Medical termination of pregnancy or (MTP) is a medical procedure to end the pregnancy. It is also known as Medical [Link] pregnancy is terminated either by taking medicines or by performing a surgical procedure. Most abortions are carried out before 24 weeks of pregnancy. It can be ended medically if the pregnancy is 7-9 weeks old or earlier, otherwise, a surgery is required. Medical abortion is permitted in India if the pregnancy has not exceed 20 weeks. Legally, approval of only the pregnant woman is required for a pregnancy termination. we y CThere is often confusion in understanding miscarriage vs abortion. While both involve the termination of a pregnancy, there are some key differences between the two. oa The main difference between abortion and miscarriage is that abortions are induced, while miscarriages occur naturally. In other words, an abortion is a planned termination of a pregnancy, while a miscarriage is an unplanned one. ye >.What is miscarriage ( spontaneous abortion)? Miscarriage is the ending of the pregnancy naturally before the 20th week. Miscarriages are also called spontaneous abortions. The majority of miscarriages are unavoidable and happen when the foetus stops developing. Miscarriages are very common in the first trimester of pregnancy. The most common signs of miscarriage include bleeding of tissues and clots, abdominal cramps and lower back pain. What is induced Abortion ( Deliberate Abortion) ? Abortion is a legal procedure by which a woman can end her pregnancy deliberately. It can be done till the 24th week of gestation. A pregnant woman can abort her pregnancy using medicines or surgery if she doesn't want to deliver the baby. It is better to abort in the early stages of pregnancy to reduce risks. As it involves going through emotional turmoil, the patient must consider carefully and take the advice of specialists before going ahead with the procedure. DaanSeptic-common Threatened Inevitable © Complete Incomplete Missed Septic (Less common)Bleeding with closed cervix but no evidence of foetal demise on ultrasound scan; 50% chance of complete miscarriage Inevitable Open cervix but products of conception not yet expelled. Almost all progress to complete miscarriage Inc Products of conception partially expelled. All progress to complete miscarriage All products of pregnancy are expelled Ultrasound scan shows foetal demise but products of conception remain in uterus. Can be asymptomatic. All will progress to complete miscarriage Rare. Often results from pelvic instrumentation (i.e. non- sterile conditions)Figure showing types of miscarriageIn the first trimester, options for abortion commonly include medical abortion or vacuum aspiration. Aperson can usually access medical abortion until about 7—9 weeks after their last period. It involves taking two types of medication. Surgical options, such as vacuum aspiration and dilation and evacuation, are more common between 6 and 14 weeks of pregnancy. In the second trimester, a pregnant person may undergo dilation and evacuation (D&E). Doctors typically perform this between weeks 12 and 24. In the third trimester, a pregnant person may undergo labor induction abortion. However, this is very rare.* If a woman's health is under danger because of pregnancy. If a woman is pregnant because of rape. If it is known that the fetus will be unwell or handicapped after birth. * Pregnancies that happen despite contraception. * If a girl under the age of eighteen or a ‘lunatic’ (a person who is not in his/her senses) is pregnant. It is considered illegal to perform MTP unless it is conducted in either of the following places. * A hospital which is under the government. * Any other place which is approved by the government to work according to the MTP Act. * Medical abortion can be performed at a clinic, but the doctor needs to be attached to the government approved MTP 12 center.Medical abortion is not a safe option for those who: Are too far along in the pregnancy. Have a pregnancy outside of the uterus (ectopic pregnancy). Have a blood clotting disorder or significant anemia. Have chronic adrenal failure. Use long-term corticosteroids. Have an intrauterine device (IUD). Have an allergy to the medications used. Do not have access to emergency care. Can't return for a follow-up visit. itis important to discuss your medical history with your healthcare Pee