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Friday, 17 February 2017

Medical Termination Of Pregnancy (MTP)

INTRODUCTION

To control the population explosion, the Government of India and other parts of the world  have legalised abortions. There are many methods available for the termination of pregnancy, which may or may not be accompanied by sterilization.

A family should be wanted and planned. It  cannot be an accident. The quality and upbringing of a child is important than the quantity. The family should be able to give the child the best of education. Before implementing any procedure or abortion, confirmation of pregnancy is very important. Depending upon the days or weeks of pregnancy method of termination is planned.



MENSTRUAL REGULATION (MR)

This is a very simple procedure done to terminate pregnancy  within 63 days. This is an outpatient procedure with minimal pain and blood loss. This can be done as soon as pregnancy is suspected. The complications are minimum such as incomplete abortion, pelvic infection and rarely continuation of pregnancy. In may many years of practice, I have not come across incomplete abortion nor continuation of pregnancy and have seen 2-3 cases of mild pelvic infection responding to drugs. This is the best way to terminate pregnancy. The apparatus used here is only a plastic cannula and a syringe. Succeeding menstrual periods are generally normal after the procedure.

Contraindications


The M.R. Syringe should not be used for pregnancy over 10 menstrual weeks of gestation. Nor should it be used as an office procedure for women with suspected large fibroids, pelvic inflammatory disease, or in those with a history of blood dyscrasias.

Follow-up-Care

The patient should be made aware of the following:

She may have an intermittent menstrual type flow during the next week, varying from spotting to regular flow. If bleeding is more severe than this, however, she should seek medical care.

Cramps are not usually a problem, but if they do occur, they will be comparable to menstrual cramps. Severe or persistent cramps should be reported.

Persistent low grade fever or severe discomfort should also be reported.

She need not limit her usual activities, sexual intercourse should be restricted till next menstrual flow.

Conception may occur unless adequate contraception is practiced.

If her next menstrual period dose not occur within 4-5 weeks after the procedure, she should seek medical care.

SUCTION EVACUATION

The apparatus used here is by far the best for pregnancies between 60-80 days. It is not advisable to terminate pregnancies beyond 90 days by vaginal route. In these cases, the blood loss will be more than in menstrual regulation and can be done under local (Pudendal block) or general anesthesia. The patient can be hospitalised for the procedure in the morning and go home the same evening.

INTA-AMNIOTIC SALINE

A hypertonic saline solution is injected into the pregnant uterus according to the number of weeks of pregnancies. Due to more advanced and safe techniques of termination being available this method is not practiced widely due to complications like coagulation failures, thromboembolism and Retained products of conception.

ETHACRIDINE LACTATE (EMCREDIL)

Emcredil is a derivative of acridine used for termination of pregnancy after 12 weeks of gestation. Even in high risk cases like severe pre-eclampsia, chronic nephritis and essential hypertension, pulmonary tuberculosis, missed abortion and intrauterine foetal death, Emcredil is the drug of choice. Emcredil has a wide margin of safety.

Mechanism of action

1. Mechanical stimulation of uterus and extensive detachment of membranes.

2. Reflex stimulation of pituitary gland for secretion of oxytocin.

3. Increased oxytocin sensitivity of the uterine musculature by its direct action.

4. Direct oxytocin effect on the uterus.

5. Release of prostaglandin from membranes. 

Administration: After clinical examination to determine the period of gestation and routine investigations, a sterile catheter (Preferably Foley's) is introduced through the cervix with necessary aseptic precautions. After inflating the bulb with sterile distilled water it is brought above the internal os by a gentle pull on the catheter.

Emcredil is drawn into a 50ml syringe after opening the 50ml bottle and is injected through the Foley's Catheter by 50 C.C. syringe in the dose of 10ml/week.

Infusion of Emcredil can also be supplemented by intravenous pitocin drip after 6 hours; dose depending upon the clinical response and uterine contractions.  

The patient aborts within 30 to 48 hours in most cases (upto 90% success rate) after instillation. In rare cases when placenta is not expelled manual or surgical removal may be necessary. 

Caution: The drug should be used with care if there is history of surgery on uterus or cervix.

PROSTAGLANDINS

They are used for pregnancies for more than 14 weeks. They are two types PGE2 used for dilation of the mouth of uterus and PGF2 in the injection from, which when given in calculated doses causes expulsion of the fetus. Prostaglandins are naturally secreted in the human body and they help in producing contractions of the uterus. The medicine has to be imported. Therefore they can be used only for selective cases. 

HYSTEROTOMY

When the pregnancy goes beyond 12 weeks i.e. 3 months and above, and the uterus is felt per abdomen, then the abdomen can be opened by a vertical or transverse incision, a small incision made over the uterus and the products of conception removed or suctioned out. The uterus is then closed and the abdomen is sutured. If required, the patient can have the sterilization done at the same time, thus avoiding opening of the abdomen for the second time. I do not advise hysterotomy since it may lead to a condition called endometriosis where a small nodule forms on the line of the incision and becomes painful during periods (Scar endometriosis). This will require operative procedure at a later date to provide relief.

All said and done prevention is better than cure. It is always better to plan a family than to go in for termination of pregnancy, unless it is case of missed abortion. Newly married couple should plan for a year or two to understand each other and to stabilize financially. After one child it is always better to space for three years with the help of your obstetrician for healthy upbringing of the first child.

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