Post on 21-Apr-2017
transcript
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