MTP Act of 1971 and its Amendment, 2022.pptx

This ppt describes the updated MTP Act as amended in the year 2022. It describes the medical and surgical methods of abortion for 1st and 2nd trimester in brief along with the contra-indications and complications.

1. Recent scenario of mtp act Dr. Shivani Siddhpura M.S. ObsGyn

2. Induced abortion It is defined as the medical or surgical termination of pregnancy before the time of viability of fetus .

3. Medical termination of pregnancy (MTP) act MTP Act was enforced to safeguard the health of mother undergoing abortion and the interest of the doctor performing procedure on her. In India it is governed by MTP Act of 1971 passed by the Parliament of India, enforced in April 1972 and revised in 1975. It was last amended in 2022.

4. I. Conditions under which a pregnancy can be terminated. There are five conditions that have been identified in the MTP Act. Therapeutic or Medical Indication: Where continuation of pregnancy might endanger the mother’s life r cause grave injury to her physical or mental health. Very few suitable indications are as follows: Severe Cardiac disease (NYHA category III and IV) End stage renal disease Malignant and severe hypertension Cervical, breast or other cancers Diabetes mellitus complicated with retinopathy or nephropathy Severe epilepsy or psychiatric illness with the advice of a psychiatrist

5. 2. Eugenic: Where there is a “substantial risk of the child being born with serious physical or mental abnormalities as to be handicapped for life.” The indications are rare and as follows: Structural (anencephaly and other major anomalies), chromosomal (Down’s syndrome) or genetic ( hemophilia ) abnormalities of the fetus . When the fetus is likely to be deformed due to action of teratogenic drugs (isotretinoin, warfarin) or radiation exposure (>10 rads in early pregnancy). Rubella infection in first trimester. 3. Humanitarian: When the pregnancy is result of rape. (<5% cases).

6. 4. Socioeconomic: Where actual or reasonably foreseeable environment (whether social or economic) can lead on to the risk of injury to the physical or mental health of the mother. Multiparous women with unplanned pregnancy and low socio-economic status (almost 80% cases). Pregnancy caused due to failure of any device (15%) cases of MTP. This is the most liberal indication which is a unique feature of the Indian law and virtually allows abortion on request in all cases due to difficulty in proving that the pregnancy was not caused by failure of contraception. 5. When pregnant women is not mentally sound (e.g. schizophrenia, mania).

7. ii. The person who can perform abortion MTP can only be performed by a registered medical practitioner with a certificate to do MTP like: Who has got a degree (MD, MS) or Diploma (DGO) in obstetrics and gynaecology. Who has done 6 months housejob in Obstetrics & Gynaecology Who has assisted in at least 25 MTPs in an authorised centre and has a certificate to do MTP. 2. Termination is permitted upto 20 weeks of pregnancy. Registered Medical Practitioner can perform MTP upto 12 weeks.

8. 3. Written consent of the woman is needed. Husband’s consent is not needed. 4. In case of a minor girl or lunatic or mentally retarded woman, consent of her parents or legal guardian is to be taken.

9. iii. Place where abortions can be performed MTP can only be performed in government hospitals, nursing homes or centres approved by the Directorate of Health Services (DHS) or Chief Medical Officer (CMO) or district. The abortion has to be performed confidentially and has to be reported to the Director of Health Services of the state on the prescribed MTP form.

10. contraindications There are very few contraindications but one needs to be very careful in performing MTP in the following conditions: Medical disorders like heart disease Suspected ectopic pregnancy or undiagnosed adnexal mass Chronic renal failure Hematological disorders Allergy to any drugs used.

11. The MTp ( Ammendement ) Act 2021 (25 th march 2021) All the provisions of the MTP Act 1971 will continue with following changes: Gestational age: It in increased upto 24 weeks in the new MTP act (instead of 20 weeks in the previous act) for: Pregnancy due to rape or sexual violence Pregnancy due to incest Differently abled women (women with disabilities) Minor girls Mentally challenged women

12. In the amendment acct upper gestational age will not apply in cases of pregnancy with substantial fetal abnormalities diagnosed by medical board as maybe prescribed by the rules made under this act. The Solicitor General of India on behalf of the Honourable Supreme Court of India has directed the ministry of Health and Family Welfare to establish permanent medical boards across the country to assist in responding to urgent request for termination of higher gestational age pregnancies. The medical board should have a gynaecologist, a pediatrician , a radiologist and other members notified in the official gazette by State governments or Union Territories.

