Abortions and Maternal Termination of Pregnancy ppt

Abortion means spontaneous or induced expulsion of products of conception before the period of viability( 28 weeks).
In medical practice, the abortion occurs in 1st trimester, miscarriage in the 2nd trimester and premature labor in the 3rd trimester.
legally all the above terms are synonymous.

1. ABORTIONS AND MTP Presented by: Michael Kino MBBS, NEIGRIHMS

2. OVERVIEW Definition Incidence Types of abortion and clinical features Aetiology of early pregnancy bleeding(D/D of abortion) Diagnosis Treatment MTP Methods of MTP Complications of abortion

3. ABORTION? MISCARRIAGE? EARLY PREGNANCY LOSS? In the first trimester, the terms miscarriage, spontaneous abortion, and early pregnancy loss are used interchangeably.

4. DEFINITION Abortion : the expulsion of a  fetus  from the  uterus before it has reached the stage of viability ( the 20th week of gestation)  An abortion that occurs without intervention is known as a  miscarriage  or "spontaneous abortion" .  When deliberate steps are taken to end a pregnancy, it is called an  induced abortion , or less frequently "induced miscarriage". The unmodified word  abortion  generally refers to an induced abortion.

5. DEFINITION (WHO & CDC): Termination of pregnancy prior to 20 weeks of gestation/fetus born weighing less than 500 grams ( abortus). RCOG : 24 weeks

6. Incidence 10% of all pregnancies 80% occur in the 1 st trimester

7. Etiology and Risk Factors F etal chromosomal abnormalities(80%) A dvanced maternal age P rior early pregnancy loss

8. Latest update on abortion laws in INDIA The MTP (amendment bill) 2020: Proposes to extend the upper limit from 20 to 24 weeks. Need to increase the upper limit?

9. TYPES OF ABORTIONS INDUCED SPONTANEOUS

10. TYPES OF ABORTIONS THREATENED ABORTION INEVITABLE ABORTION INCOMPLETE ABORTION COMPLETE ABORTION MISSED ABORTION SEPTIC ABORTION INDUCED ABORTION

11. Differential diagnosis of early pregnancy bleeding Related to pregnancy Unrelated to pregnancy Implantation bleeding Cervical or vaginal pathology such as erosion, polyp , fibroids, cancer Miscarriage Trauma to the cervix and vagina Ectopic pregnancy Gestational trophoblastic neoplasms Cervical insufficiency

12. Diagnosis Serum ß hCG Serum Progesterone Transvaginal USG

13. Serum B hCG Rate of increase of 2 levels done 48 hours apart <50% Serum Progesterone: <5ng/ml

14. Transvaginal USG The single most important investigation in a woman with bleeding in early pregnancy TVS > transabdominal Increase quality and accuracy

15. Treatment of an early pregnancy loss before confirmed diagnosis can have detrimental consequences, including interruption of a normal pregnancy, pregnancy complications, or birth defects 

16. Management Principles: Acknowledgement of loss of a pregnancy by the care provider and appropriate counselling Assessing the need for uterine evacuation Method of uterine evacuation

17. Management Conservative/Expectant Medical Surgical

18. Management Definite and urgent need for uterine evacuation : Significant vaginal bleeding with shock or a change in haemodynamic parameters Evidence of infection Pain or discomfort

19. INDUCED ABORTION MEDICAL : 1 st and 2 nd trimester SURGICAL: 1 st trimester PREFERRED METHOD?

20. For pregnancies of less than 14 weeks of gestation Surgical abortion Either manual or electric vacuum aspiration: • There is no lower limit of gestation for surgical abortion. • It is best practice to inspect aspirated tissue at all gestations to confirm complete evacuation; this is essential following vacuum aspiration at under 7 weeks of gestation.

21. For pregnancies of less than 14 weeks of gestation Medical abortion: If mifepristone is available, it is best practice to use it in combination with misoprostol as it shortens the induction–abortion interval, reduces side effects and decreases the rate of ongoing pregnancy. at up to 63 days of gestation , mifepristone 200mg orally, followed 24–48 hours later by misoprostol 800 micrograms given by the vaginal, buccal or sublingual route.

22. For pregnancies of less than 14 weeks of gestation from 64 days to 13 weeks and 6 days, mifepristone 200mg orally, followed 24–48 hours later by misoprostol 800 micrograms given by the vaginal, buccal or sublingual route, followed by misoprostol 400 micrograms every 3 hours until abortion occurs OR • If mifepristone is not available, and for all gestations up to 13 weeks and 6 days, misoprostol 800 micrograms given by the vaginal, buccal or sublingual route, followed by misoprostol 400 micrograms every 3 hours until abortion occurs.

23. For pregnancies of 14 weeks of gestation or more Surgical abortion Surgical abortion can be performed by trained providers using: • vacuum aspiration using large bore cannulae • dilatation and evacuation (D&E) Medical abortion At 14 weeks of gestation or more, medical abortion should be undertaken in a medical facility. Mifepristone 200 mg orally, followed 12–48 hours later by misoprostol 800micrograms vaginally, followed by misoprostol 400micrograms orally or vaginally every 3 hours until abortion occurs; if after 24 hours abortion does not occur, mifepristone can be repeated 3 hours after the last dose of misoprostol, and 12 hours later misoprostol may be recommenced -where mifepristone is not available, misoprostol 800 micrograms followed by misoprostol 400 micrograms every 3 hours until abortion occurs.

24. INDUCED ABORTION SURGICAL METHODS : 1 st trimester 1. VACUUM ASPIRATION 2. DILATATION AND EVACUATION

25. Vacuum aspiration

26. DILATATION AND EVACUATION

27. INDUCED ABORTION MEDICAL METHODS : MIFEPRISTONE (RU 486): Inhibits Progesterone receptors. MISOPROSTOL: Prostaglandin E1.

28. MEDICAL TERMINATION OF PREGNANCY TYPE OF INDUCED ABORTION

29. IS ABORTION LEGAL IN INDIA? MEDICAL TERMINATION OF PREGNANCY(MTP) ACT

30. UNWANTED PREGNANCY AND ITS IMPLICATIONS Every child should be desired and every pregnancy planned . Premarital unsafe sexual intercourse has become prevalent the world over: ramifications of acting on impulses may have undesirable consequences. “ Unsafe ” – No safeguard against pregnancy or STD’s (Sexually transmitted diseases).

31. UNSAFE ABORTION conducted by a “Quack”, carried out in a set up not approved by the Government. CONCERNS: Complications related to the procedure. Long term psychological effects.

32. Complications of abortion Uterine haemorrhage Pelvic infection Cervical injury Uterine perforation Retained products Continuation of pregnancy Maternal mortality and morbidity Long term sequelae

33. UTERINE PERFORATION

34. ANTI D CONTRACEPTION

35. PRO LIFE/ PRO CHOICE?

36. THANK YOU