Safe abortion

Moderator:
Dr R C Prameela
Associate Professor & Unit chief Dr Ravindra Anteen
Dr Babitha M C
SAFE ABORTION CARE

 Williams obstetrics, 23rd edition
 “Comprehensive abortion care, Training and service delivery guidelines,
Government of India, 2010”
 FOGSI focus, safe abortion care- 2002
 FOGSI focus comprehensive abortion care- 2012
 Practical guide to high risk pregnancy and delivery, 3rd edition- F. Arias, S N Daftary, A
G Bhide
 WHO- safe abortion, technical and policy guidelines for health systems- 2012
REFERENCES

 Abortion- types, characteristics
 Scenario- world, india
 MTP act
 Pre- abortion care
 First trimester termination
 Second trimester termination
 Post abortion care
OVERVIEW

 Abortion is the termination of pregnancy, either spontaneously or intentionally,
before the fetus develops sufficiently to survive.
 By convention, abortion is usually defined as pregnancy termination prior to 20
weeks' gestation or less than 500-g birthweight.
Types:
 Spontaneous
 Induced
– Therapeutic
– elective
ABORTION

THREATENED
ABORTION
INEVITABLE
ABORTION
INCOMPLETE
ABORTION
COMPLETE
ABORTION
MISSED
ABORTION
SEPTIC ABORTION
Definition Bloody vaginal
discharge or
bleeding
through the
closed os in the
first half of
pregnancy
The ovum
separated from
the wall, bound
to be expelled
but not yet
The products of
conception are
partially
expelled and
partially
retained
The entire
products of
conception has
expelled
Symptoms of
abortion occur,
subside
without
products being
expelled
Infected abortion
complicated by fever,
endometritis and
parametritis
Symptom
s
Amenorrhea
Slight colicky in
lower abdomen
and backache
Slight vaginal
bleeding
Amenorrhea
Moderate to
sever pain
Usually heavy
vaginal bleeding
Along with
symptoms of
inevitable
abortion, history
of expulsion of
products of
conception
Amenorrhea
Abdominal
pain, vaginal
bleeding with
passage of
some products
Amenorrea
with subsided
symptoms of
pregnancy
H/O
threatened
abortion
Amenorrhea
fever
Diffuse abd pain
Signs GC- stable
No pallor/
tachycardia
Tachycardia and
hypotension
may be present
Tachycardia and
hypotension
may be present
Usually stable Breast changes
usually regress
Tachycardia, tachypnea,
hypotension, foul
smelling discharge,
TYPES OF ABORTION

THREATENED
ABORTION
INEVITABLE
ABORTION
INCOMPLETE
ABORTION
COMPLETE
ABORTION
MISSED
ABORTION
SEPTIC
ABORTION
P/A Uterus
corresponding
to the POA
Uterus
corresponding
to the POA
Less than the
period of
amenorrhea
Uterine size
less than the
POG or not
palpable
Uterus doesn’t
enlarge
anymore,may
become
smaller
Diffuse
tenderness +
P/S Cervix os
closed, slight
bleeding
Os dilated,
bleeding
Products are
seen
protruding
through the OS
Os closed,
minimal
bleeding
Minimal
bleeding
Foul smelling
discharge
P/V Cervix soft,
Uterus
corresponding
to the POA
Os dilated and
products of
conception
may be felt
Os dilated and
products of
conception
may be felt

 Ancient times- abortifacient herbs
 Sharpened implement
 Applying abdominal pressure
 Other techniques
 Earliest evidence –code of Hammurabi 1760 BCE
 Only evidence of death penalty for inducing abortion was in assyrian law 1075 BCE
 Ist recorded evidence of induced abortion- egyption eborus papyrus in 1550 BCE
 8th century, INDIA- to sit over pot of steam/ stewed onion, Massage, pressure on
abdomen
 Physical means- battering, vigorous exercise, tightening the girdle

68
137
205 million pregnancies
unintended
intended
20
80
Unintended pregnancies
induced
abortion
continued

Scenario
 Between 1995 and 2003,
the abortion rate for the
world overall dropped from
35 to 29.
 It remained virtually
unchanged, at 28, in 2008.
0
5
10
15
20
25
30
35
40
1995 2003 2008
abortion rates
abortion
rates

 WHO defines as “any procedure for terminating an
unwanted pregnancy [carried out] either by persons lacking
the necessary skills or in an environment lacking the
minimal medical standards, or both”
 easily prevented cause of maternal death.
UNSAFE ABORTION

 Between 1995 and 2008, the rate of
unsafe abortion worldwide remained,
at 14.
 the proportion of all abortions that
were unsafe increased from 44% to
49%.
41%
42%
43%
44%
45%
46%
47%
48%
49%
50%
Unsafe Abortion
Proportion of Unsafe Abortions
Annually
1995
2003
2008

 Nearly half of all abortions worldwide
are unsafe, and nearly all unsafe
abortions (98%) occur in developing
countries.
Unsafe Abortions
Developin
g
Countries:
98%
Develope
d
Countries:
2%

94
6
Abortions
in developed countries
safe
unsafe
44
56
Abortions
in Developing Countries
safe
unsafe
In the developing world, 56% of all abortions are unsafe,
compared with just 6% in the developed world.

