Medical Termination of Pregnancy (MTP) — Steps

Pre-procedure Assessment

1. Confirm intrauterine pregnancy — by history (last menstrual period), bimanual examination, quantitative β-hCG, and/or ultrasonography
2. Determine gestational age — method of termination depends on this
3. Rule out contraindications:
   • Suspected ectopic pregnancy (medical abortion does NOT treat ectopic)
   • Coagulopathy or anticoagulant therapy
   • Chronic adrenal failure or corticosteroid use
   • IUD in situ (remove first)
   • Severe anemia
   • Allergy to mifepristone or misoprostol
4. Obtain informed consent — patient signs agreement after reviewing medication guide
5. Counsel on what to expect — cramping, bleeding, passage of products; emergency contacts

Method Selection by Gestational Age

Medical Abortion (Mifepristone + Misoprostol) — Steps

• Administer Mifepristone 200 mg orally in the clinic
• Mifepristone is a selective progesterone receptor modulator → causes decidual necrosis (blocks progesterone → breaks down the pregnancy lining)

• Administer Misoprostol 800 µg (four 200-µg tablets)
• Route options:
  • Buccal (between gum and cheek) — FDA-approved
  • Sublingual (under tongue)
  • Vaginal
• Misoprostol is a prostaglandin E1 analogue → causes uterine contractions and expulsion of pregnancy

• Confirm complete abortion by clinical assessment, serial β-hCG levels, and/or ultrasound
• Ensure no retained products or ongoing pregnancy (rare ~3% failure rate)

What to Expect After Misoprostol

• Uterine cramping and bleeding begin within 1–4 hours — this is the intended effect
• Passage of gestational sac and products typically occurs within a few hours
• Lighter bleeding may continue for 1–3 weeks
• Less common: nausea, vomiting, diarrhea, low-grade fever/chills

Serious Complications (~0.3% of cases)

• Excessive bleeding → may require surgical completion (suction aspiration or D&C)
• Infection (including rare Clostridium sordellii toxic shock following mifepristone + intravaginal misoprostol)
• Incomplete abortion → surgical intervention required
• Risk of death: 0.00063% — approximately 14× lower than the risk associated with live birth

Efficacy

• ~97% effective in early first trimester
• Slightly higher efficacy at earlier gestational ages

Key Points to Remember

• Medical abortion does not treat ectopic pregnancy — always rule out ectopic first
• If misoprostol-only regimen is used (where mifepristone is unavailable), efficacy is somewhat lower (~80–85%)
• The regimen can be provided entirely outpatient, including via telemedicine with mail-order medications

Informed Consent for Medical Termination of Pregnancy (MTP)

1. Counseling Before Consent

• Use non-judgmental, open-ended questions and active listening
• Acknowledge and discuss any ambivalence

• Termination of pregnancy
• Continuing pregnancy with parenting
• Continuing pregnancy with adoption
• Risks, advantages, and disadvantages of each option must be explained in the context of the woman's specific situation

• Encourage the patient to seek trusted support (partner, family, spiritual counselors)
• Establish a clear timetable for decision-making based on gestational age (time-sensitive)

• Extreme anxiety or ambivalence
• Drug or alcohol use
• Medical or psychological problems
• These may require individualized counseling before proceeding

2. Capacity to Give Informed Consent

• Age — in many jurisdictions, minors require parental consent or judicial bypass
• Mental status — patient must have decision-making capacity
• Coercion — must be ruled out; the decision must be entirely voluntary

A support person may be present during any procedure, but consent must come from the patient herself.

3. Disclosure of Risks and Benefits

For Medical Abortion (Mifepristone + Misoprostol):

For Surgical Abortion (Aspiration/D&C):

4. Information to Be Provided to the Patient

• Correct dosing and administration of medications (for medical abortion)
• What to expect at home — cramping, bleeding, passage of tissue
• Aftercare instructions
• Emergency contact information and when to seek immediate care
• Follow-up visit schedule
• Post-procedure contraception options (e.g., IUD can be inserted immediately after first-trimester surgical abortion)

5. Documentation

• Patient signs a Medication Guide acknowledgment (for mifepristone — required by manufacturer/FDA)
• Patient signs a Patient Agreement form (Danco Laboratories form for mifepristone)
• Clinic-specific informed consent form is signed, covering:
  • Risks and benefits
  • Possible complications
  • Dosing and administration instructions
  • Aftercare guidance

6. Post-procedure Counseling (Discussed at Consent Stage)

• Need for follow-up visits and confirmation of complete abortion
• Contraceptive counseling — particularly long-acting reversible contraception (LARC)
• Signs and symptoms requiring emergency care
• Availability of additional psychological counseling if needed

Who Can Give Consent for MTP?

Under the Indian MTP Act, 1971 (Amended 2021)

1. The Woman Herself — Primary Consent

• A competent adult woman (≥18 years) gives consent herself
• No consent from husband, partner, or any other person is required or valid
• The decision is entirely hers

2. Special Circumstances — When Guardian Consent Is Required

Important: "Mentally ill" here refers to a woman who lacks the mental capacity to give informed consent — not simply someone with a mild psychiatric condition.

3. Married vs. Unmarried Women

• No spousal consent is required — a married woman does NOT need her husband's consent
• The Supreme Court of India (Justice D.Y. Chandrachud, 2022) affirmed that unmarried women also have equal rights to safe abortion under the MTP Act

4. Key Principles of Valid Consent

• Voluntary — free from coercion, pressure, or undue influence (from partner, family, or anyone else)
• Informed — patient understands the procedure, risks, alternatives, and consequences
• Competent — patient has the mental and legal capacity to decide
• Specific — consent is for the particular procedure being performed

5. Confidentiality

• The identity of the woman seeking MTP is strictly confidential under the MTP Act
• No information can be disclosed except to persons authorised by law

Summary Table

Note: These provisions are based on the Indian MTP Act 1971 (amended 2021) and are most relevant in the Indian clinical/legal context. In other countries (UK, USA, etc.), specific legislation governs consent — but the universal principle remains: a competent adult woman consents for herself, and guardian consent applies only for minors or those lacking capacity.