What are the procedures for medical termination of pregnancy (MTP)?

Medical Termination of Pregnancy (MTP) Procedures

For second-trimester MTP (beyond 14 weeks), dilation and evacuation (D&E) is the safest and preferred method, with significantly lower complication rates than medical methods—hemorrhage occurs in 9.1% versus 28.3% and infection in 1.3% versus 23.9% with medical approaches. 1, 2, 3

First Trimester MTP (Up to 14 weeks)

Medical Method

• Mifepristone 200 mg orally followed by misoprostol 800 μg (vaginal, buccal, or sublingual) 24-48 hours later is the recommended regimen 4
• Complete abortion rate is approximately 95%, with highest efficacy (92%) at ≤49 days gestation, declining to 83% at 50-56 days and 77% at 57-63 days 5
• If mifepristone is unavailable, misoprostol alone can be used, though repeated doses may be required and efficacy is lower 4
• For gestations 63-90 days, use mifepristone 200 mg followed by misoprostol 800 μg vaginally, with repeat doses every 3 hours (maximum 5 doses) achieving 91.7% success 6

Surgical Method

• Vacuum aspiration (electrical or manual) is the surgical method of choice with approximately 97% complete abortion rate 4
• Pre-operative misoprostol 400 μg administered 2 hours before the procedure reduces complications 7
• Risk of significant bleeding is ≤5%, with major complications occurring in <1% 4

Second Trimester MTP (14+ weeks)

Preferred Approach

• D&E should be performed in a hospital setting by experienced providers 1, 2, 3
• Most D&E procedures are performed under sedation or general anesthesia 2
• At 6 months gestation (24 weeks), specialized expertise is required due to increased risks 1

Medical Alternative (if D&E unavailable)

• Prostaglandin regimens (misoprostol or prostaglandin E2) can be used to evacuate the uterus 2
• Avoid prostaglandin F compounds as they increase pulmonary arterial pressure and may decrease coronary perfusion 2
• Monitor systemic arterial oxygen saturation with transcutaneous pulse oximetry during prostaglandin administration 2

Essential Post-Procedure Care

Infection Prevention

• Antibiotic prophylaxis is mandatory to prevent post-abortal endometritis, which occurs in 5-20% of women without antibiotics 1, 2, 3

Rh Immunization Prevention

• All Rh-negative women must receive anti-D immunoglobulin 1, 2, 3

Follow-up Timing

• Clinical examination including ultrasonography should be performed 8-14 days after medical abortion 6
• Beta-hCG levels should decrease by >97.5% in successful terminations 6

Special Clinical Situations

Cancer During Pregnancy

• Pregnancy termination is advised if chemotherapy or radiotherapy is required during the first trimester, as these treatments carry up to 20% risk of fetal malformations 8
• Chemotherapy can be administered during second and third trimesters with reasonable safety, though risks of stillbirth, growth retardation, and premature delivery increase 8
• Allow 3 weeks between last chemotherapy dose and delivery to avoid the nadir period 8
• Do not administer chemotherapy beyond week 33 of gestation 8

Timing Considerations

• No lower limit of gestational age exists for TOP, though extra precaution is required for confirmation of completion and exclusion of ectopic pregnancy at very early gestations 4
• Medical abortion efficacy decreases with advancing gestational age, requiring repeated misoprostol doses beyond 9 weeks 4

Critical Safety Points

Fetal Analgesia

• Fetal analgesia is not recommended during pregnancy termination as there is no evidence of fetal pain awareness before 24-25 weeks gestation 8, 2, 3

Contraindications and Warnings

• Pregnancy must be excluded before initiating mifepristone treatment and prevented during treatment with non-hormonal contraception 9
• If mifepristone treatment is interrupted for >14 days, pregnancy must be excluded before resuming 9

Common Pitfalls

• Abdominal pain, nausea, vomiting, diarrhea, and vaginal bleeding increase with advancing gestational age in medical abortion 5
• Failure rates (requiring surgical intervention) increase from 1% at ≤49 days to 9% at 57-63 days 5
• Unplanned or emergency admissions are higher after medical versus surgical abortion 7