21.MTP and abortion

Medical Terminology and Definitions

• Abortion: Premature expulsion of a fetus, considered medically before viability (28 weeks).

• Abortus: Non-viable product of abortion.

• Abortifacient: Any agent that induces abortion.

• Criminal Abortion: Illegal induction of abortion.

Legal Aspects of Abortion in India

• IPC Sections on Abortion:

  • Sec 312, BNS 88: Imprisonment for causing miscarriage with consent (up to 3 years), increases to 7 years for a 'quick' child.

  • Sec 313, BNS 89: Causing miscarriage without woman's consent, up to 10 years to life.

  • Sec 314, BNS 90: Death caused by miscarriage actions results in 10 years imprisonment or life with fine.

  • Sec 315, BNS 91: Actions leading to stillbirth, outside good faith saving of life, may result in 10 years imprisonment.

  • Sec 316, BNS 92: Culpable homicide related to causing death of an unborn child may lead to 10 years imprisonment.

Medical Termination of Pregnancy Act, 1971 (UQ)

• Passed to legalize and reduce unsafe abortions.

• Allows termination for medical, eugenic, humanitarian, and social grounds (Amendments in 2002).

Indications for Termination of Pregnancy:

1. Medical Grounds:

   • Risk to the life or grave injury to health of the woman.

   • Congenital illnesses like heart disease.

   • Cancers (breast, cervix).

   • Severe pregnancy conditions, such as uncontrollable hemorrhage, acute psychosis, schizophrenia

   • Toxemia

   • Severe depression

2. Eugenic Grounds:

   • Substantial risk of serious handicaps if the child is born.

   • Hydatidiform mole

   • Ectopic pregnancy

   • Maternal rubella, chicken pox and viral hepatitis

   • Chromosomal anomalies

   • Down’s syndrome

   • Exposure to teratogenic drugs, radiation

3. Humanitarian Grounds: Pregnancies resulting from rape or severe mental distress.

4. Social Grounds:

   • Unwanted pregnancies in women using contraception methods.

   • Pregnancy from failed contraceptives may substantially impact mental health.

Consent Requirements

• Below 18 years or mentally ill: Guardian consent is required.

• Above 18 years: Woman's consent is necessary.

• Married women do not need husband's consent.

Qualifications for Performing MTP

• Must be performed by a registered medical practitioner:

  1. Holding an MD/DGO.

  2. Experienced with evidence of participation in 25 termination cases.

  3. Six months house surgery experience in Obstetrics & Gynecology.

  4. One year or more practice in OBG.

• 3 and 4 can only do MTP up to 12 weeks

Emergency Situations

• In emergencies to save life, any registered practitioner can perform MTP.

  • Protections are in place under the Act if done in good faith.

Amendment 2021 Highlights

• Pregnancy less than 20 weeks may be terminated by one practitioner.

• For 20-24 weeks, consultation with two practitioners is necessary if significant fetal abnormalities are not diagnosed.

• Provisions about the length of pregnancy does not apply in case of substantial foetal abnormalities.

Medical Board

• Gynaecologist

• Pediatrician

• radiologist/sonologist

• Other members notified by the State Government

Privacy and Confidentiality

• Practitioners must maintain strict confidentiality about patient identities; violations may result in imprisonment.

Approved Termination Facilities

• Terminations can occur in: a. Government hospitals. b. Approved private facilities.

Methods of Medical Termination of Pregnancy (MTP)

1st Trimester (up to 12 weeks):

• Medical:

  • Prostaglandins PGE1(misoprostole), PGE2, PGE2a

  • Antiprogesterone-Mifepristone, tomoxifen, methotrexate

  • Mifepristone followed by prostaglandins - most effective medical method.

• Surgical:

  • Manual vacuum aspiration

  • Dilatation and Curettage.

2nd Trimester (12-20 weeks):

• Dilatation and evacuation (13-14 weeks)

• Intrauterine installation of hyperosmotic solutions.

  • Intra-amniotic- hypertonic saline, urea

  • Extra-amniotic- Ethacrydine lactate

  • Prostaglandins (PGE, PGE, PGE)

  • Oxytocin infusion

Criminal Abortion (UQ)

• Criminal abortion includes the unlawful termination of pregnancy using various methods, including abortifacients, general violence, or local violence.

