than three years.
• Completed six months of house surgery in
gynaecology and obstetrics
• One has got diploma or degree in Obs & Gynae.
  FRIST TRIMESTER SECOND TRIMESTER
(UPTO 12 WEEKS) (13-20 WEEKS)
1. 1. SURGICAL Dilatation and evacuation (13- 14 weeks
 Manual vaccum aspiration Intra uterine instillation of hypersomatic
 Sunction evacuation and / solutions
or curettage (a) Intra- amniotic hypertonic urea (40%) ,
 Dilatation and evacuation saline (20%)
I. Rapid method (b) Extra-amniotic – ethacrydine lactate,
II. Slow mwthod prostaglandins (PGE2,PGF2 a)
2. MEDICAL Prostaglandins: misoprostol, carboprost,
Mefepristone used- intra vaginally, IM, intra-
Mefepristone and misoprostol amniotically)
Methotrexate and misoprostol Oxytocin infusion high dose used along
Tamoxifen and misoprostol with either of the above two method
Hysterotomy (abdominal)-less
commonaly done
COMPLICATION-
IMMEDIATE:
1. Trauma to the cervix and uterus leading to haemorrhage
and shock.
2. Haemorrhage and shock due to trauma, incomplete
abortion, atonic uterus or rarely coagulation failure
3. Trombosis and embolism
4. Post abortal triad of pain,bleeding and low grade fever
due to retained clots or products, antibiotic should be
continued, may need repeat evacuation.
5. Related to the methods employed
 Saline- hypernatremia, pulmonary oedema, enditoxic
shock, DIC, renal failure,cerebral haemorrhage.
 Prostaglandins- intractable vomiting, diarrhoea, fever,
uterine pain and cervico-vaginal injury.
 Oxytocin- Water intoxication and convulsion
 Hyperotomy
REMOTE: The complications are grouped into
 Gynaecology
 Obstetrical
Gynaecology complication include-
I. Menstrual disturbances
II. Chronic pelvic inflammation
III. Infertility due to cornual block
IV. Scar endometriosis
V. Uterine synehiae leading to secondary amenorrhea
Obstetrical complications include
I. Recurrent midtrimester abortion due to cervical
incompetence
II. Ectopic pregnancy
III. Preterm labour
IV. Dysmaturity
V. Increased peritonial loss
VI. Rupture uterus
VII. Rh isoimmunisation in Rh-negative women, if not
prophylactically protected with immunoglobulin
VIII. Fail abortion and continued pregnancy
PRE-OPERATIVE CARE FOR SURGICAL ABORTION
• Instruction to be delivered to the client/ patients :
• For morning appointments: NBM, no smoking, after
12:00 am the day of the procedure.
• For afternoon appointements: NBM, no smoking, after
8 am the day of the procedure.You may have clear fluid
(water, block coffee/ tea, cranberry juice) untill 10 am,
after then, nothing to drink.
• No recreational drugs or alcoholic beverages for 48
hours prior to surgery.
• Please dress comfortably;no make-up, jewelry, contact
lenses, or high heel shoes.brings a frist morning urine
sample, a bathrole or blanket, and a pair of slippers or
socks.
• Please do not brings children with you to the office.
Make sure that you have a reliable escort to drive you
home as it is illegal to drive after anaesthesia.
• Do not use aspirin, aspirin products, narcotics or street
drugs for 48 hours prior to your appointment time.
• If you are using insurance, please bring your insurance
card and a valid state picture ID such as a motor vehicle
ID or driver’s licence.
POST-OPERATIVE CARE
• Monitor vital signs to identified any internal bleeding or
infection. BP and pulse.
• Assess the client’s conscious level, the presence of
malaise, cold clammy skin, pale or dizziness to rule out
possibility of hypovolemic shock.
• Assess for severity of pain usings pain scale.
Administration analgesics as prescribed and assess the
effectiveness of the medication.
• Check for any excessive vaginal bleeding or soakness
of the sanitary pad and its characteristics. (vaginal
bleeding normally stop within 3-5 days.
• Assess the IV line and drip to make sure no kinging, no
obstruction and in accurate rate flow.
• Encourage fluid intake to prevent dehydration due to
blood loss durings surgery.
• Monitor and strict on intake and output.
• Strictly aseptic technique to prevent cross infection and
provide perineum care. Educate the client to maintain
effective hand washing technique and perineal care.
• Note any pus or foul smelling from the vaginal discharge to
rule out possible infection.
• Maintain healthy diet to provide the body with enough
nutrition for fast recovery of the operated site and regaining
of energy
• Provide emotional support encourage family support due to
pregnancy loss.
• Allowing grieving and expression of her concerns over the
loss pregnancy.
• Refer the client to social support groups.
 Nursing responsibility
• Check patient’s name, type of surgery, Hx
• Monitor V/S, blood test, bleeding and vaginal secretion
(character, colour & volume)
• Strict aseptic technique
• Strengthen the perineum care & maintain the vulva
cleanliness.
• Psychological care : sympathizing, understanding &
caring
• To check/ trace ultrasound result
• No SI 3 days before op.R:prevent infection
• Empty the bladder.
• Comfort the patient.
 BIBLIOGRAPHY
 DUTTA D.C. “TEXT BOOK OF GYNAECOLOGY”
EDITION - 7 TH EDITION
PAGE NO 159- 178
 MYLES “TEXT BOOK OF MIDWIVES” EDITED BY
DIANE M. FRASER & MARGRET A. COOPER,
FOREWORD BY GILLIAN FLETCHER
EDITION -14 TH EDITION
PAGE NO 279-284
 WANI REENA J “TEXT BOOK OF MIDWIFERY FOR
NURSES” INDARAJIT WALIA,
EDITION – 1 ST EDITION ,
PAGE NO 273-283