SISTER NIVEDITA GOVERNMENT NURSING COLLEGE

IGMC, SHIMLA

SUBJECT: OBSTETRICS AND GYNAECOLOGICAL NURSING

ASSIGNMENT ON: MEDICAL TERMINATION ACT

SUBMITTED TO: SUBMITTED BY:

Mrs. Prema Negi Archita Sharma

Lecturer (Obstetrics and Gynaecological Nursing) MSC (N) 1st Year

SNGNC, IGMC SNGNC, IGMC

Shimla Shimla

SUBMITTED ON:

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INTRODUCTION

 A medical abortion is brought about by taking medications that will end a pregnancy,
alternative is the surgical abortion which ends a pregnancy by emptying the uterus
(womb) with special instruments.
 Hippocratic oath forbade physicians from inducing elective abortions.
 But, Aristotle held that abortion was ethical if performed in the first trimester of
pregnancy.
 BEFORE 1971:
 Abortion – purposely causing miscarriage
 1860 IPC under British rule – induced abortion is illegal
 Abortion practitioners would either be incarcerated for 3 years or fined or both
 Women could be imprisoned up to 7 years and also would be fined
 Only exception was abortion done to save women life.

DEFINITION

Deliberate termination of pregnancy either by the medical or surgical method before the
viability of the fetus is called induction of abortion.

MTP 1971

 The Indian Abortion law falls under the Medical Termination of Pregnancy (MTP)
Act, which was enacted by the Indian Parliament in the year 1971 with the intension
of reducing the incidence of illegal abortion and subsequent maternal mortality and
morbidity. The MTP Act came into effect from 1 April 1972 and has been amended
many times since then for the betterment and upliftment of the women and girls.
 Abortion was criminalized under Section 312 of IPC, 1861.
 MTP Act came into force in August 1971 after Shantilal Shah Committee report,
1964.
 Extended to entire India except the erstwhile state in J and K.
 Pregnancy up to 12 weeks could be terminated by and up on an opinion of a registered
medical practitioner.

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 Pregnancy up to 20 weeks could be terminated up on opinions of not less than two
registered medical practitioners.
 The Supreme Court permitted a rape supervisor to terminate her pregnancy at 24
weeks, which is beyond the permissible 20 weeks limit prescribed under the Medical
Termination of Pregnancy Act, 1971
 Conditions under which a pregnancy can be terminated.
 Who can perform such terminations.
 The place where such terminations can be performed.
 CONDITIONS WHERE PREGNANCY CAN BE TERMINATED:
 Medical
 Eugenic
 Humanitarian
 Socio economic
 Failure of contraceptives
 OUALIFICATIONS TO PERFORM ABORTION
 Assistance of at least 25 cases of MTP in approved institution.
 6 months of Housemanship in OBG
 3 years of practice in OBG for those doctors registered before 1971 MTP act was
passed.
 PLACE WHERE MTP IS PERFORMED
 Place established and maintained by Government
 Non government institutions can perform provided they obtain license from Chief
Medical Officer of the district.

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MTP (AMENDMENT) BILL

January
20 Cleared by the Union Cabinet
20
17 March
20 Bill passed by Lok Sabha
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16 March
20 Bill passed by Rajya Sabha
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25 March
20 Becomes an Act by extraordinary Gazette
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LEGAL ABORTION

 Termination is performed by the medical practitioners by the act.

 Termination is done at the place approved by this act.
 Termination is done for condition and within the gestation week prescribed by the act.
 The abortion has to be reported to the director of health service of the state.

CONSENT

 Can only be terminated on a written informed consent of the woman, husband consent
not required.
 <18 years or lunatic – written consent of parent or legal guardian.
 Termination is permitted up to 20 weeks of pregnancy

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  When pregnancy >12 weeks 2 medical practitioners opinion required.
 The abortion has to be performed confidentiality and reported to Director of Health
Services in prescribed form.

