MTP (Medical termination of pregnancy) Act

1971

The original Act of 1971 came into force on 1st April

1972 and amended in 2002 to provide for the
termination of certain pregnancies by the registered
medical practitioners (RMP) for protection and
preservation of the lives of women.
• Indications for Termination of Pregnancy:
i. Therapeutic: In order to prevent injury to the
physical health of pregnant woman. Indications are:
• Cardiac disease (Grade III and IV)
• Chronic glomerulonephritis
• Intractable hyperemesis gravidarum
• Malignant hypertension
• Epilepsy/Insanity
• Cervical or breast carcinoma
• Diabetes with retinopathy
• Toxemia of pregnancy
ii. Eugenic: Risk of the child being born with serious
physical or mental abnormalities. Indications are:
• Mother exposed to teratogenic drugs (warfarin) or
radiation exposure (> 10 rads) in early pregnancy.
• German measles (Rubella), chicken pox, viral
hepatitis or other viral infections, if contacted
within 1st trimester.
• Structural (anencephaly), chromosomal (Down's
syndrome) or genetic abnormalities of the fetus.
• Parents have inheritable mental condition or
chromosomal abnormalities.
iii. Social: Almost the sole indication, to prevent grave
injury to physical & mental health of the pregnant
lady. Conditions include:
• Unplanned pregnancy with low socioeconomic status
(80% of cases).
• Pregnancy in a woman as a result of contraceptive
failure. All the pregnancies can be terminated using
this criterion.
iv. Humanitarian: Pregnancy caused by rape.
v. Environmental
• When a woman suffering from some serious disease,
has no one to help in her domestic work and will be
incapable of bearing the strain of rearing a child.
• If there is already a subnormal child, who demands
considerable attention, making it difficult to look after the
new arrival.
MTP Act Rules
Length of pregnancy: Under MTP Act, pregnancy cannot
be terminated after 20 weeks of pregnancy.13 Above 20
weeks, the pregnancy can be terminated only on
therapeutic considerations, i.e. to save the life of the
mother. In such cases, decision can be taken by a single
doctor.
• Upto 12 weeks of pregnancy, it can be terminated on
the opinion of a single doctor.
• Between 12-20 weeks, decision should be taken jointly
by two doctors.
• Place where MTP can be Performed
MTP's can only be conducted at:
i. A hospital established /maintained by Government,
ii. A place approved by Government or a District level
Committee with the Chief Medical Officer or District
Health Officer as Chairperson of the said Committee.

• Qualification and Experience of RMP

For RMP conducting MTP upto 12 weeks
The doctor should have the experience of assisting an
RMP in conducting 25 cases of MTP, out of which at
least 5 cases should have performed independently, in
an approved hospital by the Government.
For RMP's conducting MTP between 12-20 weeks period
The doctor should have either:
• Post-graduate degree/diploma in Obs & Gynaec
• Six months of house surgency in Obs & Gynae or
• One year or more in the practice of Obs & Gynae at
any hospital.
• Emergency cases: Pregnancy can be terminated by
any
- RMP, even without required experience at any place,
irrespective of duration of pregnancy, if it is necessary
Consent: Consent of woman is mandatory, except when
she is minor (< 18 years) or mentally ill, where consent
of the guardian is obtained. Consent of husband is not
necessary.
Maintenance of register: The head of the hospital should
- maintain a register, recording the details of the patient
- undergoing termination of pregnancy for a period of 5
years, and professional secrecy should be maintained.
Contravention of the rules by the doctor: Liable to be
punished with rigorous imprisonment of 2-7 years and
if he is a government servant, he will be liable to face
disciplinary action including dismissal from service.
• Methods of abortion:
1. 1st trimester (upto 12 weeks):
Medical
- Mifepristone (RU-486)
- Mifepristone and misoprostol (PGE1)
- Methotrexate and misoprostol
- Tamoxifen and misoprostol
Surgical
- Manual vacuum aspiration (MVA)
- Dilatation and evacuation (D & E)
- Suction evacuation and/or curettage
2. 2nd trimester (upto 20 weeks):
- Dilatation and evacuation (13-14 weeks).
- Intra-uterine instillation of hyperosmotic solution
i. Intra-amniotic hypertonic urea (40%), saline (20%)
ii. Extra-amniotic: Ethacrydine lactate, prostaglandins
Tamoxifen and misoprostol (PGE2, PGF2).
- Prostaglandins [PGE1, PGE2, PGF2]: Intravaginally,
intra-muscularly or intra-amniotically
- Oxytocin infusion
- Hysterotomy
 Abortion
Def: Medically, abortion (Latin: 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). But in India, independent
viability of fetus is taken as more than 28 weeks of
Gestation.
Legally, miscarriage or abortion, means termination of
pregnancy by premature expulsion of the foetus
from then uterus at any time.
• Abortus: The non-viable product of abortion.
• Abortifacient: Any agent that induces abortion.
• Types of abortion:
A. Spontaneous:
1. Natural
2. accidental
B. Induced:
3. Legal or justifiable
4. Criminal.

