What type of abortion is recommended for a patient undergoing Medical Termination of Pregnancy (MTP)?

Medical Termination of Pregnancy (MTP): Recommended Methods

For first-trimester MTP (≤9 weeks), use mifepristone 200 mg orally followed by misoprostol 800 μg vaginally 24-48 hours later, which achieves 95% complete abortion rates. 1 For second-trimester MTP (14-24 weeks), dilation and evacuation (D&E) is the safest procedure and should be performed in a hospital setting. 1, 2, 3

First Trimester Medical Abortion (≤9 weeks gestation)

The standard regimen is mifepristone 200 mg orally followed by misoprostol 800 μg vaginally 24-48 hours later. 1, 4 This combination achieves success rates of 92-98% for pregnancies ≤49 days gestation. 5, 6

Key Technical Details:

• Mifepristone dose: 200 mg is as effective as 600 mg, with no significant difference in complete abortion rates (RR 1.07,95% CI 0.87-1.32). 6, 4
• Misoprostol route: Vaginal administration is more effective than oral (RR of failure with oral route: 3.00,95% CI 1.44-6.24). 6, 4
• Timing: The interval between mifepristone and misoprostol should be at least 24 hours for optimal effectiveness. 4
• Gestational age impact: Risk of failure increases when >25% of patients have gestational age >8 weeks. 4

Essential Prophylaxis:

• Antibiotic prophylaxis is mandatory to prevent post-abortal endometritis, which occurs in 5-20% without antibiotics versus 1.3% with prophylaxis. 1, 2, 3
• Anti-D immunoglobulin is required for all Rh-negative women to prevent alloimmunization. 1, 2, 3

Second Trimester Termination (14-24 weeks gestation)

Dilation and evacuation (D&E) is the safest procedure for second-trimester termination and should be the preferred method. 1, 2, 3 This recommendation is based on dramatically lower complication rates compared to medical methods.

D&E Superiority Evidence:

• Hemorrhage rate: 9.1% with D&E versus 28.3% with medical methods 1
• Infection rate: 1.3% with D&E versus 23.9% with medical methods 1
• Setting: Must be performed in a hospital with emergency support services available 7, 1
• Anesthesia: Most D&E procedures are performed under sedation or general anesthesia 7, 2

Medical Alternative (When D&E Not Feasible):

If surgical evacuation is not feasible in the second trimester, prostaglandin E1 (misoprostol) or E2 can be used. 7 Critical warning: Never use prostaglandin F compounds—they significantly increase pulmonary artery pressure and may decrease coronary perfusion. 7, 1

When using prostaglandins for medical termination:

• Monitor systemic arterial oxygen saturation with transcutaneous pulse oximetry 7, 3
• Have norepinephrine available to support diastolic blood pressure if needed 7
• Expect greater hemodynamic effects with E2 than E1 (lower systemic vascular resistance, decreased BP, increased heart rate) 7

Special High-Risk Situations

High-risk patients (cardiac disease, pulmonary hypertension, cyanosis) should be managed in experienced centers with on-site cardiac surgery. 7, 2 First-trimester termination is the safest option for these patients. 7, 2

For women with congenital heart disease and pulmonary arterial hypertension (CHD-PAH), especially Eisenmenger physiology:

• Pregnancy should be absolutely avoided due to maternal mortality rates up to 50% 7
• If pregnancy occurs, termination in the first trimester is the safer option 7, 2
• Termination in mid-to-late pregnancy carries high maternal risk due to volume and hormonal fluctuations 7

Critical Pitfalls to Avoid

• Never delay counseling or the procedure—timing directly impacts success rates and complication risks 1, 2
• Never use prostaglandin F compounds—they cause adverse hemodynamic effects 7, 1
• Never omit antibiotic prophylaxis—infection rates increase from 1.3% to 5-20% 1, 2
• Never forget anti-D immunoglobulin in Rh-negative women 1, 2, 3
• Never use saline abortion—it can cause intravascular volume expansion, heart failure, and clotting abnormalities 7

Counseling Requirements

Counseling must be performed expeditiously and should cover: 1, 2

• Short- and long-term maternal health risks
• Risks/benefits of pregnancy continuation versus termination
• All treatment options available
• Contraception options addressing safety, effectiveness, accessibility, affordability, and acceptability 1

Fetal Analgesia Consideration

Fetal analgesia is not recommended during pregnancy termination procedures. 7 The vast majority (>99%) of abortions occur before 24-25 weeks gestation, which is the minimum gestational age at which fetal pain awareness is developmentally plausible. 7 Administering additional analgesic medications for potential fetal benefit offers no value and may cause maternal harm. 7