before a medical abortion procedure.Consent : If married--- her own written consent. Husband’s consent not required. If unmarried and above 1 8years ---her own written consent If below 18 years ---written consent of her guardian. If mentally unstable --- written consent of her guardian. A consent assures the clinician performing the abortion that she: Has been informed of all her options. Has been counselled about the procedure, its risks and how to care for herself after she chosen the abortion of her own free will.Who can perform MTP? _ Physicians qualified to do MTP are: Any qualified registered medical practitioner who has assisted in 25 MTPs. A house surgeon who has done six months post in Obstetrics and Gynaecology. A person who has a diploma /degree in Obstetrics and Gynaecology. 3 years of practice in Obstetrics and Gynaecology for those doctors registered before the 1971 MTP Act was passed. 1 year of practice in Obstetrics and Gynaecology for those doctors registered on or after the date of commencement of the Act. Whenever the pregnancy exceeds 12 weeks but is below 20 weeks opinion of two registered medical practitioners is necessary. 45The World Health Organization (WHO) recommends three safe abortion methods for terminating early pregnancies. The choice of each method depends on pregnancy length and the patient's medical condition. These are: 1. The medical abortion method ~ ea 2. Vacuum aspiration abortion method > 3. Surgical abortion method 16Medical Methods Mifepristone ( RU 486) and Mesoprostol: MiMifepristone(zoomg) an analog of progestin (norethindrone) acts as an antagonist, blocking the effect of natural progesterone. Addition of low dose prostaglandins (800mg) (PGE1) improves the efficiency of first trimester abortion. It is effective upto 63 days and is highly successful when used within 49 days of gestation.Methotrexate and Misoprostol 8 Methotrexate 50 mg/m? IM (before 56 days of gestation) followed by 7 days later misoprostol 800 Lig vaginally is highly effective. HMisoprostol may have to be repeated after 24 hours if it fails. MMethotrexate and misoprostol regimen is less expensive but takes longer time than Mifepristone and Misoprostol. Methotrexate iT: 2.5mg Tablets MISOPROSTOL UWASurgical Methods of First Trimester Abortion: Menstrual Regulation v9 @it is 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 Wit is done with aseptic precautions. @After introducing the posterior vaginal speculum, the cervix is steadied with an Allis forceps. A. Syringe Plastic Cannula with whistle tip used in suction evacuationMenstrual Regulation Toe Contd... Si} — | Cervix may be gently dilated using 4 or 5 mm size dilators. @The cannula is rotated, pushed in and out with gentle strokes. The operator should examine the aspirated tissue by floating it ina clear plastic dish over a light source. This will help to detect failed abortion, molar pregnancy or ectopic pregnancy. @s-6 mm suction cannula (Karman’s) is then inserted and attached to the 50 mL syringe for suction. @The procedure is contraindicated in the presence of pelvic inflammation.§ Manual Vacuum Aspiration ( MVA) Done upto 12 weeks with minimal cervical dilatation =" Wit 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. ) Mit is quicker (15 minutes), effective (98-100%), less traumatic and safer than tation, evacuation and curettage. | mThe procedure may be manual vacuum aspiration (MVA) or electric vacuum aspiration (EVA). Hand operated double valve plastic syringe is attached to a cannula. ®The cannula is inserted transcervically into the uterus and the vacuum is activated. IMA negative pressure of 660 mm Hg is created. BB Aspiration of the products of conception is done Gs| Diaton and evacuation 22 The operation consists of dilatation of the cervix and evacuation of the product conception from the uterus 1. Vaginal examination is done to note the size and position of the uterus and to note the state of cervix. USG should be performed when there is any doubt about the gestational age. 2. Posterior vaginal speculum is introduced and an assistant is asked to hold it. [Link] anterior lip of the cervix is to be grasped by an Allis forceps.4, The cervix may have to be dilated with smaller size graduated metal dilators up to one size less than that of the suction cannula. Feeling of “snap” of the endocervix around the dilator is characteristic. Instead laminaria tent 12 hours before (osmotic dilator) or misoprostol (PGE1) 400 lug given vaginally 3 hours prior to surgery produces effective dilatation. « Intravenous methargin 0.2 mg is administered. 