Justifiable abortion (therapeutic abortion)

It is also called as therapeutic abortion or legal abortion

In 1970 the World Medical Association WMA) adopted a resolution
on therapeutic abortion, known as Declaration of Oslo
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It is performed either in accordance with the legal provisions under
the Medical Termination of Pregnancy (MTP Act 1971 (i e legal
abortion) or caused in good faith to save the life of the pregnant
woman

1. J ustifiable Abortion ( T herapeutic abortion ) Dr Faiz Ahmad

2. It is also called as therapeutic abortion or legal abortion. In 1970, the World Medical Association ( WMA) adopted a resolution on therapeutic abortion, known as “ Declaration of Oslo ”. It is performed either in accordance with the legal provisions under the Medical Termination of Pregnancy (MTP ) Act 1971 (i.e. legal abortion) or caused in good faith to save the life of the pregnant woman.

3. Medical Termination of Pregnancy W ith enactment of Medical Termination of Pregnancy ( MTP) Act 1971, abortion is liberalized in India, under the provisions of Act, but it is not legalized . Indications(u/s 3 of MTP Act-1971) As per MTP Act 1971, pregnancy can be terminated on the following grounds (mnemonic “SETH” ) S = S ocial E = Eugenic T = T herapeutic H = H umanitarian

4. 1. Therapeutic [S.3(2)( i )] When continuation of pregnancy may cause risk to the life of the pregnant woman or may cause grave injury to her physical or mental health, it can be terminated on therapeutic ground .

5. 2. Eugenic [S.3(2)( ii)] If there is possibility that child born would be suffering from physical or mental abnormalities that lead the child to be handicapped, then such pregnancy can be terminated on eugenic grounds . Disease- If during the first 3 months pregnant women suffers from Chickenpox German measles Smallpox Toxoplasmosis Viral hepatitis Viral Infection

6. b) Drugs- If the pregnant women is treated with Aminopterin Antimimetic drugs Cortisone Thalidomide Antidepressent Hallucinogens

7. c)X-ray- If mother is treated with x-ray /radioisotope d) Heritable mental disease like Schizophrenia 3 . Humanitarian When the pregnancy is caused by rape then it can be terminated on humanitarian ground . Woman has not lodged complaints with police, wants MTP MTP can be done Doctor must report the matter to police Preserve the product of conception and hand it over to police for DNA profiling

8. 4 . Social When pregnancy has resulted due to failure of contraceptive method adopted by married woman or her husband for the purpose of limiting the number of children, then such pregnancy can be terminated on social grounds. Rape and failure of contraception in married women are presumed by law to cause grave injury to the mental health of pregnant women

9. Important note In an emergency, a Registered Medical Practitioner can terminate pregnancy at any place, irrespective of duration of pregnancy. Abortion done in good faith to save the life of a woman, if it appears that continuance of pregnancy would endanger maternal health is not considered as criminal abortion.

10. Rules for Doing MTP 1. Qualification Required (rule 4 of MTP Rules 2003) Only qualified Registered Medical Practitioner, having following required experience can terminate the pregnancy. Any registered medical practitioner who has assisted 25 cases out of which 5 cases he has done independently in a hospital approved by the government can perform the MTP A Doctor with MD/DGO in Gynecology and Obstetrics H as 6 months of experience in house- surgeonship in obstetrics in a recognized hospital . One years experience in department of OBG&GYN

11. 2. Place – MTP can be Carried Out at A hospital maintained or established by government Non-government hospital approved by government (license to be obtained from the Chief Medical Officer/ Civil surgeon of the district).

12. 3. Consent A female above 18 years of age with sound mind can give consent for MTP In minor females (i.e. age less than 18 years) or mentally ill (lunatic), consent of parents or guardian is necessary . Consent of husband – not legally required

13. 4. Duration of Pregnancy When duration of pregnancy is below 12 weeks of gestation, one Registered Medical Practitioner (RMP) can terminate the pregnancy. When duration of pregnancy is above 12 weeks but less than 20 weeks (i.e. 12–20 weeks), then two RMP are required to terminate the pregnancy . Above 20 week-Court order is required

14. 5. Documentation and Record According to regulation 5 of MTP Regulations, all approved centers are required to maintain an admission register in the format prescribed in form III . A fresh register should be started in each calendar year with new serial number generated by mentioning the year against the serial number The admission register is a secret document. It should be maintained for at least 5 years from the last entry.

