MEDICAL TERMINATION OF PREGNANCY- ACTS, METHODS &.pptx

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1. MEDICAL TERMINATION OF PREGNANCY- ACTS, METHODS & PCPNDT

2. Act- 1971 ACT- 1971 by the government of India For improving maternal health: Preventing unsafe abortions Legalizing abortion services Access to safe abortions Amendment- 2020

3. Indications Risk to the life or grave injury – physical or mental health of the woman Substantial risk of physical or mental abnormalities in the fetus- seriously handicapped Pregnancy cased by rape Contraceptive failure CONSENT Consent of pregnant women Minor(<18 years) or mentally ill- guardian

4. MTP- Amendment, 2020 ( A) requirement of opinion of one registered medical practitioner for termination of pregnancy up to twenty weeks of gestation; (B) requirement of opinion of two registered medical practitioners for termination of Pregnancy of twenty to twenty-four weeks of gestation ; (C) enhancing the upper gestation limit from twenty to twenty-four weeks for such Category of woman as may be prescribed by rules in this behalf; (D) non applicability of the provisions relating to the length of pregnancy in cases Where the termination of pregnancy is necessitated by the diagnosis of any of the substantial Foetal abnormalities diagnosed by a medical board;

5. Cont ….. (E) protection of privacy of a woman whose pregnancy has been terminated. 4. The proposed bill is a step towards safety and well-being of women and will enlarge the ambit and access of women to safe and legal abortion without compromising on safety and quality of care. The proposal will also ensure dignity, autonomy, confidentiality and justice for women who need to terminate pregnancy. 5. The bill seeks to achieve the above objects.

6. Where the length of the pregnancy >20 weeks but does not exceed 24 weeks in case of such category of woman as may be prescribed by rules made under this Act, if not less than two registered medical practitioners are of the opinion, formed in good faith, that— ( i ) the continuance of the pregnancy would involve a risk to the life of the pregnant woman or of grave injury to her physical or mental health; or (ii) there is a substantial risk that if the child were born, it would suffer from any serious physical or mental abnormality. Explanation 1.—For the purposes of clause (a), where any pregnancy occurs as a result of failure of any device or method used by any woman or her partner for the purpose of limiting the number of children or preventing pregnancy, the anguish caused by such pregnancy may be presumed to constitute a grave injury to the mental health of the pregnant woman.

7. Cont …….. Explanation 2.—For the purposes of clauses (a) and (b), where any pregnancy is alleged by the pregnant woman to have been caused by rape, the anguish caused by the pregnancy shall be presumed to constitute a grave injury to the mental health of the pregnant woman. (2B) The provisions of sub-section (2) relating to the length of the pregnancy shall not apply to the termination of pregnancy by the medical practitioner where such termination is necessitated by the diagnosis of any of the substantial foetal abnormalities diagnosed by a Medical Board.

8. PRE- PROCEDURE PREPARATIONS HISTORY- LMP Medical illness ASSESSMENT OF GESTATIONAL AGE- LMP Clinical examination Ultrasonography COUNSELLING- Procedures available Complications Subsequent contraception or sterilization

9. INVESTAGATIONS- Hemoglobin and hematocrit Blood grouping and Rh typing HIV/Hepatitis B antigen screening Urine sugar or protein INFORMED CONSENT

10. 1 ST TRIMESTER MTP DIFFERENCE- Fetal bony structures not formed- removed vaginally

11. MEDICAL METHODS- Very safe and effective Method of choice in 1 st trimester MTP Success rate- 95 – 99% Prophylactic antibiotics- not required

12. MIFEPRISTONE- Derivative of norethindrone Binds to progesterone receptor with an affinity greater than progesterone but it does not activate the receptor( antiprogestin ) Acts by- Decidual degeneration Induces uterine contractions Softens the cervix Increased prostaglandin sensitivity Dosage-200 microgram oral