6, The appropriate suction cannula is fitted to the suction apparatus by a thick rubber or plastic tubing. The cannula is then introduced into the uterus, the tip is to be placed in the middle of the uterine cavity. 7 .The pressure of the suction is raised to 400-600 mm Hg. The cannula is moved up and down and rotated within the uterine cavity (360°) with the pressure on. The suction bottle is inspected for the products of conception and blood loss. The suction is regulated by a finger placed over a hole at the base of the cannulaThe end point of suction is denoted by: @-No more material is being sucked out b. Gripping of the cannula by the contracting smaller size uterus [Link] of bubbles in the cannula or in the transparent tubing. After being satisfied that the uterus is remaining firm, and there is minimal vaginal bleeding, the patient is brought down from the table after placing a sterile vulval pad.Second Trimester Termination Of Pregnancy?> Prostaglandin Prostaglandin WiThey act on the cervix and the uterus. WiThe PGE (dinoprostone, sulprostone, gemeprost, misoprostol) and PGF (carboprost) analogues are commonly used IPGEs are preferred as they have more selective action on the myometrium and less side effects.A 26 400-800 jig of misoprostol given vaginally at an interval of 3-4 hours is most effective as the bioavailability is high. @ Alternatively, first dose of 600 pg misoprostol given vaginally, then 200 ig, orally every 3 hours are also found optimum. @ Recently 400 1g misoprostol is given sublingually every 3 hours for a maximum of five doses. This regimen has got 100% success in second trimester abortion. 2..Gemeprost (PGE: analogue): 1g vaginal every 3-6 hours for five doses in 24 hours has got about 90% success. @ The mean induction-abortion interval was 14-18 hours. Misoprostol CyaH5,0, He 9,(Contd... 27 3, Mifepristone and prostaglandins: }Mifepristone 200 mg oral, followed 36-48 hours later by misoprostol ug vaginal; then misoprostol 400 ig oral every 3 hours for 4 doses is used. Success rate of abortion is 97% and median induction delivery interval is 6.5 hours. © Pretreatment with mifepristone reduces the induction— abortion interval significantly compared to use of misoprostol alone. 4. Prostaglandin F2 (carboprost):- -250mg IM every 3 hours for a maximum 100 dose can be usedHigh dose oxytocin asa single agent can be used for second trimester abortion. HI is effective in 80% of cases. [mit 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. Mode of action — Myometrial oxytocin receptor concentration increases| maximum (200-300 fold) during labour Hi Oxytocin acts through receptor and voltage mediated calcium channels to initiate myometrial contraction i 4It is difficult to terminate pregnancy in the second trimester with reasonable safety as in first trimester. _ Between 13-15 weeks — Dilation and Evacuation in the midtrimester is less commonly done. @ Pregnancies at 13 to 14 menstrual weeks are evacuated. In all midtrimester 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. @ he procedure may need to be performed under ultrasound guidance to reduce the risk of complications. @ Simultaneous use of oxytocin infusion is useful.(20%) is less commonly used now. instilled through the abdominal route. 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 fetus. MiProcedure: © 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. 30Extra-amniotic instillation of 0.1% ethacrydine lactate @ done transcervically through a number 16 Foley's cathete: @ 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. @ !t can be used in cases contraindicated for saline instillation. 31 @ 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 tiation 1 of the aboHysterotomy 32 Hysterotomy is an operative procedure of extracting the products of conception out of the womb before 28" week by cutting through the anterior wall of the uterus. The operation is usually done through the abdominal route. ‘The operation is rarely done these days for the purpose of MTP. Complications: | Hemorrhage and shock Incision I Peritonitis Ml Intestinal obstruction= Injury to the cervix (cervical lacerations) uterine perforation during D and E = Haemorrhage and shock due to trauma, incomplete abortion, atonic uterus or rarely coagulation failure = Thrombosis or embolism The complications are grouped into: @ Gynecological @ Obstetrical 33Contd.. 