MTP Act

MTP Act: It is an Act to provide for the termination of certain pregnancies by registered Medical Practitioners.

:Short title, extent and commencement:
1) This Act may be called the Medical Termination of Pregnancy Act, 1971.
2) It extends to the whole of India except the State of Jammu and Kashmir.

:Definitions: - In this Act, unless the context otherwise requires -

1) “guardian” means a person having the care of the person of a minor or a lunatic
2) “minor” means a person who, under the provisions of the Indian Majority Act, is to be deemed not to have attained his majority
3) “registered medical practitioner” means a medical practitioner who possesses any recognized medical qualification, whose name has been entered in a State Medical Register and who has such experience or training in gynaecology and obstetrics as may be prescribed by rules made under this Act.

:When pregnancies may be terminated by registered medical practitioners:

- Pregnancy may be terminated by a registered medical practitioner -
(a) Where the length of the pregnancy does not exceed twelve weeks, if one registered medical practitioner agrees.
(b) Where the length of the pregnancy exceeds twelve weeks but does not exceed twenty weeks, if not less than two registered medical practitioner are of opinion, formed in good faith that
1) 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; or
2) There is a substantial risk that if the child were born, it would suffer from such physical or mental abnormalities to be seriously handicapped.(Genetic Grounds)
3) 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(Social Grounds)
4) 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 resumed to constitute a grave injury to the mental health of the pregnant woman.
5) The continuance of a pregnancy would involve such risk of injury to the health of mother, account may be taken of the pregnant women’s actual or reasonable foreseeable environment.
6) No pregnancy of a woman, who has not attained the age of eighteen years, or, who, having attained the age of eighteen years, is a lunatic, shall be terminated except with the consent in writing of her guardian.
7) No pregnancy shall be terminated except with the consent of the pregnant woman.

Place where pregnancy may be terminated:
....No termination of pregnancy shall be made in accordance with this Act at any place other than
1) a hospital established or maintained by Government
2) a place for the time being approved for the purpose of this Act by Government

Protection of action taken in good faith:

No suit or legal proceedings shall lie against any registered medical practitioner for any damage caused or likely to be caused by anything, which is in good faith done or intended to be done under this Act.

Myasthenia Gravis

..... Myasthenia Gravis is a neuro-muscular disorder charecterized by weakness and fatigability of skeletal muscles.

Defect: Decrease in the number of available Acetyl-Choline receptors(AChRs) at the neuro-muscular(NM) junctions due to an antibody-mediated autoimmune attack.




Normal Phyz at NM Junction:
.... At NM Junction Acetyl Choline(ACh) is synthesized in motor nerve terminals and stored in vesicles(quanta).
.... When action potential travels down a motor nerve and reaches the nerve terminal, ACh
from 150 to 200 such vesicles is released and combines with Acetyl-Choline Receptors on post-synaptic folds.
.... When ACh combines with AChR, the channels in AChR opens, permitting rapid entry of cations, chiefly sodiumm which produce depolarization at the end-plate region of the muscle fibre(End Plate Potential - EPP).
.... If the depolarization is sufficiently large, it initiates an action potential that is propagated along the muscle fibre and triggers muscle contraction.

.... This process is rapidly terminated by two mechanisms.
1) Hydrolysis of Acetyl Choline by Acetyl-Choline Esterase(AChE), which is present within synaptic folds.
2) Diffusion of ACh away from the receptors.

Patho-Physiology:
.... In MG, the fundamental defect is decrease in the number of available AChRs at the postsynaptic muscle membrane.
.... Hence, ACh is released normally but it produce a small end plate potential(EPP) that may fail to trigger muscle action potential and hence contraction and hence muscle weakness occurs.

..... Presynaptic Rundown: Normally, the amount of ACh released per impulse declines on repeated activity. This is known as Presynaptic Rundown.

.... In MG patients, there is decreased efficiency of neuromuscular transmission, along with which is combined normal presynaptic rundown, so successively there is increased weakness and muscle fatigability.

.... The cause of this pathology in MG is antibody mediated autoimmune response towards Acetyl-Choline Receptors. This Anti-AChR antibodies reduce the number of available AChRs at the neuromuscular junctions by three distinct mechanisms:
1) By accelerated turnover of AChR
2) By blockade of active site of AChR that normally binds ACh
3) Damage to the post-synaptic muscle membrane in collaboration with complements.


Clinical Features:
.... The cardinal features are weakness and fatigability of muscles. Weakness increases on repeated use(Presynaptic rundown + decreased efficiency of transmission).

Distribution of muscle weakness:
1) Cranial Muscle particularly lids and extraocular muscle are involved early in the course. So, Diplopia and Ptosis are common complains.
2) Facial Weakness produces snarling expression when the patient attempts to smile. Weakness in chewing seen after prolonged effort.
3) Speech has nasal timbre cause of weakness of palate.
4) Difficulty in swallowing cause of weakness of palate, tongue and pharynx.
5) Limb Weakness is often proximal but deep tendon reflexes are preserved.
6) Difficulty in Respiration: If it becomes so severe that patient require respiratory assistance then patient is said to be in Myasthenic crisis.

Diagnosis: Suspected diagnosis on basis of clinical symtoms. Always confirm by various tests.

1) Edrophonium test:
Edrophonium is a drug that inhibit anticholine esterase and thereby increase the life of ACh. So when Edrophonium is given, it produces rapid improvement in symptoms in MG patients.

2) Electro-diagnostic Testing:
Repetitive nerve stimulation often provides diagnostic evidence of MG. On repetitive stimulation in MG patient decrease in response is very brisk as compared to normal. This is because of combined effects of Presynaptic rundown and decreased efficiency of transmission.

3) Anti-Acetylcholine receptor antibody:
Virtually diagnostic and very specific. If found, its definately MG.

Treatment:

1) Anticholineesterase medications: Drugs that inhibit acetylcholine esterase(e.g. Pyridostigmine) decrease its breakdown and increase ACh and hence the response.

2) Thymectomy

3) Immunosuppression: Using glucocorticoids. IV Ig is also given.

4) Plasmapheresis: Reduces circulating anti-AChR antibodies.

Coagulation pathway

Factor I -----> Fibrinogen
Factor II -----> Prothrombin
Factor III -----> Tissue factor; Tissue thromboplastin
Factor IV -----> Calcium
Factor V -----> Pro-accelerin; Labile factor; Ac-G
Factor VII -----> Pro-convertin; Stable factor
Factor VIII -----> Anti-hemophilic A
Factor IX -----> Anti-hemophilic B; Christmas Factor
Factor X -----> Stuart Prower factor
Factor XI -----> Anti-hemophilic C
Factor XII -----> Hageman Factor
Factor XIII -----> Fibrin Stabilizing Factor
Prekallikrein -----> Fletcher Factor
HMWK -----> Fitzgerald Factor