GOVT.

COLLEGE OF NURSING,ALAPPUZHA

CLINICAL TEACHING
ON
MATERNAL
TERMINATION OF
PREGNANCY
SUBJECT:OBSTETRICS AND GYNECOLOGY NURSING

SUBMITTED TO SUBMITTED BY
MRS ANJU B MOHAN PRIYA P
ASISSTANT PROFESSOR IST YEAR MSC NURSING
GOVT COLLEGE OF NURSING GOVT COLLEGE OF NURSING
ALAPPUZHA ALAPPUZHA
 MEDICAL TERMINATION OF PREGNANCY (MTP)
Deliberate termination of pregnancy either by medical or by surgical method before the
viability of the foetus is called induction of abortion.
• The induced abortion may be legal or illegal (criminal).
• There are many countries in the globe where the abortion is not yet legalized. In India, the
abortion was legalized 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.
Since legalization of abortion in India, deliberate 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 continuation of pregnancy would involve serious risk of life or grave injury to the
physical and mental health of the pregnant woman.
• 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 a contraceptive.
In practice, the following are the indications for termination under the MTP Act:
• To save the life of the mother (Therapeutic or Medical termination): The indications are
limited and scarcely justifiable nowadays except in the following cases:
[Link] diseases (Grade III and IV) with history of decompensation in the previous
pregnancy or in between the pregnancies.
[Link] glomerulonephritis.
[Link] hypertension.
[Link] hyperemesis gravidarum.
[Link] or breast malignancy.
[Link] mellitus with retinopathy.
[Link] or psychiatric illness with the advice of a psychiatrist.
• Social indications: This is almost the sole indication and is covered under the provision “to
prevent grave injury to the physical and mental health of the pregnant woman”. In about 80%,
it is limited to parous women having unplanned pregnancy with low socioeconomic status.
Pregnancy caused by
rape or unwanted pregnancy caused due to failure of any contraceptive device also falls in this
category (20%).
• Eugenic: This is done under the provision of “substantial risk of the child being born with
serious physical and mental abnormalities so as to be handicapped in life”. The indication is
rare.
[Link] (Anencephaly), chromosomal (Down’s syndrome) or genetic (Haemophilia)
abnormalities of the foetus.
[Link] the foetus is likely to be deformed due to action of teratogenic
drugs (warfarin) or radiation exposure (>10 rad) in early pregnancy.
[Link], a viral infection affecting in the first trimester, is an indication for termination.
RECOMMENDATIONS
[Link] the revised rules, a registered medical practitioner is qualified to perform an MTP
provided:
(a) One has assisted in at least 25 MTP in an authorized centre and having a certificate.
(b) One has got 6 months house surgeon training in obstetrics and gynaecology.
(c) One has got diploma or degree in obstetrics and gynaecology.
2. Termination can only be performed in hospitals, established or maintained by the
government or places approved by the government.
3. Pregnancy can only be terminated on the written consent of the woman. Husbands consent
is not required.
[Link] in a minor girl (below the age of 18 years) or lunatic cannot be
terminated without written consent of the parents or legal guardian.
[Link] is permitted up to 20 weeks of pregnancy. When the pregnancy exceeds 12
weeks, opinion of two medical practitioners is required.
[Link] abortion has to be performed confidentially and to be reported to the Director of Health
Services of the State in the prescribed form.
FIRST TRIMESTER TERMINATION OF PREGNANCY MEDICAL METHODS OF
FIRST TRIMESTER ABORTION:
[Link] (RU-486) and Misoprostol:
Mifepristone an analogue of progestin (norethindrone) acts as an antagonist, blocking the effect
of natural progesterone. Addition of low-dose prostaglandins (PGE1) improves the efficiency
of first trimester abortion. It is effective up to 63 days and is highly successful when used within
49 days of gestation.
PROTOCOL:
200 mg of mifepristone orally is given on day 1. On day 3, misoprostol (PGE1) 400 μg orally
or 800 μg vaginally is given. Patient remains in the clinic for 4 hours during which expulsion
of the conceptus (95%) often occurs. Patient is re-examined after 10–14 days. Complete
abortion is observed in 95%, in- complete in about 2% of cases and about 1% do not respond
at all.
Oral mifepristone 200 mg (1 tab) with vaginal misoprostol 800 μg (4 tab, 200 μg each) after
6–48 hours is equally effective. This combi-pack (1+4) is approved by DGHS, Government of
India for MTP up to 63 days of pregnancy. Medical methods are safe, effective, non-invasive
and have minimal or no complications.
[Link] and Misoprostol:
Methotrexate 50 mg/m2 IM (before 56 days of gestation) followed by 7 days later misoprostol
800 μg vaginally is highly effective. Misoprostolmay have to be repeated after 24 hours if it