INDICATIONS

 Women whose physical and/or mental health was endangered by the pregnancy.
 Women facing the birth of a potentially handicapped or malformed child
 Rape
 Pregnancies in unmarried girls under the age of eighteen with the consent of a
guardian
 Pregnancies that are a result of failure in sterilization

METHODS OF TERMINATION

 Ist TRIMESTER
 Medical
 Mifepristone
 Mifepristone and Misoprostol
 Methotraxare and Misoprostol
 Tamoxifene and Misoprostol
 Surgical
 Vacuum aspiration
 Menstrual regulation
 Suction evacuation and/or curettage
 Dilatation and evacuation (Rapid and slow method)
 2nd Trimester
 MEDICAL METHODS
 Prostaglandins
 Misoprostol

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 Carboprost
 Dinoprost
 Intrauterine instillation of hypertonic solutions
 Oxytocin infusion
 SURGICAL METHODS
 Between 13-15 weeks
 Dilatation and Evacuation (Rapid and slow method)
 Between 16 and 20 weeks
 Intra amniotic instillation of hypertonic saline (20%).
 Extra amniotic instillation of 0.1% ethacrydine lactate
 Hystrectomy

CLASSIFICATION OF DRUGS USED IN MTP

Carboplast Mifepristone Methotraxate

Sulprostone Lilopristone
Dinoprostone Onapristone
Gemeprost Ulipristal
Misoprostol

 MIFEPRISTONE:
 Synthetic steroid
 Antiprogesterone, antiglucocorticoid and antiandrogen.
 Partial agonist, competitive antagonist in presence of progesterone
 80-85% effective in causing abortion.
 Mode of action

Mifepristone blocks progesterone receptors

Endometrial decidual degeneration

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 Trophoblast detachment

Decrease HCG from syncytotrophoblast

In turn decrease progesterone by corpus luteum

 Pharmacological Actions
 Decidual breakdown by blockade of uterine PR.
 Detachment of the blastocyst which decreases HCG production
 Decrease in progesterone secretion from the corpus luteum.
 Increase uterine PG levels.
 Sensitizes the myometrium to their contractile actions
 Cervical softening, which facilitates expulsion of the detached blastocyst.
 Pharmacokinetics
 Orally active with good bioavailability.
 T1/2 of 20-40 hrs.
 Bound with alpha 1 acid glycoprotein.
 Hepatic metabolism and enterohepatic circulation.
 Metabolic products are found predominantly in the feaces.
 Contraindications
 Ectopic pregnancy
 In presence of IUD
 Adrenal failure
 Hemorrhagic disorders
 Porphyria
 Patients on long term therapy with corticosteroids.
 MISPROSTOL (PGE1)
 Synthetic prostaglandin E1.
 Inexpensive and can be stored at room temperature.
 Mechanism of action
 Binds to myometrial cells causes myometrial contraction and expulsion of tissues.

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 Also causes ripening of cervix.
 Pharmacokinetics
 After oral administration, rapidly absorbed from the GI tract
 T1/2 20-40 minutes.
 DOSE: 400ug oral misoprostol, the plasma misoprostol level increase rapidly and
peaks at about 30 minutes declines rapidly by 120 minutes and remains low thereafter.
 ROUTES OF ADMINISTRATION: Oral, vaginal, sublingual, buccal and rectal.
 Mainly urinary excretion.
 PROTOCOL
200mg of mifepristone given orally on day 1

On day 3 misoprostol 400mcg PO or 800mcg PV

Patient remains in hospitals for 4 hours during which expulsion occurs in 95% of cases

 GEMEPROST
 PGE1 analouge (16, 16-dimethyl-trans-d2-PGE1 methyl ester)
 Used as a vaginal pessaary. Every 3-6 hours for 5 doses in 24 hours.
 Has got 90% success rates.
 Used as a non surgical method to dilate the cervix before VA in late first and early
second trimester abortion.
 Side effects:
 Vaginal bleeding
 Cramps
 Nausea
 Vomiting
 Diarrhea
 Headache
 Muscle weakness
 Backache
 Chest pain
 CARBOPROST
 Carboprost tromethamine PGF2alpha analogue.

