Medical induction in first trimester miscarriages – experience at Royal Hospital Qamariya Ambusaidi – OMSB, obs/Gyn resident – R2 Supervisor: Dr. Anita Zutshi , senior consultant , obstetrics & gynecology department, Royal hospital. Presented by : Qamariya Ambusaidi
Outlines • Introduction • Objective of the study • Methodology • Results & discussion • Conclusion • Limitations • Recommendations
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.
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.
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
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.
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
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
Study population distribution 35.3% 33.8%
Surgical evacuation after medical termination with misoprostol for all patients
Surgical evacuation after medical termination of incomplete miscarriages with misoprostol (600 mcg single dose) P value < 0.001 70% Percentage 30%
Surgical evacuation after medical termination of missed miscarriages with misoprostol (400 mcg X 4hrly, total 5 doses) P value < 0.001 75% Percentage 25%
Indications for surgical evacuation after medical termination with misoprostol 70% Percentage 6.7% 20% 3.3%
Indications for surgical evacuation after medical termination with misoprostol 1/3 of patients had repeat Hb post evacuation ( anemia symptoms) drop in Hb 1.5 - 2.4 g/dL. 70% Percentage 42% 25% 25% 27% 4% 4% 3%
Last dose of misoprostol / evacuation interval in hours 61% Percentage 23% 16%
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.
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)
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. 20
Limitations • Patient satisfaction was not assessed in this study. • Duration of bleeding post complete termination / evacuation was not assessed.
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. 22
I would like to extend my heartfelt gratitude to Dr. Anita Zutshi for her vital encouragement, support, constant reminders & mush needed motivation