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INTRODUCTION: -
MTP in medical disorders in pregnancy is to be viewed from two
angles:
1)
Those
medical disorders where continuing this pregnancy would prove a
grave risk to the life of the mother. In these situations. The
medical disorders itself becomes an indication for MTP.
2)
Situations where MTP has to be done and a medical disorders is
found incidentally, herein, the extra care that is required to
be taken, especially due to this medical disorders in pregnancy,
is to be considered.
MTP
and Hypertensive Disorders of Pregnancy: -
This area in obstetrics is admittedly one where clinicians face
a big dilemma. In clinical situations where BP of a woman is
rising in spite of a rational and correct treatment, termination
of pregnancy is considered Pre-eclampsia remote from term is now
acknowledged as a distinct entity. It has strong immunological
basis. In absence of any signs of abetting of its fury and
development of complications, MTP becomes a natural choice.
However, this stage comes usually in late second trimester.
Second trimester termination with ethacridine lactate usually
doses not give any problems and can be easily carried out. In
such immunological problems of pregnancy even eclampsia can
occur. Therefore, it is not without reasons to consider an
immediate MTP if eclampsia has occurred.
On the other side, a woman may solicit MTP for some other
reasons and is incidentally found to be hypertensive. It is
likely that she may be a known hypertensive and is now
soliciting MTP for some other cause. It is always to be stressed
to the patient that hypertension worsens with increasing age. It
is therefore advisable to continue this pregnancy if reasons for
MTP are not very compelling. In spite of all of these attempts,
if MTP has to be done, then BP has to be taken in control with
suitable antihypertensives. Once this is achieved, first-
trimester MTP under short general anesthesia, can be safely
carried out. A well-controlled BP does not go haywire during the
procedure and even postoperatively. Most physicians advice that
the morning does of antihypertensives must to be taken albeit
with small sips of waters. In cases where BP goes alarmingly
high postoperatively, sublingual dose of drugs like nifedipine 5
mg becomes a good treatment method.
MTP
in Cardiac Disorders in Pregnancy: -
Coarctation of aorta has been much asked and answered as an
absolute indication of MTP amongst these conditions. Though
discussed many a times, an average clinician might hardly see
one such case in his or her career. This is not to undermine its
dangers. Agreeably, it can produce a dissection, and some cases
of spontaneous rupture have been reported. On the other hand,
many physicians have frantically referred patients with common
valvular heart disease to obstetricians for MTP. It is with a
sense of satisfaction one notes that on most occasions,
obstetricians have correctly refused such terminations.
Therefore, the bottom line is valvular heart diseases to be per
se are no indication for termination of pregnancy. In fact MTP
can prove more stressful and decompensation for the mother than
pregnancy and childbirth.
An often –debated issue is worth touching here. Valvular heart
disease with incorrigible cardiac failure-these are those rare
situations where with advancing pregnancy and in spite of
correct treatment, cardiac failure fails to correct itself. Some
authorities are advocating that the added stress of pregnancy
will worsen the cardiac condition. It can even prove fatal.
Keeping the risk of anesthesia in such cases in mind, many
workers suggest that these MTPs should be carried out under Para
cervical block with skilled anesthetists remaining present as
standby. It is very difficult to make a broad policy judgment in
this situation. However, the best policy would be to
individualize such cases and handle them with due caution.
The other aspect of this is where a subject solicits MTP and is
incidentally found to have a cardiac disease. It is noteworthy
that on most instances these are valvular heart disease. If the
subject can be convinced, it is advisable to continue this
pregnancy. Risks of termination require to be explained in case
MTP becomes a must. A through cardiac respiratory assessment
will help in foreseeing problems that may develop in due course.
A rotational antibiotic umbrella must cover the procedure to
prevent development of subsequent scary complications like
endocarditis.
MTP in
Diabetes in Pregnancy: -
Per-sé diabetes is not an indication for MTP. Poorly controlled
diabetes leading to congenital malformations in the baby is a
valid indication for pregnancy termination. It is nowadays
believed that even conception could occur in a controlled
diabetic state. In absence of good diabetic control, obstetric
complications can occur. However, these are to be handled by
proper adjustments of doses of antidiabetics. MTP is not the
solution to the problem. Like cardiac disease many times
obstetricians do get references from their physician friends
soliciting MTP for diabetic mothers, Most of the times
obstetricians do not agree to do so and this is admittedly a
wise policy.
The other angle is of soliciting MTP for some other
indication and the subject is found to be diabetic on a routine
preoperative assessment. It need not be overstressed that such
patients should be counseled for continuing pregnancy. This is
because diabetes is known to worsen with increasing age. If the
patient in concern is desirous of a child subsequently, in all
wisdom, if reasons for MTP are not very compelling, this
pregnancy should be continued. Needless to add, proper control
of diabetes should be instituted now.
However, if MTP has to be performed in a diabetic subject than
the situation becomes demanding. A preoperative control of
diabetes has to be achieved. Proper maintenance of euglycemia
state on the day of the procedure will require more than a
trifle attention. It is advisable to have the subject a little
toward the hyperglycemic side. Hypoglycemia can go undetected
and can prove dangerous. Postoperatively, the woman has a higher
chance of going in hypoglycemia. This is because the time
elapsed from her taking meals the previous night to that at
present is increasing. It is advisable to supplement parenteral
glucose adequately in such conditions. Some workers have advised
a urinary glucose monitoring for management of such situation.
However, blood glucose estimation is more precise.
Susceptibility to infections in postoperative phase in diabetics
is known. A proper and rational cover with antibiotics is
mandatory.
MTP in Hematological Problems in Pregnancy: -
Anemia is the most common hematological disorder in pregnancy.
It is quite logical to note that nutritional anemias are no
indication for termination of pregnancy. However, the
non-nutritional anemias do come up for termination in clinical
practice.
Subjects testing positive for thalassemia in both partners may
solicit a termination of pregnancy. In modern obstetric
practice, CVB or cordocentesis for detecting thalassemia in the
unborn fetus is well known. A pregnancy in which the fetus is
affected by thalassemia major may be considered for termination.
This holds true for parents having a fetus with sickle cell
disease, as well.
MTP after proper counseling may be required in these cases.
These mothers who are invariably thalassemia minors may be
having anemia. Their hemoglobin levels titer around 8 gm
percent. In such a situation, a proper oxygenation intensive
monitoring of SPO2 and other vital parameters and prevention of
cardiac overload, tests the anesthetist. However,
postoperatively these subjects remain stable.
By and large second trimester MTP in such subjects with
ethacridine lactate is done. Excessive blood loss after the
abortion should be actively prevented. If its still occurs, the
obstetricians have to be very active and treat it
enthusiastically. However, it need not be misconstrued that
these subjects are more likely to develop post-abortal bleeding.
Her chances of this bleeding are same as in general population.
Subjects who solicit MTP for other indications, and are found
anemic, are usually advised to wait till her anemia is
corrected. Such a policy is wise and recommended.
MTP in Jaundice in Pregnancy: -
Probably nowhere has the role of pregnancy termination been
poorly understood by our colleagues in internal medicine than in
jaundice. In modern obstetrics, there is no role of MTP for
jaundice in pregnancy. In fact MTP can worsen the maternal
condition and can take her to complications, much more speedily.
Usually hepatitis is the cause of jaundice in an average
obstetric practice. This is known to worsen consistently
following on MTP. It is also true that mothers so suffering are
very likely to develop complications like post procedural
bleeding, which can even prove fatal. It is therefore
recommended, not to terminate pregnancies in such conditions,
however, on nature taking it sown course, the pregnancy is
spontaneously aborted, then it should be managed as such.
No obstetrician will ever do an MTP in a woman soliciting the
same for some other reasons and is incidentally found to be
jaundiced. Such a decision is commendable and appreciated.
MTP in
Respiratory Disease: -
None of the respiratory diseases are an indication of MTP in
modern obstetrics. However those using prostaglandins for
routine MTPS are advised to rule out bronchial asthma before the
procedure.
Anesthesia risk in women having respiratory problems is well
known. Besides a good preoperative control, a vigilant intraoperative monitoring is also vital. However, it is
advisable not to take up mothers for MTP in presence of active
respiratory infections including upper respiratory infections.
Treatment is usually very effective and postponement if at all,
is at the most for a fortnight.
CONCLUSION:
-
Any mother who is pregnant can have a medical disorder in
pregnancy. Any of such mothers can solicit an MTP. Wisdom lies
in correctly understanding the diseases, its problems, and the
treatment. Once they are understood, decision making for MTP is
not difficult.
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