fails. If the procedure fails, ultrasound examination is done to confirm the failure. Then suction
evacuation should be done. Methotrexate and misoprostol regimen is less expensive but takes
longer time than mifepristone and misoprostol. Misoprostol has less-side effects and is stable
at room temperature unlike other PGs, which must be refrigerated.
Contraindications:
Mifepristone should not be used in women aged over 35 years, heavy smokers and those on
long-term corticosteroid.
SURGICAL METHODS OF FIRST TRIMESTER ABORTION:
[Link] REGULATION
[Link] ASPIRATION (MVA/EVA) is done up to 12 weeks with minimal cervical
dilatation. It is performed as an outpatient procedure using a plastic disposable cannula (up to
12 mm size) and a 60 mL plastic (double valve) syringe (Fig. 41.20). It is quicker (15 minutes),
effective (98–100%), less traumatic and safer than dilatation, evacuation and curettage.
[Link] EVACUATION AND/OR CURETTAGE: This improvised method consists of
a suction machine fitted with a cannula either plastic (Karman) or metal available in various
sizes.
Advantages:
• It is done as an outdoor procedure.
• Hazards of general anaesthesia are absent as it is done, at best, under paracervical block
anaesthesia.
• Ideal for termination for therapeutic indications.
• A blood loss is minimal.
• Chance of uterine perforation is much less especially with the plastic cannula.
Drawbacks:
• The method is not suitable with bigger size uterus of more than 10 weeks as chance of retained
products is more.
• Requires electricity to operate and the machine is costly.
4. DILATATION AND EVACUATION:
a) Rapid method
b) Slow method
Rapid method: This can be done as an outdoor procedure with diazepam sedation and
paracervical block anaesthesia.
Advantages:
• As it can be done as an outdoor procedure, the patient can go home after the sedative effect
is over.
• Chance of sepsis is minimal. Drawbacks:
• Chance of cervical injury is more.
• Uterus should not be more than 6–8 weeks of pregnancy.
• All the drawbacks of D&E
Slow method: Slow dilatation of the cervix is achieved by inserting laminaria tents
(hygroscopic osmotic dilators) into the cervical canal (synthetic dilators like Dilapan, Lamicel
are also used). This is followed by evacuation of the uterus after 12 hours. Vaginal misoprostol
(PGE1) 400 μg 3 hours before surgery is equally effective for cervical ripening.
Advantages:
• Chance of cervical injury is minimal.
• Suitable in cases of therapeutic indications. Drawbacks:
• Hospitalization is required at least for 1 day.
• Chance of introducing sepsis.
• All the complications of D&E.
MIDTRIMESTER TERMINATION OF PREGNANCY MEDICAL METHODS:
1. PROSTAGLANDINS: Prostaglandins and their analogues are very much effective.
They are used extensively, special in the second trimester. They act on the cervix and the uterus.
The PGE (dinoprostone, sulprostone, gemeprost,
misoprostol) and PGF (carboprost) analogues are commonly used. PGEs are preferred as they
have more selective action on the myometrium and less side effects.
1. Misoprostol (PGE1 analog): 400–800 μg of misoprostol given vaginally at an interval
of 3–4 hours is most effective as the bioavailability is high. Alternatively, first dose of 600 μg
misoprostolgiven vaginally, then 200 μg, orally every 3 hours are also found optimum. This
regimen reduces the number of vaginal examinations. Recently 400 μg misoprostol is given
sublingually every 3 hours for a maximum of five doses. This regimen has got 100% success
in second trimester abortion. The mean induction—abortion interval is 11–12 hours.
2. Mifepristone and prostaglandins: Mifepristone 200 mg oral, followed 36–48 hours later
by misoprostol 800 μg vaginal; then misoprostol 400 μg oral every 3 hours for four doses is
used. Success rate of abortion is 97% and median induction delivery interval is 6.5 hours. Pre-
treatment with mifepristone reduces the induction-abortion interval significantly compared to
use of misoprostol alone.
3. Gemeprost (PGE1 analogue): 1 mg vaginal pessary every 3–6 hours for five doses in 24
hours has got about 90% success. The mean induction-abortion interval was 14–18 hours.
[Link] (PGE2 analogue): 20 mg is used as a vaginal suppository every 3–4 hours
(maximum for 4–6 doses). When used along with osmotic dilators, the mean induction to
abortion interval is 17 hours. PGE2 is thermolabile (needs refrigeration) and is expensive.
5. Prostaglandin F2α (PGF2α), carboprost trometha mine-250 μg IM every 3 hours for a
maximum ten doses can be used. The success rate is about 90% in 36 hours. Side effects of
PGF2α (nausea, vomiting, diarrhoea and pain at injection site) are more. It is contraindicated
in cases with bronchial asthma.
2. OXYTOCIN: High-dose oxytocin as a single agent can be used for second trimester
abortion. It is effective in 80% of cases. It can be used with intravenous normal saline along