13. 2. Opinion of the practitioner on the amended act: There is a requirement of opinion of only one RMP for termination of pregnancy upto 20 weeks of gestation and requirement of opinion of two RMPs from 20 to 24 weeks of gestation. In previous act, requirement was one RMP upto 12 weeks and 2 RMPs between 20 to 24 weeks of gestation. 3. Failure of contraceptive as a condition for MTP is now extended to any woman or her partner. In previous act, it was applicable to only married women or their partners. 4. Confidentiality: Name and other particulars of a woman whose pregnancy has been terminated shall not be revealed except to a person authorised by any law for the time being in force.

14. Methods of abortion: first trimester ( upto 12 weeks) Surgical Methods (method of choice) Medical Methods 1. Manual Vacuum Aspiration (MVA) Mifepristone (less effective) 2. Suction evacuation 2. Misoprostol (less effective) 3. Dilatation & Evacuation (D & E) 3. Mifepristone and misoprostol (most commonly used method being effective) 4. Methotrexate and Misoprostol

15. Methods of abortion: Second trimester ( upto 13 - 20weeks) Surgical Methods (less commonly done) Medical Methods (method of choice) Dilatation & Evacuation ( upto 15 weeks) Various Prostglandins : E2, F2a, E1 Intra-amniotic injection Extra-amniotic injection Vaginal insertion Prenatal injections Oral ingestion 2. Dilatation & extraction (between 13- 15 weeks) 2. Extra-amniotic: ethacridine lactatae , prostaglandins (PGE2, PGF2a) 3. Hysterotomy (rarely required for intractable cases) (16-20 weeks) 3. Intra-amniotic hyperosmotic fluids: hypertonic saline 20%, 40% urea, mannitol 4. Intravenous high dose oxytocin 5. Antiprogesterones: Mifepristone- IM & oral 6. Methotrexate: IM & oral 7. Various combination of the above

16. Relative advantages and disadvantages of medical and surgical methods of abortion Medical Methods Surgical Methods Advantages Avoids surgery and anaesthesia More natural, like menses Less painful Easier and entertains woman’s wishes Quicker More certain Can be done under general or local anaesthesia Disadvantages Bleeding, cramping, nausea Waiting, uncertainty due to unpredictable success Extra visits to clinic and compliance needed Need of surgical evacuation for failure Invasive Small risk of uterine, cervical and bowel injury or infection. Success Rate 95% 98%

17. Medical methods of abortion (MMA) According to MOHFW, MMA can be used to termination pregnancies upto 49 days after date of LMP. Mifepristone 200mg followed by misoprostol 800ug has been approved by the Central Drug Standard Control Organisation – DGHS for MTP upto 63 days gestation in December 2008.

18. MMA with precaution Women not sure about LMP or with lactational amenorrhea Pregnancy with IUCD in situ: IUCD to be removed prior to giving MMA Pregnancy with uterine scar: caution with history of LSCS, hysterotomy or myomectomy Pregnancy with fibroid: Large fibroid encroaching on endometrial cavity can cause heavy bleeding and can interfere with uterine contractility Women on anti-tubercular drugs Breastfeeding: With-hold breastfeeding for 4 hours after misoprostol administration

19. contra-indications of medical methods of abortion Absolute: Suspected ectopic pregnancy or unidentified adnexal mass Chronic renal failure Chronic adrenal failure or concurrent corticosteroid therapy (Mifepristone binds to glucocorticoid receptors and blocks action of cortisol. Misoprost diminishes glucocorticoid activity.) Anemia (Hb<8gm/dl) Uncontrolled seizure disorder Uncontrolled hypertension of Bp >160/100mmHg

20. 7. Cardiac disease 8. Hemorrhagic disorder or concurrent anticoagulant therpay 9. Allergy to any drug 10. Deranged liver function tests (for Methotrexate) Relative: Heavy Smoker More than 35 years

21. Complications of MTP Early complications (within 24 hours of the procedure): Hemorrhage due to trauma, incomplete abortion, atonic uterus or coagulation failure Shock due to hemorrhage , trauma and perforation, Uterine perforation Cervical laceration Thrombosis of embolism Post abortal triad of bleeding, lower abdominal pain and low grade fever can occur due to RPOC

22. Late (from 24 hours to 2 weeks after the procedure): Post abortal bleeding Uterine atony or postabortal hematometra Continued pregnancy Uterine infection Subinvolution Post abortal dysfunction uterine bleeding (DUB) Infertility due to cornual block Uterine synechiae ( asherman’s syndrome)