SURGICAL METHODS OF MTP

DR RAJEEV SOOD ASSTT PROF OBG IGMC SHIMLA

MTP has been legalized in India since 1971 MTP service is used as a health measure to avoid criminal abortion & not as a contraceptive technique

Abortion scenario in India

Abortions account to 9% of MMR. Deaths mostly preventable 2/3rd of total abortions are unsafe Low awareness that abortions are legal Lack of privacy at health facilities lead to back-street abortions

ABORTION STASTICS

Each year an estimated 42 million women worldwide undergo an induced abortion 59% abortions took place at 8 weeks gestations or earlier 88% abortions occurred at 12 weeks gestations or earlier 4.3% occurred between 16-20 weeks

First trimester surgical methods

(i) (ii) (iii) (iv) Menstrual regulation Manual vacuum aspiration Electric vacuum aspiration Dilation & curettage

Menstrual Regulation

Done between 1 to 3 weeks after the failure to menstruate.

Women, who have missed their regular menstrual period and strongly suspect that they are pregnant, but do not, or, cannot wait for confirmatory pregnancy tests, go in for menstruation regulation.

Procedure:- A thin plastic tube is inserted into the uterus and its contents sucked out by negative pressure created in a syringe Advantages : No hospitalization required. Done without anesthesia. Surgical risks are minimal. Disadvantages : Failure of the procedure Bleeding Infection

MANUAL VACUUM ASPIRATION

Indications for MVA

Induced abortions up to 12 weeks Missed abortions Blighted ovum Molar pregnancy up to 12 weeks

Pre procedure assessment

History taking General physical examination Bimanual pelvic examination Hemoglobin, ABO-Rh, urine for protein & sugar Informed consent Counseling Contraceptive advise

Procedure

Patient should fast for at least 6 hrs Antimicrobial prophylaxis Patient should empty her bladder before being placed in dorsal lithotomy position Paracervical block is used for anesthesia Vacuum is created in 60 ml syringe & attached to cannula which is inserted transcervically into the uterus, release pinch valve to begin suctioning Vacuum is activated & produces up to 660mm of Hg suction Abortion involves rotary & in and out cannula movement Empty contents of aspirator into container & look for POCs

Signs of empty uterus

Red or pink foam without tissue passing through cannula Gritty sensation Cervix gripping over the cannula

Advantages over EVA

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Cost is lower. MVA is quieter than electric suction technique No electricity required Convenient for mobile services Tissue inspection is easy

Complications

Vagal reaction Incomplete evacuation Uterine perforation Cervical laceration Pelvic infection Hemorrhage Hematometra

Electric vacuum aspiration

PREABORTION CERVICAL PREPRATION

1.

Prostaglandins: Misoprostol PGE1

derivative 400ug orally or vaginally 3-4 hrs prior to procedure sufficiently soften the cervix & facilitates dilation Inj. 15 methyl PGF2 alpha 250ug can be given 45 min. prior to procedure

2. Hygroscopic dilators: laminaria, lamicel, Dilapan-S

Act by drawing water from cervical tissue After 4-6 hrs laminaria swollen & dilate the cervix gradually Reduces risk of cervical injury Disadvantages: cost, inconvenience & occasional cramping

Laminaria tents

Procedure

Antimicrobial prophylaxis should be given Patient should fast for at least 6 hrs Patient should empty her bladder before being placed in dorsal lithotomy position Antiseptic is applied to cervix & vagina Paracervical anesthesia is given Cervical dilation: cervix is dilated upto desired extent with grduated metal dilators. 4th & 5th finger of hand introducing dilator should rest on perineum & buttocks which minimizes forceful dilatation & provides safeguard against perforation

Hegar

Hawkin

Pratt dilator

Procedure cont.

Sims speculum introduced & cervix held with tenaculum Cannula inserted then attached to suction machine, cannula is turned circumferentially to cover entire surface of uterine cavity Negative suction of 600-660mm of Hg is applied & contents aspirated till gritty sensation is felt & no tissue obtained Rh ve should be given 50ug of Anti-D inj. after abortion

Post procedure care

Take vital signs Evaluate bleeding per vaginum & abdominal pain Pain management Provision of antibiotics Rh ve should be given 50ug Anti-D

Conditions requiring immediate attention

Significant decline in vital signs Dizziness, shortness of breath, fainting attacks Severe vaginal bleeding Loss of resistance during procedure, severe abdominal pain or cramps

COMPLICATIONS
1.

Immediate: develop during or within 3 hrs of operation Anesthesia complication Hemorrhage 0.05- 4.9% Cervical injury 0.01-1.6% Hematometra 0.1-1% Perforation 0.2%

Delayed: develop more than 3 hrs & up to 28 days after the procedure Incomplete abortion <1% Postoperative sepsis <1%

Late: develop after 28 days Rh senstization 2.6% Intrauterine adhesions 16-19% Cervical incompetence

Dilatation & Curettage

Dilation and curettage uses a sharp instrument to remove tissue from inside the uterus. Increased risk of bleeding and injury to the uterus compared with the usual procedure that uses suction to clear the uterus
Can be used to:

1. Remove tissue that may remain after

incomplete abortion 2.Remove tissue that may remain after a vacuum aspiration abortion.

