Methods of termination of pregnancy

methods of termination of pregnamcy used commonly in INDIA

1. METHODS OF TERMINATION OF PREGNANCY By – Annu Kohli Roll no. -16

2. First Trimester (Up to 12 Weeks) Second Trimester (13–20 Weeks) Medical • Prostaglandins PGE1 (Misoprostol ), 15 methyl PGF2a ( Carboprost ), PGE2 ( Dinprostone ) and their analogues (used-intravaginally, intramuscularly or intraamniotically) • Mifepristone • Mifepristone and Misoprostol (PGE1) • Dilation and evacuation (13–14 weeks) • Methotrexate and Misoprostol • Intrauterine instillation of hyperosmotic solutions • Tamoxifen and Misoprostol a. Intra-amniotic hypertonic urea (40%), saline (20%) Surgical b. Extra-amniotic— Ethacrydine lactate, Prostaglandins (PGE2, PGF2a) • Menstrual regulation • Oxytocin infusion high dose used along with either of the above two methods • Vacuum Aspiration (MVA/EVA) • Hysterotomy (abdominal)— less commonly done • Suction evacuation and/or curettage • Dilatation and evacuation: i . Rapid method ii. Slow method

3. FIRST TRIMESTER TERMINATION OF PREGNANCY MEDICAL METHODS OF FIRST TRIMESTER ABORTION : Mifepristone (RU-486) and Misoprostol – Mifepristone an analog of progestin ( norethindrone ) acts as an antagonist, blocking the effect of natural progesterone. Addition of low dose prostaglandins (PGE1) improves the efficiency of first trimester abortion. It is effective upto 63 days and is highly successful when used within 49 days of gestation .

4. 200 mg of mifepristone orally is given on day 1. On day 3, misoprostol (PGE1) 400 μg orally or 800 μg vaginally is given. Patient remains in the clinic for 4 hours during which expulsion of the conceptus (95 %) often occurs . Patient is re-examined after 10–14 days. Complete abortion is observed in 95%, incomplete in about 2% of cases and about 1% do not respond at all. Oral mifepristone 200 mg (1 tablet) with vaginal misoprostol 800 μ g (4 tablet , 200 μ g each) after 6–48 hours is equally effective . This combipack (1+4) is approved by DGHS, Government of India for MTP up to 63 days of pregnancy. Medical methods are safe, effective , non-invasive and have minimal or no complications. Protocol

5. Contraindications — Mifepristone should not be used in women aged over 35 years, heavy smokers and those on long-term corticosteroid .

6. Methotrexate and Misoprostol – Methotrexate 50 mg/m 2 IM (before 56 days of gestation) followed by 7 days later misoprostol 800 μg vaginally is highly effective . Misoprostol may have to be repeated after 24 hours if it fails. If the procedure fails , ultrasound examination is done to confirm the failure . Then suction evacuation should be done. Methotrexate and misoprostol regimen is less expensive but takes longer time than Mifepristone and Misoprostol. Misoprostol has less side effects and is stable at room temperature unlike other PGs, which must be refrigerated.

7. SURGICAL METHODS OF FIRST TRIMESTER ABORTION : MENSTRUAL REGULATION : It is the aspiration of the endometrial cavity within 14 days of missed period in a woman with previous normal cycle. The operation is done as an out patient or an office procedure It is done with aseptic precautions and in apprehensive patients, sedation or paracervical block anesthesia may be employed. After introducing the posterior vaginal speculum , the cervix is steadied with an Allis forceps.

8. Cervix may be gently dilated using 4 or 5 mm size dilators. 5–6 mm suction cannula (Karman’s) is then inserted and attached to the 50 mL syringe for suction. The cannula is rotated, pushed in and out with gentle strokes . The operator should examine the aspirated tissue by floating it in a clear plastic dish over a light source. Placental tissue appears fluffy and feathery when floats in normal saline. This will help to detect failed abortion, molar pregnancy or ectopic pregnancy. The procedure is contraindicated in advanced pregnancy and in the presence of local pelvic inflammation.

9. Menstrual regulation equipment — Syringe (B) Plastic cannula with whistle tip used in suction evacuation A B

10. VACUUM ASPIRATION (MVA/EVA ): D one upto 12 weeks with minimal cervical dilatation It is performed as an outpatient procedure using a plastic disposable Karman’s cannula (up to 12 mm size) and a 60 mL plastic (double valve) syringe. It is quicker (15 minutes), effective (98–100%), less traumatic and safer than dilatation , evacuation and curettage. The procedure may be manual vacuum aspiration (MVA) or electric vacuum aspiration (EVA ). H and operated double valve plastic syringe is attached to a cannula. The cannula is inserted transcervically into the uterus and the vacuum is activated . A negative pressure of 660 mm Hg is created. Aspiration of the products of conception is done

11. SUCTION EVACUATION AND/OR CURETTAGE : It is a procedure in which the products of conception are sucked out from the uterus with the help of a cannula fitted to a suction apparatus . Preliminaries: General anaesthesia is usually not needed. If the patient is apprehensive, intravenous diazepam 5–10 mg (conscious sedation) supplemented by paracervical block is quite effective. The patient is put on the table after she empties her bladder .

