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Medical termination of pregnancy in second trimester
- 1. A 18 year old girl was brought to the opd by her mother with h/o amenorrhea for last 2 weeks. Girl was dull and silent. UPT was done by nurse and the results were positive. Later, the girl gave h/o 14 weeks amenorrhea. And want to terminate the pregnancy. YOUR APPROACH??!!!!
- 2. MEDICAL TERMINATION OF PREGNANCY IN SECOND TRIMESTER Surjeet Acharya VMC
- 5. WHO? • PG degree or diploma holder in OBG • Completed 6 months of house surgeon in OBG • Atleast 1 year of experience in OBG in any hospital having all the facilities
- 6. WHERE? • Hospital established or maintained by government • A place approved by govt. or DLC
- 7. Points for approval of a place by DLC • Gynaecological examination or labor table • Resuscitation and sterilization equipment • Drugs and parenteral fluids • Backup facilities (to treat shock etc.) • Operation table and instruments for performing abd. & gynac surgeries • Anesthetic equipments
- 8. How to approach in this case?? • History • Examination • Diagnosis • Investigations • OPNION BY FELLOW OG doctor • CONSENT • Management
- 9. MANAGEMENT • MEDICAL PROSTAGLANDINS AND ANALOGS OXYTOCIN • SURGICAL D&E (13-15wk) INTRAUTERINE INSTILLATION OF HYPERTONIC SOLUTION (>16wk)
- 10. PG & analogs MISOPROSTOL= 400-800microg, vaginally at 3- 4hrs (or) 600microg vaginally then 200microg oral, every 3 hrs (or) 400microg, sublingual every 3 hrs (max 5 doses) Mean induction-abortion interval is 11-12 hrs
- 11. MIFEPRISTONE & PG= 200mg oral, misoprostol 800microg vaginal after 36-48 hrs; then misoprostol 400microg oral every 3hrs (4 dose) Mean induction abortion time 6.5hrs GEMEPROST= 1mg vaginal, every 3-6 hrs (5 dose) in 24 hrs Mean induction-abortion time is 14-18 hrs
- 12. DINOPROSTONE= 20mg vaginal 3-4hrs (4- 6 dose) PGE2 analog Expensive Needs refrigeration Mean induction-abortion time is 16-17 hrs PROSTAGLANDIN F2alpha= carboprost tromethaine 250 microg IM 3 hrs (ten doses) More A/E, C/I in Bronchial asthma
- 13. OXYTOCIN= used with IV NS alongwith other intra-amniotic or extra-amniotic space 300units in 500mL dextrose saline is used
- 14. SURGICAL D&E= less commonly done cervical preparation (laminaria osmotic dilator, mifepristone, misoprostol) are used generally USG guided oxytocin infusion can be done
- 15. INTRAUTERINE INSTILLATION OF HYPERTONIC SOLUTION EXTRA-AMNIOTIC= 0.1% ethacridine lactate, trancervically, No.16 Foley’s catheter Liberation of PGs (due to stripping of membrane) from decidua & dilatation of cervix INTRA-AMNIOTIC= abdominal route amniocentesis is done (15 cm 18-guage needle), amount of saline to be filled is number of weeks of gestation X 10ml PGs are liberated (due to necrosis of amniotic epithelium and decidua) excites uterus causing contraction
- 16. C/I= in cases of cardiovascular, renal diseases PRECAUTIONS= needle position instillation rate (10mL/min) vitals are to be checked and maintained A/E like abd pain, headache, tingling of fingers ampicillin 500mg thrice X 3-5d A/E= Headache, fever, abd pain, cervical tear or laceration, hypernatremia, renal failure, death (0-5 in 1000 cases)
- 17. Intra amniotic instillation of hyperosmotic urea 40% urea sol. (80g in 200ml distilled water) can be mixed with PGF2alpha less complicated induction-abortion time is 13-15 hrs
- 18. HYSTEROTOMY INDICATIONS- failed in all previous attempts fibroid in lower segment uterine anomalies placental abnormalities A/E- hemorrhage, shock, anesthetic complication, intestinal obstruction, hernia, scar endometriosis, menstrual abn., Always combined with sterilization operation
- 19. What to do in this case???
- 20. SUMMARY Midtrimester termination of pregnancy is done 13-20 weeks Medical management with PGE analogs are best and most effective Surgical approach is less commonly advised
- 21. Thank you