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 First analogue to be tested clinically on a large scale for the termination of a second
trimester pregnancy.
 Mechanism of action
 It acts on the corpus luteum to cause leutolysis, forming a corpus albicans and
stopping the production of progesterone.
 DOSE: IM 100-200ug
 Postpartum hemorrhage
 ADR: diarrhea (most common)
 Fever
 Chills
 Vomiting
 Cardiovascular collapse
 Postural hypotension
 DINOPROSTONE
 Synthetic derivative of PGE2
 ROUTE OF ADMINISTRATION: vaginal/oral
 Intra vaginal suppository 20mg 3-5 hours repeated.
 Half life: 2.5-5 minutes. Excreted in urine
 Induction abortion in second trimester/early abortion
 Cervical ripening: 10mg tab/0.5mg gel 6 hrly.
 Side effects:
 Prolonged vaginal bleeding
 Severe menstrual cramps
 GI toxicity
 METHOTRAXATE
 MTX is an anti folate belonging to the anti metabolite class of anti neoplastic agent.
 MTX is a cell cycle specific chemotherapeutic agents that acts on S phase
 Inhibit DNA synthesis.
 Pharmacokinetics
 Readily absorbed from the GI tract at doses of <25mg/m2
 7 hydroxy methotraxate NEPHROTOXIC
 T1/2 8 hours IM
 50% of methotraxate binds to plasma proteins.

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 Up to 90% of a given dose is excreted unchanged for long periods
 Weeks in the kidneys and for several months in the liver.
 Methotraxate/Misoprostol Regimens
 Methotraxate: 50 mg/m2 or IM or 50mg PO
 Misoprostol: 800ug PV 3-7 days later
 Efficacy decreases after 49 days gestation
 Initial follow up 1 week after methotraxate.
 Subsequent care based on the results of physical examination, ultrasonography
 If HCG has fallen by >80% over 7 days, procedure was successful
 Treatment effects and side effects associated with MTX (25-27, 35, 42-44)
 Treatment effects:
 Increase in abdominal girth.
 Increase in HCG during initial therapy
 Vaginal bleeding or spotting
 Abdominal pain
 Drug effects:
 Gastric distress
 Nausea
 Vomiting
 Stomatitis
 Dizziness
 Severe neutropenia
 Reversible alopecia
 Pneumonitis
 Contraindications
 Anemia (Hgb<10g/dl)/leucopenia/thrombocytopenia
 Known coagulopathy
 Active renal or liver disease
 Uncontrolled seizure disorder
 Acute inflammatory bowel disease
 Intrauterine device in situ
 High initial HCG concentration> 5000mU/ml
 Ectopic pregnancy>4cm in size as in TVS
 Regimens for Medical Abortion and their effectiveness

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REGIMENS EFFECTIVENESS UP TO
Mifepristone + Misoprostol >96% 9 weeks from last menstrual
or Mifepristone + period
Gemeprost
Misoprostol alone >83% 12 weeks from last menstrual
period
Methotraxate + Misoprostol >90% 9 weeks from last menstrual
period

 OLDER METHODS
 Hystrectomy
 Intra amniotic injection of hypertonic saline/hyper osmolar urea
 Intra or extra amniotic administration of ethacryidine lactate (Rivanol)
 Parenteral/intra amniotic/extra amniotic administration of prostaglandin (PG)
analogues
 IV/IM administration of oxytocin.
 ETHACRIDINE LACTATE
 Ethacridine Lactate/Rivanol is a yellow dye with antiseptic properties.
 Mechanism of Action: Stimulus endogenous PG and thromboxane production,
promoting cervical priming and initiating labor.
 DOSE: 0.1% solution of ethacridine lactate- extra amniotic space through a sterile
catheter at a dose of 10ml/gestation week.
 20-40 hrs mini labor
 Maximum of 150ml
 HYPERTONIC SALINE
One of the first described instillation methods
 When used alone, intra amniotic hypertonic saline has a long latent period until the
onset of contractions.
 Time to abortion of 30 hours
 Addition of oxytocin to this regimen improves the efficiency and expulsion time.
 Use of concentration exceeding 20%
 Maternal hypernateria
 Coagulopathy

