Medical termination of pregnancy

DEFINITION , GROUNDS , INDICATIONS OF MTP
ALONGWITH METHODS OF PERFORMING MTP IN FIRST AND SECOND TRIMESTER
WITH THE SCENARIO IN INDIA

1. Medical Termination of Pregnancy PRESENTED BY :- VISHESH SAXENA

2. Definition The Indian Act permits the wilful termination of pregnancy before the age of fetal viability (20-weeks’ gestation) for well-defined indications. It has to be performed by recognized medical practitioners in a recognized place approved by the competent authority under the Act.

3. Incidence It has been estimated that the total number of abortions performed globally is approximately 46 million annually; of these, 26 million take place in countries where abortions are legalized. In India, 6.7 million MTPs take place; 40% pregnancies are unplanned and 25% are unwanted.

4. The written consent of the patient on specially prescribed form is necessary prior to undertaking the procedure. The written consent of the legal guardian must be obtained in case the woman is under the age of 18 years or she is a lunatic, even if she is older than 18 years.

5. The Place for Performing MTP a hospital established and maintained by the government, a place recognized and approved by the government, under this Act. Abortion services are provided under this Act at these centres under strict confidentiality. The identity of the person is treated as a statutory personal matter. Ultrasonic scanning plays an important role in confirming uterine pregnancy, estimating gestational age detecting malformed embryo and sometimes in performing MTP under ultrasonic guidance

6. How to Comply with the Indian MTP Act and Ensure Quality Care

7. Implications of the MTP Act Mortality and morbidity increases with each week of gestation, and is fivefold to tenfold in the second trimester as compared to the first. Repeated abortions are not conducive to a woman’s health, hence, MTP should not be considered as a birth control measure and should not replace prevailing methods of contraception. Even in the best of circumstances, there is a small inherent risk in the procedure of MTP. This should serve as a warning that MTP can never be as safe as efficient contraception. The woman undergoing MTP should be educated to accept contraception. Thus, MTP can indirectly promote family planning and population control.

8. Methods of MTP

9. The above methods are used singly or in combination. The oxytocic drugs stimulate myometrial activity and shorten the induction –abortion interval in the second trimester. Similarly, the use of prostaglandins (gel, suppository) a few hours prior to the procedure helps to attain a gradual softening and atraumatic dilatation of the cervix, facilitating further dilatation and evacuation procedures.

10. Menstrual Regulation Menstrual regulation consists of aspiration of the contents of the uterine cavity by means of a plastic cannula (Karman’s cannula). It has a plastic 50 mL syringe capable of creating a vacuum of of 65 cm Hg. It has a simple thumb-operated pressure control valve and piston locking handle. It is independent of electricity, is portable and washable. It is carried out effectively within 42 days of the beginning of the last menstrual period (LMP). A paracervical local anaesthetic block or preoperative sedative alone usually suffices but sometimes in an apprehensive patient, general anaesthesia with intravenous thiopentone sodium may be necessary. This procedure can be performed in an office set-up, outpatient clinic, or day-care centre .

11. Since 1972, this method has been extensively evaluated and found to be efficient, safe, and easy to use in terminating early pregnancy . It is a good practice to examine the products of conception. The occasional complications encountered include failure to evacuate leading to continuation of pregnancy, incomplete evacuation, haemorrhage , cervical laceration, perforation, infection and anaesthetic complications . A failure to evacuate is due to: 1. Too early pregnancy. 2. Ectopic pregnancy. 3. Uterus bicornuate , aspiration being carried out in nonpregnant horn. Sometimes, tip of the cannula breaks but comes out in the next menstrual bleeding—and it may not be necessary to retrieve it. RH anti-D globulin 100 mcg IM should be given to a RH negative nonimmunized woman.

12. Vacuum Evacuation M ost efficient method of terminating pregnancy up to 12 weeks of gestation The operation can be generally undertaken under local anaesthetic , paracervical block, coupled with some sedation if necessary. Apprehensive patients may need general anaesthesia . The procedure involves examination of the patient in the operation theatre observing full aseptic precautions. The gestation size and the position of the uterus are carefully assessed. After administering a paracervical block, the cervix is held with an Allis forceps and dilated by means of specially designed dilators with a guard, until adequate dilation is achieved to permit introduction of the suction cannula of the appropriate size (diameter corresponding to the weeks of gestation) into the uterine cavity A standard negative suction of 650 mm (65 cm) of Hg is applied and the products are aspirated. When the procedure is completed, a grating sensation is felt all around the uterine cavity, no further tissue is aspirated, and the internal os begins to grip the Karman cannula which reveals a blood-stained froth. There is no need to follow this up with a check curettage with a sharp curette, as this step can be traumatic and lead to complications like perforation, synechiae ( Asherman syndrome), and predispose to placenta accreta in a future pregnancy.

