SURGICAL METHODS SURGICAL METHODS OF MTPOF MTP

DR RAJEEV SOODDR RAJEEV SOOD

ASSTT PROF OBGASSTT PROF OBG

IGMC SHIMLAIGMC SHIMLA

MTP has been legalized in India since MTP has been legalized in India since 19711971

MTP service is used as a health MTP service is used as a health measure to avoid criminal abortion & measure to avoid criminal abortion & not as a contraceptive techniquenot as a contraceptive technique

Abortion scenario in IndiaAbortion scenario in India

Abortions account to 9% of MMR. Abortions account to 9% of MMR. Deaths mostly preventableDeaths mostly preventable

2/32/3rdrd of total abortions are unsafe of total abortions are unsafe Low awareness that abortions are Low awareness that abortions are

legallegal Lack of privacy at health facilities Lack of privacy at health facilities

lead to back-street abortionslead to back-street abortions

ABORTION STASTICSABORTION STASTICS

Each year an estimated 42 million Each year an estimated 42 million women worldwide undergo an women worldwide undergo an induced abortioninduced abortion

59% abortions took place at 8 weeks 59% abortions took place at 8 weeks gestations or earliergestations or earlier

88% abortions occurred at 12 weeks 88% abortions occurred at 12 weeks gestations or earliergestations or earlier

4.3% occurred between 16-20 weeks4.3% occurred between 16-20 weeks

First trimester surgical First trimester surgical methodsmethods

(i)(i) Menstrual regulationMenstrual regulation

(ii) Manual vacuum aspiration(ii) Manual vacuum aspiration

(iii)(iii) Electric vacuum aspirationElectric vacuum aspiration

(iv) Dilation & curettage(iv) Dilation & curettage

Menstrual RegulationMenstrual Regulation

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

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

ProcedureProcedure:- A thin plastic tube is inserted into the :- A thin plastic tube is inserted into the uterus and its contents sucked out by negative uterus and its contents sucked out by negative pressure created in a syringepressure created in a syringe

AdvantagesAdvantages :- :- No hospitalization required. No hospitalization required. Done without anesthesia. Done without anesthesia. Surgical risks are minimal.Surgical risks are minimal. DisadvantagesDisadvantages :- :- Failure of the procedureFailure of the procedure BleedingBleeding InfectionInfection

MANUAL VACUUM ASPIRATIONMANUAL VACUUM ASPIRATION

Indications for MVAIndications for MVA

Induced abortions up to 12 weeksInduced abortions up to 12 weeks Missed abortionsMissed abortions Blighted ovumBlighted ovum Molar pregnancy up to 12 weeksMolar pregnancy up to 12 weeks

Pre procedure assessmentPre procedure assessment

History takingHistory taking General physical examinationGeneral physical examination Bimanual pelvic examinationBimanual pelvic examination Hemoglobin, ABO-Rh, urine for Hemoglobin, ABO-Rh, urine for

protein & sugarprotein & sugar Informed consentInformed consent CounselingCounseling Contraceptive advise Contraceptive advise

ProcedureProcedure Patient should fast for at least 6 hrsPatient should fast for at least 6 hrs Antimicrobial prophylaxisAntimicrobial prophylaxis Patient should empty her bladder before being Patient should empty her bladder before being

placed in dorsal lithotomy positionplaced in dorsal lithotomy position Paracervical block is used for anesthesiaParacervical block is used for anesthesia Vacuum is created in 60 ml syringe & attached to Vacuum is created in 60 ml syringe & attached to

cannula which is inserted transcervically into the cannula which is inserted transcervically into the uterus, release pinch valve to begin suctioninguterus, release pinch valve to begin suctioning

Vacuum is activated & produces up to 660mm of Vacuum is activated & produces up to 660mm of Hg suctionHg suction

Abortion involves rotary & in and out cannula Abortion involves rotary & in and out cannula movement movement

Empty contents of aspirator into container & look Empty contents of aspirator into container & look for POC’sfor POC’s

Signs of empty uterusSigns of empty uterus

Red or pink foam without tissue Red or pink foam without tissue passing through cannulapassing through cannula

Gritty sensationGritty sensation Cervix gripping over the cannulaCervix gripping over the cannula

Advantages over EVAAdvantages over EVAo Cost is lower.Cost is lower.o MVA is quieter than electric suction MVA is quieter than electric suction

techniquetechniqueo No electricity requiredNo electricity requiredo Convenient for mobile servicesConvenient for mobile serviceso Tissue inspection is easyTissue inspection is easy