A. Spontaneous abortion:
• Incidence: 10-20% of all pregnancies (approx).
1. Natural:
- Most frequent within first 3 months due 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
i. Genetic: Majority of early abortions are due to
chromosomal abnormality.
- Hydatidiform mole.
- Autosomal trisomy is the commonest cause (50%)
and most common is trisomy (30%).
- Monosomy and chromosomal aberration (including
deletion, duplication, translocation and inversion)
constitutes 20% and 2-4% of all abortions.
ii. Anatomic: Cervico-uterine factors usually cause
second trimester abortions.
- Cervical incompetence
-Congenital malformation of uterus, e.g. hypoplasia,
- Low implantation of zygote or placenta privia.
- Uterine fibroid, disease of decidua or placenta.
iii. Endocrine and metabolic abnormalities
- Diabetes mellitus
- Hypo- or hyperthyroidism
- Luteal phase defect
- Deficient progesterone secretion from corpus
luteum
- Hormonal deficiency (progesterone)
iv. Infecton:
Viral: Rubella, cytomegalovirus, variola or HIV. TORCH
syndrome
- Bacterial: Ureaplasma, Chlamydia, Brucella, syphillis
- Parasitic: Toxoplasma or malaria.
All causes hyperpyrexia of mother.
v. Immunological: Both autoimmune and alloimmune factors
can cause miscarriage.
vi. Others
- Maternal illness: Cyanotic heart disease, hemoglobinopathies.
- Antifetal antibodies.
- Blood group incompatibility: Incompatible ABO and Rh group.
- Premature rupture of the membranes.
- Environmental factors: Cigarette smoking, arsenic/lead toxicity,
drug toxicity, vegetable poisoning, in-situ contraceptive
agents, X-ray exposure and antineoplastic drugs.
Unexplained (40%): In spite of the numerous factors
mentioned, it is sometimes difficult to pinpoint exact
cause of abortion.

2. Accidental: accidental abortion may occur due to

- Trauma
- Accidental poisoning

B. Induced abortion:
1. Legal or justifiable:
When it is done in good faith to save the life of the
woman and performed within the legal provisions of
2. Criminal abortion:
Induced destruction/expulsion of fetus from womb
unlawfully. It is usually induced before 3rd month,
and causes infection and inflammation of the
endometrium.
- Punishment for criminal abortion described under
sections 312 to 316 of Indian penal code.
• Sec. 312 IPC: Whoever voluntarily causes criminal
abortion with the consent of the patient is liable for
imprisonment upto 3 years and/or fine, and if the
woman is quick with child, imprisonment may extend
upto 7 years.
• Sec. 313 IPC: If miscarriage is caused without the
consent, imprisonment of life or upto 10 years and
fine.
• Sec. 314 IPC: If pregnant woman dies from this act,
imprisonment upto 10 years and fine.
• Sec. 315 IPC: Any act done with intent to prevent
the child being born alive or cause its death before
birth is punished with imprisonment upto 10 years
and/or fine.
• Sec. 316 IPC: Any act which cause death of quick
unborn child amounts to culpable homicide and
imprisonment upto 10 years and fine.
• Methods for Inducing Criminal Abortion :
i. Abortifacient drugs – in 2nd month of pregnancy
ii. General violence – up to end of 1st month
iii. Local violence – during 3rd & 4th month.

