Termination of pregnancy in adolescents.
Despite the apparent liberalization of attitudes in recent years, unwanted pregnancy for a variety of complex social economic and cultural reasons continued to be a source of stress on the adolescent girl and her immediate family.6 In case of unmarried adolescent particularly it has been observed to precipitate a broad range of events that combine to disturb both education and family.
According to World Health Organisation, the approximate age range for adolescence is from 10 years to 20 years. This study was carried out to identify variables that influence medical termination of pregnancy (MTP) in teenage girls coming to a municipal general hospital.
Case records of all adolescent girls who had undergone M.T.P. in a municipal general hospital, from January 1978 to December 1983 were utilised for this study.
Altogether 784 adolescent girls had undergone M.T.P. during the six year period.
1. Incidence of teenage MTPs over total MTPs:
[Table 1] sets out yearwise incidence of adolescent MTP cases. On an average it is 17.78% of total MTPs. In this six year study incidence showed very slow declining trend [Fig.1].
50.13 per cent of cases in this study were of age 20 years and 19 per cent were of age 17 years and below. Average age of M.T.P. in this study was 18.52 years.
3. Marital status:
[Table II] shows yearwise distribution of marital status. Out of total, 45.28% were unmarried girls and 2.17% were separated or widows. As seen in [Fig. 1], the incidence of unmarried teenagers who had undergone abortions (over total teenage abortions) showed a very slow increasing trend.
4. Period of gestation:
Period of gestation (in weeks) at which these adolescent girls approached hospital for MTP is an important parameter. This largely depends upon educational and marital status of these girls.
58.57 per cent of unmarried pregnant teenagers approached hospital for M.T.P. in their second trimester while 74.1 per cent married ones had undergone M.T.P. in their first trimester, (p < 0.001, [Table 3a]. Also, there is a direct relationship between educational status and gestation period at the time of M.T.P. It is significantly seen that lower the standard of education, more is the gestation period at which pregnant adolescents had undergone M.T.P, (p < 0.02, [Table 3b]).
5. Methods of M.T.P. and complications:
[Table 4] shows the methods in which adolescent M.T.P.s were carried out and complication, dilatation, evaluation and vaccum aspiration are carried out in 1st trimester and they are associated with least number of complications. (1.09% and 0.6% respectively in this study [Table 5].
Extra-amniotic route of administration of suitable medium via a catheter passed through cervical canal, is adopted for cases in between 13 weeks to 16 weeks of gestation. In this study, this method was applied to only 7.6 per cent of cases but it was associated with common complication of retained products (28.34%1 for which women had to undergo another M.T.P, procedure viz. dilatation and curettage under anaesthesia.
After 16 weeks of pregnancy, the commonest method of MTP is intra-amniotic injection of saline. Complications were observed in 21.56 per cent of cases, major complication being retained products of conception. Prostaglandin instillation through intra-amniotic route was observed in only 2.04 per cent of cases as prostaglandin is very expensive and associated with highest rate of complication of retained products.
In India, about 6 million abortions take place every year of which 4 millions are induced and 2 millions spontaneous. I.C.M.R. study on Induced Abortions during the period from 1st December 1975 to 31st March 1977 has shown that unmarried women (5.4%), teenagers (5.2%) and nullipara (7.6%) formed a small but high risk group because they reported more often in 2nd trimester. In our study, 58.57 per cent of unmarried girls aproached hospital in the 2nd trimester of pregnancy [Table3a].
Dass et al have studied 80 patients who were subjected to intra-amniotic injection of hypertonic saline and observed that 73 per cent were of age between 14-25 years, 76.3% single and 80% nulliparous. This probably reflects their inexperience in recognising the symptoms of pregnancy and fear in seeking medical advice and thus presenting themselves late. Also, in another study carried out by Alwani el al, unmarried girls formed nearly 28 per cent of the total 300 2nd trimester terminations.
In this study, the percentage of the immediate complication rate was 11 .22 percent [Table 4]. It was lower in 1st trimester abortions (0.91%), but was higher in 2nd trimester abortions (24.35%) where retained products of conception were the commonest complication [Table 4]. In the study of 12,000 abortions reported in 1975 in U.S.A., there was a total complication rate of 3.1 per cent before the 13th week and 12 per cent at more than 13 weeks.
We thank, Dean, T. N. Medical College and B.Y.L. Nair Charitable Hospital for permitting us to use M.T.P. case records and send this paper for publication.