Termination of pregnancy, either spontaneously or intentionally

Pregnancy termination prior to 20 weeks’ gestation or less than 500-g birthweight [who &national centre for health statistics&centre for disease control and prevention]

Definition vary according to state laws for reporting abortions, fetal deaths, and neonatal deaths

Word abortion derives from latin word aborii – to miscarry

DEFINITION-

ABORTION -1-SPONTANEOUS/MISCARRIAGE

2-INDUCED SPONTANEOUS MAY BE 1- SPORADIC 2-RECURRENT BOTH MAY BE 1-THREATENED 2-INEVITABLE 3-COMPLETE 4-INCOMPLETE 5-MISSED 6-SEPTIC 2-INDUCED ABORTION MAY BE LEGAL/MTP&ILLEGAL OR

UNSAFE

CLASSFICATION OR VARIETIES

Before 8 wks –the ovum surrounded by villi with the decidual covering is expelled out intact,sometimes entire mass is accomodated in cervical canal ,ext os fails to dilate k/as cervical miscarriage.

b/w 8-14wks-expulsion of fetus occurs leaving behind the placenta and membranes.a part of it may be partially separated with brisk hege or remains totally attached to uterine wall.

Beyond 14 wks- process is similar to that of a minilabour –expelsion of fetus-f/by expelsion of placenta and membranes.

Mechanism of abortion

Abortion occurring without medical or mechanical means to empty the uterus is referred to as spontaneous

Another widely used term is miscarriage

Pathology Hemorrhage into the decidua basinalis, followed by necrosis of

tissues adjacent to the bleeding If early, the ovum detaches, stimulating uterine contractions

that result in its Expulsion Gestational sac is opened , fluid surrounding a small macerated

fetus or alternatively no fetus is visible → blighted ovum-is also called as silent miscarriage –it’s a sonographic diagnosis,there is absenceof fetal pole in a gestational sac with a diameter of 3cm or more ,uterus is to be evacuated if diagnosis is made.

Pathology

In later abortion, the retained fetus may undergo maceration The skull bones collapse, the abdomen distends with blood- stained fluid, and the internal organs degenerate The skin softens and peels off in utero or at the slightest tough When amnionic fluid is absorbed, the fetus may become

compressed and desiccated → fetal compressus

The fetus become so dry and compressed that it resembles parchment - a fetus papyraceous

1-genetic A-autosomal trisomy-is the commonest(50%) most

common trisomy is trisomy 16(30%) B-polyploidy C-monosomy Structural chromosome rearrangement 2-endocrine and metabolic factors(10-15%) Luteal phase defect ,thyroid disorders,DM Anatomical-1-cong malformation of uterus(3-38%) 2-cervical incompetence 3-fibroid and uterine synechia

etiology

Etiology

Spontaneous abortion

Etiology

The exact mechanism responsible for abortion are not apparent

In the first 3 months of pregnancy Death of the embryo or fetus nearly always precedes

spontaneous expulsion of the ovum Finding of the cause of early abortion involves ascertaining the cause of fetal death

In subsequent months The fetus frequently does not die before expulsion Other explanations for its expulsion should be sought

Aneuploid abortion

Approximately 50 to 60 percent of embryos and early fetuses that are spontaneously aborted contain chromosomal

abnor-malities accounting for most of early pregnancy wastage

Jacobs and Hassold (1980)

95 percent of chromosomal abnormalities d/t maternal gametogenesis error

5 percent → d/t paternal error

Etiology of spontaneous abortionfetal factors-

Aneuploid abortion - Autosomal trisomy

The most frequently identified chromosomal anomaly associated with first-trimester abortions

Most trisomies result from isolated nondisjunction , balanced structural chromosomal rearrangements are present in one partner in 2 to 4 percent of couples with a history of recurrent abortions

Autosomes 13, 16, 18, 21, and 22 – most commom

Monosomy X

The second frequent chromosomal abnormality Usually results in abortion Much less frequently in liveborn female infant (Turner

syndrome)

Triploidy

Associated with hydropic placental (molar) degeneration Incomplete (partial) hydatidiform moles may contain

triploidy or trisomy for only chromosome 16

Tetraploid abortuses

Rarely are liveborn and most often are aborted early in gestation

Chromosomal structural abnormalities

Identified only since the development of banding techniques, infrequently cause abortionEuploid abortion

Abort later in gestational than aneuploid

Three fourths of aneuploid abortions occurred before8 weeks

Euploid abortions peak at about 13 weeks

The incidence of euploid abortions increased dramatically after maternal age exceeded 35 years

