Medical Termination of Pregnancy

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Medical Termination of Pregnancy
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• Prof. Ashis Kumar Mukhopadhyay
• Professor, G O
• Medical Superintendent-cum-Vice Principal
• CSS College of Obstetrics Gynaecology, Kolkata
• National Chairperson,
• Medical Education Committee of FOGSI

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Perspective

• 26 million pregnancies are terminated annually
  legally.
• 20 million terminated illegally.
• Unsafe (Illegal) abortions may far exceed safe
  abortions, the ratio being 16 to 111.
• 78000 annual deaths. In India 11.8 of MMR (GOI,
  1990).
• Abortion care centres are few far between,
  accessibility is poor, training inadequate and do
  not meet MTP Act requirements.
• Paramedics and quacks are involved more often
  than not.

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Methods of Abortion

• A. Surgical
• S/E is safer less painful than D/E . Success
  rate 98-99.
• Disadvantages of Surgical abortion-
• Requires highly skilled personnel, because-
• Blind technique.
• Pregnant uterus is very soft prone to injury
• Problems of under-curetting, and
• Overzealous curettage? Ashermans.

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Methods of Abortion

• Surgical.contd.
• Requirement of Anaesthesia GA or local
• Higher chance of septic abortion.
• Mostly following illegal induced abortion (gt90).
  6.5 from legal surgical abortion.
• Very high mortality 6-13
• Serious morbidity including fecal fistula.

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Methods of Abortion

• Medical- also called Chemical abortion.
• Advantages-
• Possible at earlier stage of pregnancy.
• Private procedure.
• No trauma to the utrus cevix and other organs.
• Post-abortal endometritis very rare.
• No anaesthetic hazards.

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Methods of Abortion

• Medical abortion.contd.
• Disadvantages-
• Lengthy procedure
• Uncertain
• Unpredictable (timing).
• Failure rate 2-10.
• Psychological effect.
• Difficulty in diagnosing ectopic pregnancy.
• Side-effects of drugs.

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Development of medical methods of induced
abortion with mifepristone
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(No Transcript)
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Randomised comparison of medical and surgical
abortion at 10-13 weeks gestation(Total of 486
women)
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Mechanism of Medical Abortion

• 3 ways to do it-
• Antagonising or negating the action of
  Progesterone.
• Inhibiting development of trophoblast.
• Inducing myometrial contraction.
• Agents used for the purpose are
• Mifepristone as anti-progesterone (RU-486).
• Methotrexate as cytotoxic drug for growing embryo
• Misoprostol, which stimulates uterine
  contraction.

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The Combinations

• Methotrexate Misoprostol 90-95 SR
• Mifepristone Misoprostol 95-99 SR.
• Most useful within 49 days of
  pregnancy, although approved in
  England for use upto 63
  days (9 weeks).
• Pre-requisites-
• Bimanual pelvic examination
• Baseline hematocrit
• ABO/Rh.

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Mifepristone

• M/A Antagonises progesterone at target tissue.
• Chemistry
• The 11-beta substitution is responsible for
  anti-progestogenic activity.

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Misoprostol

• Synthetic PG E1 analogue. (other agent is
  gemeprost)
• Inexpensive, can be stored at room temp.
• Used in many countries for treatment prevention
  of peptic ulcer caused by NSAIDs.
• 85 protein-bound.
• Half-life of 30 mins.
• Also used for midtrimester abortion, cervical
  ripening, induction of labour, t/t of PPH.
• Available as oral tab which can be used vaginally.

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Mifepristone Misoprostol

• The preferred combination.
• Mifepristone alone gives low success rate.
• Misoprostol is a weak abortifacient, success rate
  varying from 66 to 83.
• But with the combination-
• Complete abortion rate at 49 days is 83-87
• At 56 days it is 87-90
• At 63 days it is 92-95.

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Studies on Mifepristone Misoprostol or
Gemeprost
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Studies on Mifepristone Misoprostol or
Gemeprost
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Studies on Mifepristone Misoprostol or
Gemeprost
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Dosage and Administration

• 3 clinic visits by the patient-
• Day 1 Single dose Mifepristone 600 mg orally
  (now-a-days 200 mg.)
• Day 3 If abortion has not occurred a single oral
  dose of misoprostol 400 mcg (2 tabs). 2-5 pts.
  abort by now following mifepristone alone.
  Followed up in clinic for 4 hours then
  discharged.
• Day 14 follow-up. Clinical and/or ultrasound to
  assess for completed abortion.