Medical termination of pregnancy is a procedure of terminating pregnancy using medicines by a registered medical practitioner in the interest of the mother’s health and life, up to 20 weeks of pregnancy.
MTP refers to the induction of abortion before the viability of the fetus and is legalized by the “Medical termination of pregnancy Act” of 1971, in India. Abortion is not yet legalized in many countries.
Indications of MTP
- To save the life of the mother in certain conditions such as heart diseases, kidney disorders, hypertension, malignancies, convulsions and psychiatric disorders.
- When pregnancy is caused by rape or due to failure of the contraceptive devices.
- To prevent injury to the physical and mental health of the mother.
- There is a risk of the child being born with physical and mental abnormalities.
Recommendations
- A registered medical practitioner is qualified to perform an MTP.
- Pregnancy can only be terminated with the written consent of the woman.
- Pregnancy in a minor girl can only be terminated with the written consent of the parents or legal guardians.
- Termination of pregnancy is permitted up to 20 weeks of pregnancy and the opinion of 2 medical practitioners is required in case pregnancy exceeds 12 weeks.
- Confidentiality of performing the procedure is maintained.
Methods of termination of pregnancy
Termination of pregnancy is done up to 20 weeks and divided into first-trimester termination and second-trimester termination. A medical practitioner may carry out a pregnancy test and ultrasonography to confirm the period of pregnancy so that a suitable method could be opted to terminate the pregnancy.
First trimester termination
1. Surgical methods
- Manual vacuum aspiration– It is an outpatient procedure, performed up to 7 weeks of pregnancy by using a flexible vacuum cannula and a plastic syringe. It is quicker, less traumatic and safer than any other procedure.
- Suction evacuation and curettage– This procedure involves sucking out the products of conception from the uterus with the help of the cannula fitted to a suction apparatus. It is also done as an outdoor procedure and up to 10 weeks of pregnancy.
- Dilatation and evacuation(D&E)- It consists of dilatation of the cervix and evacuation of the products of conception from the uterine cavity. Vaginal Misoprostol for dilatation of the cervix before the procedure is very effective. One day hospitalization is required for this procedure.
2. Medical methods
- Mifepristone and misoprostol pills are used to terminate medically. It is highly successful when used within 50 days of gestation. They block the effect of natural progesterone and its shortage affects the uterine lining. If the level of progesterone falls, it prevents the pregnancy to proceed further and results in contraction and expulsion of the foetus within a few hours or days. The patient is re-examined after 10 to 14 days to confirm the complete termination of pregnancy and check for any complications. In 95% of cases, complete abortion occurs; in 2% of cases incomplete abortion occurs (D & E done) and about 1% do not respond at all.
- Methotrexate and Misoprostol regimen is less expensive and takes longer time and taken before 56 days of gestation.
- Tamoxifen and misoprostol- Tamoxifen is taken orally for 4 days followed by Misoprostol vaginally results in complete abortion and gestation should be less than 63 days.
Second trimester termination
1. Between 13-15 weeks
There is a risk associated with the termination of pregnancy in the second trimester. The following are the procedures involved in inducing the abortion process-
- Dilatation and Evacuation– This procedure is less commonly done in the second trimester, if done then pregnancy at 13 to 14 weeks is evacuated with prior cervical dilation with laminaria tents or metal dilators and Misoprostol.
- Prostaglandins such as Misoprostol, Carboprost and Dinoprostone are used intra vaginally, intra muscularly and intra amniotically especially in the second trimester. They act on the cervix and uterus.
- Pregnancy is allowed to continue about 16 weeks so that the uterus will be enlarged enough when the available intrauterine installation techniques can be employed using pharmacological agents.
2. Between 16-20 weeks
- Intra amniotic instillation of hypertonic saline– In this process, saline is instilled into the amniotic sac with the fine polythene tube connected with the drip set. It excites uterine contractions and results in the expulsion of the foetus.
- Intra amniotic installation of hyperosmotic urea– In this process, installation of 40% urea solution with syntocinon drip is effective.
- Extra amniotic instillation of 0.1% ethacrydine lactate-Procedure involves the passage of Foley’s catheter into the uterine cavity between the membranes and myometrium and the balloon is inflated (10 ml) with saline and removed after 4 hours. Stripping the membranes with the liberation of prostaglandins from decidua and dilation of the cervix by the catheter are some of the factors for initiation of the abortion.
- Oxytocin– Most commonly used is syntocinon along with the medications used either intra amniotic or in extra amniotic space in an attempt to initiate the abortion process.
- Hysterotomy– It is a surgical procedure through the abdominal route and is less commonly done these days. It is only indicated in case of failure of medical induction of abortion.
Complications of MTP
If termination is done before 8 weeks then complications are less than 5%. The complications are about 5 times more in second-trimester termination.
1. Immediate complications
- Hemorrhage
- Injury to the cervix and uterus lead to shock
- Bleeding, pain and fever due to retained clots
- Thrombosis or embolism
2. Remote complications
- Menstrual irregularities
- Pelvic inflammatory diseases
- Infertility
- Recurrent abortion due to cervical incompetence
- Rupture of the uterus
- Increased perinatal loss
- Preterm labour
- Ectopic pregnancy
- Dysmaturity
- Rh isoimmunization in Rh negative women
Conclusion
In the above post, we have discussed medical termination of pregnancy, the MTP Act, indications, recommendations, different methods of termination and complications.