Infections (responsible for 5% of abortions)

Uncommon causes of abortion in human Acc to AICOG infections are an uncommon cause of

early abortions. Listeria monocytogenes Clamydia trachomatis Mycoplasma hominis Ureaplasma urealyticum Toxoplasma gondii Spirochetes hardly cause abortion before 20th wk

becoz of effective thickness of placenta

Spontaneous abortion-maternal factors

Chronic debilitating diseases

In early pregnancy, fetuses seldom abort secondary to chronic wasting disease such as tuberculosis or carcinomatosis

Celiac sprue

Cause both male and female infertility and recurrent abortions Endocrine abnormalities

Hypothyroidism Iodine deficiency associated with excessive miscarriages Thyroid autoantibodies → incidence of abortion↑

Diabetes mellitus The rates of spontaneous abortion & major congenital malformations Poor glucose control → incidence of abortion↑

Progesterone deficiency Luteal phase defect Insufficient progesterone secretion by the corpus luteum or placenta Poor glucose control → incidence of abortion↑

Nutrition Dietary deficiency of any one nutrients → not important cause

Drug use and environmental factor Tobacco ↑ Risk for euploid abortion More than 14 cigarettes a day → the risk twofold greater ↑ Smoking increases risk due to formation of carboxy haemoglobin and Decreased oxygen transfer to fetuses Alcohol Spontaneous abortion & fetal anomalies → result from frequent alcohol

use during the first 8 weeks of pregnancy Drinking twice a week → abortion rates doubled ↑ Drinking daily → abortion rates tripled ↑ Caffeine At least 5 cups of coffee per day → slightly increased risk of abortion

Drug use and environmental factor

Radiation In sufficient doses → abortifacient,in therapeutic doses given to

treat malignancy radiation is certainly abortifacient.acc to brent exposure to < 5 rads does not increase risk for miscarriage.

Contraceptives When intrauterine devices fail to prevent pregnancy → abortion↑ Environmental toxins Anesthetic gases : exact fetal risk of chronic maternal exposure is

unknown Arsenic, lead, formaldehyde, benzene, ethylene oxide →

abortifacient Video display terminal & accompanying electromagnetic fields short waves & ultrasound do not increase the risk of abortion

Immunological factors – two primary pathophysiological models are autoimmune theory –immunity against self,and alloimmune theory-immunity against another. Autoimmune factors are-

Recurrent pregnancy loss patients : 15% Antiphospholipid antibody : most significant Apla are 1-lupus anticoagulant 2-anticardiolipin antibodies 3-beta glycoporin antibodies Antiphospholipid antibodies are a family of autoantibodies that bind to negatively charged

phospholipids;phospholipids-binding proteins or combination of two they also are found in women without lupus.instead of causing miscarriage,they more likely are found with fetal death after mid pregnancy.

Women with both a history of early fetal loss and high antibody levels may have a 70% miscarriage recurrence rate.

LCA (lupus anticoagulant), ACA (anticardiolipin Ab) Reduce prostacyclin production → facilitating thromboxane dominant milieu → thrombosis Prostacyclin : produced by vascular endothelial cell → potent vasodilator & inhibit platelet aggregation Thromboxane A2 : produced by platelets → vasoconstrictor & platelet aggregator Strong association with Decidual vasculopathy , placental infarction, fetal growth restriction Early-onset preeclampsia, recurrent abortion, fetal death

Mechanism of pregnancy loss in women with apla are 1-inhibition of trophoblast function and differentiation 2-activation of complement pathway 3-Release of local inflammatory mediators

(cytokines,interlukins) 4- thrombosis of uteroplacental vascular bed IMMUNE FACTORS-cytokines are immune molecules .its

response may be due to T helper 1orT helper2. Th1 response is-prodn of IL2,interferon,TNF, TH2 response is prodn of antiinflammatory cytokines IL4,6,10 Successful pregnancy is the result of predominantly TH2

Cytokine response,women with recurrent miscarriage have more th1 response.

Immunological factors – alloimmune factors

Allogeneity Genetic dissimilarities between animals of the same species,normal

pregnancy requires formation of blocking factors that prevent maternal rejection of foreign fetal antigens that are paternally derived.

Human fetus is allogenic transplant tolerated by mother, a woman will not produce these serum blocking factors if she has HLAs similar to her husband.

