DR.

ROMAN AL MAMUN

Lecturer and Autopsy Surgeon

Forensic Science and Toxicology

Abortion is premature expulsion of products of conception from womb, either

spontaneous or induced at any time before the period of gestation is completed.
The word abortion is derived from the Latin word ' Abortion ' that means, "to get
detached from the proper site.
Legally there is no difference between Abortion, miscarriage or premature
delivery. However, medical jargon carries different meaning. Medical terminology
is given below. In medical terminology.
> Abortion means expulsion of products of conception in the first trimester of
pregnancy.
> Miscarriage means expulsion of product of conception in second trimester.
> Premature delivery refers to expulsion of fetus after 7 months of pregnancy but
before term.
CTASSIFICATION
Abortion is classified into following two major groups
1. Natural (spontaneous)
2. Artificial (Induced)
Induced abortion may be:
 Justifiable abortion (therapeutic)
 Criminal abortion
Natural abortion may be:
 Isolated abortion
  Recurrent Abortion

Natural Abortion
Spontaneous or natural abortion occurs usually in first or Second trimester of
pregnancy .
Unsafe Abortion
. This term has been proposed by WHO
. It means abortion not provided through approved facilities and/or persons.
Fabricated Abortion
. This is false sort of abortion with malicious intention to accuse someone
. A female may allege a person that due to assault by that person, she has aborted.
In her support, she may produce false things such as menstrual pads or killed
animal fetus pertaining that it is abortus material.

INDUCED ABORTION
. It is a type of Abortion which is deliberately induced. It may be justifiable
(therapeutic) or criminal.

CRIMINAL ABORTION.
Any abortion, which does not come under the rules of the Medical Termination of
pregnancy (MTP) , is considered as criminal abortion.
Thus, in other words, it is an unlawful expulsion of product of conception at any
stage of gestation by any unqualified person or a qualified doctor and is punishable
under the law.
MOTIVES FOR CRIMINAL ABORTION
1. Unmarried girls and widows may, at times, resort to criminal abortion when
child is product of illicit sexual intercourse.
2. A poor family may procure criminal abortion to avoid the addition of a member
to family.
3. Female feticide i.e. killing of female fetus. When female is pregnant, these
people do sex determination test (at present unlawful act) and if the sex of baby is
found to be female, they persuade the pregnant lady to abort the product of
conception.
METHODS TO INDUCE CRIMINAL ABORTION ARE :
1. Use of abortifacient drugs
2. Application of mechanical violence .

1. Abortifacient Drugs
These drugs are classified as:
1. Ecbolics: These drugs initiate uterine contraction and causes abortion. Examples
are;
 Ergot preparations
 Synthetic estrogen
 Pituitary extract
 Quinine
2. Emmenagogues: These drugs promote uterine congestion and induce bleeding
thus expelling product of conception. Examples are:
 Borax
 Oil of savin
3. Irritants: These are of following types
 o Genitourinary tract irritants - these agents produce inflammation of
genitourinary tract and reflexly irritate the uterus and induce uterine
contraction example Cantharides, turpentine oil.
o Gastrointestinal tract irritants these agents cause reflex contraction of
uterine muscles - example; croton oil etc.
o Systemic poisons - For example: arsenic, mercury, fruit of papaya etc.
o Abortion pills etc.
VIOLENCE
l. General violence - may act directly or indirectly on uterus.
Following are examples of general violence
 Severe form of exercise like excessive cycling, riding, jumping etc.
 Application of blows or kicks over abdomen or pressure on abdomen
by kneading or firmly massaging the abdomen
 Cupping: a flame light is placed on abdomen and a metal mug is
placed over the flaming light.
2. Local method
A) By unskilled or semiskilled person.
Rupture of membrane by abortion stick, metal rod, knitting needle, hair Pin
etc.
 Application of abortion Paste
 Use of root of plant as Abortifacient agent
 Syringing: either for aspiration of fluid or forced filling of uterine
cavity with fluid and air.
B) By skilled Person
 Low rupture of membrane
 Vacuum aspiration
  Dilatation and evacuation
 Use of Prostaglandins.

Abortion Stick
. This is a thin wooden or bamboo stick about 15 to 20 cm in length and 0.5
to 1 cm in diameter' One end of stick is wrapped with cloth or cotton wool
and is soaked in or smeared with irritant abortifacient substances
. The substances consist of juice of marking nut, or paste made up of arsenic
or lead etc'
. The stick is then passed into the uterus per vaginally resulting in rupture of
membrane and expulsion of product of conception.
Complications of abortion sticks are:
l. Local injury
2. Hemorrhage and shock
3. Perforation of uterus
4. Perforation peritonitis
5. Incomplete abortion
6. Embolism
7. Septicemia

COMPLICATION OF CRIMINAL ABORTION

Immediate
l. Hemorrhage
2. Perforation of uterus
3. Shock due to vagal inhibition resulting from instrumentation
4. Fat embolism
5. Air embolism
6. Amniotic fluid embolism
7. Incomplete abortion
8. Local injury
Delayed
l. Septicemia
2. Tetanus
3. Endometritis
4. Renal failure
5. Peritonitis
6. Sterility
7. Recurrent abortion
Causes of Death in Criminal Abortion
l. Vaso-vagal shock
2. Hemorrhagic shock
3. Perforation of uterus
4. Septicemia
5. Embolism
6. Disseminated intravascular coagulation

DUTIES OF REGISTERED MEDICAL PRACTITIONER IN

CRIMINAL ABORTION
Unsafe abortion today, constitutes the single largest cause of pregnancy-
related deaths.
When a female comes to RMP with history of criminal abortion or
attempted criminal abortion, then:
1. Doctor should record history of the incident, the method
adopted to procure abortion.
2. If death is imminent, doctor must arrange for dying declaration.
3. If female dies, he should report matter to the police.
Medical Evidence of Abortion
It consists of
1. Examination of female.
2. Examination of aborted material.

EXAMINATION OF FEMALE (DURING LIFE)

1. General: Female will have exhaust look, increase temperature, increase

pulse.
2. Breasts; Are heavy, enlarged, areola and nipples are pigmented,
colostrum/milk may ooze on squeezing the breasts .
3. Abdomen: Is lax and wrinkled. Striae may be present along with linea
nigra. Involuting uterus may be palpable.
4. Perineum: Laceration or bruises may be noted, inflammation is evident
5. Labia: majora and minora will be inflamed and bruised
6. Vagina: Tags of membrane, partial aborted material, blood, foreign body,
abortion stick etc. may be found. The vaginal wall is contused, abraded or
lacerated. The wall is lax, dilated.
7. Cervix: The external os would be patulous, ulceration or erosions may be
present. Cervical canal may be dilated with abrasions or lacerations.
8. Uterus: May be enlarged on bimanual examination or may be showing
signs of involution.
9. Swab from cervical canal will reveal chemical used for procuring
abortion and can be used for bacteriological examination.
10. Urine examination: hCG may be detected up to 7 days.

EXAMINATION OF FEMALE (AFTER DEATH)

In addition to above, following findings may be noted at autopsy

. Clothes: Undergarments may show blood, clots, pieces of product of
conception, stains of chemicals used etc.
. Uterus: Enlarged, cavity may show presence of partially separated product
of conception, foreign body, blood clots, presence of any paste or chemical,
evidence of injury or perforation etc.
. Evidence of infection .
Ovaries: Presence of corpus luteum
EXAMINATION OF ABORTED MATERIAL
. ''Police may request medical examiner to examine a substance alleged to
have been expelled from uterus as product of conception.
Doctor should examine the substance carefully.
. The alleged product of conception should be washed.
If it happens to be product of conception, it may be suggestive of criminal
abortion.
. Difficulty arises in early months of pregnancy when embryo is small or not
found.
In such cases presence of chorionic villi on microscopic examination
will confirm that it is product of conception.
. During first three months of pregnancy, the fetus is expelled with its
membrane en mass but after this period, the fetus is born first and then after
that placenta is detached and expelled. If only placenta is sent for medical
examination then it should also be examined to ascertain injuries or tears
and any degenerative changes in its surface.
. The fetus should be examined to determine its:
l. Probable intrauterine age.
2. Presence or absence of injuries on body.
3. Viability of child.

Medicolegal importance of placenta

1. At term placenta is about 500 gm in weight.
2. Period of gestation can be estimated.
3. Some poisons may be detected in placenta.
4. Retained placenta or pieces of placenta may be found in criminal abortion
and may be the cause of death due to hemorrhage.
5. Disease can be ascertained.
6. Transfer of poisons, drugs, bacteria or antibodies acrossplacenta
(placental barrier) may result in fetal death, fetal
infections or fetal malformations.
JUSTIFIABLE ABORTION THERAPEUTIC
. It is also called as therapeutic abortion or legal abortion .
. It is performed either in accordance with the legal provisions under the
Medical Termination of Pregnancy (MTP) Act 1971 (i.e. legal abortion) or
caused in good faith to save the life of the pregnant .
Medical Termination of Pregnancy
INDICATIONS
1. Therapeutic
When continuation of pregnancy may cause risk to the life of the pregnant
woman or may cause grave injury to her physical or mental health, it can be
terminated on therapeutic ground.
2. Eugenic
If there is possibility that child born would be suffering from physical or
mental abnormalities that lead the child to be handicapped, then such
pregnancy can be terminated on Eugenic grounds.
3. Humanitarian
When the pregnancy is caused by rape then it can be terminated on
humanitarian ground.
4. Social
When pregnancy has resulted due to failure of contraceptive method adopted
by married woman or her husband for the purpose of limiting the number of
children, then such pregnancy can be terminated on social grounds.
Important:
In an emergency, a Registered Medical Practitioner can terminate
pregnancy at any place, irrespective of duration of pregnancy.
Abortion done in good faith to save the life of a woman, if it appears that
continuance of pregnancy would endanger maternal health is not considered
as criminal abortion.
Rules for Doing MTP

1. Qualification Required
 Only qualified Registered Medical Practitioner, having
following required experience can terminate the pregnancy.
 A RMP who has assisted in at least 25 cases of MTP in a recognized
hospital
 A Doctor with MD in Gynecology and Obstetrics or DGO
qualification or has 6 months of experience in house-surgeon ship in
obstetrics in a recognized hospital.
2. Place - MTP can be Carried Out at A hospital maintained or established
by government . Non-government hospital approved by government
3. Consent
 A female above 18 years of age with sound mind can give consent for
MTP
 In minor females (i.e. age less than 18 years) or mentally ill ,
consent of parents or guardian is necessary.
4. Duration of Pregnancy
. When duration of pregnancy is below 12 weeks of gestation, one
Registered Medical Practitioner (RMP) can terminate the pregnancy.
. When duration of pregnancy is above 12 weeks but less
that 20 weeks (i.e. 12-20 weeks), then two RMP are required to terminate
the pregnancy.
5. Documentation and Record
Date generated by mentioning the year against the serial number
. The admission register is a secret document.
It should be maintained for at least 5 years from the last entry.

Methods of Inducing MTP

Up to 12 Weeks
l. Manual vacuum aspiration
2. Suction evacuation and/or curettage
3. Dilatation and curettage
4. Mifepristone
5. Methotrexate and misoprostol

Between 13 to 20 Weeks
1. Dilatation and evacuation
2. Oxytocin infusion
3. Induction by prostaglandins E, (misoprostol) (Used as intravaginally,
intramuscularly or intra amniotically)
4. Hysterotomy - less common method
Complications of MTP
Immediate
1. Hemorhage and shock
2. Perforation of uterus, intestine
3. Laceration of cervix or vagina
4. Incomplete abortion
5. Endometritis
6. Embolism
Delayed
l. Menstrual disturbances
2. Sterility
3. Pelvic inflammatory disease
4. Recurrent abortion or premature labor
5. Rh isoimmunization
 6. Psychological sequelae

MEDICOLEGAL LMPORTANCE OF ABORTION

1. When abortion is induced without proper indication or in contravention

to the provisions of MTP Act, it is considered as criminal abortion and is
punishable by law.
When Doctor violates the provisions of MTP Act, he is liable to be punished
by the law and similarly his act amount to misconduct in professional sense.
To bring a false charge of assault against any person, a female may plead
that she has been assaulted and due to assault, abortion was induced.
A female may be falsely charged or implicated for inducing criminal
abortion.

Under the Bangladesh Penal Code of 1860, abortion is

permissible only to save the life of a woman.
In all other circumstances, abortion—self-induced or otherwise—is
a criminal offense punishable by imprisonment, fines or
both. Menstrual regulation (MR)—officially recognized as
an interim method for establishing nonpregnancy—has
been available free of charge in the government’s family
planning program as a public health measure since 1979.
MR services were introduced in Bangladesh in 1974 on
a small scale to assess the feasibility of providing them
nationally; in 1979, a training program was initiated in
seven medical college hospitals and two district hospitals.
3
In the years since, service provision has expanded and
is now national in scale. MR is included within the family
planning program not as a contraceptive method, but
rather as a backup for ineffective use of contraceptives, as
no contraceptive is completely successful in preventing
unwanted pregnancy.

A government authorization rule regulates MR,which is generally performed with manual

vacuum aspiration (MVA). The rule gives specific guidance for the provision
of MR services, covering the types of providers who can offer the service, namely, doctors,
family welfare visitors (FWVs) and paramedics*; the context of service provision,
either outpatient or inpatient; and the maximum number
of weeks permitted since the last menstrual period (LMP).
Unsafe abortion was prevalent in Bangladesh before the
advent of MR services and has continued since the MR
program was established, as noted above.

Definitions
Menstrual regulation (MR):
We used the government’s definition of MR, that is, a procedure
to establish nonpregnancy that is performed by
a trained provider in a facility and within the
permissible number of weeks LMP (according to
the type of provider).
However, we also included
an additional category in our count of MRs:
Because we recognize that some trained FWVs
and paramedics also unofficially provide MRs
outside of facilities or in women’s homes, we
also classify and count these as MR procedures.

Induced abortion:
We defined induced abortion
as the termination of a pregnancy by a procedure
or action taken by a provider or a woman herself,
outside of the definition of MR above.
Unsafe abortion:
We defined unsafe abortion as the termination of a pregnancy by an untrained provider, in
an unhygienic environment or both.

