MEDICAL

TERMINATION OF
PREGNANCY (MTP)

FOGSI

EDITORS

Dr. Alpesh Gandhi Dr. Bharti Maheshwari

FOGSI President FOGSI MTP committee chairperson

FOGSI-FOCUS Medical Termination of Pregnancy (MTP)

 FOGSI FOCUS
ON
Medical Termination Of Pregnancy (MTP)
Recent Update on Clinical and Legal Aspects

DEDICATED TO FRONT LINE CORONA WARRIORS

 EDITORS

Dr. Alpesh Gandhi Dr. Bharti Maheshwari

FOGSI President FOGSI MTP Committee Chairperson

Head of Dept, Obs and Gyn
Muzaffarnagar medical college
bhartinalok123@gmail.com
Mob: 9927856780

1
 PRESIDENT’S MESSAGE

Dear FOGSIANs
I wish you season’s gree ngs on behalf of FOGSI.
Reproduc on is a woman’s fundamental right. When a woman chooses to have a child, should be
her explicit choice. As gynaecologists, we wish to offer her this choice in a safe, risk-free manner,
so she has control on her own life choices without having to resort to unsafe and dangerous
prac ces.
The process of Medical Termina on of Pregnancy is, in this context, a step in the right direc on.
However, it has been used by many in an unlawful manner to exploit women in vulnerable
situa ons. It therefore became necessary to strictly regulate the prac se of MTP.
It is said that during the last year incidence of unwanted pregnancy and unsafe abor on increases
significantly because of COVID-19 lockdown. Recently parliament has also made an amendment
in MTP act and increases it’s limit up to 24 weeks for certain condi ons and with certain
regula ons.
In this FOGSI Focus, we talk about the methods and clinical aspects of abor ons. We also discuss
topics like infec on preven on, management of complica ons, difficult cases and procedures to
be followed in case of failures. We also cover counselling, which is an important part of the MTP
procedures, and is o en overlooked. We help navigate the minefield of government laws that
each gynaecologist has to follow, as well as discuss safety prac ces and service provision.
The theme for this year ac vi es of FOGSI is Safety First for Indian women and FOGSIANs. This
FOGSI FOCUS will help our members in their prac ce. It is my hope and expecta on that this issue
will be an asset to our prac sing consultants, and will serve as a handy guide for day to day use.
I wish safety to all of you and your pa ents.

Kind regards
Dr. Alpesh Gandhi
FOGSI President

2
 VICE PRESIDENT’S MESSAGE

If One does not support Legal abor on,

in effect, one is suppor ng illegal abor on”
Prof Arulkumaran

Every individual has the right to decide freely and responsibly – without discrimina on, coercion
and violence – the number, spacing and ming of their children, and to have the informa on and
means to do so, and the right to a ain the highest standard of sexual and reproduc ve health
Access to legal, safe and comprehensive abor on care, including post-abor on care, is essen al
for the a ainment of the highest possible level of sexual and reproduc ve health. Three out of
ten of all pregnancies end in induced abor on. Nearly half of all abor ons are unsafe, and almost
all of these unsafe abor ons take place in developing countries.
Access to safe abor on protects women’s and girls’ health and human rights Abor ons are safe
when they are carried out by following the rules and regula ons framed under the MTP act of
1971
When women with unwanted pregnancies do not have access to safe abor on, they o en resort
to unsafe abor on. An abor on is unsafe when it is carried out either by a person lacking the
necessary skills or in an environment that does not conform to minimal medical standards, or
both. Characteris cs of an unsafe abor on touch upon inappropriate circumstances before,
during or a er an abor on.
Unsafe abor on can lead to immediate health risks – including death – as well as long-term
complica ons, affec ng women’s physical and mental health and well-being throughout her life-
course. It also has financial implica ons for women and communi es.
I would like the congratulate Dr Bhar Maheshwari for the amazing work she has done as the
chairperson of the MTP Commi ee of FOGSI. In spite of the corona pandemic she has virtually
visited most socie es of FOGSI to update our members on the Do’s and Dont’s of safe abor ons.

Dr Atul Gantra
FOGSI Vice President

3
 SECRETARY GENERAL’S MESSAGE

Unsafe abor on is a tragedy. It is not simply a tragedy of circumstances, but one of a woman being
deprived of one of her most basic Human rights - the right to control her body and her
reproduc ve
ability.
Unsafe Abor on cuts across age, demography and geography. The issues and the s gma which
surrounds abor on lead to a low awareness of these problems which have significant effects on
women’s lives extending beyond the purely medical problems to their personal and social
rela onship and lives.
The implica ons of unsafe abor on are even more resonant when you consider the fact that
preven on of unsafe abor on is one the fastest and most scalable ways to reduce maternal
mortality. Technology available is now safe, efficacious, and cheap. It is of course not enough to
simply provide the services but also provide them with care, quality and dignity. Post Abor on
care
has been shown to be a vital component of CAC.
FOGSIans across the country have gone above and beyond in this pandemic to minimise the
impact
of this crisis on SRHR issues and I believe that the country and the world owes a debt of gra tude
to
all FOGSIans and Healthcare Providers.
I would like to congratulate the MTP Commi ee and its chair Dr Dr Bhar Maheshwari in
par cular
for leading the produc on of this document. It is a comprehensive and easy to read FOGSI Focus
which will be a valuable resource for all those who seek informa on on this topic.
Keep safe, keep healthy.
Warm regards,
Dr. Jaydeep Tank
Secretary General FOGSI.
Chair FIGO committee for Safe Abortion.
Deputy Secretary AOFOG.

4
 EDITOR’S DESK

Acc to WHO-Access to legal, safe and comprehensive abor on care, including post-abor on care, is
essen al to a ain the highest possible level of sexual and reproduc ve health. Three out of ten of all
pregnancies end in induced abor on. Nearly half of all abor ons are unsafe, and almost all of these
unsafe abor ons take place in developing countries. Emergency treatment of abor on complica ons is
essen al to reduce deaths and injuries from unsafe abor on. S ll, it cannot replace the protec on of
women’s health and their human rights afforded by safe, legal induced abor on. In india, abor on has
been legalized since 1971 with mely amendments, but it s ll has 8%maternal mortality due to unsafe
abor on. Most important reason is unawareness about legality of abor on ,MTP related acts. To ensure
safe abor on services in prac ce each obstetrician should be,not only aware of MTP and related acts
,maintaining proper documenta on but also has to improve clinical skills .This FOGSI FOCUS on MTP is
having all important informa ons related to it and I hope ,will be very useful for prac oners. All
contributors are expert and experienced in their field and given very relevant informa ons in each
chapter.
I am grea ul to all FOGSI MTP commi ee advisors,members , and FOGSI leaders to make my journey of
3 yrs as MTP commi ee chairperson frui ul and supported lot to disseminate knowledge among
members.
I am specially thankful to current FOGSI president Dr Alpesh Gandhi, vice president dr Atul gantra,
secretary dr jaideep tank and all esteemed contributors for bringing this FOGSI focus in shape .
Words are not enough to express gra tude for my mentor prof padmashri usha sharma and other
teachers dr Rukma idnani,dr chandrava ,dr Meera agnihotri,dr Kir dubey,dr Abhilasha guptafor their
guidance and encouragement.
In the last , lots of adversity due to corona pandemic in yr 2021,one step towards safety and well-
being of the women, is approval of MTP act amendment 2021 which will increase the ambit and
access of women to safe abor on services and will ensure dignity, autonomy, confiden ality and jus ce
for women who need to terminate pregnancy

Let’s make efforts together for saving women’s life from abor on-related causes.

Thanks,
Prof. Bharti Maheshwari
FOGSI MTP COMMITTEE CHAIRPERSON-2018-2020

5
FOGSI 2020 Office Bearers

President - Dr. Alpesh Gandhi

Secretary General - Dr. Jaydeep Tank

Vice President (West Zone) - Dr. Atul Ganatra

Vice President (West Zone) - Dr. Archana Baser

Vice President (North Zone) - Dr. Ragini Agrawal

Vice President (East Zone) - Dr. Anita Singh

Vice President (South Zone) - Dr. Ramani Devi

Deputy Secretary General - Dr. madhuri Patel

Treasurer - Dr. Suvarna Khadilkar

Joint Treasurer - Dr. Parikshit Tank

Joint Secretary - Dr. Sunil Shah

Immediate Past President - Dr. Nandita Palshetkar

President ELECT - Dr. S. Shantha Kumari

6
Chairpersons of FOGSI Committees

Adolescent Health - Dr. Girish Mane

Clinical Research - Dr. Meena Samant
Endocrinology Dr. Rakhi Singh
Endometriosis - Dr. Asha Rao
Endoscopic Surgery - Dr. B Ramesh
Ethics and Medicolegal - Dr Manish Machave
Family Welfare - Dr. Shobha Gudi
Food Drugs Medico Surgical Equipment - Dr. Vidya Thobbi
Genetics and Fetal Medicine - Dr. Mandakini Pradhan
HIV/AIDS - Dr. Anju Soni
Imaging Science - Dr. Meenu Agarwal
Infertility - Dr. Kundan Ingale
International Academic Exchange - Dr. Varsha Baste
MTP - Dr. Bharti Maheshwari
Medical Education - Dr. Abha Singh
Medical Disorders in Pregnancy - Dr. Komal Chavan
Midlife Management - Dr. Rajendra Nagarkatti
Oncology - Dr. Bhagyalaxmi Nayak
Perinatology Dr. Vaishali Chavan
-
Practical Obstetrics Dr. Sanjay Das
-
Public Awareness Dr. Kalyan Barmade
-
Quiz Dr. Sebanti Goswami
-
Safe Motherhood Dr. Priti Kumar
-
Breast Dr. Sneha Bhuyar
-
Sexual Medicine Dr. Niraj Jadav
-
Urogynaecology Dr. JB Sharma
-
Young Talent Promotion Dr. Neharika Malhotra Bora
-

7
List of Contributors 8. Dr. Kalyan B Barmade
Latur Fer lity Center Pvt Ltd.
Barmade Hospital,
Authors Latur-Maharashtra
chairperson-public awareness commi ee
TREASURER- IAGE 2020-21,
1. Dr. Atul Ganatra
Obstetrician Gynecologist & Gynecological Endoscopist
Dr. R. J. Ganatra's Nursing Home & For s Hospitals,
9. Dr. Komal N. Chavan
MD ,DNB, MNAMS, FCPS, DGO, FICOG,
Mumbai –
Diploma in Reproduc ve Medicine (UKSH- Germany)
Vice President (west Zone) Fogsi 2020-2021
Chairperson Medical Disorders in Pregnancy
Chairperson Mtp Commi ee Fogsi (2012-2014) Ary,
Commi ee, FOGSI
Fogsi–2018
Honorary, Dr R. N. Cooper Hospital &
H BT Medical College, Juhu, Mumbai.
2. Dr. Ashis Kumar Mukhopadhyay
Principal and Professor
CSS College of obs, gyne and child health, 10. Dr. Kiran Kurtkoti
Kolka a Director- Shashwat Healthcare (Aundh) Pvt. Ltd.
Vice president FOGSI- 2016-17 PUNE
EX CHAIRMAN-Medical Educa on Commi ee-FOGSI Past MTP Comm Chairperson

3. Dr. Basab Mukherjee 11. Dr. MC Patel

Md, Ficog, Frcog (london) MB DGO LLM
Consultant Gynaecologist , Gynecologist and Medico Legal Counsellor
Columbia Asia Hospital, Mumbai. Niru Maternity and Nursing Home
Vice President Elect Fogsi 2021 Ahmedabad, Gujarat, India
Chairperson Fwc Fogsi (2013-2015)

12. Dr. Meena Samant

4. Dr. Bharti Maheshwari MD DNB MRCOG FICOG
Prof and HOD Senior consultant &
Dept of obs and gyne HOD Dept of ObGy
Muzaffarnagar Medical college Kurji Holy Family
Muzaffarnagar Hospital,Patna
Fogsi MTP commi ee Chairperson
13. Dr Manish Y Machave
5. Dr. Charmila Ayyavoo Gyn Endoscopic surgeon , Pune
Md Dgo Dfp Ficog Pgdcr Chairperson-
Director Ethics and Medicolegal Commi ee FOGSI 2020-22
Department Of Obstetrics And Gynecology,
Adi Hospital And Parvathy Ayyavoo
Fer lity Centre Trichy, Tamil Nadu, India 14. Dr. Narendra Malhotra
Md Ficmch Ficog Fics Fmas Frcog Afiapm
Past Fogsi President
6. Dr. Girish Mane Rainbow Hospital
Chairperson Agra, U ar Pradesh, India
Adolescent Health Commi ee, FOGSI
Director
Mane Hospital, Yavatmal M.S.
15. Dr. Nozer Sheriar
Senior Consultant gyne and obs (Mumbai)
7. Dr. Jaydeep Tank Past secretary general FOGSI
Secretary General FOGSI. Past MTP Commi ee chairperson
Chair FIGO commi ee for Safe Abor on. Member of Technical advisory Panel-
Deputy Secretary AOFOG. Ministry of health and family welfare

8
 List of Contributors 23. Dr. Vidya Thobbi
Professor and Head Department of
Obstetrics and Gynaecology
Authors Al-Ameen Medical College
Bijapur, Karnataka
CP- FOGSI Food & Drug Commi ee
16. Dr. P K Shah
Professor
Dept. of Obstetrics & Gynecology Co Authors
Seth G. S. Medical College, K. E. M. Hospital,
Parel, Mumbai
1. Dr. Aarti Chitkara
M.B.B.S, M.D (PGI, Chandigarh)
Ex president FOGSI
ICOG Fellow: Gynecology Endoscopy
Senior Resident (AIIMS, New Delhi)
17. Dr. Richa Sharma 2. Dr. Aayashi Rathore
Professor, OBGy, Senior Resident, VMMC &
University college of Medical Sciences & Safdarjang Hospital, Delhi
GTB Hospital,Delhi
3. Dr. A Neha Tabbasum
DNB PG K C General Hospital
18. Dr. Ritu Joshi Banglore.
Consultant, Obstetrics and gynecology, 4. Dr. Deepali Prakash Kale
For s escorts Hospital, Jaipur DGO, FCPS, DNB, FMAS
Past Vice President and Chair, Assistant Professor Seth G.S. Medical College
Family welfare Commi ee, FOGSI. & amp; Nowrosjee Wadia Maternity Hospital Mumbai

5. Dr. Divya Suman

19. Dr. Sadhana Gupta Consultant Dept of OBGY
FOGSI Representa ve To Safog 2018-2020 JKT Medical College & amp; Hospital Bihar
Vice President - Fogsi (2016)
Senior Consultant Obstetrician & Gynaecologist 6. Dr. Freni Shah
Jeevan Jyo Hospital & Medical Research Centre Mumbai
Bobina Road, Gorakhpur – 273001
7. Dr. Hema Shobhane
Head of Department of Obs & Gyne
20. Dr. Sheela Mane Government medical college
DNB Professor K C GENERAL HOSPITAL and super facility hospital, Azamgarh
Banglore
Vice President FOGSI 2014 8. Dr. Keshav Pai
Safe Motherhood Commi ee Chairperson 2008 to 2011 Ex Assistant Professor
Dept. of Obstet. & amp; Gynec.
Seth G S MEDICAL COLLEGE MUMBAI
21. Dr. Shyamal Seth
Past Chairperson of MTP Commi ee of 9. Dr. Neharika malhotra
FOGSI (2015 to 2017), Chairperson-FOGSI -YTP Commii ee
President Elect of The Bengal Obstetric and INFERTILITY CONSULTANT- RAINBOW HOSPITAL AGRA
Gynaecological Society] 10. Dr. Sukant Misra
Professor & H.O.D. of Obst & Gynae,
Vivekananda Ins tute of Medical Sciences, Kolkata
22. Dr. Shobha N Gudi Past President of The Bengal Obstetric and
MD, DNB, FICOG, CIMP Gynaecological Society]
Professor and Head
Department of Obstetrics and Gynaecology 11. Dr. Zubin Sheriar
St. Philomenas Hospital ,Bengalore Senior Resident, Obstetrics and Gynecology,
CP- FOGSI FW Commi ee KB Bhabha Hospital, Mumbai.

9
 Title Authors

1 ABORTION SCENARIO IN INDIA - AN OVERVIEW Dr. Nozer Sheriar

2 MTP ACT AND AMENDMENTS Dr. Jaideep Tank

3 POCSO ACT-TERMINATION IN MINOR GIRL Dr. Atul Ganatra

4 MTP AND PCPNDT ACT-CONFLICTS,HOW TO HANDLE Dr. M C Patel

CONTENTS
5 DOCUMENTATION AND CHECKLIST FOR LEGAL ABORTION Dr. Bharti Maheshwari
6 VIOLATION OF MTP ACT Dr. Shyamal Seth
7 COMPREHENSIVE SEXUAL EDUCATION IN PREVENTION OF UNSAFE ABORTION Dr. Narendra Malhotra
8 INFECTION PREVENTION DURING MTP Dr. Ashis Mukhopadhyay

9 MTP-PRE PROCEDURE COUNSELLING Dr. Kalyan Barmade

10 ROLE OF USG IN CASES OF MTP Dr. P K Shah

11 CLINICAL EXAMINATION BEFORE MTP Dr Sadhna Gupta

12 PAIN MANAGMENT Dr. Meena Samant

13 MEDICAL METHOD OF ABORTION-DRUGS,DOSE AND PROTOCOL Dr. Kiran Kurkotti

14 FAILED MEDICAL METHOD-MANAGEMENT Dr. Richa Sharma

15 SURGICAL METHOD OF ABORTION Dr. Bharti Maheshwari

16 MANUAL VACUME ASPIRATION-INDICATION, METHOD Dr. Vidhya Thobhi

17 POST ABORTION COUNSELLING AND FOLLOW UP Dr. Shobha Gudi

18 POST ABORTION CONTRACEPTION Dr. Ritu Joshi

19 MANAGEMENT OF COMPLICATIONS WITH MTP
A.) HAEMORRHAGE Dr. Sheela Mane
B.) PERFORATION Dr. Charmila Ayyavoo

C.) SEPSIS Dr. Basab Mukharjee

20 MTP IN DIFFICULT CASES-

A.) SCARRED UTERUS Dr. Bharti Maheshwari

B.) MEDICAL DISORDER Dr. Komal Chavan

C.) NULLIPAROUS WOMEN Dr. Girish Mane

21 MEDICOLEGAL ISSUES IN MTP Dr Manish Y Machave
22 SURAKSHIT GARBHPAT-BETI BACHAO KE SATH Dr. Bharti Maheshwari
(SAFE ABORTION WITH SAVING GIRL CHILD)
 1 Abortion Scenario in India - DR. NOZER SHERIAR
An Overview
DR. ZUBIN SHERIAR

It is estimated that of the 48·1 million Tamil Nadu and Uttar Pradesh and from NGO
pregnancies in India each year, nearly half of clinic data. National medication abortion drug sales
were unintended and abortions accounted for a and distribution data were obtained from IMS
third.The history of induced abortions in India is Health and six principal NGOs (Singh et al, 2018).
one of successes and achievements, difficulties
and lost The studydocumented a dramatic shift of induced
opportunities. While India was one of the first abortions out of health facilities and to medication
countries to legislate a law to ensure safe abortion. Of these only 3·4 million abortions (22%)
abortion for women four decades ago, unsafe were obtained in health facilitieswhile 11·5 million
abortions still account for significant maternal (73%) abortions were medication abortions done
morbidity and mortality, with unsafe abortion outside of health facilities. Overall 12·7 million
still (81%) abortions were medication abortions, 2·2
remaining the third leading cause of maternal million (14%) abortions were surgical and an
mortality. unfortunate 0·8 million (5%) abortions were done
through other methods that were probably unsafe.
Incidence and Prevalence of Induced Abortion
Current legal situation of Induced Abortion
Earlier studies of abortion prevalence in India from
the Abortion Assessment Project estimated that 6.7 Even today voluntarily causing miscarriage to a
million induced abortions took place in India each woman with child, other than in good faith for the
purpose of saving her life is a crime under Section
year.Then in 2015 the Guttmacher Institute which
312 of the Indian Penal Code, punishable by simple
has acknowledged expertise in undertaking global,
or rigorous imprisonment and/or fine. Consequent
regional and national abortion prevalence studies,
sections IPC Sections 313-316 relating to causing
conducted the first truly scientific national abortion
miscarriage without a pregnant woman's consent or
incidence study in collaboration with the IIPS and causing maternal death due to the procedure, are
Population Council. In the study published in the stricter, with punishments ranging from up to 10
Lancet in 2018, it was estimated that 15.6 million years imprisonment and extending up to life
abortions were performed each year with the imprisonment.
abortion rate 47/1000 women aged 15-49 years. The Medical Termination of Pregnancy (MTP) Act
The study had three components; abortions in of 1971 provides the legal framework for making
facilities, medication abortions outside facilities comprehensive abortion services available in India.
and abortions outside of facilities and with methods To date the termination of pregnancy was permitted
other than medication abortion. Facility based for a broad range of conditions up to 20 weeks of
abortions were estimated from a survey of 4001 gestation but with the MTP Act Amendments in
public and private health facilities in six Indian 2021 the gestation limit has been conditionally
states, Assam, Bihar, Gujarat, Madhya Pradesh, extended.
The MTP Amendment Act No. 64, 2002 and MTP The passage of the amendments was preceded by
Amendment Rules, 2003 was the first amendment serious discussion in both the Lok Sabha and the
of the MTP Act and Rules after 1971. FOGSI had an Rajya Sabha. Valid suggestions that were made by
important role in actually formatting the Members of Parliament and could provide
amendments. The salient amendments then were - guidance for the future were -
Ÿ Increasing awareness about the legality and
Ÿ Lunatic wasreplaced by mentally ill person, a availability of safe services.
person in need of treatmentby reason of a mental Ÿ Training and permitting nurses, ANMs and
disorder other than mental retardation. AYUSH practitioners to provide early abortions in
Ÿ Power of centre recognition was devolved to rural areas with shortage of allopathic practitioners.
district level committees constituted with CMO or Ÿ Setting up fast-track courts especially for minor
DHO as the chairperson and consisting of 3 to 5 rape survivors.
members. Ÿ Steps to be taken in case the fetus is delivered
Ÿ Concept of punishment wasintroduced within alive in the course of the MTP.
the Act with rigorous imprisonment for not less Ÿ Proactively combating stigma associated with
than 2 years extending to 7 years. abortion.
Ÿ Registration of facilities for first trimester MTP Ÿ Paid maternity leave to women who undergo
was simplified, segregating these from second abortion especially in the later stages.
trimester abortions.
Ÿ Early medication abortions were madefeasible Even today abortion in India is not considered to b
and accessible by permitting prescription by the right of a woman and women continue to face
registered medical practitioners at their clinics with challenges while accessing safe abortion services
just a notional access to an approved centre.
.According to the MTP Act, abortion needs the
The recent MTP Amendment Act No. 8, 2021 was opinion and approval of a medical practitioner and
legislated by Parliament on March 25, 2021. The a woman cannot get an abortion solely on her
recommendations for amendment came from a request. This is reflective of the general perception
diverse expert group that worked between 2006 and that a woman cannot and should not control her
2010 of which FOGSI was an important reproductive choices. These attitudes extend even
constituent. The salient features were - to providers, who often ask for spousal or family
consent before providing an abortion though it is
Ÿ Requiring the opinion of a single Registered not a legal requirement and biases such as these
Medical Practitioner up to 20 weeks. also prevent women from accessing safe abortion.
Ÿ Extension of gestational age limit from 20 to 24
weeks for the vulnerable women including minors, Current Practice, Medication and Techniques
unmarried, rape survivors and victims of incest.
Ÿ Termination at anytime in pregnancyfor
According to the WHO, when performed in early
substantial fetal abnormalities with the approval of pregnancy by well-trained practitioners in
a Medical Board consisting of a gynecologist, a adequate facilities, abortion has an excellent safety
record and early abortions are undoubtedly the
pediatrician a radiologist or sonologist besides
safest. The evidence-based guidance of WHO
other members.
guides the practice of abortion worldwide.In India
Ÿ Confidentiality for women whose pregnancy
the clinical practice of safe abortion is guided by
has been terminated under this Act except to a
the FOGSI Safe Abortion Consensus of 2004, the
person authorised by law.
FOGSI ICOG Good Clinical Practice
Recommendationsin 2010 and the Comprehensive perform MVA throughout the first trimester. Of the
Abortion Care Guidelines of MOHFW GOI,2010 1686 MVA procedures complete evacuation with
and 2018 which were formulated by a committee MVA was possible in 99.5% of cases below 8
that included WHO, ICMR, FOGSI, Ipas and PSS. weeks and 98.2% of cases over 8 weeks gestation,
Early medication abortions. with incomplete abortion and other complications
reported in 2.9% of cases. The study concluded that
In the study published in the Lancet, 12.7 million MVA is an effective procedure with few
were medication abortions. Of these11.5 million complications and can be safely throughout the
(73%) were obtained outside medical facilities first trimester of pregnancy.
through medication abortion and it is estimated that
a large percentage of these were self-managed. This was followed up by a pioneering project to
Medication abortion has proven its potential for introduce MVA in healthcare down to PHC level
making abortion safer, more accessible and having conducted by FOGSI for the GOI and WHO in
the potential for widening the provider base.
2004. A training program and system was created
and MVA training was conducted for over 120
Mifepristone-misoprostol were approved for use in
doctors with accompanying nurses from 16
India in 2002. An early study by FOGSI and
districts from 8 states.The success of the project
Population Council studied a scientifically selected
national representative sample of 440 FOGSI established the effectiveness, safety and simplicity
members within a year of introduction of of the MVA procedure and the feasibility of training
medication abortion. Mifepristone was used by doctors in peripheral public service earned it an
69% of respondents and the commonest dose of endorsement as an essential basic procedure. It
mifepristone use was 200 mg in 50% and directly led to the introduction of MVA into the
misoprostol use was 400 g in 73%, with home- public healthcare system under RCH II.
based administration in 30%.
Late abortions
This was far better than experiences of other
countries and in no small measure due to the work While late abortions have traditionally been
of FOGSI. induced by numerous methods, they are almost
The Sample Registration System that provides exclusively induced medically by practitioners in
direct estimates of maternal mortality through a India. While the CAC Guidelines describe the use
nationally representative sample reported a ofextraamnioticethacradine lactate, the use of
reduction in maternal mortality caused by unsafe mifepristone misoprostol is now the preferred
abortion from 12% in 2001 to 8% in 2006. The method in India.
reason for this significant decrease is most likely
due to the widespread availability of medication To address the concerns of the mifepristone
abortion, withself-managed abortion in a majority misoprostol combination not being approved by
of cases. DCGI, its use is supported by the WHO and CAC
Guidelines. Interestingly the national CAC
Early surgical abortions guidelines while stating that mifepristone and
In the Lancet study 2·2 million abortions were misoprostol are presently not an approved method
surgical.The effectiveness of vacuum aspiration for in India, go ahead toacknowledge that evidence
early induced abortion is well established. The from other countries that this is a safe and effective
FOGSI lpas Multicentric Study was a prospective method for termination and then provide the
multicentric study conducted to assess the suggested protocol in an annexure giving the
effectiveness of using the double valve syringe to method an indirect sanction.
Where we are - The way ahead significant seen legislative and technological
change. It is now time for society and our
Considering the 15.6 million abortions undertaken profession toset aside all our reservations and stand
each year in India our greatest challenge is to up to for women we care for and their reproductive
ensure easy access to safe, legal abortion provided rights particularly safe abortion.
by an adequate system of capable, well trained
providers. In response to a Parliament Question on References
the per capita availability of doctors in India in
2020, it was reported that there are 12.5 lakh 1.Singh S, Shekhar C, Acharya R et al. The
allopathy doctors in the country of which 3.71 lakh incidence of abortion and unintended pregnancy in
are specialist doctors. Medical abortion questions India, 2015. Lancet, Glob Health. 2018; 6:e111-
and challenges the need for the mandatory e120.
fulfillment of conventional often difficult to
comply conditions with a role for less qualified 2.Chhabra R andNuna SC. Abortion in India,
providers, delinkage from surgical facilities and Veerendra Printers, New Delhi, 1994
provider training that is knowledge based and not
surgical skill based. 3.The Medical Termination of Pregnancy Act.
Going ahead there are practical strategies to Gazette of India, Part II, Section 1, 1971.
support women's access to safe abortion in India.
4.WHO, Safe Abortion-Technical and Policy
Guidance, Geneva, 2012.
These include but are not limited to -
"Training and certifying more medical doctors,
maybe all general practitioners, to perform early 5.WHO, Clinical Practice Handbook for Safe
abortions. Abortion, Geneva, 2014.
Ÿ Permitting and training practitioners who are
trained in traditional or alternative medicine, 6.FOGSI, Safe Abortion Consensus 2004 and
midwifery or nursingto be mid-level providers to FOGSI ICOG Good Clinical Practice
offer early medication abortion services. Recommendations, FOGSI ICOG, 2010.
Ÿ Streamlining the process for approving private-
sector facilities to provide abortion care. 7.MOHFW, Comprehensive Abortion Care -
Ÿ Ensuring adequate supplies of medication
Training and Service Delivery Guidelines, New
abortion pills and MVA equipment in public-sector Delhi, 2010 and 2018.
facilities.
Ÿ Improving the quality of abortion and 8.Elul B, Sheriar NK, Anand and Philip N, J
contraceptive services in the public sector by ObstetGynecol India, 2006
training providers to offer women confidential and
respectful services and in-depth counselling. 9.Sheriar NK, Tank JD and Ganatra B. First
Ÿ Leveraging the recently accepted modality of Trimester MTP using MVA: Report of a FOGSI
telemedicine to provide early medical abortion multicentric study across 27 clinics. J
either in part or entirety ObstetGynecol India 2002; 57(2):162.
Mahmoud Fathallawrote "Women need power to
secure their right to health. Powerlessness of 10.WHO, Health worker roles in providing safe
women is a serious health hazard." The right to abortion care and post-abortion care, Geneva,
personal choice and access to safe abortion has 2015.
been one of the most difficult rights for society to
extend to women. In recent times we in India have
 2 MTP ACT AND AMENDMENTS DR. JAYDEEP TANK
IN INDIA
DR. BHARTI MAHESHWARI

The Medical Termination of Pregnancy (MTP) Ÿ Equipment requirement at the sites

Act, enacted in india 1971, governs the provision Ÿ Experience and training required by an RMP
of abortions in India. This Act allows the MTP Regulations: are made by the state
termination of a pregnancy up to 20 weeks, for a government and passed by the state legislature
broad range of indications. It also offers protection Salient features of MTP Regulations:
to a practitioner if he/she adheres to and fulfils all Ÿ Documentation and reporting
the requirements of this Act. The MTP Act was Ÿ Penalty for violations of the MTP Act
amended in December 2002 and the Rules, in June Ÿ Comparative objectives of PCPNDT Act and
2003. MTP Act

