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??!!!!

MEDICAL TERMINATION OF PREGNANCY IN SECOND TRIMESTER

Surjeet AcharyaVMC

TERMINATION OF PREGNANCY

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

WHERE?

• Hospital established or maintained by government

• A place approved by govt. or DLC

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

How to approach in this case??

• History• Examination• Diagnosis• Investigations• OPNION BY FELLOW OG doctor• CONSENT• Management

MANAGEMENT

• MEDICAL PROSTAGLANDINS AND ANALOGS OXYTOCIN

• SURGICAL D&E (13-15wk) INTRAUTERINE INSTILLATION OF

HYPERTONIC SOLUTION (>16wk)

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

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

DINOPROSTONE= 20mg vaginal 3-4hrs (4- 6 dose)

PGE2 analogExpensiveNeeds refrigerationMean 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

OXYTOCIN= used with IV NS alongwith other intra-amniotic or extra-amniotic space

300units in 500mL dextrose saline is used

SURGICAL

D&E= less commonly done cervical preparation (laminaria

osmotic dilator, mifepristone, misoprostol) are used

generally USG guided oxytocin infusion can be done

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

C/I= in cases of cardiovascular, renal diseasesPRECAUTIONS= needle position

instillation rate (10mL/min)vitals are to be checked and maintainedA/E like abd pain, headache, tingling of fingersampicillin 500mg thrice X 3-5d

A/E= Headache, fever, abd pain, cervical tear or laceration, hypernatremia, renal failure, death (0-5 in 1000 cases)

Intra amniotic instillation of hyperosmotic urea40% urea sol. (80g in 200ml distilled

water)can be mixed with PGF2alphaless complicatedinduction-abortion time is 13-15 hrs

HYSTEROTOMYINDICATIONS- failed in all previous attempts

fibroid in lower segmentuterine anomaliesplacental abnormalities

A/E- hemorrhage, shock, anesthetic complication, intestinal obstruction, hernia, scar endometriosis, menstrual abn.,

Always combined with sterilization operation

What to do in this case???

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

Thank you