Postabortion care (PAC):

In this study, we obtained information on two aspects of PAC:
treatment given to women with postabortion
complications for the complications, and contra-
ceptive counseling and services. Comprehensive
PAC includes these types of care and, in addition,
counseling regarding STI/HIV prevention and pro-
vision of or referral for testing and treatment of
STIs (topics that were not included in this study)

 Under Bangladesh’s penal code of 1860, induced abortion is illegal except to save a
woman’s life.
 Menstrual regulation (MR), however, has been part of Bangladesh’s national family
planning program since 1979. MR is a procedure that uses manual vacuum aspiration or a
combination of mifepristone and misoprostol to “regulate the menstrual cycle when
 menstruation is absent for a short duration.” MR performed using medication is referred
to as MRM.
 Government regulations allow for MR procedures up to 10–12 weeks after a woman’s
last menstrual period (depending on the type of provider), and MRM is allowed up to
nine weeks after a woman’s last menstrual period.
 Despite the availability of MR services, many women resort to clandestine abortions,
some of which are unsafe.
 In 2014, some 2.8 million pregnancies— 48% of all pregnancies—were unintended.
Abortion and MR procedures accounted for close to three-fifths of unintended
pregnancies.*

Incidence of MR and abortion

 In 2014, an estimated 430,000 MR procedures were performed in health facilities
nationwide, representing a sharp 34% decline since 2010.
 In addition, an estimated 1,194,000 induced abortions were performed in Bangladesh in
2014, and many of these were likely done in unsafe conditions or by untrained providers.
 The annual rate of MR in 2014 was 10 per 1,000 women aged 15–49, down from 17 in
2010.
 The annual abortion rate in 2014 was 29 per 1,000 women aged 15–49. Because of
changes to the methodology for estimating abortion incidence, this rate is not comparable
to the rate estimated for 2010. The rate was highest in Khulna (39) and lowest in
Chittagong (18).

Provision of and trends in MR services

 Nationally, only 53% of public-sector facilities permitted to provide MR services actually
did so in 2014 (down from 66% in 2010). At 20%, this proportion was much lower
among private-sector facilities (down from 36% in 2010).
 Only about half of all union health and family welfare centres (UH&FWCs) capable of
providing MR procedures did so in 2014, a significant decline from two-thirds in 2010.
These facilities are the primary health providers in rural areas, where the majority of the
population lives.
 The number of MRs provided by UH&FWCs also dropped precipitously, from 302,000
in 2010 (close to half of all MR procedures in the country) to 138,000 in 2014. The
decline in procedures at UH&FWCs accounted for close to three-quarters of the total
nationwide decline.
 The decline in the proportion of UH&FWCs providing MR services may have been due,
in part, to a lack of training among a recently recruited cohort of providers who were
recruited to replace a large cohort of providers reaching retirement age. At UH&FWCs
that did not offer MR services in 2014, 92% of providers aged 20–29 said they did not
provide MR because they lacked training in the procedure.
 In 2014, 57% of MR procedures were performed in public facilities, down from 63% in
2010. NGOs provided 35%, and private clinics provided 8%, of MR services.
  Facilities reported that almost all MR patients received contraceptive counseling (99%),
but much smaller proportions were given a contraceptive method: 77% of those receiving
MRs at public facilities and only 7% of those attending private facilities.

Treatment for complications of unsafe abortion

 An estimated 384,000 women suffered complications from clandestine abortion in 2014.
One-third of those requiring facility-based treatment did not receive the postabortion care
(PAC) they needed.
 In 2014, 91% of public and private health facilities considered able to provide PAC did
so, an increase from 84% in 2010. The most common complications treated were
hemorrhage and incomplete abortion; more serious complications, such as shock, sepsis
and uterine perforation, were also reported.
 Between 2010 and 2014, there was a marked increase in the proportion of PAC patients
diagnosed with hemorrhage, from 27% to 48%.† It is possible that this rise is related to
an increase in the incorrect clandestine use of misoprostol.
 Poor women and rural women are the groups considered most likely to be at risk for
complications from unsafe abortion. Respondents to the 2014 Health Professionals
Survey estimated 85% of nonpoor urban women in need of facility-based care for
complications from clandestine abortion would receive it, compared with only 47%
among their poor rural counterparts.
 Nearly all public and private facilities that provided PAC in 2014 (99%) offered family
planning counseling to the vast majority of their PAC patients. However, only 18% of
these facilities provided their patients with contraceptive methods.

Abortion Law

Abortion is only permitted to save the life of the woman.

MR (menstruation regulation) is permitted up to 12 weeks of pregnancy.

Bangladesh Penal Code (Act XLV, 1860), 6 October 1860.

Section 312. Whoever voluntarily causes a woman with child to miscarry shall, if such
miscarriage be not caused in good faith for the purpose of saving the life of the pregnant woman,
be punished with imprisonment of either description for a term which may extend to three years,
or with fine, or with both; and, if the woman be quick with child, shall be punished with
imprisonment of either description for a term which may extend to seven years, and shall also be
liable to fine.

Explanation—A woman who causes herself to miscarry is within the meaning of this section.

Section 313. Whoever commits the offence defined in the last preceding section without the
consent of the woman, whether the woman is quick with child or not, shall be punished with
transportation for life, or with imprisonment of either description for a term which may extend to
ten years, and shall also be liable to fine.
Section 314. Whoever, with intent to cause the miscarriage of a woman with child, does any act
which causes the death of such woman shall be punished with imprisonment of either description
for a term which may extend to ten years, and shall also be liable to fine; and if the act is done
without the consent of the woman, shall be punished either with transportation for life, or with
the punishment above mentioned.

Explanation—It is not essential to this offence that the offender should know that the act is likely
to cause death.

Section 315. Whoever, before the birth of any child, does any act with the intention of thereby
preventing that child from being born alive or causing it to die after its birth, and does by such
act prevent that child from being born alive, or causes it to die after its birth, shall, if the act be
not caused in good faith for the purpose of saving the life of the mother, be punished with
imprisonment of either description for a term which may extend to ten years, or with fine, or
with both.

Section 316. Whoever without lawful excuse does any act knowing that he is likely to cause
death to a pregnant woman, and does by such act cause the death of a quick unborn child, shall
be punished with imprisonment of either description for a term which may extend to ten years,
and shall also be liable to fine.

Misoprostol Availability

Misoprostol is available under the brand names Miclofenac, Ultrafen-plus, Erdon Super,
Misoclo, Profenac plus, Misofen, Arthrofen, and Dix Extra.

Facts

 Annually, more than 12,000 women die due to pregnancy or pregnancy-related causes.
 The estimated maternal mortality rate (MMR) is about 322 deaths per 100,000 live births.
 About 29% of these deaths are due to hemorrhage.

It is estimated that more than 85% of deliveries are conducted at home, and the majority of births
are attended by untrained birth attendants, relatives, or neighbors (> 80%) that are not medically
trained for delivery. Most of these delivery attendants are unaware of the fatal consequences of
any delay in management of obstetric emergencies especially postpartum hemorrhage.
Moreover, emergency obstetric care is neither easily available nor accessible to pregnan In
Bangladesh, the punishment of crime is regulated by the Penal Code 1860 while under sections
312-316, punishment of causing miscarriage, causing miscarriage without women's consent and
death caused by the act done with intention to cause miscarriage -are conspicuous. Abortion is
only allowed when the women's life is in danger, which proves the ground to be circumscribed
and confined. In our country abortion was legalised for a certain period in 1972, for the rape
victims of the liberation war. However attempts, taken by Bangladesh National Population
Policy to make abortion legal for the first time were failed in 1976. We haven't faced any active
or consistent protests against the law so far but research says, in Bangladesh abortion is more
prevalent among unmarried adolescent girls than married women. The comparison is about thirty
five times more among the girls who are less than eighteen years of age and these are in most of
the cases unlawful abortion.

Ours is a country where law is seldom seen to be executed, and still we are struggling with law
enforcement. But such actions of miscarriage are being adapted unlawfully to deceit the law,
which raises a question to the health and hygiene of particularly the young girls who seek to get
rid of their pregnancy.

More often than not such incidents seem to be correlated with rape incidents or pre-mature
marriage which again brings the execution of law to question. So, laws in our country need to
recognize the circumstances of the cases before reaching any judgment and need to be reformed
in a way to adapt to the situation of people for whom the laws are made.

 t women in rural Bangladesh.

 Abortion in Bangladesh is illegal under most situations, but menstrual regulation is
often used as a substitute. Bangladesh is still governed by the penal code from 1860,
where induced abortion is illegal unless the woman in danger.[1][2]
 Historically, abortion has been prevalent, especially during the years following the
Bangladesh Liberation War. For example, in 1972, the law allowed for abortion for those
women who has been raped during the war.[2] In 1976, the Bangladesh National
Population Policy unsuccessfully attempted to legalize abortion in the first trimester.[3]
 Since 1979, menstrual regulation has been the favored alternative to induced abortion,
and it is legally permitted because pregnancy cannot be established.[3][2] In 2012, the
Drug Administration for Bangladesh legalised the combination of mifepristone and
misoprotol for medical abortion.[4]
 Contents
 An abortion can be legally performed by a physician in a hospital, if it is necessary to
save the life of the mother. A person who performs an abortion under any other
circumstances, including a woman who self-aborts, can be punished by a fine and
imprisonment.[2]
 Menstrual regulation allows a woman to terminate within 10 weeks of her last period, but
unsafe methods to terminate pregnancy are widespread. In response, a hotline was created
for women to get information about fertility control, including menstrual regulation.[8]
 According to an article by the Guttmacher Institute, which studied the rural district of
Matlab, illegal abortion is becoming increasingly prevalent despite the availability of
safer methods of fertility control.[9]
 A study by Mizanur Rahman and Julie DaVanzo showed that between 2000 and 2008, a
woman was more likely to die from the complications of unsafe abortion than from
childbirth itself, and that death rates from childbirth were similar of the death rates for the
complications of menstrual regulation.[10]

Another study in Matlab found that between 1982 and 1998, abortion about 35 times more
prevalent among unmarried adolescent girls than among married adolescent girls, and it was
much higher among who were less than 18 years of age and those who passed or ha Part of the
family planning program in Bangladesh since 1979, menstrual regulation is a procedure that uses
manual vacuum aspiration to make it impossible to be pregnant after missing a period.[1] It is
simple and can be done with inexpensive equipment. Its procedure also goes without the use of
anaesthesia.[5]

A study about menstrual regulation in 2013 studied 651 consenting women from 10 different
facilities in Bangladesh, who were seeking menstrual regulation and were about 63 days or less
late of their menstrual cycle. They were given about 200 mg of mifepristone, followed later by
800 mg of misoprostol. The researchers found that 93% of the women had evacuated the uterus
without the use of the surgical intervention, and 92% of the women were satisfied with the pills
and the rest of the treatment.[6]

Although menstrual regulation centers are centralized and free of charge, many women still lack
access due to socioeconomic barriers and social stigma.[6] Centers charge additional fees if the
pregnancy is beyond 10 weeks, and many women are unaware of menstrual regulation or face
male opposition to the procedure. As a result, some women turn to illegal abortions.[7]

 Abortion is described as the expulsion of the products of conception before the embryo
or fetus is viable. Any interruption of human pregnancy prior to the 28th week of
gestation or the delivery of a fetus weighing less than 500 grams is known as abortion.

