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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
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Outlines
Introduction Objective of the study
Methodology
Results & discussion
Conclusion
Limitations
Recommendations
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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.
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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.
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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
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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.
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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
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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
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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
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Results
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Study population distribution
33.8%
5.9%
29.4%
64.7%
TOP
missed
incomplete
35.3%
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Surgical evacuation after medical
termination with misoprostol for all patients
45.6% 54.4%
yes no
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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
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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
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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
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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.
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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
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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.
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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)
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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.
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Limitations
Patient satisfaction was not assessed in this study.
Duration of bleeding post complete termination / evacuation was not assessed.
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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
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