Medical Termination of Pregnancy
MTP Act 1971 and 2002 amendment
Legal abortions :
- Termination done for conditions and within the gestation prescribed by the Act with the consent of women.
- Termination done by a medical practitioner approved by the Act.
- Termination done at a place approved under the Act.
- Gestational age à Up to 20 weeks of gestation, with the consent of the woman,
- If the woman is below 18 years or is mentally ill, then with consent of a guardian.
- The opinion of a RMP has been formed in good faith, under certain circumstances.
- Opinion of two RMPs required for termination of pregnancy between 12 and 20 weeks
Indications :
- Risk to the life or grave injury to the physical or mental health of woman
- Substantial risk of physical or mental abnormalities in the fetus.
- Pregnancy caused by rape (presumed grave injury to mental health)
- Contraceptive failure in married couple (presumed grave injury to mental health)
Contraindications
- suspected ectopic pregnancy,
- intrauterine device in place,
- anemia, some hemorrhagic disorders,
- anticoagulant therapy,
- chronic adrenal failure, long-term corticosteroid therapy, inherited porphyrias, and inability to comply with the regimen or lack of access to emergency care in the case of a complication
Medications used for first-trimester medication abortion
Mifepristone —
- The progesterone receptor antagonist
- was approved by the US Food and Drug Administration (FDA) in 2001 as a 600 mg dose, but 200 mg is now commonly used.
- A meta-analysis of four randomized trials demonstrated 200 mg is equally effective for pregnancy termination as the originally approved 600 mg dose
- results in some softening and dilation of the cervix.
- Mifepristone’s primary effect in mifepristone-misoprostol medication abortion is to increase the sensitivity of the uterine and cervical muscle to the effect of misoprostol, resulting in greater success in pregnancy expulsion as compared with misoprostol alone
Misoprostol —
- a synthetic prostaglandin E1
- widely available and can be stored at room temperature, making it an ideal prostaglandin complement to mifepristone for first-trimester medication abortion.
- Misoprostol is the sole prostaglandin approved by the FDA for use for medication abortion, and the FDA requires that misoprostol be used in conjunction with mifepristone for medication abortion.
- Misoprostol given alone, whether by the vaginal or the buccal route, is less effective than when given in combination with mifepristone
Methotrexate-based regimens —
- Prior to FDA approval of mifepristone, methotrexate (50 mg/m2) followed by vaginal misoprostol (800 mcg) three to seven days later was used for medication abortion.
- However, a methotrexate/misoprostol regimen is less effective and requires a longer time to complete abortion compared with mifepristone/misoprostol.
- Another disadvantage to the methotrexate regimen is the prolonged interval from treatment to complete abortion associated with this regimen.
- The two drugs approved for use in India are Mifepristone and Misoprostol.
- In India, use of these drugs (Mifepristone and Misoprostol) for termination of pregnancy is approved up to nine weeks.
First-trimester medication abortion
- method of pregnancy termination with use of medications rather than a surgical procedure.
- Mifepristone (a progesterone antagonist), in combination with misoprostol (a synthetic prostaglandin E1), is approved for this use
- Medication abortion and aspiration abortion in the first trimester are both safe and effective procedures for appropriately selected patients.
- The choice between medication abortion and aspiration is based upon gestational age, availability, and patient preference.
- For women undergoing abortion at <63 days of gestation, medication abortion for women who place value on avoiding surgery or anesthesia and who are willing to accept more discomfort and awareness of the procedure
- Women who place a high value on completing the procedure in one visit are more likely to choose aspiration abortion.
- The steps of the procedure include
- Initial visit and mifepristone administration –
- This outpatient visit includes confirmation of pregnancy and
- medication abortion eligibility,
- counseling about options and informed consent, and
- blood typing (and administration of Rh immune globulin if needed).
- A single dose of mifepristone (oral, 200 mg) is administered.
- Misoprostol self-administration –
- Misoprostol 800 mcg is given to the patient to be self-administered buccally or vaginally at home 24 to 48 hours after taking mifepristone.
- Follow-up – Final follow-up to confirm complete abortion is conducted within two weeks
- Complete abortion is confirmed by measurement of human chorionic gonadotropin or by transvaginal ultrasound
- For women undergoing first-trimester medication abortion, we recommend buccal or vaginal administration of misoprostol rather than other routes à Oral administration of misoprostol is a reasonable option for women at ≤49 days of gestation.
- Failed medication abortion is treated with repeat misoprostol or surgical uterine evacuation.
- Side effects following administration of mifepristone and misoprostol primarily consist of
- nausea, crampy abdominal pain, vaginal bleeding, and gastrointestinal discomfort. Potential complications include hemorrhage, infection, incomplete abortion, or unrecognized ectopic pregnancy.
Second-trimester induction abortion
- Current protocols for second-trimester induction abortion typically include a prostaglandin, usually misoprostol, and may utilize mifepristone or oxytocin.
- Prior protocols that used hypertonic saline have been largely abandoned due to risks such as hypernatremia, coagulopathy, and hemorrhage.
ACOG recommends the following protocols for second-trimester induction abortion
An example of a protocol is mifepristone, 200 mg, administered orally followed by either:
•Misoprostol, 800 mcg, administered vaginally, followed by 400 mcg administered vaginally or sublingually every three hours for up to a maximum of five doses.
OR
•Misoprostol, 400 mcg, administered buccally every three hours for up to a maximum of five doses also may be used.