i. Abortifacient drugs:
1. Ecbolics: They increase uterine contractions, e.g.
ergot preparations, synthetic estrogens, pituitary
extract, strychnine and quinine.
2. Emmenagogues: These drugs initiate or increase
menstrual flow, e.g. estrogen, savin, borax and
sanguinarin
3. GIT irritants: These causes irritation of uterus, e.g.
purgatives like castor or croton oil, julap, senna and
MgSO4, calomel, Rhubarb, podophylum.
4. Genitourinary irritants: They produce reflex uterine
contraction, e.g. cantharides, and oil of turpentine
or tansy or pennyroyal.
5. Drugs having other systemic toxicity:
• Inorganic irritants, e.g. lead, arsenic, phosphorus,
copper, iron & mercury, antimony.
• Organic irritants, e.g. Abrus precatorius, Calotropis,
plumbago, seeds of custard apple and carrots, and
unripe fruit of papaya or pineapple, methi used in
abortion stick.
ii. General violence:
1. Severe pressure on abdomen by kneeling, fist
blows, kick, tight bandage and massage of uterus
through abdominal wall.
2. Heavy violent exercise eg. Jumping, jolting, riding,
running.
3. Alternate hot and cold bath on lower abdomen.
4. Cupping: A mug is turned upside down over a
lighted wick and placed on the hypogastria. Air
escapes due to heat and the mug sets tightly on the
abdomen. The mug is then pulled which may result
in partial separation of placenta.
5. Introduction of utus paste (containing mercury,
thymol, iodine and some other agents) inside the
uterus leads to abortion.
6. Rupturing of membranes: The membranes are
ruptured by introduction of an instrument, like probe,
stick, uterine sound, catheter, pencil, pen holder,
knitting needle and hairpin.
7. syringing: Higginson’ syringe. Soap water, KMnO4
solution, cresol or lysol or tincture iodine like irritant is
inserted in uterus.
8. Abortion stick: It is a wooden or bamboo stick, 12-18
cm long, wrapped at one end with cotton, wool or
piece of cloth and soaked with juice of marking nut,
calotropis or paste made of arsenious oxide or lead.
• It is introduced into the vagina by dais (traditional
birth attendants) and retain there, till contraction
starts.
• Instead of this stick, a twig of some irritant plant,
like Plumbago, Calotropis or Nerium odorum may be
used.
9. Vacuum aspiration: The cervix is dilated and a tube
attached to a suction pump extracts the fetus.
10. Dilation of cervix: Foreign bodies are introduced
and left in cervical canal, like pessaries, laminaria
(a dried seaweed) or sea tangle tent which dilate the
cervix, irritate uterine mucosa and produce marked
congestion and uterine contractions with expulsion of
- Cervical canal may be dilated by introducing a
compressed sponge into the cervix and leaving it
there. Sponge swells from moisture in the uterine
segment with expulsion of fetus.
- Slippery elm bark (Ulmus fulva) obtained from tree
in Central America, is inserted into cervical canal in
portions of 1-3 inches long. It absorbs moisture and
on each side of the bark, a jelly like layer is
produced that is as thick as the bark itself, due to
which the cervical canal is dilated.
11. Air insufflations: Air is introduced into vagina and
uterus by various means, like pumps or syringes
leading to abortion.
12. Electric current: An electric current of 110 V with
negative pole applied to posterior vaginal cul-de-sac
and positive pole to lumbosacral region, leads to
contraction of uterus and expulsion of contents.

• Causes of death in criminal abortion:

a. Causes of immediate death:
1. Haemorrhage due to incomplete abortion.
2. Perforation: by instrument leads to hemorrhage,
shock, peritonitis.
3. Vagal shock
4. Fat embolism from syringe containing fatty
Material used in criminal abortion
5. Air embolism: from syringing.

b. Causes of delayed death: death occurs in some

days due to local/general infective condition.
1. Peritonitis due to perforation
2. Complicated local infection
3. Tetanus
4. Septic abortion and septicemia

c. Remote causes:
5. Jaundice, hepatitis
6. Acute renal failure
- Endocarditis, memningitis
- Pneumonitis
- Pulmonary embolism
- Endotoxic shock

d. Toxic effect of abortifacient drug may cause death

depending upon dose of that drug.

• Medical findings of criminal abortion:

These are available from examination of
1. Woman concerned
2. Product of conception available
1. Examination of woman
a. In living woman:
- The signs are similar to that of delivery but not all signs
of delivery are
• Clothing must be examined, specially undergarments for
bloodstains, stains from abortifacients (fluid, soapy
materials)—preserved and sent to FSL.
• Clinical examination
- Since most of the abortifacients are irritants, the
woman may show signs of ill health, GIT disturbances
and exhaustion.
• In case of sepsis, there will be pyrexia with chills and
rigor, pain abdomen and increased pulse rate (100-
• Local examination:
- Labia majora & minora are congested depending
upon the size of foetus expelled.
- Injuries like abrasion, contusion or tear laceration
are present.
- Post. Commissure, fourchette and vaginal wall are
congested with decrease in rugosity in case of
advanced stage of pregnancy.
- Character and amount of discharge is noted. In case
of sepsis, offensive purulent vaginal discharge or a
tender uterus with patulous os may be found.
- Presence of chemical around vagina and cervix used
• Laboratory investigations: Serum and urine gives
• positive result for the test for hCG upto 7-10 days.
In abortion during early months of gestation, the
signs will be ill defined, whereas signs will persists
for a longer time if sepsis has taken place and if
abortion has been carried out in late months of
gestation.

