MEDICAL TERMINATION

OF PREGNANCY
MEDICAL TERMINATION
OF PREGNANCY
THE MEDICAL OR SURGICAL TERMINATION OF PREGNANCY BEFORE THE
PERIOD OF VIABILITY OF FETUS.
MEDICAL TERMINATION OF
PREGNANCY(MTP) ACT

 In india, Medical Termination of Pregnancy Act passed in 1971, enforced

in 1972 and revised in 1975.
MEDICAL TERMINATION OF
PREGNANCY(MTP) ACT

 In india, Medical Termination of Pregnancy Act passed in 1971, enforced

in 1972 and revised in 1975.
 It is re-revised as Medical Termination of Pregnancy (MTP amendment)
Act
in 2021.
MEDICAL TERMINATION OF
PREGNANCY(MTP) ACT

 In india, Medical Termination of Pregnancy Act passed in 1971, enforced

in 1972 and revised in 1975.
 It is re-revised as Medical Termination of Pregnancy (amendment) Act
in 2021.
 MTP Act enforced to safeguard the health and life of mother undergoing
abortion.
I. Conditions under which a
pregnancy can be terminated

 1. Therapeutic or Medical indications- pregnancy

might endanger the mother's life or cause grave injury to her physical
or mental health.
(1) Severe cardiac disease
(ii) End stage renal disease
(iii) Malignant and severe hypertension
(iv) Cervical, breast or other cancers
(v) Diabetes mellitus complicated with retinopathy or nephropathy
(vi) Severe epilepsy or psychiatric illness with the ad
I. Conditions under which a
pregnancy can be terminated

 2. Eugenic- Where there is "substantial risk of the child being

born with serious physical or mental abnormalities so as to be
handicapped for life."
(i) Structural (anencephaly and other major anomalies), chromosomal
(Down's syndrome) or genetic (hemophilia) abnormalities of the fetus.

(ii) The fetus is exposed to teratogenic drugs (Isotretinoin, Warfarin) or

radiation exposure (> 10 rads) in early pregnancy.

(iii) Rubella infection in first trimester.vice of a psychiatrist

 3. Humanitarian.-Where pregnancy is the result of rape (<5% cases).
 4. Socio-economic indications
(i) Multiparous women with unplanned pregnancy and low socio-economic status
(almost 80% cases).
(ii) Pregnancy caused due to failure of any contraceptive device (15%) cases of
MTP.
( This is the most liberal indication which is a unique feature of Indian law and
virtually allows abortion on request in all cases due to difficulty in proving that the
pregnancy was not caused by failure of contraception.)
 5. When pregnant woman is not mentally sound (e.g.schizophrenia).
II. The person or persons who can
perform abortion

 1. MTP can only be performed by a registered medical practitioner

(i) Who has got a degree (MD, MS) or Diploma (DGO) in Obstetrics and
Gynecology.
(ii) Who has done 6 months house job in Obstetrics and Gynecology.
(iii) Who has assisted in at least 25 MTPs in an authorized center and has a
certificate to do MTP.
 3. Written consent of woman is needed. Husband's consent is not
required.
 4. In case of minor girl or lunatic or mentally retarded woman, written
consent of her parents or legal guardian is to be taken.
 2. Termination is permitted up to 20 weeks of pregnancy. Registered

medical practitioner can perform MTP up to 12 weeks.

 2. Termination is permitted up to 20 weeks of pregnancy. Registered

medical practitioner can perform MTP up to 12 weeks.) x

 2. Termination is permitted up to 20 weeks of pregnancy. Registered

medical practitioner can perform MTP up to 12 weeks.) x

 All the provisions of MTP Act 1971 (Principal act) will continue with
the following changes in Medical Termination of Pregnancy
(amendment) Act.
 1. Gestational age: It is increased up to 24 weeks (in the new MTP act
instead of 20 weeks in the previous act) for -
o Pregnancy due to rape or sexual violence.
o Pregnancy due to incest.
o Differently abled women (women with disabilities)
o Minor girls
o Mentally challenged women
 In the amendment act upper gestational age will not apply in cases of
pregnancies with substantial fetal abnormalities diagnosed by Medical
Board
 The medical board should have a gynecologist, a pediatrician, a radiologist
or sonologist and other members
 2. Opinion of practitioner on the amended act: opinion of only one
registered medical practitioner (RMP) required for termination of
pregnancy up to 20 weeks of gestation and opinion of two registered
medical practitioners (RMPs) required for termination of pregnancy from
20 to 24 weeks of gestation.
 3. Failure of contraceptive as a condition for MTP is now extended to
any woman or her partner, whether she is married or not.
 4. Confidentiality: Name and other particulars of a woman whose
pregnancy has been terminated shall not be revealed except to a
person authorized by any law for the time being in force.
III. Place where abortion can be
performed

 MTP can only be performed in government hospitals, nursing homes or

centers approved by the Directorate of Health Services (DHS) or Chief
Medical Officer (CMO) of district.
 The abortion has to be performed confidentially and has to be reported
to the Director of Health Services of the State on the prescribed MTP
form.
Contraindications

