medical-termination-of-pregnancy presentation.pptx

Mtp indications and methods

1. MEDICAL TERMINATION OF PREGNANCY

2. FIRST TRIMESTER MTP

3. PREREQUISITES Ascertain pregnancy by pregnancy test and bimanual examination Assess gestational age from LMP and bimanual examination Ultrasound in case of doubt and to rule out an ectopic gestation Local infection to be treated Cardiovascular and other systems to be checked Routine blood examination and urine analysis Explain the procedure and the method to be used Information about contraception Written informed consent

4. MEDICAL METHODS OF FIRST TRIMESTER MTP MIFEPRISTONE AND MISOPROSTOL 200 mg mifepristone is given followed 48 hrs later by vaginal administration of 800 mcg Misoprostol (up to 9 weeks) Anti-D on day one if Rh-ve Patient observed for 4 hrs and sent home if there is no excessive bleeding Patient asked to report on the day if there are no problems and a proper history and examination with a scan is taken Retained products Surgical evacuation to be done 95% success rate  

5. 2 . MISOPROSTOL ALONE Single dose of 800mcg effective in early gestation 800mcg daily for 3 days required in late first trimester 3. METHOTREXATE AND MISOPROSTOL Oral methotrexate 25-50 mg followed by 800mcg misoprostol(usually after a week)

6. COMPLICATIONS Failure necessitating curettage Heavy bleeding – necessitates surgical evacuation as period of gestation increases Missed ectopic gestation Teratogenicity – Methotrexate Infants born after exposure to misoprostol have an increased risk of developing Mobius syndrome, equinovarus, arthrogryposis

7. ADVANTAGES Avoids hospitalisation No interference with privacy More acceptable to women Nonsurgical No special training needed & can be given by any healthcare professional

8. DISADVANTAGES Bleeding and cramping Repeat visit to ensure completeness Cost of the drugs

9. SURGICAL METHODS SUCTION EVACUATION / VACUUM CURETTAGE / VACUUM ASPIRATION Most widely used technique Usually carried out on an outpatient basis Dilatation of cervix followed by vacuum aspiration Patient is made to lie in lithotomy position and bimanual pelvic examination is done to assess size and position of uterus

10. Anaesthesia – combination of intravenous sedation and paracervical block is employed Cervical dilation - vaginal misoprostol 400mcg kept about 4 hrs before procedure. Laminaria tents were used previously. Vacuum aspiration - cannula of appropriate size is introduced and connected to vacuum suction apparatus. Cannula introduced into uterine cavity and machine started. Negative pressure of 50-70 mm Hg assures rapid evacuation and does not injure my ometrium. Once vacuum is created cannula tip is advanced to the fundus where it is rotated and withdrawn to the external os. The procedure is repeated by rotating the cannula first clockwise and then counter-clockwise IV methergine or IM oxytocin given to contract uterus

11. Curettage can be done to ascertain completeness of evacuation Once again the cannula is inserted and vacuum switched on to remove any fragments At the end, the uterus should be firmly contracted around the cannula The cannula is removed and the patient should be observed for half to one hour in a nearby room and then discharged with necessary advice

12. 2. MANUAL VACUUM ASPIRATION(MVA) Done prior to 12 weeks There is an aspirator and cannulae of different sizes.

13. ADVANTAGES No electric suction As cannula is made of plastic and flexible, less cervical trauma Controlled suction leading to separation of products in the correct plane leading to less bleeding Less perforation. If it occurs, vacuum automatically goes off, hence minimal bowel injury Products can be seen through cannula and aspirator Sterile products, can be sent for karyotyping if needed No anaesthesia; only minimal sedation Less expensive and can be reused after sterilisation DISADVANTAGES Incomplete abortion, especially after 10 weeks

14. 3. DILATATION AND EVACUATION Dilatation as done in case of vacuum aspiration Evacuation done by ovum forceps Followed by curettage with a sharp curette

15. 4. MENSTRUAL REGULATION May be done upto 42 days Karman cannula attached to 50 ml syringe and vacuum created. No need for prior dilatation and anaesthesia Can lead to incomplete evacuation and if done early, the conceptus may be missed completely leading to continuation of pregnancy

16. SECOND TRIMESTER MTP

17. MEDICAL METHODS MISOPROSTOL . 400 mcg vaginally, 3 doses, 3 hrs apart - first choice MIFEPRISTONE AND MISOPROSTOL 200 mg mifepristone followed 48 hrs later by 600 mcg misoprostol vaginally and then by 400 mcg misoprostol vaginally every 3 hrs is one regime. ETHACRIDINE LACTATE OR EMCRIDIL 10 mL of 0.1% ethacridine used for each gestational week up to a maximum of 150 mL, introduced extra amniotically by means of Foley catheter. Releases PGs from the decidua. HYPERTONIC SALINE AND UREA Main complication of saline is haemorrhage, infection and hypernatremia. Abandoned in most countries

18. SURGICAL METHODS DILATATION AND EVACUATION Can be done upto 16 weeks but requires cervical dilatation with laminaria tents or misoprostol and evacuation with ovum forceps. HYSTEROTOMY Removal of fetus through an incision in the lower segment as in caesarean section. Never done as a primary procedure; only if other methods have failed or there is a coexisting problem like cervical cancer.

19. COMPLICATIONS OF FIRST TRIMESTER ABORTION IMMEDIATE Bleeding due to uterine atony, incomplete evacuation or perforations Cervical injury (rare) Thrombosis or embolism DELAYED Bleeding within 1 wk due to retained products of conception Infection – bleeding, pain and fever Continuation of pregnancy Ectopic pregnancy due to failure to diagnose beforehand(first trimester MTP)

20. GYNECOLOGICAL COMPLICATIONS Menstrual disturbances Chronic pelvic inflammation Infertility Scar endometriosis(1%)

21. OBSTETRIC COMPLICATIONS Recurrent midtrimester abortion Ectopic pregnancy(3 fold increase) Preterm labour Rupture uterus

22. THANK YOU