13. In case the pregnancy exceeds 8-weeks gestation size, the patient is nulliparous, or there is presence of a uterine scar, general anaesthesia may be preferred. In case of large uterus of 10- to 12-week gestation size, or nulliparous cervix, priming the cervix with prostaglandin gel or suppository, at least 4 h earlier, helps to soften the cervix so that it yields more easily and undue force is avoided during cervical dilatation. This precaution safeguards against complications like cervical tear, lacerations, and injury to the internal os leading to incompetent cervix; 200–400 mcg misoprostol pessary is inserted in the vagina (prostaglandin E1). Vacuum aspiration as a method of MTP has a very low failure rate (less than 1%). Complications like incomplete evacuation, infection, uterine perforation and excessive bleeding occur in less than 2% of cases. The mortality is less than 2 per 100,000 procedures. Nonimmunized Rh-negative mothers must receive 100 mcg of anti-D immunoglobulin after undergoing MTP. Failure to end pregnancy is due to a very early pregnancy, unrecognized ectopic pregnancy and pregnancy in a rudimentary horn. Preoperative ultrasound is useful in preventing these complications

14. Medical Methods Prostaglandins and RU 486 have been extensively used as medical methods of MTP in early pregnancy. Acting singly, they are not as effective as when used in combination. The medical method avoids hospitalization but the prolonged observation, occasional need of surgical termination (failure) and the cost of the drugs are some of the disadvantages. Medical method is permissible up to 9 weeks of gestation (63 days).

15. Prostaglandins Prostaglandin Injections ( Prostin , Carboprost -prostaglandin F2a) 250 mcg given intramuscularly every 3 h up to a maximum of 10 doses has been found to be effective in initiating the process of abortion. It has not been popular in the first trimester because of an unacceptably high incidence of incomplete abortion (20%) requiring surgical intervention to complete the procedure, and the high rate of unpleasant side effects like nausea, vomiting diarrhoea , cramping abdominal pain, bronchospasm and mild fever at times.

16. Mifepristone ( Mifegest –RU 486) First invented in France 1980, RU stands for Roussel Uclaf 486 (laboratory number) It is a synthetic steroid, a derivative of 19-nortestosterone, with antiprogestogenic effect. It also has antiglucocorticoid and weak antiandrogenic action. By competing with progesterone receptors it reduces the endometrial glandular activity, accelerates degenerative changes and increases stromal action, thereby causing sloughing of endometrium. It thus prevents or disturbs implantation of the fertilized ovum through luteolysis . It also causes uterine contractions, softens and slightly dilates the cervix. Used singly, it is effective in only 83%, causes incomplete abortion in 10–20% cases. Adding prostaglandin yields a success rate of 95% in pregnancies less than 63 days duration, with 4% incomplete abortion and continuation of pregnancy in 1% cases.

17. The protocol is as follows:- Written consent for MTP is required. Blood group RH, Hb % urine Ultrasound is done to confirm uterine pregnancy and duration, and exclude ectopic pregnancy. Day 1 : 200 mg of mifepristone given as a single dose— the woman is observed for half an hour and then allowed home. Anti-D globulin to RH negative woman. Day 3 : 400 mcg of oral misoprostol (prostaglandin) is administered (two tablets) unless abortion has occurred. Sublingual or vaginal prostaglandin is also used but stronger action of sublingual route can cause uterine rupture in a scarred uterus. Pulse BP is observed for 2 h, if all well—allow home. Nowadays, misoprostol (PGE1) vaginal tablet of 400 mcg is inserted instead of oral tablet. Day 14 : Follow-up to confirm abortion has occurred; if not, surgical MTP is done. The bleeding usually starts within few hours of taking mifepristone, and abortion occurs in about a week.

18. Contraindications to mifepristone are: IUCD in situ—IUCD should be removed prior to medical termination to avoid the risk of perforation. Suspected ectopic pregnancy—ultrasound should be done before termination. Hypertension, anaemia, glaucoma, cardiovascular disease, smoker, asthmatic. A woman on anticoagulant (coagulopathy) and glucocorticoid therapy. Allergy, porphyria, seizures (adrenal failure) Previous uterine scar—scar rupture can occur with misoprostol. Fibroid uterus. Lactating woman—the drug is secreted in the milk or lactation stopped temporarily. Infant gets diarrhoea. Gestation period should not exceed 63 days (preferably 49 day).

19. Advantages of Misoprostol Easily stored in room temperature Shelf life 3 years Cheap Easy administration No cardiovascular or asthma complications.

