Abortion,

Abortion is the termination of pregnancy by any method (spontaneous or induced) before the fetus is viable (less than 20 weeks of pregnancy) to survive independently. Out of almost 35 million abortions, which take place annually in the world, more than half of them are illegal and performed by untrained, unskilled personnel under highly unhygienic conditions.

• What is abortion?
• Abortion in the first three months of pregnancy
• Abortion in the second three months of pregnancy:
• What is the Indian MTP Act?
• Who are the person(s) qualified to do MTP?
• What are the approved places where MTP can be performed?
• Why is counselling done?
• What are the complications from legal abortion?
• What are the signs of a Post - Abortion Complication?
• How to prevent complications?

What is abortion?

 Abortion is the termination of pregnancy by any method (spontaneous or induced) before the fetus is viable (less than 20 weeks of pregnancy) to survive independently.

Induced abortion:

Out of almost 35 million abortions, which take place annually in the world, more than half of them are illegal and performed by untrained, unskilled personnel under highly unhygienic conditions.

Abortion in the first three months of pregnancy

 By Cervical dilatation followed by evacuation of uterus or

Menstrual aspiration (MR)

•  Surgical methods in the first three months
•  Medical methods

The main drugs used today are a group of drugs known as prostaglandin, which can be used orally or through injection intramuscularly / intravenously, or vaginally. These drugs are used by themselves or in combination with other drugs.

1. The methotrexate – misoprostol method: A woman receives an injection of methotrexate. Between five to seven days later she returns and inserts suppositories of misoprostol into her vagina.

2. The mifepristone – misoprostol method: Mifepristone also known, as RU-486 is an antiprogesterone. A woman swallows a dose of mifepristone. She returns in five to seven days and inserts suppositories of misoprostol into her vagina.

Risks:

•  Mifepristone, Methotrexate and misoprostol cause nausea and diarrhoea.
•  Incomplete abortion may require surgical evacuation.
•  Heavy bleeding may continue up to 7 days.

Abortion in the second three months of pregnancy:
 Methods of second trimester abortion (13 – 20 week)

What are Medical methods?

•  Ethacridine lactate.
•  Prostaglandin

What are the Surgical methods?

•  Aspirotomy
•  Hysterotomy
•  Hysterectomy

Medical methods:

1. Ethacradine lactate: This drug is introduced through a sterile catheter through the vagina into the uterine cavity and placed behind the pregnancy sac. This procedure is not painful. A maximum of 150 ml is installed. It takes between 48 to 72 hours to abort. The procedure is safe, cheap and easily available. To hasten the abortion, ethacridine can be used along with prostaglandin or oxytocin (a naturally available drug to increase uterine contractions).

2. Prostaglandin: PG-E2: A gel of prostaglandin is inserted into the cervix at the clinic and the patient is asked to lie down for about half an hour and then allowed to go home. Early the following morning in the hospital a drip of oxytocin is started intravenously. Abortion is usually achieved in less than 24 hours and the abortion is complete

3. Misoprostol: It is available in tablet form and given orally or can be inserted vaginally. Two tablets of Mifepristone are given 24 hours later by an oral or vaginal dose of misoprostol. The uterus contracts causing cramping followed by the expulsion of the fetus. The cramps and the bleeding stops after the products have been expelled

4. Others: Drugs like urea, hypertonic saline, glucose, which are introduced into the pregnant sac have all been done away with in favour of the above mentioned methods.

Risks:

•  One needs to be at a hospital up to 3 days
•  Infection
•  Increased bleeding
•  Retained products, which may need surgical evacuation.

Surgical methods:

Anaesthesia: General anaesthesia can be given depending on the pain threshold/apprehension of the patient.

Procedure:

•  Aspirotomy.
•  Hysterotomy.
•  Hysterectomy.

Aspirotomy:

Aspirotomy is a procedure similar to what is done in the first trimester. This method can be employed between 13-20 weeks of pregnancy. Prostaglandins might be used to help in dilatation of the cervix.

Hysterotomy:

Hysterotomy is a major operating procedure where the abdomen is opened. In hysterotomy, the uterus is opened and the contents of the uterus are removed directly under vision. This is like a caesarean.

Hysterectomy:

In hysterectomy, the uterus along with the pregnancy is removed in toto. At times hysterotomy or hysterectomy may be necessary because of a failure of a medical induction during the second trimester.

In the second trimester of pregnancy, medical methods are followed rather than surgical methods. This is because the risks and the convenience of the medical methods are far less than surgical termination.

An early diagnosis of pregnancy with early termination is safer in the second trimester.

What is the Indian MTP Act?

 To avoid the misuse of induced abortions, laws have been enacted all over the world so that only qualified gynaecologists can perform MTP for definite indications at clinics or hospitals that are approved. The Medical Termination of Pregnancy Act was enacted in 1971 and was again revised in 1975.

It lays down the conditions under which a pregnancy can be terminated and the people and places authorised to do so.