ComplicationsComplications

Vagal reaction Vagal reaction Incomplete evacuationIncomplete evacuation Uterine perforationUterine perforation Cervical lacerationCervical laceration Pelvic infectionPelvic infection HemorrhageHemorrhage HematometraHematometra

Electric vacuum Electric vacuum aspirationaspiration

PREABORTION CERVICAL PREABORTION CERVICAL PREPRATIONPREPRATION

1.1. ProstaglandinsProstaglandins: Misoprostol PGE1 : Misoprostol PGE1 derivative 400ug orally or vaginally derivative 400ug orally or vaginally 3-4 hrs prior to procedure 3-4 hrs prior to procedure sufficiently soften the cervix & sufficiently soften the cervix & facilitates dilationfacilitates dilation

• Inj. 15 methyl PGF2 alpha 250ug Inj. 15 methyl PGF2 alpha 250ug can be given 45 min. prior to can be given 45 min. prior to procedureprocedure

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

Act by drawing water from cervical tissue Act by drawing water from cervical tissue After 4-6 hrs laminaria swollen & dilate the After 4-6 hrs laminaria swollen & dilate the

cervix graduallycervix gradually Reduces risk of cervical injuryReduces risk of cervical injury Disadvantages: cost, inconvenience & Disadvantages: cost, inconvenience &

occasional cramping occasional cramping

Laminaria tentsLaminaria tents

ProcedureProcedure Antimicrobial prophylaxis should be givenAntimicrobial prophylaxis should be given Patient should fast for at least 6 hrsPatient should fast for at least 6 hrs Patient should empty her bladder before being Patient should empty her bladder before being

placed in dorsal lithotomy positionplaced in dorsal lithotomy position Antiseptic is applied to cervix & vaginaAntiseptic is applied to cervix & vagina Paracervical anesthesia is givenParacervical anesthesia is given Cervical dilation: cervix is dilated upto desired Cervical dilation: cervix is dilated upto desired

extent with grduated metal dilators. 4extent with grduated metal dilators. 4thth & 5 & 5thth finger finger of hand introducing dilator should rest on perineum of hand introducing dilator should rest on perineum & buttocks which minimizes forceful dilatation & & buttocks which minimizes forceful dilatation & provides safeguard against perforationprovides safeguard against perforation

Hegar Hawkin Hegar Hawkin Pratt dilatorPratt dilator

Procedure contProcedure cont..

Sims speculum introduced & cervix held Sims speculum introduced & cervix held with tenaculumwith tenaculum

Cannula inserted then attached to suction Cannula inserted then attached to suction machine, cannula is turned machine, cannula is turned circumferentially to cover entire surface of circumferentially to cover entire surface of uterine cavityuterine cavity

Negative suction of 600-660mm of Hg is Negative suction of 600-660mm of Hg is applied & contents aspirated till gritty applied & contents aspirated till gritty sensation is felt & no tissue obtainedsensation is felt & no tissue obtained

Rh –ve should be given 50ug of Anti-D inj. Rh –ve should be given 50ug of Anti-D inj. after abortionafter abortion

Post procedure carePost procedure care

Take vital signsTake vital signs Evaluate bleeding per vaginum & Evaluate bleeding per vaginum &

abdominal painabdominal pain Pain managementPain management Provision of antibioticsProvision of antibiotics Rh –ve should be given 50ug Anti-DRh –ve should be given 50ug Anti-D

Conditions requiring immediate attentionConditions requiring immediate attention

Significant decline in vital signsSignificant decline in vital signs Dizziness, shortness of breath, Dizziness, shortness of breath,

fainting attacksfainting attacks Severe vaginal bleedingSevere vaginal bleeding Loss of resistance during procedure, Loss of resistance during procedure,

severe abdominal pain or crampssevere abdominal pain or cramps

COMPLICATIONSCOMPLICATIONS

1.1. ImmediateImmediate: develop during or within : develop during or within 3 hrs of operation3 hrs of operation

Anesthesia complicationAnesthesia complication Hemorrhage 0.05- 4.9%Hemorrhage 0.05- 4.9% Cervical injury 0.01-1.6%Cervical injury 0.01-1.6% Hematometra 0.1-1%Hematometra 0.1-1% Perforation 0.2%Perforation 0.2%

Delayed: Delayed: develop develop more than 3 hrs & more than 3 hrs & up to 28 days after up to 28 days after the procedurethe procedure

Incomplete Incomplete abortion <1%abortion <1%

Postoperative Postoperative sepsis <1% sepsis <1%

Late: Late: develop after develop after 28 days28 days

Rh senstization Rh senstization 2.6%2.6%

Intrauterine Intrauterine adhesions 16-19%adhesions 16-19%

Cervical Cervical incompetenceincompetence

Dilatation & CurettageDilatation & Curettage Dilation and curettage uses a sharp Dilation and curettage uses a sharp

instrument to remove tissue from inside instrument to remove tissue from inside the uterus. the uterus.