12. Steps: Vaginal examination is done to note the size and position of the uterus and to note the state of cervix. USG ( TAS/TVS) should be performed when there is any doubt about the gestational age . Posterior vaginal speculum is introduced and an assistant is asked to hold it. The anterior lip of the cervix is to be grasped by an Allis forceps. An uterine sound is to be introduced to note the length of the uterine cavity and position of the uterus .

13. The cervix may have to be dilated with smaller size graduated metal dilators up to one size less than that of the suction cannula. Feeling of “snap” of the endocervix around the dilator is characteristic. Instead laminaria tent 12 hours before (osmotic dilator) or misoprostol ( PGE1) 400 μg given vaginally 3 hours prior to surgery produces effective dilatation . Intravenous methergin 0.2 mg is administered. The appropriate suction cannula is fitted to the suction apparatus by a thick rubber or plastic tubing. The cannula is then introduced into the uterus, the tip is to be placed in the middle of the uterine cavity. The pressure of the suction is raised to 400–600 mm Hg . The cannula is moved up and down and rotated within the uterine cavity (360°) with the pressure on. The suction bottle is inspected for the products of conception and blood loss. The suction is regulated by a finger placed over a hole at the base of the cannula.

14. The end point of suction is denoted by: No more material is being sucked out Gripping of the cannula by the contracting smaller size uterus Grating sensation Appearance of bubbles in the cannula or in the transparent tubing. The vacuum should be broken before withdrawing the cannula down through the cervical canal to prevent injury to the internal os . It is better to curette the uterine cavity by a small flushing curette at the end of suction and the cannula is reintroduced to suck out any remnants. After being satisfied that the uterus is remaining firm, and there is minimal vaginal bleeding, the patient is brought down from the table after placing a sterile vulval pad.

15. Excessive haemorrhage : may be due to - incomplete evacuation or atonic uterus Injury : Cervical lacerations of varying degree which may lead to formation of a broad ligament hematoma Uterine perforation. Shock due to : Local anaesthesia—Convulsions , cardiorespiratory arrest, death due to intravascular injection or over dose. Excessive blood loss. Cervical shock—Vasovagal syncope due to cervical stimulation. Complications

16. Perforation —Injury to major blood vessels, bowel or bladder. Risk is more with advanced gestation. Sepsis —Endometritis , myometritis and pelvic peritonitis. Hematometra may cause pain. Increased morbidity . Continuation of pregnancy (failure) – 1%.

17. DILATATION AND EVACUATION (D+E ): The operation consists of dilatation of the cervix and evacuation of the products of conception from the uterine cavity. The operation may be performed: One stage — Dilatation of the cervix and evacuation of the uterus are done in the same sitting . Two stages — First phase includes slow dilatation of the cervix Second phase includes rapid dilatation of the cervix and evacuation .

18. ONE STAGE OPERATION INDICATIONS: Incomplete abortion ( commonest) Inevitable abortion Medical termination of pregnancy (6–8 weeks) Hydatidiform mole in the process of expulsion . PROCEDURES : Preliminaries: The patient is put under general anaesthesia. Internal examination is done to note the size and position of the uterus and state of dilatation of the cervix.

19. Steps: If the cervix is not sufficiently dilated to admit the index finger (usually it does), it should be dilated. Sim’s posterior vaginal speculum is introduced and an assistant is asked to hold it. The anterior lip of the cervix is grasped by an Allis forceps to steady the cervix. Uterine sound is not to be introduced. Sounding provides no information but risks perforation and bleeding . The cervical canal is gradually dilated up to the desired extent by the graduated metal dilators. The products are removed by ovum forceps. The uterine cavity is finally curetted gently by a flushing (blunt) curette. Injection methergin 0.2 mg is to be administered intravenously during the procedure. The speculum and the Allis forceps are to be removed. The uterus is to be massaged bimanually with the help of the external hand and the internal fingers, placed inside the vagina. After being satisfied that the uterus is firm and the bleeding is minimal, the vagina and perineum are toileted; a sterile vulval pad is placed and the patient is sent back to her bed.