The Medical Termination of Pregnancy (MTP) Act

MTP act Development Processes 1971, was amended in 2002
MTP Act: is passed by both houses of parliament Ÿ To facilitate better implementation and increase
and receives assent by the President. access for women especially in the private health
oSalient Features of the MTP Act: sector.
-Under what conditions can pregnancy be Ÿ The amendments to the MTP Act in 2002
terminated? decentralized the process of approval of a private
-Who can terminate a pregnancy? place to offer abortion services to the district level.
-Places where pregnancy can be terminated? Ÿ The District level committee is empowered to
approve a private place to offer MTP services in
order to increase the number of providers offering
MTP Rules: are made by the Central Government
CAC services in the legal ambit.
and passed by the parliament; notified in the
official gazette District Level Committee:
Salient Features of MTP Rules: Composition-
-District Level Committee: composition and site Three to five members including the Chairperson.
approval process Ÿ Chairperson: Chief Medical Officer or District
Health Officer
One member shall be a Gynecologist/Surgeon/ Experience and Training Requirement-
Anesthetist
1.A practitioner who holds a post-graduate degree
Ÿ Other members should be from the local or diploma in Obstetrics and Gynaecology
medical profession, Non-Governmental 2.A practitioner who has completed six months as
Organization and Panchayati Raj Institution of the House Surgeon in Obstetrics and Gynaecology
district 3.A practitioner who has at least one year
Ÿ At least one member of the committee should be experience in the practice of Obstetrics and
a woman Gynaecology at any hospital that has all facilities
Ÿ The tenure of the committee will be for two 4.A practitioner who has assisted a Registered
calendar years and the tenure of the NGO member Medical Practitioner (RMP) in 25 cases of medical
will not be for more than two terms (four years) termination of pregnancy of which at least five
have been performed independently in a hospital
established or maintained by the government or a
training institute approved for this purpose (Such a
Is abortion available on demand practitioner can only perform fi rst trimester
and a woman's legal right in India?
Consent for Procedure-
Answer: No. Pregnancy can be terminated in
certain conditions only and Indications When Consent for MTP has to taken on fixed format -
FORM C
Pregnancy can be Terminated-
Ÿ In case of a woman more than 18 years,
1. Continuation of pregnancy is a risk to the life of
married/unmarried, only the consent of the woman
the pregnant woman or can cause grave injury to
is required to terminate pregnancy
her physical or mental health
Ÿ In case of a minor (less than 18 years) or a
2. Substantial risk that the child, if born, would be
mentally ill person, consent of a guardian is
seriously handicapped due to physical or mental
required
abnormalities Ÿ Guardian means a caretaker willing to be
3. The pregnancy was caused by rape responsible for the woman Spousal consent is not
4. Pregnancy was caused due to failure of mandatory
contraception in a married couple
Sex selection is not an indication for pregnancy Opinion of RMP-
termination under the law.
Ÿ For termination of pregnancy up to 12 weeks,
Who can Terminate a Pregnancy- the opinion of one RMP is required
Ÿ For termination of pregnancy between 13-20
Ÿ Only a Registered Medical Practitioner (RMP) weeks, opinion of two RMPs is required
under the MTP Act can terminate pregnancy. Ÿ Acc to amendment 2021-up to 20 wks-1 RMP
Ÿ He/she should possess a recognized medical opinion and more than 20 , opinion of 2 RMP is
qualification asdefined in the Indian Medical required
Council Act, 1956
Ÿ Have her/his name entered in the state Sites for Pregnancy Termination-
medical register
Ÿ Have experience or training in gynaecology 1) Hospital established or maintained by the
and obstetrics as prescribed by the MTP Rules Government
2)Private site approved by the Government or a 3. Anesthetic equipment
District Level Committee constituted by the 4. Resuscitation and sterilization equipment
Government for the purpose 5. Drugs and parenteral fluids for emergency use
6. Back-up facilities for treatment of shock
As per the National CAC Guidelines, pregnancy 7. Facilities for transportation
may be terminated at Government facilities up
to: Certificate of Approval -Form B-
Ÿ Eight weeks of gestation at Primary Health The certificate of approval for a 'private' place
Centre (PHC); issued by the DLC chaired by the CMO shall be
Ÿ 12 weeks of gestation at Community Health conspicuously displayed such that it is easily
Centre (CHC) or 24x7 PHC; visible to visitors.
Ÿ 20 weeks of gestation at District Hospital and All Government facilities are by default approved
above facilities. to provide CAC services and therefore do not need
The DLC may approve a (private) place to a certificate of approval.
conduct:
Terminations up to 12 weeks; or Terminations up Inspection of the Approved Place - Taking
to 20 weeks. Suitable Action
Ÿ The CMO is authorised to inspect the places
MTP Site Approval- approved for conducting MTP to verify whether
MTP is conducted under safe and hygienic
Ÿ All private sites need approval before starting conditions.
abortion services Ÿ The DLC, in appropriate cases, after affording
Ÿ Public sector sites do not need separate opportunity to the owner, may suspend or cancel
approval, provided they have the required the certificate of approval.
infrastructure Ÿ The owner may file a review application (within
Ÿ Approval of private sites is granted at the district 60 days) to the Government against such
level by the District Level Committee (DLC) suspension or cancellation.
One has to apply for site approval on FORM A and
has to submit at CMO office,after inspection and Ÿ The Government, after giving the owner an
get satisfaction CMO approve site and FORM B is opportunity of being heard may confirm, modify or
issued to respective site . reverse the order.
Infrastructure Requirement: First Trimester Ÿ DLC members are not authorised to conduct
Site approval- inspections without permission of CMO
1.Gynaecology examination/labour table
2.Resuscitation and sterilization equipment Medical Methods of Abortion (MMA)
3.Drugs and parenteral fluids for emergency use,
notified by Government of India from time to time Provider's eligibility: Only an RMP, as under the
4.Back-up facilities for treatment of shock MTP Act, can prescribe MMA drugs
5.Facilities for transportation
Site eligibility: Medical Methods of Abortion up to
Infrastructure Requirement: Second Trimester seven weeks of gestation can be provided by an
Site- RMP under the MTP Act, from an OPD clinic with
1. An operation table established linkage to an approved site. However, a
2. Instruments for performing abdominal or certificate to this effect by the owner of the
gynecological surgery approved site has to be displayed at the OPD clinic
All the records of pregnancy termination have to be c) Form II: Head of the hospital or owner of the
maintained for MMA also (Consent Form, RMP place shall send a monthly statement of cases to the
Opinion Form, Admission Register and Monthly CMO of the district in this form
Reporting Form) d)Form III: (Admission Register): An approved
site shall maintain case records in Form III. This
Mandatory Documentation under the MTP Act- register is kept for a period of five years from the
a) Form 'C': Consent Form date of last entry
b) Form I (Opinion Form): RMP shall certify this
form within three hours from the termination of 1.The Admission Register is a confidential
pregnancy document and is not open to inspection by any
Ÿ The column for indicating the reason for person expect under the authority of law.
termination of the pregnancy must never be left 2.The same has to be kept in safe custody.
blank. 3.No entry of an MTP done shall be made in any
Ÿ It must be filled as per the conditions prescribed case-sheet, operation-theatre register, follow-up
in the MTP Act as relevant for the pregnant woman card or any document or register other than the
Ÿ Sex selection is not a legal ground for Admission Register maintained at the facility.
terminating a pregnancy. 4. Admission Register needs to be preserved for a
Ÿ The provider/s must ensure that the ground for period of five years from the date of last entry.
termination is clearly stated in the opinion form. 5.There is no requirement for recording sex of the
Ÿ The opinion of the provider is adequate to abortus in the Admission Register or any other
certify ground/s for providing abortion service. records.
Documentation for Other Types of Abortion- 3.Mandatory documentation of consent, opinion,
case recording and monthly reporting is not
Types: Spontaneous, Inevitable, Incomplete and adhered to
Missed: None of these come under the purview of
the MTP Act. Essential Protocols of Safe and Legal Abortion-
Documentation: 1.It is performed by a Registered Medical
1.Form I not required Practitioner as defined under the MTP Act
2.Consent as taken for any other procedure and not 2.It is performed at an approved site I), monthly
on Form C reporting (Form II) etc. are fulfilled
3.Procedure not recorded in Admission Register 3.The pregnancy is within the gestation limit
(Form III) but in Labour (OT) Procedure approved by the law
4.The provider will get the protective cover of this
Violation of the MTP Act- legislation only when he or she fulfils the above-
The following offences can be punished with mentioned requirements completely under the Act
rigorous imprisonment for two to seven years:- and recorded in Form III
1.Any person terminating a pregnancy who is not a 5.Other requirements of the Act such as consent
registered medical practitioner as under the MTP (Form C), opinion of RMP Form I), monthly
Act reporting (Form II) etc. are fulfille
2.Terminating a pregnancy at a place that is not 6.The pregnancy is within the gestation limit
approved approved by the law
The provider will get the protective cover of this (2) It shall come into force on such date as the
legislation only when he or she fulfills the above Central Government may, by notification in the
mentioned requirements completely. Official Gazette, appoint.
2 .In the Medical Termination of Pregnancy Act,
Useful DOs DON'Ts-NHM guidelines 1971 (hereinafter referred to as the principal Act), in
POSITIONING according to the National Health section 2,- (i) after clause (a), the following clause
Mission(NHM) shall be inserted, namely:-
Ÿ National policy is to make abortion safe and '(aa) "Medical Board" means the Medical Board
widely available as per the law: Abortion is legal constituted under sub-section (2C) of section 3 of
for a number of reasons but not for reasons of the Act;'; Short title and commencement.
selecting the sex of the foetus. Even today, eight Amendment of section 2.34 of 1971. Bill No. 55-C
percent of maternal mortality is due to unsafe of 2020 5 10 AS PASSED BY LOK SABHA ON
abortions. 17.03.2020
Ÿ Safe abortion should not be jeopardised in (ii) after clause (d), the following clause shall be
preventing sex selection: Estimates indicate that inserted, namely:-
about nine percent of abortions are sex-selective '(e) "termination of pregnancy" means a procedure
and therefore ninety percent are not. to terminate a pregnancy by using medical or
Ÿ Do not discourage service providers from surgical methods.'.
providing safe and legal abortion, through 3. In section 3 of the principal Act, for sub-section
measures such as tracking of abortion outcomes or (2), the following sub-sections shall be substituted,
reviewing data for second-trimester abortions. namely:-
Quite obviously, half of the legal abortions will "(2) Subject to the provisions of sub-section (4), a
involve femalefoetuses and this will be true pregnancy may be terminated by a registered
regardless of the sex ratio of that area or the level of medical practitioner,-
compliance with the law (a) where the length of the pregnancy does not
exceed twenty weeks, if such medical practitioner
is, or
MTP act amendment 2021
(b) where the length of the pregnancy exceeds
The Medical Termination of Pregnancy
twenty weeks but does not exceed twenty-four
(Amendment) Bill, 2021 is for expanding access of
weeks in case of such category of woman as may be
women to safe and legal abortion services on
prescribed by rules made under this Act, if not less
therapeutic, eugenic, humanitarian or social
than two registered medical practitioners are, of the
grounds.
opinion, formed in good faith, that- (i) the
The amendments include a substitution of certain
continuance of the pregnancy would involve a risk
sub-sections, insertion of certain new clauses under
to the life of the pregnant woman or of grave injury
some sections in the existing Medical Termination
to her physical or mental health; or
of Pregnancy Act, 1971, with a view to increase the (ii) there is a substantial risk that if the child were
upper gestation limit for termination of pregnancy born, it would suffer from any serious physical or
under certain conditions and to strengthen access to mental abnormality.
comprehensive abortion care, under strict Explanation 1.-For the purposes of clause (a), where
conditions, without compromising service and any pregnancy occurs as a result of failure of any
quality of safe abortion. device or method used by any woman or her partner
1. (1) This Act may be called the Medical for the purpose of limiting the number of children or
Termination of Pregnancy (Amendment) Act, preventing pregnancy, the anguish caused by such
2021. pregnancy may be presumed to constitute a grave
injury to the mental health of the pregnant woman.
Explanation 2.-For the purposes of clauses (a) and
(b), where any pregnancy is alleged by the pregnant 5. In section 6 of the principal Act, in sub-section
woman to have been caused by rape, the anguish (2), after clause (a), the following clauses shall be
caused by the pregnancy shall be presumed to inserted, namely:-
constitute a grave injury to the mental health of the "(aa) the category of woman under clause (b) of
pregnant woman. (2A) The norms for the registered sub-section (2) of section 3;
medical practitioner whose opinion is required for (ab) the norms for the registered medical
termination of pregnancy at different gestational practitioner whose opinion is required for
age shall be such as may be prescribed by rules termination of pregnancy at different gestational
made under this Act. age under sub-section (2A) of section 3;
(2B) The provisions of sub-section (2) relating to (ac) the powers and functions of the Medical Board
the length of the pregnancy shall not apply to the under sub-section (2C) of section 3
termination of pregnancy by the medical
practitioner where such termination is necessitated
by the diagnosis of any of the substantial foetal
abnormalities diagnosed by a Medical Board.
(2C) Every State Government or Union territory,
as the case may be, shall, by notification in the
Official Gazette, constitute a Board to be called a
Medical Board for the purposes of this Act to
exercise such powers and functions as may be
prescribed by rules made under this Act.

(2D) The Medical Board shall consist of the

following, namely:- (a) a Gynaecologist; (b) a
Paediatrician; (c) a Radiologist or Sonologist; and
(d) such other number of members as may be
notified in the Official Gazette by the State
Government or Union territory, as the case may
be.”

4. After section 5 of the principal Act, the following

section shall be inserted, namely:- "5A. (1) No
registered medical practitioner shall reveal the
name and other particulars of a woman whose
pregnancy has been terminated under this Act
except to a person authorised by any law for the
time being in force.

(2) Whoever contravenes the provisions of sub-

section (1) shall be punishable with imprisonment
which may extend to one year, or with fine, or with
both.".
 3 Teenage Pregnancy Dr. Atul Ganatra

and POCSO Act Dr. Freni Shah

"You can tell the condition of the nation by looking at the status of its women"

-Jawaharlal Nehru

Introduction :
Approximately 21 million girls aged 15-19 years
get pregnant each year in developing world, of
which 12 million give birth.1 However, 10 million
are unintended pregnancies. Of the estimated 5.6
million abortions that occur each year among
adolescent girls aged 15-19 years, 3.9 million are
unsafe, contributing to maternal mortality,
morbidity and lasting health problems.1The
estimated global adolescent-specific fertility rate
has declined by 11.6% over the past 20 years.2The Fig.1: Distribution of pregnancies by outcome, India, 20154
largest number of births occur in Eastern Asia
(95,153) and Western Africa (70,423).3

India has one of the highest rates of early marriage

in the world. The recent National Family Health
Survey (NFHS) estimates that 27 percent of girls in
India are married before their 18th birthday due to
culture and social norms, accounting to third of all
our young women. India has one of the world's
highest numbers of teenage mothers (11 percent),
as pregnancies occur in the context of marriage and
due to poverty and lack of education and
employment opportunities. Also, motherhood is
valued and marriage or union and childbearing may
be the best of the limited options available to these
teenagers.The worst affected state is Bihar where
70 percent of women in their early twenties are
reportedly married by the age of 18.

Fig.2: State-wise adolescent birth rate 2005-06, India5

Risk: Prevention:
Adolescent mothers (ages 10-19 years) face higher Prevention of adolescent pregnancy and related
risks of eclampsia, puerperal endometritis, and mortality and morbidity and prevention of HIV and
systemic infections than women aged 20 to 24 HIV- related mortality in adolescents and young
years, and babies of adolescent mothers face higher people were not given sufficient attention during
risks of low birth weight, preterm delivery and the early part of the Millennium Development
Goals era. As the world has transitioned to the
severe neonatal conditions.6Complications during
Sustainable Development Goals era, adolescents
pregnancy and childbirth are the leading cause of
have moved to the center of the global health and
death for 15-19-year-old girls globally.
development agenda.9WHO works closely with
Social consequences for unmarried pregnant
partners within and outside the United Nations
adolescents may include stigma, rejection or system to contribute to the global effort to prevent
violence by partners, parents and peers. Girls who children becoming wives and mothers. WHO
become pregnant before the age of 18 years are works to strengthen the evidence base for action,
more likely to experience violence within a and to support the application of the evidence
marriage or partnership.7The greatest threat of through well-designed and well-executed national
teenage pregnancy is higher rate of pregnancy and sub national programs. WHO works closely
related complications like anemia, hypertension, with the UNICEF, UNFPA and UN Women on a
hemorrhage and unsafe abortions, malnutrition, global programme to accelerate action to end child-
sexually transmitted infections (STI) , cervical marriage.
cancers and the psychological issues. It also
Multi-pronged approaches like comprehensive
affects the society and economy.
sexual education, change in social norms by
involving village and community and religious
In Indian culture, adolescents have little access
leaders, life skills education of both girls and
to correct and comprehensive information on boys, access to contraception, setting up of
family planning and access to contraceptives, confidential and adolescent friendly clinics are
whether married or not, though the need is twice helpful in prevention of teenage pregnancies.
that of adults.Adolescents face barriers to Only 9-12% of sexually active unmarried 15-24-
accessing contraception including restrictive laws year-olds were using a modern method in 2005-
and policies regarding provision of contraceptive 2006, compared with 52% of unmarried 25-49-
based on age or marital status, health worker bias year-olds, in India.
and/or lack of willingness to acknowledge India has successfully reduced the proportion
adolescents' sexual health needs, and adolescents' of pregnancy between 15-19 years to half (16
percent during NFHS 3 in 2005-06 and 7.9
own inability to access contraceptives because of
percent during NFHS 4 in 2015-16).
knowledge, transportation, and financial
constraints. Addressing Vulnerabilities Among Young and
Unmarried Women:
Young and unmarried women represent a
subset of the population in India that is
particularly vulnerable with regard to their
sexual and reproductive health care needs. There
is often limited awareness among young
women about health-promoting behaviors and
Fig.3: Teen Pregnancy
service availability.
 Most communities and providers offer little Another hallmark of the POCSO Act was that it set
support to young women in seeking safe up procedures to make the criminal justice system
abortion services. These women often experience child-friendly and prevent re-traumatisation. The
delays in obtaining services or turn to unsafe act incorporated child-friendly mechanisms for
providers. Efforts to raise awareness around the recording, reporting of evidence, investigation and
needs of young and unmarried women including speedy trial of offences through appointment of
their need for contraceptive services and to Special Public Prosecutors and designated Special
reduce the stigma around sexual activity, Courts.
unintended pregnancy and abortion should be
prioritized. Under provisions of the POCSO Act, a child is
entitled to the following:
POCSO ACT: The Protection of Children from
Sexual Offences 10 Getting their statement recorded at their
residence or a place of their choice, and preferably
The POCSO Act was enacted on 14th November by a woman police official or an official not below
2012 and applicable to whole of India. It is gender the sub-inspector rank, in civilian clothes.
neutral, unlike The Indian Penal Court - it The police official should ensure that
recognizes that boys can be victims of sexual during the investigation, the child shouldn't come
violence as well. It defines a child as someone in contact with the accused.
under the age of 18. The Act also increased the The child cannot be detained at the police
scope of reporting sexual crimes against children. It station at night, and his/her identity should be
expanded the definition of sexual assault to include protected from the public and media unless directed
non-penetrative sexual assault as well as otherwise by a Special Court.
aggravated penetrative sexual assault. It also If the survivor is a girl, the medical
included grave punishment for persons in positions examination should be done by a woman doctor,
of trust of authority like public servants, staff of and the examination can only be done in the
educational institutions, hospitals, remand home, presence of a parent, or a person the child trusts. If
protection or observation home, police officer, any neither of the two are there, then the examination
member of army or security forces. Notably, this should be done in the presence of a woman
law recognises sexual harassment of a child which nominated by the head of the medical institution.
involves touch, and also that which doesn't such as
stalking, making a child expose themselves or There are also provisions if the case requires
exposing themselves to a child, and so on.The support from NGOs or social workers as well as
POCSO Act also specifically lays down stringent experts (psychologists, interpreters and so on) in
punishment for exposing children to, or using them the pre-trial and trial stages for the child.
to create child sexual abuse material (CSAM, also
referred to as child pornography) under sections 13,
14, and 15. The law lays down the procedures for
reporting sexual crimes against children. Under
section 19 of the Act, it is mandatory to report
sexual crimes against children, including when
there is an apprehension that an offence under the
Act has been committed.This child protection law
is also unique because it places the burden of proof
on the accused, following 'guilty until proven
innocent' unlike the IPC.
Fig. 4: What a sexual abuse report should contain.10

10
Under section 19.1 of the POCSO Act any person 2. Ganchimeg T, et al. Pregnancy and
who has apprehension that an offense is likely to be childbirth outcomes among adolescent mothers: a
committed or has knowledge that it has been World Health Organization multicountry study.
committed, should bring the incident to the notice Bjog. 2014;121(S Suppl 1):40-8.
of the Special Juvenile Police Unit (SJPU) or the 3. Every Woman Every Child. The Global
local police. Or call on Childline 1098, child Strategy for Women`s, Children`s and
welfare committee and local police has be Adolescents` Health (2016-2030). Geneva: Every
connected. Woman Every Child; 2015.
4. https://www.thelancet.com/journals /langlo
The POCSO Act requires anyone who knows that a /article/PIIS2214-109X1730453-9/fulltext
sexual offence has been committed to report the 5. Kumar N, Bajaj K (2016) Global Facts
case to the appropriate authorities or to the relevant about Wed and Unwed Adolescent Pregnancies and
person in the organization who could report the Their Psychosocial Effects: A Review of
pregnancy to the appropriate authorities, failing Literature. Obstet Gynecol Int J 5(5): 00174. DOI:
which the person can be punished with up to six DOI: 10.15406/ogij.2016.05.00174
months prison and a fine. 6. WHO. Global health estimates 2015: deaths
by cause, age, sex, by country and by region, 2000-
The MTP Act guarantees protection for providers 2015. Geneva: WHO; 2016.
who act in good faith. This recognizes that above all 7. Raj A, Boehmer U. Girl child marriage and
else, it is imperative that girls and women receive its association with national rates of HIV, maternal
the highest standard of medical care available. The health, and infant mortality across 97 countries.
providers should fulfil their reporting requirements Violence Against Women 2013;19(4).
and legal obligations under the MTP Act and the 8 .
POCSO Act after ensuring essential services. https://www.medindia.net/news/healthinfocus/tee
n-pregnancy-a-major-challenge-in-india-linked-
However, the provider does not need to wait till the to-child-stunting-187840-1.htm
authorities take action and may proceed with the 9. UNESCO. International Technical
termination of pregnancy in line with the provision Guidance on Sexuality Education: An evidence-
of the MTP Act after maintaining complete and informed approach for schools, teachers and health
detailed records of the case. educators. Paris: UNESCO; 2009.
10. h t t p s : / / w w w. i n d i a c o d e . n i c . i n / s h o w
The provider is not obliged to file a FIR or to data?actid=AC_CEN_13_14_00005_201232_151
conduct an investigation. The provider's duty is 7807323686&orderno=24
only to inform the authorities when providing safe
abortion service under the MTP Act.

"If one does not support Legal abortion, in

effect, one is supporting illegal abortion”
-Prof Arulkumaran.

Bibliography:

1. Darroch J, Woog V, Bankole A, Ashford

LS. Adding it up: Costs and benefits of meeting the
contraceptive needs of adolescents. New York:
Guttmacher Institute; 2016.

10
 4 MTP and PCPNDT ACT
Conflicts Dr. M.C. Patel

As such there is no conflict between the It was enacted to provide umbrella to registered
PCPNDT Act and the MTP Act. medical practioner who is providing abortion
services. Because before MTP act all the cases
Notwithstanding, the more important unresolved related to abortion were decided under Indian
issue is the confusion that seems to prevail in Penal Code sect.312 to 316 irrespective of
government and civil society about intention of pregnancy terminated with consent or without
the Pre-Conception and Pre-Natal Diagnostic consent.
Techniques (PCPNDT) Act, and the Medical
Termination Of Pregnancy MTP Act, 1971, Before MTP act 1971,Abortion was absolutely
and which is being exploited by many "pro-life" prohibited and no consideration for any
organisations of all religious hues to rouse public circumstances whatsoeverrequired
support against the legal entitlement of abortion. /compelled the woman to procure the abortion.

The MTP Act allows abortion under grounds Abortion or Induced Miscarriageunder the
provided in act, while the PCPNDT prohibits purview of the IPC sections 312-316.
pre-natal sex determination to stop selective
female foeticide. Both were guilty:
Person performing the abortion or causing
By conflating the two, confusion is being created the miscarriage.
in the minds of the public against a basic right of Woman undergoing abortion
women.
When using child sex ratio, be aware that this
Basic objectives of MTP act 1971 was to ratio also includes post birth factors that might
liberalize provisions of termination of pregnancy skew the ratio, such as underreporting,
To protect the Registered Medical Practitioner infanticide, selective neglect and resultant
who perform abortion as per the provisions under female mortality. This underscores the need to
this Act also work on some of these post birth
To keep the record of a woman under -MTP contributors to an imbalance in child sex ratio.
secret
Do not discourage service providers from
So, aim of MTP act is to provide safe and secret providing safe and legal abortion, through
abortion services under prescribed indications measures such as tracking of abortion out
decided by registered medical practioner to comes or reviewing data for second trimester
avoid criminal abortions in untrained, abortions.
unauthorised hand. It should be provided in
government hospital or government approved Excuses were only two
hospital. Abortion done in good faith
In order to save the life of woman

10
THE APPLICABILITY OF THE MTP ACT It is designed for the prohibition of sex
VIS-À-VIS IPC determination or sex selection before
"Notwithstanding anything contained in the Indian and/orafter conception.
Penal Code a Registered Medical Practitioner shall Does not restrict access to safe abortion or
not be guilty of any offence under that code or any require monitoring of abortion services.
other law for the time being in force, if any At times, it is assumed that most abortions
pregnancy is terminated by him in accordance with are for sex selection. This perception is untrue
the provisions of this Act. and not supported by any study or facts.

It simply means that if pregnancy is terminated in Positioning

accordance with provisions of MTP act, Sect.312
to 316 of Indian Penal Code will not be applied National policy is to make abortion safe and
widely available as per the law: Abortion is legal
PCPNDT act 1994 (regulation and prevention of for a number of reasons but not for reasons of
misuse of technique was enacted to check gender selecting the sex of the foetus. Even today, eight
imbalance percent of maternal mortality is due to unsafe
abortions.
In census of 1971,1981 and 1991 sex ratio of male
children to female children of 0-6 years was Safe abortion should not be jeopardised in
deteriorated at serious rate. It was social issue. In preventing sex selection: Estimates indicate that
spite of PNDT act 1994 in census of 2001, ratio of about nine percent of abortions are sex selective
male to female children of 0-6 years was further and therefore ninety percent are not.
deteriorated. In 1991 ratio of Male to female
children of 0-6 years was 1000:945 which was Promote use of data related to sex ratio at birth
further dropped to 1000:928 in 2001. and emphases it as a more accurate indicator of the
extent of sex selection.
It was observation by "Chetna" for children, young
people and women that every day about 2000 girls When using child sex ratio, be aware that this
go missing in India. Considering all these, there ratio also includes post birth factors that might
was public interest litigation in supreme court for skew the ratio, such as underreporting, infanticide,
strict implementation of PNDT act. So, in 2003 selective neglect and resultant female mortality.
there was amendment in PNDT act and prohibition This underscores the need to also work on some of
of pre conceptional sex selection was also included these post birth contributors to an imbalance in
and now it is called PCPNDT act. child sex ratio.

Due to strict implementation of PCPNDT act Do not discourage service providers from
,genuine termination of pregnancy during 2nd providing safe and legal abortion, through
trimester is also seen with suspicion as there are measures such as tracking of abortionoutcomes or
also possibility of sex determination and sex reviewing data for second trimester abortions.
selected abortion during this gestation period. So,
Quite obviously, half of the legal abortions will
really indicated and needy patient has to suffer.
involve female foetuses and this will be true
The PC&PNDT Act prohibits use of technology regardless of the sex ratio of that area or the level of
such as ultrasound for the purposes of sex compliance with the law (BY NHM GUIDELINES
determination and finally, it prohibits asking for or for Monitoring Authorities)
disclosure of sex of the foetus or advertising for
such a service.

11
 Do not imply that all women who previously Do not use population sex ratio (number of
have daughters are opting for an abortion for sex females to 1,000 males in total population) to point
selection. Several studies have shown that to the problem of sex selection
education of the woman and unintended pregnancy
are variables more closely correlated with opting
for abortion as opposed to sex of the previous child.

Let us see salient features of both the acts

MTP Act PCPNDT Act

Create a legal situation to terminate Improve sex ratio

a pregnancy upto 20 weeks,
Objective on a number of therapeutic, Check female
eugenic, humanitarian or social foeticide and decline
grounds. in sex ratio

Son/gender preference in
Wish to terminate an
Underlying the community, low valuation
unintended or
Reason of girls, increasing dowry
unwanted pregnancy
demands

Expected
Reduce unsafe abrtions Improve sex ratio
Outcome

So there is no conflicts between MTP act and PCPNDT act.