Several test for diagnosis of alloimmune factors Maternal & paternal HLA comparison Maternal serum test for blocking antibodies : blocking antibodies to paternal antigens : ig G origin Maternal serum test for antipaternal antibodies : cytotoxic antibodies to paternal leukocyte

Inherited thrombophilia Many studies of aggregated thrombophilias These are genetically determined abnormal clotting factors that can cause pathological

thrombosis from an imbalance between clotting and anticoagulation pathway. The most widely studied include resistance to activated protein c caused by factor V Leiden

mutationor another decreased or absent antithrombin 3 activity,prothrombin gene mutation,and mutation in gene for methylene tetra hydrofolate reductase that causes elevated serum levels of homocysteine- hyperhomocysteinemia.

→ excessive recurrent abortions

Laparotomy Surgery performed during early pregnancy, → no evidence of tncreased abortion,if performed prior to10 wks gestation ovary with

corpus luteum is removed then supplemental progesterone is indicated. If 8-10 wks-only one inj of i/m 17- hydroxyprogesterone caproate 150mg is required ,if 6-

8wks then two additional doses should be given one and Peritonitis increases the likelihood of abortion

Physical trauma Major abdominal trauma → abortion↑

Uterine defects – acquired uterine defects Uterine leiomyoma : usually do not cause abortion Placental implantation over or in contact with myoma → placental abruption, abortion, preterm labor ↑ → location is more important than size

Uterine synechiae (Asherman syndrome) Partial or complete obliteration of the uterine cavity by

adherence of uterine wall Cause : destruction of large areas of endometrium by curettage → insufficient endometrium to support implantation &

menstruation → recurrent abortion, amenorrhea, hypomenorrhea

Uterine defects – acquired uterine defects Uterine synechiae-asherman syndrome –usually result from

destruction of large areasof endometrium by curettage.

Diagnosis of uterine synechiae Hysterosalpingogram → characteristic multiple filling defects Hysteroscopy → most accurate & direct diagnosis

Treatment of uterine synechiae Lysis of adhesions via hysteroscopy Prevention of adherence : IUD Promotion of endometrial proliferation : Continuous high-dose estrogen (60-90 days)

1-Uterine defects – developmental uterine defects,Mostly responsible for 2nd triamester abortion

Consequence of abnormal mullerian duct formation or fusion Spontaneously Induced by in utero exposure to DES (diethylstilbestrol) Causes of fetal loss are 1-reduced intrauterine vol 2-reduced expansile property of ut 3- reduced placental vascularity when implanted over the septum 4-increased uterine irritability and contractility 2- uterine fibroid-mainly submucus variety causes distortion or

partial obliteration of uterine cavity Fibroid causes decreased vascularity at implantation site,red

degeneration of fibroid & increased uterine irritability.

Maternal anatomical anomalies

Incompetent cervix Painless dilatation of cervix in the 2nd or early in the 3rd

trimester → prolapse & ballooning of membranes into vagina → rupture of membrane & expulsion of immature fetus Unless effectively treated, tends to repeat in each pregnancy Diagnosis in nonpregnant women Hysterography Pull-through techniques of inflated Foley catheter balloons Acceptance without resistance at the internal os of specifically

sized cervical dilators The use of transvaginal ultrasound in pregnant women Cervical length - shortening Funneling

Incompetent cervix – Treatment

The operation is performed to surgically Reinforcement of weak cervix by some type of purse string suture

( Cerclage )

Prophylactic surgery : generally performed between 12 & 16weeks Should be delayed until after 14 weeks’ gestation → Early abortion due to other factors will be completed

The more advanced the pregnancy, the more likely the risk that surgical intervention stimulate preterm labor or membrane rupture

Usually do not perform after about 23 weeks

Incompetent cervix – Preoperative evaluation

Sonography : Confirm living fetus & exclude major fetal anomalies

Cervical cytology

Cultures for gonorrhea, chlamydia, group B streptococci Obvious cervical infections → treatment is given For at least a week before & after surgery → sexual

intercourse should be restricted

Incompetent cervix – Cerclage procedures

Types of operations commonly used

McDonald

Modified Shirodkar

→ 85~90% success rate

Incompetent cervix – Complications

High incidence when performed much after 20 weeks

Membranes ruptures Chorioamnionitis Intrauterine infection

Urgent removal of suture Operation fails Signs of imminent abortion or delivery

Little is known in the genesis of spontaneous abortion

Chromosomal translocations in sperm can lead to abortion Common causes of miscarriage First trimester- 1-genetic factors 2-endocrine disorders –LPD,diabetes,thyroid disorders 3-immunological (autoimmune&alloimmune) 4-infection 5-unexplained Causes of 2nd triamester abortions 1-anatomical abnormalities A-cervical incompetence cong/acquired B-mullerian fusion defects (bicornuate/septate) C-uterine synechia D-uterine fibroid 2-maternal medical illness 3- unexplained

