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

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Appendices

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