13. After 24 to 48hours- T. Misoprostol administration -vaginal route preferred. Dosage-800 microgram single dose or two divided dosed 4 to 6 hours apart Oral or parenteral NSAIDs for pain or cramping If pregnancy is ongoing, surgical evacuation If abortion is incomplete – repeat misoprostol or proceed with surgical evacuation

14. MISOPROSTOL Prostaglandin E1 analogue ALONE- less effective than when used with mifepristone . Used alone when mifepristone is not available site directly

15. METHOTREXATE: Blocks dihydrofolate reductase Action is primarily on cytotrophoblast rather than the developing embryo Inhibits syncytialization of the cytotrophoblast Stops the process of implantation rather than weakening the implantation

16. METHOTREXATE AND MISOPROSTOL 75 microgram oral or 50 microgram/ sq.m IM 5 to 7 days later 800 microgram of misoprostol Less efficacious and longer

17. COMPLICATIONS Side effects of drugs- nausea, vomiting, diarrhea, dizziness, headache  symptomatic treatment Abdominal pain and cramps  NSAIDs Excessive bleeding  exclude incomplete abortion  repeat misoprostol or MVA Ongoing pregnancy  surgical methods Fever and infection  antibiotics

18. SURGICAL METHODS MANUAL VACUUM ASPIRATION: In very early pregnancy( upto 10 weeks) Incomplete abortion CONSISTS OF Handheld 50-60 ml plastic syringe Karman cannula ( 6- 8mm size)

19. ELECTRIC VACUUM ASPIRATION Suction evacuation Anytime in 1 st trimester Vesicular mole Incomplete abortion Missed abortion

20. CERVICAL DILATATION less than 7 weeks Manual dilatation- Hegar’s dilator Osmotic dilators Vaginal misoprostol

21. MIDTRIMESTER ABORTIONS MEDICAL METHODS prostaglandins Misoprostol Mifepristone Gemeprost Dinoprostone PGF2 alpha oxytocin

22. SURGICAL METHODS Between 13- 15 weeks Dilatation and evacuation Between 16- 20 weeks Intrauterine instillation of hypertonic saline Extra amniotic Intra amniotic hysterotomy

23. MEDICAL METHODS PROSTAGLADINS : They act on cervix and uterus Selective action on myometrium MISOPROSTOL: 400 – 800 microgram PV every 3- 4 hrs 600 microgram PV followed by 200 microgram orally every 3 hrs Recently 400 microgram sublingually every 3 hrs (5 doses) Success rate- 100% Mean induction- abortion interval 11- 12 hrs

24. MIFEPRISTONE: Mifepristone 200mg oral followed by 36-48 hrs Misoprostol 800 microgram vaginally / misoprostol 400 microgram oral every 3 hrs (4 doses) Success rate- 97% Mean induction to delivery interval- 6.5 hrs GEMEPROST(PGE1 Analog ) : 1 mg vaginal pessary every 3-6 hrs (5 doses) in 24 hrs Success rate- 90% Mean induction- abortion interval 14- 18 hrs

25. DINOPROSTONE(PGE2 Analogue): 20 mg is used as vaginal suppository every 3-4 hrs maximum 4- 6 doses Mean induction to abortion interval- 17 hrs PROSTAGLANDIN(PGF2 alpha): Carboprost tromethamine 250mcg IM every 3 hrs maximum 10 doses Success rate- 90% in 36 hrs Side effect: nausea, vomiting, diarrhoea, pain at injection site C/I in bronchial asthma

26. Oxytocin : high dose oxytocin (300 units in 500 ml dextrose saline)

27. SURGICAL METHODS 13-15 WEEKS: DILATATION AND EVACUATION Less commonly done Pregnancies at 13- 14 menstrual weeks are evacuated Intracervical tent ( laminaria osmotic dilator), mifepristone or misoprostol are used as cervical priming agents