1. Abortifacient drugs

   • Ecbolics:

     • increase uterine contractions and expulsion of products of conception

     • E.g. Ergot, quinine

   • Emmenagogues:

     • produce or increase menstrual flow.

     • E.g. estrogen, savin, borax, sanguinarine

   • Irritants of genito-urinary tract :Turpentine, cantharides, potassium permanganate

   • Irritants of Gastrointestinal Tract

     • They irritate the colon, produce hyperemia of the uterus and induce abortion

     • E.g. Castor oil, colocynth, croton oil, senna, saline cathartics, phenolphthalein etc.

   • Drugs having poisonous effect

     • Heavy metals like lead, mercury, iron, antimony etc.

     • Organic irritants like papaya, calotropis, unripe pineapple, bark of plumbago rosea etc.

2. General violence: violent exercise, cycling, jumping, jolting etc.

3. Local violence:

   • Cupping

   • Hugginson’s syringe

   • Rupture of membrane

   • Abortion stick:

     • Stick with cotton cloth dipped in juices of marking nut, calotropis

     • Causes irritation and uterine contraction

     • Complications:

       • Inflammation and sloughing

       • Sepsis: Cl. welchi, E. coli, Streptococci

   • Syringe aspiration

   • Dilation and curettage

   • Utus paste

Common Complications of Criminal Abortion: (UQ)

1. Immediate:

   • Vasovagal shock

   • Perforation of vaginal wall and hemorrhage

   • Laceration of cervix and hemorrhage

   • Perforation of uterus and bowel

   • Hemorrhage from placenta

   • Air/Fat embolism: Introduction of soap and water may cause fat and air embolism

   • Amniotic fluid embolism: due to entry of amniotic fluid into the circulation

2. Delayed:

   • Cervical necrosis.

   • Infected laceration of cervix

   • Septic metritis

   • Salpingitis

   • Oophoritis

   • Peritonitis

   • Septicemia

   • Pneumonia

   • Tetanus

3. Late complications:

   • Pulmonary embolism and thrombophlebitis

   • Renal failure

   • Hepatic failure and jaundice

Amniotic Fluid Embolism (AFE)

• A condition where amniotic fluid enters maternal blood circulation leading to severe complications, including high mortality rates shortly after onset.

• Causes

  • 1. Inducing abortion by rupture of membranes.

  • 2. Amniocentesis.

  • 3. Caesarean sections.

  • 4. In normal deliveries, at time of rupture of membranes.

  • 5. Uterine rupture, placenta previa, abruptio placenta

• Materials in the amniotic fluid produce severe pulmonary vasospasm, pulmonary, hypertension, right ventricular failure and hypoxia.

• May cause disseminated intravascular coagulation, ARDS.

• Treatment: No specific treatment. Cardiovascular and respiratory resuscitation and correction of coagulopathy

Postmortem Findings in AFE

• Potential indications include petechial hemorrhages among vital organs.

• Histopathology: fetal cells and lanugo in lung

• Lendrum’s stain: detects AFE

Duties of Medical Practitioners in Criminal Abortion Cases

1. Record patient's history and allegations.

2. Maintain confidentiality.

3. Consult professional colleague.

4. Treat the patient competently and inform authorities as required.

5. Arrange for dying declaration

6. Should not issue death certificate

Postmortem examination

• GIT examined for evidence of irritant drugs

• Urinary tract - signs of infection

• Vagina: injury, inflammation

• Presence of air in large veins

• Evidences of perforation

• Viscera, blood, tissue sample preserved

Natural (Spontaneous) Abortion

• Occurs in 10-15% of pregnancies, often in the first trimester.

• Causes Include:

  • Fetal abnormalities.

  • Maternal constitutional diseases.

  • Anomalies of uterus

  • Local disease of genital organs

  • Trauma and sudden stress.

Fabricated Abortion Claims

• Women may falsely allege abortion due to assault or other reasons; DNA analysis can help confirm or deny such claims.