PNDT AND MTP ACT.pptx

pndt and mtp act defination,objectives , features, pndt procedure, mtp procedure

1. PNDT AND MTP ACT SPARSHA S K 3rd BAMS TAMC

2. PNDT ACT Introduction Definition Objectives Salient features

3. introduction Pre natal diagnostic technique Act Citation Act No.57 of 1994 Enacted by Parliment of India Date of assented to 20 September 1994 Date of commence 1 January 1996 Amends The Pre-Conception and pre natal Diagnostic Technique Act in 2003

4. Definition An act to provide for the prohibition of sex selection, after conception, and for regulation of prenatal diagnostic techniques for the purposes of detecting genetic abnormalites or metabolic disorders or chromosomal abnormalites or certain congenital malformations or sex linked disorders and for the prevention of their misuse for sex determination leading to female feticide.

5. Sex selection It is any act of identifying the sex of the foetus and elimination of the foetus if it is of the unwanted sex. Includes Procedure Technique Test Administration Prescription Provision of anything for the purpose of ensuring or increasing the probability that an embryo will be of a particular sex

6. objectives To ban the use of sex selection techniques after conception and prevent the misuse of prenatal diagnostic technique for sex selective abortion.

7. Prenatal diagnostic technique Includes Ultrasonography (USG) Test or analysis of amniotic fluid chronic villi blood any tissue fluid

8. WHY PNDT IS DONE? To detect Genetic abnormalities Metabolic disorders Chromosomal abnormalities Congenital malformations Sex linked disorders Haemoglobinopathies

9. WHEN CAN PNDT BE CONDUCTED? Pregnant women is above 35 years Pregnant women has undergone a spontaneous abortion or foetal loss Pregnant women has been exposed to potentially teratogenic agents such as drugs/ radiation/ infection/ chemicals. Pregnant women or her spouse has a family history of mental retardation/ physical deformities such as spasticity or any other genetic disease Any other condition specified by central supervisory board

10. When can a person conduct of pnd procedures? PND procedure will be conducted only after Explaining all known side and after effects of the procedures to the pregnant women. Obtained her written consent to undergo the procedures in the language which she understands Copy of her written consent is given to the pregnant women

11. Where pndt can be conducted? In registered Diagnostic laboratories Genetic counselling centres institute hospital Nursing home Genetic laboratories Genetic clinics Ultrasound clinics

12. Who can conduct pndt? QUALIFIED PERSONS LIKE Radiologist Sonologist Gynecologist Pediatrician Registered medical practitioner Medical geneticist Note: should not conduct/ cause to be conducted/ or aid in conducting by himself or through any other person any other PNDT other than a registered place

13. Amendment in 2003 PNDT Act ,1994 was amended in 2003 to the Pre conception and Pre Natal Diagnostic Technique Act (PCPNDT Act) to improve the technology used in sex seection .

14. MTP ACT MTP ACT

15. INTRODUCTION MTP ACT was enforced to safeguard the health of mother undergoing abortion and the interest of the doctor performing the procedure on her. Medical Termination of Pregnancy Act Enacted by Parliment of India Date of assented to 1971 Date of commence 1 April 1972( J&K 1 Nov 1976) Amends in December 2002 and rules in June 2003

16. rules The condition under which the pregnancy can be terminated The person or persons who can perform such termination The place where such termination can be performed

17. condition There are five conditions that have been identified in the MTP Act Therapeutic or medical indication: where continuation of pregnancy might endanger the mothers life or cause grave injury to her physical or mental heath. Eugenic: where there is “ substantial risk of the child being born with serious physical or mental abnormalities so as to be handicapped for life”.

18. Humanitarian: where pregnancy is the result of rape Socio economic indication: where actual or reasonably forceeable environment can lead to risk of injury to the physical or mental health of the mother. When pregnant women is not mentally sound

19. Person or persons MTP can only performed by a registered medical practitioner with the certificate to do MTP like Who has got a degree or DGO Who has done 6 months house job in obstetrics and gynecology . Who has assisted in at least 25 MTPs in an authorized center and has a certificate to do MTP. 3 years of practice in obstetrics or gynecology for the doctors registered before the 1971 MTP act passed.

20. place Approved by the DHS or CMO of district

21. Important issues related to mtp Consent: guardian concent - women under 18 years and mentally disturbed women above 18 years. Period of gestation : less than 12 weeks – single medical practitioner exceeds 12 weeks – 2 medical practitioners opinion is requried .

22. Contra indications Medical disorders like heart disease Suspected ectopic pregnancy Chronic renal failure Hematological disorders Allergy to any drugs used

23. Prerequisites for mtp Counselling risk reason Clinical assessment: it provides Confirmation of pregnancy Gestational age Womens general health condition Associated gynecological conditions Associated medical conditions.