0.5
13
40
95
97
0% 20% 40% 60% 80% 100%
Developed Countries
Eastern Europe
Asia
Latin America
Africa
Unsafe
Safe

0.5
60
61
65
0% 20% 40% 60% 80% 100%
Eastern Asia
Western Asia
South-eastern Asia
South-central Asia
Unsafe
Safe

 The estimated annual
number of deaths from
unsafe abortion declined
from 56,000 in 2003 to
47,000 in 2008.
 Complications from unsafe
abortion account for an
estimated 13% of all
maternal deaths worldwide.
0
2
4
6
8
10
12
14
maternal deaths
maternal
deaths

UN
•MTP is legalized in India way back in 1971
•6.4 million induced abortions
•2/3rd is unsafe.
•12,000 deaths per year
•9% of maternal deaths due to unsafe abortions
2.4
1.6
2
induced abortions
uncertified facilities
untrained providers
safe
Year 1972 1975 1980 1985 1990 1995 2000 2003 2007 2010
Number
of
abortions
reported
24300 214197 388405 583704 581215 570914 725149 763126 641786 620472

 Abortion rates in Karnataka are 1.3 times the national average.
 16 % of pregnancies in Karnataka end in abortion, compared to
13 .3 % nationally.
 80 % of abortions in Karnataka are induced,compared to 60 %
nationally.

 Section 312 of the Indian Penal Code, defines the offence of 'causing miscarriage' as
follows
 "whoever voluntarily causes a woman with child to miscarry shall, if such
miscarriage be not caused in good faith for the purpose of saving the life of the
woman, be punished with imprisonment for a term which may extend to 3 years, or
with fine, or both;
 if the woman be quick with child, shall be punished with imprisonment of either
description for a term which may extend to 7 years, and shall also be liable to fine.
Before MTP act

 An act to provide for the termination for certain pregnancies by registered medical
practitioners and for matters concerned therewith or incidental thereto
 It was enacted in 1971
 when
 where
 grants the central government- rules
 state government- regulations
MTP ACT

 Lays down who can terminate the pregnancy
 Training requirements
 Approval process for place
MTP RULES

 Lays down norms for opinion
 Making forms
 Maintenance of records
 Custody of forms
 Reporting of cases
MTP REGULATIONS

 Termination of pregnancy, written consent of the pregnant women in Form- C
 is mandatory provided she has completed 18 yrs of age
 If less than 18 years old or mentally ill, consent of guardian is mandatory
CONSENT

 A pregnancy can be terminated by a RMP when
 duration does not exceed 12 weeks of gestation
 or opinion of two RMPs 12- 20 weeks
Gestation limit

Indication for termination
 Therapeutic
 Eugenic-
 Humanitarian
 Social
Any induced abortion after 20 weeks is illegal, except to save maternal life as per
Section 5

 hospital established and maintained by the govt
 a private hospital approved for this purpose by the govt or DLC
Place for termination

1. The following facilities should be provided
First trimester terminations
 Gynecology / labour table, backup for treating shock & facilities for
transportation
Second trimester terminations
 OT table & instruments for abdominal & gynecological surgery,
anesthetic equipment
All terminations
 Resuscitation & sterilisation equipment, drugs & parenteral fluids

FORM B
Certificate of approval
The place described below is hereby approved for the purpose of the
MTP act 1971
Name of the Place Address and Other
Description
Name of the owner
Place:
Date: To the government of the………………………

The person carrying out the termination of pregnancy must fulfill one of the
following requirements
 Any degree or diploma in OBG
 6 months of residency in OBG
 1 year at any hospital in the field of OBG
 assisted a RMP in the performance of 25 cases of MTP
– 5 has been performed independently in a hospital established /maintained /approved by
govt [ valid only for 1st trimester MTP]
ELIGIBILITY CRITERIA FOR RMP

