Misoprostol and early pregnancy loss i.e. < 13 weeks

1
Misoprostol and early pregnancy loss i.e. lt 13
weeks

• Types of miscarriage
• Missed miscarriage - intact sac .
• Incomplete - heterogenous mass of tissue
• Complete

2
Dedicated EPAU

• Staff
• Transvaginal scanning
• Direct access for GPs and some patient subgroups
• Miscarriage Scan findings
• Intact mean sac diameter gt20mm with no contents
• or
• Fetal pole gt 6mm with no FH
• Rescan in 1 week.

3
Management options for Miscarriage lt 13 weeks

• Surgical ERPC Risk perforation
• Risk G.A
• Risk retained
  products
• Risk
  infection
• Medical (Misoprostol) Risk retained products
• 
  Risk infection
• 3 . Expectant - Risk Retainied
  products
• - Risk of
  infection

4
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

5
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

6
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
  

7
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)

8
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 gt 24 hours may have
  infection
• Nausea / vomiting 2 6 hours
• Diarrhoea lt 1 day
• Taste / numbness of tongue

9
Differences 1st Trimester vs 2nd Trimester 3rd
Trimester management

• Hospitalisation not necessary. Expulsion of
  tissue hours to weeks
• Extremely low rates of uterine rupture.

10
In Summary

• lt 13weeks gestation
• Willing patient
• Haemodynamically stable
• Sac size lt5cm
• 600ug X 2 for missed miscarriage (subling.)
• 600ug X 1 for incomplete miscarriage (oral)
• See for scan 2 weeks later