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1. MTP ACT Presented by: PRIYAL SHARMA Under guidance of: Dr.NISHAT AHMED(Assistant Professor) Dept. Of Obst & Gynae .

2. MEDICAL TERMINATION OF PREGNANCY Since legalization of abortion in india , deliberate induction of abortion by a registered medical practitioner in the interest of mother’s health and life is protected under the mtp act. the following provisions are laid down: 1. the continuation of pregnancy would involve serious risk of life or grave injury to the physical and mental health of the pregnant woman. 2. there is a substantial risk of the child being born with serious physical and mental abnormalities so as to be handicapped in life. 3.when the pregnancy is caused by rape, both in cases of major and minorgirl and in mentally imbalanced women. 4.pregnancy caused as a result of failure of a contraceptive .

3. 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 MEDICAL TERMINATION OF PREGNANCY ACT 1971 passed by the Parliament of India , enforced in April 1972 & revised in 1975

4. MTP Act has the following RULES-

5. 1) CONDITIONS UNDER WHICH PREGNANCY CAN BE TERMINATED THERAPEUTIC / MEDICAL INDICATION- When continuation of pregnancy might endanger mother’s life or cause grave injury to her physical or mental health. Conditions are as follows- Severe cardiac disease End stage renal ds. Malignant/ severe HTN DM complicaticated with RETINOPATHY / NEPHROPATHY Severe epilepsy or psychiatric illness with the advice of a psychiatrist

6. 2) EUGENIC- When there is SUBSTANTIAL RISK of the child being born with serious physical or mental abnormalities , so as to be HANDICAPPED for life. INDICATIONS are as follows- Structural (anencephaly) , chromosomal ( Down’s synd.) , genetic ( hemophillia ) TERATOGENIC DRUGS ( isotretinoin , warfarin) Radiation exposure (>10 rads ) in early pregnancy. RUBELLA infection in 1 st trimester.

7. 3) HUMANITARIAN- When preg . Is result of RAPE. 4) SOCIO- ECONOMIC INDICATION- Multiparous women with unplanned preg . and low socio- economic status (80%) Failure of contraceptive device (15%) When preg . Women is not MENTALLY SOUND (schizophrenia , mania)

8. 2) PERSON WHO CAN PERFORM ABORTION MTP can only be performed by a REGESTERED MEDICAL PRACTITIONER with a CERTIFICATE to do MTP like- MD/MS or DGO in OBGYN. 6 months house job in OBGYN Assisted in at least 25 MTPs in an authorised center If preg . <12 weeks – one RMP If preg . >12 week till 20 weeks – TWO RMPs (acc. To 2020 amendment MTP can be performed upto 24 weeks) 3. Written consent of only WOMEN is needed. 4. In case of MINOR GIRL or LUNATIC or MENTALLY RETARDED women , written consent from parents or LEGAL guardian to be taken.

9. 3) PLACE WHERE ABORTION CAN BE PERFORMED- MTP can be performed at – Govt. hospital Nursing homes Centers approved by DHS / CMO ABORTION has to be performed confidentially and has to be reported to director of HEALTH SERVICES of state.

10. FIRST TRIMESTER ABORTIONS MEDICAL METHODS SURGICAL METHODS Mifepristone (RU486) alone Manual Vaccum Aspiration Misoprostol Alone Suction n evacuation Mifepristone followed by Misoprostol (M/C used method) Dilatation and Evacuation Methotrexate and Misoprostol Dilatation and currettage

11. SECOND TRIMESTER TERMINATION OF PREGNANCY

12. MEDICAL METHODS PROSTAGLANDINS They are used extensively, specially in the second trimester. They act on the cervix and the uterus. The PGE ( dinoprostone , sulprostone , gemeprost , misoprostol) and PGF ( carboprost ) analogs are commonly used. PGEs are preferred as they have more selective action on the myometrium and less side effects.

13. MISOPROSTOL 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.

14. Mifepristone Mifepristone 200 mg oral, followed 36–48 hours later by misoprostol 800 µg vaginal; then misoprostol 400 µg oral every 3 hours for four 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.

15. 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 is thermolabile (needs refrigeration) and is expensive.

