Making abortion safe

MAKING ABORTION SAFE

Dr Sujoy DasguptaMBBS (Gold Medalist, Hons)

MS (OBGY- Gold Medalist)

DNB (OBGY)

MRCOG (London)

FIAOG

Consultant, Bavishi Pratiksha Fertility Institute, Kolkata

Visiting Consultant, RSV Hospital, Kolkata

Secretary, Website and Bulletin Committee, Bengal Obstetric

and Gynaecological Society (BOGS)- 2017-18

Managing Committee Member, BOGS- 2017-18

• Do not perform abortion at all !!!!!

Why Safety is so important in Abortion

• It’s NOT Criminal Abortion

MTP ACT IN INDIA• Therapeutic Abortion Act by IPC 1860

• Code of Criminal Procedure 1898

• MTP Act 1971 – implemented on 01.4.1972- When and Where

• Revised in 1975

• Amended in 2002 ( MTP Amendment Act, 2002)

• MTP Rules ( amended in 2003)- Who can perform, approval of place- made by the

Central Government and passed by the parliament; notified in the official gazette

• MTP Regulations , 2003 ( applicable to all Union Territories)- Opinion, Consent,

Documentation, Record keeping- made by the state government and passed by the state

legislature

Are you a Doctor or a Lawyer?

• Over 100 million acts of Sexual Intercourse per day

• Result in over 900,000 pregnancies

50% are unplanned

25% are actually unwanted

• 150,000 pregnancies are terminated by induced abortions per day i.e. > 50 million per year worldwide

• WHO– at least 1/3rd are unsafe abortions

• 78000 women die/ year from complications of unsafe abortion

• Accounts for 13% of maternal mortality worldwide

• In India, 70 – 90 women /100,000 live birth die from unsafe abortions

GLOBAL SCENARIO OF ABORTION

• International Institute for

Population Sciences (IIPS),

Mumbai

• Population Council, New Delhi

• Guttmacher Institute, New York

2015 Data• Total 48.1 million

pregnancies

• About half were unintended

• 15.6 million abortions

Per 1,000 woman aged 15-49

• Unintended pregnancy rate =70

• Abortion rate = 47

CONCERN !!!

• Currently, slightly fewer than 1 in 4

abortions are provided in health facilities.

HOW CAN WE ENSURE SAFETY

Patient

Place

Doctor

Patient Safety

Why Abortion?1. Continuation of pregnancy is a risk to the life of the

pregnant woman or can cause grave injury to her

physical or mental health (Therapeutic)

2. Substantial risk that the child, if born, would be

seriously handicapped due to physical or mental

abnormalities (Eugenic)

3. The pregnancy was caused by rape (Humanitarian)

4. Pregnancy was caused due to failure of contraception in

a married couple (Social)

Sex selection is NOT an indication for pregnancy termination

under the law

When Abortion?

• Up to 20+0 weeks of pregnancy

Up to 12 weeks, opinion of one RMP is required

From 12+1 to 20+0 weeks

• Opinion of 2 RMPs

When?

• ONLY in places specially approved for 2nd

trimester MTP

How Abortion?

Surgical Abortion

• Failure (Requiring further

procedure) 2:100

• Uterine Perforation 1-4:1000

Increases with gestation

Reduced if done by Experience

clinician

• Cervical Trauma <1:100

More in Early Abortion

Reduced if done by Experience

clinician

• Severe Bleeding (Requiring

Transfusion) 1-4 :1000

• Infection 1:100

Medical Abortion

• Failure (Requiring further

procedure) 6:100

• Uterine Rupture 1:1000

More if previous CS

• Severe Bleeding (Requiring

Transfusion) 1-4 :1000

• Infection 1:100

How Abortion?

