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Misoprostol and early pregnancy loss i.e. < 13 weeks Types of miscarriage Missed miscarriage - intact sac. Incomplete - heterogenous mass of tissue Complete
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Dedicated EPAU 1.Staff 2.Transvaginal scanning 3.Direct access for GPs and some patient subgroups Miscarriage Scan findings Intact mean sac diameter >20mm with no contents or Fetal pole > 6mm with no FH Rescan in 1 week.
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Management options for Miscarriage < 13 weeks 1.Surgical ERPC – Risk perforation Risk G.A Risk retained products Risk infection 2.Medical (Misoprostol) Risk retained products Risk infection 3. Expectant - Risk Retainied products - Risk of infection
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Review of Misoprostol in Missed Miscarriage Cervix closed Slight bleeding FIGO 2007 800ug vaginally 3 hourly( max x 2) or 600ug Sublingual 3 hourly ( max x 2) Follow-up 2 weeks Sublingual associated more frequently with diarrhoea than vaginal administration but similar efficacy
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Misoprostol in incomplete miscarriage FIGO review – Advise 600mg oral single dose 2 studies compared 1 vs 2 doses – no difference in efficacy ( 90%) Take care not to over –diagnose failed medical management
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Contra - indications Haemodynamically unstable Suspected ectopic Known allergy to Misoprostol Previous uterine rupture Signs of intrauterine infection Trophoblastic Disease Precautions –? 2 previous Caesarean Sections ? Previous myomectomy ? Taking Anti-coagulants
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Predictors of success Higher for incomplete Lower for anembryonic pregnancy 2 RCTS of pretreatment with Mifepristone conflicting results many studies poorly defined ultrasound / clinical criteria Does not increase risk of infection vs surgery (Trinder MIST et al BMG 2006) No effect on future fertility (Blohm et al Lancet 1997)
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Information sheets for patients Uterine contractions usually start within a few hours Routine antibiotics not necessary Tylex + or – Difene At 2 week check a further course of Misoprostol or ERPC or expectant management Bleeding lasts for up to 2 weeks If syncopal or presyncopal – emergency room Transient chills are common Fever less common if persists > 24 hours may have infection Nausea / vomiting 2 – 6 hours Diarrhoea < 1 day Taste / numbness of tongue
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Differences 1 st Trimester vs 2 nd Trimester +3 rd Trimester management Hospitalisation not necessary. Expulsion of tissue hours to weeks Extremely low rates of uterine rupture.
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In Summary < 13weeks gestation Willing patient Haemodynamically stable Sac size <5cm 600ug X 2 for missed miscarriage (subling.) 600ug X 1 for incomplete miscarriage (oral) See for scan 2 weeks later
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