Both the act should be respected in their own merits.
Make sure that 'all' abortion is not understood as illegal.
Abortion for reasons of sex selection definitely needs to be prevented, and its illegality
should be emphasized (NHM GUIDELINES)

12
 5 Documentation and checklist
for legal abortion DR. BHARTI MAHESHWARI

Confirmation of pregnancy
Confirmation of gestational age
Pregnant woman come for MTP Identification of MTP indication
Discuss method of MTP
Contraception counseling

Obtain informed consent of

Perform MTP woman/guardian on form C
Complete Form 1,

FORM 1 and form C should be

kept in sealed envelop
Secret and serial no should be
written on sealed envelop In case of medical abortion-all forms
Complete form 3-admission has to be filled
register All record to be preserved till 5 yrs of
All forms has to be in custody last entry of register
of owner of hospital In admission register, serial no 1 will
Only CMO can inspect these be restarted from month of january
confidential forms
Strict confidentiality has to be
maintained
Form 2 has to be submitted in
CMO office every month
MANDATORY DOCUMENTATION UNDER THE MTP ACT
a. Form 'C': Consent Form

b. Form I (Opinion Form): RMP shall certify this form within three hours from the termination of
pregnancy

c. Form II: Head of the hospital or owner of the place shall send a monthly statement of cases to the CMO of
the district in this form

d. Form III (Admission Register): An approved site shall maintain case records in Form III. This register is
kept for a period of five years from the date of last entry

Essential Protocols of Safe and Legal Abortion-

A. It is performed by a Registered Medical Practitioner as defined under the MTP Act

B. It is performed at an approved site under the Act and recorded in Form III
C. Other requirements of the Act such as consent (Form C), opinion of RMP (Form I), monthly reporting
(Form II) etc. are fulfilled
D. The pregnancy is within the gestation limit approved by the law

The provider will get the protective cover of this legislation only when he or she fulfills the above
mentioned requirements completely
In case less than 18 yrs seeking termination service provider has to report the case to the appropriate
authorities (either the Local Police or Special Juvenile Police) or to the concerned authority in the Hospital
responsible for medico-legal cases to report the same under POCSO ACT-(Protection of Children Against
Sexual Offences)

VIOLATION OF MTP act-

The following offences can be punished with rigorous imprisonment for two to seven years:-
Ÿ Any person terminating a pregnancy who is not a registered medical practitioner as under the MTP
Ÿ Terminating a pregnancy at a place which is not approved
Ÿ Mandatory documentation of consent, opinion, case recording and monthly reporting are not adhered to
MTP SITE APPROVAL-
Ÿ All private sites need approval before starting abortion services
Ÿ Public sector sites do not need separate approval, provided they have the required infrastructur
Ÿ Approval of private sites is granted at the district level by the District Level Committee (DLC)
Mtp site approval not require renewal
RMP OPINION FORM
CHECKLIST FOR MEDICAL METHOD OF ABORTION:
FOLLOW UP CARD SHOULD BE USED IN EACH
PATIENT GIVEN MEDICAL METHOD

Follow-up Card
 INCOMPLETE,MISSED ABORTION,BLIGHTED OVUM DOES
NOT COME UNDER MTP ACT PERVIEW SO NEED TO FILL FORMS

DO*S FOR LEGAL ABORTION-

Ÿ Dysplay site approval certificate (form b) at hospital
Ÿ All private sites has to be approved, only once ,not need renewal
Ÿ Check site approval for gestational age and perform MTP accordingly
Ÿ Check age of girl/woman.if less than 18 yrs,follow POCSO act and inform police
Ÿ Medical method can be given in OPD having displayed affilation with approved centre
Ÿ Do proper preprocedure counseling
Ÿ Don't deny for MTP,if women not adopt any contraceptive method
Ÿ All documentation should be completed and kept at secured place
Ÿ Consent has to be taken on form C
Ÿ Spouse consent is not mandatory
Ÿ Confidentiality of woman has to be maintained
Ÿ All second trimester abortion should be done where OT and resuscitation facility is there
and patient should be admitted
 6 Violation of MTP Act Dr Shyamal Sett

Dr Sukanta Misra

[ Past Chairperson of MTP Committee of FOGSI Abortion situation in India is a growing

(2015 to 2017), President Elect of The Bengal concern not only because of poor socio-
Obstetric and Gynaecological Society] economic conditions and preference for male
child, but also due to lack of awareness and
[ Professor & H.O.D. of Obst & Gynae, lack of facilities available and accessible at an
Vivekananda Institute of Medical Sciences, affordable cost to them who need those most.
Kolkata Past President of The Bengal Obstetric
Therefore, to reduce the incidences of unsafe
and Gynaecological Society]
abortions and unfortunate maternal morbidity
The concept of abortion includes several and mortality therefrom, abortion was
issues beyond the right to life of the considered to be allowed under legal
foetus/embryo to privacy and right to bodily regulations.
autonomy of the pregnant woman. Arguments
between pro-life activistsand pro-choice MTP ACT 1971 -- Shantilal Shah Committee
advocates have gone as far as resulting in (1964) recommended liberalization of abortion
deaths for upholding the right of the unborn law in 1966. In 1969 MTP Bill was introduced
child. Logically, irrespective of the foetus in RajyaSabha and LokSabha, and passed by
possessing the quality of a person, almost all the Indian Parliament on 10th August 1971.
countries accept the foetus having some right MTP Act 1971 was implemented from 1st April
to be protected. So, the right to life cannot 1972 exceptin J & K (From 01.11.1976) (MTP
authenticate any person to take the life of an Rules and Regulations were revised in 1975).
unborn child, except -- (i) where the child poses
a threat to the life of the mother; (ii) the The MTP Act mainly encompasses -- 1) Who
continued lives of the child and the mother are can terminate a pregnancy, 2) Where can a
mutually incompatible. These invoke two pregnancy be terminated, 3) In which
privileges to the mother - of self-defence and conditions a pregnancy can be terminated, and
of self-preservation. 4) Upper age limit of 20 weeks for termination
of pregnancy.
Every year, 19 to 20 million unsafe abortions
are performed worldwide of which 97% are in
Salient features of MTP Rules 1975
developing countries, and about 55% are in
Asia (mostly south-central Asia). WHO defines (amended in 2003) -- 1) Formation of District
Unsafe Abortion as "a procedure for Level Committee -- defining its composition
terminating an unintended pregnancy either by and tenure; and dealing with MTP site approval
individuals without the necessary skills or in process, 2) Formulating infrastructure
an environment that does not conform to requirements at the MTP sites according to
minimum medical standards, or both". different trimesters, and 3) Experience and
training requirements of the RMP.

15
 Salient features of MTP Regulations In such cases, punishment may extend to
1975 (amended in 2003) - Importance of imprisonment for life, or imprisonment of
mandatory Documentation and Reporting in either description for a term that may be upto
different Forms. 10 years or fine.

VIOLATION OF MTP ACT -- The following According to Section 314 of IPC, if during
offences can be punished with rigorous the process of doing an abortion there is
imprisonment for three to seven years : (1) accidental death of the pregnant woman, the
Termination of pregnancy done by any person accused can be punished with imprisonment
who is not an RMP as under Clause 2(h) of the from 10 years upto life. It is not important
IMC Act 1956 and Clause 2(d) of the MTP Act whether the accused is aware that the process
1971. (2) Terminating a pregnancy at a place to carry out the abortion is likely to cause
not approved under the MTP Act. (3) death of the woman. If such a procedure is
Terminating a pregnancy without following the done without the consent of the woman, the
provisions of the MTP Act. (4) Mandatory culpability of the accused is going to be high
documentation of Consent, Opinion, Case with more stringent punishment.
recordings and Monthly reporting are not
done. Section 315 of IPC can punish a person who
does an act that causes : (a) death of the child
Penal Provisions - Indian Penal Code after birth, or (b) birth of a dead child, for any
Well before MTP Act 1971 came into force, purpose which is not intended to save the life
Indian Penal Code (IPC) already had the of the pregnant woman. The punishment may
provisions for punishments for 'causing be in the form of imprisonment upto 10 years.
miscarriage'-- under Therapeutic Abortion Act
by IPC 1860 and Code of Criminal Procedure
Section 316 of IPC deals with the incidences
1898.
where a person carries out termination of a
Section 312 of IPC defines the offence of pregnancy with the intention to cause death of
'voluntarily causing a woman to miscarry' the woman, may not succeed in doing so, but
without any intention of saving her life. In causes death of the unborn child in the womb,
other words, if someone assists or conducts an he/she would have committed the offence of
abortion with the purpose of saving the life of "causing death of the quick unborn child by an
the woman in good faith, he/she would not be act amounting to culpable homicide".
considered as an offender. Otherwise, such a
convicted person can be imprisoned for upto 3 ** However, all legal systems recognize the
years, or even upto 7 years with or without
right of an individual to protect
fine if the woman is "quick with the child".
Even the pregnant woman herself may be himself/herself from the danger to his/her
liable to be punished under Section 312. own life, and for that purpose to use
However, the pregnant woman can ask for her necessary means or force even to the extent
relief from conviction by : (i) Privilege of self- of causing death of that person or life
defence or (ii) Privilege of self-preservation. creating the danger.

Section 313 of IPC dictates that when an With the implementation of the MTP
abortion is carried out without the consent of Act 1971, the punishments have been
the woman and is also not really intended for incorporated within the provisions of the Act
the purpose of saving her life, the quantum of
offence of that person also goes up.

16
 VIOLATIONS UNDER THE MTP ACT AND THE PENALTIES

SECTION/RULE OF THE
VIOLATIONS PENALTIES
MTP ACT
Termination of pregnancy
1. Termination of pregnancy (Sec. S (2) (Explanation- 2).
in violation of provisions
by a person, who is not a The possession by RMP
of the Act 19 is an offence
Registered Medical of experience or training in
punishable with Rigorous
Practitioner Gynaecology and Obstetrics
Imprisonment (R.I.) for a
i.e. provisions of See.2, (d)
term which shall not be
shall not apply (Sec. S (2)
less than 2 years but which
(Explanation- 2)
may extend to 7 years.
{Sec.5 (2), (3), (4)}
Note: It is important and
worth wise to mention here
that it is now a cognizable
offence for which a police
officer can arrest a doctor
for violations without
Warrant.

2. Whoever terminates Section 5(3), 5(4) Termination of pregnancy in

pregnancy in a place that is violation of provisions of the
'unapproved' Any person, Act 19 is an offence
being 'owner' of a place that punishable with Rigorous
is not approved, and doing or Imprisonment (R.I.) for a
allowing the termination of term which shall not be less
Pregnancy at such place (See. than 2 years but which may
5(4). The expression "owner" extend to 7 years.
means any person who is the {Sec.5 (2), (3), (4)}
administrative head or
otherwise responsible for the Note: It is important and
working or maintenance of a worth wise to mention here
hospital or place, by whatever that it is now a cognizable
name (DM, MS, DP etc.) offence for which a police
called.{Sec.5 (4) Explanation-2} officer can arrest a doctor
for violations without
Warrant.

3. If a person willfully Section 7(3) Penalty of One Thousand

contravenes or willfully fails Rupees.
to comply with the
requirements of any

17
4. Irregularities in Rules 5(7)
registered centre

Display of Certificate --
It should be conspicuously
displayed at the place to be
easily visible to persons
visiting the Place.

5. Record Keeping Section 3, 4, 5,6,7,8 of GSR

a) Forms of Certifying Opinion 2544 dated 10th October 1975
b) Custody of Forms and Rule-9.
c) Maintenance of Admission
Register
d) Admission Register not be
open to inspection
e) Entries in registers maintained
in Hospital or approved place

Note :- All offences under the Act are cognizable, non-bailable and non-compoundable.

References -
1.Shaun D. Pattison, Medical Law and Ethics (London: Sweet & Maxwell, 2006), p 209

2.David A. Grimes et al, 'Unsafe Abortion: The Preventable Pandemic', The Lancet of the
Department of Reproductive Health and Research at World Health Organisation,Vol XXIXX,
2006, pp 1 - 13at p.5

3.Indian Penal Code 1860

4.SuchitraDalvie, AlkaBarua and HemantApte, 'Safe Abortions as Women's Rights : Perceptions

of Law Enforcement Professionals', Economic and Political Weekly, Vol 1, No 33, pp 62 - 66 at p 65

5.KritiDwivedi, 'Medical Termination of Pregnancy Act, 1971: An Overview', available

at < http://www.legalservicesindia.com/articles/pregact.htm>

18
 7 Comprehensive Sexuality Education Dr. Narendra Malhotra
Dr. Neharika Malhotra
In Preventing Unsafe Abortions
Dr. Aarti Chitkara

INTRODUCTION
Almost 73.3 million induced (safe & unsafe)
abortions occurred each year between 2015 to
2019(1). It is estimated by WHO that 3 out of 10
pregnancies are unintended (30%) and 6 out of
these 10 will end up in induced abortion (61% of all
unidentified pregnancy) and 1 out of these 3
induced abortions are carried out in unsafe
(dangerous) condition(2).
SCOPE OF CSE
Half of these unsafe abortions were in Asia (South
We need comprehensive sexuality education for
& central) and 4% - 13.2% of all maternal deaths
all adolescents and even adults for various
are attributed to unsafe abortions (3).
reasons listed below:-
Women (adolescent) resort to unsafe abortion
1. CSE goes beyond education about reproduction,
because of lack of access to safe abortion & lack of
risks and disease
comprehensive sexuality education.
2. CSE provides information on all approaches
for preventing unwanted pregnancy, STIS and
WHAT IS COMPREHENSIVE SEXUALITY
HIV
CARE ?
3. CSE uses a learner-centredapproach
4. Schools play a central role in the provision of
Comprehensive sexuality education is a
CSE
curriculum-based process of teaching and learning
5. Non-formal and community-based settings
about the cognitive, emotional, physical and social
are also important opportunities to provide
aspects of sexuality(4).
curriculum- based CSE
Comprehensive sexuality education should
6. CSE for safe sexual practice, access to
be medically accurate, evidence-based, and age-
contraception & safe abortions
appropriate, and should include the benefits of
delaying sexual intercourse, while also providing
COMPONENTS OF CSE (5)
information about normal reproductive
Emphasis on human rights values of all
development, contraception (including long-acting
individuals, including gender equality, gender
reversible contraception methods) to prevent
identity, and sexual diversity, and differences in
unintended pregnancies, as well as barrier
sexualdevelopment.
protection to prevent sexually transmitted
Encourage consideration of implants and
infections(STIs).
intrauterine devices for all appropriatecandidates.
Comprehensive sexuality education if
Include information on consent and decision
given to all adolescents with special emphasis on
making, intimate partner violence, and healthy
safe sexual practices & contraception will go a long
relationships.(Fig-2)
way in preventing unsafe abortions(Fig-1).
 Participatory and culturally sensitive each in gap THE ROLE OF OBSTETRICIAN- GYNAE
poachers that are appropriate to the student' sagas COLOGIST
well as identification with distinct sub populations, 1. In addition to counselling and service provision
including adolescents with intellectual and to adolescent patients, obstetrician-gynecologists
physical disabilities, sexual minorities, and can serve parents and communities by supporting
variations in sexual development." and assisting sexuality education by developing
Knowledgeable about and inclusive of state evidence-based curricula that focus on clear health
specific consequences of sexual activity during
goals (eg, the prevention of pregnancy and STIs,
adolescence, including online and social media
including HIV) and providing health care that
activity.
Discussion of the benefits and pitfalls of online focuses on optimizing sexual and reproductive
information (eg, gross misinformation on sexuality health and development, including, for example,
in cyberspace). education about and administration of the human
Provide access to adolescent clinics, papilloma virus vaccine (6)
contraceptive availability & safe abortion services. 2. Because of their knowledge, experience, and
There are 7 essential components to awareness of community’s unique challenges,
comprehensive sexuality education which will help obstetrician-gynaecologists can be an important
to reduce unsafe abortion practices (Fig-3) resource for sexuality education programs(7)
3. Additionally, obstetrician-gynaecologists can
encourage patients to engage in positive behaviors
to achieve their health goals and discourage
unhealthy relationships and behaviors that put
patients at high risk of pregnancy and STIs
4. Obstetrician-gynaecologist shave the unique
opportunity toact" bi-generationally" byas king
their patients about their adolescents' reproductive
development and sexual education, human
papilloma virus vaccination status, and
[Fig-2] contraceptive needs.
5. When a responsible adult communicates about
7 ESSENTIAL COMPONENTS OF CSE
sexual topics with adolescents, there is evidence of
delayed sexual initiation and increased birth
control and condom use(8)

CONCLUSION
The purpose of introducing comprehensive sexual
education is:

1. To recognize that informed sexual decision-

making (i.e. being knowledgeable and confident in
deciding if, when and with whom to become
sexually active) is important to their health and
well- being(attitudinal);
[Fig-3]
2. Recognize tha teach person's decision to be 6. Human papillomavirusvaccination . Committee
sexually active is a personal one, which can change Opinion No. 641. American College of
over time and should be respected at all Obstetricians and Gynecologists. Obstet Gynecol
times(attitudinal); 2015;126:e38-43. [PubMed] [Obstetrics
3. Make responsible decisions about their sexual &Gynecology]
behavior (skill) 7. Kirby D. Emerging answers 2007: new research
4. To have access to safe abortion services & findings on programs to reduce teen pregnancy.
contraceptive availability Washington, DC: The National Campaign to
Prevent Teen and Unplanned Pregnancy; 2007.
SUMMARY Available at: https://thenationalcampaign.org
A revised edition of UN's International technical /sites/default/files/resource-primary-
guidance on sexuality education (2019) includes download/EA2007_full_0.pdf.
new recommendations on abortion. Evidence now 8. Martinez G, Abma J, Copen C. Educating
shows that CSE reduces unintended pregnancy and teenagers about sex in the United States. NCHS
unsafe abortions. Data Brief 2010;(44):1-8.
9. Haberland N, Rogow D. Sexuality education:
REFERENCES emerging trends in evidence and practice. J
1. Bearak J, Popinchalk A, Ganatra B, Moller A-B, Adolesc Health 2015;56:S15- 21
Tuncalp O, Beavin C, Kwok L, Alkema L,
Unitented pregnancy and abortio by income,
region, and the legal status of abortion estimates
from comprehensive model for 1990-2019. Lancet
Glob Health. 2020 Sep; 8(9):e1152-e1161.
doi:1016/S2214-109X(20)30315-6.
2. Ganatra B, Gerdts C, Rossier C, Johnson Jr B R,
Tuncalp O, Assifi A, Sedgh G, Singh S, Bankole A,
Popinchalk A, Bearak J, Kang Z, Alkema L.
Global, regional and subregional classification of
abortions by safety, 2010-14 estimates from
aBayesian hierarchical model. The Lancet
2017Sep.
3. Say L, Chou D, Gemmill A, Tucalp O, Moller
AB, Daniels J, Gulmezoglu AM, Temmerman M,
Alkema L. Global causes of maternal death: a
WHO systematic analysis. Lancet Glob Health.
2014 Jun;2(6):e323-33.
4. https://en.unesco.org/news/why-
comprehensive-sexuality-education-important
5.http://www.ippf.org/sites/default/files/ippf_
framework_for_comprehensive_sexuality _
education.pdf
 8 INFECTION PREVENTION
FOR ABORTION CARE
DR. ASHIS MUKHOPADHYAY

Today, abortion care is comprehensive. The DIAGNOSIS AND EVALUATION

concept of CAC not only entails safety and An accurate initial assessment is essential The
completeness of the procedures, but also critical signs and symptoms of complications that
prevention of infection, in order to improve QOL. require immediate attention include:
1. Excessive bleeding per vagina
INFECTION SCENARIO IN ABORTION CARE 2. Severe pelvic infection with excruciating
pain
Estimates from 2010 to 2014 showed that around 3. Circulatory collapse and shock.
45% of all abortions were unsafe. Almost all of
these unsafe abortions took place in developing At times, the complications of unsafe abortion are
countries1 difficult to diagnose. For example, a woman with
Estimates from 2012 also indicate that in an ectopic pregnancy may have symptoms similar
developing countries alone, an estimated 7 million to those of incomplete abortion.
women per year needed hospital carefor Laboratory investigations are rarely possible in
complications of unsafe abortion2. acute cases, but they are useful in subacute or
Each year between 4.7% - 13.2% of maternal chronic cases. Blood tests like CBC, CRP, Urine
deaths can be attributed to unsafe abortion.. In R/E, M/E and C/S and blood culture in few cases
developed regions, it is estimated that only 30 are extremely useful to arrive at a rational
women die for every 100 000 unsafe abortions. diagnosis. An endometrial biopsy specimen
Whereas the mortality is seven times higher in should be taken to diagnose endometritis..
developing nations and almost 20 times more in
sub-Saharan Africa3 PRINCIPLES OF TREATMENT AND CARE
Prevention and timely replacement of blood
COMPLICATIONS OF UNSAFE ABORTION loss . Delays can be fatal..
Complications can range from non-severe Broad spectrum antibiotics and evacuation
morbidities like chronic pelvic pain and vaginal of retained POC as fast as possible.
discharge which affects her QOL, to fatal If injury is suspected, early referral to an
conditions endangering life : appropriate level of health care is essential.

1. Incomplete abortion leading to heavy

bleeding ANTIBIOTIC PROPHYLAXIS
2. Infection of upper and lower genital tract This is a very important but controversial issue.
3. Uterine perforation or or damage to other For medical abortion, treatment-dose antibiotics
organs like intestines. may lower the risk of serious infection. However,
the number-needed-to-treat is high4
Neither Povidone Iodine nor Chlorhexidine have PREVENTION : PRIMARY
been shown to alter the risk of infection when used Prevention of unsafe abortion is the most effective
as cervicovaginal preparation, although measure. This can be achieved through
Chlorhexidine reduces the bacterial load in vagina comprehensive sexuality education; effective
better than Iodine4 contraception including emergency contraception
Randomized controlled trials support the use of and provision of safe legal abortion to women
seeking abortion in unplanned and unintended
prophylactic antibiotics for surgical abortion in the
pregnancies
first trimester5
Timely provision of emergency treatment of
But no controlled studies have examined the complications . All these are outlined in the
efficacy of antibiotic prophylaxis for induced Evidence based resources from WHO (2012)7
surgical abortion beyond 15 weeks of gestation.
The risk of infection is not altered when an SECONDARY PREVENTION
intrauterine device is inserted immediately post- This essentially means prevention and control of
procedure. septic abortionin a proper set up.
The risk of infection of upper genital tract by Anticipation, diagnosis and Effective treatment
Chlamydia trachomatis, Neisseria Gonorrhoeae ofEndometritis by a senior and experienced doctor
acute cervicitis is significantly reduced with prevents many serious complications. After a rapid
antibiotic prophylaxis. Bacterial vaginosis (BV) initial assessment a detailed history is taken. The
also have an increased risk of infection,but there is abdominal and pelvic examinations merit special
no evidence of benefit with BV screening and attention. Careful evaluation also demands
appropriate lab tests to confirm the diagnosis and
culture separately.5
treatment is directed to removal or correction of
Antibiotic prophyllaxis in abortion :NICE
offending factor.
guidelines(September 2019)6 The polymicrbial bacteriology of septic abortion
a) Antibiotic prophylaxis following Medical derived from the normal flora of the vagina and
abortion is controversial. endocervix, demands broad spectrum antibiotics.
Antibiotics are to be used only in Medication In developing countries, tetanus contributes to
abortion cases with high risk of infection, or if they septic abortion death.26
screen positive for sexually transmitted infection. The initial 3-day course of broad spectrum
and not routinely, because it may increase antibodies in severe cases should be followed up
antibiotic resistance and adherence will also be with doxycycline 100 mg orally twice a day for 14
low. days, with or without metronidazole 500 mg orally
Drugs used are: : Oral azithromycin , Doxycycline twice a day for 14 days.8Quinolone group of
and Oral or rectal metronidazole (single agent or antimicrobials are no longer the 1st choice because
combination). A three-day course is enough. of quinolone resistant gonococcus in PID 8
b) Surgical abortion: Antibiotic prophylaxis is
TERTIARY PREVENTION
part of current clinical practice for women having a
Tertiary prevention avoids serious consequences
surgical abortion. Cochrane review showed the
of infection, including hysterectomy and death. It
effectiveness of nitroimidazoles (such as also involves prevention of Systemic inflammatory
metronidazole), tetracyclines (such as response syndrome (SIRS) or septic shock and
doxycycline) and beta lactams (such as adult respiratory distress syndrome (ARDS)
amoxicillin). A 7-day course of doxycycline is .Management of severe sepsis requires early
currently used in practice, but a 3-day course seems aggressive volume resuscitation, eradication of the
more logical. infection and supportive care
ERADICATING THE INFECTION
Emptying the uterus by a proper, careful gentle 3.Say L, Chou D, Gemmill A, Tunçalp Ö, Moller
method is extremely important, and should be AB, Daniels J, Gülmezoglu AM, Temmerman M,
undertaken by a senior Gynaecologist under Alkema L. Global causes of maternal death: a
anaesthesia WHO systematic analysis. Lancet Glob Health.
2014 Jun; 2(6):e323-33.
The role of laparotomy cannot be overemphasized. 4.Sharon L. Achilles, Matthew F. Reeves,
It can be life saving at times. In other instances, just Prevention of infection after Induced abortion.
drainage of collection and /or pus may be extreley Contraception, Volume 83, Issue 4, April 2011,
relieving for some cases. Pages 295-309
Laparotomy will be needed if the patient does not 5.N Engl J Med: . 2019 Mar 14;380(11):1012-
respond to uterine evacuation and adequate 1021. A Randomized Trial of Prophylactic
medical therapy. Other indications are uterine Antibiotics for Miscarriage Surgery
perforation with suspected bowel injury, pelvic 6.Antibiotic prophylaxis for medical and surgical
abscess, and clostridial myometritis.9 abortion - NICE guideline [NG140] Published: 25
Supportive care and adjunctive therapy with September 2019, available online at
steroids oxygen and blood transfusion are https://www.nice.org.uk › guidance › evidence
extremely important 7.Safe abortion: - by World Health Organization ·
2012 · - Safe abortion: technical and policy
KEY POINTS: guidance for health systems - Second edition ...
"Infection is still an important cause of Maternal World Health Organization 2012. ... Standard
mortality and morbidity even today. precautions for infection control.
"Most of the infections develop in unsafe abortion. 8.Centers for Disease Control: Sexually
"Antibiotics play a major role in surgical abortion, Transmitted Diseases Treatment Guidelines, 2010.
but in medication abortion their role is http://www.cdc.gov/std/treatment/2010/pid.htm-
controversial. regimens.htm, accessed January 26, 2011.
"Death and serious complications from abortion- 9.Sweet RL, Gibbs RS: Infectious Diseases of the
related infection are almost entirely avoidable. Female Genital Tract. pp 229, 240 2nd ed.
"Primary prevention is always better than Baltimore, Williams & Wilkins, 1990
secondary or tertiary levels of prevention of
infection.

REFERENCES
1.Ganatra B, Gerdts C, Rossier C, Johnson Jr B R,
Tuncalp Ö, Assifi A, Sedgh G, Singh S, Bankole A,
Popinchalk A, Bearak J, Kang Z, Alkema L.
Global, regional, and subregional classification of
abortions by safety, 2010-14: estimates from a
Bayesian hierarchical model. The Lancet. 2017 Sep
2.Singh S, Maddow-Zimet I. Facility-based
treatment for medical complications resulting from
unsafe pregnancy termination in the developing
world, 2012: a review of evidence from 26
countries. BJOG 2015
 9 MTP - Pre Procedure Counselling
DR KALYAN B BARMADE

The Comprehensive Abortion Care: Training and gain her confidence, as abortion is a very sensitive
Service Delivery Guidelines (2018) emphasise on issue and she may be reluctant to discuss it.
the importance of informed consent from the 4. Building rapport is also critical for finding out
women and, therefore, highlight the importance of whether there have been any attempts to terminate
the present pregnancy; this is important for
pre-procedure counselling:
predicting likely problems and may affect their
management.
'Counselling is a structured interaction in which a 5. Make the woman feel comfortable mentally as
person voluntarily receives emotional support and well as physically. (The former is extremely
guidance from a trained person in an environment important as she may have strange feelings about
that is conducive to open sharing of thoughts, terminating the pregnancy)
feeliangs and perceptions.' 6. Identify the reason for the termination of
Every woman who seeks CAC services must be pregnancy by asking relevant questions related to
offered counselling. her personal, social, family and medical history and
the past use of contraceptive methods
Providers, nursing staff/ paramedical staff and
7. Use simple language and allow the woman to
counsellors (where available) may be clarify her doubts
appropriately trained to offer abortionrelated 8. If she has made up her mind for termination of
counselling services. her pregnancy, assess her for the CAC procedure.
Counselling is an integral part of comprehensive
abortion services and is as important as performing If found eligible for MTP, explain to her, in simple
the procedure correctly. language: The range of available options of MTP
The process of decision-making may be difficult techniques based on gestation
for the woman and she may need help. The MTP technique chosen by her. For instance,
if she has opted for medical methods of abortion,
Counselling is also important to help her decide then discuss her preference for the place of
misoprostol use.
whether to use a temporary or permanent method
The likely risks associated with the procedure.
of contraception to avoid another unwanted
The care required after the procedure,
pregnancy.
That this will not affect her future fertility, if
Wherever possible, the spouse should also be done under safe conditions,
counselled. The immediate risk of pregnancy if no
contraceptive method is used, as fertility can
Pre-procedure Counselling: return as early as 10 days after the first trimester
1. Ensure that privacy (visual and auditory) and abortion and within four weeks after a second
confidentiality are maintained during trimester abortion,
counselling She should wait for at least six months before
2. Be non-judgmental while interacting with the trying to conceive again,
woman and be sensitive to her needs Need and schedule for a follow-up,
3. Establish rapport with the woman and Help the woman to sign the consent,
 Discuss various contraceptive methods (refer In case the method is not available at the centre,
Annexure 1: Post-abortion Contraceptive provide information and other assistance for
Methods) including their advantages, getting the appropriate service elsewhere.
Help the woman to choose a contraceptive method If the woman is not willing to accept a
and assess whether the method is appropriate contraceptive method: Do not refuse MTP, as she is
(based on history and examination) for her If the likely to go elsewhere, probably to an illegal
chosen method is not appropriate, explain the abortion provider, and suffer complications,
reason and help her choose another one. Assure the woman that she will not be refused
If the method is appropriate, provide the method- MTP.
specific information. Wait for an opportunity to counsel her after the
procedure. If she is still not willing to accept a
contraceptive method, call her for follow-up in a
week's time and counsel her again. Record the
assessment findings, procedure, contraception or
refusal to accept contraception and advice given
(including referral)
MTP should not be denied irrespective of the
woman's decision to refuse concurrent
contraception.

pre-procedure counselling:
It helps the woman to decide about the termination of pregnancy.
It helps the woman to choose the method of termination.
It ensures that the consent for the procedure is given after receiving complete information
about the procedure and understanding its implications.
It helps the woman to adopt a contraceptive method after the procedure.
It is crucial that privacy is ensured during the pre-procedure counselling.
aIt is necessary to be non-judgmental while interacting with the woman and be sensitive to her needs.

MTP should not be denied irrespective of the woman's

decision to refuse concurrent contraception.