Increased risk of bleeding and injury to the Increased risk of bleeding and injury to the uterus compared with the usual procedure uterus compared with the usual procedure that uses suction to clear the uterus that uses suction to clear the uterus

Can be used toCan be used to::1. 1. Remove tissue that may remain after Remove tissue that may remain after

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

vacuum aspiration abortion. vacuum aspiration abortion.

22NDND TRIMESTER SURGICAL TRIMESTER SURGICAL METHODMETHOD

1.1. Intra-amniotic instillation of hypertonic Intra-amniotic instillation of hypertonic solutionsolution

2.2. Extra amniotic instillation of drugsExtra amniotic instillation of drugs

3.3. Dilatation and evacuationDilatation and evacuation

4.4. HysterotomyHysterotomy

5.5. Hysterectomy Hysterectomy

Intra-amniotic instillation of hypertonic Intra-amniotic instillation of hypertonic solutionsolution

1.1. Hypertonic salineHypertonic saline (20%) (20%) – abdominal route – abdominal route

• Less commonly used nowLess commonly used now• Amount to be instilledAmount to be instilled – no. of weeks of – no. of weeks of

gestation x 10 mlgestation x 10 ml• Infused at rate of 10 ml/minInfused at rate of 10 ml/min• Mode of actionMode of action – liberation of prostaglandins – liberation of prostaglandins

following necrosis of amniotic epithelium and following necrosis of amniotic epithelium and deciduadecidua

• ContraindicationsContraindications: cardiovascular and renal : cardiovascular and renal disease, severe anemiadisease, severe anemia

• Effective in 90-95% casesEffective in 90-95% cases• Induction to abortion interval – 32 hoursInduction to abortion interval – 32 hours• Failure if abortion fails to occur in 48 hrsFailure if abortion fails to occur in 48 hrs

Side effectsSide effects

Minor – fever, headache, nausea, Minor – fever, headache, nausea, vomitingvomiting

Cervical tear and lacerationCervical tear and laceration Retained productsRetained products InfectionInfection Hypernatramia, cardiovascular collapseHypernatramia, cardiovascular collapse Pulmonary and cerebral edemaPulmonary and cerebral edema Renal failureRenal failure DICDIC Death – 0-5 per 1000 instillationDeath – 0-5 per 1000 instillation

2.2. Hyperosmotic urea(40%)Hyperosmotic urea(40%)• Combination with intraamniotic Combination with intraamniotic

15methyl PGF215methyl PGF2αα 2mg reduces mean 2mg reduces mean induction to abortion interval to 13 hrs induction to abortion interval to 13 hrs and effective in 80% casesand effective in 80% cases

Extra amniotic instillation of Extra amniotic instillation of drugsdrugs

0.1% ethacrydine lactate0.1% ethacrydine lactate Mechanism of action:Mechanism of action: Direct oxytocic effect on myometriumDirect oxytocic effect on myometrium Stripping of membranes with release of prostaglandinsStripping of membranes with release of prostaglandins Antiseptic action, prevent infectionAntiseptic action, prevent infection Dose : Dose : 10ml per week of gestation maximum of 150 ml10ml per week of gestation maximum of 150 ml Procedure : Procedure : no. 16 Foley’s catheter passed up the no. 16 Foley’s catheter passed up the

cervical canal for about 5cm above the internal os between cervical canal for about 5cm above the internal os between membranes and uterine wall and balloon inflated with 20-membranes and uterine wall and balloon inflated with 20-30ml saline, catheter clamped & then strapped to thigh. 30ml saline, catheter clamped & then strapped to thigh. Remove catheter after 4-6 hrs Remove catheter after 4-6 hrs

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

-Incomplete abortion-Incomplete abortion

-Kidney damage-Kidney damage

-Rarely hemorrhage, embolism, anaphylactic reaction-Rarely hemorrhage, embolism, anaphylactic reaction