20. Post-abortion care : Emergency treatment of complications of any abortion spontaneous or induced. Family planning counselling and referral services. Linkages to other unproductive health services (comprehensive services). Male partner should be involved.

21. TWO STAGE OPERATION INDICATIONS: Induction of 1st trimester abortion (commonest) Missed abortion (uterus 8–10 weeks) Hydatidiform mole with unfavourable cervix (long, firm and closed os ). To prevent damage to the cervix during rapid dilatation, a two stage operation is, however, preferred in such cases . PROCEDURES: First Phase: It consists of introduction of laminaria tents or lamicel (MgSO 4 sponge) into the cervical canal to effect its slow dilatation. The same may be effective by intravaginal insertion of misoprostol (PGE1 ), 400 μg 3 hours before surgery. It has less side effects .

22. Preliminaries The patient should empty her bladder beforehand. No anaesthesia is required. The appropriate size and number of the tent required are selected. The threads attached to one end are tied to the roller gauze . Steps : Internal examination is done to note the size and position of the uterus and state of the cervix. Sim’s posterior vaginal speculum is introduced and an assistant is asked to hold it. The anterior lip of the cervix is grasped by an Allis forceps to steady the cervix. The cervical canal may have to be dilated specially in primigravidae by one or two smaller metal dilators ( Hawkin Ambler—size 3/6 or 4/7) to facilitate the introduction of the tents. The tents are introduced one after the other, holding it by tent introducing forceps (Fig. 36.1). The tents should be introduced for at least 4 cm (1.5”), so that the tips are placed beyond the internal os . The tents can also be introduced manually.

23. Laminaria tent: (a) Prior to introduction ( b) Marked swelling due to hygroscopic action while kept in cervical canal. A B

24. The roller gauze is used to pack the upper vagina so as to prevent the displacement of the tents. The patient is returned and preferably confined to her bed. Prophylactic antibiotic (Doxycycline 100 mg PO BID for 3 days and metronidazole PO 400 mg BID for 5 days ) is usually administered . Second Phase: It consists of further dilatation of the cervix by graduated metal dilators followed by evacuation of the uterus . Procedures The patient is brought back to the operation theatre usually after 12 hours. The patient should empty her bladder beforehand .

25. Steps: (MTP – 8 weeks) The posterior vaginal speculum is introduced after removing the roller gauze. The tents are removed with the help of sponge forceps. The vagina and the cervix are swabbed with antiseptic (povidone-iodine) solution. The posterior vaginal speculum is removed . Vaginal examination is done to note the size of the uterus, position of the uterus and state of dilatation of the cervix Posterior vaginal speculum is reintroduced and is to be held by an assistant. The anterior lip of the cervix is to be grasped by the Allis forceps to steady the cervix. The cervix is dilated with the graduated metal dilators up to the desired extent (10/13 to 12/15) to facilitate introduction of the ovum forceps. The products are removed by introducing the ovum forceps. Intravenous methergin 0.2 mg is to be given during this stage to minimize blood loss. Firm and well contracted uterus facilitates curettage

26. The uterine cavity is thoroughly curetted by a flushing curette. The posterior vaginal speculum and the Allis forceps are removed. The uterus is massaged bimanually and after being satisfied , that the uterus is empty (evidenced by a well contracted uterus with minimal bleeding), the patient is sent to her bed after placing a sterile vulval pad. Oxytocic agents: Injection methergin 0.2 mg IM is given. Alternatively oxytocin 20 units in 500 mL of normal saline IV is given intraoperatively and continued after the operation for 30 minutes. Prophylactic antibiotics (doxycycline and metronidazole) are prescribed.

27. DANGERS OF D + E OPERATION Immediate : Excessive haemorrhage : may be due to - incomplete evacuation or atonic uterus Injury : Cervical lacerations of varying degree which may lead to formation of a broad ligament hematoma Uterine perforation. Shock due to : Local anaesthesia—Convulsions , cardiorespiratory arrest, death due to intravascular injection or over dose. Excessive blood loss. Cervical shock—Vasovagal syncope due to cervical stimulation.

28. Perforation —Injury to major blood vessels, bowel or bladder. Risk is more with advanced gestation. Sepsis —Endometritis , myometritis and pelvic peritonitis. Hematometra may cause pain. Increased morbidity . Continuation of pregnancy (failure) – 1 %. Late : Pelvic inflammation Infertility Cervical incompetence Uterine synechiae .

29. SECOND TRIMESTER TERMINATION OF PREGNANCY MEDICAL METHODS : PROSTAGLANDINS : They act on the cervix and the uterus. The PGE ( dinoprostone , sulprostone , gemeprost , misoprostol) and PGF ( carboprost ) analogues are commonly used PGEs are preferred as they have more selective action on the myometrium and less side effects.