 There are very few contraindications but one needs to be very careful in
performing MTP in the following conditions.
1. Medical disorders like heart disease
2. Suspected ectopic pregnancy or undiagnosed adnexal mass
3. Chronic renal failure
4. Hematological disorders
5. Allergy to any drugs used
METHODS OF TERMINATION OF
PREGNANCY
First Trimester (Up to 12 Weeks)
 Medical-
 Mifepristone alone- less effective
 Misoprostol alone- less effective
 Mifepristone and misoprostol (PGE1 )- most commonly used,
It is effective up to 63 days and is highly successful when used within 49
days of gestation.
 Methotrexate and misoprostol-Methotrexate 50 mg/m2 IM (before 56
days of gestation) followed by 7 days later misoprostol 800 µg vaginally
is highly effective.
Methotrexate and misoprostol regimen is less expensive but takes longer
time than mifepristone and misoprostol.
PRE-REQUISITES FOR MEDICAL
ABORTION

1. Falling within the defined criteria for the medical abortion especially
gestational age.
2. There should be no medical contraindication.
3. Good support system in case of need of surgical evacuation or any
complication.
4. Ability to follow-up visits.
5. Patient should be willing for it.
 Patient should be informed that if medical method fails, she will have to
undergo surgical evacuation as the drugs are teratogenic.
 Counselling of the patient is very important.
 All formalities like filling MTP form and taking consent are like that of
surgical evacuation.
Side-effects of Medical Methods

1. Cramping pain
2. bleeding -Median blood loss is less than 100 mL, although the range can
extend up to several hundred milliliters and is significantly correlated with
the period of gestation.
3. About one-third of patients complain of nausea, vomiting, diarrhea.
4. dizziness or fatigue.
Contraindications

 Absolute Contraindications- 1. Suspected ectopic pregnancy or undiagnosed adnexal

mass.
2. Chronic renal failure
3. Chronic adrenal failure or concurrent corticosteroid therapy
4. Anaemia (Hb < 8g%)
5. Uncontrolled seizure disorder
6. Uncontrolled hypertension or BP > 160/100 mmHg
7. Cardiac disease
8. Hemorrhagic disorder or patient on anticoagulanttherapy
9. Allergy to any drug
10. Deranged liver function tests (for Methotrexate)
 Relative Contraindications- More than 35 years ,Heavy smoker.
 Bronchial asthma is not a contraindication since misoprostol is a bronchodilator.
 First Trimester (Up to 12 Weeks)
 Surgical-
 Vacuum aspiration (MVA/EVA)
 Suction evacuation and/or curettage
 Dilatation and evacuation:  Rapid method  Slow method
 Surgical-
 Vacuum aspiration (MVA/EVA)- is done up to 12 weeks
with minimal cervical dilatation.
 outpatient procedure
 using a plastic disposable 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.
 Suction evacuation and/or curettage-
Advantages: (1) an outdoor procedure.
(2) can be done under paracervical block anesthesia.
(3) Ideal for termination for therapeutic indications.
(4) Blood loss is minimal.
(5) Chance of uterine perforation is much less especially with the plastic
cannula.
Drawbacks: (1) The method is not suitable with bigger size uterus of more
than 10 weeks as chance of retained products is more.
(2) Requires electricity to operate and the machine is costly.
 Dilatation and evacuation:
 Rapid method -Advantages: (1) As it can be done as an outdoor
procedure, the patient can go home after the sedative effect is over. (2)
Chance of sepsis is minimal.
Drawbacks: (1) Chance of cervical injury is more. (2) Uterus should not be
more than 6–8 weeks of pregnancy. (3) All the drawbacks of D&E.
 Slow method-Advantages: (1) Chance of cervical injury is minimal.
(2) Suitable in cases of therapeutic indications.
Drawbacks: (1) Hospitalization is required at least for 1 day. (2) Chance of
introducing sepsis.
SECOND TERMINATION OF
PREGNANCY

 Prostaglandins-PGE1 (misoprostol), 15 methyl PGF2 α (Carboprost),

PGE2 (Dinoprostone) and their analogs (used—intravaginally,
intramuscularly or intra amniotically)
 Dilation and evacuation (13–14 weeks)
 Intrauterine instillation of hyperosmotic solutions
 Extra-amniotic—ethacridine lactate, Prostaglandins (PGE2 , PGF2 α)
 Extra-amniotic saline infusion (isotonic) with a transcervical catheter
balloon
 Intra-amniotic hypertonic urea (30%), saline (20%)
 Oxytocin infusion—high dose used along with either of the above two
methods
 Hysterotomy (abdominal)—less commonly done
COMPLICATION OF MTP

IMMEDIATE:
(1) Injury to the cervix (cervical lacerations).
(2) Uterine perforation during D&E.
(3) Hemorrhage and shock due to trauma, incomplete abortion, atonic uterus or
rarely coagulation failure.
(4) Thrombosis or embolism.
(5) Postabortal triad of pain, bleeding and low-grade fever due to retained clots
or products. Antibiotics should be continued, may need repeat evacuation.
(6) Related to the methods employed:
 Prostaglandins—intractable vomiting, diarrhea, fever, uterine pain and
cervicouterine injury.
 Oxytocin—water intoxication and rarely convulsions
 Hysterotomy
COMPLICATION OF MTP
 REMOTE:
 menstrual disturbances
 chronic pelvic inflammation
 infertility due to cornual block
 scar endometriosis (1%)
 uterine synechiae leading to secondary amenorrhea.
 recurrent mid trimester abortion due to cervical incompetence,
 ectopic pregnancy (threefold increase),
 preterm labor,
 rupture uterus,
 Rh-isoimmunization in Rh-negative women, if not prophylactically protected with
immunoglobulin and

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