Oxytocin drip is desirable in case of failure to initiate Oxytocin drip is desirable in case of failure to initiate uterine activity within 24hrsuterine activity within 24hrs

In case of failure in 72 hrs , reinstallation of ethacrydine In case of failure in 72 hrs , reinstallation of ethacrydine may be tried or resort to other method may be tried or resort to other method

Supplementation to hasten process of Supplementation to hasten process of abortion:abortion:

Induction-abortion interval is reduced to 12-Induction-abortion interval is reduced to 12-18 hours18 hours

1.1. 1ml of prostodin injection diluted in 10 ml 1ml of prostodin injection diluted in 10 ml of distilled water through catheter just of distilled water through catheter just before removing Foleysbefore removing Foleys

2.2. Addition of 0.5 mg prostaglandin E2 gel to Addition of 0.5 mg prostaglandin E2 gel to Emcredil solution prior to instillationEmcredil solution prior to instillation

3.3. Inj. Prostodin 250ug intramuscularly every Inj. Prostodin 250ug intramuscularly every 3 hrs , commencing from time of removal 3 hrs , commencing from time of removal of catheter of catheter

Dilatation and evacuationDilatation and evacuation Suction curettage abortions 13 weeks Suction curettage abortions 13 weeks

gestation or latergestation or later Accurate determination of gestational age Accurate determination of gestational age

preoperatively is essentialpreoperatively is essential D&E requires wider cervical dilatationD&E requires wider cervical dilatation Cannula primarily drains amniotic fluid at the Cannula primarily drains amniotic fluid at the

beginning of evacuation & draws tissue into beginning of evacuation & draws tissue into lower segment of uterus for forcep extractionlower segment of uterus for forcep extraction..

Confirm completion by identifying all major Confirm completion by identifying all major fetal partsfetal parts

Contraceptive counsellingContraceptive counselling

Ovulation may resume as early as 2 weeksOvulation may resume as early as 2 weeks To prevent pregnancy contraception should be To prevent pregnancy contraception should be

initiated soon after abortioninitiated soon after abortion After 1After 1stst trimester abortion any method can be trimester abortion any method can be

used except diaphragm or capsused except diaphragm or caps After 2After 2ndnd trimester abortion any method can be trimester abortion any method can be

used except diaphragm, caps, IUCDused except diaphragm, caps, IUCD

HysterotomyHysterotomy

IndicationsIndications : : MTP where other methods MTP where other methods of termination have failedof termination have failed

AdvantageAdvantage : : concurrent permanent concurrent permanent sterlisation can be donesterlisation can be done

ComplicationsComplications : : Immediate : uterine bleeding, anesthetic Immediate : uterine bleeding, anesthetic

hazardshazards Remote : scar endometriosis, scar rupture Remote : scar endometriosis, scar rupture

in subsequent pregnancyin subsequent pregnancy

Management of Management of complicationscomplications

Uterine perforationUterine 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 & If perforation is suspected & evacuation is completeevacuation is complete

Continue stabilizing stepsContinue stabilizing steps Begin antibioticsBegin antibiotics Ergometrine 0.2mg i/mErgometrine 0.2mg i/m Observe for 2 hrs;Observe for 2 hrs;- Continue observation if patient Continue observation if patient

becomes stablebecomes stable- Diagnostic laproscopy or laprotomy if Diagnostic laproscopy or laprotomy if

condition gets worsecondition gets worse

If perforation is suspected & If perforation is suspected & evacuation is not completeevacuation is not complete

Continue stabilizing stepsContinue stabilizing steps Begin antibioticsBegin antibiotics Complete evacuation under direct Complete evacuation under direct

visual control (laproscopy)visual control (laproscopy) If perforation is extensive laprotomy If perforation is extensive laprotomy

may be neededmay be needed

Immediate laprotomyImmediate laprotomy

Rigid abdomenRigid abdomen Acute abdominal painAcute abdominal pain Persistent low blood pressurePersistent low blood pressure Shock not stable after 1-3liters i/v Shock not stable after 1-3liters i/v

fluidsfluids Abdominal Xray shows air under Abdominal Xray shows air under

diaphragmdiaphragm

2.2. Hematometra HematometraAccumulations of clot less than 100 cc are more common and can remain asymptomatic for a fewweeks.

Symptoms: intermittent expulsion of maroon-colored 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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