Recurrent Abortion

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

Types of Abortions

Abortions can be classified as either of the following:

Recurrent
Spontaneous
Induced

Recurrent Abortion

Recurrent abortion, habitual abortion, or recurrent pregnancy loss (RPL) is the occurrence of three or more consecutive pregnancies that end in miscarriage of the fetus before viability. About 1% of couples trying to have children are affected by recurrent miscarriage.

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 persons and done under highly unhygienic conditions.

The Indian MTP Act

To avoid the misuse of induced abortions, most countries have enacted laws whereby only qualified Gynecologists under conditions laid down and done in clinics/hospitals that have been approved can do abortions. The Medical Termination of Pregnancy Act was enacted by the Indian Parliament in 1971 and came into force from 01 April, 1972. The MTP act was again revised in 1975.

The MTP Act lays down the condition under which a pregnancy can be terminated, the persons and the place to perform it.

The reasons for which MTP is done, as interpreted from the Indian MTP Act, are:

(i) Where a pregnant woman has a serious medical disease and continuation of pregnancy could endanger her life like:

Heart diseases.
Severe rise in blood pressure.
Uncontrolled vomiting during pregnancy
Cervical/ breast cancer.
Diabetes mellitus with eye complication (retinopathy).
Epilepsy.
Psychiatric illness.

(ii) Where the continuation of pregnancy could lead to substantial risk to the newborn leading to serious physical / mental handicaps examples like

Chromosomal abnormalities.
Rubella (German measles) viral infection to mother in first three months.
If previous children have congenital abnormalities.
Rhiso-immunisation.
Exposure of the foetus to irradiation.

(iii) Pregnancy resulting of rape.

(iv) 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 Contraceptive Device irrespective of the method used (natural methods/ barrier methods/ hormonal methods).

This condition is a unique feature of the Indian Law. All the pregnancies can be terminated using this criterion. Consent:

If married--- her own written consent. Husband’s consent not required.
If unmarried and above 18years ---her own written consent.
If below 18 years ---written consent of her guardian.
If mentally unstable --- written consent of her guardian.

A consent assures the clinician performing the abortion that she:

Has been informed of all her options.
Has been counseled about the procedure, its risks and how to care for herself after she chosen the abortion of her own free will.

Person or persons who can perform MTP are:

Any qualified registered medical practitioner who has assisted in 25 MTPs.
A house surgeon who has done six months post in Obstetrics and Gynecology.
A person who has a diploma /degree in Obstetrics and Gynecology.
3 years of practice in Obstetrics and Gynecology for those doctors registered before the 1971 MTP Act was passed.
1 year of practice in Obstetrics and Gynecology for those doctors registered on or after the date of commencement of the Act.
Whenever the pregnancy exceeds 12 weeks but is below 20 weeks opinion of two registered medical practitioners is necessary.

Place where MTP can be performed :

Any institutions licensed by the Government to perform MTP. The certificate issued by the Government should be conspicuously displayed at a place easily visible to persons visiting the place.

Methods of Induced Abortion:

Abortion can be induced by different methods depending on the weeks of pregnancy completed.

Tests to be done:

A thorough medical examination including blood pressure and weight.
An internal examination to confirm the duration of pregnancy.
Urine test for confirmation of pregnancy.
Routine urine analysis.
Routine blood counts including hemoglobin estimation.
Blood group and Rh factor.
At times, an ultrasound may be required.

First trimester abortion

Surgical methods:

Cervical dilatation followed by evacuation of uterus by: Curettage /Suction evacuation / vacuum aspiration / Dilatation and evacuation
Menstrual aspiration (MR)

Surgical methods in first trimester

Anaesthesia :

Cervix is numbed (local anesthesia) with an injection so that the patient is pain free. This is given alone or with a sedative.
General anaesthesia can be given if the lady is apprehensive or has a low pain threshold or in selected cases like unmarried women or if it is her first pregnancy or if she opts for it.