2ND TRIMESTER SURGICAL METHOD

1.

2. 3.

4.
5.

Intra-amniotic instillation of hypertonic solution Extra amniotic instillation of drugs Dilatation and evacuation Hysterotomy Hysterectomy

Intra-amniotic instillation of hypertonic solution

1.

Hypertonic saline (20%) abdominal route Less commonly used now Amount to be instilled no. of weeks of gestation x 10 ml Infused at rate of 10 ml/min Mode of action liberation of prostaglandins following necrosis of amniotic epithelium and decidua Contraindications: cardiovascular and renal disease, severe anemia Effective in 90-95% cases Induction to abortion interval 32 hours Failure if abortion fails to occur in 48 hrs

Side effects
Minor fever, headache, nausea, vomiting Cervical tear and laceration Retained products Infection Hypernatramia, cardiovascular collapse Pulmonary and cerebral edema Renal failure DIC Death 0-5 per 1000 instillation

2.

Hyperosmotic urea(40%)
Combination with intraamniotic 15methyl PGF2 2mg reduces mean induction to abortion interval to 13 hrs and effective in 80% cases

0.1% ethacrydine lactate

Extra amniotic instillation of drugs

Mechanism of action:
Direct oxytocic effect on myometrium Stripping of membranes with release of prostaglandins Antiseptic action, prevent infection

Dose : 10ml per week of gestation maximum of 150 ml Procedure : no. 16 Foleys catheter passed up the

cervical canal for about 5cm above the internal os between membranes and uterine wall and balloon inflated with 2030ml saline, catheter clamped & then strapped to thigh. Remove catheter after 4-6 hrs

Mean induction to abortion interval : 24-36 hrs Contraindications : kidney disease Complications:

-Incomplete abortion -Kidney damage -Rarely hemorrhage, embolism, anaphylactic reaction

Oxytocin drip is desirable in case of failure to initiate uterine activity within 24hrs In case of failure in 72 hrs , reinstallation of ethacrydine may be tried or resort to other method

Supplementation to hasten process of abortion:

Induction-abortion interval is reduced to 1218 hours 1. 1ml of prostodin injection diluted in 10 ml of distilled water through catheter just before removing Foleys 2. Addition of 0.5 mg prostaglandin E2 gel to Emcredil solution prior to instillation 3. Inj. Prostodin 250ug intramuscularly every 3 hrs , commencing from time of removal of catheter

Dilatation and evacuation

Suction curettage abortions 13 weeks gestation or later Accurate determination of gestational age preoperatively is essential D&E requires wider cervical dilatation Cannula primarily drains amniotic fluid at the beginning of evacuation & draws tissue into lower segment of uterus for forcep extraction. Confirm completion by identifying all major fetal parts

Contraceptive counselling

Ovulation may resume as early as 2 weeks To prevent pregnancy contraception should be initiated soon after abortion After 1st trimester abortion any method can be used except diaphragm or caps After 2nd trimester abortion any method can be used except diaphragm, caps, IUCD

Hysterotomy

Indications : MTP where other methods

of termination have failed

Advantage : concurrent permanent

sterlisation can be done

Complications :
Immediate : uterine bleeding, anesthetic hazards Remote : scar endometriosis, scar rupture in subsequent pregnancy

Management of complications

Uterine perforation
The most frequent site of myometrial perforation with all types of intrauterine surgery is the relatively avascular anterior or posterior midline surface of the active segment Suspicion of perforation: Instruments pass farther than expected without resistance Bleeding is excessive; or when contact with the gritty surface of the endometrium is lost Sighting of bowel or omentum in the cannula or through the cervix

If perforation is suspected & evacuation is complete

Continue stabilizing steps Begin antibiotics Ergometrine 0.2mg i/m Observe for 2 hrs; Continue observation if patient becomes stable Diagnostic laproscopy or laprotomy if condition gets worse

If perforation is suspected & evacuation is not complete

Continue stabilizing steps Begin antibiotics Complete evacuation under direct visual control (laproscopy) If perforation is extensive laprotomy may be needed

Immediate laprotomy

Rigid abdomen Acute abdominal pain Persistent low blood pressure Shock not stable after 1-3liters i/v fluids Abdominal Xray shows air under diaphragm

2.

Hematometra

Accumulations of clot less than 100 cc are more common and can remain asymptomatic for a few weeks. Symptoms: intermittent expulsion of marooncolored clots, pelvic pressure, and mild fever. Pelvic examination: enlarged, firm, tender uterus Sonography: intrauterine heterogeneous echo complex Treatment : The process is often self-limiting and responds immediately to resuctioning. Mild fever is usually not indicative of true infection; it dissipates rapidly with reevacuation, regardless of antibiotic coverage.

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