16. 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. The drip rate can be increased up to 50 milliunits or more per minute. Currently high dose (up to 300 units in 500 mL of dextrose saline) is favored.

17. SURGICAL METHODS OF TERMINATION Between 13 weeks and 15 weeks Dilatation and Evacuation in the midtrimester is less commonly done. Pregnancies at 13–14 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.

18. Between 16 weeks and 20 weeks: INTRAUTERINE INSTILLATION OF HYPERTONIC SOLUTION: Extra-amniotic : Extra-amniotic instillation of 0.1% ethacridine lactate (estimated amount is 10 mL/ week) is done transcervically through a No. 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. Intra-amniotic : Intra-amniotic instillation of hypertonic saline (20%) is less commonly used now. It is instilled through the abdominal route

19. Procedure : Preliminary amniocentesis 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. Contraindications: It should not be used in presence of cardiovascular or renal lesion or in severe anemia because of sodium load. 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. Success rate: The method is effective in 90–95% cases with induction-abortion interval of about 32 hours.

20. 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 edema . Renal failure. Disseminated intravascular coagulopathy.

21. HYSTEROTOMY: The operation is performed through abdominal route. Indications: Prior failed medical termination of pregnancy (TOP) Cases where D&E cannot be safely done: (a) fibroid in the lower uterine segment, (b) uterine anomalies, (c) patients with repeated scarred uterus with placenta accreta or percreta . It is less commonly done these days. The operation should be combined with sterilization operation.

22. Hazards: Immediate: ( i ) Hemorrhage and shock (ii) Anesthetic complications. (iii) Peritonitis (iv) Intestinal obstruction. Remote: Menstrual abnormalities Scar endometriosis (1%) Incisional hernia If pregnancy occurs, chance of scar rupture.

23. COMPLICATIONS OF MTP IMMEDIATE: Injury to the cervix (cervical lacerations) Uterine perforation during D&E Hemorrhage 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

24. REMOTE: Gynecological complications include menstrual disturbances chronic pelvic inflammation infertility due to cornual block scar endometriosis (1%) uterine synechiae leading to secondary amenorrhea.

25. Obstetrical complications include ectopic pregnancy (threefold increase) preterm labor Dysmaturity increased perinatal loss rupture uterus Rh-isoimmunization in Rh-negative women, if not prophylactically protected with immunoglobulin failed abortion and continued pregnancy. recurrent midtrimester abortion due to cervical incompetence.

26. The Act to protect children from offences of sexual assault, sexual harassment and pornography and provide for establishment of Special Courts for trial of such offences. It defines a child as any person below 18years of age The POCSO Act of 2012 looks into a support system for children through a friendly atmosphere in the criminal justice system with the existing machinery i.e. The CWC and the commission. • The positive aspect is the appointment of the support person for the child who would assist during investigation, pre- trial, trial and post trial. Offences covered under the Act:
( i ) sexual assault
(ii) aggravated sexual assault
(iii) sexual harassment (iv) using child for pornographic purpose and (v) trafficking of children for sexual purposes

27. Medical examination of the child to be conducted in the presence of parent of the child or any other person in whom the child has trust or confidence. • Incase the victim is a girl child, the medical examination shall be conducted by a female doctor. • Child not to be called repeatedly to testify. • No aggressive questioning or character assassination of the child. • Special courts conduct trial in-camera without revealing child identity. • For speedy trial, the evidence of the child is to be recorded within a period of 30 days. Also, the Special Court is to complete the trial within one year. Section 357 C CrPC states that the hospital shoild first conduct the examination. All these legal changes thus ensures the right of sexual violence victim to voluntary report to the hospital instead of to the Police/ Court after sexual violence and also that the medical examination of Sexual violence victim is a Medico-legal emergency.

28. Section 357 C CrPC now mandates all hospitals irrespective of being Government, public sector or private sector the responsibility of immediately providing first aid or medical treatment free of cost; thus removing the major barrier which existed earlier of insisting Government hospitals only. Rule 5 of POCSO Rules specify that treatment should include care for: Injuries, STD, HIV, Pregnancy testing, Emergency contraception, psychological counselling. Section 357 C CrPC insists that such treatment should be free of cost and non-compliance of such treatment can drag the doctor to one year imprisonment and/or fine.

29. THANK YOU