MEDICAL TERMINATION OF

PREGNANCY- ACTS,
METHODS & PCPNDT
Act- 1971

 ACT- 1971 by the government of India

 For improving
 maternal health:
 Preventing unsafe abortions
 Legalizing abortion services
 Access to safe abortions
Amendment- 2020
Indications
i. Risk to the life or grave injury – physical or
mental health of the woman
ii. Substantial risk of physical or mental
abnormalities in the fetus- seriously handicapped
iii. Pregnancy cased by rape
iv. Contraceptive failure
CONSENT
 Consent of pregnant women
 Minor(<18 years) or mentally ill- guardian
MTP- Amendment, 2020

 (A) requirement of opinion of one registered medical practitioner for

termination of pregnancy up to twenty weeks of gestation;
 (B) requirement of opinion of two registered medical practitioners for
termination of Pregnancy of twenty to twenty-four weeks of gestation;
 (C) enhancing the upper gestation limit from twenty to twenty-four weeks
for such Category of woman as may be prescribed by rules in this behalf;
 (D) non applicability of the provisions relating to the length of pregnancy in
cases Where the termination of pregnancy is necessitated by the diagnosis
of any of the substantial Foetal abnormalities diagnosed by a medical
board;
Cont…..

 (E) protection of privacy of a woman whose pregnancy has been

terminated.
 4. The proposed bill is a step towards safety and well-being of
women and will enlarge the ambit and access of women to safe
and legal abortion without compromising on safety and quality
of care. The proposal will also ensure dignity, autonomy,
confidentiality and justice for women who need to terminate
pregnancy.
 5. The bill seeks to achieve the above objects.
 Where the length of the pregnancy >20 weeks but does not exceed 24 weeks in case
of such category of woman as may be prescribed by rules made under this Act, if not
less than two registered medical practitioners are of the opinion, formed in good faith,
that—
 (i) the continuance of the pregnancy would involve a risk to the life of the pregnant
woman or of grave injury to her physical or mental health; or
 (ii) there is a substantial risk that if the child were born, it would suffer from any
serious physical or mental abnormality.
 Explanation 1.—For the purposes of clause (a), where any pregnancy occurs as a
result of failure of any device or method used by any woman or her partner for the
purpose of limiting the number of children or preventing pregnancy, the anguish
caused by such pregnancy may be presumed to constitute a grave injury to the
mental health of the pregnant woman.
Cont……..

 Explanation 2.—For the purposes of clauses (a) and (b),

where any pregnancy is alleged by the pregnant woman
to have been caused by rape, the anguish caused by the
pregnancy shall be presumed to constitute a grave injury
to the mental health of the pregnant woman.
 (2B) The provisions of sub-section (2) relating to the
length of the pregnancy shall not apply to the
termination of pregnancy by the medical practitioner
where such termination is necessitated by the diagnosis
of any of the substantial foetal abnormalities diagnosed
by a Medical Board.
 PRE- PROCEDURE PREPARATIONS
 HISTORY-
i. LMP
ii. Medical illness
 ASSESSMENT OF GESTATIONAL AGE-
i. LMP
ii. Clinical examination
iii. Ultrasonography
 COUNSELLING-
i. Procedures available
ii. Complications
iii. Subsequent contraception or sterilization
 INVESTAGATIONS-

i. Hemoglobin and
ii. hematocrit
iii. Blood grouping and Rh typing
iv. HIV/Hepatitis B antigen screening
v. Urine sugar or protein

 INFORMED CONSENT
1ST TRIMESTER MTP

DIFFERENCE-
 Fetal bony structures not formed- removed vaginally

METHO
DS

Medical Surgical
 MEDICAL

MIFEPRISTON MISOPROSTO METHOTREXA

E L TE
 MEDICAL METHODS-

 Very safe and effective

 Method of choice in 1st trimester MTP
 Success rate- 95 – 99%
 Prophylactic antibiotics- not required
 MIFEPRISTONE-