FORM I
I_______________________________________________________________________
( Name and qualifications of the Registered Medical practitioner in block letters )
________________________________________________________________________
( Full address of the Registered Medical practitioner )
I_______________________________________________________________________
( Name and qualifications of the Registered Medical practitioner in block letters )
________________________________________________________________________
( Full address of the Registered Medical practitioner ) hereby certify that *I/We am/are of
opinion, formed in good faith, that it is necessary to terminate the pregnancy of
________________________________________________________________________
( Full name of pregnant women in block letters ) resident of
________________________________________________________________________
( Full address of pregnant women in block letters )
for the reasons given below**.
* I/We hereby give intimation that *I/We terminated the pregnancy of the woman referred to
above who bears the serial no. _______________ in the Admission Register of the
hospital/approved place.
Signature of the registered Medical Practitioner(s)
Place :
Date :
*Strike out whichever is not applicable, if the reasons specified items (i) to (v) write the one
which is appropriate.
(i) (i) in order to save the life of the pregnant women,
(ii) (ii) in order to prevent grave injury to the physical and mental health of the pregnant women,
(iii) (iii) in view of the substantial risk that if the child was born it would suffer from such
physical or mental abnormalities as to be seriously handicapped,
(iv) (iv) as the pregnancy is alleged by pregnant women to have been caused by rape,
(v) (v) as the pregnancy has occurred as result of failure of any contraceptive device or methods
used by married woman or her husband for the purpose of limiting the number of children
Note : Account may be taken of the pregnant women’s actual or reasonably foreseeable
environment in determining whether the continuance of her pregnancy would involve a grave
injury to her physical or mental health.
Place :
Date :
Signature of the Registered Medical Practitioner

 Every hospital should maintain a register in form 3
 It should be kept for 5 years from the end of the calender year
 It is a secret document
 No entry should be made in any other hospital register
MAINTAINANCE OF REGISTER

FORM III
ADMISSION REGISTER ( To be destroyed on the expiry of five years from the dated of the
last entry in the Register )
1 2 3 4 5 6 7
Sl no Date of
Admission
Name of the
Patient
Wife/Daug
hter of
Age Religion Address
8 9 10 11 12 13 14
Duration of
pregnancy
Reasons on
which
Pregnancy
is
terminated
Date of
termination
of
Pregnancy
Date of
discharge
of patient
Result and
Remarks
Name of
Registered
Medical
Practitioner
(s) by who
the opinion
is formed
Name of
Registered
Medical
Practitioner (s)
by whom
Pregnancy is
terminated

FORM II
1. Name of the State
2. Name of the Hospital/approved place
3. Duration of pregnancy ( give total No. only )
(a) Up to 12 weeks.
(b) Between 12 - 20 weeks
4. Religion of woman
(a) Hindu
(b) Muslim
(c) Christian
(d) Others
(e) Total
5. Termination with acceptance of contraception.
(a) Sterlisation.
(b) I.U.D.
6. Reasons for termination :
( give total number under each sub-head )
(a) Danger to life of the pregnant woman.
(b) Grave injury to the physical health of the pregnant woman.
(c) Grave injury to the mental health of the pregnant woman.
(d) Pregnancy caused by rape.
(e) Substantial risk that if the child was born, it would suffer from such
physical or mental abnormalities as to be seriously handicapped.
(f) Failure of any contraceptive device or method.
Signature of the Officer Incharge with Date

Termination of pregnancy by a person who in a place not a RMP as per the act or
other than that mentioned in sec 4 of the act shall be an offence punishable with
Rigorous Imprisonment for a term not less than 2 yrs but may be extended upto 7
yrs
PENALTY

 No suit or any other legal proceedings shall lie against any RMP for any damage
caused or likely to be caused by anything which is done or is intended to be done in
good faith under this act

 Aims to improve the maternal health scenario by preventing unsafe abortions
 Legalising abortion services
 De-criminalizes the abortion seeker
 Offers protection to medical practitioners

MTP (Amendment) Act, 2002
MTP Rules, 2003

MEDICAL METHOD OF ABORTION
 MTP Rules allow for the use of the medical agents up to 49 days of pregnancy i.e. 7
weeks from LMP.
 Medical methods for termination of pregnancy not exceeding seven weeks, may be
prescribed by a registered medical practitioner as prescribed under Section 2 (d)
and Rule 3, having access to a place approved by the Government under Section 4
(b) & Rule 5 of MTP Rules. RMP should display a certificate to this effect from the
owner of the approved place
 MTP act applies in all respects.
 Consent vital
 Ultrasound is not mandatory

 A place approved by govt or DLC
 Chairperson- CMO or DHO
 3-5 members
 One must be gyn/anaes/surgeon
 Others- local medical professional, NGO, panchayat
 One must be a woman
 Tenure- 2 yrs, NGO mebers- 4 yrs
WHERE IT CAN BE TERMINATED

 Counselling is a structured interaction in which a person voluntarily receives
emotional support and guidance from a trained person in an environment tht is
conducive to open sharing of thoughts, feelings and perception
Pre- procedure counselling

 It helps the woman to decide about
the termination of pregnancy
 It ensures that the consent for the
procedure is given after receiving the
complete information
 It helps the woman to adopt a
contraceptive method after the
proceudre