20. C omplications Adrenal failure Headache, malaise, skin rash, fever, nausea vomiting, diarrhoea Failure to abort, 1% Misoprostol causes Möbius syndrome in the fetus (congenital facial palsy, limb defects, bladder extrophy , hydrocephalus). Therefore, termination of pregnancy is strongly recommended if medical termination fails. It takes longer time for termination compared to surgical termination and longer follow-up of 2 weeks is necessary. Surgery is required in case of failure or is incomplete. In case the woman starts bleeding profusely, emergency surgical evacuation is required. Emergency surgical backup is a must. The subsequent menstruation may be delayed by 10– 14 days. Sublingual misoprostol is as effective as vaginal pessary but side effects are more severe than with oral tablets and vaginal pessaries . If vomiting occurs soon after oral misoprostol repeat the dose. Vaginal pessary is safe.

21. Alternative protocols used are: 200 mg of oral mifepristone followed by 800 mcg vaginal misoprostol on the third day. n 200 mg mifepristone and 1 mg tablet of prostaglandin E1 analogue, gemeprost vaginally—pregnancy failure is reported in 0.2–2.3% cases. Methotrexate 50 mg intramuscular or oral followed 5–7 days later by 800 mcg vaginal misoprostol (repeat misoprostol 24 h later if required). Epostane —A progesterone-blocking agent is administered in doses of 200 mcg every 6 h for 7 days. Choice between medical and surgical termination of early pregnancy. There is not much difference in terms of safety and efficacy in two methods. It is mainly the contraindications prevailing and the choice of the woman that decides which method is chosen. If the endometrium is more than 15 mm thick, the risk of incomplete evacuation favours surgical method.

22. Second-Trimester MTP The incidence of second-trimester MTP has dropped with the passage of time, from about 30% of all MTPs performed two decades ago to about 10% in the present times, and is mostly performed for fetal malformations.

23. Dilatation and Evacuation In some western countries, MTP up to 16 weeks is accomplished by slow and deliberate dilatation of the cervix with laminaria tents, prostaglandin gel or pessary , prior to evacuation of the uterine contents using either vacuum aspiration or aspirotomy with ovum forceps. Complications such as cervical trauma, uterine perforation or tear, incomplete evacuation, haemorrhage and infection are more common with second-trimester MTP than first– trisemester MTP.

24. Aspirotomy Aspirotomy involves suction aspiration of the liquor amnii , followed by evacuation of the fetal parts in pieces with the help of a specially designed instrument called the aspirotomy forceps. The procedure is carried out in the operation theatre observing full surgical asepsis. The cervix is exposed under a good light with the help of a Sims’ vaginal speculum and an anterior vaginal wall retractor. A paracervical block given with a local anaesthetic agent such as 1% Xylocaine is followed by intracervical infiltration of the cervix and uterine isthmus with Xylocaine with adrenaline to help alleviate pain, facilitate cervical dilatation, and reduce bleeding during the procedure. The cervix is dilated up to Hegar size 12–14, and the amniotic fluid is drained with the help of a large-bore suction cannula

25. With aspirotomy forceps, the fetus is dismembered, crushed and extracted through the dilated cervix. The extracted mass is assembled to ensure that the fetus has been totally extracted. It is desirable to have an oxytocin infusion running throughout the procedure to reduce the risk of uterine perforation and bleeding. Performed by technically competent experts, the procedure is safe, the blood loss is reduced, and permits discharge of the patient from the hospital within 8 h, thus reducing hospital stay and cost. Slow cervical dilatation with misoprostol prior to aspiration reduces cervical trauma.

26. Medical Methods of MTP Extraovular Instillation of Drugs . Several drugs such as ethacridine lactate, hypertonic saline and prostaglandins have been successfully used in the past, but the drug of choice has been ethacridine lactate. ethacridine lactate. Ethacridine lactate is available as Emcredil . The advantage is that extraovular instillation can be easily performed in second trimester with low failure rate. The procedure should be undertaken in the operation theatre. After steadying the anterior lip of the cervix, a Foley catheter is introduced transcervically into the extraovular space. The bulb of the Foley catheter is inflated with 10–20 mL of distilled water to seal off the internal os . Ethacridine lactate 0.1% pre-prepared solution is instilled into the extraovular space in a dose of 10 mL/week of gestation up to a maximum of 150 mL. The catheter is left in place for 6 h, whereupon it gets gradually expelled spontaneously. Alternatively, the Foley catheter bulb is deflated and the catheter removed. Uterine activity usually begins within 12–18 h. The mean induction–abortion interval varies between 24 and 36 h.