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  Hemorrhage
 Cervical laceration
 IV OXYTOCIN
 First described by Winkler and associates
 100 units/500ml of DNS, is infused over 3 hours
 The dose is increased 50 units/500ml of DNS until delivery is achieved.
 Maximum of 300 units.
 Mean time to delivery of 8.2 hours.
 UREA
 Rapidly traverses cell membranes.
 Has a long instillation to abortion interval when used alone
 Intra amniotic urea, 80-90g, with intravenous oxytocin
 Average time to expulsion of 19-29 hours.

COMPLICATIONS OF MTP

 IMMEDIATE
 Injury to the cervix (cervical laceration)
 Uterine perforation during D and E.
 Hemorrhage and shock due to trauma, incomplete abortion, atonic uterus or rarely
coagulation failure
 Thrombosis or embolism
 REMOTE
 Gynecological
 Obstetrical
 Gynecological
 Menstrual disturbances
 Chronic pelvic inflammation
 Scar endometriosis (1%)
 Obstetrical
 Ectopic pregnancy (threefold increase)
 Preterm labor

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  Dysmaturity
 Ruptured uterus

MEDICAL TERMINATION OF PREGNANCY (MTP) AMENDMENT

ACT, 2021

As in 2021, the Delhi High Court has allowed the medical termination of pregnancy of a
woman who had completed 22 weeks of gestation as the fetus was suffering from multiple
abnormalities.

 Gestation is the fetal development period from the time of conception till birth.
 In India, the Medical Termination of Pregnancy Act stipulates a ceiling f 20 weeks,
for termination of pregnancy, beyond which abortion of a fetus is statutorily
impermissible.

KEY POINTS IN MTP ACT, 2021

 About MTP Act:

 The Medical Termination of Pregnancy Act, 1971 was passed due to the progress
made in the field of medical science with respect to safer abortions.
 In a historic move to provide universal access reproductive health services, India
amended the MTP Act 1971 to further empower women by providing comprehensive
abortion care to all.
 The new Medical Termination of Pregnancy Amendment Act 2021, expands the
access to safe and legal abortion services on therapeutic, eugenic, humanitarian and
social grounds to ensure universal access to comprehensive care.

THE MTP ACT 1971 AND THE MTP ACT AMENDMENTS 2021

MTP ACT 1971 MTP AMENDMENT ACT 2021

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Indications Only applies to married women Unmarried women are also
(Contraceptive Failure) covered
Gestational Age Limit 20 weeks for all 24 weeks for rape survivors
Before 24 weeks for substantial
fetal abnormalities.
Medical practitioner One RMP till 12 weeks One RMP till 20 weeks
opinions required before Two RMPs till 20 weeks Two RMPs 20-24 weeks
termination Medical Board approval after 24
weeks
Breach of the woman’s Fine up to Rs.1000 Fine and/or imprisonment of 1
confidentiality year

MTP ACT 2022

 The Medical Termination of Pregnancy (MTP) Act 1971 was amended in 2021. The
MTP Amendment Act, 1971 was amended in 2021.
 The MTP Amendment Act of 2022 states that all women, regardless of marital status,
are entitled to access legal and safe abortions up to 24 weeks of gestation.
 The MTP Amendment Act also provides for the constitution of the Medical Boards at
approved facilities, which may allow or deny termination of pregnancy beyond 24
weeks.
 The Supreme Court of India’s judgment on 29th September, 2022, held that
unmarried women have the same right to abortion as well as married women. The
court emphasized that all women, regardless of marital status, are entitled to access
legal and safe abortions up to 24 weeks of gestation.

