What is the recommended regimen for Medical Termination of Pregnancy (MTP)?

Medical Termination of Pregnancy: Recommended Regimens

For first-trimester MTP (≤7 weeks), use mifepristone 200 mg orally followed by misoprostol 800 μg, achieving 92-98% success rates; for second-trimester MTP (14+ weeks), dilation and evacuation (D&E) is the safest method with dramatically lower complication rates than medical approaches. 1, 2

First Trimester (≤49 days/7 weeks gestation)

Medical regimen is the standard approach:

• Administer mifepristone 200 mg orally, followed 24-48 hours later by misoprostol 800 μg 1
• Success rates are gestational age-dependent: 92% at ≤49 days, declining to 83% at 50-56 days and 77% at 57-63 days 3
• Most terminations occur within 4 hours (49%) to 24 hours (75%) after misoprostol administration 3
• Provide prophylactic antibiotics to reduce infection risk from 5-20% down to 1.3% 1, 2
• Administer anti-D immunoglobulin to all Rh-negative women 1, 2

Critical caveat: Failures increase with advancing gestational age, particularly ongoing pregnancies (1% at ≤49 days vs 9% at 57-63 days), requiring surgical intervention 3

Second Trimester (14-27 weeks gestation)

Surgical approach is strongly preferred:

• D&E is the safest procedure with significantly lower complication rates compared to medical methods 1, 2, 4
  • Hemorrhage: 9.1% (D&E) vs 28.3% (medical methods) 2, 4
  • Infection: 1.3% (D&E) vs 23.9% (medical methods) 2, 4
• Perform D&E in hospital settings by experienced providers under sedation or general anesthesia 1, 2, 4
• At ≥24 weeks gestation, specialized expertise is mandatory due to increased risks 2

Medical alternative (if D&E unavailable):

• Use mifepristone 200 mg orally followed by misoprostol regimens (at least 200 mcg doses) 5
• Mifepristone pretreatment increases effectiveness (complete abortion at 24-48 hours) compared to misoprostol alone 5
• Avoid prostaglandin F compounds—they increase pulmonary arterial pressure and may decrease coronary perfusion 2, 4
• Use prostaglandin E1 (misoprostol) or E2 instead 2, 4
• Monitor systemic arterial oxygen saturation with pulse oximetry during prostaglandin administration 4

Important safety consideration: Women with ≥2 prior cesarean sections have increased uterine rupture risk with misoprostol, though absolute risk remains low 5

Essential Post-Procedure Care (All Gestational Ages)

• Mandatory antibiotic prophylaxis to prevent post-abortal endometritis (occurs in 5-20% without antibiotics) 1, 2, 4
• Anti-D immunoglobulin for all Rh-negative women 1, 2, 4
• Monitor for infection, retained products, and excessive bleeding 1
• Most contraceptives can be started immediately following abortion 5

Special Clinical Situations

Cancer patients requiring treatment:

• Pregnancy termination is advised if chemotherapy or radiotherapy is required during first trimester (up to 20% risk of fetal malformations) 6, 2
• Chemotherapy can be administered during second/third trimesters with reasonable safety, though risks of stillbirth, growth retardation, and premature delivery increase 6, 2
• Allow 3 weeks between last chemotherapy dose and delivery to avoid the nadir period 2
• Do not administer chemotherapy beyond week 33 of gestation 2

High-risk cardiac patients:

• Women with pulmonary arterial hypertension should undergo earliest possible first-trimester termination 1
• Manage high-risk patients in experienced centers with on-site cardiac surgery capabilities 1, 4

Common Pitfalls to Avoid

• Never use MTP pills without proper medical supervision—self-administration leads to serious complications including excessive bleeding (78%), incomplete abortion (66%), and undetected ectopic pregnancy (12%) 7
• Do not delay counseling or procedures—this directly impacts success rates and complication risks 1
• Fetal analgesia is not recommended during termination procedures as there is no evidence of fetal pain awareness before 24-25 weeks gestation 1, 2, 4