Paternal factors of causes of abortions

Categories of spontaneous abortion

Definition Any bloody vaginal discharge or bleeding during 1st half of

pregnancy Bleeding is frequently slight, but may persist for days or weeks One physiological cause of bleeding occurs near the time of

expected menses-implantation bleeding Cervical lesions ,cervical polyp Frequency Extremely common (one out of four or five pregnant women)

Prognosis Approximately ½ will abort Risk of preterm delivery, low birthweight, perinatal death↑ Risk of malformed infant does not appear to be increased

Threatened abortion

Treatment : slight bleeding persists for weeks Vaginal sonography Serial serum quantitative hCG Serum progesterone → can help ascertain if the fetus is alive & its location

Vaginal sonography Gestational sac(+) & hCG < 1000mIU/ml → gestation is not likely to survive → If any doubt(+), check the serum hCG level at intervals of 48hrs → if not increase more than 65%, almost always hopeless Serum progesterone value < 5 ng/ml → dead conceptus

Inevitable abortion

Complete abortion Following complete detachment & expulsion of the

conceptus The internal cervical os closes

Incomplete abortion Expulsion of some but not all of the products of

conception during 1st half of pregnancy The internal cervical os remains open & allows passage of

blood The fetus & placenta may remain entirely in utero or may

partially extrude through the dilated os → Remove retained tissue without delay

complete or incomplete abortion

Retention of dead products of conception in utero for several weeks

Many women have no symptoms except persistent amenorrhea

Uterus remain stationary in size, but mammary changes usually

regress → uterus become smaller

Most terminates spontaneously

Serious coagulation defect occasionally develop after prolonged retention of fetus

Missed abortion

Definition : Three or more consecutive spontaneous abortions

Clinical investigation of recurrent miscarriage Parental cytogenetic analysis Lupus anticoagulant & anticardiolipin antibodies assays Postconceptional evaluation Serial monitoring of ß–hCG from missed mens period ß–hCG>1500mIU/ml → USG Maternal serum α-fetoprotein assessment (GA16-18wks) Amniocentesis → fetal karyotype Prognosis Depends on potential underlying etiology & number of prior

losses

Recurrent abortion

The medical or surgical termination of pregnancy before the time of fetal viability

Classfication 1-therapeutic 2-elective[voluntary]

Therapeutic abortion

Termination of pregnancy before of fetal viability for the purpose

of saving the life of the mother

Induced abortion

Indication

Continuation of pregnancy may threaten the life of women or seriously impair her health

Persistent heart disease after cardiac decompensation Advanced hypertensive vascular disease Invasive carcinoma of the cervix

Pregnancy resulted from rape or incest

Continuation of pregnancy is likely to result in the birth of child with severe physical deformities or mental retardation

Elective (voluntary) abortion

Interruption of pregnancy before viability at the request of the women, but not for reasons of impaired maternal health or

fetal disease

Counseling before elective abortion

Continued pregnancy with its risks & parental responsibilities Continued pregnancy with its risks & its responsibilities of

arranged adoption The choice of abortion with its risks

Dilatation and curettage

Performed first by dilating the cervix & evacuating the product of conception

Mechanically scraping out of the contents (sharp curettage) Vacuum aspiration (suction curettage) Both

Before 14-15 weeks, D&C or vacuum aspiration should be performed

After 16 weeks, dilatation & evacuation (D&E) is performed Wide cervical dilatation Mechanical destruction & evacuation of fetal parts

Dilatation and curettage Hygroscopic dilators : swell slowly & dilate cervix → cervical trauma can be minimized

Laminaria tents : stem of brown seaweed ( Laminaria digitata or japonica) → drawing water from proteoglycan complexes of cervix → dissociation allow the cervix to soften & dilate Insertion technique : tip rests just at the level of internal os Usually after 4-6hours, laminaria dilate the cervix sufficiently to allow easier

mechanical dilation & curettage May cause cramping pain → easily managed with 60 mg codeine every 3-4 hours Synthetic hygroscopic dilators such as lamicel and dilapan-s are also

available Prostaglandins-400mcg misoprost kept in vagina 4hrs before termination

causes more dilatation and less pain of insertion compare to laminaria tent.