15. Methods of Inducing MTP Up to 12 Weeks 1. Manual vacuum aspiration 2. Suction evacuation and/or curettage 3. Dilatation and curettage 4. Mifepristone 5. Mifepristone and misoprostol (PgE1) 6. Methotrexate and misoprostol 7. Tamoxifen and misoprostol

16. Between 13 to 20 Weeks 1. Dilatation and evacuation 2. Oxytocin infusion 3. Induction by prostaglandins E1 (misoprostol) 15 methyl PGF2ά ( carboprost ), PGE2 ( dinprostone ) and their analogues. (Used as intravaginally , intramuscularly or intraamniotically ) 4. Hysterotomy – less common method

17. Complications of MTP Immediate 1. Hemorrhage and shock 2. Perforation of uterus, intestine 3. Laceration of cervix or vagina 4. Incomplete abortion 5. Endometritis 6. Embolism

18. Delayed 1. Menstrual disturbances 2. Sterility 3. Pelvic inflammatory disease 4. Recurrent abortion or premature labor 5. Rh isoimmunization 6. Psychological sequelae

19. Medicolegal Importance of Abortion When abortion is induced without proper indication or in contravention to the provisions of MTP Act, it is considered as criminal abortion and is punishable by law. When Doctor violates the provisions of MTP Act, he is liable to be punished by the law and similarly his act amount to misconduct in professional sense.

20. 3 . To bring a false charge of assault against any person, a female may plead that she has been assaulted and due to assault, abortion was induced. 4 . A female may be falsely charged or implicated for inducing criminal abortion.

21. T he Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act [PCPNDT], 1994 It was enacted in 1994 , and subsequently amended in 2002 Aims Pre-natal diagnostic techniques for determination of sex of fetus were prohibited- to prevent female feticide Advertisement of prenatal diagnostic techniques for detection or determination of sex were prohibited Pre-natal diagnostic techniques for detection of genetic abnormalities were allowed

22. Some important definitions Diagnostic procedures Pre-natal diagnostic procedures means all gynecological or obstetrical or medical procedures such as ultrasonography , fetoscopy , taking or removing samples of amniotic fluid, chorionic villi, blood or any other tissue or fluid of a man, or of a woman for being sent to a Genetic Laboratory or Genetic Clinic for conducting any type of analysis or pre-natal diagnostic tests for selection of sex before or after conception

23. Genetic clinic Genetic clinic is a place where such procedures are performed. It includes a vehicle where ultrasound machines, or other equipment capable of determining sex is kept. pre-natal diagnostic techniques ” includes all pre-natal diagnostic procedures + prenatal diagnostic tests

24. Pre-natal diagnostic test P re-natal diagnostic test” means ultrasonography or any test or analysis of amniotic fluid, chorionic villi, blood or any tissue or fluid of pregnant woman or conceptus conducted to detect genetic or metabolic disorders or chromosomal abnormalities or congenital anomalies or hemoglobinopathies or sex-linked diseases Genetic laboratory - is a place where such tests are performed Genetic Counselling Centre- is a place which provides genetic counselling to patients

25. Regulation of Genetic Counselling centers, genetic laboratories and genetic clinics No person can conduct a sex selection No person can sell any ultrasound machine or imaging machine or scanner or any other equipment capable of determining sex of fetus to any person or clinic etc not registered under the Act

26. Regulation of pre-natal diagnostic techniques [ PNDT ] Prenatal Diagnostic Techniques can be conducted only for Chromosomal abnormalities Congenital Abnormalities Genetic metabolic diseases Hemoglobinopathies Sex-linked genetic diseases Any other abnormalities or diseases as may be specified by the Central Supervisory Board

27. Any one or more of the following c onditions must be fulfilled before the techniques can be carried out Age of the pregnant woman >35 years Pregnant woman has undergone ≥2 Spontaneous abortions or fetal loss Pregnant woman had been exposed to potentially Teratogenic agents such as drugs , radiation, infections or chemicals

28. P regnant woman has a Family history of mental retardation or physical deformities such as spasticity or any other genetic disease Any other condition as may be specified by the Central Supervisory Board. The person undertaking the procedure must record the fulfilling condition in writing

29. Informed consent Prenatal diagnostic procedures can only be conducted after a written informed consent. A copy of the written consent is to be given to pregnant woman. Prohibition of communicating sex of fetus Person conducting prenatal diagnostic procedure cannot communicate sex of fetus to the pregnant woman concerned or any other person by any means.

30. Determination of sex- prohibited No person or clinic etc can determine the sex of a fetus or cause selection of sex before or after conception PENALTIES ( i ) On Advertisement – of any of sex selection or sex determination techniques; 3 y + `10,000 [ S.22 ] ( ii) On Sex selection or sex determination To doctor – 1st conviction"3 y + `10,000. Subsequent convictions"5 y + `50,000 [ S.23(1) ]. On conviction, name will be removed from medical register for 5 y for 1st offence and permanently [ professional death sentence] on 2nd offence [ S.23(2) ] ( b) To patient - 3 y + `50,000 for 1 st offence and 5 y + `100,000 for 2nd offence [ S.23(3 ) ]. If the woman was compelled she will not be punished [ S.23(4) ], but the person compelling her would be.

31. THANKS