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Misoprostol and early pregnancy loss i.e. < 13 weeks

Misoprostol and early pregnancy loss i.e. < 13 weeks. Types of miscarriage Missed miscarriage - intact sac . Incomplete - heterogenous mass of tissue Complete. Dedicated EPAU. Staff Transvaginal scanning Direct access for GPs and some patient subgroups Miscarriage Scan findings

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Misoprostol and early pregnancy loss i.e. < 13 weeks

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  1. Misoprostol and early pregnancy loss i.e. < 13 weeks Types of miscarriage • Missed miscarriage - intact sac . • Incomplete - heterogenous mass of tissue • Complete

  2. Dedicated EPAU • Staff • Transvaginal scanning • Direct access for GPs and some patient subgroups Miscarriage Scan findings Intact mean sac diameter >20mm with no contents or Fetal pole > 6mm with no FH Rescan in 1 week.

  3. Management options for Miscarriage < 13 weeks • Surgical ERPC – Risk perforation Risk G.A Risk retained products Risk infection • Medical (Misoprostol) Risk retained products Risk infection 3 . Expectant - Risk Retainied products - Risk of infection

  4. Review of Misoprostol in Missed Miscarriage Cervix closed Slight bleeding FIGO 2007 800ug vaginally 3 hourly( max x 2) or 600ug Sublingual 3 hourly ( max x 2) Follow-up 2 weeks Sublingual associated more frequently with diarrhoea than vaginal administration but similar efficacy

  5. Misoprostol in incomplete miscarriage • FIGO review – Advise 600mg oral single dose • 2 studies compared 1 vs 2 doses – no difference in efficacy ( 90%) • Take care not to over –diagnose failed medical management

  6. Contra - indications • Haemodynamically unstable • Suspected ectopic • Known allergy to Misoprostol • Previous uterine rupture • Signs of intrauterine infection • Trophoblastic Disease Precautions –? 2 previous Caesarean Sections ? Previous myomectomy ? Taking Anti-coagulants

  7. Predictors of success • Higher for incomplete • Lower for anembryonic pregnancy • 2 RCTS of pretreatment with Mifepristone conflicting results many studies poorly defined ultrasound / clinical criteria • Does not increase risk of infection vs surgery (Trinder MIST et al BMG 2006) • No effect on future fertility (Blohm et al Lancet 1997)

  8. Information sheets for patients • Uterine contractions usually start within a few hours • Routine antibiotics not necessary • Tylex + or – Difene • At 2 week check a further course of Misoprostol or ERPC or expectant management • Bleeding lasts for up to 2 weeks • If syncopal or presyncopal – emergency room • Transient chills are common • Fever less common if persists > 24 hours may have infection • Nausea / vomiting 2 – 6 hours • Diarrhoea < 1 day • Taste / numbness of tongue

  9. Differences 1st Trimester vs 2nd Trimester +3rd Trimester management • Hospitalisation not necessary. Expulsion of tissue hours to weeks • Extremely low rates of uterine rupture.

  10. In Summary • < 13weeks gestation • Willing patient • Haemodynamically stable • Sac size <5cm • 600ug X 2 for missed miscarriage (subling.) • 600ug X 1 for incomplete miscarriage (oral) • See for scan 2 weeks later

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