 Treat each patient well
 Counsellor should interact, listen, learn and respond to the client
 Tailor information
 Avoid too much information
 Provide the option
 Help the client understand
Principles of counselling

 Ensure privacy and confidentiality
 Be sensitive and non-judgemental
 Gain confidence and make her comfortable mentally and physically
 Address issues like cultural belief, guilt
 enquiry into why she wants termination of pregnancy and possibilty of continuation
of pregnancy
 If the woman insists about termination assess the eligibilty of woman to MTP
procedure
CRITICAL STEPS

 If eligible counsel for range of available options, after care and when to return
 Help make a contraceptive choice
 If method is not appropriate, explain the reason and help her choose the other
method
 If method chosen is not available at the centre, provide proper referral
 If any woman refusing contraception, MTP should never be denied

Consent form for medical method of MTP
 I have read the medication guide for using Mifepristone and misoprostol to end my
pregnancy. I have also discussed the information with my doctor who answered all my
questions and told me about the riska and benefits of using mifepristone and
misoprostol to end my pregnancy. I have decided to take mifepristone and misoprostol
to end my pregnancy and will follow my doctor’s advice about when to take each drug
and what to do in emergency
 I believe I am not more than 49 days pregnant counting my LMP
 I understand that I must return to doctor’s clinic 2 days from the first dose of medication
and again after 14 days
 I understand that during this entire period and until my doctor declares the abortion
complete and the pregnancy terminated, I must remain under self observation and
within contact of my doctor’ds clinic
 I understand that I must report immediately if I develop heavy bleeding or emergency
care due to treatment
 I know tht in some cases the treatment will not work. This happens in about 2-3%
women. I understand that if my pregnancy continues after any part of the treatment,
there may be chances of birth defects
 If my pregnancy continues after this treatment, I will undergo surgical procedure to end
my pregnancy
 I have my doctor’s name, address and phone number and I can call if I have any
questions
Patient’s Name:……………………………………………..
AGE:…………
Father’s/ husband’s name: Address:
Date:
Place: Patient’s signature
Husband’s signature( if available) Witness signature( if any)
THE PATIENT CONSENT FORM has been signed in my presence after I counseled her and
answered all her questions. I have given her the medication guide for mifepristone and
misoprostol combination.
Doctor’s signature:…………………… Name of Doctor:………………………………
Date:…………………………………. Place:

 Medical history
 Physical examination
 Investigations
 Ultrasonography

 Hemoglobin
 Urine routine
 Blood grouping and Rh typing
INVESTIGATIONS

 In documenattion of pregnancy
 Dating of pregancy
 Diagnosis of multifetal pregancy
 Localistation of co-existing IUCD
 Diagnosis of co-existing Mass
 Diagnosis of congenital uterine anamolies
 Diagnosis of abnormal pregnancy
Before MTP

To avoid complications in ‘at risk’ patients
 Guide introduction of dilators in prev LSCS
 Co-existing fibroid/ ovarian cyst
 Bicornuate uterus
 Multifetal
 Extra amniotic instillation/ intra amniotic instillation
 For aspirotomy
 Prior failed evacuation
During MTP

 Incomplete evacuation
 Perforation
 Pelvic hematoma
 Sepsis
 TO mass
 IUCD placement
 Continuation of pregnancy
After MTP

 USG is not mandatory
 It is useful when establishing the period of gestation is difficult
– The woman does not know her LMP
– Conception during lactational amenorrhea
– Wrong dates
– Missed or incomplete abortion
 Useful if ectopic pregnancy is suspected
 For selective reduction in multifetal pregnancy
ROLE of USG

 It has potential role for
– less qualified providers and training requirements
– more knowledge based, not surgical skill based.
 promises easier access to safe abortion care
 by freeing the abortion services from a limited pool of surgical sites and providers
 For medical methods of induction of abortion:
 Prostaglandins
 Mifepristone

 Mifepristone was invented in france in 1980
 US- FDA approved it in 2000
 Approved by the Drug controller of india in 2002
 RU-486
MIFEPRISTONE

 Nor- ethindrone derivative with anti-progestin action
 It binds to progesterone receptors at endometrium and decidua resulting in necrosis
and detachment of placenta
 softens the cervix
 mild uterine contractions
 It causes increased sensitivity to prostaglandins
MECHANISM OF ACTION

 Needs refrigeration and is expensive
 Available in india as 200mg tablets under the trade name mifegestroid
 Other indications:
– Emergency contraception
– Fibroids
– Endometriosis
– Breast, ovarian, prostate CA
– Cushing’s syndrome

 Two types of prostaglandins available:
 Misoprostol
 Gemeprost
MISOPROSTOL
 Synthetic PG analogue, developed in 1991-1992
 Inexpensive and stable at room temperature
 Enhances uterine contraction and causes expulsion of products
 Causes cervical ripening
PROSTAGLANDINS

Clinical recommendations
Medical Abortion
Mifepristone followed by misoprostol
Module 2: Clinical Care

Medical Abortion up to 7 weeks
Mifepristone & Misoprostol
Up to 7
weeks*
DAY 1
Mifepristone 200 mg Oral
DAY3
Misoprostol 400 mcg Oral/
vaginal
DAY 15
History, examination
USG if required
Counsel for contraception

 Side-effects include
– nausea
– vomiting
– diarrhoea.