Procedure:

The lady is made to lie on her back with her legs raised and placed in stirrups (lithotomy position)

Dilatation and evacuation:- Cervical dilatation followed by evacuation of uterus by –curettage / vacuum aspiration / suction evacuation / suction curettage/dilation and evacuation

Surgical abortion done in the early pregnancy, that is before 12 weeks is done by first dilating the cervix, which is done by introducing hollow metal rods of increasing diameters and then evacuating the contents of the uterus mechanically by scraping or by suction or both. The procedure takes about 15 minutes.

Advantages

A single step procedure.
Safe.
Possible to carry out Sterilization or insertion of an intra-uterine device.
Can go home on the same day.
Can resume working the next day.

Risks

Reaction to the drugs used in anesthesia
Bleeding
Infection of the uterus and fallopian tubes.
Accidental perforation of the uterus.
Emotional distress.

Menstrual aspiration/ Menstrual regulation (MR) :- Menstrual aspiration also called minisuction, miniabortion, vacuum aspiration, lunchtime abortion which is done between 1 to 3 weeks after the failure to menstruate. This procedure is done as an out patient. A thin plastic tube is inserted into the uterus and its contents sucked out by negative pressure created in a syringe. The procedure takes about 10 minutes to complete.

Advantages

No hospitalization required.
Done without anesthesia.
Surgical risks are minimal.
Person can go home and resume her normal activities.

Risks

Failure of the procedure.
Bleeding.
Infection

Medical Methods in the first trimester

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

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. The pregnancy usually ends at home within a day or two. The embryo and other tissue that develops during pregnancy are passed out through the vagina.
The mifepristone – misoprostol method : Mifepristone also known, as RU-486 is antiprogesterone. A woman swallows a dose of mifepristone. She returns in five to seven days and inserts suppositories of misoprostol into her vagina. The pregnancy usually ends at home within four hours. The embryo and other tissue that develops during pregnancy are passed out through the vagina.

Risks

Mifepristone, Methotrexate and misoprostol cause nausea and vomiting, diarrhea.
Incomplete abortion may require surgical evacuation.
Heavy bleeding , which may continue upto 7 days.

In the first trimester abortions the preference is for termination by the surgical method of dilatation and curettage as the drugs are not easily available and expensive.

These drugs can be misused and hence FDA approval for these agents has not yet been given.

Second Trimester Abortions

Methods of second trimester abortion (13 – 20 week)

Medical methods using drugs like:

Ethacridine lactate.
prostaglandin

Surgical methods

Aspirotomy
Hysterotomy
Hysterectomy

Medical Methods in second trimester

Ethacradine actate:

1. Drug named as Emcredyl or Rivanol:

This is a drug that 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 called Cerviprime inserted into the mouth of the uterus- (the cervix) in the evening in 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 hrs and the abortion is complete
Misoprostol : It is available in tablet form and given by mouth or can be inserted vaginally. Two tablets of Mifepristone is given followed 24 hrs later by an oral or vaginal dose of misoprostol. The uterus will contract causing cramping followed by the expulsion of the fetus. The cramps and the bleeding will stop after the products have been expelled
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

Needs to be in a hospital upto 3 days
Infection.
Increased bleeding.
Retained products, which may need surgical evacuation.

Surgical Methods in the second trimester

Anaesthesia:

General anesthesia can be given depending on the pain threshold / apprehension of the lady.

Procedure

Aspirotomy.
Hysterotomy.
Hysterectomy.

Aspirotomy

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

Hysterotomy

Hysterotomy is a major operating procedure where the abdomen is opened. In a hysterotomy the uterus is opened and the contents of the uterus removed directly under vision. This is like a caesarean. In a 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, the procedure followed is by the medical methods rather than by the 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 than in the second trimester.

Counselling

Counselling is normally done by the attending Obstetrician.The aim of counselling is to help 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 allay the anxiety of the person who intends to under-go the procedure.
To provide information about the methods, safety, risks etc
To screen for guilt, or any psychiatric ailment.
To help the lady understand and to cope with her feelings.
To help her to prevent future unplanned pregnancy.