24. Components of clinical assessment History General physical examination Gynecological examination Laboratory tests Investigation Hemoglobin estimation Urine examination Blood group examination

25. Methods of abortion

26. medical methods of first trimester abortion Mifepristone Mifepristone (RU 486) and Misoprostol Methotrexate and Misoprostol Tamoxifen and Misoprostol Misoprostol

27. Mifepristone (RU 486) and Misoprostol Mifepristone (RU 486) acts as a antagonist , blocking the effect of natural progesterone. Addition of low dose prostaglandins (PGE 1 ) improves the efficency of the first trimester abortion. Effective up to 63 days Successful when used within 49 days of gestation.

28. protocol: Day 1: 200mg of Mifepristone Day 3: Misoprostol 400µg orally or 800µg vaginally After 10-14 days again re examined Note Oral 200mg of Mifepristone (1 tab) with vaginal Misoprostol 800µg( 4 tab, 200µg each) after 6 to 48 hours is equally effective.

29. Side effects Nausea Vomiting Diarrhea Headache Pain

30. Contra indication Mifepristone should not be used in womens Aged over 35 years Heavy smokers Those who on long term corticosteroids

31. Surgical methods of first trimester abortion MENSTRUAL REGULATION/ ASPIRATION Aspiration of the endometrial cavity, using a flexible 5-6 mm Karman cannula and syringe, within 6 weeks of amenorrhea has been reffered to as MR.

32. EQUIPMENTS (A) Syringe (B) Plastic cannula with whistle tip used in suction evacuation

33. 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.  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.

34. 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.

35. VACUUM ASPIRATION (MVA/EVA) Done 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). Hand 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

36. Contra indication Acute vaginal, cervical or pelvic infections Suspection of ectopic pregnancy Suspection of perforation

37. 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: 1. General anaesthesia is usually not needed. 2. If the patient is apprehensive, intravenous diazepam 5–10 mg (conscious sedation) supplemented by paracervical block is quite effective. 3. The patient is put on the table after she empties her bladder.

38. Steps: 1. 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. 2. Posterior vaginal speculum is introduced and an assistant is asked to hold it. 3. 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.

39. 4. 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. 5. Intravenous methergin 0.2 mg is administered. 6. 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.

40. 7. 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 . The end point of suction is denoted by: (a) No more material is being sucked out (b) Gripping of the cannula by the contracting smaller size uterus (c) Grating sensation (d) Appearance of bubbles in the cannula or in the transparent tubing.

41. 8. The vacuum should be broken before withdrawing the cannula down through the cervical canal to prevent injury to the internal os . 9. 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. 10. 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.

42. Complications Excessive haemorrhage Injury Shock Perforation Sepsis Hematometra may cause pain

43. 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: o One stage — Dilatation of the cervix and evacuation of the uterus are done in the same sitting. oTwo stages — a) First phase includes slow dilatation of the cervix b) Second phase includes rapid dilatation of the cervix and evacuation.

44. ONE STAGE OPERATION   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.

45. 2nd STAGE OPERATION   Slow dilation of the cervix- inserting laminaria tents into cervical canal. After 12 hr evacuation from the uterus is done.

46. complications immediate: same as d&c Late: Pelvic inflammation Infertility Cervical incompetence Uterine synechiae .

47. Medical methods of SECOND TRIMESTER TERMINATION OF PREGNANC Y 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 .

48. 1 . Misoprostol (PGE1 analogue) 400–800 μg of misoprostol - vaginally at an interval of 3–4 hours. Alternatively, first dose of 600 μg misoprostol - vaginally-200 μg orally every 3 hours Recently 400 μg misoprostol is given sublingually every 3 hours for a maximum of five doses. 2 . Gemeprost (PGE1 analogue): 1 mg vaginal pessary every 3–6 hours for five doses in 24 hours.  

49. Mifepristone and prostaglandins: Mifepristone 200 mg oral, followed 36–48 hours later by misoprostol o 800 μg vaginal; then misoprostol 400 μg oral every 3 hours for 4 doses is used. 4. 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. 5. Prostaglandin F2 (PGF2α), carboprost tromethamine — o 250 μg IM every 3 hours for a maximum 10 doses can be used.

50. 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.

51. Surgical methods of second trimester abortion Between 13 and 15 weeks   Dilatation and Evacuation  

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

53. 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. 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.

54. 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

55. HYSTEROTOMY Hysterotomy is an operative procedure of extracting the products of conception out of the womb before 28th 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: I. Hemorrhage and shock II. Anesthetic complications III. Peritonitis IV. Intestinal obstruction .

56. COMPLICATIONS OF MTP IMMEDIATE : Injury to the cervix (cervical lacerations) uterine perforation during D and E Haemorrhage and shock Thrombosis or embolism Postabortal triad of pain, bleeding

57. REMOTE: o Gynecological o Obstetrical Gynecological complications menstrual disturbances chronic pelvic inflammation infertility due to cornual block scar endometriosis (1%) uterine synechiae leading tosecondary amenorrhea

58. Obstetrical complications 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 .

59. MORTALITY: First trimester : The maternal death is lowest (about 0.6/100,000 procedures) in first trimester termination specially with MVA and suction evacuation. 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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