28. 16-20 weeks: Intrauterine instillation of hypertonic solution Extramniotic : 0.1% ethacridine lactate transcervically through no. 16 foley’s catheter Catheter is passed upto cervical canal for about 10 cm above the internal os between membranes and myometrium and the balloon is inflated with saline Removed after 4 hrs Stripping of membranes with liberation of prostaglandins from decidua and dilatation of cervix by catheter for initiation of abortion Isotonic saline is infused extra amniotically using transcervical catheter balloon

29. INTRAAMNIOTIC : Intra-amniotic instillation of hypertonic saline less common Instilled through abdominal route Procedure: preliminary amniocentesis done by 15 cm 18 gauge needle Amount of saline to be instilled is calculated as no of weeks of gestation multiplied by 10 ml at the rate of 10 ml/min

30. Contraindication: Cardiovascular, renal or severe anemia because of sodium load Precautions: To be sure needle in needle is in amniotic cavity evidenced by clear liquor Instillation should be slow process(10ml/min) To stop procedure if symptoms like acute abdominal pain , headache or thirst or tingling in finger Rapid infusion of 1000 ml dextrose in water is indicated Ampicillin 500mg TDS for 3 days

31. MODE OF ACTION : liberation of PGS following necrosis of the amniotic epithelium and decidua -- uterine contraction and expulsion of fetus COMPLICATIONS : fever, headache, nausea, vomiting and abdominal pain, cervical tear and laceration, retained products, infection, hypernatraemia , cvs collapse , pulmonary and cerebral edema , renal failure and DIC

32. INTRAMNIOTIC INSTILLATION OF HYPEROSMOTIC UREA : Instillation of 80 gms of urea in 200 ml of distilled water along with syntocinon is effective with less complications Combination of intra amniotic hyperosmotic urea and 15 methyl PGF2 alpha reduces the induction abortion interval to 13 hours

33. HYSTEROTOMY : less common indications : Prior failed MTP In cases where D and C cannot be safely done Fibroid in lower uterine segment Uterine anomalies Repeated scarred uterus with placenta accreta or percreta

34. complications Immediate- hemorrhage and shock, anesthestic comlication , peritonitis,intestinal obstruction Remote –menstrual abnormalities,scar endometritis,incisional hernia,if pregnancy occurs chance of uterus rupture

35. DILATATION AND EVACUATION dilatation followed by evacuation using ovum forceps Finally curettage with metal catheter High risk of perforation

36. Pre-Conception & Pre-Natal Diagnostic Techniques Act , 1994 THE PRE-NATAL DIAGNOSTIC TECHNIQUES (REGULATION AND PREVENTION OF MISUSE) ACT, 1994 AND THE PRE-NATAL DIAGNOSTIC TECHNIQUES (REGULATION AND PREVENTION OF MISUSE) AMENDMENT ACT, 2002 An Act to provide for the prohibition of sex selection, before or after conception, and for regulation of pre-natal diagnostic techniques for the purposes of detecting genetic abnormalities or metabolic disorders or chromosomal abnormalities or certain congenital malformations or sex-linked disorders and for the prevention of their misuse for sex determination leading to female foeticide; and, for matters connected therewith or incidental thereto. Whole of India, except Jammu & Kashmir

37. Regulation of pre-natal diagnostic techniques.- 1 . No place including a registered Genetic Counselling Centre or Genetic Laboratory or Genetic Clinic shall be used or caused to be used by any person for conducting pre-natal diagnostic techniques except for the purposes specified in clause (2) and after satisfying any of the conditions specified in clause (3); 2. no pre-natal diagnostic techniques shall be conducted except for the purposes of detection of any of the following abnormalities, namely:— ( i ) chromosomal abnormalities; (ii) genetic metabolic diseases; (iii) haemoglobinopathies; (iv) sex-linked genetic diseases; (v) congenital anomalies; (vi) any other abnormalities or diseases as may be specified by the Central Supervisory Board;

38. 6. Determination of sex prohibited.- On and from the commencement of this Act,— (a) no Genetic Counselling Centre or Genetic Laboratory or Genetic Clinic shall conduct or cause to be conducted in its Centre, Laboratory or Clinic, pre-natal diagnostic techniques including ultrasonography, for the purpose of determining the sex of a foetus; (b) no person shall conduct or cause to be conducted any pre-natal diagnostic techniques including ultrasonography for the purpose of determining the sex of a foetus; (c) no person shall, by whatever means, cause or allow to be caused selection of sex before or after conception.

