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Medical Termination of Pregnancy

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.

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Medical Termination of Pregnancy

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  1. Medical Termination of Pregnancy

  2. 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

  3. Perspective • 26 million pregnancies are terminated annually legally. • 20 million terminated illegally. • Unsafe (Illegal) abortions may far exceed safe abortions, the ratio being 1:6 to 1:11. • 78000 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. • Paramedics and quacks are involved more often than not.

  4. Methods of Abortion A. Surgical: • S/E is safer & less painful than D/E . Success rate: 98-99%. • Disadvantages of Surgical abortion:- Requires highly skilled personnel, because:- • Blind technique. • Pregnant uterus is very soft & prone to injury • Problems of under-curetting, and • Overzealous curettage Asherman’s.

  5. Methods of Abortion • Surgical….contd. • Requirement of Anaesthesia: GA or local • Higher chance ofseptic abortion. • Mostly following illegal induced abortion (>90%). 6.5% from legal surgical abortion. • Very high mortality: 6-13% • Serious morbidity including fecal fistula.

  6. Methods of Abortion • Medical:-also called “Chemical abortion”. Advantages:- • Possible at earlier stage of pregnancy. • Private procedure. • No trauma to the utrus cevix and other organs. • Post-abortal endometritis very rare. • No anaesthetic hazards.

  7. Methods of Abortion • Medical abortion….contd. Disadvantages:- • Lengthy procedure • Uncertain • Unpredictable (timing). • Failure rate: 2-10%. • Psychological effect. • Difficulty in diagnosing ectopic pregnancy. • Side-effects of drugs.

  8. Development of medical methods of induced abortion with mifepristone

  9. Randomised comparison of medical and surgical abortion at 10-13 weeks gestation(Total of 486 women)

  10. Mechanism of Medical Abortion 3 ways to do it:- • Antagonising or negating the action of Progesterone. • Inhibiting development of trophoblast. • Inducing myometrial contraction. Agents used for the purpose are: • Mifepristone as anti-progesterone (RU-486). • Methotrexate as cytotoxic drug for growing embryo • Misoprostol, which stimulates uterine contraction.

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

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

  13. Misoprostol • Synthetic PG E1 analogue. (other agent is gemeprost) • Inexpensive, can be stored at room temp. • Used in many countries for treatment & prevention of peptic ulcer caused by NSAIDs. • 85% protein-bound. • Half-life of 30 mins. • Also used for midtrimester abortion, cervical ripening, induction of labour, t/t of PPH. • Available as oral tab which can be used vaginally.

  14. Mifepristone + Misoprostol The preferred combination. • Mifepristone alone gives low success rate. • Misoprostol is a weak abortifacient, success rate varying from 66% to 83%. • But with the combination:- • Complete abortion rate at 49 days is 83-87% • At 56 days it is 87-90% • At 63 days it is 92-95%.

  15. Studies on Mifepristone + Misoprostol or Gemeprost

  16. Studies on Mifepristone + Misoprostol or Gemeprost

  17. Studies on Mifepristone + Misoprostol or Gemeprost

  18. Dosage and Administration 3 clinic visits by the patient:- • Day 1: Single doseMifepristone 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 14: follow-up. Clinical and/or ultrasound to assess for completed abortion.

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