THE MTP AMENDMENT ACT OF 2022 ALSO STATES THAT:

 Minors (under 18 years age) or lunatics can only terminate a pregnancy with written
consent of a guardian.
 Adult women over 18 years age can terminate a pregnancy with their valid consent.
 Medical Boards at approved facilities may “allow or deny termination of pregnancy”
beyond 24 weeks.

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  The MTP Act of 1971 and its rules of 2003 prohibit unmarried women who are
between 20 weeks to 24 weeks pregnant to abort with the help of registered medical
practitioners.
 In the final order dated 29 September 2022, the apex Court laid down the principle of
autonomy of every woman in accessing medical termination of her pregnancy.

MTP ACT 2023

 By its order dated 9th October 2023, this Court allowed the petition and permitted the
medical termination of the pregnancy on the ground that continuing with the
pregnancy could seriously imperil the mental health of the petitioner.
 The medical provider can give guidance on what is best for your situation. This
information does not constitute medical advice or diagnosis.

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CONCLUSION

 Section 3[1](B)(i) of MTP Act (1971) states that if the continuation of pregnancy
poses a risk to the life of the pregnant woman or grave injury to her physical or
mental health, it is valid indication for termination of pregnancy.
 MTP for unplanned pregnancy can be prevented if the people are well informed
about methods of contraception. MTP is an opportunity for healthcare professionals
to discuss fertility needs and need for contraception with women seeking MTP so
that appropriate decisions can be taken for suitable family planning.
 Married clause dropped – the MTP Act earlier permitted termination of pregnancy
by only a married woman in case of failure of contraceptive method or device. With
the amendment, unmarried women can now seek safe abortion services on grounds
of contraceptive failure.
 MTP approach is effective for reducing inappropriate medicine use in hospitals,
including drug use problems in hospitalized patients.
 MTP approach is feasible to implement at minimum cost, and feasible to be
incorporated in the existing hospital managerial activities.
 MTP approach is promising for nationwide implementation.
 The MTP approach was effective in solving drug use problems in small setting,
especially the specific problem in the department of hospitals.
 The MTP can solve any problems by discussion and agreement in the teamwork.

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SUMMARY

 An act to provide for the termination of certain pregnancies by registered medical

practitioners and for matters connected therewith or incidental thereto.
 In India, it is legal to terminate pregnancy upto 20 weeks, under special
circumstances.
 Only the consent of women (more than 18 years) is required for MTP.
 For private sites: MTP site approval is done by District Level Committee.
 There are different experience/training and site requirements for 1 st and 2nd trimester
MTPs.
 Documentation of the MTP procedure includes filling up the following forms: C
(Consent form), I (Opinion form), II (Monthly Reporting form), III (Admission
Register).
 Rights available to married women under Medical Termination of Pregnancy Act,
1971, to abort a fetus will also be available to unmarried women.
 The distinction between married and unmarried women under the abortion laws is
“artificial and constitutionally unavailable” and perpetuates the stereotype that only
married women are sexually active.

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BIBLIOGRAPHY

 http://www.slideshare.net/manjuprasad16/mtp-75946799
 http://www.slideshare.net/SnehlataPrashar/medical-termination-of-pregnancy-
133170776
 http://slideplayer.com/amp/13398514/
 http://www.drishtiias.com/daily-updates/daily-news-analysis/medical-termination-of-
pregnancy-mtp-amendment-act-2021
 http://www.slideshare.net/AshishGupta215/medical-termination-of-pregnancy-act-
2021
 http://www.fogsi.org/wp-content/uploads/committee-2020-activities/fogsi-mtp-
committee-bulletin-4.pdf
 http://main.sci.gov.in/supremecourt/
2023/42181/42181_2023_1_24_47700_Judgement_16-Oct-2023.pdf
 http://www.ctdt.co.in/doi/CTDT/pdf/10.5005/jp-journals-10055-
0162#:~:text=(AMENDMENT)%20ACT%202022&text=The%20court
%20emphasized%20that%20all,to%2024%20weeks%20of%20gestation

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