medical termination of pregnancy

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Medical Termination Medical Termination of Pregnancy of Pregnancy

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

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Page 1: Medical Termination  of Pregnancy

Medical Termination Medical Termination of Pregnancyof Pregnancy

Page 2: Medical Termination  of Pregnancy

Prof. Ashis Kumar MukhopadhyayProf. Ashis Kumar MukhopadhyayProfessor, G & OProfessor, G & O

Medical Superintendent-cum-Vice PrincipalMedical Superintendent-cum-Vice Principal

CSS College of Obstetrics & Gynaecology, KolkataCSS College of Obstetrics & Gynaecology, Kolkata

National Chairperson, National Chairperson,

Medical Education Committee of FOGSIMedical Education Committee of FOGSI

Page 3: Medical Termination  of Pregnancy

PerspectivePerspective 26 million pregnancies are terminated annually legally.26 million pregnancies are terminated annually legally.

20 million terminated illegally.20 million terminated illegally.

Unsafe (Illegal) abortions may far exceed safe abortions, Unsafe (Illegal) abortions may far exceed safe abortions, the ratio being 1:6 to 1:11.the ratio being 1:6 to 1:11.

78000 annual deaths. In India: 11.8% of MMR (GOI, 1990).78000 annual deaths. In India: 11.8% of MMR (GOI, 1990).

Abortion care centres are few & far between, accessibility Abortion care centres are few & far between, accessibility is poor, training inadequate and do not meet MTP Act is poor, training inadequate and do not meet MTP Act requirements.requirements.

Paramedics and quacks are involved more often than not. Paramedics and quacks are involved more often than not.

Page 4: Medical Termination  of Pregnancy

Methods of AbortionMethods of AbortionA. Surgical: A. Surgical:

S/E is safer & less painful than D/E . Success rate: S/E is safer & less painful than D/E . Success rate: 98-99%.98-99%.

Disadvantages of Surgical abortion:-Disadvantages of Surgical abortion:-

Requires highly skilled personnel, because:-Requires highly skilled personnel, because:-

Blind technique.Blind technique.

Pregnant uterus is very soft & prone to injuryPregnant uterus is very soft & prone to injury

Problems of under-curetting, andProblems of under-curetting, and

Overzealous curettageOverzealous curettage Asherman’s. Asherman’s.

Page 5: Medical Termination  of Pregnancy

Methods of AbortionMethods of Abortion SurgicalSurgical….contd….contd..

Requirement of Anaesthesia: GA or localRequirement of Anaesthesia: GA or local

Higher chance ofHigher chance of septic abortion.septic abortion.

Mostly following illegal induced abortion Mostly following illegal induced abortion (>90%). 6.5% from legal surgical abortion.(>90%). 6.5% from legal surgical abortion.

Very high mortality: 6-13%Very high mortality: 6-13%

Serious morbidity including fecal fistula.Serious morbidity including fecal fistula.

Page 6: Medical Termination  of Pregnancy

Methods of AbortionMethods of Abortion Medical:-Medical:- also called “Chemical abortion”.also called “Chemical abortion”.

Advantages:-Advantages:-

Possible at earlier stage of pregnancy.Possible at earlier stage of pregnancy.

Private procedure.Private procedure.

No trauma to the utrus cevix and other organs.No trauma to the utrus cevix and other organs.

Post-abortal endometritis very rare.Post-abortal endometritis very rare.

No anaesthetic hazards.No anaesthetic hazards.

Page 7: Medical Termination  of Pregnancy

Methods of AbortionMethods of Abortion Medical abortionMedical abortion….contd.….contd.

Disadvantages:-Disadvantages:- Lengthy procedureLengthy procedure UncertainUncertain Unpredictable (timing).Unpredictable (timing). Failure rate: 2-10%.Failure rate: 2-10%. Psychological effect.Psychological effect. Difficulty in diagnosing ectopic pregnancy.Difficulty in diagnosing ectopic pregnancy. Side-effects of drugs.Side-effects of drugs.

Page 8: Medical Termination  of Pregnancy

Development of medical methods of Development of medical methods of induced abortion with mifepristoneinduced abortion with mifepristone

1984 Mifepristone alone 1985 Mifepristone and Pg 1987 Mifepristone and vaginal Pg 1991 Mifepristone and oral Pg 1993 Reduced doses of mifepristone 1995 Mifepristone and misoprostol 2000 Medical methods at all gestations

Page 9: Medical Termination  of Pregnancy
Page 10: Medical Termination  of Pregnancy

Randomised comparison of medical and Randomised comparison of medical and surgical abortion at 10-13 weeks gestationsurgical abortion at 10-13 weeks gestation

(Total of 486 women)(Total of 486 women) Medical Surgical

Complete abortion 95% 98%

Pelvic infection (8 weeks) 4% 8%

Psychological morbidity (8 weeks) 6% 5%

Pain and bleeding (8 weeks) 3% 4%

- Ashok et al, 2001

Page 11: Medical Termination  of Pregnancy

Mechanism of Medical AbortionMechanism of Medical Abortion 3 ways to do it:-3 ways to do it:-

Antagonising or negating the action of Progesterone.Antagonising or negating the action of Progesterone.