30. Misoprostol (PGE1 analogue) 400–800 μg of misoprostol given vaginally at an interval of 3–4 hours is most effective as the bioavailability is high. Alternatively , first dose of 600 μg misoprostol given vaginally, then 200 μg , orally every 3 hours are also found optimum. This regimen reduces the number of vaginal examinations. Recently 400 μg misoprostol is given sublingually every 3 hours for a maximum of five doses. This regimen has got 100% success in second trimester abortion. The mean induction—abortion interval is 11–12 hours.

31. Gemeprost (PGE1 analogue): 1 mg vaginal pessary every 3–6 hours for five doses in 24 hours has got about 90% success. The mean induction-abortion interval was 14–18 hours. Mifepristone and prostaglandins : Mifepristone 200 mg oral, followed 36–48 hours later by misoprostol 800 μg vaginal; then misoprostol 400 μg oral every 3 hours for 4 doses is used. Success rate of abortion is 97% and median induction delivery interval is 6.5 hours. Pretreatment with mifepristone reduces the induction— abortion interval significantly compared to use of misoprostol alone.

32. Dinoprostone (PGE2 analogue): 20 mg is used as a vaginal suppository every 3–4 hours (maximum for 4–6 doses ). When used along with osmotic dilators, the mean induction to abortion interval is 17 hours. PGE2 s thermolabile (needs refrigeration) and is expensive. Prostaglandin F2 (PGF2 α ) , carboprost tromethamine — 250 μg IM every 3 hours for a maximum 10 doses can be used. The success rate is about 90% in 36 hours. Side effects of PGF2α (nausea, vomiting, diarrhoea and pain at injection site) are more. It is contraindicated in cases with bronchial asthma.

33. OXYTOCIN: High dose oxytocin as a single agent can be used for second trimester abortion. It is effective in 80% of cases. It can be used with intravenous normal saline along with any of the medications used either intra-amniotic or extra-amniotic space in an attempt to augment the abortion process. MODE OF ACTION: Myometrial oxytocin receptor concentration increases maximum (100-200 fold) during labour. Oxytocin acts through receptor and voltage mediated calcium channels to initiate myometrial contractions.

34. It stimulates amniotic and decidual prostaglandin production. Bound intracellular calcium is eventually mobilized from the sarcoplasmic reticulum to activate the contractile protein. The uterine contractions are physiological i.e. causing fundal contraction with relaxation of the cervix. The drip rate can be increased upto 50 milli units or more per minute. Currently high dose ( upto 300 units in 500 mL of dextrose saline) is favoured.

35. SURGICAL METHODS: It is difficult to terminate pregnancy in the second trimester with reasonable safety as in first trimester. Between 13 and 15 weeks Dilatation and Evacuation in the midtrimester is less commonly done . Pregnancies at 13 to 14 menstrual weeks are evacuated. In all midtrimester abortion cervical preparation must be used (WHO 1997) to make the process easy and safe. Intracervical tent ( Laminaria osmotic dilator), mifepristone or misoprostol are used as the cervical priming agents. The procedure may need to be performed under ultrasound guidance to reduce the risk of complications . Simultaneous use of oxytocin infusion is useful.

36. Between 16 and 20 weeks : INTRAUTERINE INSTILLATION OF HYPERTONIC SOLUTION Intra-amniotic Extra-amniotic

37. Intra-amniotic: Intra-amniotic instillation of hypertonic saline (20%) is less commonly used now. It is instilled through the abdominal route. Mode of action : There is liberation of prostaglandins following necrosis of the amniotic epithelium and the decidua . This in turn excites uterine contraction and results in the expulsion of the fetus . Procedure : Preliminary amniocentesis is done by a 15 cm 18 gauge needle. The amount of saline to be instilled is calculated as number of weeks of gestation multiplied by 10 mL. The amount is to be infused slowly at the rate of 10 mL/min.

38. Contraindications: It should not be used in presence of cardiovascular or renal lesion or in severe anemia because of sodium load . Precautions : To be sure that the needle is in the amniotic cavity evidenced by clear liquor coming out . If there is a bloody tap, the needle should be pushed further or change the direction until clear liquor comes out. If fails, the procedure is to be abandoned . The instillation should be a slow process (10 mL/min ). Vital signs should be checked immediately after the instillation and she should be kept at bed rest for at least 1 hour. To stop the procedure if the untoward symptoms like acute abdominal pain, headache, thirst or tingling in the fingers appear (feature of intravascular injection of the hypertonic saline). A rapid infusion of 1000 mL dextrose in water along with intravenous diuretics is indicated in such cases .