Derivative of norethindrone
Binds to progesterone receptor with an affinity greater than
progesterone but it does not activate the receptor(antiprogestin)
Acts by-
i. Decidual degeneration
ii. Induces uterine
contractions
iii. Softens the cervix
iv. Increased prostaglandin sensitivity
Dosage-200 microgram oral
 After 24 to 48hours- T. Misoprostol administration
-vaginal route preferred.
 Dosage-800 microgram single dose or two divided
dosed 4 to 6 hours apart
 Oral or parenteral NSAIDs for pain or cramping
 If pregnancy is ongoing, surgical evacuation
 If abortion is incomplete – repeat misoprostol or
proceed with surgical evacuation
MISOPROSTOL

 Prostaglandin E1 analogue
 ALONE- less effective than when used with
mifepristone.
 Used alone when mifepristone is not
available
 site directly
 METHOTREXATE:
 Blocks dihydrofolate reductase
 Action is primarily on cytotrophoblast rather than the
developing embryo
 Inhibits syncytialization of the cytotrophoblast
 Stops the process of implantation rather than weakening
the implantation
 METHOTREXATE AND MISOPROSTOL

75 microgram oral or 50 microgram/sq.m IM

5 to 7 days later

800 microgram of misoprostol

Less efficacious and longer

 COMPLICATIONS

 Side effects of drugs- nausea, vomiting, diarrhea, dizziness,

headache symptomatic treatment
 Abdominal pain and cramps  NSAIDs
 Excessive bleeding  exclude
incomplete abortion

 repeat misoprostol or MVA

 Ongoing pregnancy  surgical methods
 Fever and infection  antibiotics
 SURGICAL METHODS

MANUAL VACUUM ASPIRATION:

 In very early pregnancy(upto 10 weeks)
 Incomplete abortion

 CONSISTS OF
 Handheld 50-60 ml plastic syringe
 Karman cannula ( 6- 8mm size)
 ELECTRIC VACUUM ASPIRATION

Suction evacuation
Anytime in 1st trimester
• Vesicular mole
• Incomplete abortion
• Missed abortion
CERVICAL DILATATION

 less than 7 weeks

 Manual dilatation- Hegar’s

dilator
 Osmotic dilators
 Vaginal misoprostol
 MIDTRIMESTER ABORTIONS

 MEDICAL METHODS
 prostaglandins
 Misoprostol
 Mifepristone
 Gemeprost
 Dinoprostone
 PGF2 alpha

 oxytocin
 SURGICAL METHODS
 Between 13- 15 weeks
 Dilatation and evacuation
 Between 16- 20 weeks
 Intrauterine instillation of hypertonic saline
 Extra amniotic
 Intra amniotic
 hysterotomy
MEDICAL METHODS

PROSTAGLADINS:
 They act on cervix and uterus
 Selective action on myometrium

MISOPROSTOL:
 400 – 800 microgram PV every 3- 4 hrs
 600 microgram PV followed by 200 microgram orally every 3 hrs
 Recently 400 microgram sublingually every 3 hrs
(5 doses)
 Success rate- 100%
 Mean induction- abortion interval 11- 12 hrs
 MIFEPRISTONE:
 Mifepristone 200mg oral followed by 36-48 hrs
Misoprostol 800 microgram vaginally / misoprostol 400 microgram
oral every 3 hrs
(4 doses)
 Success rate- 97%
 Mean induction to delivery interval- 6.5 hrs

GEMEPROST(PGE1 Analog):
 1 mg vaginal pessary every 3-6 hrs (5 doses) in 24 hrs
 Success rate- 90%
 Mean induction- abortion interval 14- 18 hrs
DINOPROSTONE(PGE2 Analogue):
 20 mg is used as vaginal suppository every 3-4 hrs
maximum 4- 6 doses
 Mean induction to abortion interval- 17 hrs