1 menstrual disturbances ll chronic pelvic inflammation ll scar endometriosis (1%) | Obstetrical complications include: I ectopic pregnancy (three-fold increase) I preterm labour ti dysmaturity, IVrupture uterus 34b OY TU U) ~ LAW, Although abortion in India has been legal under various circumstances since the introduction of the Medical Termination of Pregnancy (MTP) Act in 1971, we look back at the history of various judgments that were passed and debated to allow women autonomy over their bodies, or somewhat so.Illegal abortion to Shantilal Shah Committee, the 1960s Until the 1960s, abortion was illegal in India and was punishable under law. Under Section 312 of the Indian Penal Code (IPC), a woman could face three years of imprisonment and a fine. Section 312 of the IPC criminalizes the intentional causing of miscarriage if it was not done in good faith for the purpose of saving the child. ‘The discussion of the need for abortion laws started in India in the mid-1960s when’ the government set up the Shantilal Shah Committee headed by medical professional, Dr Shantilal Shah. The committee was assigned with the task of looking into matters of abortion and whether the country required laws around the] same. In 1964, the Committee suggested the liberalisation of abortion laws in India that will help in reducing unsafe abortions and decrease maternal mortality in the country. Based on the report of the Shantilal Shah Committee, a medical termination bill was introduced in Lok Sabha and Rajya Sabha and was passed by Parliament in August 1971.* Came into force in 1972 * Amendments in 1975, 2002 and 2003 Grounds for MTP — * Therapeutic : risk to pregnant woman * Eugenic: risk to the child to be born * Humanitarian : pregnancy caused by rape * Socioeconomic : pregnancy due to failure of contraceptive, Unwanted pregnancy with low SE status 37 * Environemental: no one to help from society@iThe Indian abortion laws falls under the Medical Termination of 38 Pregnancy (MTP) Act, which was enacted by the Indian Parliament in the year 1971 with the intention of reducing the incidence of illegal abortion and consequent maternal mortality and morbidity. The MTP Act came into effect from 1 April 1972 and was amended in the years 1975 and 2002. fmRecently, the Supreme Court permitted a rape survivor to terminate her pregnancy at 24 weeks, which is beyond the permissible 20 weeks limit prescribed under the Medical Termination of Pregnancy Act, 1971ENSURING SAFETY AND WELL-BEING OF WOMEN Amendment in medical termination of pregnancy bill 2020Changes proposed in conditions for terminating a pregnancy at different gestational period ‘Time since conception _ Requirement for terminating pregnancy MTP Act,1971 MTP (Amendment) Up to 12 weeks Advice of one doctor Advice of one doctor 12 t0 20 weeks Advice of two doctors Advice of one doctor “Two doctors for tome categories of pregnant 20 to 24 weeks Not allowed Laie Medical Board in case of substantial foctal abnormality More than 24 weeks Not allowed Any time during the ‘One doctor, if immediately necessary to save pregnant woman's life Pregnancy- Abortion laws worldwide: ‘* Abortion is allowed in most countries (97 percent) in order to save a woman's life. ‘Though the laws vary across the world. * In 2003 the WHO developed technical and policy guidelines to help governments ass progressive abortion laws. ‘* Worldwide, abortion is acknowledged as an important aspect of reproductive health of women. * At present, 26 countries including Egypt, Angola, Thailand, the Philippines, Madagascar and iraq do not permit abortion. * 39 countries including Brazil, Mexico, Sudan, Indonesia and Sri Lanka permit abortion when the woman's life is at risk. ‘© Only some countries like China, Russia, Canada, Australia, South Africa permit ——abortion on request mostly up-to t2-weeks * India will now stand amongst nations with a highly progressive law which allows legal abortions on a broad range of therapeutic, humanitarian and social grounds,Bibliography =” . [Link] . Wikipedia . NCERT text book Biology Class 12 . D.C. Dutta text book of obstetrics and Gynaecology . [Link]. . Www. [Link].