Download Dr Qamariya - Obgyncluboman.com

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
1
Outlines
 Introduction
 Objective of the study
 Methodology
 Results & discussion
 Conclusion
 Limitations
 Recommendations
2
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.
3
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.
4
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
orally
In previous LSCS cases ½ above dose to be given
5
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.
6
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
7
365 patients
Threatened = 9
patients (6.5%)
All miscarriages
=138 pts (37.8%)
TOP = 4 patients
(1.1%)
Complete = 12
patients (8.7%)
Incomplete &
missed = 117 pts
(84.8%)
Others = 223
patients (61.1%)
Surgical = 41
patients (35%)
Study
population
Medical = 76
patients (65%)
1st trimester = 64
patients (84.2%)
2nd trimester = 12
8
patients (15.8%)
Pretreatment evaluation
 Full medical history
 Physical examination
 Ultrasound
 CBC, blood group
 Informed consent
•Absolute contraindications:
• Suspected or confirmed ectopic
• Gestational trophoblastic
disease
• High risk of uterine rupture
• Intrauterine device
•Allergy to prostaglandins
• hemodynamically unstable
9
Results
10
Study population distribution
TOP
35.3%
5.9%
missed
33.8%
29.4%
incomplete
64.7%
11
Surgical evacuation after medical
termination with misoprostol for all patients
yes
45.6%
no
54.4%
12
Surgical evacuation after medical
termination of incomplete miscarriages with
misoprostol (600 mcg single dose)
70
Percentage
60
P value < 0.001
70%
50
40
30
20
30%
10
0
yes
no
13
Surgical evacuation after medical
termination of missed miscarriages with
misoprostol (400 mcg X 4hrly, total 5 doses)
80
P value < 0.001
Percentage
70
60
75%
50
40
30
20
25%
10
0
yes
no
14
Indications for surgical evacuation after
medical termination with misoprostol
70
60
70%
Percentage
50
40
30
20
20%
10
6.7%
3.3%
0
failed
bleeding
fever
patient
request
15
Indications for surgical evacuation after
medical termination with misoprostol
70
60
1/3 of patients had repeat
Hb post evacuation ( anemia
symptoms)  drop in Hb
1.5 - 2.4 g/dL.
70%
Percentage
50
40
30
20
incomplete
missed
42%
25%
25%
27%
10
3%
0
no
evacuation
failed
bleeding
4%
fever
4%
pt request
16
Last dose of misoprostol /
evacuation interval in hours
70
60
Percentage
50
61%
40
30
20
23%
10
16%
0
0 - 12 hrs
12 - 24 hrs
> 24 hrs
17
Remarks
 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.
18
Results
 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)
19
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
needed.
20
Limitations
 Patient satisfaction was not assessed in this
study.
 Duration of bleeding post complete
termination / evacuation was not assessed.
21
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.
22
I would like to extend my heartfelt
gratitude to Dr. Anita Zutshi for
her vital encouragement,
support, constant reminders &
mush needed motivation
24