Surgical Abortion

Up to 12-14 weeks

• Vacuum aspiration is the

recommended technique

– Replace D&C

– No need to use sharp

curettage routinely

– MVA preferable

Beyond 12-14 weeks

• D&E is the recommended

surgical technique

– Cervical preparation

recommended

– Ultrasound can be

helpful, but not

necessary

Medical Abortion

• Recommended-mifepristone followed by misoprostol

– Misoprostol alone recommended where

mifepristone is unavailable

– Misoprostol 1st dose- preferably at clinic

• NSAID can be safely prescribed as pain-relief

• Ondansetron/ Metoclopramide as antiemetic

• Urine Pregnancy test after 3 weeks-

Gestation

(Weeks)

Misoprostol (After36-48 hours)

in µg

<7 Mifepristone

(200 mg) Oral

800 Vaginal/ Oral/ SL/ buccal

7-9 800 Repeat 400 after

4 hours if no

bleeding

9-13 800 Vaginal 400 Vaginal/ Oral

3 hourly

Max- 3 such

≥13 As 9-13

weeks

Mife (200) 3

hours after last

dose of Miso

Repeat Miso

regime 12 hours

after Mife

Your Safety

• Can you perform

abortion

• Do you know the law

• Record Keeping

• Can you handle the

complications

• Have you done

proper counseling

Can You Perform Abortion?

• A practitioner who

1. holds a post–graduate degree or diploma in O & G

2. has completed 6 months as House Surgeon in O & G

3. has at least 1 year experience in the practice of O & G at

any hospital that has all facilities

4. has assisted a RMP in 25 cases of MTP of which at least 5

have been performed independently in a hospital

established or maintained by the government or a training

institute approved for this purpose. Such a practitioner can

perform ONLY 1st trimester pregnancy termination

Know the Law

a) Form C: Consent Form

b) Form I (Opinion Form): RMP shall certify this form within

3 hours from the MTP

c) Form II: Head of the hospital or owner of the place shall

send a monthly statement of cases to the CMO of the district

in this form

d) Form III (Admission Register): An approved site shall

maintain case records in Form III. This register is kept for a

period of 5 years from the date of last entry

Consent for Procedure

• Woman more than 18 years, only the consent of the woman

Unmarried?

Spouse Consent?

• If minor (<18 years) or a mentally ill person, consent of a

guardian

• Guardian = caretaker , responsible for the woman

• Age Proof?

Managing Complications

• Infection- Antibiotics, Repeat evacuation (selective cases)

• Bleeding- Oxytocics, Uterine Message, Transfusion, Laparotomy,

Hysterectomy

• Retained Product- based on clinical features

Routine ultrasound follow up NOT necessary

Repeat evacuation not decided on ultrasound findings

• GTN- 1:600- 1:2699

Routine H/P exam is NOT necessary

Managing Uterine Perforation

Shakir F, Diab Y. The perforated uterus. The Obstetrician & Gynaecologist 2013;15:256–61.

If anything goes wrong

• Maintain proper documentation

• Communicate

• Debrief

• Multidisciplinary Team Involvement

• Legal Advice

• The provider will get the protective cover of this

legislation only when he or she fulfills the medico-

legal requirements completely.

Counseling Before Abortion• Ensure eligibility

• Choose between abortion methods

• Possible outcomes

• Warning signs

• Complications- short term, long term

• Management of complications

• Offer tests- Hb%, Blood Group, Serology, STI Screening

• Future contraception

Safety Of The Place

• Approval

• Documentation

MTP Site Approval

Public Sites

• Hospital established or maintained by the Government

do not need separate

approval, provided they

have the required

infrastructure

Private Sites

• Approved by the Government or

a District Level Committee (DLC)

constituted by the Government

for the purpose

All private sites need approval

(Form B) before starting abortion

services

Private MTP Site Approval Process

Apply in Form A to the C.M.O. of the District

Site inspection

Not satisfiedSatisfied

Approved Deficiency

reported,

rectified

Site re-inspected

Certificate issued

in Form B

Infrastructure Requirement

1st Trimester Site

• Gynaecology examination/labour table

• Resuscitation and sterilization equipment

– Drugs and parenteral fluids for emergency use, notified by Government of India from time to time