 Spontaneous Abortion (Miscarriage)•

This is defined as the delivery of a nonviable embryo or fetus (the fetus cannot survive) before
the 20th week of pregnancy due to fetal or maternal factors.
Recurrent spontaneous abortion- the occurrence of three or more consecutive losses of clinically
recognized pregnancies prior to the 20th week of gestation (Immunological reactions, in which
maternal antibodies mistake the fetus for foreign tissue, have been implicated in recurrent, or
habitual spontaneous abortions)
.• It is estimated that at least 20% of all pregnancies end in miscarriage (estimates range from
15% to 75%). Most occur in the first two weeks after conception, and in many cases the mother
is not aware of the pregnancy.
 Therapeutic Abortion
• This procedure is performed to preserve the health or life of the mother. It can be induced for
medical reasons or an elective decision to end the pregnancy (eg.prevent the birth of a deformed
child or a child conceived as a result of rape or incest).
Elective (Induced) Abortion
• Defined as a procedure intended to terminate a suspected or known intrauterine pregnancy and
to produce a nonviable fetus at any gestational age(CDC, 2010), deemed necessary by the
woman carrying it and performed at her request.
 Methods Of Conducting AbortionsSUCTION (VACUUM ASPIRATION) ABORTION-The
cervix is stretched to allowpassage of a hollow suction tubewith a sharp-edged openingsnear its
tip into the uterus. -Powerful suction force is thenapplied, allowing the fetus to beripped apart
then suctioned out of the uterus into a collectioncontainer.-Most 1st trimester abortions inNorth
America and the UnitedKingdom are done in this manner.
 DILATATION & EVACUATION (D and E) ABORTION -Used for 2nd trimester abortions,
at which point in fetal development the fetal bones become calcified.
 SALT POISONING ABORTION-Used after 16 weeks, this technique isemployed often in
third world nations becauseof its cost effectiveness and ease ofadministration.-A syringe of a
concentrated salt solution isinjected into the amniotic fluid via a long needlethrough the mother‘s
abdomen. The fetus thenbreathes and swallows the hyper-salted amnioticfluid. The fetus
struggles and sometimes seizesuntil dead within usually one hour. -The mother typically then
delivers a dead fetuswithin one to two days. The fetal skin upondelivery, having been chemically
burned away,usually presents as a glazed red surface.-This abortion procedure was first
developed inNazi concentration camps during WorldWar II.
 DILATION and EXTRACTION (D and X); akaPARTIAL BIRTH ABORTIONUsed in well
developed 2nd and 3rd trimester pregnancies.
. HYSTEROTOMY ABORTION-Used for late term abortions in rareinstances.-Identical to a
Caesarian Section deliveryused to deliver a live baby in the presence ofcertain pregnancy/fetal
complications, exceptthe objective there is to deliver a dead fetus.-The live fetus is first
terminated while still inthe mother‘s womb, such as by cutting of theumbilical cord.-Once the
fetus is dead, the fetus is thenphysically lifted out of the mother‘s womb andthe abortion is
completed.
 PROSTOGLANDIN ABORTIONUsed to abort mid and later term pregnancies. Thehormone
is administered to the pregnant woman into theamniotic fluid or by vaginal suppositories. It
inducesviolent premature labor contractions, thus expelling thefetus which usually dies in the
process of delivery. Drugslethal to the fetus are often injected into the amniotic fluid,to assure
fetal death before delivery.INDUCED LABOUR (LIVE BIRTH) ABORTIONPremature
delivery of a commonly midterm fetus isinduced via various means, the objective being to
deliver apremature baby that is not capable of surviving outside theuterus.When such abortions
typically produce the complication oflive birth, the now delivered living baby is provided
only―comfort care― - wrapping the infant in a blanket - anddenied all medical and nursing
care. Such infants canlinger for hours before dying of ―natural causes.‖
 12. Background History of Abortion• The moral and legal issues raised by the practice of
abortion has tested the philosophers, theologians, and statesmen of every age since the dawn of
civilization.• The Stoics belief that abortion should be allowed up to the moment of birth was
vigorously opposed by the Pythagoreans who believed that the soul was infused into the body at
conception and that to abort a fetus would be to commit murder.
 13. • Early Roman law was silent as to abortion; and abortion and infanticide was common in
Rome, especially among the upper classes.• Abortion induced by herbs or manipulation was used
as a form of birth control in ancient Egypt, Greece, and Rome and probably earlier. In the Middle
Ages in Western Europe it was generally accepted in the early months of pregnancy.• Opposition
by scholars and the growing influence of the Christian religion brought about the first prohibition
of abortion during the reign of Severus ( 193-211 A.D.). These laws made abortion a high
criminal offense and subjected a woman who violated the provisions to banishment.
 14. • Chinese folklore dates back to 3000 BC where Emperor Shennong prescribed mercury to
induce an abortion.• In 2nd & 3rd century, Tertullian (A Christian theologian) described surgical
methods for carrying out abortions.• In the eight century Sanskrit text instructed women wishing
to induce an abortion to sit over a pot of steam or stewed onions.• However, in the 19th century
opinion about abortion changed.
 15. • In 1803, Britain first passed antiabortion laws, which then became stricter throughout the
century.• In 1869 the Roman Catholic Church prohibited abortion under any circumstances.• The
U.S. followed as individual states began to outlaw abortion. By 1880, most abortions were illegal
in the U.S., except those ``necessary to save the life of the woman.‗• However, In the 1950s,
about a million illegal abortions a year were performed in the U.S. Poor women and women of
colour ran the greatest risks with illegal abortions.
 16. • Techniques used in those days were non-surgical; the most common methods used were
either dosing the pregnant woman with a near- fatal amount of poison so that a miscarriage could
occur, or letting poison directly into the uterus with one of a variety of ― long needles, hooks,
and knives.‖• Attitudes toward abortion became more liberal in the 20th cent. By the 1970s,
abortion had been legalized in most European countries and Japan; as well as in the United
States, under a 1973 Supreme Court ruling which took precedence over state laws that banned
abortion. However, there were restrictions in the legislation for later stage abortions.
 17. Abortion & the Laws of GuyanaPrior to the Medical Termination of Pregnancy Act,
theperformance of abortions in Guyana was found to be illegal underthe Criminal Law
(Offences) Act.The 1995 Medical Termination of Pregnancy Act was passed soasTo preserve
or enhance both the dignity and the sanctity of ―life‖by decreasing the incidence of induced
abortionTo enhance the attainment of ―safe motherhood‖ by theelimination of deaths and
complications stemmed from unsafeabortionTo specifically stipulate the circumstances in
which a woman isgranted termination of her pregnancy
 18. Definition of Terms Approved Institution- any institution proved by the Minister for the
purposes of this act, such as that of a clinic, hospital, maternity home, etc. Authorized Medical
Practitioner- any person registered as duly qualified practitioner under the Medical Practitioner
Act. Fetus- An unborn human baby which also includes an embryo. Person of Unsound
Mind- a person who is suffering from mental derangement.
 19.  Pregnancy- an intra-uterine human pregnancy where the fetus is viable. Termination
of Pregnancy- termination of human pregnancy with an intention other than to produce a live
birth. Pro-Life -This is defined as the responsibility or obligation of the government to preserve
all human life regardless of intent, viability or quality of life concerns. Pro-Choice -This is the
belief that women have the right to choose to abort the baby. (A pro-choice view is that a baby
does not have the human rights).
 20. Counselling The Act states with regards to counselling, that any female seeking
treatment for the termination of her pregnancy must undergo both pre and post abortion
counselling. The pregnant woman is also expected to wait for a 48 hour time period after she
has made a request for medical termination of pregnancy to facilitate these requirements or
regulations.
 21. Laws Regarding A Woman’s Termination of Pregnancy The Act distinctly states four
different time periods; all of which carries separate regulations that must be abided or adhered to
before termination of the pregnancy can lawfully take place. These time periods include:
Termination of pregnancy of NOT more than eight (8) weeks Termination of pregnancy of
MORE than eight weeks (8) but NOT more than twelve (12) weeks Termination of pregnancy
of MORE than twelve weeks (12) but NOT more than sixteen (16) weeks Termination of
pregnancy of MORE than sixteen (16) weeks
 22. Termination of pregnancy of NOT more than eight (8) weeks The treatment for the
termination of a pregnancy of not more than eight weeks by the use of any other ―lawful‖
method outside that of surgical procedures must at all times be administered or supervised by a
medical practitioner. However, it is not necessary for this termination process to be carried out
in an approved institution such as hospitals or clinics.
 23. Termination of pregnancy of MORE thaneight weeks (8) but NOT more than twelve (12)
weeks This must also be administered by a medical practitioner or an assistant under the
supervision of an authorised medical practitioner. In this case, however it is mandatory that this
termination process takes place within an approved institution. Additionally, the treatment
regarding the termination of a pregnancy can only be administered if: It is an institution
approved for that particular purpose The medical practitioner administering the treatment
believes that-the continuance of pregnancy would involve risk to the pregnant woman or may be
of grave injury to her physicalor mental health
 24. - there is substantial risk that if the child were born, it would suffer from physical or
mental abnormalities and can be seriously handicapped - on account of being a person of
―unsound mind‖, the pregnant woman will not be capable of taking care of the infant Where
the pregnant woman reasonably believes that her pregnancy was caused by an act of rape or
incest and submits a paper to that effect. Where the pregnant woman is known to be HIV
positive. Where there is clear evidence that the pregnancy resulted in spite of the use of a
recognized contraceptive method by the pregnant woman or her partner.
 25. Termination of pregnancy of MORE thantwelve weeks (12) but NOT more than sixteen
(16) weeks This treatment must also be administered by a medical practitioner and the
termination process must take place within an approved institution. Treatment can only be
administered if TWO medical practitioners are of the opinion of matters previously listed or
specified in the time period ―more than 8 weeks but not less than 12 weeks‖.
 26. Termination of pregnancy of MORE than sixteen (16) weeks The treatment of
termination of pregnancy of more than sixteen weeks must be administered by only an authorised
medical practitioner in an approved institution. Treatment can only be administered if THREE
medical practitioners are of the opinion of matters also previously listed or specified in the time
period ―more than 8 weeks but not less than 12 weeks‖.
 27. ConsentThe Act also thoroughly states the circumstances under which consentis required
and the restrictions with which a medical practitioner musthave. These include: Written or oral
consent must be given from a pregnant woman of sound mind before administering treatment for
the termination of her pregnancy. Conversely, in the case of the treatment or termination of a
pregnancy of a woman of “unsound mind”, medical practitioner must be given a written or oral
consent by her guardian. In the treatment concerning abortion for a child of any age, the
medical practitioner should encourage the child to inform her parents /guardians, but is NOT
required to obtain any consent from them or even notify them. In relation to a pregnant woman
of any marital status, the medical practitioner may encourage the patient to inform her partner,
but again is NOT required to obtain this partner‘s consent or even notify them.
 28. Non-liability of a Medical Practitioner No medical practitioner including persons
authorised by a medical practitioner is held liable or legally responsible for the treatment and
supervision of the termination of a pregnancy once consent has been given. unless of course the
actual procedure was conducted in a negligent manner. Non-Application of Particular
Provisions Counseling, consent and the number of medical opinions may not be required where
the termination of the pregnancy is immediately necessary to save the life of the woman or to
prevent permanent injury to her physical or mental health. Under such circumstances any
authorised medical practitioner can administer the treatment.
 29.  No person should be held under legal duty to participate in any part of a termination of
pregnancy when he is said to hold a conscientious objection. Conscientious objection to
participate in the treatment may be discharged by a statement on oath or affirmation to the
effect. Nothing should affect the duty of a person to participate in the treatment for termination
of a pregnancy where the immediate treatment is necessary to save the life of the patient or
prevent grave permanent injury.
 30. Penalties Inadequate Record Keeping Should any individual or approved institution
deliberately refuse, incompletely maintain, document misleading information of the patient or
completely fails to maintain medical records concerning termination, that person or the owner or
manager of that institution will be held responsible or liable and can be fined $20,000 along with
6 months of imprisonment. False Grounds for Abortion Any statement made by a pregnant
woman is deemed to be intentionally false or misleading, this patient shall be held liable for this
offence and can be fined $7000 fine in addition to 6 months of imprisonment.
 31.  Breach of Confidentiality Should any medical practitioner, approved institution or
person employed or working in this institution with lawful access to records and shares this
information with any member of the general public or other parties, thereby breaching
confidentiality, he or she can be fined $100,000 as well as 1 year of imprisonment. Failure to
Comply With Any Provision of this Act Any person who contravenes or fails to comply with any
provision of the this Act, for which no penalties has been stated by the Act or Criminal Law
(Offences) Act, shall be held liable and can be fined $10, 000 along with 3 months of
imprisonment.
 32. Guyana’s Abortion Laws vs. The Morality of Society- Our Findings Number of Persons
that Participated In survey35302520 number of Participants1510 5 0 Males Females
 33. Religious Backgrounds Of Participants Number of Participants0 5 10 15 20 25
 34. Graph showing the various age groups interviewed 25 20No. of persons 15 No. of Persons
10 5 0 <18 18-25 25-35 35-45 >45 Age As visible in the graph above, a majority of the persons
were between the ages 18- 25 while a minority of persons were below 18 years old. The second
most interviewed group was between the ages 35- 45.
 35. Graph showing how the different genders view abortion3025201510 5 0 Pro-life Pro-
choice M FThe Graph above shows that 8 males and 17 females view anabortion as pro-life
while 10 males and 15 females view anabortion as pro- choice. It can be seen that there is an
equaldistribution between the choice of pro-life and pro- choice.
 36. Chart showing religion influence the views of abortion. 2% 42% 56% yes no unsureFrom
the above graph it can be seen that 56% of thepeople say that religion influence their views on
abortion.The other 42% claimed that religion has no influence ontheir views while another 2%
were unsure.
 37. CHART SHOWING RESPONSES TO IF ABORTION IS MURDER 38403530 2625 total
persons that respond20 total males that respond15 12 12 total females that respond10 5 6 5 0 yes
no
 38. Pie chart showing what are persons views of an abortion 26% Killing a Fetus Killing a
clump of tissues Killing a baby 10% 64%The above figure shows a pie chart which displays
persons‘ views ofan abortion. 64%, which is the majority of persons, view an abortionas killing a
fetus, followed by 26% who view an abortion as killing aclump of tissues. A very small
percentage (10%) view an abortion akilling a baby.
 39. Graph showing the various considerations that should be made if Abortion was illegal in
Guyana. others 2% foetus examined to be teenage pregnancy abnormal. 21% 20% women who
are dependent on drugs/alcohol 16% pregnancy as the result of sexual assault/rape 34% single
women 7%As displayed on the graph, Majority of the respondents (34%) consideredthat
Pregnancy as a result of sexual assault/rape should be kept forconsideration if abortion was
illegal, then followed by Teenagepregnancy (21%). However, a small quantity of the respondents
agreed thatsingle women are to be considered in relation to abortion.
 40. CHART SHOWING RESPONSES TO IF ABORTION IS A WOMANS ISSUE 11 total
females that respond 21 total males that respond 12 6 23 total persons that respond 27 0 5 10 15
20 25 30 brown= yes pink= noOut of 50 participants, 27 viewed abortion is a woman‘s issue
while23 persons disagreed.For males, 6 persons said yes and 12 persons said it is not a
woman‘sissue.
 41. CHART SHOWING IF ABORTION IS DANGEROUS60B50 64030 420 44 2 2810 16 0
total persons that respond total males that respond total females that respond Blue- yes red= no•
Total persons that responded positive to this question were 44 while 6 persons responded
negative.
 42. CHART SHOWING IF THE FETUS SHOULD BE GIVEN PINK= YESGREEN= NO
HUMAN RIGHTS PINK- YES GREEN- NO 34 25 16 9 9 7total persons that respond total
males that respond total females that respond
 43. Pie chart showing persons opinion as whether abortion should be a free/fee procedure 26%
FEE FREE 74%As visible in the pie chart 74% of the populationinterviewed believes that a fee
should be paid for anabortion while 26% believes that an abortion must befree of cost.
 44. CHART SHOWING RESPONSES TO WHEN ABORTION SHOULD TAKE PLACE 40
40 30 26 20 14 10 10 4 6 0 total persons that respond total males that respond total females that
respondBLUE= BEFORE 4TH MTHPINK=AFTER 4TH MTH BUT BEFORE 6TH MTH
 45. Graph showing who is responsible for the woman death during and after an abortion. 25 22
20 19 15 Respondents. 10 5 5 1 0 0 patient doctor relative counsellor all ResponceAs showed in
the graph above majority of the respondents claim thatthe Patients (19) as well as the Doctor (22)
are responsible for thedeath, if the woman dies during or after an abortion. 5 ofrespondents also
agreed that all of the persons involved during theabortion are responsible.
 46. Group’s Position on Abortion CHART SHOWING THE GROUPS VIEWS ON
ABORTION 36% PRO-CHOICE PRO-LIFE 64% CHART SHOWING IF RELIGION
INFLUENCES GROUP MEMBERS 45% YES 55% NO
 47. Countries Worldwide & Abortion Laws Liberalization• Between 1950 and 1985, nearly all
industrialized countries-and several others-liberalized their abortion laws. Since 1994, more than
25 countries worldwide have liberalized their abortion laws-while only a handful have tightened
legal restrictions on abortion.• Liberal abortion laws do not increase abortion rates The World
Health Organization has recognized that "women all over the world are highly likely to have an
induced abortion when faced with an unplanned pregnancy - irrespective of legal conditions."
 48. • Countries in the Global North and north Asia generally have the most liberal abortion
laws• These countries generally permit abortion either without restriction as to reason or on
broad grounds, such as for socioeconomic reasons. However, some countries in these regions,
including Poland, Malta, and the Republic of Korea, maintain restrictive abortion laws that run
counter to the regional trend.• In contrast, countries in the Global South have generally adopted
restrictive abortion laws• Most countries in Africa, Latin America, the Middle East, and southern
Asia have severe abortion laws. Furthermore, three of the four countries generally considered to
prohibit abortion altogether-Chile, El Salvador, and Nicaragua-are located in Latin America.
 49. WORLDWIDE INCIDENCE AND TRENDS• Between 1995 and 2003, the abortion rate
(per 1,000 Women aged 15–44) for the world overall dropped from 35 to 29, but remained
virtually unchanged, at 28, in 2008.• Since 2003, the number of abortions fell by 600,000 in the
developed world but increased by 2.8 million in the developing world.• In 2008, six million
abortions were performed in developed countries and 38 million in developing countries.•
Globally there is no consensus on the issue of abortion, but in order to prevent the misuse of
induced abortions, most countries have created independent abortion laws.
 50. WORLD MEDICAL ASSOCIATION- Declaration on Therapeutic AbortionThis
international organization postulates that:-The physician is morally obligated to ―maintain
respect forhuman life from beginning to end.‖-Further, the decision to terminate a pregnancy is a
―matter ofindividual conviction and conscience that must be respected.‖-―Where the law
allows therapeutic abortion to be performed,the procedure should be performed by a physician
competentto do so in premises approved by an appropriate authority.‖-If the physicians
convictions do not allow for this, they maywithdraw while ensuring the continuity of medical
care by aanother qualified physician.
 51. Abortion by country
 52. RUSSIA• Russia was the first country in the world to legalize abortion, in 1920. The
procedure was briefly driven underground, but was lifted in 1953.• A decade later, the practice
had become so common that the USSR registered 5.5 million abortions, compared to 2 million
live births.• 2006 showed 1.6 million abortions compared to 1.5 million live births -- a dismal
figure, especially in a country struggling with a looming demographic crisis.• The most recent
law cap abortions at 12 weeks, imposes a waiting period of up to one week from initial
consultations and requires women over six weeks pregnant to see the embryo on ultrasound, hear
its heartbeat and have counseling to determine how to proceed.• Its abortion rate - 1.3 million, or
73 per 100 births in 2009 - is the worlds highest.
 53. UNITED STATES OF AMERICA• In consultation with their physician, women have a
constitutionally protected right to have an abortion in the early stages of pregnancy—that is,
before viability upon request—free from government interference.• Abortion has been legal in
the USA since 1973, but may be restricted by any of the 56 states to varying degrees.•
Approximately 3700 abortions are conducted daily in the United States.
 54. INDIAEnacted in 1971, India‘s abortion laws stipulated the followingconditions to execute
an act of abortion:1. A pregnancy may be terminated by a registered medical practitioner where
pregnancy does not exceed 12 consultation of two registered practitioners required
weeks(between 12-20 weeks) under the belief that- (i) the continuance of pregnancy would
involve risk to the life of the pregnant woman or grave injury to her physical or mental health ;
or (ii) substantial risk exists that if the child were born, it would suffer from such physical or
mental abnormalities as to be seriously handicapped2. A pregnancy occurring as a result of
rape3. Failure of contraceptive device used by a couple
 55. ISRAELA 1977 law ensures a legal abortion to any woman who fills one of four criteria:•
She is under 18 or over 40• She is carrying a fetus with a serious mental or physical defect• She
claims that the fetus results from forbidden relations such as rape or incest or, in the case of a
married woman, that the baby is not her husband‘s• She shows that by continuing the pregnancy,
her physical or mental health would be damagedOf the 19,544 cases of abortion granted of the
20,900 submittedthat took place in Israel in 2007, data showed that 55% ofabortions were a
result of incest, illegal relations or out-ofwedlock conception.
 56. CHINA• China began trying to control its massive population growth in 1970 and
introduced a one-child-per-family policy in 1980. As such has made abortion legal in order to
maintain population control. Approximately 13 Million abortions are carried out each year in
China.“ Illegal Births and Legal Abortion”• Illegal Birth-The birth of aChild outside the approval
of the government.• Legal Abortion- The abortionof a child to comply with theone-child policy.
 57. VENEZUELA In Venezuela abortion is only permitted to save the life of the woman in
which case the woman, her husband or her legal representative must present her written consent.
The law establishes up to 2 years prison for the woman who aborts while whoever practices the
abortion faces up to 30 months prison.CUBA Cuba was the first country to sign and the second
to ratify the Convention on the Elimination of All Forms of Discrimination against Women
(CEDAW). Abortion is legal in the country since 1965. The maximum period of time to file for
legal abortion is 10 weeks of pregnancy, from then onwards abortion is only legal if the health of
the woman is at risk. Abortions practiced outside the public health system are penalized.
 58. RELIGION & ABORTIONCHRISTIANITYChristians believe that life begins at the
instant ofconception. Therefore, abortion is murder and isprohibited by the Ten Commandments.
(Exodus20:13)The Church today firmly holds that "the first rightof the human person is his life"
and that life isassumed to begin at fertilization. The equality ofall human life is fundamental and
complete, anydiscrimination is evil.
 59. ISLAMA notable verse from the Qur‘an reads: ―Do not kill yourchildren for fear of
poverty: we shall provide sustenancefor them as well as for you. Verily the killing of them isa
great sin‖ (17:31).For a woman carrying an illegitimate child from extramarital sex or rape, the
consensus is that she should givebirth, however, if the scar of rape is too heavy, then thedecision
is hers.However, All schools of Muslim law accept that abortionis permitted only if continuing
the pregnancy would putthe mothers life in real danger.
 60. HINDUISMClassical Hindu texts strongly opposed abortion:one compares abortion to the
killing of a priest,one considers abortion a greater sin than killingof one‘s parents and another
says that a womanwho aborts her child will lose her caste.Unless a mothers health is at risk,
traditionalHindu teachings and texts condemn abortionbecause it is thought to violate the
religionsteachings of non-violence (Ahisma).
 61. Many people are very, very concerned with thechildren in India, with the children in
Africawhere quite a number die, maybe ofmalnutrition, of hunger and so on, but millionsare
dying deliberately by the will of the mother.And this is what is the greatest destroyer of
peacetoday. Because if a mother can kill her own child -what is left for me to kill you and you
kill me --there is nothing between- MOTHERTERESA, Nobel Lecture, Dec 11, 1979
 62. ReferencesAbortion. (2004). Retrieved from:
http://www.pjmwh2pt1.lunarpages.com/PPT%20Presentations/NURS%205405%20St
udent/4%20-%20Abortion/2004%20PPP%20Abortion.pdfAbortion. (2010). Retrieved from:
http://www.medterms.com/script/main/art.asp?articlekey=17774Abortion. (2012). Retrieved
from: http://www.emedicinehealth.com/abortion/article_em.htmAbortion. (2012). Retrieved
from: http://www.nrlc.org/abortion/facts/abortiontimeline.htmlAbortion. (2012). Retrieved from:
http://www.feminist.com/resources/ourbodies/abortion.htmlAbortion. (2012). Retrieved from:
http://worldabortionlaws.com/about.htmlAbortion. (2010). Retrieved from:
http://www.who.int/reproductivehealth/publications/unsafe_abortion/induced_abor
tion_2012.pdfAbortion internationally. (2012). Retrieved from:
http://worldabortionlaws.com/map/
 63. Abortion laws in India. (2011). Retrieved from: lifestyle.iloveindia.com/lounge/abortion-
laws-in-india-240.htmlAbortion laws in Israel. (2010). Retrieved from:
http://www.ynetnews.com/articles/0,7340,L-3642871,00.htmlAbortion laws in Israel. (2010).
Retrieved from: http://www.jewishvirtuallibrary.org/jsource/Health/abort1.htmlAbortion laws in
Russia. (2007). Retrieved from: http://www.iol.co.za/dailynews/lifestyle/russia-world-s-highest-
rate-of-abortions- 1.1176756Abortion laws in Russia. (2007). Retrieved from:
http://www.rferl.org/content/Abortion_Remains_Top_Birth_Control_Option_Russia/11
45849.htmlBoland, R. & Katzive, L., (2008) Developments in laws on induced abortion: 1998-
2007, 34(3) International Family Planning Perspectives. pp.110-113Boston Womens Health
Book Collective, (1998) Our Bodies, Ourselves for the New CenturyComplete abortion. (2011).
Retrieved from:http://medical-dictionary.thefreedictionary.com/complete+abortionDefinition of
abortion. (2012). Retrieved from: http://reference.yourdictionary.com/word-
definitions/definition-of-abortion.html
 64. Horrors of abortions. (2012). http://www.jesus-is-
savior.com/Evils%20in%20America/Abortion%20is%20Murder/horror_of_abortion.htmMuldoo
n, M., (1991) The Abortion Debate in the United States and Canada: A Source BookProgramme
of Action of the International Conference on Population and Development , Cairo, Egypt, Sept.
5-13, 1994, para. 8.25, U.N. Doc A/CONF.171/13/Rev.1 (1995).Rahman, A. et al.,(1998) A
Global Review of Laws on Induced Abortion from 1985-1997, 24(2) International Family
Planning Perspectives 56, 60Riddle, J.M., (1994) Contraception and Abortion from the Ancient
World to the RenaissanceRubin, E.R.(1994). The Abortion Controversy: A Documentary
History. Greenwood Press. pp. 3.Recurrent abortion. (2010). Retrieved from:
http://www.uptodate.com/contents/definition-and- etiology-of-recurrent-pregnancy-lossSedgh,
G. et al.,(2012) Induced Abortiom: incidence and trends worldwide from 1995- 2008, Lancet,
(forthcoming).Spontaneous abortion. (2012). Retrieved from:
http://miscarriage.about.com/od/pregnancylossbasics/g/threatenedmisc.htmThe Columbia
Encyclopedia, Sixth Edition Copyright© (2004), Columbia University Press. Licensed from
Lernout & Hauspie Speech Products N.V. All rights reserved.Theraputic abortion. (2012).
Retrieved from: http://dictionary.reference.com/browse/therapeutic+abortion