 Contraindications to the use of mifepristone and prostaglandin analogue include
– chronic or acute adrenal or hepatic failure,
– inherited porphyria
– allergy to any of the drugs used.

 Caution and clinical judgement are required for women
– using corticosteroids long term,
– bleeding disorders,
– severe anaemia,
– pre-existing heart disease
– cardiovascular risk factors

 Prophylactic antibiotics
 Analgesics
 Anti-emetic, antidiarrheal
Adjunct medications

 Failure of the method
 Heavy bleeding
 Abdominal cramps
 Fever or feeling of warmth
 Incomplete abortion
 Risk of teratogenesis
 Delay in onset of menses
Complications and management

 Methotrexate, which is a cytotoxic drug
 used in combination with misoprostol where mifepristone has not been available.
 success rate of greater than 90%
 50 mg of methotrexate orally or intramuscularly, followed by 800 μg vaginal
misoprostol 3–7 days later.
 WHO toxicology panel recommended against the use of methotrexate
 concerns of teratogenicity.
Other medical methods

Effect on lactation,
teratogenecity

 There is some evidence that mifepristone is excreted into breastmilk
 unlikely to cause harm.
 Small amounts of misoprostol enter breastmilk soon after administration
 misoprostol levels decline rapidly,
 Taken immediately after a feed
 The next feed given after four hours
Effect on lactation

Surgical Methods
Up to 12 weeks
Manual vacuum aspiration (MVA)
Replace
D&C (sharp curettage)
with MVA or EVA
Electric vacuum aspiration (EVA)

 VACCUUM ASPIRATION: contents of uterus are evacuated using a plastic or metal
cannula that Is attached to a vacuum source. It includes MVA and EVA.
 It is a safe and simple technique till 12 weeks of gestation
 Providers in PHC’s can perform VA up to 8 weeks of GA
 8-12 weeks of GA at CHCs/ subdistrict hospitals and higher level facilities
 Successful in over 98% of cases
 It has advantage over Dilatation and curettage
SURGICAL METHODS

 Other indications of MVA:
– Incomplete abortion uto 12 weeks
– Missed abortion
– Hydatiform mole
– Removal of decidua with surgical removal of ectopic
 Contraindications
– Presence of acute infection
– Suspicion of perforation
– Suspicion of ectopic

VACUUM ASPIRATION D&C
Excessive bleeding, cervical
and vaginal injury, uterine
perforation
lesser 2-4 times higher
Dilatation required Lesser Greater
Pain control medication Lower level Higher level
Recovery period and hospital
stay
lesser more
Post procedure bleeding Lesser more

Valve buttons Plunger ring Collar stop
cylinder
c
a
p

 A hand held plastic aspirator providing vacuum source is attached to a cannula.
 Two types of aspirator:
MVA
FEATURES DV ASPIRATOR SV ASPIRATOR
Capacity 60cc 50cc
Negative pressure 66cm of Hg 66cm of Hg
Cannula size used Upto 12mm Upto 6mm
Vacuum manitained Till 80% is full Till 50% is full
Material used for valves Silicone Latex
Sterilisation option Chemical sterilisation
Boling, Autoclaving
Chemical sterilisation

 Two types of cannulae are available:
– Disposable, single use cannula [KARMANN]
– Autoclavable, reusable [ Easygrip]
CANNULA
Uterine size Preferred cannula size
4-6 weeks LMP 4-6mm
7-9weeks LMP 6-10mm
9-12 weeks LMP 8-12mm

 Perineum hair to be trimmed
 Analgesic/ anti-spasmodic an hour before
 Prophyalctic antibiotic – oral ampicillin [1gm]
 Local anesthesia- Paracervical block
 Instruments to be prepared and checked
 Cervical priming may be used in GA more than 9 weeks
– T. Misoprostol 400mcg orally or vaginally 3-4 hours before
– Inj. Prostadin 250mcg IM 45 min before the procedure
Pre-op requisites

Prepare the Syringe
Create the Vacuum

Dilating the Cervix  Inserting Cannula

Releasing the Pinch Valve  Evacuating the Uterus

 After the procedure is complete
– Inspect POC to identify decidua and villli
– Concurrent procedures like sterilisation, IUCD insertion can be done
 Instrument soaked, cleaned and sterilisation/ High level disinfection done

