Medical Termination of Second Trimester

1. TITLE:  

Medical Termination of Second Trimester.

2. PURPOSE:

To create guideline for medical termination of pregnancy in the second trimester with the available recourses and explain the alternative modality in induction of second trimester abortion and termination of missed abortion.

3. CONDITION/APPLICABILITY:

Applies to all pregnant women who are in their second trimester and might undergo a medical termination. 

4. DEFINITION:

1. Missed abortion: is the presence of a non-viable pregnancy in utero prior to 20 weeks’   gestation.

2. Second trimester abortion: start from 14week gestation till 22 weeks.

3. Termination of viable pregnancy due to congenital anomalies in computable with life: scan should be done by consultant obstetrics and gynecology and confirm by certified maternal fetal maternal medicine MFM consultant license by Saudi council, the recommendation should be written from MFM consultant clearly to terminate, two consultants should agree on termination, the gestation age shouldn’t exceed 19 wks +2days.

5. POLICY:

This policy written to guide the medical termination in the second trimester with deferent medication according to the gestational age 

6. PROCEDURE:

   1. The diagnosis of the condition is made and confirm by ultrasound scans. Patient should be admitted to labor room council regarding the mode of termination should explain to the patient the actual procedure and the possible side effects. 

   2. Consent should be taken, vital sign checked, necessary bloods are taken and results are verified.

3. In-charge Nurse should check the vital signs every4-6 hours, and observe for vaginal bleeding or any Sid effect of medication.

4. No need to keep the patient NPO unless the patient has moderate to severe amount of vaginal bleeding.

5. If the patient has nausea antiemetic medication should be prescribed.

6. If the patient has pain analgesic medication should be prescribed.

7. The doctor in-charge should check the patient identity and confirm with the patient the acceptance for termination of pregnancy, vaginal examination be carried out and   cervical assessment should be documented.

8. Second trimester abortion with Misoprostol:

   1. Induction dose and route of misoprostol.

      1. Vaginal route (should be inserted deep in the posterior fornix) more    effective than oral route, sublingual has similar efficacy to vaginal dose, Rectal route is not included as a recommended route because the pharmacokinetic profile is not associated with the best efficacy.

      2. Doctor should avoid vaginal route if bleeding and/or signs of infection.

      3. Start with 400 microgram PV or SL every three hours (maximum 5 doses.

      4. For incomplete/inevitable abortion women should be treated based on their uterine size rather than last menstrual period (LMP) dating.

      5. An additional dose can be offered if the placenta has not been expelled 30 minutes after fetal expulsion.

2. Pregnancy termination between 13-24 weeks:

Starting dose 400μg per vagina /sublingual / buccal every 3 hours.

3. Pregnancy termination for missed abortion between 13–24 weeks

Starting dose 200 microgram PV every 4-6hrs (maximum 4 doses).

4. Misoprostol in special situation

   1. Management of incomplete abortion

Recommended dose is misoprostol 600μg po (x1) or 400μg sublingual  (x1) or 400–800μg per vagina * (x1)

2. Cervical preparation for surgical abortion

• If gestational age between13–19 weeks: 400μg per vagina 3–4 hours before procedure.

• If gestational age between >19 weeks: needs to be combined with other modalities.

5. Induction of high-risk patients

High risk patient includes Pregnancy termination in the second trimester in cases with previous uterine scar should be made on a case-by-case basis, after consideration of the number of previous cesarean sections and gestational age, and careful labor monitoring of these patients. Suggested dose 100 microgram to be inserted into posterior vagina fornix every24 hours for a maximum of 3 doses.

9. Second trimester abortion with PGE2:

Induction dose and route

1. Induction dose and route of PGE2.

   1. PGE2 suppositories in the posterior fornix (20 mg) every three to five hrs. till abortion occur.

   2. Dose can be adjusted to 5 mg if the uterus has tetanic contraction or to reduce systemic side effect.

2. Oxytocin may be use after at least 2-3 hrs. after the last dose of PGE2 to avoid unwanted side effect (uterine rapture).

10. Second trimester abortion with OXYTOCIN 

    1. oxytocin can be administered as intravenous route

    2. Dose of 10-20 mill units /minute; maximum total dose: 30 units/12 hrs.

    3. Start 100 units in 500ml (LR, 1/2 normal saline) 1mili international =. 3ml starting dose 10 mill units/minute which equal to 3ml/hrs. continued (rate of infusion 160 ml/hrs.) over three hours 

    4. After an hour of rest

    5. The infusion is repeated using 60 units of oxytocin. This regimen is    continued up to a maximum of 300 units oxytocin in 500 mL solution         (i.e., 1667 milli U/min).

11. Second trimester abortion with Intraamniotic infusion:

    1. Induction dose and route Prostaglandin F2 alpha infusion.

       1. patient should empty her bladder

       2. an 18-gauge spinal needle is inserted into the amniotic cavity.

       3. The location is confirmed by withdrawing a small amount of amniotic fluid. (to avoid intravascular or intra-myometrial infusion)

       4. Starting dose 2.5 to 5 mg PGF2 alpha is infused as a test dose, followed by 17.5 to 35 mg if the test dose is tolerated.

       5. if not aborted within 6hrs 2nd dose of 17.5 mg can be repeated.

       6. Prostaglandin F2 alpha should not be used in women with asthma, epilepsy, glaucoma, pulmonary hypertension, or hypertension

    2. Induction dose and route carboprost tromethamine infusion:

       1. follow steps 6.11.1.4,6.11.1.5,6.11.1.6

12. Placenta expulsion

    1. placenta should be expelled within 30 to 120 minutes of expulsion of the fetus.

    2. Expectant management of a retained placenta up to four hours after fetal expulsion, if placental expulsion is delayed, then the placenta can be removed by suction curettage.

13. Antibiotic prophylaxis should only be given based on individual clinical indications.

14. anti D: Blood type and antibody status are checked and Rh immune globulin given if indicated.

15. Analgesia: should be prescribe according to the patient level of pain (Non-Steroidal Anti Inflammatory Drug ,or Opiate).

7. RESPONSIBILITY:

All physicians in obstetrics and gynecology department. 

8. FORMS/EQUIPMENT:

9. REFERENCE:

   1. The 2nd edition of Safe abortion: technical and policy guidance for health systems was published in June 2012 by WHO.

   2. Clinical protocol for management of mid trimester termination of (NHS-2003) Up to date 21.6.

   3. FIGO misoprostol Dosage chart release 2017

10. REVISION:

11.  APPROVALS: