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  Use of Misoprostol in first and second trimester

Shobhana Mohandas:  TOGS bulletin , Vol 1 No7,September  2005.

 

 Misoprostol is a drug that has fairly recently been introduced in the field of obstetrics. With the rising use of early ultrasound, an increasing number of miscarriages present as missed abortions before the onset of cramping and bleeding. Misoprostol is used in various doses by oral and vaginal route by many workers across the globe.  A review of some of the literature on the use of this drug is presented below along with the author’s personal experience of its use.  

Author’s personal experience:  I have been using Misoprostol for missed abortion in the dose of 800microgram intravaginally followed by 200 microgram after 12 hours with repetition after 12 hours if necessary.  In cases where the gestational sac is small, the termination is successful. In larger gestational sacs, the patients do get bleeding per vagina with passage of clots, but it may not be complete.  Another problem with larger gestational sacs is that  when the product of conception (POC) comes into the cervical canal without getting expelled,the patient gets severe cramps and sometimes may even send a call in the middle of the night.  Removing the POC from the cervical canal immediately will give relief of pain.  However, it is prudent to immediately do a sonography to be sure that the entire product has come out.  In one case of first trimester missed abortion, I got a call in the middle of the night in a such a patient and a small piece of POC was removed.  The pain was relieved.  Next day at the same time another call came for severe cramps.  This time, I ordered misoprostol to be placed vaginally and went to see the patient after 2 hours, when a large piece of the POC, which was protruding through the os, was seen and removed. 

In patients who are bleeding, sometimes, it is difficult on ultrasonography to differentiate between blood clots in the uterus and unexpelled POC.  I usually call the patient after a week when the bleeding is almost over, to make sure the product is fully gone. 

The use of mifiprestone is unnecessary in patients with a nonviable foetus.  In medical termination of pregnancy it is used for its antiprogesterone action by which the foetus is rendered nonviable.  In nonviable pregnancies, misoprostol alone is enough. 

In second trimester pregnancy, a rubber bougie is instilled extra-amniotically followed by misoprostol vaginally, 200microgram 12 hourly in my unit.

Review of literature: 

Use of Misoprostol in missed abortion:

Although curettage is relatively safe for termination of pregnancy , it can be associated with intrauterine infection, adhesion, perforation, and cervical stenosis.

Alternatives are expectant treatment without any drugs or medical treatment.  Expectant treatment has high failure rates and can be assossiated with uncertainities.  Misoprostol is a cheap alternative to surgery and expectant management.  The drug is absorbed through mucous membranes and can be administered sublingually, orally, vaginally, and rectally1

Vaginal administration appears to be more effective than oral administration for the inducement of uterine contractions and cervical effacement,while minimizing systemic side effects such as diarrhea, fever, nausea, and vomiting. Gilles et al compared moistened misoprostol tablets with unmoistened tablets and found that both were equally effective, in one study.  The criteria of inclusion in their study could act as a guideline for readers of TOGS in their practice while using misoprostol.  The criteria were, one of the following transvaginal ultrasound findings: embryonic pole or crown-rump length between 5 and 40 mm without cardiac activity, mean anembryonic gestational sac diameter between 16 and 45 mm or no growth over at least 1 week,or an increase in human chorionic gonadotropin of <15% over 2 days with a yolk sac.Women were excluded if they were anemic (hemoglobin level, <9.5 mg/dL), if their condition was hemodynamically unstable, or if they had a contraindication to treatment with prostaglandins or nonsteroidal anti-inflammatory drugs. In this study, If the gestational sac remained on day 3, a second dose of misoprostol was administered in the same manner as the first. Curettage was performed on the day 8 visit if the sac persisted.

Wood et al , used the following criteria to diagnose missed abortion: embryo greater than 7 mm with no embryonic cardiac activity, irregular gestational sac with mean sac diameter greater than 16 mm2, or a gestational sac greater than 15 mm with no visible fetal pole.

Dose:800 microgram of misoprostol could be administered orally or vaginally. It was found to be equally effective by Ngoc et al.Demetroulis et al. found that 800 mcg vaginal misoprostol achieved complete abortion for 82.5% of women.

Side effects: Vomiting and diarrhoea are common reported side effects. In one meta analysis it was shown that in contrast with the common belief that expectant or medical management might increase the risk of infections, it was found that there were equal number of women with PID after curettage or after undergoing non-invasive management options3. Moreover, women treated with misoprostol followed by curettage (failed misoprostol) seemed to have less direct surgery related complications as compared to women initially treated with curettage, which could be explained by the cervical priming effect of misoprostol allowing easy surgical access to the uterine cavity.

References:

1.Gilles JM,CreininMDet al: A randomized trial of saline solution–moistened misoprostol versus dry misoprostol for first-trimester pregnancy failure: American Journal of Obstetrics and Gynecology:Volume 190 • Number 2 • February 2004 Copyright © 2004 Mosby, Inc.

2.Ngoc.N.T.N,Blum.J et al: Medical treatment of missed abortion using misoprostol: Int.J.Obs&Gyn: Vol27,Iss2,Nov2004: pp:138-142.

3.Gracios.G.C.M, Mol.B.W: Management of early pregnancy loss: Int.J.Obs &Gyn.vol 86,Iss3: pp337-346.

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