with any of the medications used either intra-amniotic or extra-amniotic space in an attempt to
augment the abortion process.
The drip rate can be increased up to 50 milliunits or more per minute. Currently high dose (up
to 300 units in 500 mL of dextrose saline) is favoured.
SURGICAL METHODS:
It is difficult to terminate pregnancy in the second trimester with reasonable safety as in first
trimester. The following surgical methods may be employed.
[Link] 13 weeks and 15 weeks
Dilatation and Evacuation in the mid-trimester is less commonly done. Pregnancies at 13–14
menstrual weeks are evacuated. In all mid-trimester abortion, cervical preparation must be used
(WHO 1997) to make the process easy and safe. Intracervical tent (Laminaria osmotic dilator),
mifepristone or misoprostol are used as the cervical priming agents. The procedure may need
to be performed under ultrasound guidance to reduce the risk of complications Simultaneous
use of oxytocin infusion is useful.
[Link] 16 weeks and 20 weeks:
INTRAUTERINE INSTILLATION OF HYPERTONIC SOLUTION:
• Extra-amniotic
•Intra-amniotic
a) Extra-amniotic: Extra-amniotic instillation of 0.1% ethacridine lactate (estimated amount is
10 mL/ week) is done trans-cervically through a No. 16 Foleys catheter. The catheter is passed
up the cervical canal for about 10 cm above the internal os between the membranes and
myometrium and the balloon is inflated (10 mL) with saline. It is removed after 4 hours. The
success rate is similar to saline instillation but is less hazardous. 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.
• Isotonic saline is infused extra-amniotically using a transcervical catheter balloon. Results
are similar to that of Foley’s catheter use alone.
b) Intra-amniotic: Intra-amniotic instillation of hypertonic saline (20%) is less commonly used
now. It is instilled through the abdominal route.
Procedure:
Preliminary amniocentesis is done by a 15 cm 18-gauge needle. The amount of saline to be
instilled is calculated as number of weeks of gestation multiplied by 10 ml. The amount is to
be infused slowly at the rate of 10 mL/min. Contraindications:
It should not be used in presence of cardiovascular or renal lesion or in severe anaemia because
of sodium load.
Precautions:
• To be sure that the needle is in the amniotic cavity evidenced by clear liquor coming out. If
there is a bloody tap, the needle should be pushed further or change the direction until clear
liquor comes out. If fails, the procedure is to be abandoned.
• The instillation should be a slow process (10 mL/min).
• Vital signs should be checked immediately after the instillation and she should be kept at bed
rest for at least 1 hour.
•To stop the procedure if the untoward symptoms like acute abdominal pain, headache, thirst
or tingling in the fingers appear (feature of intravascular injection of the hypertonic saline). A
rapid infusion of 1,000 mL dextrose in water along with intravenous diuretics is indicated in
such cases.
• Strict vigilance is taken during and following instillation till expulsion occurs.
•Routine antibiotic is given such as ampicillin 500 mg thrice daily for 3–5 days.
Mode of 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 foetus.
Success rate:
The method is effective in 90–95% cases with induction-abortion interval of about 32 hours.
The method failure (end point) is considered when abortion fails to occur within 48 hours. If
the method fails, some other method may be employed.
Complications:
• Minor complaints like fever, headache, nausea, vomiting, abdominal pain.
• Cervical tear and laceration.
• Retained products for which exploration has to be done.
• Infection.
• Hypernatremia, cardiovascular collapse—due to intravascular injection.
• Pulmonary and cerebral oedema.
• Renal failure.
• Disseminated intravascular coagulopathy.
The incidence of death rate varies from 0 to 5 per 1,000 instillations.
Intra-amniotic instillation of hyperosmotic urea: Intra-amniotic instillation of 40% urea
solution (80 g of urea in 200 mL distilled water) along with syntocinon drip is effective with
less complications. Combination of intraamniotic hyperosmotic urea and 15 methyl PGF2α
reduces the induction-abortion interval to 13 hours.
HYSTEROTOMY: The operation is performed through abdominal route.
Indications:
[Link] failed medical termination of pregnancy (TOP)
[Link] where D&E cannot be safely done: (a) fibroid in the lower uterine segment.
(b) uterine anomalies.
(c)patients with repeated scarred uterus with placenta accreta or percreta. It is less commonly
done these days. The operation should be combined with sterilization operation
Hazards:
(a) fibroid in the lower uterine segment.
(b) uterine anomalies.
(c) patients with repeated scarred uterus with placenta accreta or percreta. It is less
commonly done these days. The operation should be combined with sterilization operation.