39. 3. No pre-natal diagnostic techniques shall be used or conducted unless the person qualified to do so is satisfied for reasons to be recorded in writing that any of the following conditions are fulfilled, namely:— ( i ) age of the pregnant woman is above thirty-five years ; (ii) the pregnant woman has undergone of two or more spontaneous abortions or foetal loss; (iii) the pregnant woman had been exposed to potentially teratogenic agents such as drugs, radiation, infection or chemicals; (iv) the pregnant woman or her spouse has a family history of mental retardation or physical deformities such as, spasticity or any other genetic disease; (v) any other condition as may be specified by the Central Supervisory Board;

40. No person including a relative or husband of a woman shall seek or encourage the conduct of any sex-selection technique on her or him or both. Written consent of pregnant woman and prohibition of communicating the sex of foetus. (a) he has explained all known side and after effects of such procedures to the pregnant woman concerned; (b) he has obtained in the prescribed form her written consent to undergo such procedures in the language which she understands; and (c) a copy of her written consent obtained under clause (b) is given to the pregnant woman. 2. No person including the person conducting pre-natal diagnostic procedures shall communicate to the pregnant woman concerned or her relatives or any other person the sex of the foetus by words, signs or in any other manner.

41. 3B. Prohibition on sale of ultrasound machines , etc., to persons, laboratories, clinics, etc. not registered under the Act.- No person shall sell any ultrasound machine or imaging machine or scanner or any other equipment capable of detecting sex of foetus to any Genetic Counselling Centre, Genetic laboratory, Genetic Clinic or any other person not registered under the Act.

42. Offences and penalties Every offence under this Act shall be cognizable, non-bailable and non-compoundable. Any person who contravenes the provisions of sub-section (1) or sub-section (2) shall be punishable with imprisonment for a term which may extend to three years and with fine which may extend to ten thousand rupees and on any subsequent conviction, with imprisonment which may extend to five years and with fine which may extend to fifty thousand or 1 lakh rupees Explanation.—For the purposes of this section, “advertisement” includes any notice, circular, label, wrapper or any other document including advertisement through internet or any other media in electronic or print form and also includes any visible representation made by means of any hoarding, wall-painting, signal, light, sound, smoke or gas. The name of the registered medical practitioner shall be reported by the Appropriate Authority to the State Medical Council concerned for taking necessary action including suspension of the registration if the charges are framed by the court and till the case is disposed of and on conviction for removal of his name from the register of the Council for a period of five years for the first offence and permanently for the subsequent offence.

43. Registration of genetic counselling centre 1. Duly registered under the Act. 2. Every application for registration under sub-section (1), shall be made to the Appropriate Authority in such form and in such manner and shall be accompanied by such fees as may be prescribed. 3. Shall apply for registration within sixty days from the date of such commencement. 4. Shall cease to conduct any such counselling or technique on the expiry of six months from the date of commencement of this Act unless such Centre, Laboratory or Clinic has applied for registration and is so registered separately or jointly or till such application is disposed of, whichever is earlier.

44. Cont …… Appropriate Authority is satisfied t hat such Centre, Laboratory or Clinic is in a position to provide such facilities, maintain such equipment and standards as may be prescribed. Every certificate of registration shall be renewed in such manner and after such period and on payment of such fees as may be prescribed. The certificate of registration shall be displayed by the registered Genetic Counselling Centre, Genetic Laboratory or Genetic Clinic in a conspicuous place at its place of business.

45. Thank you