REFERENCES :
1. Ensuring Access to safe Abortion and Addressing Gender Biased Sex Selection
Ministry of Health & Family Welfare Government of India February 2015 E
2. The MTP regulations
3. The Comprehensive Abortion Care: Training and Service Delivery Guidelines (2018)
 10 Role of Ultrasound in Medical
Termination of Pregnancy Dr. P.K. Shah

Unsafe abortions contribute to eight percent of Ultrasound scanning should be provided in a

maternal deaths in India. In absolute numbers, setting and manner sensitive to women's situation.
close to 10 women die due to unsafe abortions each Before ultrasound is undertaken, women must be
day. While abortion has been legal in India since asked whether they would wish to see the image or
1971, available research shows that 56% of the 6.4 not. All ultrasounds must be registered under Pre-
million abortions that take place in the country are Conception and Pre-Natal Diagnostic Techniques
unsafe1.Despite abortion being legal, the high (PC&PNDT) (Prohibition of Sex Selection) Act as
estimated prevalence of unsafe abortion applicable for all other ultrasounds of pregnant
demonstrates a major public health problem in women.
According to the American Institute of Ultrasound
India2. It is unfortunate that women continue to
in Medicine (AIUM), in collaboration with the
face severe complications which are totally
American College of Obstetrics and Gynecology
preventable through just ensuring easy access to
and the American College of Radiology, a "limited
safe abortion services. The Medical Termination of
ultrasound examination" is performed when a
Pregnancy Act, 1971 (MTP Act) was enacted in
specific question requires investigation4.
India to reduce the mortality and morbidity
associated with unsafe abortions. It entitles women
A limited ultrasound exam must include the
access to safe abortion services under certain
following:
specific conditions. The MTP Act lays down the
criteria for which a pregnancy can be terminated,
(1) A full scan of the uterus in both the transverse
by whom, where and up to which gestational age.
and longitudinal planes to confirm an intrauterine
MTP is performed by qualified health providers
pregnancy;
using surgical methods or medical abortion drugs (2) Evaluation of embryo/fetal number;
(mifepristone and misoprostol). Only induced (3) measurements to document gestational age;
abortions come under the purview of the MTP Act, (4) evaluation of pregnancy landmarks, such as
which therefore does not cover spontaneous, yolk sac or the presence or absence of
missed, inevitable and incomplete abortions. The fetal/embryonic cardiac activity; and
MTP Act offers protection to a practitioner if she/he (5) placental location in second trimester
adheres adheres to the provisions of the MTP Act; (6) When clinically indicated, evaluation of other
and Rules and Regulations made under the MTP pelvic structures (i.e., adnexal structures and the
Act. cul de sac) should be performed and documented or
It is imperative to understand that it is not an appropriate referral should be made for further
mandatory or binding upon the clinician to evaluation.
advise/perform ultrasound before undergoing (7) When a patient with a prior uterine scar is found
MTP3.Clinical finding of intrauterine pregnancy is to have placenta previa or a low anterior placenta,
enough to perform MTP-both medical and surgical. or when other placental abnormality is suspected,
There are certain situations though where additional sono graphic imaging should be
ultrasound can be useful before, during after MTP. performed on-site or an appropriate referral made5.
Ultrasound prior to MTP could be beneficial in Ultrasound following medical or surgical MTP
following scenarios: could be beneficial in following scenarios.
1.Documentation of pregnancy when there is a 1.Incomplete evacuation
doubt about the presence of a pregnancy. 2.Dating 2.Failed medical abortion
of pregnancy when it is felt that the patient is not 3.Ruling out Gestational Trophoblastic disease
sure of her dates or the clinical examination does 4.Patients after surgical evacuation presenting with
not correspond to history. symptoms suggestive of perforation.
5.Post MTP suspicion of heterotopic pregnancy or
3.Diagnosis of co-existing mass like fibroid,
extrauterine gestation.
helping determine its size & location.
4.Diagnosis of congenital uterine anomalies. 1.Incomplete Evacuation
5.Diagnosis of extrauterine gestation, Vesicular Hyperechogenic shadows inside the uterine cavity
mole & Missed abortion. with collection of fluid (bleeding) as an hypoechoic
area can be seen.(Fig 2)
Missing an ectopic : There is a major fear amongst
many service providers. However a large study Cowett et al suggested that the mean endometrial
done by Gynuity Health Projects, New York6 thickness 24 hours after using misoprostol in
showed that ectopic pregnancy was diagnosed very women with a complete medical abortion may
infrequently following medical abortion range from 7.6 to 29 mm7.One week after the
procedures, occurring in only 10 of 44,789 (0.02%) abortion, the mean thickness was 11.3 mm but
women. This eliminates the need of mandatory ranged from 1.6 to 24.9 mm. A thickness of more
ultrasound before all medical abortions. However than 15 mm as suspicious for incomplete abortion.
if the patient does not bleed 6 hrs. to 8 hrs. after the However if the thickness is more that 15 mm & the
misoprostol dose then a suspicion of ectopic patient is clinically asymptomatic with no P/V
pregnancy must be made & appropriate diagnostic bleeding she need not be subjected to vacuum
facility should be restored to. Seeking a second aspiration even if the endometrial thickness is more
opinion and repeating scans before making a than 15 mm.
diagnosis in cases of miscarriage and ectopic It is normal to visualize clot and debris in the uterus.
gestation should be embedded in clinical practice to The final decision to intervene should be made on
avoid medico-legal hassles. clinical signs and symptoms, such as ongoing or
Torrential or intractable hemorrhage during heavy bleeding, rather than on ultrasound findings.
surgical evacuation could lead to suspicion of
cervical pregnancy which can be diagnosed with
ultrasound.(Fig 1)

Fig 1 : Cervical ectopic Fig 2: Retained products of conception

2.Intact Gestational Sac amenorrhoea, clinical discrepancy or uncertainty
Occasionally an intact sac is found on day 14 in examination and to exclude an ectopic gestation
without cardiac activity. Management in this before a medical termination of pregnancy.
situation can be expectant, or may involve a repeat
dose of misoprostol or aspiration curettage. References:
1. Duggal R, Ramachandran V: The abortion
assessment project - India: key findings and
recommendations. Reprod Health Matters 2004;
12:122-129.

2.Yokoe R, Rowe R, Choudhury SS, et alUnsafe

abortion and abortion-related death among 1.8
million women in India BMJ Global Health
2019;4:e001491.

3.FOGSI-ICOG GCPR guidelines.

Fig 3 :Intact Gestational Sac 4.American Institute of Ultrasound in Medicine.
AIUM Practice Parameter for the Performance of
3.Failure of medical abortion. Obstetric Ultrasound Examinations. Laurel, MD:
Presence of cardiac activity 2 weeks after the dose American Institute of Ultrasound in Medicine,
of misoprostol indicates failed medical 2013.
abortion(Fig 4). If patient complains of
continuation of amenorrhoea or pregnancy 5.Rac MWF, Dashe JS, Wells CE, Moschos E,
symptoms USG can confirm or rule out McIntire DD, Twickler DM. Ultrasound predictors
continuation of pregnancy of placental invasion: the placenta accreta index.
Am J Obstet Gynecol. 2015;212(3):343.e1-.e7.

6.Shannon C, Brothers LP, Philip NM, Winikoff B.

Ectopic pregnancy and medical abortion. Obstet
Gynecol. 2004 Jul;104(1):161-7.
doi:10.1097/01.AOG.0000130839.61098.12.
PMID: 15229016.

7.Cowett, A. A., Cohen, L. S., Lichtenberg, E. S., &

Stika, C. S. (2004). Ultrasound evaluation of the
Fig 4: cardiac activity in failed medical abortion. endometrium after medical termination of
pregnancy. Obstetrics & Gynecology,103(5, Part
Conclusion : 1), 871-875.
A . It is not mandatory to perform ultrasound before
a medical termination of pregnancy.
B. There are certain situations where ultrasound
may be helpful before, during and after a surgical
abortion.
C. Ultrasound may be performed for dating a
pregnancy with irregular cycles, lactation
 11 Clinical Evaluation Dr. Sadhana Gupta

Before MTP Dr. Hema Jai Shobhane

It is estimated that 15.6 million abortions take place Physical examination: Basic routine
in India every year. Despite abortion being legal, a observations (pulse, blood pressure and, in some
significant proportion of these are expected to be cases, temperature) are useful baseline
unsafe. Unsafe abortion is the third largest cause of measurements. Additionally, health-care providers
maternal mortality leading to death of 10 women must confirm pregnancy and estimate its duration
each day and thousands more facing morbidities1. by a bimanual pelvic and an abdominal
There is a need to strengthen women's access to examination. Signs of pregnancy that are
comprehensive abortion care services. Clinical detectable during a bimanual pelvic examination as
evaluation before MTP is a significant approach for early as possible before 6-8 weeks of gestation
safe abortion. include softening of the cervical isthmus and
softening and enlargement of the uterus. A pregnant
Clinical evaluation before MTP : woman's uterus that is smaller than expected could
Best practice in comprehensive abortion care be due to a pregnancy that is less advanced than
includes, it must be confirmed that the woman is estimated from the date of the LMP, an ectopic
seeking abortion voluntarily, assessment of pregnancy, or a missed abortion, a uterus that is
gestational age, blood tests, any serious chronic larger than expected may indicate a pregnancy that
medical conditions should be excluded, referred to is more advanced than calculated from the date of
appropriate centre as soon as possible, and any the LMP, a multiple pregnancy, a full bladder, the
ongoing genital tract infection is excluded or presence of uterine fibroids or other pelvic
properly managed. tumours, or a molar pregnancy. A physical
examination is generally more accurate and
Taking the medical history: The woman should
reliable if the woman empties her bladder prior to
be asked about the first day of her last menstrual
the examination.During the physical examination,
period and regularity of cycle. Some women who
the health-care provider should also assess whether
are pregnant may not report having missed a period
the uterus is anteverted, retroverted or otherwise
(breast feeding, injectable contraception). Some
positioned in a way that might affect assessment of
women may experience non-menstrual bleeding in
the gestational age or complicate a surgical
early pregnancy, and this can be a cause of missing
abortion.
or misdating pregnancy. In addition to estimating
the duration of pregnancy, clinical history-taking Determinationof gestational age : It is not
should serve to identify contraindications to necessary to determine the exact gestational age
medical or surgical abortion methods and to but rather to make sure that the gestation falls
identify risk factors for complications of treatment within the range of eligibility for a particular
and referred to appropriate centre without delay2,3. method of inducing abortion.
The date of onset of the last menstrual period, Contraception: Effective methods of
bimanual pelvic examination, abdominal contraception should be discussed with women at
examination and recognition of symptoms of the initial assessment and a plan agreed, and
pregnancy are usually adequate after a positive documented, for contraception after the abortion.
pregnancy test4 Immediately after surgical abortion is an optimal
time for insertion of an IUD (and is safe after both
Blood Tests: laboratory investigations are not first- and second-trimester surgical abortions).
necessary for MTP services. Hemoglobin or Contraceptive implants can be provided at any time
haematocrit levels to detect anaemia may be useful once the abortion procedure has started11.
when initiating treatment in the rare cases of
Rh-isoimmunization: All MTPs less than 12
hemorrhage occurring at the time of or following
weeks require 50 mcg Rh-immunoglobulin and
the abortion procedure. Tests for Rhesus (Rh) blood 300 mcg in MTPs more than 12 weeks.In
group typing should be provided when feasible, to pregnancies up to 9 weeks' (63 days') gestation,
administer Rh-immunoglobulin when indicated5. however, the theoretical risk of maternal Rh-
sensitization with medical abortion is very low12.
STI Screening : It is best practice to undertake a Thus, determination of Rh status and the offer of
risk assessment for STIs for all women (e.g. HIV, anti-D prophylaxis are not considered prerequisites
chlamydia, gonorrhoea, syphilis), and then to for early medical abortion. If Rh-immunoglobulin
screen for them if appropriate andavailable6. This is available, administration of the immunoglobulin
should be done without delaying the abortion and to Rh-negative women having a medical abortion is
offer condoms for STI prevention to all women recommended at the time of the prostaglandin
undergoing abortion. administration. For women using misoprostol at
home, Rh-immunoglobulin may be administered at
Ultrasound Scanning : Ultrasound is not the time mifepristone is taken.
routinely required for the provision of abortion.
Where it is available, a scan can help identify an Ectopic Pregnancy: Signs and symptoms that
intrauterine pregnancy and exclude an ectopic one might indicate extrauterine pregnancy include
from 6 weeks of gestation7. It may also help uterine size smaller than expected for the estimated
determine gestational age and diagnose length of pregnancy, cervical motion tenderness,
pathologies or non-viability of a pregnancy. lower abdominal pain particularly one sided,
especially if accompanied by vaginal bleeding and
Prevention of infective complications: Routine spotting, dizziness or fainting, pallor, and, in some
women, an adnexal mass13. If ectopic pregnancy is
use of antibiotics at the time of surgical abortion is
suspected, it is essential to confirm the diagnosis
best practice as it reduces the risk of infection by
immediately and to initiate treatment or transfer the
half after the abortion8. However, abortion should
woman as soon as possible to a facility that has the
not be delayed if antibiotics are not available. The capacity to confirm diagnosis and provide
following regimens are recommended for peri- treatment14. The inspection of aspirated tissue
surgical abortion, 200mg doxycycline within 2 following a surgical abortion procedure can nearly
hours before the procedure or 500mg azithromycin eliminate the risk of an ectopic pregnancy going
within 2 hours before the procedure. Following undetected. Itshould be noted that it is more
medical abortion, the risk of intrauterine infection difficult to diagnose an ectopic pregnancy during
is very low and prophylactic antibiotics are and after medical methods of abortion, due to the
therefore not necessary9,10. similarity of symptoms14.
 Additionally, neither mifepristone nor misoprostol 4.Safe abortion: technical and policy guidance for
are treatments for ectopic pregnancy, which, if health systems. Geneva: World Health
present, will continue to grow. These may include Organization; 2003.
pelvic ultrasound and serial human chorionic 5.Baker A, Beresford T. Informed consent, patient
gonadotrophin (hCG) measurements. If these are education and counseling. In: Paul M, et al.,
not possible, or if ectopic pregnancy is diagnosed editors. Management of unintended and abnormal
or strongly suspected, the woman should be pregnancy: comprehensive abortion care.
transferred to an appropriate referral center for Hoboken, NJ: Wiley-Blackwell; 2009. pp. 48-62.
6.Managing the complications of pregnancy and
treatment.
childbirth: a guide for midwives and doctors. 2nd
As with many other procedures, adherence to ed. Geneva: World Health Organization; 2003.
7.Laing FD, Frates MC. Ultrasound evaluation
best practice standards will ensure that the most
during the first trimester of pregnancy. In: Callen P,
effective and safest services are delivered15.
editor. Ultrasonography in obstetrics and
Extending the upper gestation limit from 20 to gynecology. 4th ed. Philadelphia: WB Saunders;
24 weeks for special categories of women which 2010. pp. 118-119.
includes vulnerable women including survivors 8.Penney GC, et al. A randomised comparison of
of rape, victims of incest and other vulnerable strategies for reducing infective complications of
women (like differentlyabled women, minors) induced abortion. British Journal of Obstetrics and
etc. Upper gestation limit not to apply in cases of Gynaecology. 1998;105:599-604.
substantial foetal abnormalities diagnosed by 9. Low N, et al. Perioperative antibiotics to prevent
Medical Board. Thusevery woman is unique infection after first-trimester abortion. Cochrane
and deserves for sincere adherence with the best Database of Systematic Reviews. 2012;(3):
pre abortion care, and is not only important to CD005217.
develop confidence, satisfaction in family 10.Sawaya GF, et al. Antibiotics at the time of
planning services but also helps in reducing the induced abortion: the case for universal
complications and mortalities associated with prophylaxis based on a metaanalysis. Obstetrics
procedure. and Gynecology.1996;87:884-890.
11.Shannon C, et al. Infection after medical
References: abortion: a review of the literature.
Contraception.2004;70:183-190.
1.Grimes DA, Cates W Jr. Complications from 12. Naik K, et al. The incidence of fetomaternal
legally-induced abortion: a review. Obstetrical and haemorrhage following elective termination of
first-trimester pregnancy. European Journal of
Gynecological Survey. 1979;34(3):177-191.
Obstetrics Gynecology and Reproductive
2.Kulier R, et al. Medical methods for first
Biology.1988;27:355-357.
trimester abortion. Cochrane Database of 13.Majhi AK, et al. Ectopic pregnancy-an analysis
Systematic Reviews. 2011;(1):CD002855. of 180 cases. Journal of the Indian Medical
11.Kulier R, Kapp N. Comprehensive analysis of Association.2007;105:308-312.
the use of pre-procedure ultrasound for first- and 14. Barnhart KT, et al. Risk factors for ectopic
second-trimester abortion. Contraception. pregnancy in women with symptomatic first-
2010;83:30-33. trimester pregnancies. Fertility and
3.Slade P, et al. A comparison of medical and Sterility.2006;86:36-43.
surgical termination of pregnancy: choice, 15. Royal College of Obstetricians and
emotional impact and satisfaction with care. British Gynaecologists. The care of women requesting
Journal of Obstetrics and Gynaecology. induced abortion. London: RCOG Press; 2004.
1998;105:1288-12954. Evidence-based guideline no. 7.
 12 Pain Management Dr. Meena Samant

in Abortion Dr. Divya Suman

Every year nearly 56 million induced abortions are considered in reducing the pain with early medical
performed globally[1]. Pain is one of the abortion as it is a non-traditional opioid and
commonest predictable symptoms of the abortion, indicated for the use of acute and chronic moderate-
whether by medical method or any surgical to-severe pain [4].Paracetamol is not
recommended because it has not been shown to
procedure. In medical methods pain is due to the
provide better pain relief than compared with
contraction of smooth muscles of uterus. As the
placebo.
gestation age progresses, the duration and intensity
of pain increases. In surgical abortions, pain is due Tramadol is considered as an effective agent to treat
to the discomfort of instrumentation, cervical labor pain as well as pain associated with medical
dilatation and uterine contractions. abortion in the second trimester [5]. It is observed
Adequate pain management plan is considered as that tramadol rectal suppository prior to surgical
elemental in abortion care. The very purpose of abortion required less intraoperative anesthesia and
pain management is to minimize the discomfort also resulted in lower postoperative pain scores [6]
and anxiety of a woman. It improves the woman's If equipment and monitoring are available, epidural
experience. anesthesia or patient controlled analgesia may
benefit the woman undergoing second trimester
abortion.
Medical Abortion-
Surgical Abortion
WHO currently recommends sub-lingual, vaginal
A quiet and comfortable setting with clear
and buccal and routes for provision of misoprostol
explanation of procedure is necessary to allay the
as part of a combined mifepristone and misoprostol fears. Ibuprofen 400-800 mg or naproxen 500mg
regimen for medical abortion through 63 days given 30-60 minutes prior to procedure is
gestation. The use of non-steroidal anti- recommended [7]. It reduces both the procedural
inflammatory drugs (NSAIDs) is recommended and post procedural pain. Use of hot water bottle
during medical abortion for pain management [2]. and heated pads after the procedure can be
The most commonly used NSAID is Ibuprofen. It is comforting. Listening to music has been found to
given as 400 to 800mg, at the initiation of decrease procedural pain. It reduces anxiety levels
and catecholamine, as well as provides distraction
Misoprostol. It is repeated 6 to 8 hours as needed.
to pain.
Possible gastrointestinal upset can be the side
effect. It should not be given in women with peptic Paracervical Block-
ulcer or renal failure. Local anesthesia is an effective option for surgical
Studies have demonstrated that prophylactic abortion. Paracervical block is a relatively easy
Ibuprofen with Metoclopramide may increase the method and particularly useful in the outpatient or
efficacy and decreases the side effect of Ibuprofen office setting. Pain associated with uterine
Prophylactic use of tramadol may be also contraction and cervical stretching is transmitted
via visceral afferent nerve fibres which accompany depressionas coma, respiratory arrest and
sympathetic fibers sequentially passing through cardiovascular depression can be seen. As soon as
aggregates of nerve fibres and entering the spinal lidocaine toxicity is identified, its administration is
cord at T11-T12. These fibres run adjacent to the stopped. Oxygenation is done by face mask. 20%
cervix, just deep to the lateral fornix. intralipid should iv should be given bolus to reverse
cardiac and neurological toxicity.Lipid rescue
A lidocaine syringe is prepared using 20mL of 1% should be used in cases of collapse secondary to
lidocaine and a 3cm needle. Cervical local anaesthetic toxicity. The mechanism by
antisepticpreparation is done after placing which lipids reverse local anesthetic cardiotoxicity
speculum. Two mL of lidocaine is injected into the may be increasing clearance from cardiac tissue.
anterior lip of the cervix at 12 o'clock position and This extraction of local anesthetics from aqueous
after grasping with tenaculum. Remaining plasma or cardiac tissues is termed a 'lipid
lidocaine in injected in equal amounts at the sink'.Treatment of cardiac arrest with lipid
cervicovaginal junction, at 2, 4, 8 and 10 o'clock. emulsion42,102consists of an intravenous bolus
10mL of 2% may be substituted. A two-point injection of
paracervicalblock technique (injecting at 4 and 8 Intralipid 20%,1.5 ml/kg over 1 min(100 ml
o'clock) may be used. One ml Sodium bicarbonate for a woman weighing 70 kg). this is followed by an
may be added to the paracervical block to reduce intravenous infusion of Intralipid 20% 15 ml/kg/h
the injection pain of acidic lidocaine. (1000 ml/h1 for a woman weighing 70 kg). The
Maximum dose of lidocaine is 4.5mg/kg or 200 mg bolus injection can be repeated twice at 5-minute
total. intervals if an adequate circulation has not been
Aspirate before injecting to prevent intravascular restored (a further two 100 ml boluses at 5-
injection and deeper administration (3cm) provides minuteintervals for a woman weighing 70 kg).
better pain relief than superficial one. After another 5 minutes, the infusion rate should be
increased to 30 ml/kg/hr if an adequate circulation
has not been restored. Cardiovascular system of the
person is monitored carefully. Small doses of
epinephrine are administered to the patient.
Intravenous fluids and vasopressor drugs causing
constriction of blood vessels are used to support the
patient's health. Seizures are controlled by the use
of benzodiazepines.

IV sedation
Providing intravenous sedation increases the
expense, complexity and potential risks of an
abortion procedure. It requires a trained provider
with equipment for patient monitoring. It is
generally not needed.

General Anesthesia
Lidocaine toxicity-Complaints of a "metallic taste" It is very effective for intra operative pain control.
(Garrulousness) may be an early sign of systematic But GA increases the expense, complexity and
toxicity. It can be followed by numbness of the potential risks associated with abortion and is not
tongue, lightheadedness, visual disturbances, recommended for routine procedures (Atrash,
tinnitus, muscular twitching and seizures. After Cheek, & Hogue, 1988; Bartlett et al., 2004;
that signs of central nervous system MacKay, Schulz, & Grimes, 1985; WHO, 2014).
Choosing The Right Pain Management 2. World Health Organization. Safe abortion:
Individual experiences with pain, responses to technical and policy guidance for health systems.
pain, and responses to analgesics are complex and 2012.
subjective. It can vary according to ethnicity,
socioeconomic status, cultural factors, physiology, 3. Dragoman MV, Grossman D, Kapp N, Huong
previous experience and genetics, besides other NM, Habib N, Dung DL, Tamang A. Two
prophylactic medication approaches in addition to
things. An individualized and tailored approach
a pain control regimen for early medical
should be followed. Non pharmacological methods
abortion?<?63 days' gestation with mifepristone
should be adjunct. VAS (Visual Analogue Score) and misoprostol: study protocol for a randomized,
for analyzing the pain management can be used in controlled trial. Reprot Health. 2016 Oct
clinics. 12;13(1):132. doi: 10.1186/s12978-016-0246-5.
This pain management tool helps the health care PMID: 27733165; PMCID: PMC5062865.
providers to assess pain to individual patient needs.
4. Schug SA. The role of tramadol in current
treatment strategies for musculoskeletal pain.
TherClin Risk Manag. 2007;3(5):717-23.

5. Orbach-Zinger S, Paul-Keslin L, Nichinson E,

Chinchuck A, Nitke S, Eidelman LA. Tramadol-
metoclopramide or remifentanil for patient-control
analgesia during second trimester abortion: a
double-blinded, randomized controlled trial. J
ClinAnesth. 2012;24(1):28-32.

Conclusions- 6. Khazin V, Weitzman S, Rozenzvit-Podles E,

Pain relief should be provided routinely and when Ezri T, Debby A, Golan A, et al. Postoperative
requested for both medical and surgical abortions. analgesia with tramadol and indomethacin for
In most cases, nonsteroidal anti-inflammatory diagnostic curettage and early termination of
pregnancy. Int J ObstetAnesth. 2011;20(3):236-9.
drugs (NSAIDS)), local anesthesia and/or
conscious sedation supplemented by verbal 7. Wiebe ER, Rawling M. Pain control in abortion.
reassurance are sufficient. The need for pain Int J Gynaecol Obstet 1995;50:41-6.
management increases with gestational age and
narcotic analgesia maybe required. Prophylactic 8. Renner RM, Jensen JT, Nichols MD, Edelman
NSAIDs should be given at the time of starting A. Pain control in first trimester surgical abortion.
misoprostol for second-trimester medical abortion. Cochrane Database of Systematic Reviews 2009,
This is likely to reduce the need for narcotic Issue 2. Art. No.: CD006712. DOI:
analgesia. 10.1002/14651858.CD006712.pub2. Accessed 06
March 2021.
References
9. Chu J, Johnston TA, Geoghegan J, on behalf of
1. Ganatra B, Gerdts C, Rossier C, Johnson BR, the Royal College of Obstetricians and
Tunçalp Ö, Assifi A, et al. Global, regional, and Gynaecologists. Maternal Collapse in Pregnancy
subregional classification of abortions by safety, and the Puerperium. BJOG 2020;127 e14-e52
2010-14: estimates from a Bayesian hierarchical
model. Lancet 2017;390(10110):2372-81 10. World Health Organization.clinical practice
handbook for safe abortion.2014.
 13 Medical Method Of Abortion-
Drugs,Dose And Protocol Dr. Kiran Kurkotti

1.Introduction 1.1Introducing A New Drug Mifepristone -

There has always been a traditional demand for non Pharmacology
surgical methods for induced abortion from a
variety of formal and informal sources being met 1.2Mechanism of action:
by irrational hormones, indigenous medicines and Progesterone is imperative for sustaining early
meaningless decoctions. In a study, 495 women pregnancy. Withdrawal of progesterone support
seeking MVA in rural Rajasthan, 32% admitting to results in expulsion of the embryo by a PG
have earlier used medical remedies such as tablets medicated mechanism. Mifepristore, a
derivative of norethindrone, binds to the
(65%), decoctions (33%) and injections (8%)
progesterone receptor with an affinity greater
(Iyengar&Iyengar, 2002).1
than that of progesterone itself, without
activating the receptor, hence acting as an
Following the US FDA approval on October 2001,
antiprogestin. These drugs are characterized by
medical abortion using mifepristone was approved
the substitutions of the 11-Beta and 17 alpha
by the Drug Controller of India on February 13,
positions of the steroid ring system and bind
2002. With this India joined a select group of 28 strongly to both progesterone and
countries worldwide to approve this option for glucocorticoid receptors.
women's health, choice and autonomy (Drug
Controller of India, 2002). 2 1.3 Effects on uterus and cervix during early
pregnancy:
The approval came with certain accepted Alters the endometrium by affecting the
preconditions capillary endothelial cells of the decidua,
Medical termination of intrauterine pregnancy resulting in separation of the trophoblast from
through 49 days of pregnancy the decidua, resulting in separation of
To be sold by retail on the prescription of a trophoblast from the deciduas , with resultant
gynecologist only. decrease
To be used only under the supervision of expert in HCG and bleeding. This results in increased
(gynecologist) and in a hospital where back-up PG release.
facilities are available for blood transfusion and Softens the cervix and facilitates expulsion.
MTP
1.4 Pharmacokinetics:
With in the legal framework in India, the term Given orally, mifepristone is rapidly absorbed,
gynecologist may be interpreted as any RMP reaching peak concentration in 2 hours. Peak serum
certified under the MTP Act and Rules concentrations of 2-2.5 micro gram /ml occur in
women given 100, 400, 600 or 800 miligrams
mifepri stone. The half life is approx 24-29 hours,
hence the circulating levels persist for 48 hours.
By 11 days after a 600 mg single oral dose, 83% of the drug is accounted for the faeces and 9% by the urine.
Serum levels are undetectable after 11 days.

1.5 Drug Interactions:

On the basis of this drugs metabolism by CYP 3A4, it is possible that ketoconazole, intraconazole,
erythromycin and grapefruit juice may inhibit its metabolism and rifampin, dexamethasone, phenytoin etc
may induce mifepristone metabolism.

2. Studies on Misoprostol Used alone for medical abortion.

To date eight studies written in English have examined the efficacy of misoprostol alone for
inducing early abortion. Reported success rates, sample sizes, and study locations are listed in the table
below. These studies have proved that success rate with misoprostol alone is not satisfactory. In all but one
study misoprostol was administered vaginally.

Table 1.Studies conducted or, the use of rnisopro stone alone for early termination of pregnancy

Sample Route of Gestational Success

Author (year) Location
size administration age rate

Norman, Thong, and Lothian, Scotland 40 Oral <56 days 5%

Baird (1991)3

Creinin and Vittingh

San Francisco, US 30 Vaginal <56 days 47%
off (1994)4

Bugalho, Faundes, Maputo, Ia 45 Vaginal 5-7 wk 19%

Ib 57 8-1 1 wk 25%
Jamisse, Usfa; Maria, Mozambique. Iia 87 5-7 wk 37%
and Bique (1996)5 IIb 46 8-11 wk 30%
50%
Koopersmith and California, US I 10 Vaginal <10 wk 100%
Mishell (1996)6 II 3 60%
III 15 60%
IV 5 94%
Carbonell, Varela, Havana, Cuba Vaginal
141
Velazco, and <70 days
Fernandez (1997)7

Carbonell,. Varela, Havana, Cuba 175 Vaginal < 63 days 92%

Velazco, Fernandez,
and Sanchez (1997)8

Carbonell, Varela, Havana, Cuba 120 Vaginal 64-84 days. 87%

Velazco, Cabezas,

Tanda, and Sanchez

(1998)9

Jain, Mishell, Mekstroth, Los Angeles, US 30 Vaginal <56 days 97%

and Lacarra (1998)10
3. Combinationof Mifepristone and Misoprostol
Numerous studies have the efficacy of various regimes of mifepristone and misoprostol or intra vaginal
gemprost in the termination of early pregnancy upto 49 days duration, when followed 48 hours later by oral
misoprostol or vaginal gemprost.

Duration of Mifepristone
Outcome
Reference pregnancy and prostaglandin Adverse effect
(%)
(no. of patient) doses

Who Task 200-600mg+ Pain requiring medication

<56 days
Force lmggemeprost 94 26% vomiting 23%,
(1182)
Multicenter11 vaginally dizziness 19%

600mg + 400mg Pain requiring medication

12<60 days
Peyron et al. misoprostol 96 13- 16%, vomiting 15- 17%,
(890)
PO diarrhoea 10-14%

McKinley et 13<63 days 200-600mg + 600ug Pain requiring medication

94
al. (220) mioprostolpo 46%,opiate8%,NSAID38%

Safety and efficacy data from U.S. clinical trails14 and two French trails15 are reported. Success was
defined as complete expulsion of the products of conception without need of surgical intervention. The
overall success rate and failure shown by reason for failure, for the U.S. and French studies appear in table 2.