 MTP Act: Objectives MTP Act  Aims to improve the maternal health scenario by preventing
large number of unsafe abortions and consequent high incidence of maternal mortality &
morbidity  Legalizes abortion services  Promotes access to safe abortion services to women 
Offers protection to medical practitioners who otherwise would be penalized under the Indian
Penal Code (sections 315-316)
 4. Legal framework • MTP Act – lays down when & where pregnancies can be terminated –
Grants the central govt. power to make rules and the state govt. power to frame regulations •
MTP Rules – lays down who can terminate the pregnancy, training requirements, approval
process for place, etc. • MTP Regulations – lays down forms for opinion, maintenance of records
– custody of forms and reporting of cases
 5. Legal abortions Abortions are termed legal only when all the following conditions are met:
– Termination done by a medical practitioner approved by the Act – Termination done at a place
approved under the Act – Termination done for conditions and within the gestation prescribed by
the Act – Other requirements of the rules & regulations are complied with
 6. When can pregnancies be terminated? • RMP shall not be guilty of offence under law • Up
to 20 weeks gestation • With the consent of the women. If the women is below 18 years or is
mentally ill, then with consent of a guardian • With the opinion of a registered medical
practitioner, formed in good faith, under certain circumstances • Opinion of two RMPs required
for termination of pregnancy between 12 and 20 weeks
 7. MTP Act: Application  Continuation of pregnancy constitutes risk to the life or grave
injury to the physical or mental health of woman  Substantial risk of physical or mental
abnormalities in the fetus as to render it seriously handicapped  Pregnancy caused by rape
(presumed grave injury to mental health)  Contraceptive failure in married couple (presumed
grave injury to mental health)
 8. MTP Act: Place for conducting MTP  A hospital established or maintained by
Government or  A place approved for the purpose of this Act by a District-level Committee
constituted by the government with the CMHO as Chairperson
 9. MTP Act amendment 2002 • Decentralizes site registration to a 3-5 member district level
committee chaired by the CMO/DHO • Approval of sites that can perform MTPs under the act
can now be done at the district level • Stricter penalties for MTPs being done in a un- approved
site or by a persons not permitted by the act
 10. Medical Abortion • MTP using Mifepristrone (RU 486) & Misoprostol approved for up to
7 weeks termination • Only an RMP (as defined by the MTP Act) can prescribe the drugs • Has
to follow MTP Act, Rules & Regulations • Can prescribe in his/her clinic, provided he/she has
access to an approved place • Should display a certificate from owner of approved place agreeing
to provide access
 11. Implications of amendments • Simplifies registration of sites which can be done at district
level now • Providers can get their sites approved for providing abortions under the MTP Act for
1st trimester only or up to 20 weeks and thereby come under the protective cover of the MTP Act
 12. Implications of amendments • Offers potential to increase number of approved sites, which
would enable women to access safe abortion services • Effective implementation will help to
bring all abortions within legal frame work
 13. MTP rules: what do they cover? • Experience & training required for providers • Approval
of a place for terminating pregnancy under the Act • Composition & tenure of District Level
Committee • Inspection, cancellation or suspension of approval; review • Consent form
 14. MTP rules: Who can perform? A medical practitioner (RMP) – who has a recognized
medical qualification as defined in clause (h) of section 2 of Indian Medical Council Act, 1956 –
Whose name has been entered in a State Medical Register and – Who has such experience or
training in Gynecology and Obstetrics as prescribed by Rules made under the Act
 15. MTP rules: training requirement - 1 For termination up to 12 weeks: – A practitioner who
has assisted a registered medical practitioner in performing 25 cases of MTP of which at least 5
were performed independently in a hospital established or maintained or a training institute
approved for this purpose by the Government
 16. MTP rules: training requirement - 2 For termination up to 20 weeks – A practitioner who
holds a post-graduate degree or diploma in Obstetrics and Gynecology – A practitioner who has
completed six months house job in Obstetrics and Gynecology – A practitioner who has at least
one-year experience in practice of Obstetrics and Gynecology at a hospital which has all
facilities – A practitioner registered in state medical register immediately before commencement
of the Act, experience in practice of Obstetrics and Gynecology for a period not less than three
years.
 17. Approval of a place by trimester For sites up to 12 weeks (1st trimester) • Gynecology
examination/ labor table • sterilization equipment • Drugs & parental fluids • Back up facilities
for treatment of shock • Facilities for transportation
 18. Approval of a place by trimester For sites up to 20 weeks (1st and 2nd trimester): • All
requirements for up to 12 weeks + • Operation table and instruments for performing abdominal
or gynecological surgery • Anesthetic equipment, resuscitation equipment and sterilization
equipment • Drugs & parental fluids notified for emergency use, notified by Government of
India from time to time
 19. Regulatory body: D L C • District level MTP Committee – Minimum of 3 & Maximum of
5 members including chairperson (CM H O) • Composition of the committee: – One medical
person (Gyne/Surgeon/Anestheist) – One member from local medical profession; NGO &
Panchayati Raj Institution of the district. – At least one member shall be a woman. • Tenure 2
calendar years – NGO members shall not have more than 2 terms
 20. Approval Process • Application in Form A to be addressed to CMHO by place seeking
approval • CMHO verifies or inspects the place to satisfy that termination can be done under safe
& hygienic conditions • CMHO recommends approval to the committee • Committee considers
application & recommendation and approve and issue certificate of approval in Form B
 21. Approval Process • Place to be inspected within 2 months of receiving application •
Certificate to be issued within 2 months of inspection • If deficiency found, within 2 months of
deficiency having been rectified
 22. Inspection • CMHOs to inspect to ensure safe & hygienic conditions for conduction of
MTPs. • Call for information and seize in case found otherwise
 23. Cancellation/ Suspension • CMHO to report the committee for unsafe and unhygienic
conditions. • Committee can suspend or cancel approval after giving the owner an opportunity
for representation • Owner can reapply to the committee after making additions and
improvements. • During suspension the place be deemed as non- approved

