Medical termination of pregnancy in second trimester

second trimester medical termination of pregnancy in very crucial in terms of place where it is done, person who conducts it and method followed to conduct it. the PPT deals with only second trimester of MTP based on a case scenario

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

3. TERMINATION OF PREGNANCY

4. 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

5. WHERE? Hospital established or maintained by government A place approved by govt. or DLC

6. 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

7. How to approach in this case?? History Examination Diagnosis Investigations OPNION BY FELLOW OG doctor CONSENT Management

8. MANAGEMENT MEDICAL PROSTAGLANDINS AND ANALOGS OXYTOCIN SURGICAL D&E (13-15wk) INTRAUTERINE INSTILLATION OF HYPERTONIC SOLUTION (>16wk)

9. 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

10. 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

11. 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

12. OXYTOCIN = used with IV NS alongwith other intra-amniotic or extra-amniotic space 300units in 500mL dextrose saline is used

13. SURGICAL D&E = less commonly done cervical preparation ( laminaria osmotic dilator, mifepristone , misoprostol ) are used generally USG guided oxytocin infusion can be done

14. 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

15. 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)

16. 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

17. 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

18. What to do in this case???

19. 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

20. Thank you