Complications : uterine perforation 2 important determinants Skill of the physician Position of the uterus (retroverted)

Small defects by uterine sound or narrow dilator → often heal without complication Suction & sharp curettage → Considerable intra-abdominal damage risk↑ → Laparotomy to examine abdominal content (safest action)

Other complications – cervical incompetence or uterine synechiae

Complications of surgical technique

Menstrual aspiration

Aspiration of endometrial cavity using a flexible cannula and syringe within 1-3 weeks after failure to menstruate

Several points at early stage of gestation

Woman not being pregnant Implanted zygote may be missed by the curette Failure to recognize an ectopic pregnancy Infrequently, a uterus can be perforated Manual vaccum aspiration- Office based procedure used for termination upto 12 wks,uses a

60ml syringe n canula .a vaccum is created in the syringe and attached to canula which is inserted transcervically

Oxytocin

Successful induction of 2nd trimester abortion is possible with high doses of oxytocin administered in small volumes of IV fluids

Satisfactory alternatives to PG E2 for midtrimester abortion

Laminaria tents inserted the night before Chance of successful induction is greatly enhanced

Oxytocin

Successful induction of 2nd trimester abortion is possible with high doses of oxytocin administered in small volumes of IV fluids

Satisfactory alternatives to PG E2 for midtrimester abortion

Laminaria tents inserted the night before Chance of successful induction is greatly enhanced

Prostaglandins

Used extensively to terminate pregnancies, especially in the 2nd T PG E1, E2, F2α

Technique : Can act effectively on the cervix & uterus (86~95%

effectiveness) Vaginal prostaglandin E2 suppository & prostaglandin E1

(misoprostol) As a gel through a catheter into the cervical canal & lowermost

uterus Injection into the amnionic sac by amniocentesis Parenteral injection Oral ingestion

Intra-amnionic hyperosmotic solutions 20-25% saline or 30-40% urea injected into amnionic sac → stimulate uterine contraction & cervical dilatation Action mechanism : prostaglandin mediated ? Complications of hypertonic saline Death Hyperosmolar crisis (early into maternal circulation) Cardiac failure Septic shock Peritonitis Hemorrhage DIC Water intoxication Hyperosmotic urea : less likely to be toxic

Antiprogesterone RU 486 Oral agent used alone in combination with oral PG to effect

abortions in early gestation High receptor affinity for progesterone binding site → Block progesterone action Abortion rate Single 600mg dose prior 6 weeks → 85% Addition of oral, vaginal or injected PG → over 95% If given within 72 hours Also highly effective as emergency postcoital contraception Progressively less effective after 72 hours Side effects Nausea, vomiting, & gastrointestinal cramping Major risk → hemorrhage is a risk if abortion is incomplete

Septic abortion

Most often associated with criminal abortion

Metritis is usual outcome, but parametritis, peritonitis, endocarditis, and septicemia may all occur

Management Prompt evacuation of products of conception Broad-spectrum IV antimicrobials

RESUMPTION OF OVULATION AFTER ABORTION

Any abortion associated with clinical evidences ofinfection of the uterus and its contents is called septic abortion.

Criterias are 1-temp of atleast 100.4degree faranhite for

24hrs or more 2-offensive or purulent vaginal discharge 3-other evidences of infection such as lower

abdominal pain and tenderness 10% abortions are septic either due to

incomplete or due to illegal

SEPTIC ABORTION

Due to endogenous microorganisms present in vagina these are

Anaerobic-bacteroides,anaerobic strepto,c.welchi and tetani.

Aerobic-ecoli,klebsialla.pseudomonas,staph,beta hemolytic streptococcus(usually exogenous),methcillin resistant staphylococcus.

Mode of infection

History of unsafe termination by an unauthorized person mostly concealed

Women looks sick and anxious Temp> 38 c Chills &rigors Persistent tachycardia >90bpm Hypothermia (endotoxic shock)<36c Abdominal or chest pain Tachypnea RR >20/min. Impaired mental state Diarrhea and or vomitting Renal angle tenderness Pelvic examinations- offensive,purulent vaginal discharge,uterine

tenderness,boggy feel in the POD(PELVIC ABSCESS)

Clinical features

Grade 1-infection is localised to uterus Grade2-beyond the uterus to parametrium ,tubes,ovaries or pelvic

peritonium Grade 3-generalised peritonitis ,endotoxic shock ,or jaundice,or renal

failure INVESTIGATIONS-1- 1-hvs 2-culture in aerobic and anaerobic media 3- sensitivity towards antibiotics 4-smer for gram+ or gram_ 5-cbc ,haemogram,ABO cross match 6-usg for rpocs any foreign body or pelvic abscess Blood culture,serum lectrolytes,CRP,coagulation profileserum lactate

greater than or equal to 4mmol/l indicates tissue hypoperfusion. Plain xray abdomen to rule out any bowel injury xray chest for cases

with pulmonary complications.