PROSTAGLANDIN(PGF2 alpha):
 Carboprost tromethamine 250mcg IM every 3 hrs maximum
10 doses
 Success rate- 90% in 36 hrs
 Side effect: nausea, vomiting, diarrhoea, pain at injection
site
 C/I in bronchial asthma
Oxytocin:
 high dose oxytocin
 (300 units in 500 ml dextrose saline)
 SURGICAL METHODS
 13-15 WEEKS: DILATATION AND EVACUATION
 Less commonly done
 Pregnancies at 13- 14 menstrual weeks are evacuated
 Intracervical
tent (laminaria osmotic dilator),
mifepristone or misoprostol are used as cervical
priming agents
16-20 weeks:
Intrauterine instillation of hypertonic solution
Extramniotic :
 0.1% ethacridine lactate transcervically through no. 16 foley’s catheter
 Catheter is passed upto cervical canal for about 10 cm above the internal os
between membranes and myometrium and the balloon is inflated with saline
 Removed after 4 hrs
 Stripping of membranes with liberation of prostaglandins from decidua and
dilatation of cervix by catheter for initiation of abortion
 Isotonic saline is infused extra amniotically using transcervical catheter balloon
 INTRAAMNIOTIC :
 Intra-amniotic instillation of hypertonic saline less common
 Instilled through abdominal route
 Procedure: preliminary amniocentesis done by 15 cm 18
gauge needle
 Amount of saline to be instilled is calculated as no of weeks
of gestation multiplied by 10 ml at the rate of 10 ml/min
Contraindication:
 Cardiovascular, renal or severe anemia because of sodium load

Precautions:
 To be sure needle in needle is in amniotic cavity evidenced by clear liquor
 Instillation should be slow process(10ml/min)
 To stop procedure if symptoms like acute abdominal pain , headache or thirst
or tingling in finger
Rapid infusion of 1000 ml dextrose in water is indicated
Ampicillin 500mg TDS for 3 days
 MODE OF ACTION: liberation of PGS following necrosis of
the amniotic epithelium and decidua -- uterine contraction
and expulsion of fetus

 COMPLICATIONS:
 fever, headache, nausea, vomiting and abdominal pain,
cervical tear and laceration, retained products, infection,
hypernatraemia , cvs collapse , pulmonary and cerebral
edema, renal failure and DIC
 INTRAMNIOTICINSTILLATION OF
HYPEROSMOTIC UREA:
 Instillation
of 80 gms of urea in 200 ml of distilled
water along with syntocinon is effective with less
complications

 Combination of intra amniotic hyperosmotic urea

and 15 methyl PGF2 alpha reduces the induction
abortion interval to 13 hours
HYSTEROTOMY: less common
indications :
 Prior failed MTP
 In cases where D and C cannot be safely done
 Fibroid in lower uterine segment
 Uterine anomalies
 Repeated scarred uterus with placenta accreta or
percreta
complications
 Immediate-hemorrhage and shock,
anesthestic comlication,
peritonitis,intestinal obstruction
 Remote –menstrual abnormalities,scar
endometritis,incisional hernia,if
pregnancy occurs chance of uterus
rupture
DILATATION AND EVACUATION

 dilatation followed by evacuation using

ovum forceps
 Finally curettage with metal catheter
 High risk of perforation
Pre-Conception & Pre-Natal
Diagnostic Techniques Act, 1994
 THE PRE-NATAL DIAGNOSTIC TECHNIQUES (REGULATION AND
PREVENTION OF MISUSE) ACT, 1994 AND
 THE PRE-NATAL DIAGNOSTIC TECHNIQUES (REGULATION AND
PREVENTION OF MISUSE) AMENDMENT ACT, 2002
 An Act to provide for the prohibition of sex selection, before or
after conception, and for regulation of pre-natal diagnostic
techniques for the purposes of detecting genetic abnormalities
or metabolic disorders or chromosomal abnormalities or
certain congenital malformations or sex-linked disorders and
for the prevention of their misuse for sex determination
leading to female foeticide; and, for matters connected
therewith or incidental thereto.
 Whole of India, except Jammu & Kashmir
Regulation of pre-natal diagnostic
techniques.-
1. No place including a registered Genetic Counselling Centre or Genetic
Laboratory or Genetic Clinic shall be used or caused to be used by any person for
conducting pre-natal diagnostic techniques except for the purposes specified in
clause (2) and after satisfying any of the conditions specified in clause (3);
2. no pre-natal diagnostic techniques shall be conducted except for the purposes of
detection of any of the following abnormalities, namely:—
 (i) chromosomal abnormalities;
 (ii) genetic metabolic diseases;
 (iii) haemoglobinopathies;
 (iv) sex-linked genetic diseases;
 (v) congenital anomalies;
 (vi) any other abnormalities or diseases as may be specified by the Central
Supervisory Board;
6. Determination of sex prohibited.- On and from the
commencement of this Act,—
 (a) no Genetic Counselling Centre or Genetic Laboratory or Genetic
Clinic shall conduct or cause to be conducted in its Centre, Laboratory
or Clinic, pre-natal diagnostic techniques including ultrasonography,
for the purpose of determining the sex of a foetus;

