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
Results & discussion
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
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
TOP = 4 patients population
1st trimester = 64 Pretreatment evaluation
Full medical history
• Suspected or confirmed ectopic
• Gestational trophoblastic disease • High risk of uterine rupture
CBC, blood group
• Intrauterine device •Allergy to prostaglandins
• hemodynamically unstable Study population distribution 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
centage 30 Surgical evacuation after medical termination of missed miscarriages with misoprostol (400 mcg X 4hrly, total 5 doses) P value < 0.001
centage er 30 Indications for surgical evacuation after medical termination with misoprostol bleeding 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. incomplete bleeding pt request evacuation Last dose of misoprostol / evacuation interval in hours
centage er P 20 12 - 24 hrs > 24 hrs
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.
3 patients (4.4%) had side effects of misoprostol 2 fever & 1 diarrhea
44% did not required analgesia
54% required simple analgesia
2% received tramadol (allergic to diclofenac) Conclusion
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 Limitations
Patient satisfaction was not assessed in this
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. I would like to extend my heartfelt gratitude to Dr. Anita Zutshi for her vital encouragement, support, constant reminders & mush needed motivation
Claire Prideaux's Written Testimony: CFSAC Meeting October 2009Hello, my name is Claire Prideaux. Prior to becoming totally disabled with CFS I was a successful, practicing attorney. Up until I became totally disabled, my illness was handicapping despite my success, making it difficult to follow through on numerous employment and life opportunities. However, I managed to find a way to make my lif
Repetitive strain injury Maurits van Tulder, Antti Malmivaara, Bart Koes Repetitive strain injury remains a controversial topic. The term repetitive strain injury includes speciﬁ c disorders such Lancet 2007; 369: 1815–22 as carpal tunnel syndrome, cubital tunnel syndrome, Guyon canal syndrome, lateral epicondylitis, and tendonitis of Institute for Research in the wrist or hand. Th