Clinical grading

Haemorrhage Injury may occur to uterus or adjacent bowel Spread of infection may lead to 1-generalised peritonitis 2-endotoxic shock 3-acute renal failure ATN –common with c.welchii 4-lungs-atelactass,ARDS,thrombophlebitis Mainly occurs with grade 3. Remote complications are 1-chr debility,2-chr

pelvic pain and backache ,3-dyspareunia,4-ectopic pregnancy,5-sec infertility due to tual blockage

complications

Hospitalization To take hvs Vaginal examination Assessment of case Inv protocols Principles of m/m are To control sepsis To remove the source of infection To give supportive therapy to bring back normal

homeostatic and cellular metabolism To assess the response of treatment

Management of septic abortions

Grade 1- Antibiotics Prophylactic anti gasgangrene serum of

8000units anti tetanus serum of 3000 units i/m are givenif there is a history of interference

Analgesics and sedatives Evacuation should be performed within 24 hrs

of antibiotic therapy Blood transfusion to improve anemia and body

resistance

Grade 2-broad spectrum antibiotics Analgesic,AGS,ATS,blood transfusion Clinical monitoring CVP to be > 8mhg Surgery- evacuation of uterus Posterior colpotomy Grade 3as grade 2except surgery Active surgery-injury to ut,bowel injury,presence

of foreign body in abdomen,unresponsive peritonitis,septic shock or oliguria not responding to conservative m/m,uterus too big to be safely evacuated per vaginum.

Features of organ dysfunctio1-persistent hypotension 2-oliguria Serum creat>44.2micromol/l Coagulation abnormalities (inr >1.5) Thrombocytopenia Hyperbilirubinemia Pao2<40kpa Serum lactate >4mmol/l Indications for ICUm/m Persistent hypotention,persistently raised serum lactate>4mmol/l, pulmonary edema,mechanical ventilation Renal dialysis Impaired cosciousness Multiorgan failure,hypothermia,acidosis

Following provisions are laid down Continuation of pregnancy would involve serious

risk of life or grave injury to the physical and mental health of pregnant women

There is a substantial risk of child being born with serious physical and mental abnormalities so as to be handicapped in life

When pregnancy is caused by rape both in cases of major and minor girl and in mentally imbalanced women

Pregnancy caused as a result of failure of contraceptive

Medical termination of prenancy (MTP) act

Indications for terminations under MTP act To save life of mother (therapeutic or medical indications) 1-cardiac ds grade 3 and grade4 with h/o decompensation in prev pregnancy 0r in between

pregnancies Chr glomerulonephritis Malignant hypertension Intractable hyperemesis Cervical or breast malignancy DM with retinopathy Epilepsy or psychiatric illness with advice of a psychiatrist Social indicationa-this is almost sole indication and is covered under the provision to prevent grave

injury to the physical and mental health of the pregnant women In80% cases it is limited to parous womenhaving unplanned pregnancy with low socioeconomic

status. Pregnancy caused by rape or unwanted pregnancy caused due to failure of any contraceptive

device Eugenic-this is under the provision of sustantial risk of child being born with serous physical and

mental abnormalities so as to be handicapped in life the indication is rare 1- structural anencephaly,chromosomal downs syndromeor genetic hemophilia 2-fetus is likely to be deformed due to action of teratogenic drugs warfarin or radiation exposure

>10 rad in early preg. Rubella infection is an indication for termination

Recommendations In revised rules rmp is qualified to perform an mtp provided 1-one has assisted atleast 25 mtp in an authorised centre and having

a certificate 2-one has got 6 months house surgeon training in ob gy 3-one has got diploma or degree in ob gy. Termination can only be performed in hospitals,established or

maintained by govt or places approved by gov. Pregnancy can only be terminated on the written consent of the

women. Husband s consent is not required. Pregnancy in a minor girl or lunatic cannot be terminated without

written consent of parents or legal guardian. Termination is permitted up to 20 wks of pregnancy.when preg

exceeds 12 wks opinion of two medical practitioners is required. The abortion has to be performed confidentially and o be reported to

director of health services in prescribed form.