• Back-up facilities for treatment of shock

• Facilities for transportation

2nd Trimester Site

• An operation table

• Instruments for performing

abdominal or gynecological

surgery

• Anaesthetic equipment

• Resuscitation and sterilization

equipment

• Back-up facilities for treatment

of shock

• Facilities for transportation

Medical Methods of Abortion (MMA)

• Only an RMP, as under the MTP Act, can prescribe MMA drugs

• Site eligibility: from an OPD clinic with established linkage to

an approved site

• A certificate to this effect by the owner of the approved site

has to be displayed at the OPD clinic

• Give Emergency Contact Number

• Up to 7 weeks

Up to 9 weeks- GOI Comprehensive Abortion care Guidelines

All the records of pregnancy termination have to be maintained

for MMA also (Consent Form, RMP Opinion Form, Admission

Register and Monthly Reporting Form)

Who Can Check Your Records

• Chief Secretary of the

Govt

• A Magistrate of the 1st

Class

• A District Judge

Some Case Scenarios

Case 1Consultant Gynaecologist was practicing at his own nursing

home that was registered for M.T.P.

Performed MTP of a patient at 10 weeks of pregnancy

2 hrs after patient died

P.M. report came as perforation of uterus involving uterine

vessels.

There was only OPD Paper

Indoor paper was BLANK

* Dean appointed a committee for this case.

* Committee gave a non committal opinion.

* Police referred the case to Government prosecutor.

* The prosecutor gave opinion that as per M.T.P. Act no procedure was followed , it was not an “M.T.P.” but a CRIMINAL ABORTION

Consultant was arrested. Got the bail after 3 months.

Case 225 Yr. married pt. was admitted by a consultant in a recognized

M.T.P. centre for termination of 18 wks pregnancy

Pt. was referred to him by a G.P. having qualification as

B.H.M.S.

Consultant took signature of G.P. with B.H.M.S. qualification

as second “ R. M. P.’’

Perforated the uterus, intestine. Pt. bled to death.

Husband complained. Police took charge of body & sent for P.M.

Police took possession of all case papers & consent forms.

M.O.H. lodged a police complaint.

Case was registered as “Criminal abortion”

Case 3• A recently passed post graduate in a Govt. PHC did a 2nd

trimester MTP.

• Patient bled to death before transfer

• The doctor was arrested & jailed

• 2nd Trimester MTP is NOT allowed at PHC

Case 4• Unmarried patient came for MMA

• Consultant Gynaecologist filled up all forms

• No ultrasound was done

• After 1 week, patient was brought to the emergency

• Diagnosed as ruptured ectopic pregnancy and died before any measures taken

• Ultrasound examination is NOT mandatory

before MMA, except in selected cases

Question 5

• Antibiotic Prophylaxis?

Both Medical and Surgical Abortion

1. Azithromycin 1 g + Metronidazole 800 mg

oral (At the time of Abortion)

2. Doxycycline 100 mg BD x 7 days (from the

day of Abortion) + Metronidazole 800 mg

oralRCOG Evidence-based Clinical Guideline Number 7, 2011. The Care of Women

Requesting Induced Abortion

Question 7

• Should Mife/Miso kits be available OTC?

Question 8

• Should AYUSH doctors be allowed to do

MTP?

Summary• In India, it is legal to terminate pregnancy up to 20 weeks, under

special circumstances.

• Only the consent of woman (more than 18 years) is required for

MTP

• For private sites: MTP site approval is done by District Level

Committee

• There are different experience / training and site requirements

for 1st and 2nd trimester MTPs

• Documentation of the MTP procedure includes filling up the

following forms: C (Consent Form); I (Opinion Form); II

(Monthly Reporting Form); III (Admission Register)

Acknowledgement

Acknowledgement

Dr Shyamal Sett

• Vice President , BOGS,

2017-18

• Chairperson, MTP

Committee of FOGSI,

2015 –2017