Table-2. Outcome Following Treatment with Mifepristone and Misoprostol in the U.S.
and French Trials

U.S.Trials French Trials

N% N%

Complete medical abortion 762 92.1 1605 95.5

Timing of expulsion
Before second visit 52 (6.3) 89 (5.3)
During second visit 365 (44.1) 846 (50.3)
- less than 4 hrs after misoprostol

After second visit

- greater than 4 hrs but less than 24 hrs after misoprostol 155 (18.7) 370 (22.0)
- greater than 24 hrs after misoprostol

68 (8.2) 145 (8.6)

 Time of expulsion unknown 122 (14.8) 155 (9.2)
Surgical intervention 65 7.9 76 (4.5)
Reason for surgery
Medically necessary interventions during the study period 13 (1.6) NA NA
Patient request
Treatment of bleeding during study 5 (0.6) NA NA
Incomplete expulsion at study end NA NA 6 (0.3)
Ongoing pregnancy at study end 39 (4.7) 48 (2.9)
8 (1.0) 22 (1.3)
Total 827 100 1681 100

4.Indication and Usage 6.1 Pre-Abortion - How an ultrasound may

Mifepristone is indicated for the medical help:
termination of pregnancy through 49 days' 1. Documentation of pregnancy when there is a
pregnancy in India. The duration of pregnancy may doubt about the presence of a pregnancy.
be determined from menstrual history and clinical 2. Dating of pregnancy when it is felt that the
examination. Ultrasound should be done if the patient is not sure of her dates or the clinical
duration of pregnancy is uncertain or if ectopic examination does not correspond to history.
pregnancy is suspected. IUCD should be removed 3. Confirming the diagnosis of multi fetal
pregnancy
before treatment.
4. Localization of co-existing IUCD
5. Diagnosis of co- existing mass Ultrasound can
5.Contraindications
confirm co-existing fibroid, its size & location.
Confirmed or suspected ectopic pregnancy
Though the gestational period & exact size of
/undiagnosed adnexal mass.
embryo or fetus is smaller, clinically uterus may
Chronic adrenal failure.
be larger.
Concurrent long term steroid therapy.
6. Diagnosis of congenital uterine anomalies
History of allergy to other prostaglandins.
7. Diagnosis of abnormal pregnancy Ectopic
Hemorrhagic disorders or concurrent
pregnancy, Vesicular mole & Missed abortion.
anticoagulant therapy.
Inherited porphyrias.
6.2 Post -Abortal Ultrasound
Incomplete evacuation :
Because it is important to have access to
appropriate medical care if an emergency develops,
This is really the major concern for the provider
the treatment is contraindicated if a patient does not
after a medical MTP. An endometrial echo of
have an access to medical facilities equipped to
more than 15 mm should raise a suspicion of
provide emergency treatment of incomplete incomplete abortion. However in the absence of
abortions. symptoms ,this need not be considered.
One can see hyperechogenic shadows inside the
6.Role of Imaging Science in Medical Abortions
uterine cavity with collection of fluid (bleeding)
It is important to stress here that by no means
as anhypoechoic area. However when a medical
should it be considered that the procedure of an
abortion has been performed this finding should
MTP is deficient if an USG is not done.
be interpreted with the clinical situation as the
backdropa
There is some evidence to suggest that an 8.0 Information for patients
ultrasound done too early can actually increase the Patients should be fully advised of the
rate of surgical procedures required to complete the treatment procedure and its effects.
abortion. There is therefore a learning curve The necessity of completing treatment
attributed to dealing with the aftermath of the schedule including of follow-up visit
medical abortion. As the provider gains in approximately 14 days after taking mifepristone.
experience the incidence of surgical intervention Vaginal bleeding and uterine cramping will
probably occur.
reduces.
Prolonged or heavy bleeding is no proof of a
complete expulsion.
7.0 Warnings
If the treatment fails there is a risk of fetal
Vaginal bleeding occurs for an average of 6-
malformation.
14 days. Bleeding was reported to last for 69 days
Patients in whom medical abortion fails will be
for one patient in the French trail. In some cases
managed by surgical evacuation.
excessive bleeding may require treatment by
Patients should have a telephone number that
curettage, administration of saline infusions and/or she can call in emergency.
blood transfusion. Since heavy bleeding requiring
curettage may occur in about 1% of patients,
special care should be taken to avoid giving this
form of treatment to patients with severe anemia.
Defination of severe bleeding - more than 2 pads
per hour continuously for 2 hours.

9.Dosage and administration (WHO recommendation)16

DAY 1 13.Post Abortion Care
Mifepristone administration 13.1Infection Prevention & Control:
Patient should read medication guide and sign MTP The role of prophylactic antibiotics in reducing
consent form. the incidence of postabortal infection as well as
Patient take one 200 mg tablet of mifepristone preventing the long term sequelae has been a
orally. subject of debate. Routine use of antibiotics is
Minimum recommended interval between not recommended in medication abortion.
Mifepristone & misoprostol is 24 hours. However ,if patient has pelvic infection ,
Hence , 1 to 2 days later: antibiotics are desirable.
Misoprostol administration. 13.2 Follow up Visits:
4 tablets of 200 mcg (total 800 mcg) of misoprostol For medical methods of abortion, women should
vaginal , sublingual, buccal route. report after 15 days for confirmation of
Antiemetic (domperidone) and/or pain medication completeness of abortion. Besides follow-up
(dicyclomine) if necessary. visits provide an opportunity for providers to
Emergency contact number given. have a proper counseling on contraception,
DAY 14 hygiene & other medical ailments
Post treatment examination. .
Confirm abortion; no further treatment required. 14. Post Abortion Contraception
If still pregnant, surgical treatment recommended.

10.Drug interactions
Drugs like ketoconazole, ictraconazole,
erythromycin and grape juice may inhibit the
metabolism of mifepristone.
Drugs like rifampicim, dexamethasone and 15.Medical management of Incomplete
certain anticonvulsants (phenytoin, Abortion :
phenobarbitone, carbamazepine) may induce A. Less than 13 weeks
mifepristone metabolism (lowering the serum
levels of mifepristone)

11.Nursing mothers
Misoprostol is converted into misoprostoic
acid. This is secreted in breast milk & causes
diarrhoesa in infact. Hence it is recommended that B. More than 13 weeks
nursing mohers should feed the baby just prior to
dose of misoprostol & avoid feeding for the next 4
hours.

12.Adverse reactions
16.MEDICO-LEGAL ASPECTS OF MEDICAL 1) This training would enable the Registered
ABORTION'S Medical Practitioner (RMP) to do only 1 st
In the year 2002, it was deemed fit to modify the Trimester terminations
MTP Act due to many new developments in the ( upto 12 weeks of gestation ) ;
field. They are now presented to & steered through d) In case of a medical practitioner who has been
Parliament under the heading of registered in a State Medical Register & who holds
MTP ( Amendment ) Act ,2002 Act No. 64 of 2002 a post-graduate degree or diploma in
& published in the Gazette of India - Extraordinary, gynaecology&obstetrics , the experience or
in December 2002. training gained during the course of such degree or
As far as the Medical Termination of Pregnancy diploma.
with drugs is concerned, certain Amendments So it is important to remember that only a doctor
enacted in this Act are relevant. Under this Act who is duly qualified under MTP Act can use these
Section 5 was modified to first time legalize the use drugs.
of drugs to terminate the pregnancy. This was in 2) The medical termination of pregnancy with RU-
recognition of the prevalent use of RU-486 & 486 & Misoprostol may be carried upto 7 weeks ie.
prostaglandins for termination of early pregnancy. 49 days of pregnancy. Such prescription for these
Under the explanation to Rule 5 of MTP Rules 2003 drugs may be given either at a place registered
, first time detailed Guidelines were proclaimed for under the MTP Act or at a clinic of such Recognized
terminating pregnancy with RU-486 . Medical Practitioner provided that he has access to
a place approved under Section ( 4) of MTP Act
16.1 These are as follows : 1971 read with MTP ( Amendment ) Act,2002 and
1) The basic qualifications of a doctor for this Rule 5 of MTP Rules.
purpose remain the same, namely:
a) In the case of a medical practitioner ,who 3) When such a prescription is given by the said
was registered in a State Medical Register Registered Medical Practitioner under the MTP Act
immediately before commencement of the Act, at his clinic , then he should display a certificate to
experience in the practice of gynaecology& show that he has access to an approved place under
obstetrics for a period of not less than three years ; the MTP Act. The certificate is to be obtained from
b) In the case of a medical practitioner ,who is the owner of such approved place. e.g. a qualified
registered in a State Medical Register :- doctor who does not own his/her own nursing home
(I) if he has completed six months of house is supposed to display a certificate showing that
surgency in gynaecology& obstetrics ;or he/she has access to a place where a surgical
(ii) unless the following facilities are abortion can be performed.
provided therein ,if he has the experience at any
hospital for a period of not less than one year the 4) The consent & opinion forms should be filled as
practice of gynaecology& obstetrics ; or per any other procedures of MTP under this Act.
c) if he has assisted a registered medical The records including the register should also be
practitioner in the performance of twenty-five maintained according to the MTP Act, wherein the
cases of medical termination of pregnancy of which records of the patients to whom prescriptions for
atleast five have been performed independently, in these medicines are given should be included
a hospital established or maintained ,or a training 5) It must be understood that all the obligations,
institute approved for this purpose by the liabilities & punishments are equally applicable to
Government. the medical termination of pregnancies with drugs,
as they would be for any other first trimester MTP.
References: 9.Carbonell JLL, Varela L, Velazco A, Cabezas
1.Iyengar&Iyengar, Rep Health Matters, 10:54, E, Tanda R, Sanchez C, Contraception
2002 1998;57:329-33
2.The Drugs Controller General (India), 10.Jain JK, Mishell DR Jr, Mekstroth K, Lacarra
Directorate of Health Services, GOI, 2002 M, Abstract American Public Health Association
3.Norman JE, Thong Baird DT, Lansete 126th Annual Meeting, Washington DC,
1991;338:1233-6 November 15-18, 1998.
4.Creinin MD, Vittinghoff E, JAMA 11.WHO Task Force, Br J OBG;107:524-530-
1994;272:190-5 2000
5.Bugalho A, Faundes A, Jamisse L, Usfa M; 12.Peyron R, Aubeny E et al. N Eng J
Maria E, Bique C, Contraception 1996;53:243-6 Med;328:1509-1513, 1993
6.Koopersmith TB, Mishell DR. Jr. - 13.McKinley C, Thong A et al. Human
Contraception 1996;53:237-42 Reprod;9:1502-1505, 1993
7.Carbonell JLL, Varela L, Velazco A, Fernandez 14.Frydman R. Fernandez H et al. Hum
C, SaContraception 1997;55:165-8 Reprod;6:803-806, 1998
8.Carbonell JLL, Varela L, Velazco A, Fernandez 15.U. K. Multicentric Trail, Br J OBG;97:480-
C, Sanchez C, Eur J ContraceptReprod Health 486, 1990
Care 1997;2::181-5 16.WHO guidelines ( 2018 )
9.Carbonell JLL, Varela L, Velazco A, Cabezas
E, Tanda R, Sanchez C, Contraception
1998;57:329-33
10.Jain JK, Mishell DR Jr, Mekstroth K, Lacarra
M, Abstract American Public Health Association
126th Annual Meeting, Washington DC,
November 15-18, 1998.
11.WHO Task Force, Br J OBG;107:524-530-
2000
12.Peyron R, Aubeny E et al. N Eng J
Med;328:1509-1513, 1993
13.McKinley C, Thong A et al. Human
Reprod;9:1502-1505, 1993
14.Frydman R. Fernandez H et al. Hum
Reprod;6:803-806, 1998
15.U. K. Multicentric Trail, Br J OBG;97:480-
486, 1990
16.WHO guidelines ( 2018 )
 Management of Failed
14 Dr Richa Sharma
Medical Methods of
Termination of Pregnancy Dr. Aayshi Rathore

Abstract It also sensitizes the myometrium to the action on

Failed medical termination of pregnancy is defined prostaglandins. On the other hand misoprostol
as the need for surgical aspiration as a result of (prostaglandin E1 analogue) acts by stimulating
either ongoing pregnancy or retained products of myometrial contractions to expel the products of
conception. The incidence of failed abortion is 1- conception. Both of these drugs are currently on the
2% in India. It can have emotional, medical as well WHO list of essential medications.
as legal consequences and not onlya psychological
burden on the patient, but also poses a dilemma for Plenty of clinical trials have been conducted so far
the health care provider regarding further on the route, dose and timing of these drugs to
management. This chapter focusses on the achieve termination of pregnancy. Sequential use
strategies provided by the various Indian and of misoprostol 36-48 hrs after mifepristone has
international societies for its management. been found to be effective in this regard.The
success rate of medical termination of pregnancy is
Keywords: medical methods of termination, reported to be over 95% in most of these trials.
mifepristone, misoprostol, failed abortion, vacuum Although in 3% of the cases, patients also aborted
aspiration. Medical termination of pregnancy saw a after mifepristone alone.
paradigm shift with the entry of two crucial drugs in
the late 20th century, mifepristone and misoprostol, Even though medical termination is associated
none of which was originally developed for this with great many advantages owing to the fact that it
purpose. Until then, surgical termination by simulates the process of a natural miscarriage and
injection of chemicals like hypertonic saline, urea reduces the need of surgery and anaesthesia,
and dilatation and curettage were primarily used nevertheless it has its own limitations and
for this purpose. complications as below:
1. Incomplete abortion requiring other methods of
. This was associated with increased risk of evacuation (1-2%)
infection, visceral injuries along with anaesthesia 2. Ongoing pregnancy (1-2%)
related complications. The introduction of medical 3. Excessive vaginal bleeding requiring vacuum
means of abortion made it more accessible to aspiration (1-2%)
females thus breaking barriers and let them choose 4. Heavy bleeding requiring blood transfusion
abortion as an alternative. These drugs went on to (0.1-0.2%)
become the 'moral property of women' henceforth. 5. Infection

Mifepristone is a selective progesterone receptor Failed medical abortion is defined as the need for
modulator and acts by blocking the progesterone uterine aspiration because of ongoing pregnancy or
receptors on the uterus. retained products of conception (ACOG 2020).
The risk of failed medical termination increases T R E AT M E N T O F FA I L E D M E D I C A L
with advancing gestational age through 70 days TERMINATION
and improper drug selection, dose, route and Meticulous pre-abortion counselling regarding the
timing. In this chapter, the management of failed drugs, their route and timing along with the
medical abortion has been discussed indepth. associated side effects plays an important role in
management. Information should be provided
D I A G N O S I S O F FA I L E D M E D I C A L about the risk of failed termination before
TERMINATION commencing the treatment and consent for
surgical/ repeat medical termination has to be taken
As per WHO 2018 guidelines on medical in advance. In certain cases of failed termination,
termination of pregnancy, success of medical the female changes her heart and wishes to continue
termination of pregnancy is usually ascertained on the pregnancy even after taking the drugs for MTP.
the basis of history of heavy vaginal bleeding, In such situations, the decision of the patient should
passage of products of conception and menstrual be acknowledged and she is counselled regarding
cramps (significantly more than the normal the possibility of teratogenicity, informed consent
menstrual cycles) along with bimanual is taken and the pregnancy should be monitored
examination. It is noted that history and clinical closely.
Even though mifepristone is not particularly
examination reveal the success of abortion in 96-
notorious to cause teratogenicity, there is limited
99% cases and further investigations such as serum
evidence to suggest that mifepristone might be
hCG and ultrasonography are not mandatory to
associated with an increased risk of haemorrhage in
make diagnosis of incomplete or failed abortion.
pregnancy. Currently, treatment with progesterone
They are recommended only if there is a clinical
during pregnancy doesnot alter the risk of
suspicion of the same i.e. no-minimal bleeding
teratogenicity after taking mifepristone.
within 24 hours after taking misoprostol or if the
Misoprostol is more commonly associated with
female has signs and symptoms of continued
limb defects with or without Mobius syndrome
pregnancy or ultrasound shows gestational sac.
(congenital abnormality with features suggestive
On ultrasound evaluation, presence of gestational
of sixth and seventh cranial nerve palsy).
sac is the most important feature which suggests According to 2011 FIGO guidelines, combination
failure of medical termination (endometrial of mifepristone (200mg) followed by misoprostol
thickness is not a very good marker for this purpose (800µg) vaginally/sublingually/buccally upto 9
and it can be increased due to blood clots thus weeks (63 days) of pregnancy is found to induce
leading to unnecessary vacuum aspirations). If no abortion in 98% of the cases and failure rate is
gestational sac is seen on TVS, vacuum aspiration approximately 0.2-0.5%. It also recommends that
is required in only 1.6% of such cases. in cases of failed termination, 400 µg misoprostol
can be repeated as before. For pregnancies between
Despite the fact that serum hCG evaluation (or 9-12 weeks (63-84 days) it states that 200mg
urine pregnancy test) is not very reliable as it can be mifepristone should be followed by 800µg
increased even after four weeks of successful misoprostol vaginally after 36-48 hours at the
abortion, it can be beneficial in patients in whom health centre and then followed by 400µg
the levels are below the threshold of detection of misoprostol at 3 hourly intervals till complete
gestational sac on ultrasound. A fall of at least 80% abortion. At this time the maximum number of
over 6-7 days after start of medical termination doses for misoprostol were defined as five. The
with mifepristone and misoprostol signifies success rate of this regimen is stated as 95% and the
success of termination. rate of failure of abortion is 1.5%.
For beyond 12 weeks (>84 days), 200mg mifepristone followed by 800µg misoprostol vaginally and400µg
vaginally/sublingually/orally at 3 hourly intervals (maximum 5 doses)at the health centre are
recommended. The dose of misoprostol is reduced in cases of a scarred uterus or in case of gestational age
22-24 weeks. It is stated that second dose of misoprostol is required in 3% of the cases on this regimen

Table 1: Recommended Mifepristone and Misoprostol regimen for

induced abortion (FIGO 2011)

Period of Misoprostol Additional

Mifepristone
gestation (after 24-48 hours) Misoprostol
Upto 9 weeks
200mg PO once 800µg PV, B or SL 400µg PV, SL or PO
(63 days)
9-12 weeks 400 µg PV or SL 3 hrly
200mg PO once 800µg PV
(64-84 days) (max 5 doses)
>12 weeks 400 µg PV, PO or SL 3 hrly
200mg PO once 800µg PV
(>84 days) (max 5 doses)

B: Buccal, PO: oral, PV: vaginal, SL: sublingual

In 2017, FIGO updated its guidelines on the use of misoprostol and excluded the limit on the maximum
number of doses that can be given for achieving successful abortion and mentioned that it depends on the
clinical symptoms of the patient. In addition to this, it also advocates that misoprostol is to be given
depending on the size of the uterus rather than the LMP in cases of incomplete abortion.

Table 2: Recommended Mifepristone and Misoprostol regimen for

pregnancy termination (FIGO 2017)

Period of Mifepristone
Misoprostol
gestation (preferrable)
800µg SL every 3 hours or PV/B
<13 weeks 200mg PO once
every 3-12 hourly (2-3 doses)

13-24 weeks 200mg PO once 400µg PV/SL/B every 3 hours

B: Buccal, PO: oral, PV: vaginal, SL: sublingual

In 2016, Government of India issued guidelines on management of complications of medical methods of

termination on the basis of clinical features as well as the presence and viability of gestational sac on
ultrasound. It states that if there is continuation of pregnancy (viable gestational sac) then vacuum
aspiration should be done and if the pregnancy is non-viable, then repeat dose of misoprostol (400mcg
sublingual) is preferred and follow up is advised after 7 days to ensure that the termination is complete. The
drug protocol recommended for medical method of abortion is described in Table 3. (Flow chart 1)
Table 3: Drug protocol for Medical method of abortion (GOI 2016)
For beyond 12 weeks (>84 days), 200mg mifepristone followed by 800µg misoprostol vaginally and400µg
vaginally/sublingually/orally at 3 hourly intervals (maximum 5 doses)at the health centre are
recommended. The dose of misoprostol is reduced in cases of a scarred uterus or in case of gestational age
22-24 weeks. It is stated that second dose of misoprostol is required in 3% of the cases on this regimen

Visit Day Drugs used

200mg Mifepristone PO
1st One
Anti D
400µg Misoprostol SL/B/PV/PO
2nd Three
Analgesic, antiemetic, contraception

Confirm and ensure completion of abortion

3rd Fifteen & offer contraception

B: Buccal, PO: oral, PV: vaginal, SL: sublingual

The World Health Organization (WHO) has recently updated its recommendations (in 2018) on the
medical termination of pregnancy. In this updated version it has been advised that in cases of failed
MTP, repeat doses of misoprostol can be offered to
the patient to ensure complete abortion. However, in consensus with FIGO 2017 directions, the
maximum number of doses have been omitted and this decision has been left to the clinician's
discretion and judgement.

Table 4: Medical Management of Induced Abortion (WHO 2018)

Period of Combination Regimen (Recommended) Misoprostol Only (Alternate)

gestation
Mifepristone Misoprostol Misoprostol

>12 weeks 200mg PO once 800µg PV or SL 800µ B, PV or SL

400µ B, PV or SL 400µ B, PV or SL
>12 weeks 200mg PO once
every 3 hours every 3 hours

B: Buccal, PO: oral, PV: vaginal, SL: sublingual

TREATMENT OF INCOMPLETE ABORTION
In 2016 Government of India guidelines update on medical methods of abortion has defined heavy bleeding
after abortion as soakage of two or more thick pads per hour for two consecutive hours. In such cases the
female should be examined to rule out hypovolemia and to rule out incomplete abortion. Intravenous fluids
should be started as early as possible (ringer lactate solution at the rate of 30 drops per minute) along with
blood transfusion (if necessary) for initial resuscitation.
If after initial stabilization, if products of conception are felt on bimanual examination, they should be
removed digitally or using ovum forceps followed by vacuum aspiration. If they are not felt, further
management is guided by the clinical and ultrasound findings. In case a non-viable gestational sac on USG,
additional dose of misoprostol (600mcg oral or 400mcg sublingual) is given followed by expectant
management till expulsion of products. Conservative management is also recommended if no gestational
sac is visible on ultrasoundand the patient is advisedtofollow up after 1 week. (Flow chart 1)
RCOG 2015 recommendations on comprehensive abortion care guidelines also suggest that incomplete
medical abortion can be managed both surgically (by vacuum aspiration/ blunt forceps) or medically(using
misoprostol). The dose of misoprostol varied according to uterine size as follows:

At <14 weeks: misoprostol 600 µg orally or 400 µg sublingual

At14-28 weeks: misoprostol 200 µg vaginal/sublingual/buccal6 hourly (with or without mifepristone
200mg orally 12-48 hours prior to misoprostol)
At >28 weeks: 25 µg misoprostol vaginally 6 hourly or 25 µg 2 hourly orally

Antibiotic prophylaxis with doxycycline 200mg or azithromycin 500 mg within 2 hours of the
procedureis recommended at all gestations.

CONCLUSION

Although medical termination of pregnancy is effective in >95% cases, the possibility of failed medical
abortion should be informed to the patient beforehand along with the possibility of surgical in intervention
in such a scenario. Appropriate training of health care personnel regarding the methods of termination of
pregnancy, both medical as well as surgical, is crucial for efficient management of associated
complications.
Flow chart 1: Management of failed and incomplete abortion
(courtesy: Ministry of Health & Family Welfare (MoHFW), Government of India: Handbook on Medical
Methods of Abortion to Expand Access to New Technologies for Safe Abortion. January 2016)
 Presenting symptoms:
Continued bleeding
Excessive bleeding
With/without pain abdomen

Unstable Condition Stable condition

Proceed with examination

Resuscitative measures
Poc at the OS
Check vital signs
Ensure patent airway
Oxygen 6-8 lit/min through
Digital evacuation
mask/nasal catheter followed by vacuum
aspiration
Intravenous fluids, ns?rl with
18 g cannula
Oxytocin No POC at the os: Pelvic
Antibiotics
examination, USG
Blood transusion, if required

No sac, Treat conservatively,

only decidual bits f/u after 7 days

Additional dose of
Non viable G sac misoprostol, f/u after 7 days

Viable G sac
Vacuum aspiration
SUGGESTED READING
1. Ho PC. Development of medical termination of pregnancy: a review. BJOG 2017;124:1942-1947.
2. FIGO Working Group on Prevention of Unsafe Abortion and its Consequences; International Federation
of Gynecology and Obstetrics. The combination of mifepristone and misoprostol for the termination of
pregnancy. Int J Gynaecol Obstet. 2011 Oct;115(1):1-4. doi: 10.1016/j.ijgo.2011.07.013. Epub 2011 Aug
27. Erratum in: Int J Gynaecol Obstet. 2011 Dec;115(3):332. Faúndes, Anibal [removed]. PMID:
21872858.
3. World health organization (2018). Medical management of abortion. ISBN 9789241550406. Available
from: https://www.who.int/reproductivehealth/publications/medical-management-abortion/en/. Accessed
on 7 March 2021.
4. Committee on Practice Bulletins-Gynecology; Society of Family Planning. Medication Abortion Up to
70 Days of Gestation: ACOG Practice Bulletin, Number 225. Obstet Gynecol. 2020 Oct;136(4):e31-e47.
doi: 10.1097/AOG.0000000000004082. PMID: 32804884.
5. Ministry of Health & Family Welfare (MoHFW), Government of India: Comprehensive Abortion Care
Training and Service Delivery Guidelines 2010 (2nd edition 2014). MoHFW.
6. Ministry of Health & Family Welfare (MoHFW), Government of India: Handbook on Medical Methods
of Abortion to Expand Access to New Technologies for Safe Abortion. January 2016. Available from:
http://nhm.gov.in/images/pdf/programmes/maternal-health/guidelines/MMA_Handbook.pdf. Accessed
on 7 March 2021.
7. Royal College of Obstetricians & Gynaecologists (RCOG). Best practice in comprehensive abortion
care. Best Practice Paper No.2. June 2015. Available from: https://www.rcog.org.uk/\
globalassets/documents /guidelines/best-practice-papers/best-practice-paper-2.pdf. Accessed on 7 March
2021.
 15 Surgical Methods of Abortion
Prof. BHARTI MAHESHWARI

Termination of pregnancy can be done by surgical and evacuating the uterus using vacuum aspiration
method in first trimester by vaccum aspiration and and ovum/sponge-holding forceps
in 2nd trimester by dilatation and evacuation
PAIN MANAGEMENT -
.Patient is always counseled for option of methods
of termination for her gestational age with detailed The types of pain management medications
information about procedure, risk, complications appropriate for D&E procedure are:
and follow up. patient select method of 1. Non-narcotic analgesics, such as Ibuprofen, can
termination. be used to control pain during and after the
procedure
Indication of surgical method of termination-
2. Anxiolytics, such as Diazepam, reduce anxiety
a. Patient not prefer medical method in 1st trimester
and relax muscles. These are useful when the
b. Termination of pregnancy after 9 wksonwards
woman is anxious but is otherwise in a stable
c. Incomplete abortion physical condition
d. Failed medical method 3. Administer paracervical block
4. I/V sedation may be used with injection of
METHODS- Pentazocine 30mg and Promethazine 25mg l
IN FIRST TRIMESTER- 5. General anaesthesia may be given, if required
1)VACCUM ASPIRATION-
How to Administer paracervical block-
Manual Vaccumaspiration(MVA) is Gold standard
method according to WHO.It can be done till 12 1. Use Lignocaine one per cent (10ml; never more
weeks safely.it can be done in paracervical block or than 20ml).
30 mins before oral analgesics.An accurate clinical 2. Give the paracervical block using a 22-24 gauge
assessment, counselling and informed consent is a needle. There is increasing evidence to show that
must before a VA proceduredetails are given in next pre-testing before the administration of local
chapter.it is associated with minimal complications anaesthesia need not be mandatory
and easy to do.IT Is also very commonly used in 3. Apply slight traction with the volsellum/Allis
failed medical method or incomplete abortion. forceps to identify the area between the smooth
cervical epithelium and the vaginal tissue.
2) DILATATION AND EVACUATION 4. Insert the needle just under the epithelium to a
depth of 1.5-2cm at 4 and 8 o'clock positions and
1. The D&E method involves preparing the cervix inject 2-4ml of Lignocaine at each site Paracervical
and evacuating the uterus with a combination of Block
suction and forceps. 5. Proceed with MVA after allowing 2-4 minutes
2. It is a safe and effective surgical technique for for the local anaesthesia to be effective .
abortions beyond 12-14 weeks where skilled, 6. It is vital to aspirate before injecting the
experienced providers are available. Lignocaine to ensure that the needle is not in the
3. D&E requires preparing and dilating the cervix; blood vessel
D&E is a two-step process: HYSTEROTOMY

(i) Cervical preparation/dilatation This is not a preferred method for pregnancy

(ii) Evacuation termination.
It is helpful in the following conditions:
(i) Cervical preparation/dilatation: It is 1. Failure with the other methods
recommended for all women undergoing the 2. Other associated gynaecological conditions
termination of pregnancy over 12-14 weeks.
Ÿ It decreases the risk of cervical injury and 2ND TRIMESTER ABORTION-
uterine perforation.
Ÿ medication/devices/instruments are used for Approximately two third of all major
cervical preparation and dilatation before the complications occurs in 2 ndtrimester,though only
evacuation of the POCs: 9 -11% terminations occurs in 2ndtrimester.hence
Misoprostol l Osmotic dilators special precautions should be taken to minimise
complications and should follow MTP act.in 2nd
Misoprostol for cervical preparation: trimester MTP can be done by medical or surgical
or miscellaneous methods,rarelyhysterotomy is
Ÿ Misoprostol (400mcg) is used vaginally 3-4 required.
hours or sublingually 2-3 hours before the Site-should be done at approved site ,at tertiary
procedure for cervical dilatation. centre and as indoor patient.Patient should be
admitted, prophylactic antibiotic and inj anti D -
Ÿ One additional dose of 400mcg may be given if 300mcg in Rh negative cases should be
the dilatation is inadequate after four hours or given.Proper counseling, informed consent
dilators may be used. ,facility and expertisation for complication
management should be available.Documentation
Advantages of using misoprostol for dilatation: according to MTP act should be maintained.
Pre-procedure preparation-
1. It is a highly effective drug for inducing cervical D e t a i l e d h i s t o r y, c l i n i c a l
dilatation and uterine contractions examination ,investigations should be done to rule
2. The administration of misoprostol leads to the out any high risk factors.in scarred uterus
contraction of the uterus even before the actual ultrasound should be done to rule out scar ectopic .
procedure is initiated, thereby reducing the amount Contraception counseling should be done at the
of blood loss, possibility of perforation and the time same time.
taken for the procedure
MEDICAL METHOD FOR TERMINATION
Disadvantages of using misoprostol for IN 2ND TRIMESTER ACCORDING TO WHO
dilatation: PROTOCOLS-
Ÿ It has GI side-effects, which can discomfort the 1. 200mg Mefepristone followed by 400/800mcg
woman Mesoprostol every 3 hrs max-5 doses-s/l or
Evacuation should be done after achieving the vaginally
desired level of cervical dilatation - 2. Or only Mesoprostol-400mcg every 03 hr s/l or
Ÿ proceed with the evacuation of uterine contents vaginally
with 12-16mm cannula and forceps. 3.aPlacenta-not delivered in 2 hr----400mcg
In the unlikely event that the foetus parts cannot be mesoprostol and 20 u oxytocin
easily removed, administer additionally any one of 4. Pain management-Tab Ibuprofen
the following uterotonic agents such as:
1. 400-600mcg misoprostol orally or sublingually IN SCARRED UTERUS- Dose should be tailored
2. Injection of prostaglandin (PGF2 alpha) 250mcg according to patient. Mesoprostol is not
IM contraindicated in scarred uterus .Dose should be
3. Injection of oxytocin. decreased with increased interval.
Complications and Sequelae: References-
a. Shock 1.Comprehensive Abortion Care Second Edition
b. Secondary Haemorrhage 2018 ,Ministry of Health and FamilyWelfare
c. Infection/sepsis Government of India Training and Service
d. Continuation of pregnancy Delivery Guideline
2.L. Borgatta, N. Kapp, P. Society of
Sequelae: FamilY,Clinical guidelines. Labor induction
a. Continuation of pregnancy abortion in the second trimester,Contraception, 84
b. Asherman's syndrome (1) (2011), pp. 4-18
c. Pelvic Inflammatory Disease (PID)
3 The American College of Obstetricians and
1. Complications such as sepsis, haemorrhage and Gynecologists,ACOG practice bulletin No. 135:
tissue injury are responsible for maternal morbidity second-trimester abortion,ObstetGynecol, 121 (6)
and mortality related to abortion care (2013), pp. 1394-1406
2. Universal stabilization measures should be 4.Royal College of Obstetricians
provided to all cases of abortion complications and &Gynaecologists,Best practice in comprehensive
definitive management should be started abortion care(2015)(Best Practice Paper No. 2)
immediately after establishing the diagnosis
3. Since primary level facilities cannot treat all 5..The combination of mifepristone and
types of abortion complications, timely referral misoprostol for the termination of pregnancy,Int J
after stabilizing the woman helps in the definitive ObstetGynecol, 115 (1) (2011), pp. 1-4
treatment