MVA EVA
Hand held and portable Electronic equipment
POC check possible and easy Difficult and cumbersome
Electric supply Not required essential
Regular maintanence lesser More intensive
Equipment noise none Present, sometimes disturbing
Cost effective Lesser resources required More resources, higher
maintenance

 Due to anaesthesia
 Hemorrhage- cervical injury, incomplete emptying of uterus, uterine atony,
perforation.
 Fainting/ syncope
 Delayed complications:
– Incomplete evacuation
– Continuation of pregnancy
– Infection
Complications

 Remote complications:
– Infertility
– Recurrent abortion
– Ectopic pregnancy
– Obstetric complications
– Psychosomatic conditions

 Only 10-15% of induced abortions occur in 2nd trimester
 They are responsible for two thirds of all major complications
 A RMP with qualifications laid down by the MTP act can perform 2nd trimester
abortions
 Tertiary level health care centres and DH, FRU can provide the services
 PHCs and non designated CHCs are not permitted
 Private sector facilities need approval from DLC a/c to 2003 MTP rules
Second trimester termination

 Medical method: Ethacridine lactate extra amniotic instillation
 Surgical method: dilatation and evacuation
Methods

 Most commonly performed
 95% efficacy
 0.1% EL through foley’s catheter inserted transcervically, extra-amniotic space
 Catheter removed after few hours, oxytocin drip started
 Induction- abortion interval: 10-30 hours.
 Mechanism: release of PGs, mechanical stimulation and dilatation.
 Failure to abort in 48 hours: repeat instillation with addition of PGs.
 Volume: 10x POG in weeks.
Extra-amniotic instillation of Ethacridine lactate

 Hypersensitivity
 Infection
 Incomplete abortion
 Failure to abort
Side effects

 Urea
 Hyptertonic saline
 PF2 alpha in saline
 Concentrated oxytocin
Other drugs

Surgical Methods
After 12 to 14 weeks
Dilatation and evacuation
(D&E)
Replace
with D&E

 Preparing the cervix and evacuation of
uterus with combination of suction
and forceps.
 Useful particulary between 13-16
weeks
 Pain management with NSAIDS,
anxiolytics, LA, GA

Cervical preparation:
 Laminaria tent
 Misoprostol
 Mechanical dilators
Supplementary medication:
 20 units synto in 500ml RL
 PGF2alpha 250mcg
 Antiemetic
Other methods: hysterotomy

 Anaesthetic complications
 Hemorrhage
 Pelvic infection
 Perforation
 Cervical injury
 Acute hematometra
COMPLICATIONS

PREVENTING
COMPLICATIONS IN MTP

 Use of agents to ripen cervix
 Screening of infections of the lower genital tract
 Rh prophylaxis
 USG

Immediate:
• Check vitals
• Evaluate pain, bleeding
Before discharge:
• Check vitals
• Contraceptive counselling
• Address other reproductive health issues
• Warning signs: excess bleeding, pain, vomitting, fever
• Instruct on follow-up
• Antibiotics if needed
POST ABORTION CARE

 Day 15 when MMA is used
 Within 1-2 weeks when surgicacl method is used
 Within 2 weeks after 2nd trimester termination
 Assess vital signs, bleeding
 Enquire about warning signs
 Rule out continued pregnancy
 Re counsel for contraception if not already chosen
Follow-up

 An estimated 120–165 million women,want to prevent or space their
pregnancies but are not using a method many resort to unsafe abortion.
 unmet need for modern contraception.
 75% of women ovulate and 6 % concieve within 2-6 weeks after abortion
 All modern contraceptives can be safely provided immediately after MTP
 MTP should not be denied to any woman irrespective of her decision to
refuse concurrent contraception
CONTRACEPTION

Method Time of
administration
Advantages
OCPills Can be used after
abortion using VA or
confirmation of
completed medical
abortion
Highly effective, can
be started even if
infection present, can
be proovided by non
physician, doesn’t
interfere with
intercourse
Prog only
contraception
Can be inserted after
confirmation of
completed medical
abortion
Highly effective, can
be started even if
infection present, can
be proovided by non
physician, doesn’t
interfere with
intercourse

IUCD Can be inserted after
after next cycles
Highly effective,
immediate return of
ferltilty, doesn’t
interfer wit
intercourse, no follow-
up needed
Tubal ligation To be performed after
next LMP
Permanent, after next
menses/ concurrent,
no change in sexual
function
condoms As soon as sexual
activity is resumed
Prevents STI, no S/E,
easily obtained

 Estimates of abortions in young girls range from 1 to 4.4 million each year in developing
countries
 Adoloscents often resort to unsafe abortions
 Young girls account for 53 - 74% of septic abortions
 Counselling -sexual behaviour, contraception
 Caution during surgical procedure- cervical priming, GA
 Other health issues- anemia, RTI
Adolescents