Definitions
„ . Medically, abortion (Latin aboriri: to get detached
from the proper site) is expulsion or extraction from
its mother of an embryo or fetus weighing 500 g or
less, when it is not capable of independent survival
(WHO). This 500 g of fetal development is attained
at about 22 weeks of gestation.
„ . Legally, abortion is defind as expulsion of products
of conception from the uterus at any period before
full term.1
„ . Criminal abortion: It is the termination of a pregnancy
in violation of the legal regulations in force.
miscarriage
for the expulsion of fetus from 4th–7th months; and
premature delivery as the delivery of baby after 7 months
of pregnancy and before full-term. The term miscarriage
is synonymous with spontaneous
abortion.
Natural or Spontaneous Abortion
„ . Incidence: 10–20% of all pregnancies (approx).
„ . Most frequent within first 3 months, owing to weak
attachment of ovum to uterine wall (75% abortions
occur before 16th week, and out of these, 75% before
8th week of gestation).
„ . Abortion occurs without any induction procedures
and usually coincides with menstrual flow.
Causes
i. Genetic (50%) ii. Anatomic (10–15%)
iii. Endocrine (10–15%) iv. Infections (15%)
v. Immunological (5–10%) vi. Others
Common causes of abortion
First trimester: Genetic factors, endocrine disorders,
immunological disorders, infections and unexplained.
Second trimester: Anatomic abnormalities, maternal
medical illness and unexplained.
Artificial or Induced Abortion
It means willful termination of pregnancy before
viability. It can be:
„ . Legal or justifiable: When it is done in good faith to
save the life of the woman, and performed within
the legal provisions of the MTP Act.
„ . Criminal or illegal: Induced destruction and expulsion
of fetus from womb unlawfully. It is usually induced
before the 3rd month, and causes infection and
inflammation of the endometrium.
After conception, it takes about 7–10 days before implantation
of the developing ovum takes place when it is called embryo.
This embryo goes on developing up to the end of 8th week
and from then onwards up to birth, it is termed as foetus.
MEDICAL TERMINATION OF PREGNANCY
ACT (1971)
The Act provides the following
grounds for termination of pregnancy:
_ Where the continuance of the pregnancy would involve a
risk to the life of the pregnant woman or of grave injury to
her physical or mental health (therapeutic ground); or
_ Where there is a substantial risk that if the child is born, it
would suffer from such physical or mental abnormalities so
as to be seriously handicapped (eugenic ground).
What may constitute grave injury to pregnant woman’s
mental health has been exemplified in the explanations
attached to the Section, viz.
Explanation 1: Where any pregnancy is alleged by the
pregnant woman to have been caused by rape, the anguish
caused by such pregnancy shall be presumed to constitute a
grave injury to the mental health of the pregnant woman
(humanitarian ground).
(Though the words used are ‘shall be presumed’, but such
presumption can be rebutted on the facts of the case. There
may be no question of anguish caused by pregnancy in the
pregnant woman particularly when the girl was keen on continuing
the pregnancy and bearing the child.)
Explanation 2: Where any pregnancy occurs as a result of
failure of any device or method used by any married woman
or her husband for the purpose of limiting the number of
children, the anguish caused by such unwanted pregnancy may
be presumed to constitute a grave injury to the mental health
of the pregnant woman (socio-economic ground).
(The Act further clarifies that in determining whether the
continuance of a pregnancy would involve such risk of injury
to the health, account may be taken of the pregnant woman’s
actual or reasonable foreseeable environment.)
MTP AND DURATION OF PREGNANCY
For a pregnancy of less than 12 weeks’ duration, one medical
officer can take the decision of performing abortion. If
the pregnancy is beyond 12 weeks but less than 20 weeks,
opinion of two medical officers is required to terminate the
pregnancy.

METHODS OF INDUCING ABORTION

UNDER THE MTP ACT (Flowchart 26.1)
During the First Trimester
Medical methods presently include the use of the following
drugs:
_ Prostaglandins: PGE1 and PGE2alpha are quite effective
that bring about uterine contraction and expel the foetus.
_ Antiprogesterones are the compounds that inhibit the
action of progesterone at the receptor site. Mifepristone,
also known as RU-486, is the only antiprogesterone available
for use in the fertility control. Alone, it is not so effective
but when followed by prostaglandins (PGs), it is very
useful. For induction of abortion, RU-486 followed after
36–48 hours by PGs has been found to be the most effective
medical method (WHO, 1994). RU-486 is a synthetic
steroidal compound, having chemical configuration comparable
to progesterone; because of this, it competes and
binds to the progesterone receptor sites and inhibits the
normal biological effects of progesterone on the uterus.
Other effects include the following points:
_ It causes ripening and softening of the cervix and produces
increased contractility of the myometrium, helping
expulsion of the products of conception.
_ It acts on pituitary producing remarkable decrease of LH
secretion leading to luteolysis and shedding off endometrium
and bleeding in the luteal phase of the cycle.
_ It causes marked increase in sensitivity of the uterus to
exogenous prostaglandins. When used with PGs, much
lower doses of PGs are needed.
Combipack in the form of MTP kit is available presently.
Each kit contains one tablet (200 mg) of mifepristone and four
tablets of misoprostol (each of 200 μg). During pregnancy,
mifepristone sensitises the myometrium to the contractioninducing
activity of prostaglandins. Misoprostol is a synthetic
prostaglandin E1. It causes myometrial contractions by interacting
with specific receptors on myometrial cells. This interaction
results in a change in calcium concentration, thereby
initiating muscle contraction. By interacting with prostaglandin
receptors, it also causes softening of cervix and thereby resulting
in the expulsion of the uterine contents. The dosage schedule
constitutes mifepristone 200 mg orally followed 1–3 days
later by 800 μg (4 tablets, each of 200 μg) of misoprostol for
women at 49–63 days of gestation.
Surgical methods include two types of surgical procedures,
namely:
_ Vacuum aspiration
_ Dilatation and evacuation (also called dilatation and
curettage)
During the Second Trimester
Medical methods presently being used these days are one or
the other form and in various combinations of intra-uterine
instillation of hypertonic saline (20% NaCl) or urea or
rivanol and prostaglandins by various routes. Hypertonic
saline is used either by intra-amniotic instillation into the amniotic
sac of the foetus or by extra-amniotic instillation into the
extra-ovular space. Even during this trimester, PGs have been
found relatively more safe than hypertonic saline in inducing
abortion. The mechanism of action of hypertonic saline is not
definitely known. Several factors seem to be involved:
_ Liberation of prostaglandin from degenerated decidua and
foetal tissues;
_ Suppression of progesterone synthesis from placenta, thus
releasing progesterone block;
_ Acute salt poisoning of the products of conception (hypertonicity
and dehydration of the foetal-placental unit resulting
in foetal death);
_ Overdistension of the uterus owing to drawing of fluid by
the hypertonic solution; and
_ Change in electrolyte balance of the amniotic fluid.
Surgical methods include the following:
_ Dilatation and evacuation (D&E)
_ Hysterotomy (abdominal hysterotomy is performed when
sterilisation is wanted along with termination of mid-term
pregnancy or in some cases of failure in the induction of
labour. In India, hysterotomy is gaining relative popularity
and is preferred for termination of pregnancy in second
trimester).
_ Hysterectomy (preferred in elderly patients with fibroids
and other pelvic pathology).
CRIMINAL ABORTION
Nearly all criminal abortions take place at about 2nd or 3rd
month of pregnancy when the woman is certain about her condition.
The term ‘unsafe abortion’, proposed by the WHO
lately, has been accepted by most other international health
institutions. Unsafe abortion means ‘abortion not provided
through approved facilities and/or persons’. It may be legal or
illegal depending upon the abortion laws of the country.
Methods for Inducing Criminal Abortion
(Flowchart 26.1)
_ Abortifacient drugs
_ Mechanical violence, which may be of two types:
_ General violence
_ Local violence
Abortifacient Drugs
Use of abortifacient drugs depends, to some extent, upon local
fashions, customs, availability and the faith engendered by the
advice from some amateur abortionist. Most of them have no
effect on the uterus or the foetus unless given in toxic doses.
Drugs commonly employed may be given as follows.
Ecbolics: These are drugs that contract the pregnant
uterus, for example:
(a) Ergot preparations
(b) Synthetic oestrogens
(c) Pituitary extract
(d) Strychnine
(e) Quinine
Causes of Death and Dangers of Criminal
Abortion (Fig. 26.2)
Immediate Complications
It is well-recognised that vagal inhibition or reflex shock
may result in cardiac arrest if the cervix or uterus is manipulated,
particularly in an unanaesthetised state and if the patient
is in a state of apprehension. As mentioned earlier, the need of
secrecy and haste and the criminal nature of the procedure are
bound to create an emotional imbalance in the mind of the
victim, which predisposes to shock. Sudden death from vagal
inhibition can also occur due to rough insertion of syringe into
the cervix or rapid introduction of hot or cold fluid.
Air embolism is a common complication following the use
of enema syringe for injecting soap solution into the uterus.
About 100 ml of air is considered sufficient to cause air-lock
and death. Though death is often rapid, delayed deaths have
also been reported. It is, therefore, unwise to be too dogmatic
as to the time interval between the criminal interference and
death in case of air embolism. Sufficient time may elapse for
the woman to take a few paces or to replace the syringe or to
throw it somewhere else.
Severe haemorrhage may occur following vaginal or uterine
laceration/perforation from instrumentation and responsible
for death. Use of abortion stick may sometimes be accompanied
by lacerations and perforation leading to rapid death.
Amniotic fluid embolism: Of all the causes of sudden
disaster in labour, amniotic fluid embolism ranks high. This is
an unpredictable and unpreventable cause of maternal mortality.
During labour and in the immediate postpartum period, the
contents of amniotic fluid may enter the uterine veins and
reach right side of the heart resulting in fatal complications.
This fluid contains foetal squames, lanugo, material from the
vernix, cells from the chorion and amnion, meconium, and
other cellular detritus. The mechanism by which these amniotic
fluid components gain entry into the maternal circulation
is not clear. Possibly, the contents gain entry either through
tears in the myometrium and endocervix, or the amniotic fluid
is forced into uterine sinusoids by vigorous uterine contractions.
The cause of death may not be obvious, but death can
occur as a result of any of the following mechanisms:
_ Anaphylactoid reaction to amniotic fluid components.
_ Mechanical blockage of the pulmonary circulation in extensive
embolism.
_ Disseminated intravascular coagulation (DIC) due to liberation
of thromboplastin by amniotic fluid.
_ Haemorrhagic manifestations due to thrombocytopenia
and afibrinogenaemia.
Diagnosis is approached through histology by seeing
squames detached from the foetal epidermis. These are much
better seen under special stains. Immunohistochemical techniques
have also been used in the lung section to demonstrate
meconium and amniotic fluid-derived mucin as well as isolated
trophoblastic cells in deaths due to amniotic fluid embolism
syndrome. However, necropsy findings may get disappeared
because of autolysis if there is much delay in carrying out
the examination as is often the case owing to lengthy inquest
procedures.
Delayed Complications
The main delayed causes of death in criminal abortion are the
sepsis and hepatorenal failure. Infection can easily be conveyed
from the instrument or perineum into the uterine cavity.
Any injury to the uterine wall or the neighbouring area or the
presence of irritant products with necrosis of the tissue will
favour such infection. Infection may occur immediately or
days/weeks later. Bacterial shock resulting from endotoxins
may be associated with enterobacillary septicaemia. Septicaemia
may originate from organisms varying from E. coli to Staphylococci
and nonhaemolytic Streptococci. It occurs more rapidly from
uterine invasion by anaerobic organisms like C. welchii. Renal
failure following acute tubular necrosis used to be somewhat
common cause of death prior to methods of dialysis.
_ Tetanus is also a hazard. Infection by Clostridium tetani usually
develops after 3 days to 3 weeks, while infection by
C. welchii develops usually within 3 days.
_ When drugs have been used to procure abortion, death may
result from their toxic effects, as most of the reputed abortifacients
are irritant poisons. Death may occur during any
period depending upon the nature of the drug and the
quantity administered.
Salpingitis
Septic endometritis
and metritis
Laceration/perforation
haemorrhage into
1. Broad ligament
2. Pouch of Douglas
Laceration/perforation
Haemorrhage Infected abrasion/laceration Thrombophlebitis Oophoritis Septicaemia Peritonitis Pyaemia Deformed foetus
Haemorrhage from placental site Perforation or haemorrhage Infected placental siteretroplacental Bloodclot septicaemia
Intraperitoneal haemorrhage(damage tointestines, shock)

