Tadalafil entfaltet seine Wirkung über eine selektive Hemmung der PDE5, wodurch die Konzentration von cGMP im glatten Muskelgewebe stabil bleibt. Diese biochemische Modulation resultiert in einer langanhaltenden Relaxation der Gefäßwände. Der Wirkstoff wird nach oraler Einnahme effizient resorbiert, mit einer Bioverfügbarkeit von rund 80 %. Seine Halbwertszeit von bis zu 36 Stunden ist innerhalb dieser Substanzklasse außergewöhnlich. Abgebaut wird er in der Leber, hauptsächlich durch CYP3A4, mit anschließender biliärer Exkretion. Typische unerwünschte Wirkungen entstehen durch eine verstärkte Vasodilatation, etwa Kopfschmerzen oder Flush. Pharmakologisch wird cialis generika vor allem durch die verlängerte Wirkungsdauer charakterisiert.

Consultation

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
 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
 Physical examination
•Absolute contraindications:
• Suspected or confirmed ectopic
 Ultrasound
• Gestational trophoblastic
disease
• High risk of uterine rupture
 CBC, blood group
• Intrauterine device
•Allergy to prostaglandins
 Informed consent
• 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
 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
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

Source: http://obgyncluboman.com/programs/2009/Dr%20Qamariya.pdf