Refkas obgyn

7/23/2019 Refkas obgyn

1/9

CASE REFLECTION

Medical Abortion

William Ray Cassidy

08/268114/KU/12814

Instructor:Prof. dr. !as"adi asu#i$ %P&$ P'.$ ()*+,K-

Department of Obstetric and Gynecoloy

Fac!lty of Medicine Gad"a# Mada $ni%ersity

RS$& Dr Sard"ito

'()*

0


2/9

Case

6 yars old "oman ,+2P10- cam to R in R(UP r (ard!ito "it'

com)laints of arly amniotic mmran ru)tur. (' "as rfrrd from a "omn and

c'ild 'os)ital "it' + 20 "#s. 3' )atint 'as flt som contractions sinc nin5.

amination rsults rald imminnt aortion. 3' )atint a5rd to trminat t'

)r5nancy and rcid miso)rostol 400 micro5rams / 6 'ours orally. 3' ftus and

)lacnta "r )ulsd f" 'ours aftr"ards$ ut U(+ s'o"d si5ns of incom)lt

aortion. 7C "as t'n )lannd for t' )atint.

How do we manage patients with prolonged latent phase? Are there any correlations

between the previous history of Cesarian Section and the current vaginal delivery

attempt? When can we decide to induce labor and/or ripen the cervix?

Clinical Prolm

C'ildirt' is t' )riod from t' onst of r5ular utrin contractions until

)ulsion of t' )lacnta. 3' onst of latnt laor$ as dfind y ridman ,192-$ is

t' )oint at "'ic' t' mot'r )rcis r5ular contractions. 3' latnt )'as for most

"omn nds at t"n and ; cm of dilatation. 3'is t'rs'old may clinically

usful$ for it dfins crical dilatation limits yond "'ic' acti laor can

)ctd.


3/9

)rformd arlir t'an is a))ro)riat. @caus a))roimatly 40? of t' 1. million

csaran dliris )rformd annually in t' Unitd (tats ar r)at )rocdurs and

t' numr of csaran dliris continus to ris$ t' timin5 of lcti csaran

dliry 'as incrasin5ly im)ortant )ulic 'alt' im)lications.

s com)ard "it' infants orn a5inally$ t'os orn y csaran sction ar at

incrasd ris# for adrs rs)iratory outcoms$ s)cially "'n dliry occurs for

t' onst of laor. 3'is incrasd ris# )rsists n in infants "'o ar dlird y

csaran sction at full trm ,i..$ at or yond com)ltd "#s of 5station-.

i5ur s'o"in5 normal dilatation cur in nulli)arous laour.

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4/9

Aaor )ro5rss cur s'o"in5 ridmanBs cur.

(trat5is and idnc

Dianosis

In t'is cas$ t' a5inal amination rsult s'o"d dilatd cri "it' diamtr

around 2 cm for mor t'an 14 'ours ,in multi)ara )atint-$ "'ic' mans it is in

)rolon5d latnt )'as and not fully ri)D for laor. 3'us$ " nd to intrn in

ordr to ri)n t' cri for t' succss of inducin5 laor.


5/9

3' condition of t' cri influncs t' succss of inducin5 laor. or t'is

rason$ a crical amination is ssntial for laor induction is initiatd. In 1964$

@is'o) dlo)d a scorin5 systm to aluat multi)arous "omn for lcti

induction at trm.3' scorin5 systm is asd on )ro)rtis of t' cri t'at may

assssd clinically at t' tim of )lic amination suc' as dilatation$ ffacmnt$

consistncy$ and )osition as "ll as t' station of t' ftal )rsntin5 )art.

3' 'i5'r t' @is'o) scor$ t' mor ri)D or faoralD t' cri is for

laor induction.

Manaement

*r t' )ast f" yars$ t'r 'as n an incrasin5 a"arnss t'at if t' cri

is unfaoral$ a succssful a5inal irt' is lss li#ly. 3' @is'o) scor 'l)s dlinat

)atints "'o "ould most li#ly to ac'i a succssful induction. 3' duration of

laor is inrsly corrlatd "it' t' @is'o) scor> a scor t'at cds 8 dscris t'

)atint most li#ly to ac'i a succssful a5inal irt'. @is'o) scors of lss t'an 6

usually rEuir t'at a crical ri)nin5 mt'od usd for ot'r mt'ods.