27. About 30% of the abortions are incomplete and require oxytocin infusion and occasionally blunt curettage to remove the retained placental tissue. In the event of failure to initiate uterine activity within 24 h, an augmenting oxytocin drip is desirable. In case of failure in 72 h, reinstillation of ethacridine may be tried or some other method of MTP resorted to. Supplementation with prostaglandins helps to hasten the process of abortion.

28. Amongst the methods tried, the following merit mention: (i) instillation of 1 mL of carboprost or Prostodin injection diluted in 10 mL of distilled water into the extraovular space just before removing the Foley catheter, (ii) addition of 0.5 mg prostaglandin E2 gel ( Cerviprime gel, Prostodin tablet) to the Emcredil solution prior to its instillation into the extraovular space, (iii) Inj. prostaglandin F2a 250 mcg intramuscularly every 3 h, commencing from the time of removal of the catheter. In all such cases the induction–abortion interval is reduced to 12–18 h. A 75–80% success rate is reported.

29. Intracervical or Extraovular Instillation of Cerviprime (PGE2). PGE2 induces uterine contractions within a few hours of insertion. If the uterine contractions are weak or fail to occur, Syntocinon drip is started 6 h later. Ninety per cent abort in 24 h. Contraindications to the use of prostaglandins are cardiac, renal disease, hypertension, bronchial asthma and previous caesarean scar.

30. Mifepristone and Misoprostol Oral mifepristone (200 mg) followed 36–48 h later by 600 mcg of vaginal misoprostol and then 400 mcg of vaginal misoprostol every 3 hourly with a maximum of five doses or 200– 600 mcg of vaginal misoprostol every 12 hourly. Oral misoprostol is not effective after 49 days of amenorrhoea ; misoprostol alone 400 mcg 8 hourly for five doses is less effective than combined drugs. Postoperatively woman receives antibiotics, pain killer and RH anti-D globin in an RH negative nonimmunized woman.

31. Prostaglandins. Prostaglandin F2a is available as Inj. prostodin 1 mL ampoule (Astra-IDL) containing 0.25 mg of the drug, for parenteral use. It has been used in doses of 250 mcg (1 mL) intramuscularly every 3 h, for a maximum of 10 doses L ong-acting. Prostaglandins have also been used instead of laminaria tents to soften the cervix prior to undertaking dilatation and evacuation.

32. C ombined methods These involve the use of several methods in combination to take advantage of their synergistic effects on myometrial activity, thereby hasten the abortion process, and minimize complications. Amongst the popular combinations in use are: (i) Emcredil plus PG, (ii) PG and laminaria tent, (iii) Emcredil and oxytocin

33. I n a primigravida , ethacridine is more effective than misoprostol. Manual removal of the placenta under anaesthesia may be required if placenta is not expelled in 4 h. The fetus is dead and should be disposed off in a proper manner

34. Late Sequelae of MTP PID—chronic pelvic pain. Infertility caused by tubal infection and blockage. Incompetent os following trauma to the cervix; this may lead to preterm births and habitual mid-trimester abortions. Adherent placenta in the subsequent pregnancy. Asherman syndrome. Ectopic pregnancy following PID. Cervical ectopic pregnancy caused by trauma. IUGR. Rh- isoimmunization if anti-D has not been administered after the MTP to nonimmunized Rh-negative mothers. Psychiatric disorders, if MTP was done without proper counselling , and feeling of regret, especially if infertility follows the procedure.

35. Although MTP is restricted to 20 weeks of pregnancy, a gross fetal malformation is sometimes detected later than 20 weeks. It is desirable to terminate such a pregnancy instead of allowing it to continue to term. However, Government of India does not permit abortion beyond 20 weeks under any circumstances as of today.

36. Indian Experience with MTP Nearly 15 million MTPs are taking place in India; of these, 10 million are performed by unrecognized providers. Nearly 15,000–20,000 women die annually as a result of complications of unsafe illegal abortions. Vacuum aspiration for the first-trimester MTP has been proved effective in 98.6% cases and it can be accomplished in 94.8% under paracervical block anaesthesia with or without sedation. The ICMR investigating the sequelae of induced abortions reported an incidence of minor complications in 3.13% procedures and major complications in 0.21%.

37. Administration of two tablets of 100 mcg each of misoprostol inserted into the posterior fornix of the vagina 3 h prior to suction evacuation brings about softening of the cervix and dilation, thus facilitating cervical dilatation and reducing the time of surgery as well as its accompanying blood loss. Second-trimester MTP with ethacridine lactate can be facilitated with the addition of prostaglandins to the instillation fluid and setting up oxytocin drip. Termination of pregnancy is legally restricted to 20 weeks