Medical Termination Of

Pregnancy

Dr Manjuprasad
Moderator: Dr Princy Palatty
 Overview

 Introduction
 MTP act
 Methods of MTP
 Conclusion
 Introduction

A medical abortion is brought about by taking

medications that will end a pregnancy, alternative is the
surgical abortion which ends a pregnancy by emptying
the uterus (womb) with special instruments

 .
 Hippocratic oath forbade physicians from
inducing elective abortions

 But, Aristotle held that abortion was ethical if

performed in the first trimester of pregnancy
 Before 1971:

- Abortion – purposely causing miscarriage

- 1860 IPC under British rule – induced
abortion is illegal
- Abortion practitioners would either be
incarcerated for 3yrs or fined or both
- Women could be imprisoned upto 7yrs & also
would be fined
- Only exception was abortion done to save
women life
 MTP 1971

 Conditions under which a pregnancy can be

terminated

 Who can perform such terminations

 The place where such terminations can be

performed
 Conditions where pregnancy can be
terminated:

- Medical

- Eugenic

- Humanitarian

- Socio economic

- Failure of contraceptives
 Qualification to perform abortion
 Assistance of atleast 25 cases of MTP in
approved institution

 6months of Housemanship in OB&G

 A PG qualification in OB&G
 3yrs of practice in OBG for those doctors
registered before 1971 MTP act was passed
 Place where MTP performed

 Place established and maintained by Govt.

 Non Govt institutions can perform provided
they obtain license from Chief Medical Officer
of the district.
 Consent
- Can only be terminated on a written informed
consent of the woman, husband consent not
required
- <18yr or lunatic – written consent of parent or
legal guardian.
 Termination is permitted upto 20wks of
pregnancy
 When pregnancy >12 week 2medical
practitioners opinion required
 The abortion has to be performed confidentially
and reported to Director of Health Services in
prescribed form
 Methods of termination
1st trimester
 Medical - Mifepristone

- Mifepristone & Misoprostol

- Methotrexate & Misoprostol
- Tamoxifene & misoprostol
 Surgical – Vacuum aspiration

- suction evacuation & or curettage

- Dialatation and evacuation

Rapid Slow
2nd trimester
 Prostaglandins – Misoprostol

- Carboprost
- Dinoprost
 Dilatation and evacuation – 13-14wks

 Intrauterine instillation of hypertonic solutions

 Oxytocin infusion

 Hysterectomy
 Classification of drugs used in
MTP

CARBOPROST MIFEPRISTONE
SULPROSTONE LILOPRISTONE METHOTREXATE
DINOPROSTONE ONAPRISTONE
GEMEPROST ULIPRISTAL
MISOPROSTOL
Mifepristone:

 Synthetic steroid

 antiprogesterone, antiglucocorticoid &

antiandrogen

 Partial agonist, competative antagonist in

presence of progesterone

 80-85% effective in causing abortion

 Blockage of the progesterone receptor results
in vascular damage, decidual necrosis and
bleeding
Mifepristone blocks progesterone receptors

Endometrial decidual degeneration

Trophoblast detachment

↓HCG from syncytiotrophoblast

Inturn ↓ progesterone by corpus luteum

 Pharmacological actions
 Decidual breakdown by blockade of uterine PR
 Detachment of the blastocyst which decreases hCG
production
 Decrease in progesterone secretion from the corpus
luteum
 increase uterine PG levels
 sensitizes the myometrium to their contractile actions.
 Cervical softening, which facilitates expulsion of the
detached blastocyst
 Pharmacokinetics
 Orally active with good bioavailability

 t1/2 of 20-40 hrs

 Bound by α 1-acid glycoprotein.

 Hepatic metabolism and enterohepatic

circulation

 Metabolic products are found predominantly in

the faeces
Contraindications:

 Ectopic prgnancy
 In presence of IUD
 Adrenal failure
 Hemorrhagic disorders
 Porphyria
 Patients on long term therapy with
corticosteroids
 Misoprostol (PGE1)
 Synthetic prostaglandin E1
 Inexpensive and can be stored at room
temperature

MOA
 Binds to myometrial cells causes myometrial
contraction and expulsion of tissues
 Also causes ripening of cervix
 PHARMACOKINETICS
 After oral administration, rapidly absorbed from the GI tract.

 t1/2 20-40 mins

 DOSE:400 μg oral misoprostol, the plasma misoprostol level

increases rapidly and peaks at about 30 minutes declines
rapidly by 120 minutes and remains low thereafter.

 ROUTES OF ADMINISTRATION : Oral, vaginal, sublingual,

buccal or rectal

 Mainly urinary excretion

 Protocol

200mg of mifepristone given orally on day1

On day 3 misoprostol 400mcg PO

Or 800mcg PV

Patient remains in hospital for 4hrs during which

expulsion occurs in 95% of cases
 Mifepristone 200mg oral

36-48hrs later 800microgram misoprostol

vaginal

Then misoprostol 400microgram oral every

3hrs (4doses)

 Success rate is 97%

 Gemeprost
 PGE1 analogue (16, 16-dimethyl-trans-d2- PGE1
methyl ester)

 Used as a vaginal pessary. Every 3-6hrs for 5 doses

in 24hrs

 Has got 90% success rates

 Used as a non-surgical method to dilate the cervix

before VA in late-first and early-second-trimester
abortion

SE : Vaginal bleeding, cramps, nausea, vomiting, diarrhea,

headache, muscle weakness , backache ,chest pain
 CARBOPROST
 Carboprost tromethamine PGF2α analogue

 First analogue to be tested clinically on a large scale

for the termination of second trimester pregnancy.

