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misoprostol para la evacuaci n de abortos retenidos de primer trimestre

Alternativas de evacuaci

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misoprostol para la evacuaci n de abortos retenidos de primer trimestre

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    1. Misoprostol para la evacuacin de abortos retenidos de primer trimestre Dr Fernando Abarza Camus Junio 2005

    3. Expectant, Medical, or Surgical Management of First-Trimester Miscarriage: A Meta-Analysis. Obstetrics & Gynecology. 105(5, Part 1):1104-1113, May 2005 Datos de 1966 a 2004 Estudios randomizados. 26661 -? 35 ? 31 artculos Abortos de primer trimestre que fueron a conducta espectante, tratamiento quirrgico o tratamiento mdico Outcome primarios: Evacuacin completa Satisfaccin de usuario Outcome secundarios: Metrorragia moderada o severa Transfusin Legrado de urgencia PIP Nuseas, vmitos, diarrea

    6. Medical Compared With Expectant Management Tasa global de xito con manejo expectante: 39% (101/260, 95% CI 3345%). Manejo mdico fue 2.77-veces superior en producir una evacuacin completa. La diferencia fue de un 49.7% ms (P < .001),

    8. Surgical Compared With Expectant Management Tasa global de xito con manejo expectante: 78% (95% CI 7383%). La evacuacin completa fue ms probable en el grupo de manejo quirrgico que expectante, pero la diferencia estuvo en lmite de significacin estadstica (P = .09)

    10. Surgical Compared With Medical Management Evacuacin quirrgica present 1.5 veces ms probabilidades de xito que el manejo mdico (risk ratio 1.44, P < .001). La satisfaccin del paciente no difiri signifivativamente entre manejo mdico y quirrgico, aunque hubo una tendencia a favor de manejo mdico

    11. Surgical Compared With Medical Management No hubo diferencias significativas en relacin a metrorragia moderada o severa o en legrado de urgencia entre las dos tcnicas (P = .13) No diferencias en riesgo de PIP (P = .60), transfusin (P= .89), nusea (P = .69), y vmito.

    13. Vaginal Compared With Oral Misoprostol Vaginal and oral administration of misoprostol did not differ significantly in the rates of successful treatment (risk difference 8.3%, P = .29 ), need for blood transfusion (risk difference 0.00%, P = 1.00), nausea (risk difference 4.4%, P = .24), and vomiting

    15. Medical methods for first trimester abortion Cochrane Database Syst Rev. 2004;(2):CD002855. Misoprostol administered orally is less effective (more failures) than the vaginal route (RR 3.00, 95% CI 1.44 to 6.24) and may be associated with more frequent side effects such as nausea and diarrhoea.

    16. Expectant, Medical, or Surgical Management of First-Trimester Miscarriage: A Meta-Analysis. Obstetrics & Gynecology. 105(5, Part 1):1104-1113, May 2005 Surgical management is significantly more likely to induce complete evacuation of the uterus than medical management. According to the meta-analysis, for 3 women managed surgically rather than medically, one additional success is gained.

    17. Expectant, Medical, or Surgical Management of First-Trimester Miscarriage: A Meta-Analysis. Obstetrics & Gynecology. 105(5, Part 1):1104-1113, May 2005 Medical management was significantly more likely to be successful than expectant management, but this was determined mostly by small trials where expectant management had very low success rates

    18. Expectant, Medical, or Surgical Management of First-Trimester Miscarriage: A Meta-Analysis. Obstetrics & Gynecology. 105(5, Part 1):1104-1113, May 2005 Based on the available data, patient satisfaction differences seemed to be small with the various methods Women who were randomized to expectant management and eventually needed to undergo surgical evacuation, which show that they present the most profound anxiety and depressive reactions

    19. Expectant, Medical, or Surgical Management of First-Trimester Miscarriage: A Meta-Analysis. Obstetrics & Gynecology. 105(5, Part 1):1104-1113, May 2005 The 3 management options did not demonstrate significant differences in terms of major complications, with the possible exception of an approximately 3% lower rate of moderate or severe bleeding with medical management as compared with expectant management and also surgical management

    20. Expectant, Medical, or Surgical Management of First-Trimester Miscarriage: A Meta-Analysis. Obstetrics & Gynecology. 105(5, Part 1):1104-1113, May 2005 The reported mean time from misoprostol administration to expulsion is 9.513.5 hours. Among cases treated successfully with medical management, 88% and 100% presented complete evacuation of the uterus by days 2 and 7, respectively

    21. Expectant, Medical, or Surgical Management of First-Trimester Miscarriage: A Meta-Analysis. Obstetrics & Gynecology. 105(5, Part 1):1104-1113, May 2005 Expectant management may have a success rate of 85% in cases of incomplete miscarriage, compared with only 33% in cases of missed miscarriage.