Inhibiting development of trophoblast.Inhibiting development of trophoblast.

Inducing myometrial contraction.Inducing myometrial contraction.

Agents used for the purpose are:Agents used for the purpose are:

Mifepristone as anti-progesterone (RU-486).Mifepristone as anti-progesterone (RU-486).

Methotrexate as cytotoxic drug for growing embryoMethotrexate as cytotoxic drug for growing embryo

Misoprostol, which stimulates uterine contraction.Misoprostol, which stimulates uterine contraction.

Page 12: Medical Termination  of Pregnancy

The CombinationsThe Combinations Methotrexate + Misoprostol: 90-95% SRMethotrexate + Misoprostol: 90-95% SR

Mifepristone + Misoprostol: 95-99% SR.Mifepristone + Misoprostol: 95-99% SR.

Most useful within 49 days of Most useful within 49 days of pregnancy, although approved in pregnancy, although approved in England for use upto 63 England for use upto 63 days (9 weeks).days (9 weeks).

Pre-requisites:-Pre-requisites:-

Bimanual pelvic examinationBimanual pelvic examination

Baseline hematocritBaseline hematocrit

ABO/Rh.ABO/Rh.

Page 13: Medical Termination  of Pregnancy

MifepristoneMifepristone M/A: Antagonises progesterone at target tissue.M/A: Antagonises progesterone at target tissue. ChemistryChemistry

The 11-beta substitution is responsible for anti-The 11-beta substitution is responsible for anti-progestogenic activity.progestogenic activity.

Page 14: Medical Termination  of Pregnancy

MisoprostolMisoprostol Synthetic PG E1 analogue. (other agent is gemeprost)Synthetic PG E1 analogue. (other agent is gemeprost)

Inexpensive, can be stored at room temp.Inexpensive, can be stored at room temp.

Used in many countries for treatment & prevention of peptic ulcer caused Used in many countries for treatment & prevention of peptic ulcer caused by NSAIDs.by NSAIDs.

85% protein-bound.85% protein-bound.

Half-life of 30 mins.Half-life of 30 mins.

Also used for midtrimester abortion, cervical ripening, induction of Also used for midtrimester abortion, cervical ripening, induction of labour, t/t of PPH.labour, t/t of PPH.

Available as oral tab which can be used vaginally.Available as oral tab which can be used vaginally.

Page 15: Medical Termination  of Pregnancy

Mifepristone + MisoprostolMifepristone + Misoprostol The preferred combinationThe preferred combination..

Mifepristone alone gives low success rate.Mifepristone alone gives low success rate. Misoprostol is a weak abortifacient, success Misoprostol is a weak abortifacient, success

rate varying from 66% to 83%.rate varying from 66% to 83%. But with the combination:-But with the combination:-

Complete abortion rate at 49 days is 83-87%Complete abortion rate at 49 days is 83-87% At 56 days it is 87-90%At 56 days it is 87-90% At 63 days it is 92-95%.At 63 days it is 92-95%.

Page 16: Medical Termination  of Pregnancy

Studies on Studies on Mifepristone + Misoprostol or GemeprostMifepristone + Misoprostol or Gemeprost

Page 17: Medical Termination  of Pregnancy

Studies on Studies on Mifepristone + Misoprostol or GemeprostMifepristone + Misoprostol or Gemeprost

Page 18: Medical Termination  of Pregnancy

Studies on Studies on Mifepristone + Misoprostol or GemeprostMifepristone + Misoprostol or Gemeprost

Page 19: Medical Termination  of Pregnancy

Dosage and AdministrationDosage and Administration

3 clinic visits by the patient:-3 clinic visits by the patient:-

Day 1: Day 1: Single doseSingle dose Mifepristone 600 mg orally (now-Mifepristone 600 mg orally (now-a-days 200 mg.)a-days 200 mg.)

Day 3: Day 3: If abortion has not occurred a single oral If abortion has not occurred a single oral dose of misoprostol 400 mcg (2 tabs). 2-5% pts. dose of misoprostol 400 mcg (2 tabs). 2-5% pts. abort by now following mifepristone alone. abort by now following mifepristone alone. Followed up in clinic for 4 hours & then discharged.Followed up in clinic for 4 hours & then discharged.

Day 14: Day 14: follow-up. follow-up. Clinical and/or ultrasound to Clinical and/or ultrasound to assess for completed abortion.assess for completed abortion.