6/9

)rosta5landins$ "'ic' ar rs)onsil for crical ri)nin5.

Mec#anical Modalities

ll mc'anical modalitis s'ar a similar mc'anism of actionGnamly$ som

form of local )rssur t'at stimulats t' rlas of )rosta5landins.1 3' ris#s

associatd "it' t's mt'ods includ infction ,ndomtritis and nonatal s)sis 'a

n associatd "it' natural osmotic dilators-$ ldin5$mmran ru)tur$ and

)lacntal disru)tion. &y5rosco)ic dilators asor ndocrical and local tissu fluids$

causin5 t' dic to )and "it'in t' ndocri and )roidin5 controlld

mc'anical )rssur.

@alloon dics )roid mc'anical )rssur dirctly on t' cri as t' alloon is

filld. oly cat'tr ,26 r- or s)cifically dsi5nd alloon dics can usd.

3' addition of extra-amnionic saline infusion !AS"#$s'o"n in i5ur 22=1$

'as n r)ortd to si5nificantly im)ro t' @is'o) scor and dcras inductionFtoF

dliry tims "'n com)ard "it' t'at y ,1- ;0F 5 intraa5inal miso)rostol talts

,Hn5alil and colla5us$ 1998-$ ,2- 0.; m5 of intracrical )rosta5landin 2,+oldman

and Wi5ton$ 1999> &mlin and %llr$ 1998> (ciscion and associats$ 1999-$ or ,- ;0F

5 oral miso)rostol.

Tec#ni/!efor &lacement of -alloon Dilators

3' cat'0t0r is introduc0d into t' ndocri y dirct isualiJation or lindly y

locatin5 t' cri "it' t' aminin5 fin5rs and 5uidin5 t' cat'0t0r or t'

'and and fin5rs t'rou5' t' ndocri and into t' )otntial s)ac 20t"00n t'

amnioticm0m2ran0 and t' lo"r utrin s05m0nt.

3' alloon rsroir is inflatd "it' 0 to ;0 mA of normal salin. 3' alloon is

;


7/9

r0tract0d so t'at it rsts on t' intrnal os.

dditional st)s t'at may ta#0n:

K ))ly )rssur y addin5 "i5'ts to t' cat'0t0r nd. Constant)rssur:

attac' 1 A of intranous fluids to t'0

cat'0t0r nd and sus)nd it from t' nd of t'20d.Int0rmitt0nt)rssur: 5ntly tu5 on t' cat'0t0r nd t"o to four tims )r

'our.

K (alin infusion:

Inflat cat'0t0r "it' 40 mA of stril "atr or salin. Infus stril salin at a

rat of 40 mA )r 'our usin5 an

infusion)um).

Rmo si 'ours latr or at t' tim of s)ontan0ous )ulsion or ru)tur

of m0m2ran0s ,"'ic'r occurs first-.

K

Prosta5landin 12 infusion

O.ytocin

s )r5nancy )ro5rsss$ t' numr of oytocin rc)tors in t' utrus

incrass ,y 100Ffold at 2 "#s and y 00Ffold at t' onst of laor-. *ytocin

actiats t' )'os)'oli)as CFinositol )at'"ay and incrass intracllular calcium

lls$ stimulatin5 contractions in myomtrial smoot' muscl.2 *ytocin is t'

)rfrrd )'armacolo5ic a5nt for inducin5 laor "'n t' cri is faoral or ri).

Disc!ssion

3'r ar som )oints t'at is still nd to ans"rd r5ardin5 t'is cas$

alt'ou5' no" it is clar t'at t' )atintBs cri is not faoral 'nc a mdical

intrntion is ncssary. irst$ "'at #ind of crical ri)nin5 mt'od t'at is st for

t'is )atintL (cond$ s'ould " rally continu "it' a5inal dliryL

In t' study t'at "as )rformd y Kas'anian et al. oly cat'tr "it' diffrnt

alloon olums "r com)ard to oytocin for crical ri)nin5 and laor induction.