Nulliparous women
 Cervical priming prior to the surgical procedure
Pregnancy with History of cesarean section or uterine surgery
 Upto 9 weeks MMA is safe
 With caution beyond
 Use of ultrasound during MVA procedure
 Emergency care facilities

Pregnancy with fibroid:
 Large fibroids may cause heavy bleeding
 May interfere with contractility
Cervical stenosis
 General anaesthesia

Condition comments
Hypertension Avoid methergine
Seizure disorder Usual dose of anti-epileptic
Anaemia Blood transfusion if needed
Blood-clotting disorders Tertiary care centre, Blood and blood products
to be kept ready
Diabetes Avoid ketoacidosis, insulin dose not altered
under LA
Heart disease Tertiary care centre
Asthma PGE1, E2 can be given. PGF2alpha used with
caution
Alcohol or drug abuse Higher dose of drug may be required

Recommended Surgical Methods
Up to 12 weeks
Manual vacuum aspiration (MVA)
Replace
with MVA or EVA
Electric vacuum aspiration (EVA)

Mifepristone & Misoprostol
Up to 7
weeks* Mifepristone 200 mg Oral Wait 24-48 hours
Misoprostol 800 mcg
Vaginal OR Buccal OR
Sublingual
Misoprostol 400 mcg Oral
7-9 weeks* Mifepristone 200 mg Oral Wait 24-48 hours
Misoprostol 800 mcg
Vaginal OR Buccal OR
Sublingual
Flowchart design: Nathalie Kapp, 2012

9 -12 weeks
(63 -84 days)
Mifepristone 200 mg Oral Wait 36-48 hours
Misoprostol 800 mcg
Vaginal
Additional
Misoprostol 400
mcg Vaginal or
Sublingual every
3 hours for
maximum of 4
further doses
Medical Abortion 9-12 weeks
Mifepristone & misoprostol
In a health facility

Greater than12
weeks
(more than 84 days)
Mifepristone 200 mg
Oral Wait 36-48 hours
Misoprostol 400 mcg
Oral OR
800 mcg Vaginal
Additional Misoprostol
400 mcg Vaginal or
Sublingual every 3 hours
for maximum of 4
further doses
Medical Abortion
over 12 weeks up to 24 weeks
Mifepristone & misoprostol
In a health facility

Clinical recommendations
Medical Abortion
Mifepristone followed by misoprostol
Misoprostol alone when mifepristone is
unavailable

Up to 12 weeks
(up to 84 days)
Misoprostol 800 mcg
Vaginal or Sublingual
REPEAT Misoprostol every
3-12 hours for up to 3
doses until expulsion
Return for confirmation of
completed abortion in 7-
14 days
Misoprostol Alone

12-24 weeks
(up to 84 days)
Misoprostol 400 mcg
Vaginal or Sublingual
REPEAT Misoprostol every
3 hours for up to 5 doses
until expulsion
Return for confirmation of
completed abortion in 7-
14 days
Misoprostol Alone

Incomplete abortion
Incomplete abortion- Uterine size
<14 weeks
Misoprostol 600 mcg orally/ 400mcg
sublingually
MVA/EVA

Recommended methods of abortion for pregnancies of gestational age over 12 to 14 weeks
Mifepristone & misoprostol; misoprostol
alone

Cervical preparation
 Prior to surgical abortion, all women with a pregnancy over 12 to 14 weeks of gestation.
 may be considered for women with a pregnancy of any gestational age.
 Any one of these before surgical abortion in the first trimester is:
 oral mifepristone 200 mg (24 to 48 hours in advance)
 misoprostol 400 μg administered sublingually/vaginally, 2 to 3 hours prior to the procedure
 laminaria placed intracervically 6 to 24 hours prior to the procedure
Recommendations for care preceding induced abortion

Ultrasound scanning
 Use of routine pre-abortion ultrasound scanning is not necessary.
Prophylactic antibiotics
 All women having surgical abortion, regardless of their risk of pelvic inflammatory infection, should
receive appropriate prophylactic antibiotics pre- or peri-operatively.
 For medical abortion, routine use not recommended.
Pain management
 All women should be routinely offered pain medication (e.g. non-steroidal anti-inflammatory drugs)
during both medical and surgical abortions.
 General anaesthesia is not recommended routinely

 Contraception
 Women may start hormonal contraception at the time of surgical abortion, or as early as the
first pill of a medical abortion regimen.
 Following medical abortion, an intrauterine device (IUD) may be inserted.
 Follow-up
 There is no medical need for a routine follow-up visit following uncomplicated abortion.
Recommendations for care post-abortion