I. Immediate:
1) Haemorrhage and shock.
2) Anaesthetic complications.
3) Peritonitis.
4) Intestinal obstruction.
II. Remote:
1) Menstrual abnormalities.
2) Scar endometriosis (1%).
3) Incisional hernia.
4) If pregnancy occurs, chance of scar rupture. Rh- NEGATIVE WOMEN:
In nonimmunized women, intramuscular administration of 100 μg anti-D immunoglobulin is
given within 72 hours of abortion.
COMPLICATIONS OF MTP:
There is no 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/ curette. 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.
[Link]:
• Injury to the cervix (cervical lacerations).

• Uterine perforation during D&E

• Haemorrhage and shock due to trauma, incomplete abortion, atonic uterus or rarely
coagulation failure.
• Thrombosis or embolism.
• Post-abortal triad of pain, bleeding and low-grade fever due to retained clots or
products. Antibiotics should be continued, may need repeat evacuation.
Related to the methods employed:
• Prostaglandins: intractable vomiting, diarrhoea, fever, uterine pain and cervico-uterine
injury.
• Oxytocin: water intoxication and rarely convulsions
• Hysterotomy
• Saline: hypernatremia, pulmonary oedema, endotoxic shock. Disseminated intra
vascular coagulation (DIC), renal failure, cerebral haemorrhage
2. REMOTE: The complications are grouped into:
(i) Gynaecological (ii) Obstetrical
Gynaecological complications include:
• menstrual disturbances
• chronic pelvic inflammation
• infertility due to cornual block
• scar endometriosis (1%) and
• uterine synechiae leading to secondary amenorrhea. Obstetrical complications include:
• recurrent mid-trimester abortion due to cervical incompetence
• ectopic pregnancy (threefold increase)
• preterm labour
• dysmaturity,

• increased perinatal loss

• rupture uterus
• Rh-isoimmunization in Rh-negative women, if not prophylactically protected with
immunoglobulin
• failed abortion and continued pregnancy.
Failed abortion, continued pregnancy and ectopic pregnancy:
Pregnancy may continue following MVA (in-spite of histologically proven villi). When no
chorionic villi are found on tissue examination, ectopic pregnancy need to be excluded by
quantitative serum hCG and vaginal ultrasound. Failed MTP is defined when there is a failure
to achieve TOP within 48 hours. Failed second trimester MTP with PG analogues and the rate
of live birth is 4–10%.
MORTALITY:
First trimester: The maternal death is lowest (about 0.6/100,000 procedures) in first
trimester termination specially with MVA and suction evacuation. Concurrent tubectomy even
by abdominal route doubles the mortality rate.
Mid-trimester: The mortality rate increases five to six times to that of first trimester.
Contrary to the result of the advanced countries, the mortality from saline method has been
found much higher in India compared to termination by abdominal hysterotomy with
tubectomy.
ROLE OF A NURSE:
• Nurse should assess the condition of the mother and know the cause for the miscarriage.
• By assessing the status or condition of the mother and by history taking, nurse should identify
the causative factor and type of miscarriage.
• Nurse should identify the clinical features, complaints of the mother, bleeding per vaginal
and type of pain is recorded.
• Routine investigation like blood and urine, ultrasonography should be done.
• Nurse should educate the mother regarding the rest she should take after the treatment of
medical or surgical. The overall risk should be explained to the mother and the family.
• Nurse should explain the embryonic and parental factors which causes miscarriage
SUMMARY:
The Medical Termination of Pregnancy (MTP) Act is a legal framework in India that allows
for the safe and lawful termination of pregnancies under specific conditions. First enacted in
1971 and amended in 2021, the Act permits abortion up to 20 weeks with the opinion of one
registered medical practitioner, and up to 24 weeks in special cases such as rape survivors,
minors, or in cases of fetal anomalies with the opinion of two doctors. It also ensures the
confidentiality of the woman undergoing the procedure. The Act plays a crucial role in reducing
unsafe abortions, protecting women’s health, and upholding reproductive rights.
CONCLUSION:
The Medical Termination of Pregnancy (MTP) Act is a progressive legal framework that
safeguards women's reproductive rights in India. By allowing safe and legal abortions under
defined conditions, it reduces maternal morbidity and mortality from unsafe procedures. The
2021 amendment further enhances access, especially for vulnerable groups, while emphasizing
confidentiality and dignity. Effective implementation, provider training, and public awareness
are key to ensuring that all women can exercise their reproductive choices safely and legally.
BIBILIOGRAPHY:
• D.C. Dutta’s “a text book of obstetrics”, published by new central book agency (p)
limited, seventh edition, page no: 158-177.
• [Link]
• [Link]
• [Link] states-india