At the time of discharge-

1. Contraceptive counselling with contraceptive

provision, when requested
2. Address other health issues - anaemia,
reproductive tract infections (RTIs), HIV, domestic
violence, cancer screening
3. Suppression of lactation with tablet Cabergoline
0.5mg stat
4. Pain management with analgesics, NSAIDs
5. Provision of antibiotic therapy (tablet
Doxycycline 100mg for eight days or as
appropriate
 16 MANUAL VACUUM ASPIRATION (MVA)
DR. VIDHYA THOBHI

Vacuum aspiration is a procedure that uses a Contraindications(5):

vacuum source to remove an embryo or fetus 1) Presence of acute cervical, vaginal or pelvic
through the cervix(1.) This procedure is one of the infectio. The procedure should only be done under
easier and safe ways to perform the procedure. peri operative antibiotic cover.
2) Suspicion of perforation.
History: 3) Suspicion of ectopic pregnancy.
Vacuuming as a means of removing the uterine Relative contraindications:
contents, rather than the previous use of a hard 4) Adolescents
metal curette, was pioneered in 1958 by Dr. Wu 5) Nulliparae
Yuantai and Dr. Wu Xianzhen in China. But their 6) Cervical stenosis
paper was only translated into English on the 7) Pregnancy with uterine fibroids
fifteenth anniversary of the study that "ultimately 8) Histoty of cesaerean section or uterine surgery
led to the technique becoming the world's most 9) Medical disorders such as:
common and safest obstetric procedure."(2) Anemia with hemoglobin below 8g%
Bleeding disorders
In Canada, the method was pioneered and Hypertension
improved on by Henry Morgentaler, achieving a Heart disease
complication rate of 0.48% and no deaths in over Renal disease
5,000 cases. He was the first doctor in North Diabetes mellitus
America to use the procedure.(3)
Safety and efficacy:
Harvey Karman in the United States refined the Various studies have demonstrated that vacuum
technique in the early 1970s with the development aspiration is a very Safe and effective technique for
of the Karmann cannula, a soft, flexible cannula first trimester abortion; it is successful in over 98%
that avoided the need for initial cervical dilatation of cases. Acknowledging the superior efficacy and
and so reduced the risks of puncturing the uterus(4) safety of the procedure over conventional
dialatation and curettage a joint recommendation
Indication (5): by the WHO and the FIGO states that properly
1) Induces abortion of up to 12 weeks gestation / equipped hospitals should abandon D&C and adopt
uterine size manual/ electric aspiration methods.
2) Incomplete abortion of up to 12 weeks of
gestation/ uterine size.
3) Missed abortion.
4) Hydatidiform mole of up to 12 weeks gestation /
uterine size.
5) Removal of deciduas with surgical management
of an ectopic pregnancy.
 VACUUM ASPIRATION DILATATION AND CURETTAGE
Incidence of excessive bleeding less 2-4 times higher
Dilatation requirement lesser Greater
Pain control medication Lower level Higher level
Recovery period lesser More
Post procedure bleeding lesser more

Equipment for VA:

Vacuum aspiration can be performed using either MVA or EVA. The primary difference between the two
VA options is the source of the vacuum - MVA uses a handheld, portable aspirator whereas EVA employs
an electricity-operated device, which is referred to as the EVA or suction machine.
Manual Vacuum Aspiration In an MVA procedure, a handheld plastic aspirator providing a vacuum
source is attached to a cannula and hand-activated to suction out the uterine contents. MVA aspirators are
essentially of two types:

single-valve (also referred to as the menstrual regulation [MR] syringe) and

double-valve aspirators.
Key Features of the Two Types of MVA Equipment:

FEATURES D V ASPIRATOR S V ASPIRATOR

Capacity 60cc 50 cc
Negative pressure 26 in /660 mm Hg 26in/ 660 mm Hg
Cannula size used Upto 12 mm Up to 6mm
Vacuum maintained Till 80% full Till 50% full
Material used for valves Silicone Latex
Sterilization option Chemical sterilization, boiling, autoclaving Chemical sterilization.

Electric Vacuum Aspiration EVA uses an electric pump or suction machine attached to a cannula to evacuate
uterine contents. EVA is typically used in centralised settings with higher caseloads.
Cannula: The two varieties of plastic cannulae available for use with an MVA aspirator and EVA machine
are:
1) Disposable, single-use cannula (Karman)
2) Autoclavable, reusable cannula (EasyGrip).
Depending on the type of raw material used in the manufacturing process, the processing options of cannulae
from different manufacturers vary significantly. The preferred size of the cannula as per the gestation
age/uterine size are:

UTERINE SIZE PREFERERD CANNULA SIZE

4-6 WEEKS 4-6MM
7-9 WEEKS 6-10MM
9- 12 WEEKS 8-12 MM

Pre-procedure Care :
Clinical assessment before the procedure and the investigations required are the same as for other techniques
of pregnancy termination. Counsel the woman and explain each step of the procedure. Preparation for the
procedure:
Shaving the perineum and vulva is not recommended. Perineum hair could be trimmed.
Obtain informed consent for the procedure in Form C (if not already obtained)
Fulfill all the statutory and procedural requirements of the MTP Act and Rules
A dose of oral analgesic/antispasmodic should be given an hour before the procedure.
Administer a single dose of prophylactic antibiotic such as oral ampicillin/ azithromycin1gm and
Metronidazole 800mg. Doxycycline 100mg BD should be continued for seven days
Preliminary steps
Ensure the availability and preparation of all instruments and drugs .
Ensure that emergency drugs and equipment are readily available
Pain control Medication for pain management should always be offered. The purpose of pain control is to
alleviate the woman's discomfort where mechanical dilatation is required for surgical abortion and to
ensure that she suffers minimal anxiety, discomfort and risk to her health. While the choice of the
anaesthesia should be with the woman, local anaesthesia is a feasible, effective and safe method of
providing pain relief during a VA procedure. A combination of oral analgesic and/or local anaesthesia
(paracervical block) should help to control the pain in the first trimester abortion. Young, very anxious
women and cases of suspected cervical stenosis may require general anaesthesia.

Procedure for Vacuum Aspiration :

Manual Vacuum Aspiration :

Step 1: Prepare instruments , Charge aspirator, Leave it charged for a few seconds.l
 Push buttons to release vacuum. A rush of air In pregnancies of more than nine weeks gestation
indicates vacuum was retained. (particularly in nulliparous women and women
Replace MVA aspirator when : under 18 years of age), cervical priming may be
o Cylinder is cracked or brittle administered. This will soften the cervix so that it is
o Mineral deposits inhibit plunger movement easily dilatable up to the desired size with a reduced
o Valve is cracked, bent or broken risk of immediate complications.
o Plunger arms do not lock The commonly used methods for cervical priming
o Aspirator no longer holds vacuum are: Tablet misoprostol 400 mcg administered
sublingual 2-3 hours or vaginally 3-4 hours before
Step 2: Prepare the woman .Ensure pain control the procedure. Injection 15 Methyl F2 Alpha
medication is given at the appropriate time .Ask the Prostaglandin 250mcg intramuscularly 45 minutes
woman to empty her bladder before the procedure. This should be an option
when there is less time available for cervical
Step 3: Perform cervical antiseptic preparation before the procedure and misoprostol
preparation. Use an antiseptic such as Povidone cannot be used
Iodine to clean the cervix and vaginal walls Step 6: Insert cannula Gently apply traction to the
.Perform a bi-manual examination to confirm the cervix. Rotate the cannula while applying pressure
assessment findings. Close the valve buttons for easy insertion.
Step 7: Suction of uterine contents. Attach charged
Step 4: Administer paracervical block .Use aspirator to cannula .Release buttons to start suction
Lignocaine one per cent (10ml; never more than . Use a gentle rotatory and in and out motion to
20ml). Give the paracervical block using a 22-24 aspirate contents .Do not withdraw the cannula
gauge needle. There is increasing evidence to show opening beyond the external os till all the POCs are
that pre-testing before the administration of local aspirated . Take care to avoid holding a charged
anaesthesia need not be mandatory . Apply slight aspirator by the plunger arms
traction with the volsellum/Allis forceps to identify
the area between the smooth cervical epithelium Signs that the uterus is empty :
and the vaginal tissue. Insert the needle just under Red or pink foam without the tissue passing
the epithelium to a depth of 1.5-2cm at 4 and 8 through the cannula
o'clock positions and inject 2-4ml of Lignocaine at Gritty sensation over the surface of the uterus
each site Figure 12: Paracervical Block l Cervix gripping over the cannula
Proceed with MVA after allowing 2-4 minutes for Uterus contracting around the cannula l
the local anaesthesia to be effective It is vital to Increased uterine cramping
aspirate before injecting the Lignocaine to ensure Check curette: Generally vacuum aspiration
that the needle is not in the blood vessel. procedures can be safely completed without
intrauterine use of curette or other instruments. No
Step 5: Dilate the cervix .Use a plastic cannula data suggest that the use of curettage after VA
instead of a dilator to dilate the cervix . Use a decreases the risk of the retained products.
progressively larger plastic cannula till it fits When the procedure is complete . Push buttons
snugly in the os to hold the vacuum. down and forward to close the valve . Disconnect
the cannula from the aspirator or remove the
Cervical priming It is not mandatory to perform cannula from the uterus without disconnecting,
pre-procedure priming for all women. However, it depending on the completeness of the procedure .
should be done in women with high risk of cervical May evacuate again after inspecting the products of
injury or uterine perforation. conception, if needed.
Step 9: Concurrent procedures When the procedure The used cannulae should be ?ushed before soaking
is apparently complete, wipe the cervix with a swab them. Chlorine solution (0.5%) for instrument soak
to assess bleeding. Proceed with contraception in a plastic container is made by dissolving three
methods such as sterilization, IUCD insertion. levelled teaspoons (15gm) of bleaching powder in
Step 10: Instrument processing Proper processing one litre of water. An appropriate quantity of the
of instruments entails four steps: solution can be increased in the same proportion.
Soak the instruments in disassembled form for 10
(A) Instrument soak The use of instrument soak in minutes.
chlorine solution (0.5%) assists disinfection and (B) Cleaning: To clean the instruments, wash all the
helps remove tissue and body ?uids. This also surfaces of the instruments in warm water and
makes cleaning easier by keeping the instruments detergent. Soap is not recommended as it tends to
wet. leave a residue.

Comparative Features of the Vacuum Aspiration Techniques:

Complications and Management:

While complications with vacuum aspiration are rare, awareness of their possibility and prompt
attention and management when they do occur are vital.
1)Complications due to local anaesthesia.
2)Complication during procedure:
3)Delayed complications;
4)Remote complications:
Menstrual disturbances
Infertility may be due to tubal factors
Recurrant abortion
Ectopic pregnancy
Obstetric complications
Psychosomatic complications.

References:
1)Coombes R et al., obstetricians seek recognition for Chinese pioneers of safe abortion BMJ 336
(7657) 16 june 2008.
2)Wu Y, Wu X (1958) " a report of 300 cases using vacuum aspiration for the termination of pregnancy,
CJOG 336 477-9
3)MVA for first trimester abortion , John M Westfall et al., researchgate. Net 1998
4)Comprehensive abortion care, training and service delivery guidelines second edition 2018 by
MOHFW, India.
5)WHO guidelines on MTP 2018.
 17 Post MTP Counseling and
Follow up Dr Shobha N Gudi

Post MTP care is an important part of In second trimester abortions, lactation

Comprehensive abortion care and is also an suppression with Cabergoline 0.5mg stat oral.
important opportunity to provide the woman with Discharge instructions as above, in addition to
the following : analgesics (NSAIDS or Acetaminophen),
1. Counseling and information antibiotics Doxycycline 100 mg bid for a week.
2. Follow up care
3. Contraception Follow-up Care
A follow up visit is scheduled within two weeks of
Counseling and information : MTP.
It is normal to experience some bleeding off However, she needs to visit earlier if :
and on for a month, may be initially heavy as a There is fever > 100.40 F or chills.
period for a week and then decreases.More Heavy bleeding
Severe pain not relieved by analgesics
bleeding on straining and less on resting is to be
Foul smelling discharge
expected1.
Excessive fatigue
Mild intermittent cramping abdominal pain
Vomiting and upper abdominal pain.
for a few days is normal, relieved with mild
analgesics. The above symptoms must alert us to look for the
Normal diet can be resumed on same day. major complications of hemorrhage due to
Restrict activities and travel for one or two incomplete abortion, sepsis or visceral injury like
weeks. bowel injury in a surgical abortion. On a routine
Early return of fertility to be expected, even follow up visit, any unusual symptoms should be
before the next menstrual period. asked for, excess bleeding per vaginum, undue
Sexual intercourse to be avoided till bleeding stops pain, discharge or fever as outlined above. The
and effective contraceptive method of her choice is medical records to be reviewed, contraceptive
in place. choice to be established, provide related services
It is normal to expect a range of emotions : relief, like correction of anemia etc. and document the
regret , mild depression or emotional instability. facts in the patients file. One of the major
complications which may manifest late is Infection
Normal menstruation may follow after one or two and sepsis .A woman can present with infection any
time from several days to several weeks after an
months2.
abortion. Infection may be limited locally (uterus
Before discharge , the following check list can be
or cervix) or may become generalised sepsis3.An
followed : important part of follow up is a discussion on
Contraceptive counseling and contraception reproductive planning and contraceptive need. This
provision. is a highly pertinent situation of unmet need where
Adequate Treatment of anemia and infections. an unintended pregnancy has been terminated and
Special care in case of HIV positive women. unless care is taken ,there is a risk of being
Address domestic violence if suspected repeated4.
Post abortal contraception. Rarely, some complications may limit the available
All women undergoing induced abortion should be contraceptive options (eg, women with
informedabout their ability to get pregnant postprocedure hemorrhage or infection are not
following an induced abortion as early as before the candidates for immediate intrauterine device [IUD]
first period.Fertility returns quickly, with the first insertion).
ovulation post abortion happening 3 to 4 weeks, When to start ? All forms of contraception are safe
and so personalized contraceptive counseling and and feasible to begin on the day of the procedure.
provision is a critical component of care. It
This eliminates barriers of additional visit, cost,
involves reviewing the woman's contraceptive
time,yields higher patient satisfaction, higher use
preferences (ie, efficacy, convenience) and offering
all suitable contraceptive methods so the woman rates, and lower repeat unintended pregnancy
can choose a method as part of a shared decision rates,this is especially true for all LARC methods7.
making that meets short- and long-term planning The methods include IUD placement; subdermal
needs5. Most contraceptives can be started implant placement; permanent contraception
immediately. (sterilization); depot medroxyprogesterone acetate
injection; and initiation of oral pills, transdermal
As with other preventive care efforts such as patches, or vaginal rings. In general, contraception
smoking cessation, education and counseling by is started when it is confirmed that the abortion is
health care providers positively impacts behavior5. complete, by direct visualization of tissue or with
In general, contraceptive counseling includes ultrasound, there is no retained products, no injury
general counseling on strong need for to genital tract and no infection. With first-trimester
contraception and reviews method safety, efficacy, medication abortion, it has been shown to be safe to
mechanism(s) of action, side effects, protection
place an IUD as early as one week following
from sexually transmitted infections (STIs), and
treatment if it has been determined that the uterus is
other method-specific characteristics such as non
contraceptive benefits. empty.
The biggest impact on reducing unintended
Specific counseling considerations6 in this setting pregnancy is the immediate provision of long-
include the following: acting contraceptive methods, such as the IUD or
implant, because continuation of use to 6 or 12
Identify reasons for method failure in the past months is higher than with the use of shorter acting
Explore patient's short- and long-term methods .
reproductive plans Is back-up contraception necessary ?- If a woman
Rule out Underlying medical or gynaec starts contraception a week after the procedure is
conditions. over, a second method of contraception (ie, back-
Assess risk of sexually transmitted infection
up contraception) like a barrier is needed until the
and advice to use condoms (male or female) in
addition to their chosen method for pregnancy primary method is effective ,foreg. An injectable
prevention. contraceptive like DMPA.However , there are
Contraceptive effects on post abortion exceptions, the copper IUD, is immediately
recovery - Immediate initiation of contraception at effective and progestin-only pills, requires only
the time of induced abortion does not impact the two days of back-up contraception
post procedure recovery process. No significant
differences have been reported for When women are uncertain of choice or decline
thromboembolic events, infection rates, patient- contraception: It is essential discuss condoms
reported pain ,alteration of bleeding patterns (male and female) , emergency contraception and
following abortion . natural methods.
Contraceptive options in brief :
Permanent contraception (sterilization) - Tubal Progestin-only pills - Progestin-only pills can be
ligation (laparoscopy or mini laparotomy) can be started immediately following spontaneous or
safely performed immediately following a first- or induced abortion in the first or second trimesters12.
second-trimester abortion. Non scalpel vasectomy Unless the medication is started on the day of
for the male partner also can be advocated . surgical abortion, patients are advised to use back-
Long-acting reversible contraception
Intrauterine device - An intrauterine device (IUD) up contraception, or abstinence, for two additional
can safely be inserted at the completion of a days.
surgical first- or second-trimester induced abortion
Barrier contraception - Barrier methods (female
and after medical management in the second
trimester8. The only exception is first-trimester and male condoms) can be used immediately
medication abortion, an IUD can be inserted as following medication or surgical abortion. They
early as one week following treatment after provide the added benefit of protecting from
verifying that the uterus is empty. Expulsion sexually transmitted infections, particularly for
rates are increased after a second-trimester male condom.
procedure but the benefits outweigh the Medical termination of pregnancy is a defining
risks.Contraindications for IUDs are when moment in a woman's life , a decision which
complications like hemorrhage, uterine impacts her physical and emotional health. Safe
perforation, hematometra or septic abortion have abortion service is complete only when quality of
happened ,other methods are more suitable here care is maintained through the subsequent weeks
once patient has recovered.
and every care is given for facilitating a planned
Progestin-only implant - The progestin-
onlyetonorgestrel implant is safe in all cases of next pregnancy by choice
abortion, either trimester and any method.9,10
References :
Depot medroxyprogesterone acetate has no risks
specific to the postabortion setting of any trimester 1. Schreiber CA, Sober S, Ratcliffe S, Creinin
and either method. Some concern has been raised
MD. Ovulation resumption after medical abortion
about mifepristone efficacy with concurrent
with mifepristone and misoprostol. Contraception
administration of DMPA compared with delayed
administration (3.6 versus 0.9 percent) and whether 2011; 84:230.
2. National Abortion Federation. 2018
second dose of mifepristone needed which is under
study.But overall success rates for both groups Clinical Policy Guidelines for Abortion Care.
were above 90 percent11. Subcutaneous DMPA https://5aa1b2xfmfh2e2mk03kk8rsx-
104 mg is absorbed slowly and has lower peak wpengine.netdna-ssl.com/wp content/
serum levels of hormone , it remains to be studied. uploads/2018_CPGs.pdf. (Accessed on January
Short-acting reversible contraception - Short acting 08, 2019).
contraceptives include, combined estrogen- 3. World Health Organization. Safe abortion:
progestin methods (eg, oral pill, transdermal patch, Technical and policy guidance for health systems,
vaginal ring), progestin-only pills, and barrier 2nd ed, World Health Organization, Geneva 2012.
methods (ie, female and male condoms). These 4. Curtis KM, Tepper NK, Jatlaoui TC, et al.
methods are moderately to less effective options . U.S. Medical Eligibility Criteria for Contraceptive
Combined estrogen-progestin contraceptives - All Use, 2016. MMWR Recomm Rep 2016; 65:1.
combined estrogen-progestin contraceptive 5. Medical eligibility criteria for
methods (oral pill, transdermal patch, vaginal ring) contraceptive use, Fifth edition. World Health
can be started immediately following first- or
Organization. 2015.
second-trimester abortion.
www.who.int/reproductivehealth/publications/fa
mily_planning/Ex-Summ-MEC-5/en/ (Accessed 10. Cowett AA, Ali R, Cooper MA, et al.
on January 22, 2019). Timing of Etonogestrel Implant Insertion After
6. Madden T, Mullersman JL, Omvig KJ, et al. Dilation and Evacuation: A Randomized
Structured contraceptive counseling provided by Controlled Trial. ObstetGynecol 2018; 131:856.
the Contraceptive CHOICE Project. Contraception 11. Raymond EG, Weaver MA, Louie KS, et al.
2013; 88:243. Effects of Depot Medroxyprogesterone Acetate
7. Raymond EG, Weaver MA, Tan YL. Injection Timing on Medical Abortion Efficacy and
Medical abortion outcome following quickstart of Repeat Pregnancy: A Randomized Controlled
contraceptive implants and depot- Trial. ObstetGynecol 2016; 128:739.
medroxyprogesterone acetate. Contraception 12. Park J, Robinson N, Wessels U, et al.
2015; 92:359. Progestin-based contraceptive on the same day as
8. Okusanya BO, Oduwole O, Effa EE. medical abortion. Int J GynaecolObstet 2016;
Immediate postabortal insertion of intrauterine 133:217.
devices. Cochrane Database Syst Rev 2014;
:CD001777.
9. Raymond EG, Weaver MA, Tan YL, et al.
Effect of Immediate Compared With Delayed
Insertion of Etonogestrel Implants on Medical
Abortion Efficacy and Repeat Pregnancy: A
Randomized Controlled Trial. ObstetGynecol
2016; 127:306.
 18 Post Abortion Contraception
Dr Ritu Joshi

"Contraceptives should be used at every Firstly, it should be provided before the woman
conceivable occasion." leaves the health care facility where she had
Spike Milligan received the abortion care, and secondly,
preference to long-acting reversible contraception
Introduction- (LARC) or at least depot-medroxyprogesterone
India's population by the year 2050 is projected to acetate (DMPA) should be given.
reach 1.53 billion, making it the most populous Return of fertility after abortion-
country in the world. The current approach in Woman's future fertility after an uncomplicated
Family Planning is to offer high quality abortion has no negative consequences. Ovulation
contraceptive services among eligible clients, can occur as early as 8 days after an abortion and
laying stress on adequate spacing of births. As per 83% women ovulate during the first cycle
NFHS-5, the contraceptive prevalence in India is following and abortion2. After a surgical abortion
fertility does not differ from that following a first-
535%, which varies widely among different states
trimester medical abortion. And more than half of
and the unmet need for family planning is higher at
the women have sexual intercourse within 2 weeks
12.9%.Promoting the use of contraceptive methods
after induced abortion3. It is important to offer and
to prevent unwanted pregnancies is one of the most initiate the use of an effective contraceptive method
effective strategies to reduce abortion rates and without any delay after termination of pregnancy or
maternal morbidity and mortality. Therefore, following treatment of incomplete abortion.
providing post abortion family planning services
that include structured contraceptive counseling Safety of providing contraception immediately
with free and easy access to contraceptive methods following an abortion-
can be suitable. The WHO Medical Eligibility Criteria for
Both these should be an integral part of abortion contraceptive use states that the use of combined
care or post abortion care to help the women to hormonal contraceptives and progestin-only pills
avoid another unplanned or unwanted pregnancy may be initiated immediately after an abortion4.
and risk of unsafe abortion. This is one of the The post abortion bleeding is unaffected by
reasons that one of the strategies proposed by immediate initiation of one of these contraceptive
International Federation Gynecology and methods. These methods can or should be started
on the same day as misoprostol is used for a
Obstetrics (FIGO) initiative for the prevention of
medical abortion, on the day of surgery in cases of
unsafe abortion and its consequences. Recent
surgical abortion or on the day of discharge from
evidence suggests that post abortion contraception
hospital following treatment of incomplete or
should have two attributes to ensure maximum spontaneous abortion. Implants are routinely
effectiveness in prevention of repeat unintended inserted immediately after a first trimester surgical
pregnancy, and a repeat safe or unsafe abortion. abortion.
WHOMEC states that IUDs can be inserted 3. Tailor counseling and advice to each
immediately after a first trimester abortion, patient's expressed needs and personal situation.
spontaneous, or induced abortion. Progestrone- 4. Refrain from judging the patient and from
only injectable contraceptives (DMPA or holding preconceived perceptions about what is
norethisterone enanthate) can be administered best for them.
immediately following a surgical, medical or 5. Respect the patient's decision even if they
spontaneous abortion. According to WHOMEC choose a less effective method than your advice.
sterilization can be performed after an 6. Respect the patient's decision to switch
uncomplicated abortion, but should be avoided in from one method to another.
case of any complication. Barrier methods can be Respect the patient's decision to refuse any or all
initiated as soon as required. Diaphragm and cap services
are unsuitable until 6 weeks after a second trimester
abortion. Dual protection be recommended when POST - ABORTION CONTRACEPTION
there is a risk of transmission of sexually A women's fertility can return quickly after an
transmitted infection or HIV. Emergency pills abortion or miscarriage- as soon as two weeks after
should be offered to women relying on less (Bongaarts 1983). Yet recent data show high levels
effective methods. Natural family planning of unmet need for family planning among women
methods cannot be used until the menstrual cycle who have been treated for incomplete abortion.
has resumed. This leaves many women at risk of another
unintended pregnancy and in some cases
An Informed Choice Strategy subsequent repeated abortions and abortion related
complications. (Save sieva et al 2002). Thus it is
The principle of informed choice refers to decisions vital for programs to provide a comprehensive
that people can make for themselves-not to a
package of post abortion care services that includes
process that family planning programs and
medical treatment, family planning counseling and
providers carry out. Nevertheless, programs,
other reproductive health services such as sexually
providers, and policy-makers can do much to
support people's ability to make informed family transmitted infection evaluation and treatment.
planning choices. Programs can do so best by Post abortion contraception choice is given below
adopting a strategy that covers five areas-- in the table-
government policies, communication programs,
access to family planning, leadership and
management, and patient provider communication.
This is where we as gynecologist can help and
make a difference. We are the service providers and
we can help by providing a "cafeteria approach"
and allow them to make their choice.

1. Give our patients their desired family

planning method unless it is medically
inappropriate.
2. Provide clear, unbiased information on the
advantages and disadvantages of the various
contraceptive methods and explain correct use of
the chosen method.
 Time of
Method Advantages Remarks
administration
OC Pills May be given immediately Highly effective Requires continued
Combined and after abortion using vacuum Can be started motivation and daily use
progestin-only aspiration or confirmation immediately, even if Resupply must be available
of completed medical infection is present Effectiveness may be
abortion Can be provided by lowered with long-term use
non-physicians of certain medications,
Does not interfere including rifampin, dilantin,
with intercourse and griseofulvin

Progesterone only May be given immediately Highly effective May cause irregular
contraception after abortion using vacuum Can be started bleeding, especially
DMPA, NET-EN aspiration or confirmation immediately, even if amenorrhea; excessive
of completed medical infection is present bleeding may occur in
abortion May be Can be provided by rare instances · Delayed
appropriate for use if the non-physician return to fertility after
woman wants to delay Does not interfere with stopping use · Must
choice of a longer-term intercourse receive injections every
method Not user-dependent, two or three months
except for remembering
to come for injection
every two or three months
No supplies needed by
user

Intra-Utrine Device IUD can be inserted after Highly effective May increase menstrual
abortion using vacuum Long-term contraception; bleeding and cramping
aspiration or after next effective for five to 10 during the first few months.
cycles years, depending on the May increase risk of pelvic
type inflammatory disease (PID)
Immediate return to and subsequent infertility
fertility following removal for women at risk for RTIs
Does not interfere with and STIs (HBV and
intercourse HIV/AIDS)
No supplies needed Trained provider required
by user to insert and remove
Requires only monthly
checking for strings by
user
Only one follow-up visit
needed unless there are
problems
Tubal Ligation It is to be performed Permanent method Adequate counseling and
after next menstrual Highly effective fully informed consent are
cycles. Once completed, no required before VS
further action required procedures
Does not interfere Slight possibility of
with intercourse surgical complications
No change in sexual Requires trained staff and
function appropriate equipment
No long-term side
effects
Immediately effective

Condoms As soon as she resumes Prevents STDs, Latex condoms may

her sexual activity including HIV/AIDS cause itching for a few
Safe. No hormonal people
side effects Small possibility that
Can be used without condom will slip off or
seeing a health care break during sex
provider first
Usually easy to obtain
and sold in many places
Enable a man to take
responsibility for
preventing pregnancy
and disease

Vasectomy This procedure can be Very effective Not immediately effective.

done independent of the Permanent At least the first 20
abortion procedure No interference with sex ejaculations after vasectomy
No supplies to get, and may contain sperm. The
no repeated clinic visits couple must use another
required contraceptive method for
No apparent long-term at least the first 20
health risks ejaculations or the first 3
months-whichever comes
first
No protection against
sexually transmitted
diseases (STDs) including
HIV/AIDS.
 Time of
Method Advantages Remarks
administration
Emergency May be used immediately Important back-up Providing emergency
Contraceptive Pills after abortion using method when contraceptive pills in
vacuum aspiration or contraception fails fo advance as a back-up
confirmation of completed example, condom method may help prevent
medical abortion breaks), when no future unwanted
method is used or pregnancies
when sex is forced No protection from
STIs/HIV
Generally less effective
than other contraceptive
methods
May have side-effects
such as nausea and
vomiting

* This information applies to methods after first trimester abortion.