Examination of the Woman Who has

Allegedly Aborted
The doctor may have to examine a living subject, or sometimes
a dead body of a woman may be sent to him for the postmortem
examination for alleged abortion.
IN THE LIVING
It may include the following steps:
_ Requisition from the concerned authority
_ Identification of the female
_ Written informed consent of the female
_ Better to keep some female witness (nurse) nearby
_ Short history must be obtained as to date, time, place of
abortion, means adopted to procure abortion and material
expelled, etc.
_ Clothing must be examined meticulously, especially the
undergarments for some stains of blood and, occasionally,
of some liquid abortifacient agent used locally. These must
be retained for contact traces of any foreign substances.
The findings are more or less akin to those found in the
recent delivery and will depend upon the period of gestation,
the mode of abortion practised and the time elapsed between
abortion and the examination. As in case of delivery, so in case
of abortion too, some of the findings are related to pregnancy
and some to the expulsion of products of conception.
Therefore, the doctor should examine breasts, pigmentation
of different places and the abdominal wall. Changes will be
appreciable depending upon the period of gestation at which
the abortion was carried out.
Since most of the reputed abortifacients are irritants, the
women may show signs of ill-health, gastrointestinal disturbances
and nervous exhaustion. In case of localised sepsis,
temperature may be raised and the woman remains indisposed
for some days. The serum and urine of woman gives positive
result for the tests for hCG up to about 7–10 days.
_ Appearance of perineum, external genitals and vagina
should be noticed. See for presence/absence of injuries in
the form of abrasions, lacerations, contusions, etc.
_ Condition of os needs to be examined. It remains dilated
for a few days. The extent of dilatation and period of
its stay depends upon the size of the foetus expelled. It
may also show abrasions/tears/contusions, etc. due to
instrumentation.
_ Presence of recent tears, the marks of forceps or other
instruments in and around genitals should be observed.
_ Character and amount of discharge need to be observed.
In abortion during the earlier months of gestation, the signs
will be ill-defined and return to normal in a few days. Signs
persist for a longer time if sepsis has taken place or if abortion
has been carried out in later months of pregnancy.
IN THE DEAD
There have been relatively few deaths from criminal abortion,
but it must be borne in mind in the investigation of any unexpected
death in a female of child-bearing age. Prompt action
on the part of police is also desirable to prevent disposal of the
evidence.
External Examination
It will include formal identification of the deceased and meticulous
examination of the clothing as detailed earlier also.
General external findings upon the breasts and abdominal wall
should be noticed. Presence of scars, injuries (general as well as
local injuries) needs detailed description. Expression of fluid
from breast may be of indirect value in the diagnosis of recent
abortion. Areas of distribution of hypostasis carry significance.
In many cases, death being due to haemorrhage, the
body may look extremely pale with less prominent hypostasis.
Labia majora, minora, vagina and/or cervix, etc. may show
injuries and may be congested. These may be stained with locally
used abortifacient agent, when such agent has been used. If the
agent was injected parenterally, then the injection mark(s) will be
detectable over the usual sites of intramuscular injections.
Where air embolism is suspected, pre-autopsy radiology of
the chest and abdomen must be performed for visualising air
bubbles in the heart, great veins in the thorax, peritoneal cavity,
and pelvic veins. Availability of MRI or computed tomography
may greatly increase the chance of detecting air in the vessels.
Further, where radiology is not possible, the air needs to be
sought in the cardiovascular system through dissection. The
usual method is to open the heart chambers in situ under water
poured into the pericardial sac. Escaping bubbles are considered
to be indicative of air embolism. Delay in conduction of
postmortem allows absorption of air and therefore, at instances,
one may not be able to demonstrate air in the heart on dissection,
while it was demonstrable on radiology. Conversely, the
possibility of pseudo-embolism due to formation of gases of
decomposition may be kept in mind in cases where decomposition
has set in (see also the Chapter ‘Complications of Trauma’).
Internal Examination
Initially, a small suprapubic incision should be given and any
crepitation due to gas formation in the uterine cavity and
venous channels, if suspected, should be assessed. The uterus,
ovaries and the adnexal tissues should be removed en masse
following severance of the symphysis pubis and including
vagina, vulva and rectum with adjacent skin, taking care to collect
any foreign fluid/material.
The abdominal cavity may be seen to contain liquid and
clotted blood, if there is perforation of uterus due to instrumentation.
In such cases, injuries to the neighbouring organs
like intestine or bladder should also be noticed.
Findings in the Uterus
The size of the uterus deserves observation. It may be enlarged,
soft and congested. Wall may show thickening on longitudinal
sectioning. Cavity may show presence of products of conception
in full or in parts. It is advisable to weigh the uterus and
measure its size. Nonpregnant uterus weighs about 40 gm; it is
7.0 cm long, 5.0 cm broad and 2.0 cm thick. The length is approximately 10 cm at the end of third
month, 12.5 cm at the
end of fourth month, 16 cm at the end of sixth month, 20 cm at
the end of eighth month and 27 cm at the end of ninth month.
It may show perforation. Endometrium may show evidence
of scooping, if evacuation was done by curetting. If the evacuation
was incomplete, the placenta may still be there. Otherwise,
the site of placental attachment may be seen as a raw and
slightly depressed area. In case of use of any chemical, the
inner surface of uterine wall may be stained and/or damaged.
If soap water was used, froth may be present in the cavity. In
some cases, there may be presence of hair pin or root of a
plant if any of these elements was used. Swabs of the uterine
wall should be taken for microbiology. Tissues may be preserved
in 10% formalin for histology.
Ovaries
Either of the ovary should be examined for the presence of
corpus luteum. They may be congested. In some cases where
there is suspicion that a poisonous substance has been used
locally to induce abortion, then the specimens of vagina, uterus
and appendages need to be sent for toxicological examination.
Heart
After opening the chest cavity, right ventricle is opened to elucidate
the presence of frothy blood, which is often seen in air
embolism. Samples of blood from the inferior vena cava and
both the ventricles should be collected.
Examination of Aborted Material
Sometimes the substance alleged to have been expelled from
the uterus as a product of conception is brought to the doctor
for his opinion as to the nature of the substance/material.
When available in pieces, it is suggestive of instrumental abortion.
All material passed should be examined microscopically.
In the early months of pregnancy, if the embryo is not found,
the presence of chorionic villi found under the low power of
microscope will decide the fact of miscarriage. It is always
advisable to remove a piece of tissue from what is thought to
be the placental site and examine it microscopically for the
presence of chorionic villi. It is a sure sign of pregnancy. While
examining such an aborted foetus, it is important to ascertain
its age, as it has a bearing under the legal provisions. This may
be determined from the Hasse’s rule.
HASSE’S RULE
For the first 5 months
of the foetus
Square root of the length of the foetus
in cm gives its age in lunar months
After 5 months 1/5th of the length of the foetus in
cm gives the age in lunar months
Thus, when the foetus measures 16 cm, its age is 16 = 4
lunar months. When the foetus measures 35 cm, its age is
35/5 = 7 lunar months (also see the Chapter ‘Infanticide and
Foeticide’ for determination of age of the foetus).
IMPORTANT FOETAL AGES RELATED TO ABORTION
12th week: Length of the foetus is 9 cm, weight is about 30 gm.
Pupillary membrane is present in the eye. Scalp hair and lanugo
hair are absent. Sex is not distinguishable. Meconium is absent.
Ossification centres for clavicle, mandible, ribs and vertebrae
are present.
20th week: Length of the foetus is 25 cm; weight is about
400 gm. Scalp hair and lanugo hair have appeared. Sex can be
differentiated. Gallbladder is present. Meconium present at the
beginning of ascending colon. Ossification centres for manubrium,
1st segment of sternum and calcaneum may appear.
28th week (stillborn above this age). Length is about 35 cm,
weight around 1 kg. Scalp hair—usually more than 1 cm long.
Nails are thick and proximal to tips of fingers. Left testicle is
at the external ring. Gallbladder contains bile. Meconium is
present up to the distal end of large intestine. Pupillary membranes
vanish, eyelids can be opened. Ossification centre for
talus usually has appeared.
30th week or 210 days (usually accepted as the age of viability).
Length about 37 cm, weight around 1500 gm. Scalp hair
about 2.5 cm. Nails almost reach the tip of the fingers. Left
testicle in the scrotum, right near the external ring. Ossification
centres for all sacral vertebrae present.
Septic Abortion
„ . Definition: It is defined as a type of abortion
associated with sepsis of the products of conception
and the uterus.
„ . Infection usually involves the endometrium and
may spread into the myometrium and parametrium.
Parametritis may progress into peritonitis.
„ . Pelvic inflammatory disease is the most common
complication of septic abortion.
„ . Microorganisms causing uterine sepsis (mixed
infection is more common):
zz Anaerobic: Bacteroides group (fragilis), anaerobic
Streptococci, Clostridium welchii and tetanus bacilli.
zz Aerobic: E. coli, Klebsiella, Staphylococcus aureus,
Pseudomonas and hemolytic Streptococcus.
Cause of sepsis:
„ . Proper antiseptic and asepsis is not maintained
„ . Incomplete evacuation
„ . Inadvertent injury to the genital organs and adjacent
structures, particularly the gut.
Amniotic Fluid Embolism
Most of the cases occur during:
zz 1st and 2nd trimester abortion
zz Active labor
zz Amniocentesis
zz Abdominal trauma
„ . Amniotic fluid embolism is a rare, unforeseeable and
dreadful complication. This occurs when massive
amount of amniotic fluid enters the maternal venous
system.
„ . There may be tonic-clonic seizures, breathlessness
and loss of consciousness. In half the cases, death
occurs in the first hour.
„ . It causes DIC and fibrin deposition in many organs.
„ . Diagnosis is established by demonstration of mucin,
lanugo hair, vernix caseosa, fat globules, meconium
and fetal squamous cells in cut sections of the lung.
Lendrum’s stain (Phloxine-Tartrazine): This stain is useful to
detect amniotic fluid embolism deaths, since keratin of amniotic
squames is stained red, nuclei blue and cytoplasm yellow.9
The ‘WHO’ method: It is helpful to demonstrate keratin and
mucin-like substances in amniotic fluid embolism.
Medico-legal Aspects
„ . Nearly all criminal abortion take place at about 2nd
and 3rd month of pregnancy, when the woman in
certain about her condition.
„ . It is resorted mostly by widows and unmarried girls.
„ . Fabricated abortion: Rarely, when a woman is
assaulted, she may try to exaggerate the offence by
alleging that it caused her to abort. She may acquire
a human or an animal fetus to support the charge.
Medico-legal Importance of Placenta
„ . Gives an idea of the length of gestation.
„ . Transfer of poisons, bacteria and antibodies across the
placenta may result in death, disease or abnormalities
of fetus.
„ . In criminal abortion, pieces are often retained in
the uterus.
Second trimester abortion (rate is among the highest in the
world) increases the risk in women—they are more likely to
go to an uncertified provider, and the risk of complications is
higher for physiological reasons.
Most common reasons for second trimester abortions—sex
selective abortions and delay of accessing abortion services
for an unwanted pregnancy.
Legal abortion is not an option for most Indian women from
lower socioeconomic classes, hence these women gets the
abortion done from less trained, but more accessible providers.
Duti

eThere are,therefore,two main medico-legal problems which may confront a

medical practitioner.

The first con- cerns his ethical behavior towards so-called therapeutic abortion,
and the second his professional and civil behavior once an abortion or attempted
abortion has taken place.- where the judge considered that it
was the surgeon's duty to perform the operation of abortion if, on reasonable
grounds and with adequate knowledge, he was of the
opinion that the prob- able consequence of the continuation of pregnancy would
be to ake the patient a physical and mental wreck. When a practitioner is
consulted about the advisability of abortion, he must obviously take steps to
safeguard his pro- fessional integrity. This can best be done by consultation with
one or more practitioners, preferably specialists in the disease from which the
patient is suffering. If Their opinions support his views, then the emptying of the
uterus should be performed as overtly as possible, preferably in a public hospital,
and with the patient's and her husband'swritten consent.
s of a Doctor in Suspected Criminal
Abortion
i. He should ask the patient to make a statement
about the induction of criminal abortion. If she
refuses, he should not pursue the matter, but
inform the police.
ii. Doctor should keep all the information obtained
by him as professional secret.
iii. He must consult a professional colleague.
iv. If the woman’s condition is serious, he must
arrange to record the dying declaration.
v. If the woman dies, he should not issue a death
certificate, but should inform the police for
postmortem examination.
Postmortem Examination
The autopsy involves identification of fetal remains
and association with the alleged mother.
„ . Autopsy examination should include absolute
identification of the victim and careful examination
Abortion 343
of the clothing including undergarments which must
be preserved for any traces of foreign solutions.
„ . External features of pregnancy should be looked for.
If death is due to hemorrhage, body will look pale.
„ . Presence of injuries (general or local) is noted. If
abortifacient drug was injected, then the injection
mark(s) can be detected over usual sites.
„ . Local examination: Labia majora, minora, vagina,
cervix may show injuries and may be congested. It
may be stained by locally used abortifacient agents.
„ . To confirm or exclude air embolism, the body must be
opened after radiological examination as it may show
translucency of the right ventricle and pulmonary
artery (details in Chapter 6).
„ . The abdominal cavity is opened and may be full of
blood, if there is perforation of uterus. Uterine and
adnexal tissues are assessed for crepitation due to gas
formation in the uterine wall, and venous channels
and the inferior vena cava is inspected for air or
soap embolism bubbles.
„ . The skull vault must then be carefully removed,
avoiding puncture of the meninges and vessels
over the brain surface which allows air to enter
these vessels; a detailed examination of the basal
sinuses, veins and arteries is made for the presence
of air embolism.
„ . Following removal of the thoracic and abdominal
organs in the usual manner, the pelvic organs are
excised en-masse following separation of the symphysis
pubis and a circular dissection to include vagina,
vulva and rectum with adjacent skin, taking care to
collect any foreign fluid or material for chemical and
bacteriological examination. The vagina and uterus are
opened along their anterior surface because injuries
are more likely to occur on the posterior vaginal wall
following criminal interference.
„ . Findings in the uterus: Cavity may show presence
of products of conception in full or in parts. It may
be enlarged, soft and congested. Wall may show
thickening in longitudinal section.
„ . Samples to be collected are given in Box 22.1.
Trauma and Abortion
Allegation may be leveled against a person that because
of the alleged assault, the pregnant female suffered
an abortion. It may be a case of a mother who is the
victim of an assault, which results in premature labor,
delivery of an extremely premature infant who survives
a few hours, but then dies because of prematurity. Such
a case could be considered a homicide, and criminal
charges could well be pursued. In similar cases, where
the fetus dies in-utero, criminal charges are framed
under various sections of IPC.
„ . Travel, in the absence of trauma, does not increase
the incidence of abortion.
„ . Trauma may rarely cause an abortion, in the absence
of serious or life-threatening injury to mother.
„ . Following criteria suggests a causal relationship between
trauma and abortion:
a. The traumatic event was followed within 24 hours
by processes that ultimately lead to abortion.
b. Appearance of the fetus and placenta should be
compatible with the period of pregnancy at which
the traumatic event occurred.
c. The fetus and placenta should be normal.
d. Factors known to cause abortion should be absent,
such as:
i. History of repeated abortion without any cause
or exposure to abortifacients, e.g. X-ray or lead.
ii. Chronic infections in mother, e.g. syphilis,
toxoplasmosis or tuberculosis.
iii. Abnormalities of uterus including congenital
defect of uterine development, leiomyomas,
endometrial polyps and incompetent os.
iv. Physical attempt to induce abortion.
Samples to be collected in criminal abortion
Vaginal contents pipetted in a clean sterile container for
chemicals, drugs or soap.
Pubic hair.
Blood, urine and stomach contents.
Blood from the inferior vena cava and both cardiac ventricles.
Any fluid from the uterine cavity.
Swabs of the uterine wall.
Tissues for histology from all organs.