3'y concludd t'at oly cat'tr is a saf and suital mt'od for )atints "it' an

unfaoral cri$ and mi5't rduc t' duration of laor and incras t' numr of

dliris "it'in 24 '> moror$ t' lar5r alloon olum mi5't im)ro t's ffcts.

#rat et al. studid t'r mt'ods of crical ri)nin5 and laor induction "it' a5inal

miso)rostol and oly cat'tr and a comination of t's t"o mt'ods. 3' duration

t"n induction of laor and dliry "as si5nificantly lo"r in miso)rostol 5rou).

3'y rsultd t'at t' comination of t's t"o mt'ods didnBt 'a mor fficacy on

crical ri)nin5.

In W&* rcommndations for induction of laor$ it is statd t'at com)ard "it'

)rosta5landins$ t' alloon cat'tr "as associatd "it' a lo"r ris# of utrin

'y)rstimulation "it' ftal 'art rat c'an5s ,sn trials$ 82 )artici)ants$ RR 0.;1$

9;? CI 0.0=0.86- and t' ris# of casaran sction "it' t' t"o mt'ods "as similar,19 trials$ 20;0 )artici)ants$ RR 1.01$ 9;? CI 0.88=1.1-. Wit' r5ard to ot'r )riority

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8/9

outcoms$ t' rsults for t' )rosta5landins rsus t' alloon cat'tr com)arison "r

statistically nonFsi5nificant. Com)ard "it' oytocin$ t' alloon cat'tr "as

associatd "it' a lo"r ris# of casaran sction ,t"o trials$ 12; )artici)ants$ RR 0.4$

9;? CI 0.22=0.8-. @alloon cat'tr is rcommndd for induction of laour.

,%odratFEuality idnc. (tron5 rcommndation-.3' comination of alloon

cat'tr )lus oytocin is rcommndd as an altrnati mt'od "'n )rosta5landins

,includin5 miso)rostol- ar not aailal or ar contraindicatd.,Ao"FEuality idnc.

Wa# rcommndation.-

3'is )atint 'as a 'istory of Csarian (ction four yars a5o. a5inal dliry

aftr CF(ction dos )ossss its o"n ris#s and com)lications. (uc' com)lications

includ utrin ru)tur$ "'ic' is uncommon ut srious and may rsult in 'ystrctomy$

urolo5ic in!ury$ a nd for lood transfusion$ matrnal dat'$ and )rinatal

com)lications$ includin5 nurolo5ic im)airmnt and dat'. or "omn "it' on )rior

csaran dliry$ t' ris# of utrin ru)tur is 'i5'r amon5 t'os "'os laor is

inducd t'an amon5 t'os "it' r)atd csaran dliry "it'out laor. Aaor inducd

"it' a )rosta5landin confrs t' 'i5'st ris#. ,< n5l M %d 2001>4;:F8.-

Conclusion

Prolon5d latnt )'as in )r5nancy rEuirs immdiat intrntion from

attndin5 )'ysician ,in t'is cas oF5yn doctor or rsidnt-. &o"r$ it is st if

induction or crical ri)nin5 attm)t is don in facility "'r Csarian (ction can

)rformd. %any mt'ods of induction or crical ri)nin5 aailal for t'is #ind of)atint$ includin5 mc'anical mt'od "'ic' "as don. Womn "it' )rious 'istory of

Csarian (ction s'ould at last aoid a5inal dliry if )ossil du to ris# of utrin

ru)tur$ s)cially t'os "it' )rosta5landin analo5u induction$ ma#in5 its us not

)rfral in t'is cas. Patints "it' t'is condition s'ould monitord "it' utmost

car.

Reference

*sttrics :


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W&* Rcommndations for Induction of Aaour$ 2011.

+rn$ %. Ha5inal @irt' aftr Csaran Risitd. < n5l M %d 2004> ;1>2;.

AydonFRoc'll$ t al. Ris# *f Utrin Ru)tur urin5 Aaor mon5 Womn Wit'

Prior Csaran liry. < n5l M %d$ Hol. 4;$

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