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