1

Medical induction in first trimester miscarriages –

experience at Royal Hospital

Qamariya Ambusaidi – OMSB, obs/Gyn resident – R2Supervisor: Dr. Anita Zutshi , senior consultant , obstetrics &

gynecology department, Royal hospital.

Presented by : Qamariya Ambusaidi

2

Outlines

Introduction Objective of the study

Methodology

Results & discussion

Conclusion

Limitations

Recommendations

3

Introduction

Medical methods for induced miscarriage have emerge over the last 2 decades as safe , effective & feasible alternatives to surgical evacuation.

Misoprostol administration in pregnancy induced cervical effacement & uterine contraction at all GA.

Its potency varies with GA, route of administration,

dose & dosing interval & cumulative dose.

4

Misoprostol

It is a synthetic PGE1 developed and approved originally for the prevention of gastric ulcers.

It is not approved by the US FDA for uterine evacuation in pregnant women.

It is a safe & well tolerated medication.

GIT symptoms (nausea & diarrhea) and fever are the most common adverse effect transient & self limiting.

5

Protocol

Incomplete miscarriage (4-12 wks GA), (clinical finding : open os & vaginal bleeding): 600 microgram as a single dose, orally

Induction of miscarriage up to 24 wks: 400 microgram vaginally X 4 hourly, total 5 doses If leaking liquor PV, high WBC give same dose but

orally In previous LSCS cases ½ above dose to be given

6

Objective

To evaluate the efficacy of using misoprostol as an agent for medical termination in first trimester miscarriages.

Main outcome was to measure the complete miscarriage rate with misoprostol, defined as successful cases that did not required surgical evacuation after receiving misoprostol.

7

Study design & subjects

Study design: Retrospective study

Population: 68 patients

Place: maternity 3 ward at Royal hospital

Time: between 15th June to 15th September 2009

8

365 patients

All miscarriages =138 pts (37.8%)

TOP = 4 patients (1.1%)

Others = 223 patients (61.1%)

Threatened = 9 patients (6.5%)

Complete = 12 patients (8.7%)

Incomplete & missed = 117 pts

(84.8%)

Surgical = 41 patients (35%)

Medical = 76 patients (65%)

1st trimester = 64 patients (84.2%)

2nd trimester = 12 patients (15.8%)

Study population

9

Pretreatment evaluation

Full medical history

Physical examination

Ultrasound

CBC, blood group

Informed consent

•Absolute contraindications:• Suspected or confirmed ectopic• Gestational trophoblastic disease • High risk of uterine rupture• Intrauterine device •Allergy to prostaglandins• hemodynamically unstable

10

Results

11

Study population distribution

33.8%

5.9%

29.4%

64.7%

TOP

missed

incomplete

35.3%

12

Surgical evacuation after medical

termination with misoprostol for all patients

45.6% 54.4%

yes no

13

Surgical evacuation after medical termination of incomplete miscarriages with

misoprostol (600 mcg single dose)

0

10

20

30

40

50

60

70

yes no

30%

70%P value < 0.001

Per

cent

age

14

Surgical evacuation after medical termination of missed miscarriages with

misoprostol (400 mcg X 4hrly, total 5 doses)

0

10

20

30

40

50

60

70

80

yes no

75%

25%

P value < 0.001

Per

cent

age

15

Indications for surgical evacuation after medical termination with misoprostol

0

10

20

30

40

50

60

70

failed bleeding fever patientrequest

20%

70%

6.7% 3.3%

Per

cent

age

16

Indications for surgical evacuation after medical termination with misoprostol

Per

cent

age

0

10

20

30

40

50

60

70

noevacuation

failed bleeding fever pt request

incompletemissed

70%

25%

27%

42%

25%

3% 4% 4%

1/3 of patients had repeat Hb post evacuation ( anemia symptoms) drop in Hb 1.5 - 2.4 g/dL.

17

Last dose of misoprostol / evacuation interval in hours

0

10

20

30

40

50

60

70

0 - 12 hrs 12 - 24 hrs > 24 hrs

61%

23%16%

Per

cent

age

18

Remarks

Incomplete miscarriages 1 patient had 2 doses of 600 mcg orally

Missed miscarriages with failed medical termination (10 pts,41.7%

7 patients received 5 doses all had evacuation within < 12 hrs

1 patient received 2 doses of 400 mcg vaginally once she started bleeding , she was treated as incomplete miscarriage.

1 patient received single dose of 600 mcg orally (refused admission)

1 patient received single dose of 800 mcg vaginally.

19

Results

3 patients (4.4%) had side effects of misoprostol 2 fever & 1 diarrhea

Regarding analgesia: 44% did not required analgesia 54% required simple analgesia 2% received tramadol (allergic to diclofenac)

20

Conclusion

Misoprostol Well tolerated drug Reduce the rate of surgical evacuation by > 50% Effective in management of incomplete miscarriages Has minimal side effects & risks

> 80% of patients had early surgical evacuation (< 24hrs)

More studies for its effect on missed miscarriages are needed.

21

Limitations

Patient satisfaction was not assessed in this study.

Duration of bleeding post complete termination / evacuation was not assessed.

22

Recommendations

Misoprostol may be used safely for management of incomplete miscarriages.

Out patient management for incomplete miscarriages is more convenient for patients & health services.

Guideline for induction of cases with missed miscarriages with misoprostol after more studies results.

I would like to extend my heartfelt gratitude to Dr. Anita Zutshi for

her vital encouragement, support, constant reminders &

mush needed motivation

24