b. In dead woman:
• External findings:
- Examination includes absolute identification of a
woman.
- Undergarments may show blood stain, clot and
staining due to abortifacient agent used.
- Parts of product of conception may be present.
- Body looks pale due to death due to haemorrhage.
- In such cases PM staining is not prominent.
- Depending on duration of pregnancy the
pigmentation of parts are seen.
- Breasts may be enlarged with dark aroela and
presence of Montgomery’s tubercles.
- Abdominal wall may be lax with presence of linea
nigra and striae gravidarum.
- In case of cupping, circular mark on abdomen is
- Labia majoras are laxed, labia minoras are
pigmented, may be stained with blood, presence of
injury, marks, congested, stains of abortifacient
agent is found.
- If abortifacient agent is injected parenterally then,
injection marks are seen on Deltoid/ gluteal region,
cubital fossa.
• Internal examination:
- Injury to intra abdominal organs due to
instrumentation and perforation of uterus and
vagina may be seen.
- After opening the abdominal cavity, it is seen with
full of clotted blood if there is perforation of uterus.
- Injury to near by organs like intestine or bladder is
also seen.
• Uterus: perforation, presence of a part of
instrument used like root of plant, hairpin, a nail is
found.
- Uterus is enlarged, soft, congested. Walls are
thickened. Products of conception is found.
- In curetting, the tags or scooping of endimetrium is
found.
- Even after evacuation, the placenta is still found or
even after removal of it, the raw surface left behind
is seen.
- Stains of the chemical used are found on uterine
wall. Smell can be detected. Froths are found in
case of soap water. Internal and external os are
congested.
• Vagina: vagina may show the signs of injury.
- The vaginal sac may have blood clots and some
product of conception.
- Perforation may be found.
- If chemical is used, the wall are stained, excoriated,
lacerated due to corrosive agent.
- Typical smell of agent is detected.
• Lungs: they are congested if death occurs due to air
or fat embolism.
- Lungs are pale in death due to haemorrhage.
- Smell of ether is detected if used as general
anaesthetic agent.
• Heart: chambers are empty
- Froth is seen in case of air embolism.
- Subendocardial haemorrhage is seen in case of
death due to septicemia.
• Ovaries: either of the ovaries suggestive of active
corpus luteum.
- Marks of injury are seen in case of perforation of
• Meninges: they are congested and inflamed if death
occurs due to meningitis.
• In case of air embolism, the air bubbles are seen in
blood vessels.
• Kidneys: both are congested and may have signs of
perforation.
• Liver: is congested due to certain drug absorption.
• Poisoning: if death occurs due to oral intake of drug
then a part of drug is found in stomach.
• In case of death due to haemorrhage, the organs
are pale but if due to drugs then they are
congested.
• Materials to be preserve:
- uterus, ovaries & vagina are preserved in formal saline
for histological examination.
- A part of content of uterus and content of vagina in
saturated solution of common salt.
- Other viscera depending upon the nature of abortion
are preserved.
- Blood and urine should be preserved.
• Examination of product of conception: found in uterus
or to the medical man .
- When products are available in pieces, it is strongly
suggestive of instrumental abortion
- When products are available full, s/o mechanical injury.
- When stain or smell is found, s/o use of chemical.
- When systemic drug or rupture of membrane is
done then no sign is found.
- The placenta or foetus may be found attached with
umbilical cord.
- If cord is cut then it is not tied.
- Age of foetus should be determined in connection
with abortion.

• Medicolegal aspect of abortion:

- Abortion may be induced without proper indication
is considered against MTP act, crime.
- When a doctor violates the MTP act, the he is liable
for punishment.
- A pregnant woman or non pregnant woman may
fabricate/ malinger abortion to bring false charge.
- Abortion may be fabricated to charge for rape,
blackmail a man or intercourse by man.
- Abortion may be feigned to claim compensation by
working woman.
- A woman may be charged for inducing criminal
abortion.
- A woman who has criminally aborted may be
charged for infanticide.
• Medico-legal Importance of Placenta
- from its weight and size it 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.

• Duties of a Doctor in Suspected Criminal Abortion

1. Doctor should keep all the information obtained
by him as professional secret.
2. He must 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.
3.He must consult a professional colleague.
4. If the woman's condition is serious, he must
arrange to record the dying declaration.
5. If the woman dies, he should not issue a death
certificate, but should inform the police for
postmortem examination.