 (b) no person shall conduct or cause to be conducted any pre-natal

diagnostic techniques including ultrasonography for the purpose of
determining the sex of a foetus;

 (c) no person shall, by whatever means, cause or allow to be caused

selection of sex before or after conception.
 3. No pre-natal diagnostic techniques shall be used or
conducted unless the person qualified to do so is satisfied for
reasons to be recorded in writing that any of the following
conditions are fulfilled, namely:—
 (i) age of the pregnant woman is above thirty-five years;
 (ii) the pregnant woman has undergone of two or more
spontaneous abortions or foetal loss;
 (iii) the pregnant woman had been exposed to potentially
teratogenic agents such as drugs, radiation, infection or
chemicals;
 (iv) the pregnant woman or her spouse has a family history of
mental retardation or physical deformities such as, spasticity
or any other genetic disease;
 (v) any other condition as may be specified by the Central
Supervisory Board;
 No person including a relative or husband of a woman shall seek or encourage
the conduct of any sex-selection technique on her or him or both.
Written consent of pregnant woman and prohibition of
communicating the sex of foetus.
(a) he has explained all known side and after effects of such procedures to the
pregnant woman concerned;
 (b) he has obtained in the prescribed form her written consent to undergo such
procedures in the language which she understands; and
 (c) a copy of her written consent obtained under clause (b) is given to the
pregnant woman.
 2. No person including the person conducting pre-natal diagnostic procedures
shall communicate to the pregnant woman concerned or her relatives or any
other person the sex of the foetus by words, signs or in any other manner.
 3B. Prohibition on sale of ultrasound machines, etc., to persons,
laboratories, clinics, etc. not registered under the Act.- No person
shall sell any ultrasound machine or imaging machine or scanner or
any other equipment capable of detecting sex of foetus to any
Genetic Counselling Centre, Genetic laboratory, Genetic Clinic or any
other person not registered under the Act.
 Offences and penalties
 Every offence under this Act shall be cognizable, non-bailable and non-
compoundable.
 Any person who contravenes the provisions of sub-section (1) or sub-section (2)
shall be punishable with imprisonment for a term which may extend to three years
and with fine which may extend to ten thousand rupees and on any subsequent
conviction, with imprisonment which may extend to five years and with fine which
may extend to fifty thousand or 1 lakh rupees
 Explanation.—For the purposes of this section, “advertisement” includes any
notice, circular, label, wrapper or any other document including advertisement
through internet or any other media in electronic or print form and also includes
any visible representation made by means of any hoarding, wall-painting, signal,
light, sound, smoke or gas.
 The name of the registered medical practitioner shall be reported by the
Appropriate Authority to the State Medical Council concerned for taking necessary
action including suspension of the registration if the charges are framed by the
court and till the case is disposed of and on conviction for removal of his name
from the register of the Council for a period of five years for the first offence and
permanently for the subsequent offence.
Registration of genetic counselling
centre
 1. Duly registered under the Act.
 2. Every application for registration under sub-section (1), shall be
made to the Appropriate Authority in such form and in such manner
and shall be accompanied by such fees as may be prescribed.
 3. Shall apply for registration within sixty days from the date of such
commencement.
 4. Shall cease to conduct any such counselling or technique on the
expiry of six months from the date of commencement of this Act
unless such Centre, Laboratory or Clinic has applied for registration
and is so registered separately or jointly or till such application is
disposed of, whichever is earlier.
Cont……

 Appropriate Authority is satisfied that such Centre, Laboratory or

Clinic is in a position to provide such facilities, maintain such
equipment and standards as may be prescribed.
 Every certificate of registration shall be renewed in such manner and
after such period and on payment of such fees as may be prescribed.
 The certificate of registration shall be displayed by the registered
Genetic Counselling Centre, Genetic Laboratory or Genetic Clinic in a
conspicuous place at its place of business.
Thank you