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How to Treat Gestation 13+to 20 Weeks?

Things to note:
  • Manual vacuum aspiration of the uterus, if expulsion of products of conception is not complete.

Medical Treatment:
The dose of misoprostol decreases with increasing gestational age because of the risk of uterine rupture.
  • Mifepristone, oral, 200 mg, oral, immediately as a single dose.
Followed 24-48 hours later by:
  • Misoprostol, PV, 400-800 mcg as a single dose.
    • Then, misoprostol, oral, 400 mcg 3 hourly for 4 doses.
  • If no response after 24 hours, consider adding mechanical cervical ripening.
  • Pass a Foley catheter with 30 mL bulb through cervix with sterile technique.
  • Inflate bulb with 50 mL water or sodium chloride 0.9%.
  • Tape catheter to thigh with light traction on catheter.
  • Attach sodium chloride 0.9% 1 L with giving set to catheter.
  • Infuse sodium chloride 0.9% at 50 mL/ hour through catheter into uterus.
  • Uterine rupture may occur in women with previous Caesarean sections. Caution for this group and those of high parity: use 200 mcg misoprostol or alternative methods such as extra-amniotic 0.9 % saline infusion without misoprostol.
  • Pethidine, IM, 100 mg 4 hourly as needed.
  • Morphine, IM, 10 mg 4 hourly as needed.
If Rh-negative:
  • Anti-D immunoglobulin, IM, 100 mcg as a single dose.

When to refer:
  • Complicating medical conditions, e.g. cardiac failure, etc.
  • Failed procedure.
  • Suspected ectopic pregnancy.