Medical Termination of Pregnancy MTP😊

Indications

  • < 20 weeks → all indications
  • > 20 - 24 weeks → except social
  • > 24 weeks → Eugenic and therapeutic
    • Eugenic: Fetal abnormalities.
    • Therapeautic: Maternal disease.
    • Social: Failure of contraception.
    • Humanitarian: Rape/Incest.
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Qualifications to do MTP

  • For doing MTP till 12 weeks:
    • RMP who has assisted in 25 MTPs
    • (At least 5 should be as primary surgeon).
  • For doing MTP between 12-20 weeks:
      1. RMP with 6 months of house job in Obs gynae
      1. or RMP with 1 year of experience in any hospital with all facilities.
      1. Diploma/Degree/DNB in Obs and gynae.
  • RMP: Registered medical practitioner.

MTP Amendment 2022

  • MTP can be done till: 
    • 24 weeks.
  • In case of contraceptive failure: 
    • MTP done till 20 weeks only.
  • In severe congenital anomalies of fetus: 
    • No upper limit 
    • If medical board permits
  • Medical board: 
    • Gynaecologist, Radiologist & Paediatrician and
    • such other number of members as may be notified in the official gazette by the state gov or the union teritary as the case may be

Consent for MTP

  • Female’s consent is needed for MTP.
  • Min age >18 yrs.
  • <18 yrs/Mentally ill: Consent of guardian.
  • No need for spouse consent.
  • Age proof: Not needed.
  • Marriage certificate: Not needed.
  • FIR report of rape: Not needed.
  • All records of MTP should be maintained for 5 years.
    • To be forwarded monthly to district CMO.
    • Strictly confidential: Violation punishable.

Criminal abortion/Unlawful abortion/Voluntary miscarriage

  • 88 [P]: With consent of female.
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  • 89 [P]: Without consent of female.
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  • 90 [P]: With/without consent, resulted in death of female.
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Methods to do MTP

Medical abortion
  • T1 → Miss WIFE (Misoprostol, Mifepristone)
  • T2 → Miss SEX (Saline, Ethacridine, Oxytocin)

T1: Mnemonic: MSM

  • Mnemonic: MTP (medical) cheythillel Manual (MVA) Suction evacuation ()
  • Do not dilate in 1st trimester, always do suction with negative pressure
  • Medical abortion (OPD basis).
  • Suction evacuation.
  • Manual vacuum aspiration (MVA).
  • Menstrual regulation (Outdated).
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Medical Abortion:

  • Mnemonic: Miss Wife → Misoprostol; Mifepristone
  • Period of gestation: <9 weeks.
  • Best method of MTP.
  • Approved till 9 weeks (Indian Government/WHO).
  • Day 1: Mifepristone (RU486) 200 mg single dose orally.
  • Day 3: Misoprost 800 mcg orally/Sublingually/per-vaginally
  • Abortion (Bleeding) within 24 hours.

Suction Evacuation:

  • Mnemonic: Karma sucks
  • Period of gestation: 9-12 weeks.
  • Done using: 
    • Karman cannula + suction machine.
    • Also used for menstrual regulation (also known as menstrual aspiration or menstrual extraction)
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  • Number of Karman cannula corresponds to size of uterus
  • (Corresponding to gestational age or 1 less).
  • Pressure generated: 600 mm Hg.
  • In areas where electricity not available: MVA is done.

Manual Vacuum Aspiration:

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  • Done using MVA syringe (2 pinch valves).
  • Capacity of syringe: 60 mL.
  • Pressure generated: 660 > 600 mm Hg.
  • No Need for electricity

Menstrual regulation syringe (One pinch valve or now no valve):

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  • 50mL syringe.
  • Previously a T1 MTP: Not preferred
  • (Done only till 6 weeks of pregnancy).
  • Menstrual regulation
    • Aspiration of endometrial cavity
    • Within 14 days of missed period
    • Contraindications
      • Advanced pregnancy
      • Local pelvic inflammation
    • Not commonly done now

T2: Mnemonic: MSDH.

  • Medical abortion (IP admission):
    • Using Misoprost
      • Best method
      • 400 Ug 3 hourly
      • Max 4 - 5 doses
    • extra-amniotic ethacridine,
    • intraamniotic saline or oxytocin.
    • Mnemonic: SEX (Saline; ethacridine; oxytocin) with Miss (Misoprostol)
  • Suction evacuation.
  • Dilatation & evacuation 
    • Ovum forceps
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  • Hysterotomy.
  • Mnemonic: 2nd Trimester → MTP (Medical) cheythillel DSH → (dilatation; suction; hysterotomy)

Uterine perforation during suction evacuation

Due to Hegars dilators:

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  • Stop procedure
  • Monitor vitals
 

Due to Karman cannula:

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  • Stop procedure.
  • Do not take cannula out.
  • Immediate laparotomy.

Sims Uterine Sound

  • Not used in recanalization of fallopian tube.

Uses of Simpson’s Uterine Sound

Uterine sound → measure uterus length
Uterine sound → measure uterus length
  • Measuring Uterine Depth
  • Diagnosing Cervical Stenosis
  • Differentiating Chronic Inversion vs Fibroid Polyp
  • Assessing Uterine Tilt
    • Useful in retroverted or retroflexed uterus.
  • Dilation and Curettage (D&C)
  • IUD Placement