MTP History Taking Format

1. Patient Identification

• Name, Age, Address
• Date of registration
• IP/OP number

2. Chief Complaint

• Reason for seeking termination (e.g., unwanted pregnancy, fetal anomaly, risk to maternal health, rape/incest, contraceptive failure)

3. Menstrual History

• Age of menarche
• Cycle: duration / interval (e.g., 5/28 days)
• Last Menstrual Period (LMP) - exact date (critical for gestational age calculation)
• Expected Date of Conception (EDC) / Estimated Gestational Age (EGA)
• Any missed periods / irregular cycles
• Amount and character of flow

4. Current Pregnancy History

• Gestational age (by LMP and/or USG dating - mandatory before MTP)
• How was pregnancy confirmed? (home test / clinic UPT / serum beta-hCG / USG)
• Date and findings of ultrasound:
  • Intrauterine vs. extrauterine (rule out ectopic - absolute contraindication to medical MTP)
  • Single vs. multiple gestations
  • Viability (cardiac activity)
  • Any fetal anomalies detected
• Any antenatal care received
• Any bleeding, pain, or discharge in current pregnancy
• Reason for MTP - categorize:
  • Social/personal (unwanted pregnancy)
  • Contraceptive failure (specify method used)
  • Fetal indication (diagnosed anomaly incompatible with life or causing serious handicap)
  • Maternal indication (risk to life or physical/mental health)
  • Pregnancy due to rape or sexual assault

5. Obstetric History (G P A L)

• Gravida (total confirmed pregnancies including current)
• Para (deliveries ≥ 20 weeks)
  • Term deliveries
  • Preterm deliveries
• Abortions (spontaneous / induced / ectopic / molar) - number and management
• Living children (number, sex, age, health)
• Details of each previous pregnancy:
  • Year, period of gestation, mode of delivery, complications
  • Any previous MTP - gestational age, method used, complications (perforation, sepsis, cervical injury, incomplete evacuation)

6. Contraceptive History

• Current method being used (if any) - how did it fail?
• Previous contraceptive use
• Plans for contraception post-MTP

7. Gynecological History

• Previous pelvic infections / PID / STIs (affects risk of post-procedure infection)
• Fibroid uterus / uterine anomalies (affects procedure choice)
• Previous uterine surgery (cesarean, myomectomy - risk of perforation)
• Cervical surgery (LEEP/cone biopsy - may affect dilation)
• Endometriosis
• Ovarian cysts or masses
• Last cervical smear (Pap) result

8. Past Medical History

• Anemia (hemoglobin level - important; severe anemia may need optimization before surgical MTP)
• Bleeding disorders / coagulopathy (contraindication to medical MTP with mifepristone/misoprostol if on anticoagulants)
• Diabetes, hypertension
• Cardiac disease (important for anesthesia risk)
• Asthma (misoprostol - use with caution; prostaglandins can cause bronchospasm)
• Adrenal insufficiency / long-term corticosteroid use (relative contraindication to mifepristone, which is an anti-glucocorticoid)
• Seizure disorder
• Previous blood transfusions
• Hepatic/renal disease

9. Drug History & Allergies

• Current medications (especially anticoagulants, corticosteroids, anticonvulsants)
• Known drug allergies (especially to mifepristone, misoprostol, prostaglandins, NSAIDs)
• Use of herbal or traditional medicines

10. Surgical History

• Previous abdominal or pelvic surgeries (adhesions, altered anatomy)
• Previous anesthesia and any adverse reactions

11. Family History

• Bleeding disorders
• Genetic conditions (if fetal indication for MTP)
• Thromboembolic disease

12. Personal / Social History

• Marital status
• Occupation
• Consanguinity
• Tobacco, alcohol, substance use
• Support system (partner/family aware? consent considerations)
• Socioeconomic status

13. Counseling Points to Record

• Counseling was offered regarding all options (continuation, adoption, termination)
• The decision was voluntary and free from coercion
• Patient was informed of the procedure, risks, and alternatives
• Consent form signed (Form C under MTP Rules)
• For gestational age >20 weeks and up to 24 weeks: two registered medical practitioners must certify; this applies to specific categories (rape survivors, fetal anomalies, etc.)
• Confidentiality is maintained (name of woman not to be disclosed - MTP Act Section 5A)

14. Key Eligibility Criteria to Confirm (MTP Act 2021)

• Survivors of rape / sexual assault / incest
• Minors
• Change in marital status (widowhood, divorce)
• Women with physical disabilities
• Fetal malformation incompatible with life or causing serious handicap
• Pregnancies in humanitarian settings / emergencies

15. Pre-procedure Workup to Order (document intent)

• Ultrasound (gestational age + intrauterine location - mandatory)
• Hemoglobin / complete blood count
• Blood group and Rh typing (Rh-negative women need anti-D prophylaxis)
• Urine pregnancy test
• STI screening (if indicated)
• Coagulation profile (if bleeding disorder suspected)

1. Intrauterine pregnancy
2. Viable gestational age
3. Absence of contraindications (e.g., fibroids obstructing procedure)