1. Indications for an MTP, under the act, are:
2. When pregnant woman has a serious disease and continuation of pregnancy could endanger her life:

•  Heart disease
•  Severe hypertension
•  Uncontrolled vomiting during pregnancy
•  cancer of the cervix or breast
•  Diabetes mellitus with eye complication (retinopathy)
•  Epilepsy
•  Psychiatric disorder

3. Where the continuation of pregnancy could lead to substantial risk to the newborn causing serious physical or mental handicap:

•  Chromosomal abnormalities.
•  Rubella (German measles) infection in the mother during first three months
•  Congenital abnormalities in earlier births
•  Rh iso-immunisation
•  Exposure of the foetus to irradiation.
•  Pregnancy resulting from rape.
•  Conditions where the socio-economic status of the mother (family) hampers the progress of a healthy  pregnancy and the birth of a healthy child.
•  Failure of a contraception, irrespective of the method used (natural or barrier or hormonal)

Consent:

Married: her own written consent; husband’s consent not necessary

Unmarried and over 18 years: her own written consent

Below 18 years or mentally unstable: written consent of guardian

Consent signifies and assures the clinician performing the procedure that the woman:

•  has chosen abortion of her own free will
•  has been informed about all her options
•  has been counseled regarding the procedure (risks involved and care to be taken following it)

Who are the person(s) qualified to do MTP?

•  Any qualified registered medical practitioner who has assisted in 25 MTPs
•   A house surgeon who has done six months posting in Obstetrics and Gynaecology
•   A person who has a diploma/degree in Obstetrics and Gynaecology
•   Three years of practice in Obstetrics and Gynaecology for those doctors registered before the 1971 MTP Act was passed.
•   One year of practice in Obstetrics and Gynaecology for those doctors registered on or after the date of commencement of the Act.
•   Whenever the pregnancy exceeds 12 weeks but is less than 20 weeks, opinion of two registered medical practitioners is mandatory

What are the approved places where MTP can be performed?

 Any institution licensed by the Government to perform MTP. The certificate issued by the Government has to be prominently displayed at a site readily visible to persons visiting the place.

Why is counselling done?

 Counselling is normally done by the attending doctor with the aim of helping her come to a decision as to the need of continuation or termination of the pregnancy and to resolve it in the direction that she chooses.

The purpose of counselling is to:

•  Relieve the anxiety of the patient who intends to undergo abortion.
•  Provide information about the methods, safety and risks.
•  Screen for guilt, or any psychiatric ailment.
•  Help the patient understand and cope with her feelings.
•  Help her to prevent future unplanned pregnancy.

Serious complications arising from abortions before 13 weeks are quite unusual. About 89% of the women who obtain abortions are less than 13 weeks pregnant. Of these women, 97% report no complications; 2.5% have minor complications that can be handled in the OPD or abortion facility; and less than 0.5% require some additional surgical procedure and/or hospitalisation. Complication rates are higher for abortions performed between 13 and 24 weeks. General anaesthesia, which is sometimes used in abortion, carries its own risks.

In addition to the duration of the pregnancy, significant factors that affect the possibility of complications include:

•  Technical expertise of the provider;
•  Anaesthetic risk;
•  General health of the woman
•  Method employed

What are the complications from legal abortion?

 Possible complications from a surgical abortion procedure include:

•  Blood clots accumulating in the uterus, requiring another suctioning procedure, which occurs in less than 1% of cases;
•  Infections, most of which are easily identified and treated if the woman carefully observes instructions, which occur in less than 3% of cases;
•  Tear in the cervix, which may be repaired with stitches, which occurs in less than 1% of cases;
•  Perforation in of the wall of the uterus and/or other organs, which might heal on its own or require surgical repair or, rarely, hysterectomy, which occurs in less than 1/2 of 1% of cases;
•  Missed abortion, which does not end the pregnancy and requires the abortion to be repeated, which occurs less than 1/2 of 1% of cases;
•  Incomplete abortion, in which the tissue from the pregnancy remains in the uterus, and requires the abortion to be repeated, which occurs in less than 1% of cases;
•  Excessive bleeding caused by failure of the uterus to contract, which might require blood transfusion that occurs in less than 1% of cases.

What are the signs of a Post - Abortion Complication?

 If a woman has any of the following symptoms after an abortion, she should contact the facility that provided the abortion immediately:

•  Severe pain;
•  Chills or fever with a temperature of 100.4 0F or more;
•  Bleeding that is heavier than the heaviest day of her normal menstrual period or that soaks through more than one sanitary pad in an hour;
•  Foul-smelling discharge from her vagina
•  Continuing symptoms of pregnancy.

How to prevent complications?

 Women can certain things to lower their risks of complications. The most important thing is not to delay the abortion procedure. After six weeks from LMP, the earlier the abortion, the safer it is.

It's important to ask. Just as with any medical procedure, the more relaxed a person is and the more she understands what to expect, the better and safer her experience will be.

In addition, any woman choosing abortion should:

* Find a good clinic or a qualified, licensed practitioner
* Inform the practitioner of any health problems, current medications or; allergies to medications or anaesthetics;
* Follow post-operative instructions;
* Return for a follow-up examination.