Pre-abortion management
6.1 Prior to referral, pregnancy should be confirmed by history and a reliable
urine
pregnancy test.
The abortion decision
6.2 Healthcare staff caring for women requesting abortion should identify
those who require
more support in the decision-making process.
6.3 Women who are certain of their decision to have an abortion should not be
subjected to
compulsory counselling.
6.4 Pathways to additional support, including counselling and social services,
should be
available.
6.5 Women should be given information about the different methods of
abortion appropriate
to gestation, the potential adverse effects and complications, and their clinical
implications.
6.6 Where possible, women should be given the abortion method of their
choice.
Blood tests
6.7 Pre-abortion assessment should always include:
•
determination of rhesus blood status.
Where clinically indicated, pre-abortion assessment should also include:
•
determination of blood group with screening for red cell antibodies
•
measurement of haemoglobin concentration
•
testing for haemoglobinopathies.
6.8 It is not cost-effective or necessary to routinely cross-match women
undergoing induced
abortion.
Venous thromboembolism risk assessment
6.9 All women undergoing an abortion should undergo a venous
thromboembolism (VTE)
risk assessment.
The Care of Women Requesting Induced Abortion
Summary of recommendations

Cervical cytology
6.10 Women who have not had cervical cytology screening within the
recommended interval
should be offered screening within the abortion service, or advised on when
and where
to obtain it.
Ultrasound scanning
6.11 Use of
routine
pre-abortion ultrasound scanning is unnecessary.
6.12 Ultrasound scanning must be available to all services as it may be
required as part of the
assessment.
6.13 Ultrasound scanning should be provided in a setting and manner
sensitive to the
woman’s situation.
6.14 Before ultrasound is undertaken, women should be asked whether they
would wish to
see the image or not.
Prevention of infective complications
6.15 Services should offer antibiotic prophylaxis effective against
Chlamydia trachomatis
and
anaerobes for both surgical abortion (evidence grade: A) and medical abortion
(evidence
grade: C).
6.16 The following regimens are suitable for peri-abortion antibiotic
prophylaxis:
•
azithromycin 1 g orally on the day of abortion,
plus
metronidazole 1 g rectally or
800 mg orally prior to or at the time of abortion
OR
•
doxycycline 100 mg orally twice daily for 7 days, starting on the day of the
abortion,
plus
metronidazole 1 g rectally or 800mg orally prior to or at the time of the
abortion
OR
•
metronidazole 1 g rectally or 800 mg orally prior to or at the time of abortion
for
women who have tested negative for
C. trachomatis
infection.
STI screening
6.17 All women should be screened for
C. trachomatis
and undergo a risk assessment for other
STIs (for example, HIV, gonorrhoea, syphilis), and be screened for them if
appropriate.
6.18 A system for partner notification and follow-up or referral to a sexual
health service
should be in place.
6.19 Services should make available information about the prevention of STIs
and offer
condoms for STI prevention to women undergoing abortion.
Contraception
6.20 All appropriate methods of contraception should be discussed with
women at the initial
assessment and a plan agreed for contraception after the abortion.
Feticide
6.21 Feticide should be performed before medical abortion after 21 weeks and
6 days of
gestation to ensure that there is no risk of a live birth.
2.4 Abortion procedures
Surgical methods
Vacuum aspiration
7.1 Vacuum aspiration is an appropriate method of surgical abortion up to 14
weeks of
gestation.
7.2 Either electric or manual vacuum aspiration may be used as both are
effective and
acceptable to women and clinicians.
7.3 Vacuum aspiration under 7 weeks of gestation should be performed with
appropriate
safeguards to ensure complete abortion, including inspection of aspirated
tissue.
7.4 Vacuum aspiration may be performed from 14 to 16 weeks of gestation;
large-bore
cannulae and suction tubing may be required to complete the procedure
without the use
of forceps to remove larger fetal parts.
7.5 During vacuum aspiration, the uterus should be emptied using the suction
cannula and
blunt forceps (if required) only. The procedure should not be routinely
completed by
sharp curettage.
7.6 Access to ultrasound during vacuum aspiration is recommended but not
routinely
required for uncomplicated procedures.
Dilatation and evacuation
7.7 Surgical abortion by dilatation and evacuation (D&E), preceded by cervical
preparation,
is appropriate for pregnancies above 14 weeks of gestation.
7.8 Continuous ultrasound guidance during D&E is recommended to reduce
the risk of
surgical complications.
Cervical preparation for surgical abortion
7.9 Cervical preparation should be considered in all cases.
7.10 The following regimens are recommended for cervical preparation up to
14 weeks of
gestation:
•
Misoprostol 400 micrograms administered vaginally 3 hours prior to surgery or
sublingually 2–3 hours prior to surgery.
7.11 Vaginal misoprostol can be administered either by the woman herself or
by a clinician.
7.12 After 14 weeks of gestation, osmotic dilators provide superior dilatation to
medical
methods; however, misoprostol is an acceptable alternative up to 18 weeks of
gestation.
7.13 Use of medications containing oxytocin or ergometrine is not
recommended for
prophylaxis to prevent excessive bleeding at the time of vacuum aspiration.
The Care of Women Requesting Induced Abortion
Summary of recommendations
13
Pain relief for surgical abortion
Anaesthesia
7.14 Services should be able to provide surgical abortions without resort to
general
anaesthesia.
7.15 If conscious sedation is used during surgical abortion, it should be
undertaken only by
trained practitioners and in line with DH guidance.
Analgesia
7.16 Women should routinely be offered pain relief such as non-steroidal anti-
inflammatory
drugs (NSAIDs) during surgical abortion.
7.17 Prophylactic paracetamol (oral or rectal) is ineffective in reducing pain
after surgical
abortion and is not recommended.
Medical methods
7.18 Medical abortion regimens using 200 mg oral mifepristone and
misoprostol are effective
and appropriate at any gestation.
Medical abortion at
≤
63 days of gestation (early medical abortion)
7.19 The following regimens are recommended for early medical abortion:
•
at
≤
63 days of gestation, mifepristone 200 mg orally followed 24–48 hours later by
misoprostol 800 micrograms given by the vaginal, buccal or sublingual route
•
at
≤
49 days, 200 mg oral mifepristone followed 24–48 hours later by 400
micrograms
of oral misoprostol.
7.20 For women at 50–63 days of gestation, if abortion has not occurred 4
hours after
administration of misoprostol, a second dose of misoprostol 400 micrograms
may be
administered vaginally or orally (depending upon preference and amount of
bleeding).
Place of misoprostol administration
7.21 It is safe and acceptable for women who wish to leave the abortion unit
following
misoprostol administration to complete the abortion at home. There must be
an adequate
support strategy and robust follow-up arrangements for these women.
Medical abortion at 9–13 weeks of gestation
7.22 The following regimen is recommended for medical abortion between 9
and 13 weeks
of gestation:
•
mifepristone 200 mg orally followed 36–48 hours later by misoprostol 800
micro -
grams vaginally. A maximum of four further doses of misoprostol 400
micrograms
may be administered at 3-hourly intervals, vaginally or orally.
Medical abortion at 13–24 weeks of gestation
7.23 The following regimen is recommended for medical abortion between 13
and 24 weeks
of gestation:
•
mifepristone 200 mg orally, followed 36–48 hours later by misoprostol 800
micro -
grams vaginally, then misoprostol 400 micrograms orally or vaginally, 3-
hourly, to a
maximum of four further doses.
•
If abortion does not occur, mifepristone can be repeated 3 hours after the last
dose of
misoprostol and 12 hours later misoprostol may be recommenced.
7.24 Surgical evacuation of the uterus is not required routinely following
medical abortion
between 13 and 24 weeks of gestation. It should be undertaken only if there is
clinical
evidence that the abortion is incomplete.
Pain relief for medical abortion
7.25 Women should routinely be offered pain relief (for example, NSAIDs)
during medical
abortion.
7.26 Oral paracetamol has not been shown to reduce pain more than placebo
during medical
abortion and is not recommended.
7.27 Some women may require additional narcotic analgesia, particularly after
13 weeks of
gestation.
Histopathology
7.28 Routine histopathological examination of tissue obtained at abortion
procedures is not
recommended.
Gestational trophoblastic neoplasia
7.29 Routine screening of women for gestational trophoblastic neoplasia
(GTN) at the time of
abortion is not recommended; providers should be aware of the signs and
symptoms
and, where appropriate, facilitate referral into a GTN monitoring programme.
2.5 Care after the abortion
Rhesus prophylaxis
8.1 Anti-D IgG should be given, by injection into the deltoid muscle, to all non-
sensitised
RhD negative women within 72 hours following abortion, whether by surgical
or
medical methods.
Information after abortion
8.2 On discharge, all women should be given a letter providing sufficient
information about
the procedure to allow another practitioner elsewhere to manage any
complications.
The Care of Women Requesting Induced Abortion
Summary of recommendations
15
8.3 Following abortion, women should be provided with verbal and written
information
about:
•
symptoms they may experience, emphasising those which would necessitate
an
urgent medical consultation
•
symptoms suggestive of continuing pregnancy.
8.4 Independent providers of abortion services should have arrangements in
place for
referring women into NHS services for emergency assessment/admission.
8.5 A 24-hour telephone helpline number should be available for women to
use after
abortion if they have any concerns.
Follow-up after abortion
8.6 There is no medical need for routine follow-up after surgical abortion or
after medical
abortion if successful abortion has been confirmed at the time of the
procedure.
8.7 Women having a medical abortion in whom successful abortion has
not
been confirmed
at the time of the procedure should be offered follow-up to exclude continuing
pregnancy.
8.8 All women having an abortion should be able to choose to return for
routine follow-up
if they so wish.
8.9 Referral should be available for any woman who may require additional
emotional
support or whose mental health is perceived to be at risk.
8.10 All women should be advised where to seek help if they have any
concerns or if they
need further contraceptive advice or provision.
8.11 Ultrasound examination should not be used routinely to screen women
for incomplete
abortion.
8.12 The decision to evacuate the uterus following incomplete abortion should
be based on
clinical signs and symptoms and not on ultrasound appearance.
Contraception after abortion
8.13 Abortion services should be able to provide all methods of contraception,
including
long-acting methods, immediately after abortion.
8.14 Women should be advised of the greater effectiveness of long-acting
reversible methods
of contraception.
8.15 Before she is discharged, future contraception should have been
discussed with each
woman and contraceptive supplies should have been offered.
8.16 The chosen method of contraception should be initiated immediately.
8.17 Intrauterine contraceptives can be inserted immediately following medical
and surgical
abortion at all gestations as long as it is reasonably certain that the woman is
not still
pregnant.
8.18 Women who choose not to start a contraceptive method immediately
should be given
information about local contraceptive providers in addition to their GP.
8.19 Abortion services should have an agreed pathway of care to local
community sexual
health services.
Sterilisation
8.20 Sterilisation can be safely performed at the time of induced abortion,
although this may
be more likely to be associated with regret and failure
The role of doctors
Where a doctor prescribes the treatment for the abortion, remains in charge
and accepts
responsibility throughout and the treatment is carried out in accordance with
his/her directions, the
pregnancy is ‘terminated by a registered medical practitioner’ for the purposes
of the Abortion Act
1967 (as amended).
13

Doctors providing abortion care are bound by the same duties of a doctor, as
laid down by the General Medical Council (GMC) in its Good Medical Practice
Guidance (2008),
19

for all other aspects of their clinical practice. These principles of good practice
bear repetition here:
•
make the care of your patient your first concern
•
protect and promote the health of patients and the public
•
provide a good standard of practice and care
•
•
keep you
r professional knowledge and skills up to date
•
•
recogni
se and work within the limits of your competence
•
•
wor
k with colleagues in the ways that best serve patients’ interests
•
treat patients as individuals and respect their dignity
•
•
tre
at patients politely and considerately
•
•
respect
patients’ right to confidentiality
•
work in partnership with patients
•
•
listen
to patients and respond to their concerns and preferences
•
•
give pa
tients the information they want or need in a way they can understand
•
•
respect
patients’ right to reach decisions with you about their treatment and care
•
•
su
pport patients in caring for themselves to improve and maintain their health
3270 RCOG Abortion guideline.qxd:3270 RCOG Abortion guideline.qxd 11/11/11
14:13 Page 19
•
be honest and open and act with integrity
•
•
ac
t without delay if you have good reason to believe that you or a colleague may
be putting
patients at risk
•
•
never di
scriminate unfairly against patients or colleagues
•
•
never abu
se your patients’ trust in you or the public’s trust in the profession.
Doctors are legally required under the Abortion Act 1967 (as amended)
13

to complete abortion
forms for every abortion performed, whether carried out in the NHS or an
approved independent
sector place and whether or not the woman is a Great Britain resident. See
Section 3(1) of the Act
20

covering abortion forms for further details on this

Future reproductive outcome
RECOMMENDATION 5.11
Women should be informed that there are no proven associations between
induced abortion
and subsequent ectopic pregnancy, placenta praevia or infertility.
Evidence supporting recommendation 5.11
No new evidence of a relationship between abortion and subsequent placenta
praevia, ectopic
pregnancy, subfertility or miscarriage was identified in the course of updating
this guideline and
much of the evidence presented is based on a review article of the long-term
health consequences
of abortion published in 2002 by Thorp et al.
189

Placenta praevia
Thorp and colleagues reported an association between induced abortion and
placenta praevia
across a number of heterogeneous studies of variable quality. Subsequent
studies, however, have
reported more reassuring findings. A Danish cohort study based on national
registry data linkage
involved 15 727 women whose first pregnancy was terminated and a
reference cohort of 46 026
B
3270 RCOG Abortion guideline.qxd:3270 RCOG Abortion guideline.qxd 11/11/11
14:13 Page 43
women.
190

No association with placenta praevia was seen. A case–control study from the
USA
involved 192 cases of placenta praevia and 622 controls.
191

The investigators concluded that risk of

placenta praevia might have increased in a dose–response fashion with sharp
curettage abortions,
but that vacuum aspiration did not confer an increased risk.
Ectopic pregnancy
Thorp et al. reviewed seven case–control and two cohort studies relating to
abortion and
subsequent ectopic pregnancy.
189

Only two of the nine studies reported a positive association; these

were relatively small case–control studies which relied on self-report of
previous abortion. Large
studies based on record linkage showed no association.
Subfertility
Published studies strongly suggest that infertility is not a consequence of
uncomplicated induced
abortion.
192–194

Although women with a previous induced abortion appeared to be at an

increased
risk of infertility in countries where abortion is illegal and therefore usually
unsafe, this is not the
case in legal settings. There are some discrepancies among studies,
195

but none was of sufficient

power to detect a small association. In the review by Thorp et al., three case–
control studies and
four cohort studies relating to abortion and infertility were appraised. Two
relatively small
case–control studies, both from Greece, showed a positive association of
abortion with
subfertility.
195,196

Other studies found no association. Thorp et al.