Male and female condoms are the only methods that provide protection against transmission of STI/HIV;
they can be used in conjunction with all other methods.

Conclusion:
Family planning counseling and provision of an effective contractive method should be an integral part
of post abortion care. Every year India adds the population of Sub-Saharan Africa to the earth. Improved
obstetric services and child spacing could reduce maternal mortality in developing countries as they have
in the developed world. Contraception should become a people's movement rather than be forced upon
the people. People should insist on good quality, affordable contraceptive services as their basic right.
Family planning should come to mean 'Fewer babies- But better babies'.

References-

1. Faundes A. Strategies for the prevention of unsafe abortion. Int J Gynecol Obstet
2012;119(Suppl.1):S68-71.
2. Schreiber CA, Sober S, Ratcliffe S, Creinin MD. Ovulation resumption after medical abortion
with mifepristone and misoprostol. Contracetion 2011;84(3):230-3.
3. Boesen HC, Rarbye C, Nargaard M, Nilas L. Sexual behavior during the first eight weeks after
legal termination of pregnancy. Acta Obstet Gyecol Scand 2004;83(12):1189-92.
4. World Health Organization. Medical eligibility criteria for contraceptive use. 4th ed.
Geneva:WHO; 2010.
 19 COMPLICATIONS With MTP- Dr. Sheela Mane
(a)
Haemorrhage Dr. Neha Tabbasum

Introduction: Placental adherence can be due to primary

10-20% of pregnancies result in spontaneous deficiency of decidua, abnormal maternal vascular
abortion. Even after legalization of abortion in remodelling or excessive trophoblastic invasion.
many countries unsafe abortion still remains major whenever there is excessive bleeding during late
public health issue, cause third of all maternal first trimester and mid trimester abortions low
deaths. placentation in the uterine cavity marginal or
Haemorrhage is defined as bleeding more than or complete placenta previa should be considered.
equivalent to 500ml which needs hospital
admission with or without the need for blood Retained Tissue:
transfusions. In the first trimester haemorrhage Partial or complete retention of products (placenta
(14%) is the second common cause of abortion and other decidual tissues) more common after
related mortality following infection (33%). medical abortion, can also occur after surgical
abortion. It occurs frequently after second trimester
abortions(3.6%). It may cause both primary or
Etiopathogenesis:
secondary obstetric haemorrhage, most significant
cause of maternal morbidity and mortality.
UTERINE ATONY:
Major cause of retained products is abnormal
Most common cause of post abortion haemorrhage. adherence of placenta to underlying uterine wall. Pt
The principal mechanism of uterine hemostasis is usually present with abdominal pain, bleeding and
contraction of myometrium, which mechanically fever.
compresses the blood vessels supplying the
placental bed. In addition local hemostatic factors Cervical Lacerations:
such as tissue factor type 1 plasminogen activator Forced dilatation always causes microscopic tears.
inhibitor ,systemic coagulation factors such as High lateral cervical tears in area of uterine arteries
platelets and circulating clotting factors also can lead to hemorrhage. The use of injectable 15
contribute in preventing haemorrhage. The methyl PGF2 alpha had distinct association with
delivery of placenta leaves disrupted spiral arteries bucket handle tears of cervix, because of strong
which do not have myometrium and are dependent uterine contractions with lagging cervical
on contractions to mechanically squeeze them for dilatation. The medical priming of cervix for
hemostasis. Greater gestational age, advanced surgical abortion and use of misoprostol with or
maternal age and previous scar on the uterus are without mifepristone prepares cervix and gives it
associated risk factors. protection from injury.

Abnormal Placentation: PERFORATION:

Placental invasion beyond the myometrium can be Uterine perforation although rare extremely
major risk factor complicating abortion. Incidence dangerous complication when it goes undiagnosed
is raising due to increased rates of caesarean at the time of abortion.
sections.
Can lead to trauma to visceral structures or Post abortion triad:
uncontrolled haemorrhage requiring hysterectomy, Pain, bleeding and fever are frequently seen in
causing death. emergency situation and assosciated with retained
Multipara, uterine anomalies have been found at products of conception.
higher risk.
The site of perforation is dependent on uterine Post abortion syndrome:
position and is important as the visceral organs at Progressive worsening abdominal pain and
that anatomical site are at risk of injury. posterior hemodynamic compromise in absence of vaginal
wall is more commonly involved in anteverted bleeding. It is due to collection of blood/ products
uterus, while anterior wall is perforated in in uterine cavity causing uterine overdistension
retroverted uterus. Lateral wall can also be at risk if which is unable to contract in order to expel its
uterus is deviated to either direction. contents and cervical stenosis .
Perforation likely to occur when there is
discrepancy between surgeons estimate and actual Estimation Of Haemorrhage:
size of uterus. Most common instruments are Vagina has capacity to hold 500 ml of blood
suction cannula, uterine sound or uterine dilator. It without significant external bleeding hence a
is particularly dangerous when assosciated with bimanual examination should always be
unsafe abortions because of accompanying sepsis
performed. Intra uterine blood collection with
and peritonitis.
hematometra can be diagnosed by pelvic
ultrasound.
Bleeding Disorders:
Women on anticoagulants and with bleeding
disorders are at increased risk of haemorrhage.

Management:
Levels of management of post abortion haemorrhage

Primary Cervical Laceration Pressure Suturing

Atonic Uterus Bimanual massage Uterotonic agents

oxytocin, methyl ergometrine maleate,
15 methyl PGF2 alpha, misoprostol

Secondary Atonic uterus , retained Fluid resuscitation ,blood components

products or blood clots transfusion ,tamponade effect , uterine
pack, foleys catheter/ bakri balloon/
condom or glove Suction evacuation or
manual vacuum aspiration under
ultrasound guidance.

Tertiary Intensive surgical interventions Uterine artery embolization, compression

sutures B lynch, Cho sutures, stepwise
devascularization , laparoscopy or
laparotomy for perforation hysterectomy.
Management of Atonic Uterus: Retained Tissue:
Stabilization of patient: Ultra sound is useful in evaluating. If pt is stable
Monitor vitals uterotonic PGE1 can be used and pt can be
Trendelenburg position reassessed a week after with ultrasound.
Blood investigations For persistent cases need for evacuation under
Fluid resuscitation
Blood transfusion hysteroscopic vision.
Broad spectrum antibiotics
Mechanical methods: Uterine Perforation:
Empty the bladder Cervical priming before procedure facilitates
Bimanual massage dilatation of cervix, minimising chance of
Uterotonic agents: perforation. Uterine evacuation should be done
Oxytocin 10 U in 500 ml saline only when uterus is well contracted. Dilator and
Methyl ergometrine 0.2 mg IM/ slow IV 5 doses 2- cannula should be passed just beyond internal os
4 hrs apart
PGF2 alpha 250 microgram IM 8 doses every 15- and products should be sucked from that position
20 minutes only.
Misoprostol 800 microgram orally
Uterine packing: References:
Roller gauze
Foleys catheter 1. Robinson GE. Pregnancy loss best practice
Condom catheter or glove clinical obgy.2013;28(1):169-78
Bakri balloon 2. Sedgh G, Bearak J singhS ,et al .special
Conservative methods: tabulations of updated data from abortion
Uterine tamponade incidence between 1990 and 2014: Global regional
RUSCH catheter
and sub regional levels and trends. Lancet
Uterine artery embolization
B lynch or Cho sutures 2016;388: 258-67
Stepwise devascularization 3. WHO.(2012) safe abortion :technical and policy
guidance for health systems.
Last Resort: 4. Bashar MA , Bhattacharya S , singh A. unsafe
Total or subtotal hysterectomy abortions in india
5. Kerns J, steinauer J. management of post
Abnormal Placentation: abortion haemorrhage and contraception.
Diagnosis made by ultra sound confirmed by MRI. 2013;87(3):331-42
Use of uterotonics prophylactically is mainstay of
treatment. Conservative management, even
placental preservation can be carried out with
subsequent methotrexate therapy or pelvic artery
embolization.

Cervical injury:
Cervix should be inspected visually and digitally.
Small lacerations less than 0.5 cm will respond to
adequate pressure. Highly vascular or lacerations
greater than 1 cm need to be repaired using
absorbable sutures. If bleeding persist uterine
artery laceration should be considered and should
be shifted to ot and explored.
 19 COMPLICATIONS With MTP-
(b)
Uterine Perforation Dr. Charmila Ayyavoo

Perforation of the uterus can happen during any Prevention:

procedure in the uterine cavity. It can particularly It is better not to perform a dilatation and curettage
happen during a surgical evacuation of products of (D&C) forcibly. If the procedure results in a uterine
conception as a part of the procedure of medical perforation, it will need specialist management.
termination of pregnancy (MTP). Rarely it can be Prevention of the uterine injury is by an accurate
associated with injury to the adjacent viscera like assessment and preparation. The uterine size,
bowel, bladder and blood vessels. It can be position and attitude should be accurately
catastrophic to the mother if it leads to sepsis and estimated. The service provider should be
hemorrhage. experienced. Adequate cervical preparation with
prostaglandins will be associated with a reduced
Incidence: cervical resistance and a reduced chance for an
The incidence of perforation of the uterus is from injury. Oral or vaginal prostaglandins can be used
0.4 to 15/1000 abortions. (1) depending on the surgeon's preferences.
Using cervical dilators of gradually increasing size
Risk factors: will also prevent an uterine perforation.
1.Factors which impair access to endometrial
cavity. Ultrasound can be used to guide MTPs done
Acute anteflexed uterus, retroverted and surgically. They have proved to reduce the
retroflexed uterus, stenosis of the cervix incidence of uterine perforations in difficult cases.
2.Factors which alter the uterine wall strength They can also be used to guide if evacuations need
Pregnancy, breastfeeding, previous uterine injury to be completed after a complication like uterine
and previous cesarean scars. perforation has occurred.(3)
3.Uterine anomalies The incidence of perforation is 0% in a RCT by
Abdul Kareem et al when surgical evacuation is
4.Other causes: older mothers, multiparity and done under ultrasound guidance while it is 3%
inadequate training of the providers of the when ultrasound is not used.(4)
service.(2)
Diagnosis:
Complications: Uterine perforation is suspected if the following
Acute: There may be torrential bleeding which may features are seen:
necessitate a hysterectomy and blood transfusions. a. the cannula passes through for a longer distance
Hence urgent control of bleeding is necessary after than anticipated in the uterine cavity.
a perforation. b. if there is no resistance when the cannula is
passed
Chronic: If not treated properly, can lead on to c. if there is difficulty in withdrawing the cannula
peritoneal adhesions, subacute intestinal d. if bits of omentum or intestine is seen in the
obstruction, chronic pelvic pain and infertility aspirate
e. if there is evidence of shock
Management: If there is bleeding or suspected damage to adjacent
Prevention of the problem is the best modality. organs, a diagnostic laparoscopy is done. If
Instant recognition of the complication with urgent experienced laparoscopic surgeons are available
intervention and continuous management is and the perforated uterine wall is bleeding,
mandatory. This is necessary to reduce morbidity, laparoscopic suturing is done. The evacuation is
mortality and long-term consequences of the completed under laparoscopic guidance.(7)
uterine damage. If there is extensive damage to the uterus and there
The surgeon's experience is crucial to avoid the is ongoing bleeding, a laparotomy is necessary.
complication and for early recognition of the Hysterectomy may be needed to save the patient.
injury. (5,8)
The management will depend on If there is damage to adjacent organs, repair is done
a.The site of the perforation laparoscopically or by open surgery.
b.The completeness of the procedure
c.Gestational age Conclusion:
d.Adjacent organ damage Care is needed while performing surgical
e.Hematoma formation evacuation as a part of MTP. Experienced service
f.Ongoing bleeding providers should perform the procedure. Oral
Once the problem is identified, the procedure is abortifacients have reduced the incidence of this
stopped at once and the cannula is removed. dreaded complication. Service providers should
No uterotonics like oxytocin or methergine are take the utmost precautions as uterine perforation
given. can lead on to severe morbidity, mortality and long
If the patient is in shock, it is managed urgently. term sequella
Intravenous fluids are started and antibiotics are
given. References:
A bedside ultrasound is done to confirm the 1.Chandi A, Jain S, Yadav S, Gurawalia J: Vaginal
completeness of the evacuation. If evacuation is evisceration as rare but a serious obstetric
complete, the patient is monitored for 24 hours. complication: a case series. Case Rep Women's
Uterotonics are given to reduce bleeding. (5) Health. 2016, 10:4-6. 10.1016/j.crwh.2016.05.001

If perforation is suspected and the evacuation is 2.Augustin G, Majerovi? M, Lueti? T: Uterine

not complete: perforation as a complication of surgical abortion
The procedure is stopped. causing small bowel obstruction: a review. Arch
G y n e c o l O b s t e t . 2 0 1 3 , 2 8 8 : 3 11 - 3 2 3 .
Patient is stabilised by giving adequate intravenous 10.1007/s00404-013-2749-4
fluids or cross matched blood if necessary.
Antibiotics are started. 3.Darney PD, Sweet RL. Routine intraoperative
ultrasonography for second trimester abortion
The uterus is visualised with ultrasound if the reduces incidence of uterine perforation. Journal of
patient is stable. If there is no evidence of bleeding ultrasound in medicine. 1989 Feb;8(2):71-5.
or injury to adjacent organs, the procedure of
evacuation is completed under ultrasound 4.Abdulkareem, A. F., Abdelazim, I. A., AbuFaza,
guidance.(6) If the patient is stabilised, she is M., Abdelrazek,
observed for 24 hours.
K. M., & Farghali, M. M. Ultrasound-guided
surgical suction evacuation (US-SSE) for missed
miscarriage. J ObstetGynecolInvestig 2018; 1: 1-5

5.C l i n i c a l M a n a g e m e n t o f A b o r t i o n
Complications: A practical Guide (WHO; 1994; 86
pages)

6.Kohlenberg CF, Casper GR. The use of

intraoperative ultrasound in the management of a
perforated uterus with retained products of
conception. Australian and New Zealand journal of
obstetrics and gynaecology. 1996 Nov;36(4):48

7.Alalade, A.O., Odejinmi, F.O. Laparoscopic

management of uterine perforation following
surgical termination of pregnancy: a report of three
cases and literature review. GynecolSurg 3, 34-36
(2006). https://doi.org/10.1007/s10397-005-0150

8.Freiman SM, Wulff GJ Jr. Management of uterine

perforation following elective abortion. Obstet
Gynecol. 1977 Dec;50(6):647-50. PMID: 927753.
 19 COMPLICATIONS With MTP-
(c)
Sepsis Dr. Basab Mukharjee

Background Features of septic shock are hypothermia,

Of the severe complications that affect women after hypotension, oliguria and respiratory distress.
an abortion, especially an induced unsafe Recognition of these symptoms would again
procedure done by untrained providers, sepsis is necessitate intensive care support. If the health
one of the major ones. It contributes about 3-7% of center does not have necessary infrastructure, the
post abortion care complications in a recent survey patient needs to be referred to the nearest tertiary
done in six Indian states.1 Infection is less common
care facility at the earliest.
after a spontaneous miscarriage.

The causative organisms include beta hemolytic Investigations

streptococci, staphylococci, Escherichia coli, Aerobic and Anaerobic blood cultures should be
Enterobacter aerogenes, Proteus vulgaris and sent before starting empirical antibiotics which can
Clostridium perfringens. be changed later depending on the reports.
Usually, the products of conception become
infected with infection spreading to the uterus Blood tests may be collected while starting a wide
through the maternal inter villous space finally bore IV channel for resuscitation. Complete blood
resulting in bacteremia. count would be helpful to determine the need for
blood transfusion. Rising white blood cell counts
Signs and Symptoms and a shift to the left would be a primary assessment
Signs and Symptoms mimic those of an acute to the degree of infection. This would be
pelvic infection. The patient presents typically 2-7
corroborated by other inflammatory markers like
days after the procedure with fever, chills, vaginal
CRP and Procalcitonin. Coagulation parameters
discharge and abdominal pain. The diagnosis is
mostly clinical, but history of a recent abortion may are important to detect a developing coagulopathy
sometimes be concealed. secondary to sepsis which would require
transfusion of blood products and regular
Features of peritonitis may suggest a perforation monitoring. Blood group and Rh typing needs to be
while heavy vaginal bleeding with an open cervical known for the need of Anti-D prophylaxis if
osmay indicate an incomplete abortion. Local appropriate. Liver function tests, renal function
genital trauma also needs to be ruled out which may tests and electrolytes are required for the initial
need repair. If she is hemodynamically unstable, assessment of a patient in sepsis.
early shifting to the intensive care is appropriate.
Surgical intervention may be necessary if abdomen Imaging methods should be employed to assess the
bleeding or gut injury is suspected.
uterine cavity for products of conception and the
abdominal cavity for collection, ileus or bowel
Patients can rapidly progress to refractory
hypotension with multi organ failure secondary to injury. A transvaginal sonography would be most
massive capillary leakage.3 suited for intra uterine retained products.
 Erect X Ray of the abdomen could reveal gas fluid Posterior Colpotomy under ultrasound guidance
levels in the bowels or gas under the diaphragm in may be performed in select cases to drain a
cases of bowel perforation. The diagnosis is localized collection. Laparotomy would be
important as immediate laparotomy for repair is necessary in cases of suspected bowel injury,
paramount to reduce morbidity and mortality. A foreign body in the abdomen, internal hemorrhage
or a non-resolving peritoneal or pelvic abscess.5
USG of the whole abdomen would be helpful in
revealinga collection which may need early Prevention
assessment and drainage. Primary Prevention includes access to effective
contraception to avoid unwanted pregnancies in the
Treatment first place. For contraceptive failure, safe abortion
A multi-disciplinary team including an intensivist, within the legal framework should be resorted to.
infectious disease specialist and microbiologist Secondary Prevention requires early detection and
would be ideal in managing difficult cases. to institute treatment. Any woman in the
reproductive age group presenting with vaginal
Intensive IV antibiotic medication and supportive bleeding, lower abdominal pain and fever should
be suspected.
therapy are the cornerstones of managing sepsis.
Additional surgical procedures may be necessary in Tertiary Prevention would mean to limit harm.
some cases. Most often the patient would be in an intensive care
setting where the aim would be to avoid a
One combination of Intravenous Antibiotics hysterectomy or prevent death and long-term
initially used include Ampicillin, Gentamicin and disability from the condition.
Metronidazole. This covers most of the gram
positive, gram negative and anaerobic organisms References
responsible. Alternately, IV Clindamycin may be 1. Singh S et al.Abortion and Unintended
used in combination with Gentamicin. Evidence of Pregnancy in Six Indian States: Findings a n d
Implications for Policies and Programs, N e w
definite advantage of one regime over another is
York: Guttmacher Institute, 2018
lacking.4The culture report would guide necessary 2.Dulay TA. Septic Abortion, MSD Manual
changes which may includestepping up to a Professional VersionOct 2018
Piperacillin-Tazobactam combination. 3. Obstetric Emergencies. Obstetric and
Gynecology Clinics of North America.
Supportive therapy is best instituted in an intensive March 2013, Volume 40. No 1, Pg 74-75
care setting. Respiratory status should be stabilized 4. Udoh A et al. Antibiotics for treating
first followed by perfusion maintenance. septic abortion. Cochrane Database of
Crystalloid administration through wide bore IV Systematic Reviews 2016, Issue 7. Art. No.:
channels, supplemental use of oxygen, careful fluid CD011528
5. Rani S. Sepsis in relation to abortions.
monitoring and transfusion of blood products as
Severe Acute Maternal Morbidity. Editor
needed. Frequent use of arterial blood analysis and Arulmozhi Ramarajan. Jaypee Publication 2011
chest radiographs to track development of ARDS
would also be necessary.

Surgical Intervention includes early evacuation of

retained products if evident from clinical
examination and supported by ultrasound.
Laparoscopy in a clinically stable patient to assess
perforation may be appropriate.
 20 MTP IN DIFFICULT CASES-
(a)
Scarred Uterus Prof. Bharti Maheshwari

MTP is integral part of women reproductive health Preprocedure preparation- obtain optimal hb
care. in Recent years,incidence of caesarean level before procedure and accordingly arrange for
sections,myomectomy,hysterotomy ,giving scar on blood transfusion and pre procedure antibiotics..
uterus increased in large numbers so request for
termination in scared uterus too. Resuscitation , transport facility or laparotomy
facility has to be ensured according to gestational
Scarred uterus means women having incision on age ,method selected and risks associated.
uterus once or many times. caesarean section is
most common uterine surgery women have.such High risk factors for complications-
women have more risk for life threatening Multiple incision,2nd trimester abortion, uterine
complications of termination of pregnancy like congenital anomalies ,upper uterine segment
haemorrhage,scar dehiscence and rupture of uterus incision, history of infection after uterine surgery,
.hence such cases need especial emphasis
duration of last surgery <1 yr is associated with
All legal eligibilities for case selection ,provider
more risk of life threatning complications like
and facility has to be checked as in other cases
rupture,dehiscence and haemorrhage.
according to MTP act
Role of ultrasound-
Clinical workout includes detailed history,
In all cases of scarred uterus who needs
clinical examination, necessary investigations,
ultrasound and accordingly proper selection of termination, ultrasound and Doppler should be
method of termination .Detailed intraoperative and used to rule out scar ectopic or adhered placenta
postoperative history of previous uterine surgeries, .though it is not mandatory according to MTP act
duration of last surgery with present pregnancy but advisable in all scarred uterus. beside that usg
,gestational age are important factor to decide is helpful to find out congenital abnormality in
method of termination and risk for complications. uterus,correct gestational age and location of
Medical history should include: hypertension pregnancy. Ultrasound guided procedure can be
,heart disease ,diabetes mellitus , epilepsy ,asthma , done in high risk cases. post procedure follow up
drug allergies ,bleeding disorders , renal disease for completion of procedure or in cases of
,thyroid disease haemorrhage ,ultrasonography can be used for
optimal management.
Counseling andinformed consent - This should
be done by senior obstetritian with detailed Pain management- optimal pain management
informations to patient about all variants of minimizes risk of perforation .it ranges from oral
administration, their advantages and risks. analgesics with verbal support, paracervicalblock
or short general anesthesia.in scarred uterus,if
Individual approach is necessary.Potential doing surgical procedure ,painful and forceful
complications, such as haemorrhage and dilatation shouldbe avoided .proper cervical
uterinerupture constituting a life-threatening preparation is required.
situation should be explained in patients language
and informed consent should be taken .
Evacuation in scarred uterus -clinical methods Dickinson published his results about scarred
1.Medical method- uterus. Misoprostol was used to induce abortion
it include drugs Mefipristone and Misoprostol in with 400 mg vaginally every 6 h and the presence of
different dose protocols according to gestational a prior uterine scar did not impact on abortion
age to induce and complete the abortion process duration . Bhattacharjee et al. concluded that the
Dose protocols in unscarred uterus- use of misoprostol for mid trimester pregnancy
In first trimester- Mefipristone 200 mg followed termination is not contraindicated in women with
by 400-800mcg Misoprostol after 48 Caesarean scar and is effective and comparable
hrs.According to MTP act -can terminate by with those in women without scarred uteri.
medical method up to 9 wks OR 63 days of In study of 500 patients,205 patients had at least
gestation. 1 caesarean scar(41% one,10% had prev 2
caesarean scar,11 %patients,prev 3 and 2% prev 4
in 2nd trimester - 200mg Mefipristone followed by caesarean scar) had successful termination in 74%
400-800mcg every 3 hrly according to WHO cases of study gp(scarred uterus) in comparision to
protocol. 67.8% in unscarred uterus. Complication rate as
oThis is very safe and effective method for of uterine rupture was 0% in both groups(4)
termination , especially in first trimester,. One of
the major concerns about use of misoprostol in
pregnancy is uterine rupture ,this risk increases Fawzy and El Habdel- Hady 2012,used
in scarred uterus.There are several case reports of misoprostol 200 mg vaginally with 6 h intervals on
uterine rupture in the first trimester.but they , the 1st day and double the dose to 400 mg with the
involve a predisposing factor such as uterine same intervals since the 2nd day in the women with
anomalies, prior uterine surgery,placenta percreta, three or more prior cesarean sections. Their study
or cesarean scar ectopic. had a 90.3% successful rate without any adverse
outcome. However, for safety, they recommended
Dose protocols in scarred uterus- that women with a scarred uterus should receive
lower doses of misoprostol and do not double the
Though ,no clear recommendation about dose dose if there is no initial response
and protocols in scarred uterus,but evidence
says that misoprostol is not contraindicated in Daponte et al. (3) evaluated the safety and
termination of pregnancy in scarred uterus. efficacy of misoprostol regimen in women with
previous multiple caesarean sections. This was a
Various studies all over world shows that use of retrospective cohort study of women with more
misoprostol in women with prior caesarean than one caesarean section who underwent
delivery was not associated with an excess of termination of pregnancy (TOP) with 400 m?g of
complications compared with women with vaginal misoprostol followed by 200 m?g/6 h (max
unscarred uteri. Majority has no incidence of 800 m?g). They did not report any major
uterine rupture,when tailored dose is complication and considered the use of misoprostol
given.Misoprostol treatment was Equally effective and safe for termination of pregnancy in
Acceptable among women who received
women with previous multiple caesarean sections
misoprostol, with 81% and 78% of women with
and without prior uterine surgery, respectively,
willing to use misoprostol again if needed Berghella et al. (2)published their data and
(p=0.17). There was no difference in the concluded that incidence of uterine rupture
acceptability of side effects, with 57% and 59% of associated with second trimester misoprostol
women with and without prior uterine surgery termination was 0.4% (2/461) in women with one
finding the side effects somewhat or totally prior low transverse, 0% (0/46) in those with two
acceptable (p=0.52).(1) prior low transverse and 50% (1/2) in those with a
prior classical caesarean delivery.
One of the cases of uterine rupture in a woman with same dilatation, is associated with less discomfort
a prior low transverse caesarean required and is preferred by women
transfusion. None of the total eight cases (including Misoprostol (400mcg) is used vaginally 3-4
case reports) of uterine rupture was associated with hours or sublingually 2-3 hours before the
hysterectomy. procedure for cervical dilatation.
Hence ,no evidence that a previous caesarean
delivery affects the incidence of complications One additional dose of 400mcg may be given if
when women with such a history undergo a the dilatation is inadequate after four hours or
pregnancy termination with misoprostol. dilators may be used.
Therefore, the use of misoprostol for pregnancy ROUTE- The sublingual route appears as
termination is not contraindicated in women with effective as vaginal administration and requires
Caesarean scar and is effective and comparable less time for priming (2 h), but it is associated with
with those in women without scarred uteri more side effects. Oral administration can produce
equivalent dilation to vaginal or sublingual
DOSE- administration, but higher doses and longer
The cases,which are high risk for complications treatment
should be given less amount of dose with increase Advantages of using misoprostol for dilatation:
interval like 200 to 400 mcg instead of 400 to 800 It is a highly effective drug for inducing cervical
mcg on first day at 6 hrs interval instead of 3 dilatation and uterine contractions
hrs.Always check response before increasing the The administration of misoprostol leads to the
dose .Always remain vigilant for signs of contraction of the uterus even before the actual
dehiscence or rupture . procedure is initiated, thereby reducing the amount
of blood loss, possibility of perforation and the time
Surgical Method Of Termination In Scarred taken for the procedure
Uterus- Disadvantages of using misoprostol for
Vaccum Aspiration-manual Or Electric-mva/eva dilatation:
Dilatation And Evacuation It has GI side-effects, which can discomfort the
Hysterotomy woman

Hysterotomy is last option, when all methods VACCUM ASPIRATION-MANUAL OR

failed. Consent should be taken and patient should ELECTRIC-MVA/EVA
be told for probability.To avoid hystrotomy and Vacuum Aspiration (MVA and EVA) is a safe
successful outcome cervical preparation is very technology for uterine evacuation upto 12 weeks
important step before evacuation LMP in scarred uterus
Cervical preparation/dilatation: It is An accurate clinical assessment, counselling
recommended for all women undergoing the and informed consent is a must before a VA
termination of pregnancy over 12-14 weeks. procedure
It decreases the risk of cervical injury and Ideal pain control during VA is a combination of
uterine perforation. verbal reassurance, oral analgesic (30-60 minutes
Medication/devices/instruments are used for before the procedure) and paracervical block
cervical prepartion on and dilatation before the VA procedure should be performed as per the
evacuation of the POCs: protocol
Evacuated tissue should be inspected for
Misoprostol /OSMOTIC chorionic villi
Compared to laminaria, vaginal misoprostol Follow-up visit should take place within one to
requires a shorter period of time to achieve the two weeks after a VA procedure
Followup and post MTP Counselling- 4.The Safety of Misoprostol for Medical
Women should be closely monitored during and TERMINATION of Pregnancy in First and Second
just after perocedure till 48 hrs.DO post abortion Trimester in Women with Previous Uterine Scar
contraception counseling,if not adopted any Ahmad Talal Chamsi* , Elham Morsy, Rabab El
contraceptive method Rifaei and Rawda Al Bahyan Department of
and called for follow up after 15 days of discharge . Obstetrics and Gynecology, Security Forces
Hospital, Riyadh, Saudi Arabia *Corresponding
Take Home Message author: Ahmad Talal Chamsi, Department of
1. Mesoprostol Is Not Contraindicated In Scarred Obstetrics and Gynecology, Security -2018
Pregnancy And Can Be Used In Tailored Dose
2. Rule Out Scar Pregnancy-by Usg And Doppler 5.Misoprostol complications in second-
Before Procedurein Scar Uterus trimester termination of pregnancy among
3. Counsel Patient And Take Informed Consent women with a history of more than one cesarean
For Additional Risk section MarziehJamali 1, Mahmood Bakhtiyari 2,
4. Indoor Management With All Laprotomy Fatemeh Arab 3, Masoumeh Mirzamoradi
Facilities -should Be Available For 2ndtrimester
Termination In Scarred Uterus 6. Comprehensive Abortion Care Second Edition
5. Effective Pain Management Should Be Done 2018 lR;esot;rs Ministry of Health and Family
6. For Surgical Management-cervical Preparation Welfare Government of India Training and Service
And Use Of Mva Minimises Complication Delivery Guideline

References- 7. E. A. Schaff, S. H. Eisinger, L. S. Stadalius, P.

