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

4. TERMINATION OF PREGNANCY

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