 MOA- It acts on the corpus luteum to cause

luteolysis, forming a corpus albicans and stopping the
production of progesterone
Dose: IM 100-200 µg

 Post partum haemorrhage

ADR: diarrhoea (most common)

 fever chills vomiting
 Cardiovascular collapse, Postural
hypotension
 DINOPROSTONE
 Synthetic derivative of PGE2

 ROUTE OF ADMINISTRATION : vaginal/ oral

 Intravaginal suppository 20mg 3-5 hrs repeated. (17hrs)

 Half life 2.5-5 mins. Excreted in urine

 Induction abortion in second trimester/ early abortion

 Cervical ripening-10mg tab / 0.5 mg gel 6 hrly

 SE- Prolonged vaginal bleeding, Severe menstrual cramps ,GI

toxicity.
 Methotrexate

 MTX is an antifolate belonging to the

antimetabolite class of antineoplastic agent.
 MTX is a cell cycle specific chemotherapeutic
agents that acts on S-phase &
 thus inhibit DNA synthesis
 Pharmacokinetics
Readily absorbed from the GI tract at doses of <25 mg/m2

 7-hydroxy-methotrexate NEPHROTOXIC

 t ½ 8 hrs IM

 50% of methotrexate binds to plasma proteins

 Up to 90% of a given dose is excreted unchanged in the

urine within 48 hours

 Retained in the form of polyglutamates for long periods

 Weeks in the kidneys and for several months in the liver

 Methotrexate/Misoprostol Regimens
 Methotrexate: 50 mg/m2 IM or 50 mg PO

 Misoprostol: 800 µg PV 3–7 days later

 Efficacy decreases after 49 days’ gestation

 Initial follow-up ~1 week after methotrexate

 Subsequent care based on results of

physical exam, ultrasonography

 If HCG has fallen by >80% over 7days,procedure was

successful
 Contraindications
 Anemia (Hgb < 10 g/dL)/ leucopenia/thrombocytoenia

 Known coagulopathy

 Active renal or liver disease

 Uncontrolled seizure disorder

 Acute inflammatory bowel disease

 Intrauterine device in situ

 High intial hcg concentration >5000mU/ml

 Ectopic pregnancy > 4cm in size as in TVS

 Regimens for medical abortion and
their effectiveness
Use
Regimens Effectiveness upto
Mifepristone + misoprostol >96% 9 weeks from last
or mifepristone + menstrual period
gemeprost

Misoprostol alone >83% 12 weeks from last

menstrual period

Methotrexate + misoprostol >90% 9 weeks from last

menstrual period
 Older methods

 Hystrecotomy (sectio parva)

 Intra-amniotic injection of hypertonic saline/hyperosmolar

urea

 Intra- or extra-amniotic administration of ethacryidine

lactate (Rivanol)

 Parenteral/intra-amniotic / extra-amniotic administration

of prostaglandin (PG) analogues

 I.V / i.m. administration of oxytocin

 ETHACRIDINE LACTATE
 Ethacridine lactate/Rivanol is a yellow dye with antiseptic
properties

 MOA: Stimulates endogenous PG and thromboxane

production, promoting cervical priming and initiating labour

 DOSE:0.1%-solution of ethacridine lactate - extra-amniotic

space through a sterile catheter at a dose of 10 mL per
gestational week

 20-40 hrs mini labour

 Maximum of 150 ml
 Hypertonic Saline
One of the first described instillation methods

 When used alone, intra-amniotic hypertonic saline

has a long latent period until the onset of
contractions

 Time to abortion of 30 hours

 Addition of oxytocin to this

regimen improves the efficacy

and expulsion time

Use of concentrations exceeding 20%.
 Maternal hypernatremia
SIDE
 Coagulopathy
EFFECTS
 Hemorrhage

 Cervical laceration
 IV OXYTOCIN
 First described by Winkler and associates
 100 units per 500 mL of DNS, is infused over 3
hours
 The dose is increased 50 units per 500 mL of
DNS until delivery is achieved
 Maximum of 300 units
 Mean time to delivery of 8.2 hours
 UREA
 Rapidly traverses cell membranes
 Has a long instillation to abortion interval when
used alone
 Intra-amniotic urea, 80 to 90 g, with intravenous
oxytocin
 Average time to expulsion of 19 to 29 hours
 Bibliography
 Goodmann and Gilman’s The pharmacological basis of therapeutics
12th edition
 Text Book of Obstetrics; D.C Dutta 4th edition
 Preventive and Social Medicine 21st Edition
 Udaykumar P. Medical Pharmacology. 4th ed. New Delhi: CBS Publishers;
2013.
 Sharma HL, Sharma KK. Principles of Pharmacology. 2nd ed. New Delhi:
Paras Medical Publishers; 2011.
 Uptodate.com
 Ashok PW, Templeton AA. Non-surgical mid-trimester termination of
pregnancy: a review of 500 consecutive cases. Br J Obstet Gynaecol
1999;106:706
 Stubblefield PG, Carr-Ellis S, Borgatta L.Methods for induced abortion.
Obstet Gynecol2004;104:174-85