Induced Abortion - Methods of termination

pg-1 Report on Induced abortion –methods of termination of pregnancy till 12 wks of gestation , pre abortion counseling Def…. deliberate artificial termination of pregnancy until 22 ges. wks in a manner that ensures that the embryo\ fetus does not survive, I incidence- 1:4 preg world wide. Classification;1. early-till 12wks. –late-12-22wks 2.medical/planned-●decided by mother. no risk for preg. -●due to complications of preg.(therapeutic) maternal risk associated with contraction of preg/ fetal abortion associated with genetic chromosome structural defects note; chromosome defect anencephaly, down, fetal malformations ●w/out compli- malignancy, syphilis, rubella, cmv, hiv, hf, pulmonary failure ,kidney problems. 3.surgical medical indications preg<22wks ●,continuance of preg would involve risk to the life of mother greater than if the preg was terminated. ● termination to prevent physical/ mental health ,injury of preg female or existing child of family. ●substantial risk if child born for physical/mental abnormalities. 4. On request of mother. 5. Social factors. Methods Early surgical – 1.D&C 2.vaccum curettage till 5-6 wks maximum. Medical – 3. RU 486 (mifepristone) – antiprogesterone, 4.Laminaria – if products of conception are large. Note:- Ru 486 – 400 – 600 μg – p/o followed in 36 – 48 hrs i/m or vaginal prostaglandin analog, Used for preg < 7wks 79% effective. Methotrexate with Misoprostol (pg) – 800 μg 1wk +/- require ….cuation later i/vaginal a/f 2wks (single) at 8wks Embryo’s expected Spontaneously if not (check hCG 50mg/m³, 90% effective level If abortion fails within 36hrs, PgE, methylester pesary (Gemeprost 1mg vaginaly to complete abortion, process Misoprostol (Pg…) Surgical: Done under local anesthesia / light general D&C: Tapered dilatators in progressively ↑in size with the Ø of the …cannula is real size of the cannula correlates with gestational age, Laminaria in cervical canal atleast for 4+ or overnight, Prostaglandin E1 analogue. After dilation curette is inserted and taken out usually performed after 7 – 12 wks. D&E is performed from 12 – 18 wks. Methods of late abortion: 1. Vaginal prostaglandins: Gemeprost vagitorium (Pg E1 analogue),(Cergem) 1mg every 3 hours until abortion has happened (+vacuum curettage) Misoprostol (Pg E1 analogue) vag. 200 μg every 3 hours Dinoprostone supp. (Pg E2) 20 mg every 3 hours Dinoprostongel (Prepidil) 0.5 mg. 2. RU - 486 Mifepristone (Mifepristone) 150 – 200 – 600 mg p/o then in 24-48 hours +prostaglandins . 3. Extra – amniotic: Intermittent injection or continuous infusion: Dinoprost (Pg E2α) 0.25 mg followed by 0.75 mg every hour Diniprostone 0.05 mg followed by 0.2 mg every hour. Advantages for suction (best for early) Empties uterus rapidly ↓ Blood loss < 2%, ↓ risk for perforation of uterus < 1%. Complications for suction Ink – < 1% Mortality – 1/100:1000. Note: - D&C - other indications: Dg of abnormal uterine bleeding, Endometrial polyps. Adverse effect( ↑ chance for Asherman syndrome LATE. Induce the labour. Medical – i/uterine Pg E2 / F2α i/uterine hypertonic urea Extrauterine Pg E2 / F2α Vaginal Pg D&E (13 – 18 wks)– dilate with laminaria or Pg E1 and evacuate with larger cannula. Paracervical blockage + i/v sedation. Complications – Hemorrhage (Atony / laceration), Perforation. Rarely infection. (Retention of tissue is uncommon) Intra amniotic (>14-16wks) – Amnio infusion: Hypertonic saline – 200 ml ( Necrosis of Endometrium (10-20%) Urea (better) Glucose (CI – DU) Natural Pg 1/2 + augment with oxytocin Amnio infusion is done : via abd wall (w/ U.S control transcervically transvaginally N:…- Mortality of mother ↑ with GA. Laminaria can be used a few hrs b/f amniocentesis to ↓ risk of cervical injury. Complications of amnio infusion: Bleeding + Allergy ( Fetal death release of endogen contract the uterus ( expelled fetus. Wait for 48 hrs contraction is absent then induce contractions. C.S (crporal) or/ Hysterectomy and Hysterotomy ( can be done at any stage of pregnancy, but ↑ risk for rupture in next pregnancy. It ↑ morbidity + mortality neither is as a 1ْ met. Indications: Failure to complete a midtrimester, abortion due to cervical steno sis or failure in management of other complicant. Transverse cut’s impossible: lower segment is not developed (develops one after 30 GW) + Istmus is 1 cm (12 cm labour). Complications: retained placenta – 30-46% infection (prophylactic a/b) cervical laceration failure of labour (to expulse the products of concep.) Menstrual regulation – 4-6 wks: Aspiration of endometrium within 14 d after mensed menstrual cycle or within 42 d after beginning of last menstrual period by small cannula attached to low pressure suction eg:-syringe / suction – machine. No need for anesthesia / paracervical block. Complication - persistant pregnancy. Post abortion procedures: product of conception examined to validate complete evacuation + Hydatiform mole. Instruct to alert for danger sign - ↑ tْ , chills, muscle ache, tired, … pain, cramp, block ache, tender abdomen, prolonged or heavy bleed, foul vaginal discharge, delay >= 3 m in resuming periods. HCG ↓ gradually so (+) after procedure in blood. (… after 14 d) Pre – abortion counseling 10-19% Late complications, > 16GW (( ↑ mortality. Complications: - Immediate – during / 3hrs after procedure, - Early (within the following 28 d) -Late (a/f 28 d) Immediate + Early: hemorrhage (↓ with suction + highest in saline) cervical injury – use of LA instead of GA (Laminaria to ↓ cervical injury) ↑ in nulliporous …org cervix. uterine perforation (Multiporty, Advanced GA, inexperienced operator ↑ risk – usage of laminaria ↓ risk. Serious consequences ( hemorrhage + damage to intra abdominal organs. 4. Acute haematometra - ↓ vaginal bleeding, enlarged tender uterus, repeat curettage and administer oxytocic agents. 5. Anesthesia complications (Anaphylactic shock) 6. Amniotic …….. ---“--- - collapse, DIC, bleeding. Late: infection – ascending ; Exogenous. Bleeding. 3-6 d after retention, Recurrent miscarriages Report on Induced abortion –methods of termination of pregnancy till 12 wks of gestation , pre abortion counseling Report prepared by 1. Dr. Sajid Mahmood, MD (EU), Accident & Emergency Department, NHS Royal infirmary Liverpool United Kingdom.2. Dr. Adnan Akram, MD (EU), Department of Infectious Diseases. University Hospital Riga Latvia.3. Dr. Aftab Ahmed, MD (EU), Infection Control Department, Kaunas Medical University Clinic. Lithuania. Contact: publications [at] infekcijas.eu