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Medical Termination of Pregnancy (MTP)

Renu Maurya

Medical Termination of Pregnancy (MTP)

Medical Termination of Pregnancy (MTP)

INDICATIONS:

To save the life of the mother (Therapeutic or Medical termination):

  • Cardiac diseases (Grade III and IV) 
  • Chronic glomerulonephritis
  • Malignant hypertension
  • Intractable hyperemesis gravidarum
  • Cervical or breast malignancy
  • Diabetes mellitus with retinopathy.
  • Epilepsy or psychiatric illness with the advice of a psychiatrist.

Social indications:

  • 80% Parous women having unplanned pregnancy with low socioeconomic status.
  • Pregnancy caused by rape or unwanted pregnancy caused due to failure of any contraceptive device also falls in this category (20%).

Eugenic:

  •  Structural (Anencephaly), chromosomal (Down’s syndrome) or genetic (Hemophilia) abnormalities of the fetus.
  • Deformed fetus :teratogenic drugs (warfarin) or radiation exposure (>10 rad) in early pregnancy.
  • Rubella, a viral infection affecting in the 1st trimester

RECOMMENDATIONS:

  • Termination can only be performed in goverment hospitals 
  • Pregnancy can only be terminated on the written consent of the woman
  • Termination is permitted up to 20 weeks of pregnancy. 
  • When the pregnancy exceeds 12 weeks opinion of two medical practitioners is required.
  • Pregnancy in a minor girl (below the age of 18 years) or lunatic cannot be terminated without written consent of the parents or legal guardian
  • Registered medical practitioner is qualified to perform an MTP provided
  • Assisted in at least 25 MTP in an authorized center and having a certificate.
  • Got 6 months house surgeon training in obstetrics and gynecology
  • Diploma or degree in obstetrics and gynecology 

MEDICAL METHODS OF TERMINATION OF PREGNANCY

FIRST TRIMESTER ABORTION:

Mifepristone (RU-486) and Misoprostol:

  • Mifepristone antagonise progesterone.
  • low-dose prostaglandins (PGE1) improves the efficiency of first trimester abortion.
  • Oral mifepristone 200 mg (1 tab) with vaginal misoprostol 800 μg (4 tab, 200 μg each) after 6–48 hours

Methotrexate and Misoprostol:

  • Methotrexate 50 mg/m2 IM (before 56 days of gestation) followed by 7 days later misoprostol 800μg vaginally is highly effective
  • Misoprostol may have to be repeated after 24 hours if it fails.

Contraindications(Mifepristone):

  • Aged over 35 years
  • Heavy smokers
  • Long-term corticosteroid.

MIDTRIMESTER TERMINATION OF PREGNANCY:

PROSTAGLANDINS: (Prostaglandins and their analogs)

  • Act on the cervix and the uterus
  • PGE (dinoprostone, sulprostone, gemeprost, misoprostol) and PGF (carboprost) analogs are used
  • PGEs are preferred as they have more selective action on the myometrium and less side effects.

Misoprostol (PGE1 analog): 

  • 400–800μg of misoprostol given vaginally at an interval of 3–4 hours
  • First dose of 600 μg misoprostol given vaginally then 200 μg, orally every 3 hours are also found optimum

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 four doses is used.

Gemeprost (PGE1 analog): 

  • 1 mg vaginal pessary every 3–6 hours for five doses in 24 hours
  • The mean induction-abortion interval was 14–18 hours

Dinoprostone (PGE2 analog): 

  • 20 mg is used as a vaginal suppository every 3–4 hours
  • PGE2 is thermolabile (needs refrigeration) and is expensive.

Prostaglandin F2α(PGF2α):

  •  carboprost trometha mine—250 μg IM every 3 hours for a maximum ten doses

OXYTOCIN: 

  • High-dose oxytocin as a single agent can be used for second trimester abortion.
  • used with intravenous normal saline along with any of the medications used either intra-amniotic or extra-amniotic space
COMPLICATIONS: 
  • Prostaglandins—intractable vomiting, diarrhea, fever, uterine pain and cervicouterine injury
  • Oxytocin—water intoxication and rarely convulsions
  • Saline—hypernatremia, pulmonary edema, endotoxic shock,DIC,renal failure, cerebral hemorrhage

Exam Important

  • Maximum age of foetus for MTP is 20 weeks
  • Under the Medical Termination of Pregnancy Act the opinion of two registered medical practitio­ners is necessary to terminate the pregnancy Where the pregnancy exceeds 12 weeks
  • The minimum age for giving consent for medical termination of pregnancy is 18 years
  • Hypertonic saline methods of MTP is as­sociated with the complication of coagulopathy
  • Prostaglandin  cannot be used for MTP in a patient with bronchial asthma
  • Mifepristone & misoprostol is used in Ist trimester MTP
  • Methotrexate, Mifepristone & Misoprostol  are used in the medical termination of early pregnancy
  • Pregnancy from rape, Substantial risk of delivering seriously handicapped baby & Injury to physical and mental health of the pregnant women are  indication for doing Medical Termination of pregnancy
  • Medical termination of pregnancy can be done by a registered medical practitioner if the gestation period is less than 12 weeks
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