39. S trict vigilance is taken during and following instillation till expulsion occurs. Routine antibiotic is given such as ampicillin 500 mg thrice daily for 3–5 days . Success rate: The method is effective in 90–95% cases with induction-abortion interval of about 32 hours . The method failure (end point) is considered when abortion fails to occur within 48 hours . If the method fails, some other method may be employed.

40. Complications: minor complaints like fever, headache, nausea, vomiting, abdominal pain cervical tear and laceration retained products for which exploration has to be done infection hypernatremia , cardiovascular collapse—due to intravascular injection pulmonary and cerebral enema renal failure disseminated intravascular coagulopathy. The incidence of death rate varies from 0–5 per 1000 instillations.

41. Intra-amniotic instillation of hyperosmotic urea: Intra-amniotic instillation of 40% urea solution (80 g of urea in 200 mL distilled water) along with syntocinon drip is effective with less complications. Combination of intra-amniotic hyperosmotic urea and 15 methyl PGF2α reduces the induction abortion interval to 13 hours.

42. Extra-amniotic: Extra-amniotic instillation of 0.1% ethacrydine lactate done transcervically through a number 16 Foley‘s catheter The catheter is passed up the cervical canal for about 10 cm above the internal os between the membranes and myometrium and the balloon is inflated (10 mL) with saline . It is removed after 4 hours. The success rate is similar to saline instillation but is less hazardous. It can be used in cases contraindicated for saline instillation. Stripping the membranes with liberation of prostaglandins from the decidua and dilatation of the cervix by the catheter are some of the known factors for initiation of the abortion .

43. HYSTEROTOMY Hysterotomy is an operative procedure of extracting the products of conception out of the womb before 28 th week by cutting through the anterior wall of the uterus . The operation is usually done through the abdominal route . The operation is rarely done these days for the purpose of MTP. Complications: Immediate: Hemorrhage and shock Anesthetic complications Peritonitis Intestinal obstruction.

44. Remote: Menstrual abnormalities Scar endometriosis (1 %) I ncisional hernia If pregnancy occurs , chance of scar rupture.

45. COMPLICATIONS OF MTP There is no universally safe and effective method which is applicable to all cases. However , the complications are much less (5%) if termination is done before 8 weeks by MVA or suction evacuation/ currette . The complications are about five times more in mid-trimester termination. Use of PG analogues and mifepristone has made second trimester MTP effective and safe. The complications are either related to the methods employed or to the abortion process.

46. IMMEDIATE: Injury to the cervix (cervical lacerations) uterine perforation during D and E Haemorrhage and shock due to trauma, incomplete abortion, atonic uterus or rarely coagulation failure Thrombosis or embolism Postabortal triad of pain, bleeding and low grade fever due to retained clots or products . Antibiotics should be continued, may need repeat evacuation Related to the methods employed: Prostaglandins— intractable vomiting, diarrhoea, fever, uterine pain and cervicouterine injury Oxytocin— water intoxication and rarely convulsions Saline —hypernatremia, pulmonary oedema, endotoxic shock, DIC, renal failure, cerebral haemorrhage

47. REMOTE: The complications are grouped into: Gynecological Obstetrical Gynecological complications include — menstrual disturbances chronic pelvic inflammation infertility due to cornual block scar endometriosis (1 %) uterine synechiae leading tosecondary amenorrhea.

48. Obstetrical complications include — recurrent midtrimester abortion due to cervical incompetence ectopic pregnancy (three-fold increase ) preterm labour dysmaturity , increased perinatal loss rupture uterus Rh isoimmunization in Rh-negative women, if not prophylactically protected with immunoglobulin failed abortion and continued pregnancy.

49. Failed abortion, continued pregnancy and ectopic pregnancy : Pregnancy may continue following MVA ( inspite of histologically proven villi). When no chorionic villi are found on tissue examination ectopic pregnancy need to be excluded by quantitative serum hCG and vaginal ultrasound. Failed MTP is defined when there is a failure to achieve TOP within 48 hours . Failed second trimester MTP with PG analogues and the rate of live birth is 4–10%.

50. MORTALITY: First trimester : The maternal death is lowest (about 0.6/100,000 procedures) in first trimester termination specially with MVA and suction evacuation. Concurrent tubectomy even by abdominal route doubles the mortality rate. Midtrimester : The mortality rate increases 5–6 times to that of first trimester. Contrary to the result of the advanced countries, the mortality from saline method has been found much higher in India compared to termination by abdominal hysterotomy with tubectomy .

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