    22. Cervical Ripening Before Curettage

    24. Randomized Trial to Determine Optimal Dose of Vaginal Misoprostol for Preabortion Cervical Priming M200ug M400 ug M600 ug M800 ug p p (800v/s600) (600v/s400) Dilatacin >= 8mm 23 96 100 100 >.99 > .99 Dilatacin (mm) 6.4 8.2 8.5 9.9 <.001 .296 Restos en Canal (%) 0 10 40 90 <.001 .014

    25. Randomized Trial to Determine Optimal Dose of Vaginal Misoprostol for Preabortion Cervical Priming M200ug M400 ug M600 ug M800 ug p p (800v/s600) (600v/s400) Prdida sang. Pre-op (ml) 6.2 7.1 18.8 56.0 <.001 .003 Dolor abdominal (%) 7 36 73 100 .005 .009 Fiebre > 38C 0 0 7 43 .002 .492

    26. Evacuation Interval After Vaginal Misoprostol for Preabortion Cervical Priming: A Randomized Trial SINGH, KULDIP MD; FONG, Y. F. MRCOG; PRASAD, R. N. V. MD; DONG, F. PhD

    29. Application of vaginal misoprostol before cervical dilatation facilitate first-trimester pregnancy interruption 100 women opting for pregnancy interruption were given misoprostol or placebo vaginally 6 hours before cervical dilatation and curettage. Cervical dilatation with no resistance to a Hegar 8 dilator was achieved in 74 percent in the misoprostol-treated women and in 10 percent in placebo-treated women.

    30. Evacuation interval after vaginal misoprostol for preabortion cervival priming: a randomized trial. Singh et al. Outcome: Dilatacin cervical >=8 mm. 2 horas post 600ug: 20% 2 horas post 800 ug: 25% 3 horas post 400ug: 80%

    32. The use of repeated doses of misoprostol in the management of first trimester silent miscarriages

    33. A prospective randomized study to compare the use of repeated doses of vaginal with sublingual misoprostol in the management of first trimester silent miscarriages Oi Shan Tang et al The 80 women were randomized according to computer-generated random numbers into two groups. Group 1 received 600 g misoprostol sublingually every 3 h for a maximum of three doses Group 2 received 600 g misoprostol vaginally every 3 h for a maximum of three doses.

    34. A prospective randomized study to compare the use of repeated doses of vaginal with sublingual misoprostol in the management of first trimester silent miscarriages Oi Shan Tang Tasa de aborto completo: Grupo 1 : 90% Grupo 2 : 95%

    35. Discusin final De las cuatro formas de abordar el manejo del aborto retenido de primer trimestre, la conducta espectante hoy me parece menos atractiva La utilizacin de misoprostol ambulatorio en pacientes que desean evitar la hospitalizacin y el manejo quirrgico puede ser adecuado

    36. Discusin final En las pacientes hospitalizadas , la tcnica combinada de maduracin cervical y legrado parece lo ms adecuado La dosis nica de 600 ug de misoprostol combina una alta eficacia en lograr dilatacin cervical, superior a la dosis de 400 ug, con menos efectos adversos que la dosis de 800 ug

    37. Discusin final El intervalo entre la administracin de misoprostol y el legrado es muy importante. No debe ser menor a cuatro horas para lograr la mayor eficacia frente a una dosis determinada

    38. Discusin final Si bien en un porcentaje alto de las pacientes (75 a 100%) presentarn dilatacin cervical igual o mayor a 8 mm, existe un grupo de pacientes en que la dilatacin puede ser catalogada como de moderada o alta dificultad por el operador.

    39. Las dosis repetidas de misoprostol aumentan la expulsin de tejido trofoflstico y de aborto completo

    40. Discusin final En nuestro escenario de paciente hospitalizada, y una residencia que funciona las 24 horas del da, parece prudente examinarla antes de que entre a pabelln (4 a 6 horas post-administracin). Si la situacin es de un cuello duro, no modificado, sin sangrado, optar por repetir una segunda dosis y luego llevar a pabelln.

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