1.Termination of early pregnancy in the scarred Franks, B. Z. Gore, and S. Poppema, "Low-dose
uterus with mifepristone and misoprostol. mifepristone 200 mg and vaginal misoprostol for
Xu J1, Chen H, Ma T, Wu int J Gynaecol Obstet. abortion," Contraception, vol. 59, no. 1, pp. 1-6,
2001 Mar;72(3):245-51. 1999.View at: Publisher Site | Google Scholar
8. E. A. Schaff, L. S. Stadalius, S. H. Eisinger, and
2.Misoprostol for second trimester pregnancy P. Franks, "Vaginal misoprostol administered at
termination in women with prior caesarean: a home after mifepristone (RU486) for abortion,"
systematic review Berghella 1, J Airoldi, A M The Journal of Family Practice, vol. 44, no. 4, pp.
O'Neill, K Einhorn, M Hoffman1Division of
353-360, 1997.View at: Google Scholar
Maternal-Fetal Medicine, Department of
Obstetrics & Gynecology, Jefferson Medical 9. K. Blanchard, B. Winikoff, and C. Ellertson,
College of Thomas Jefferson University, "Misoprostol used alone for the termination of
P h i l a d e l p h i a , PA , U S A . v i n c e n z o . early pregnancy: a review of the evidence,"
berghella@jefferson.edu Contraception, vol. 59, no. 4, pp. 209-217,
1999.View at: Publisher Site | Google Scholar
3.The use of vaginal misoprostol for second- 10. E. Marinoni, M. Santoro, M. P. Vitagliano, A.
trimester pregnancy termination in women with Patella, E. V. Cosmi, and R. Di Iorio,
previous single cesarean section Alexandros "Intravaginalgemeprost and second-trimester
Daponte 1, Guy Nzewenga, Konstantinos D pregnancy termination in the scarred uterus,"
Dimopoulos, Franco Guidozzi International Journal of Gynecology and
Obstetrics, vol. 97, no. 1, pp. 35-39, 2007.View at:
4.Cervical dilation before first-trimester Publisher Site | Google Scholar
surgical abortion ( <14 weeks' gestation). SFP 11. C. Mazouni, M. Provenzal, G. Porcu et al.,
Guideline 2007 Rebecca H Allen, Alisa B "Termination of pregnancy in patients with
Goldberg, Board of Society of Family Planning previous caesarean section," Contraception, vol.
PMID: 17656184 73, pp. 244-248, 2006.View at: Google Scholar
20 MTP IN DIFFICULT CASES- Dr Komal N. Chavan
(b)
Medical Disorders
Dr Deepali Prakash Kale

Background-
When a woman with medical condition opts for induced abortion, liaison with the woman's physician or
another specialist can facilitate decision making regarding hospital referral and additional preparations
that may be required.

Vascular-untreated aneurysm
Central Nervous System
Space occupying lesions
Renal Disease Impaired renal function (serum creatinine>2.5 mg/dL)
Uncontrolled BP (systolic blood pressure> 160 or
Hypertension
diastolic blood pressure >105)
Uncontrolled hyperthyroidism
Endocrine Uncontrolled diabetes
Pheochromocytoma
Uncontrolled asthma
Pulmonary
Restrictive lung disease Pulmonary hypertension
Congenital (cyanotic disease
Right or left ventricular dilation
Uncontrolled tachyarrhythmia)
Cardiac Coronary disease - (H/0 of myocardial infarction,
treatment angina)
Cardiomyopathy - (dilated hypertrophic,
History of peripartum cardiomyopathy)
"Hepatic disease elevated PT
GI "Esophagealvarices with h/0 bleeding
"Uncontrolled inflammatory bowel disease
"Severe anaemia
"Sickle cell disease with crisis
Haematological "Idiopathic thrombocytopenia purpura with
active thrombocytopenia
"Thrombophilia requiring anticoagulation
Table 2-Considerations for Different methods of Induced Abortions-

Surgical abortion preferred Medical abortion preferred

Various anaesthetics options -tailored to the Patients at risk of surgical and anaesthetic
medical needs of the patient and administered complications may benefit with management in
in a setting with continuous monitoring. the inpatient setting [15].
Sedation during surgical abortion is important A safer alternative for patients with extreme
as it may reduce tachycardia related to pain and obesity, pelvic tumours that interfere with access
anxiety. to the cervix or a known history of serious
For women with a bleeding diathesis, surgical reactions to anaesthetic agents.
management offers direct observation and Suitable for Patients who cannot be given
immediate uterine evacuation and less often lithotomy positioning, in the context of
leads to a delayed haemorrhage [24]. orthopaedic (e.g., hip disease) or neurologic
Surgical abortion is preferred when conditions (e.g., cerebral palsy).
methotrexate is contraindicated.

Important Considerations for common chronic conditions

Type I Diabetes- Surgical /medical-
These women more prone to hypoglycaemia in the first trimester.
Disruption of glycaemic control due to -An initial increase in insulin requirements for the first trimester
is followed by a reduction in insulin requirement between 7 and 12 weeks of gestation &
Hyperemesis.
Local anaesthesia -A regular diet and usual medication can be continued before and after abortion
Deep sedation - preprocedure fasting, Reduce the patient's usual long-acting insulin dose the evening
before to half, omit the morning dose of short acting insulin.
" Scheduled first or as an early case in the day.
Post-procedure- medication requirements may decrease.
Liaison of care with her medical provider is recommended.
Post abortion contraception -all options.
The use of combined hormonal contraception, is usually contraindicated for women with evidence of
vascular disease or end-organ damage

Hypertension-
Often clinically silent and undertreated in young women.
For women with mild to moderate hypertension Outpatient setting- appropriate
Poorly controlled hypertension [systolic blood pressure (BP)> 160 mmHg; diastolic BP >105 `
mmHg]--Hospital setting.
Ergot drugs should be avoided in women with hypertension; oxytocin and misoprostol are
acceptable uterotonic agents for such patients.

Obesity-
Surgical abortion for obese women may be associated with increased technical difficulty.
 Ventilation difficulties with deep sedation may be more common with obese patients.
Consultation with an anaesthesiologist may be helpful.
Post abortion contraceptive Options-All.

Epilepsy
Women with well-controlled epilepsy may receive outpatient abortion care.
Those with recent onset or uncontrolled seizures may benefit from hospital-based care.
The dose of mifepristone may be increased in patients who take antiepileptic drugs that augmen the
hepatic p450 system that metabolizes mifepristone (i.e., phenytoin, phenobarbital, carbamazepine,
and oxcarbazepine).
If a seizure occurs during abortion in an awake patient, appropriate measures include maintaining
patient safety (safe positioning with support) and interrupting the abortion procedure if possible
until the seizure resolves.
For post abortion contraception, consideration to the interaction of certain anticonvulsants wit
combined hormonal contraception.

Cardiac diseases-
The incidence of cardiac disease in pregnant women ranges from 0.1-4%
Induced abortions in these women require extra care as they are more prone to complications.
In addition, certain drugs used frequently during the procedure may have side-effec
detrimental to the cardiac status.
Intravenous infusion of oxytocin at higher doses may result in fluid retention and pulmonar
oedema due to its antidiuretic properties.
Methylergometrine and prostaglandin F-2a have potent vasoconstrictive action and may lead
to sudden severe hypertension.
Joint care by the cardiologist, anaesthetist and gynaecologist in an institutional setting is
likely to ameliorate the risk associated with induced abortion in these women.
In women on anticoagulation due to a prosthetic valve, there is increased risk of haemorrhage
during abortion.
Discontinuing anticoagulants may lead to life threatening events like atrial fibrillation and
thromboembolism. Mifepristone and misoprostol are not used commonly for elective abortion
in women with cardiac disorders

Asthma
Women with a history of asthma without current symptoms may undergo usual care.
Women with current well-controlled asthma should be encouraged to use usual medications and to
bring an inhaler with them for their abortion visit.
Prophylactic use of an inhaler with nebulized albuterol or metaproterenol before the procedure
may be prudent.
(PGF 2?) is not recommended, as it may cause broncho constriction.
Misoprostol is not contraindicated.
Mifepristone medication abortion should be avoided in poorly controlled asthmatics & who are on
systemic glucocorticoid therapy.
 Hospital settings recommended for women with recent emergency room visits for asthma or
intubation.
Management may include premedication with steroids
Liaison with pulmonary specialists.
Local or regional anaesthesia may be preferable if severe, uncontrolled asthma is present.
Post abortion contraception for asthmatic patients is unrestricted.
Thyroid disease -
Uncontrolled hyperthyroidism results in thyroid storm so treatment should begin promptly and the
abortion should proceed after the disease is stabilized by medication.
For advanced gestational ages, hospital care may be needed to manage a thyroid storm while
performing an abortion expeditiously.
Consultation with an anaesthesiologist is advisable if the patient is to receive deep sedation or
general anaesthesia.
Post abortion contraception for patients with thyroid disease is generally unrestricted.

VonWillebrand disease (VWD)

When replacement therapy is indicated for haemorrhage prophylaxis, surgical abortion is preferred
because the onset and peak of bleeding is more predictable than during medication abortion.
Moderate or severe disease women are best served by team of an obstetrician, haematologist and
anaesthesiologist experienced in managing coagulation disorders.
NSAIDs and oxytocin should be avoided with these patients.

Anticoagulation & its Effect on management Induced abortions-

Women with a high risk of thrombosis maintained on warfarin may be transitioned to heparin, 2
which can be held for surgery, and then warfarin may be restarted.
This approach is time consuming and complex.
Medication abortion is not recommended for women who are anticoagulated.
For patients on antiplatelet therapies such as aspirin and clopidogrel, the risk of bleeding must be
carefully weighed against the risk of coronary artery ischemic events.
Low-dose aspirin therapy does not increase the severity of bleeding complications or perioperative
mortality.
Patients on combination antiplatelet therapy (clopidogrel and aspirin) face an increased risk of
systemic bleeding.
In general, the optimal period for discontinuation of antiplatelet therapy prior to any surgery is five
days.
Joint consultation with a cardiologist or neurologist is recommended .

Conclusions-
Effective post abortion care for women with such medical problems will reduce pregnancy-associated
morbidity and mortality. Hospital-based abortion is recommended for women with medical conditions.

References
1.Davey A. Mifepristone and prostaglandin for termination of pregnancy: contraindications for use,
reasons and rationale. Contraception Jul 2006;74(1):16-20.
2.Davis A, Easterling T. Medical evaluation and management. In: Paul M, Lichtenberg ES, Borgatta
L, Grimes DA, Stubblefield P, &Creinin MD, editors. Management of unintended and abnormal
pregnancy: Comprehensive
abortion care. Wiley-Blackwell, ed. Oxford: Blackwell Publishing Ltd; 2009, pp. 78-89.
 20 MTP IN DIFFICULT CASES-
(c)
Nulliparous Woman Dr. Girish Mane

Medical termination of pregnancy in nulliparous is Physical examination:

not unusual in regular clinical practice now a days. Usually the physical examination is same like the
Almost 15 to 27 % MTPs are from to this category. regular cases of MTP. Look for age, height, weight,
Broadly the patients belongs to two groups. First systemic examination, abdominal examination and
group includes the nulliparous patients undergoing pelvic examination in through. Many medical
MTP unwillingly. Second group is opposite to disorders can be ruled out by proper physical
them. The indications for the first group are missed examination like Anaemia, Asthma, Hypertension
abortions, blighted ovum, incomplete abortions, and many more.
congenital anomalies and multi-fetal pregnancy in Abdominal and Pelvic examination are important
rare case. There is remarkable rise in the incidences to confirm the age of gestation, to rule out ectopic
and diagnosis of these conditions in early weeks if pregnancy, and to know the condition of cervix and
compared with uterus.
decades ago.
Girls below the age of 18 years can be the Investigations:
patients in this category, so the clinicians should Blood investigations like blood group with Rh
be aware of POCSO act 2012 thouroghly. factor, complete blood count, Urine albumin and
Causes of increased bad outcome of pregnancies: sugar, Urine microscopy, blood sugar level, HIV,
1) Increased age of marriage VDRL, HBsAg are must and if required we should
2) Rise in the cases of PCOS and other medical go for liver function tests, renal function tests and
disorders like GDM, HDP cardiac assessment.
3) Sedentary life styles
4) Increased environmental pollution. Role of USG :
5) Increased level of physical and mental stress. USG is not compulsory by law but it is always
6) Increased exposure to various communicable useful for a clinician. One can diagnose the missed
infections. abortion or blighted ovum, ectopic pregnancy,
7) Increased use of ART Hydatidiform mole, multi-fetal pregnancy or
8) Early diagnosis of such conditions before accidental finding of vaginal, cervical or uterine
spontaneous expulsion. anomaly. Also in some patients it becomes difficult
to get the proper judgment of gestational age by
Causes of willing nulliparous MTP: physical examination because of uncooperative
1) Early unplanned conceptions behavior or obesity. In such cases USG helps to
2) Educational purpose assess the correct gestational age to decide the
3) Job or economic reasons method of termination. Whenever possible TVS
4) Unmarried pregnancies should be preferred over TAS.
5) Pregnancies out of rape
Methods: There are various methods depending Sometimes it can lead tocontinuous hemorrhage
upon the age of gestation. also. The long term side effects can be re urrent
First trimester : urinary tract infections, cervical stenosis,
Medical method : Mifepristone & Misoprostol ( Incompetency of cervix in next pregnancy. If the
most preferredupto 9 weeks) cervical injury is markedly gravious, then the
Methotrexate & Misoprostol situation may land up in secondary infertility
Tamoxifene& Misoprostol
Surgical Methods : In slow method the cervix is ripened at least 6-8
Vacuum aspiration hours prior the procedure of suction evacuation.
suction evacuation & or curettage Cervical ripening can be done physically by
dilation& evacuation hygroscopic material like Laminaria tent placed
Second Trimester : intra cervical or the medicines like
Prostaglandins- Misoprostole, Carboprost, Misoprostole placed vaginally or rectally. This
Dinoprost method has very less side effect. Sensitivity to the
Intracervical Foley's balooninflatation. medicine or hygroscopic material used is the only
Intrauterine instillation of hypertonic solutions risk factor. So unless contraindicated, the slow
Oxytocin infusion method of cervical dilatation should be preferred
Hysterotomy for the MTP in nulliparous patients to prevent the
complications.
Complications: Proper cervical ripening or
dilatation is the key to success in nulliparous cases. Take home message:
The cervix of nullipara, previously pregnant and MTP is an integral part of clinical practice of most
previously vaginally delivered patient reacts of the Obstetricians. Though this procedure is
differently to the drugs and the procedure. The comparatively easy to perform than most of the
cervix is made up of the circular and criss-cross other procedures in this subject, it has medico legal
smooth muscle fibres, which works efficiently in aspect. And the MTP in nulliparous patient has
nullipara patient and try to retain the cervical relatively more immediate & long term
closure till the end of pregnancy. This is the reason complications. If the procedure is not meticulous
why cervical as well as uterine injuries are more in can be hazardous to the future fertility of that lady.
the MTP of nulliparous patient than the So the preparation of cervix should be given more
multiparous. emphasis while performing MTP in every nullipara
whatever is the indication. And the slow cervical
Methods of cervical dilatation :Rapid & Slow. ripening should be preferred.

In rapid method, the cervix is gradually dilated

under local cervical block or anaesthesia( General
or Spinal) with the help of metal dilators starting
from lowest possible. Maximum dilation is
achieved up to 10 or 12 number, according to the
gestational age and procedure to be carried out.
There are chances of some complications in rapid
dilatation. The immediate complications are injury
to the cervix, perforation of posterior wall of
cervix, perforation of uterus, Injury to the urinary
bladder and rarely injury to the bowel.
 21 Medicolegal Issues in Medical
Termination of Pregnancy Dr Manish Y Machave

People who are crazy enough to think they can change the world,are the ones who do-Rob Siltanen

The Law Relating to Abortion- Legal Abortions-

The Indian Penal Code, 1860(IPC), declares that Abortions are termed legal only when all the
causing a woman to abort is a crime and is following conditions are met: TERMINATION
punishable underS312-S316, with imprisonment BY/FOR…
from 2-7 yrsand fine. A protective Umbrella is A medical practitioner approved by the Act
hence provided by The MTP Act, 1971, if adhered A place approved under the Act
to completely and offers complete protection to the Conditions and within the gestation under the
medical practitioner from any of the consequences Act
of the IPC.However legal protection is only Other requirements of the rules & regulations
available conditional to every requirement of the are complied with
Act being fulfilled.
Medicolegal Issues/grey areas and their
Legal framework of The MTP Act, 1971- solutions-
ACT/RULES/REGULATIONS- 1)Opinion formed in good faith -
MTP Act - This lays down when & where
pregnancies can be terminated. It also Grants the Section 3(2)- Pregnancies may be terminated by
central govt. power to make rules and the state govt. registered medical practitioners where the length of
power to frame regulations pregnancy <12 weeks and where the length of
pregnancy-13-20 weeks and opinionis given by
MTP Rules(Framed by Central Government). two registered medical practitioners.
These lay down who can terminate the pregnancy,
training requirements, approval process for place, Where to take this opinion? FORM I-
etc. Name/degrees/address/signature on the MTP
REGISTER and OPD/ IPD PAPER- Wherever
MTP Regulations(Framed by State Government). opinion is formed.
These lay down forms for opinion, maintenance of
records,custody of forms and reporting of cases Solution - The number of registered medical
practitioners is relevant only to form the opinion-
Contravention of act or rules attracts 2-7 yrs SIGNATURE. Once the opinion has been formed,
imprisonment and fine and this offence is the actual termination of pregnancy may be done by
cognizable-arrest can occur without warrant and one registered medical practitioner. It is not
nonbailable- bail is not granted as a necessary that more than one registered medical
right.Contravention of regulations attracts Rs practitioner should act together to terminate a
1000/- fine ( EXCEPT CONSENT) pregnancy.
2)MTP on demand- 4)MTP for fetal indication-
There is no question of MTP on demand even by the
patient herself. MTP had to fit into one of the That there is a substantial risk that if the child
indications given in the act. were born, it would suffer from such physical or
What about article 21 of constitution mental abnormalities as to be seriously
providing the patient with right over her own handicapped.
body????? The MTP Act does not confer or ¡How to diagnose lethal fetal anamolies??Fetal
recognize any right on any person to perform an anmolies are broadly of two types structural and
abortion or termination of pregnancy. Even the genetic but more often both coexist.
pregnant woman cannot terminate the pregnancy
Solution - A list of fetal lethal anmolies is
except under the circumstances mentioned in the
released by State family welfare Dept, Maharashtra
Act.
in jan 2020..In order to diagnose fetal genetic
abnormalities SERUM MARKERS and NTSCAN
Solution- Even during the 'first trimester', the
are not suffecient as these are screening tests. One
woman cannot abort at her will and pleasure, There
needs to confirm the chromosomal defect by doing
is no question of "abortion on demand". Sec.3 [18]
confirmatory tests like Amniocentesis ,Chorion
is only an enabling provision to save the RMP from
villous sampling etc. Social and economic
the purview of the IPC. The termination of
conditons of parents do not help for using the fetal
pregnancy under the provision of the Act, is not the
indication if the anmolies are non lethal.QUALITY
rule and it is only an exception( V Krishnan Vs G
OF LIFE-malformed child does play a major role
alias MadipuRajan and ors)
for deciding about MTP and
"Always USE THE INDICATIONS IN THE ACT
and KNOW THEM CAREFULLY. 5) Failure of contraceptive method as an
indication
3)MTP for maternal indication-
If pregnancy occurs as a result of failure of any
"RMP-Of opinion, formed in good faith, that,- the device or method used …for the purpose of limiting
continuance of the pregnancy would involve risk to the number of children, the anguish caused by such
the life of the pregnant woman or of grave injury to unwanted pregnancy may be presumed to
her physical or mental health ; constitute grave injury to mental health.
What is this Risk to the life or grave
injury??What constitutes such grave physical or Whom is this indication available for-
mental injury is not given in the act and hence is a Available only for married.This discrepancy needs
matter of speculation and debate.There are no to be corrected .Fast changing Social Culture &
CONDITIONS given in the act that serve as Scientific developments have not been thought of.
guidelines for decidingrisk to the life of the
pregnant woman or of grave injury to her physical Solution-Indication for unmarried patient"In
or mental health order to prevent grave injury to the physical or
mental health of pregnant woman".
Solution- one should hence take a proper
history, do a thorough examination, advice 6) Calculation of gestational age-
appropriate investigations and most importantly
Age of viability of fetus is different in different
document all this before forming an opinion to use
countries and in India is taken as 28 weeks but
this indication.
upper limit of MTP remains 20 weeks.
 Aldo Medical methods in the form of drugs for 8) Abortion pills- Mifepristone + Misoprostol
abortion can be given upto 7 weeks.
The GOI allows the use of medical agents to
How to calculate GA ??? CALCULATION… terminate a pregnancy up to 7 weeks gestation (49
LMP? CLINICAL EXAMINATION?USG?The days from LMP). DCI- allows upto9 weeks The
act is silent. What if there is discrepancy in LMP MTP Act, 1971, allows MTP using Mifepristrone
and USG dating????? (RU 486) & Misoprostol approved for up to 7
weeks termination
Solution - Use LMP and clinical examination What is the procedure for procurement of
for patient with regular periods.USG is not pills and who can prescribe???Records?? Only
mandatory before all MTPs but should be done for an RMP (as defined by the MTP Act) can prescribe
obese patient/ovarian cyst / uterine fibroid,PV the drugs. One has to follow MTP Act, Rules &
bleeding-undiagnosed, previous H/O or suspected Regulations
Ectopic pregnancy,pelvic mass, conceived in RMP can prescribe in his/her clinic, provided
lactationalamenorrhoea,conceived after post OCP he/she has access to an approved place and should
Amenorrhoea, LMP GA and clinical examination display a certificate from owner of approved place
do not match, post MTP Pill on day 14 to confirm agreeing to provide access
completeness of abortion etc. The term "RMP" used in this Act have different
¡READ USG CAREFULLY-BPD/FL/AC/HC meanings at different placesSec. 2 (d) of act and
ETC and AS MUCH AS POSSIBLE-AVOID Rule.4a,b,c,dIndian medical council act 1956 Sec.
DISCREPANCY and if present -BELIEVE THE 2(h) In other words, a doctor, whose name has been
GA WHICH IS MORE.\ entered in a State Medical Register and who has
such experience or training in Gynaecology and
7)Consent and age related issues Obstetrics as prescribed in Rule.4(a, b, c, d).
emem
ADULT(>18yrs) - Self consent (Indian Solution -
Majority act 1885) and person of sound All that applies to surgical abortions applies
mind.UNSOUND MIND OR MINOR-Guardian"s paripassu to Medical abortions. Only RMPs with
consent is needed certificate from registered center can
Legally Husband's consent is not necessary. prescribe/dispense pills.Purchase drugs from an
How to acertain correct age and identity of authorized distributor and keep copy of purchase
the patient??Ask for Birth certificate ?School order .Maintain records of all drugs given to patient
Leaving Certificate ??X-Ray ???AADHAR including batch no in a separate register & date of
CARD/ Liscence???? purchase Maintain records for 5 years and this
includes misoprostol used for induction
Solution- Clarify age and identity from the &PPH.Payment to be made by cheque at the time of
patient. RMP is not a fact finding agency. And arrival of stocks.Purchase in small quantities.We
neither is such proof warranted by law. But for do not need a drug license to dispense drugs to our
abundant caution it is recommended to take patients, we cannot sell drugs to other patients and
Identity and age proof also AVOID UNRELATED ideally this is to be followed for all drugs
GUARDIAN. Husband's signature may be taken
9)Termination of Pregnancy with GA> 20 weeks
for abundant caution and becomes necessary if
Section 5 of The MTP Act, 1971 states that
anesthesia and surgical MTP IS planned.INFORM
Pregnancy exceeding 20 weeks may be terminated
POLICE IF FOUL PLAY IS SUSPECTED
even without the opinion of 2 registered medical
practitioners where:
a) the registered medical practitioner is of the All records maintained for 5yrs.
opinion, formed in good faith, b) that the Monthly report to be sent to CMO on 30th , 31st or
termination is immediately necessary to save the 1st of every month.
life of the pregnant woman. d)Confidentiality of information-
Name of the patient should only come in the MTP
What is the procedure and criteria for such register and at all other places only her MTP no.
?? State family welfare department , Maharashtra Certificate for leave , if demanded can mention
SFWD, Pune published on 18/1/2020 an SOP name of the patient and the onus to keep it
which enabled this to be done through a writ confidential is with her employer..
petition under Article 226 of Constitution of India, Regulations imposing the restriction on the
to High court. disclosure of the information contained in
admission register to any person except:to the
Solution- Medical boards areestablished in Chief Secretary to the Govt. in the case
states. A WRIT PETITION IN HC which refers the departmental or other enquiry,to a Magistrate of the
matter to these Medical Boards. This is for First Class within the local limits of whose
survivors of Rape/late diagnosed anamolies. jurisdiction the approved place is situated, in the
Medical boards then submit confidential report to case of an investigation into an offence and to the
HC which forms basis of decision by HC District Judge within the local limits of whose
jurisdiction the approved place is situated, in case
This SOP provides for METHODS of of suit or other action for damages.
termination, documentation, list of fetal Anamolies e) The MTP Amendment act 2020-not
in annexure-1 and all is completed within implemented as on today chief provisions-
MAXIMUM 10 WORKING DAYS ¡Raised limit of MTP from 20 weeks to 24 weeks.
¡Opinion of one registered medical practitioner
10) Rapid fire issues- (RMP) for termination of pregnancy up to 20 weeks
Following are not MTPs- of gestation.
Missed abortions
Blighted Ovum
Incomplete abortions Opinion of two RMPs for termination of
IUFD pregnancy of 20 to 24 weeks.
Vesicular moles ¡from 20 to 24 weeks for survivors of rape,
Ectopic Pregnancy victims of incest and other vulnerable women.
AND NO LIMIT IF THE MEDICAL BOARD
b) Police involvement- Information to nearest ACCEPTS ANAMOLIES
police station incharge is mandatory if age of For unmarried women, the Bill seeks to relax
patient is <18yrs (THE POCSO ACT 2012).Take the contraceptive-failure condition for "any
ac knowledgement from police. woman or her partner”
if Rape is alleged without court"s permission if
you terminate the pregnancy it might amount to Conclusions- The MTP Act if adhered to
destroying the evidence. completely offers complete protection to the
c)Records - medical practitioner from any of the consequences
Admission register Form III-(signature of 2 of the IPC.However this legal protection is only
RMPs if GA>12 WEEKS) available conditional to every requirement of the
C form Act being fulfilled.
Form I, II (signature of 2 RMPs if GA>12 WEEKS) We need to work towards getting such grey areas
MTP report to be submitted in form II & converted to clear white areasand till this is
Proformal achieved we should follow all that we discussed-
Keep C form/FormI/II in an sealed envelope TCA- Totally, Completely and Absolutely.
and lock- write secret document on it-custody with
Owner
 22 Surakshit Garbhpat-beti Bachao Ke Sath
(safe abortion with saving girl child)-
Prof. BHARTI MAHESHWARI

The Overlap Between Abortion and Sex National policy is to make abortion safe and widely
Selection- available as per the law: Abortion is legal for a
number of reasons but not for reasons of selecting
From a gender equality perspective, sex selection is the sex of the foetus. Even today, eight percent of
a reflection of discrimination against girls and maternal mortality is due to unsafe abortions.
subordination of women as a group. Not providing
women access to safe abortion services despite Safe abortion should not be jeopardised in
preventing sex selection: Estimates indicate that
legally valid reasons deepens this subordination. It
about nine percent of abortions are sex selective
is important to note that many women seek abortion
and therefore ninety percent are not.
services for reasons that are legally valid. However,
access to safe services is an area of big concern. It is Do not discourage service providers from
estimated that of the 64 lakh abortions performed in providing safe and legal abortion, through
India every year, 36 lakh (56%) are unsafe. In fact, measures such as tracking of abortionoutcomes or
about eight percent of maternal mortality in India reviewing data for second trimester abortions.
still occurs due to unsafe abortions. Abortion Quite obviously, half of the legal abortions will
complications are the third major cause of maternal involve female foetuses and this will be true
death, after haemorrhage and sepsis. regardless of the sex ratio of that area or the level of
compliance with the law
Hence it is important to address this issue,which is
beautifully done by National Health Mission-Govt Promote use of data related to sex ratio at birth and
emphasise it as a more accurate indicator of the
of india in Ensuring Access to safe Abortion and
extent of sex selection. When using child sex ratio,
Addressing Gender Biased Sex Selection.
be aware that this ratio also includes post birth
factors that might skew the ratio, such as
FOGSI MTP Committee disseminataed this
underreporting, infanticide, selective neglect and
informations among almost all FOGSI resultant female mortality. This underscores the
societies,leaders and members by launching need to also work on some of these post birth
project -surakshitgarbhpatbetibachaokesath-safe contributors to an imbalance in child sex ratio.
abortion services should not be jeopardized in
preventing sex selection; important points and Do not imply that all women who previously have
glimpses are shared in this chapter with hope access daughters are opting for an abortion for sex
to safe and legal abortion to all women and no selection. Several studies have shown that
mortality due to unsafe abortion education of the woman and unintended pregnancy
are variables more closely correlated with opting
for abortion as opposed to sex of the previous child.
Do not use population sex ratio (number of females
to 1,000 males in total population) to point to the
problem of sex selection

Make sure that 'all' abortion is not understood as

illegal.

Abortion for reasons of sex selection definitely

needs to be prevented, and its illegality should be
emphasized

Do not make use of terms such as 'female foeticide'

or kanyabhrunhatya: these terms stigmatise Glimpses of FOGSI MTP Committee: (2018-2020)
abortion and imply it is not to be provided,
endangering women who seek abortion for legal
reasons

Do not use images of foetuses being crushed,

stabbed and strangled, daggers going through the
stomach of a pregnant woman, blood being
splattered. Use images that express joy and
celebration linked to the birth of a girl child.

Do not use images of a female foetus speaking from

the womb: This tends to ascribe life to the foetus
and furthers the perception of 'life being murdered'.
This seriously jeopardises legal abortion.

}Do not use imagery that selectively emphasises on

the value of women only as brides (like many men
waiting to marry one woman): This further
reinforces their devaluation in perceiving them as
valuable only in their roles as brides. This takes the
attention away from value of daughters in the
family.

What is required is effective implementation of the

laws governing the two distinct practices of sex
selection and abortion. It is important to remember
the distinct intents with which these laws were put
in place - to ensure safe abortion (MTP Act) and to
prevent misuse of technology (PC&PNDT Act).
For hard copy of FOGSI FOCUS or MTP bulletin on -
counseling, Documentation, medical method,
MTP act amendment Please write to
Dr. bharti maheshwari-
bhartinalok123@gmail.com or
WhatsApp :9927856780