189

commented on the
methodological limitations of all studies which date from before 1999. No
relevant new studies
were identified during the updated literature search.
Miscarriage
Thorpe et al. reviewed two cohort and three case–control studies examining
associations between
induced abortion and miscarriage, and no significant association was
identified.
189
Moreover, those
that analysed data according to the number of abortions found no dose–
response effect. However,
some studies report conflicting findings. A study by Zhou suggests that
women who become
pregnant within 3 months of abortion are at increased risk of miscarriage.
197

A further cohort study

from Shanghai of nearly 3000 women comparing primigravid women with
women undergoing
abortion by vacuum aspiration reported an adjusted odds ratio (OR) of 1.72
for miscarriage (95%
CI 1.09–2.72) between abortion and reference cohorts.
198

Preterm birth
 Therapeutic – when women life is in danger if pregnancy is continued  Eugenic – when there
is risk of child being born with serious physical or mental abnormalities (Measles, small pox, any
viral infection, TORCH, Drugs)  Humanitarian – pregnancy caused by rape  Social – failure
of contraceptive methods in married women  Environmental – poor economic status which
affects mother/child health status
 15.  Who can terminate pregnancy ?  Place of MTP ?  Consent  Duration of pregnancy 
Medico legal aspects
 16.  - Registered Medical Practitioner (MBBS) - RMO if assisted 25 cases of MTP in a
recognized hospital - MD, Diploma in OBG
 17.  Place of abortion - Govt Hospital - Hospital recognized by Govt - Private hospital after
taking license from District Health Officer Consent – 1. Written informed consent from women
2. Minor or mentally ill – guardian 3. If husband requests for abortion?
 18.  Register has to be maintained  Duration of pregnancy - if < 12 weeks : single doctor - >
12 weeks : two doctors must agree that there is an indication - In case of emergency ?
 19.  Termination of pregnancy by a person who is not RMP or in an unrecognized hospital
shall be punished with rigorous imprisonment for a term which shall not be less than 2 years but
may extend to 7 years.  Miscarriage without the consent of women – imprisonment up to 10
years (Sec.313 IPC)

 Section 312 Any one voluntarily causing miscarriage to a woman with child, other than in
good faith for the purpose of saving her life is punishable by imprisonment (simple or rigorous)
&/or a fine Sections 313 - 316 (for death due to procedure) Up to 10 years imprisonment and
fine, extending up to life imprisonment where the abortion was conducted without consent
 3. MTP ACT
 4. A Protective Umbrella The MTP Act if adhered to completely offers complete protection
to the medical practitioner from any of the consequences of the IPC However legal protection
is only available conditional to every requirement of the Act being fulfilled Sheriar, J Obs Gyn
India, 51(6):25, 2002
 5. The MTP Act (Act No. 34 of 1971) “ An Act to provide for the Termination of certain
pregnancies by registered medical practioners & for matters connected therewith & incidental
thereto” Legislated by the Parliament on August 10th , 1971 And the Act was enforced
Nationwide from April 1st , 1972 Adopted by Kashmir & Mizoram- 1980
 6. MTP Act, Rules, Regulations MTP Act Is an Act of Parliament providing an Overview of
Safe abortions and delegating authority to Central & State government Rules are framed by the
Central Government BUT must be ratified by each house of Parliament Regulations are framed
by the State Government & relate to issues involving Opinions , reporting and maintaining
secrecy
 7. Legal framework 1. MTP Act 2. Rules 3. Regulation
 8. MTP Act, Rules & Regulations
 9. MTP Act Specifies:  1  The Indications for legal Terminations  2  Who can Terminate
 3  The Place where it can be terminated  4  Last but most imp. Consent requirement
 10. When pregnancy can be terminated.. ??? 1--continuation of pregnancy is a risk to the life
of pregnant woman or it can cause grave injury to her physical and mental health 2--Substantial
risk that the child , if born ,would be seriously handicapped due to physical or mental
abnormalities 3--pregnancy caused by rape 4--failure of contraceptive in married woman
 11. Who Can Terminate a Pregnancy?
 12. Who can perform MTP ? A Registered Medical practitioner (RMP )who has a recognized
Medical qualification as defined in clause ( b) of Sec 2 of indian Medical Counsel Act, 1956
Whose name is registered in a state Medical register Who has training experience as per MTP
rules
 13. Experience of RMP- Up to 12 weeks Gestation only Before the commencement of act
experience minimum 3yrs Who is regst in state medical register ---6months of house surgeon
ship in gynae Or experience of working in dept of gynae –1yr 1-- A Practitioner who has
assisted RMP in 25 cases of Medical termination of pregnancies ,at least 5 of which have been
performed independently in a hospital established or maintained by govt or a training institute
approved for this purpose by the Govt
 14. Experience and Training Required by a RMP-upto 20 wks PG Degree or Diploma in OB
& Gynae Completed 6 months as House Surgeon in OB & Gynae At least one yr experience
in dept of ob & Gynae at any hospital that has all facilities
 15. Where pregnancy can be Terminated -- PLACE Hospitals established or maintained by
the Govt A Place approved by the Government or DLC constituted by the Govt
 16. Consent ----- Form C 1-- Only the consent of a women is required 2-- If Age <18 yrs or a
mentally ill patient consent of guardian is reqd
 17. MTP Rules A- Appointed by Govt n responsible for approval and suspension of Place
Chaired by CMO B 3-5 members C - one member shd be Gynecologist , surgeon ,
Anesthetist D -other members are from local drs , NGO, Panchayat Raj E -at least one should
be woman 1---Composition and tenure of DLC Which is
 18. Up to 12 wks -- FACILITIES - 1-Gynecological examination /labor table 2-
Resuscitation and sterilization Equipments 3-Drugs and Parenteral fluids 4- Backup facilities
for treatment of shock 2- REQUIREMENT FOR APPROVAL OF A PLACE MTP rules ….
 19. …For approval For Terminating 12 to 20 weeks of Pregnancy  FACILITIES 1-
An operation table and instruments for performing abdominal or gynecological surgery 2-
Anesthetic Equipments, resuscitation and sterilization equipments 3-
Drugs and Parentral fluids for any emergency , notified by GOI from time to time
 20. For Medical Abortion 1-up to 7 wks
An RMP does not need approval of place , can display
a certificate from owner of a approved place Only Registered doctor can prescribe
One needs to follow all rules and regulation under MTP Act
 21. MTP rules….. Approval is applied - FORM A Annexure 1 Addressed to CMO
CMO does -- verification inquiry or inspection
then recommends for approval of place to DLC
 issues a certificate of approval in FORM B (annexure -1 ) 3---APRROVAL PROCESS
 22. Inspection of Place Place should be inspected within 60 days of receipt of approval
and approval within next 2 months or within 2 month
of any deficiency being rectified by applicant to ensure safe and hygienic conditions
CMO may inspect the approved place any time if necessary to reconfirm
You have to show and give all information's to CMO anytime
 23. Cancellation / Suspension  CMO can suspend or cancel the approval , if he
suspects unsafe and unhygienic conditions . After suspension can apply again after making
improvement within 60 days of order , during
suspension place is deemed as not approved govt can modify or reverse the orders
 24. MTP rules…. Already discussed 4-- Registered medical practitioner -- Requirements
 25. Amendments to MTP rules 2003 Key features :- 1.
Detailed the composition and tenure of the DLC 2.Abortion sites approved for A-
up to 12 weeks B- 12-20 weeks, facilities and equipments required for
two types were detailed 3.Allowed medical abortion using RU-486 and
misoprostol by RMP even from site not approved
provided the RMP has referral linkage access to an approved place
4.A non OB gynae provider who is trained and certified can provide first trimester abortion
 26. MTP Regulations MTP Act empowers the state govt to form regulations ,
maintain records , reports Salient features 1-Form of certifying opinion or opinions
Form 1 Annexure - 2 RMP who terminate s, should certify it in Form 1 2- Custody
of forms Form c the consent form + Form 1 for intimation of
termination , shall be sealed n kept in safe custody & given to head or owner of approved place
A serial number is assigned to the pregnant pat in the
admission register ,name of the RMP, & shall write SECRET 3-
Head or Owner has to send monthly statement of the
MTP cases to the CMO on FORM II ( Annexure -3 )
 27. Maintenance Of Admission Register Maintain records As per Form III ( Annexure -4 )
Record the detail Keep in secret custody for 5 years from the end of calendar year it relates to;
It is not disclosed to anyone except under authority of law
 28. Recommendations to Overcome Shortcomings Requirement of 2 opinions for second
trimester termination is now a formality and could be dispensed A qualified extension of up to
22 weeks to accommodate terminations after prenatal diagnosis of birth defects Scope to
simplify and streamline bureaucratic procedures by amending MTP Rules and Regulations.
Registration of centres by meticulous application & persistent follow up Valid case for
bifurcating recognition requirements for performing first & second trimester MTPs, in view of
the documented safety & simplicity of early abortions
 29. Recommendations to Overcome Shortcomings With medical methods administered on an
outpatient basis, the act needs to be updated to keep abreast with future medical advances
Revisit documentation required. Admission register could be replaced by MTP Register
Increase the number of trained persons performing induced abortions by multiplying training
facilities
 30. Violation of The ACT Any person doing MTP and not a RMP can be punished with
rigorous imprisonment for 2-7 yrs If terminating at a place which is not approved can be
punished 2--7 yrs rigorous imprisonment The owner of unapproved place , performing
termination can also be punished with rigorous imprisonment 2--7 yrs
 31. Legal abortion means Termination done at a place approved under the Act Termination
done for conditions and within the gestation prescribed the Act Termination done by a medical
practitioner approved by the act Other requirements of the rules and regulations are complied
with
 32. Take home message • It is necessary to do register your nursing home under the MTP act,
if you are going to do MTP • Must follow all the rules and regulations under MTP strictly and
correctly • All paper work must be complete before you start an MTP ,one never knows when an
emergency arises • Cultivate good habits like keeping and preparing documents well in time .
 33. In matters of style, swim with the current; in matters of principle, stand like a rock.
The Medical Terminatio
n of Pregnancy Act, 1971
Under this Act, pregnancy can be terminated under the
following conditions.
1) Therapeutic :- When the continuation of pregnancy
endangers the life of women or may cause serious injury to
the physical or mental health.
2) Eugenic :- When there is risk of the child being
born with serious physical or mental abnormalities.
3) Humanitarian :- When pregnancy has been caused by
rape.
4) Failure of contraception :- When pregnancy has resulted
from the failure of contraceptive methods in case of a
married women, which is likely to cause serious injury to
her mental health.
5) Socio-economic :-When social or economic environment,
actual or reasonably expected can injury the mother’s
health.

Who?
• <12 weeks Only registered medical
officer with experience in OG
• 12-20 weeks Opinion of two
registered medical officers is needed
Where?
• Hospital established/maintained by
govt.
• Place established for the purpose of
this act by govt.
MTP Rule (1975 Oct)
• To eliminate the time consuming
procedures
• To make services more readily
available
Approval by Certification Board is
no longer needed
Who?
• If he has assisted a RMP in 25
cases of MTP in a approved
institution
• If he has 6 months housemanship in
OG
• PG in OG
• If he has 3 years of practice in OG
(before 1971 MTP Act)
• If he has 1 year of practice in OG
(after 1971 MTP Act)
Who?
• If he has assisted a RMP in 25
cases of MTP in a approved
institution
• If he has 6 months housemanship in
OG
• PG in OG
• If he has 3 years of practice in OG
(before 1971 MTP Act)
• If he has 1 year of practice in OG
(after 1971 MTP Act)
Where?
• No need for a Board license
• Non-governmental institutions that
have obtained a license from the
Chief Medical Officer of the
District
What else is needed
• Written consent of woman/guardian
• Professional secrecy
What is not needed
• Husbands’ consent
• Proof of age
• Police complaint of rape

Abortion indication No Percent

Maternal 12 18.46
Psychiatric 5 7.69
Tumors 6 9.23
Others 2 3.07
Fetal and maternal 9 13.84
Fetal 44 67.69
Plurimalformated fetus normal cariotype 5 7.69
Cranium/SNC anomalies (anencephaly, encephalocel, hydrocephaly,
holoprosecencephaly) 7 10.76
Facial anomalies 3 4.61
Pulmonary anomalies 2 3.07
Cardiac anomalies (Hypoplastic left hearth syndrome, TOF, ASVD) 11 16.92
Gastrointestinal anomalies (Absent stomach /esopahageal atresia) 2 3.07
Abdominal wall defects (gastroschizis, omphalocele Cantrell Pentalogy) 3 4.61
Fetal hydrops 1 1.53
Partial trophoblastic disease (embrionate mola) 1 1.53
Chromosomial anomalies (T21, T13, T18, 46 xx)
Medical termination of pregnancy (MTP)act 1971

• Came into force in 1972

• Amendments in 1975, 2002 and 2003

  Grounds for MTP:

• Therapeutic : risk to pregnant woman

• Eugenic : risk to the child to be born

• Humanitarian : pregnancy caused by rape

• Socioeconomic : pregnancy due to failure of contraceptive,

Unwanted pregnancy with low SE status

• Environemental: no one to help from society

Places for MTP

• Any government or semi-government hospital

• Any non-government hospital approved by government or CMO or district health officer

• QualificatioUp to 12 weeks: By any RMP who has performed at least 25 cases of MTP and out
of which 5 have been performed independently in an approved place.

• By doctor with any of the following:

-PG degree or diploma in OBG

-6 month of house surgency in OBG

-Experience of one year or more in OBG at any hospital

In emergency cases: By any RMP , at any place , irrespective of duration of pregnancyn and Experience
of doctors for MTP

Consent

• Only consent of pregnant woman is necessary

• No need to obtain consent from her husband

• In case of minor (less than 18 year of age),and mentally ill woman, consent from guardian is
required

Common methods of MTP

• Medical : mifepristone and misoprostol

• Dilatation and curettage (D&C)

• Vacuum aspiration technique or surgical abortion

• Intra-embryonic instillation of PG

• Extra-embryonic instillation of hypertonic saline

• Surgical