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 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, the ratio being 1:6 to 1:11. Unsafe (Illegal) abortions may far exceed safe abortions, the ratio being 1:6 to 1: annual deaths. In India: 11.8% of MMR (GOI, 1990) annual deaths. In India: 11.8% of MMR (GOI, 1990). Abortion care centres are few & far between, accessibility is poor, training inadequate and do not meet MTP Act requirements. Abortion care centres are few & far between, accessibility is poor, training inadequate and do not meet MTP Act requirements. Paramedics and quacks are involved more often than not. Paramedics and quacks are involved more often than not.

Methods of Abortion A. Surgical: S/E is safer & less painful than D/E. Success rate: 98-99%. S/E is safer & less painful than D/E. Success rate: 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 injury Pregnant uterus is very soft & prone to injury Problems of under-curetting, and Problems of under-curetting, and Overzealous curettage Ashermans. Overzealous curettage Ashermans.

Methods of Abortion Surgical….contd. Surgical….contd. Requirement of Anaesthesia: GA or local Requirement of Anaesthesia: GA or local Higher chance of septic abortion. Higher chance of septic abortion. Mostly following illegal induced abortion (>90%). 6.5% from legal surgical abortion. Mostly following illegal induced 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.

Methods of Abortion Medical:- also called Chemical abortion. Medical:- also called Chemical abortion.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.

Methods of Abortion Medical abortion….contd. Medical abortion….contd. Disadvantages:- Disadvantages:- Lengthy procedure Lengthy procedure Uncertain Uncertain 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.

Development of medical methods of induced abortion with mifepristone

Randomised comparison of medical and surgical abortion at weeks gestation (Total of 486 women)

Mechanism 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 embryo Methotrexate as cytotoxic drug for growing embryo Misoprostol, which stimulates uterine contraction. Misoprostol, which stimulates uterine contraction.

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

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

Misoprostol 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 by NSAIDs. Used in many countries for treatment & prevention of peptic ulcer caused 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 labour, t/t of PPH. Also used for midtrimester abortion, cervical ripening, induction of labour, t/t of PPH. Available as oral tab which can be used vaginally. Available as oral tab which can be used vaginally.

Mifepristone + Misoprostol The preferred combination. The preferred combination. Mifepristone alone gives low success rate. Mifepristone alone gives low success rate. Misoprostol is a weak abortifacient, success rate varying from 66% to 83%. Misoprostol is a weak abortifacient, success 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%.

Studies on Mifepristone + Misoprostol or Gemeprost

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