 Ian donald practical obstetric problems- 6th edition
 RNTCP guidelines- DOTS
 RNTCP guidelines- DOTS plus for MDR TB
 Fogsi- Focus 2012, comprehensive abortion care
 Journal of Antimicrobial Chemotherapy (2009) 64, 895–900Advance Access
publication 25 August 2009 The safety of highly active antiretroviral therapy for the
HIV-positivepregnant mother and her baby: is ‘the more the merrier’? F. Martin*
and G. P. Taylor
References

 Dr Mrs Gayatri Vs Manga s Dhake
 Case of MTP failure
The district forum observed the following:
 Doctor was RMP under the act
 Centre was recognised, All documents were maitained
 Indication was valid,“100% termination is a myth”

 Surendra chauhan vs state of Madhya pradesh 2000
 Homeopathy doctor performed second trimester MTP
 Since he was not a RMP under the MTP act- penalised Rs25,000
 Rigorous imprisonment of one and half years

 Vinitha Ashok Vs Lakshmi hospital:
 Case of cervical pregnancy, which bled and died inspite of
hysterectomy
 Complaintant plea was USG was not done before MTP
 Supreme court concluded tht USG is not mandatory before MTP

 P N Bhaskaran Vs Mrs molly robinson kera;a
 MTP failure
 State forumconcluded that <6 weeks, MTP is likely to fail
 Both D and C and suction evacuation are methods of MTP

 Untreated TB in pregnancy is associated with an increased risk of miscarriage and major
fetal abnormality.
 Anti- tuberculosis treatment should be started promptly
 first line drugs [isoniazid, rifampicin (rifampin), ethambutol have an excellent safety record
in pregnancy
 are not associated with human fetal malformations
Tuberculosis

 Pyrazinamide has also been used in pregnancy but safety profile has not been proved
beyond doubt
 there may be increased risk of hepatitis in pregnancy.
 It is prudent to advise all women of child-bearing age to avoid getting pregnant until
TB treatment is completed.
 Streptomycin should not be used in pregnancy- problems with hearing and/or
balance.

 All women of childbearing age who are receiving MDR-TB therapy should be advised
to use birth control measures because of the potential risk to both mother and foetus
 All women of childbearing age should be tested for pregnancy as part of the pre-
treatment evaluation
 whilst on treatment if there is a history of amenorrhea of any duration, the following
factors are considered
Muti- Drug Resistant TB

• Risks and benefits of MDR-TB treatment
• Severity of the MDR-TB
• Gestational age
• Potential risk to the foetus

Duration of pregnancy
<20 weeks
Pt not willing
Advise MTP
MTP
Pregnancy with MDR-TB

modified Cat IV
• ≤ 12 weeks – Omit
Kanamycin and Ethionamide;
add PAS
• >12 wks – Omit Kanamycin
only ; add PAS
•Replace PAS with
Kanamycin after delivery a
Patient not willing for MTP

> 20 weeks
Start modified Cat IV
•Omit Kanamycin; Add PAS till
delivery
•Replace PAS with Kanamycin
after delivery and continue

 No increase in birth defects following in utero ART exposure during
organogenesis has been seen
 Efavirenz is the only ART classified by the US FDA in Class D on the
basis of retrospective case reports of spina bifida and Dandy–Walker
syndrome
 It is recommended that women conceiving on an effective HAART
regimen should continue HAART this even if it contains efavirenz

 At this stage of antiretroviral development those mothers in need of
HAART can be reassured that HAART gives a survival benefit to the
mother and reduces the transmission risk of HIV to her baby 7-fold
 this outweighs the risks for adverse pregnancy outcomes associated
with HAART.
 Women in first trimester may consider delaying inititation of therapy
until 1st trimester

 To make an informed decision about whether to continue with the pregnancy
or have an abortion,
 women living with HIV/AIDS need to know the risks of pregnancy to their own
health, the risksof transmission of HIV to their infant and

 the effectiveness,the availability and cost of antiretroviral drugs for
 treating HIV infection
 for preventing HIV infection among infants as well as the potential toxicity of such
drugs.
 They also need to know the side effects and risks of the abortion procedures
available.
 The woman should make the final decision to terminate a pregnancy WHO 2006

 Cat IV regimen comprises of
 6 drugs
 kanamycin, ofloxacin (levofloxacin), ethionamide, pyrazinamide, ethambutol and
cycloserine during 6-9 months of the Intensive Phase
 4 drugs- ofloxacin (levofloxacin), ethionamide, ethambutol and cycloserine during
the 18 months of the Continuation Phase.

Safest abortions are performed early by trained medical
practitioners in hygienic settings within the appropriate
legal framework
•strengthening and widening of the
pool of qualified providers
•Promote public education about
safe abortion through clinics and
Anganwadi Centers

Safe abortion

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