Medical Termination of Delayed Miscarriage: Four-Year Experience with an Outpatient Protocol / Terminação médica de gravidez inviável do 1° trimestre: quatro anos de experiência com um protocolo de tratamento em ambulatório

Abstract Purpose To evaluate the efficacy of an outpatient protocol with vaginal misoprostol to treat delayed miscarriage. Methods Retrospective analysis of prospectively collected data on women medically treated for missed abortion with an outpatient protocol. The inclusion criteria were: ultrasound-based diagnosis of missed abortion with less than 10 weeks; no heavy bleeding, infection, inflammatory bowel disease ormisoprostol allergy; nomore than 2 previous spontaneous abortions; the preference of the patient regarding the medical management. The protocol consisted of: 1) a single dose of 800 μg of misoprostol administered intravaginally at the emergency department, after which the patients were discharged home; 2) clinical and ultrasonographic evaluation 48 hours later - if the intrauterine gestational sac was still present, the application of 800 μg of vaginal misoprostol was repeated, and the patients were discharged home; 3) clinical and ultrasonography evaluation 7 days after the initiation of the protocol - if the intrauterine gestational sac was still present, surgical management was proposed. The protocol was introduced in January 2012. Every woman received oral analgesia and written general recommendations. We also gave them a paper form to be presented and filled out at each evaluation. Results Complete miscarriage with misoprostol occurred in 340 women (90.2%). Surgery was performed in 37 (9.8%) patients, representing the global failure rate of the protocol. Miscarriage was completed after the first misoprostol administration in 208 (55.2%) women, with a success rate after the second administration of 78.1% (132/169). The average age of the women with complete resolution using misoprostol was superior to the average age of those who required surgery (33.99 years versus 31.74 years; p = 0.031). Based on the ultrasonographic findings in the first evaluation, the women diagnosed with fetal loss achieved greater success rates compared with those diagnosed with empty sac (p = 0.049). Conclusions We conclude this is an effective and safe option in the majority of delayed miscarriage cases during the first trimester, reducing surgical procedures and their consequences.

Resumo Objetivo Avaliar a eficácia de um protocolo de tratamento médico da gravidez inviável do primeiro trimestre (GI1°T) com misoprostol vaginal em regime de ambulatório. Métodos Análise retrospectiva de dados colhidos prospectivamente de grávidas tratadas com misoprostol vaginal em ambulatório. Os critérios de inclusão foram: diagnóstico de GI1°T com < 10 semanas de gestação; ausência de hemorragia abundante, infeção, doença inflamatória intestinal ou alergia ao misoprostol; 2 abortamentos anteriores; e preferência da paciente por tratamento médico. O protocolo consiste em: dia 0-aplicação demisoprostol intravaginal (800μg) no Serviço de Urgência e alta para o domicílio; dia 2-se persistência de saco gestacional intrauterino, aplicação de segunda dose de misoprostol (800μg) e alta; Dia 7-se persistência de saco gestacional intrauterino, proposto esvaziamento uterino instrumentado. O protocolo foi implementado em janeiro de 2012. Todas as grávidas receberam analgesia oral e informação por escrito com recomendações gerais. Receberam ainda um formulário a ser preenchido em cada vinda à urgência. Resultados Das 377 mulheres incluídas, observou-se abortamento completo em 340 (90,2%). As restantes 37 (9,8%) necessitaram de tratamento cirúrgico - taxa de falência global do protocolo. Em 208 (55,2%), o sucesso foi observado ao fim da 1ª dose, com uma taxa de eficácia da 2ª dose de 78,1% (132/169). A idade média das mulheres com sucesso do tratamento médico foi superior à das mulheres sem sucesso do mesmo (33,99 versus 31,74 anos; p = 0,031). O sucesso do tratamento foi maior quando o diagnóstico ecográfico inicial era de um embrião sem vitalidade comparado com os casos de ovo anembrionado (p = 0.049). Conclusões Conclui-se que esta é uma opção de tratamento eficaz e segura na maioria das situações de GI1°T, evitando a necessidade de internamento e de intervenção cirúrgica.

Efectividad del tratamiento médico con misoprostol según dosis administrada en aborto retenido menor de 12 semanas / Effectiveness of medical treatment with misoprostol as abortion retained dose administered in less than 12 weeks

Antecedentes: El manejo terapéutico del aborto retenido consiste en evacuar la cavidad uterina espontáneamente o utilizando misoprostol previo al legrado quirúrgico. Objetivo: Evaluar la necesidad de dilatación mecánica post maduración cervical con misoprostol y la tasa de perforación uterina post legrado, utilizando diferentes dosis de misoprostol en pacientes con diagnóstico de aborto retenido menor a 12 semanas. Métodos: Se registraron datos demográficos y ginecológicos de una cohorte retrospectiva de pacientes con diagnóstico de aborto retenido menor a 12 semanas, entre enero de 2008 y diciembre de 2010. Se establecieron 3 grupos de trabajo según la dosis de misoprostol administrada vía vaginal, siendo de 100 (n=131), 200 (n=231) y 400 micrones (n=230), y se observaron las complicaciones asociadas al procedimiento. Resultados: La necesidad de dilatación mecánica fue significativamente mayor en el grupo que recibió 100 micrones de misoprostol al compararlo con el de 200 micrones y 400 micrones (p<0,01). No hubo diferencias estadísticamente significativas entre las que recibieron 200 versus 400 micrones de misoprostol. No hubo diferencias significativas respecto a perforación uterina. Conclusión: En el aborto retenido menor a 12 semanas, la necesidad de dilatación mecánica post maduración cervical, es menor si se utiliza 200 o 400 micrones de misoprostol, sin diferencias en la tasa de perforación uterina.

Background: The therapeutic management of missed abortion consists on evacuating the uterine cavity, spontaneously or by administration of misoprostol previous to curettage. Objectives: Evaluate the need of mechanical dilatation after cervical maturation with misoprostol and the rate of uterine perforation before curettage, using different doses of misoprostol in patients with diagnosis of missed abortion before 12 weeks. Methods: Demographic and gynecologic data were registered of a retrospective cohort of patients with the diagnosis of missed abortion before 12 weeks, between January 2008 and December 2010. Three groups were established according to the dose of misoprostol: 100 (n=131), 200 (n=231) and 400 microns (n=230). Complications associated to the procedure were observed. Results: The need of mechanical dilatation was significant higher for the group with 100 microns of misoprostol in comparison with 200 and 400 microns (p<0.001). There was no statistical significance among who received 200 versus 400 microns of misoprostol. No statistical significance was found for uterine perforation. Conclusion: In the missed abortion before 12 week, the need of mechanical dilatation is lower with 200 or 400 microns of misoprostol, without difference in uterine perforation rate.

Perda gestacional retida: tratamento baseado em evidência / Missed miscarriage: treatment based on evidence

A perda gestacional é a complicação mais comum da gestação, a qual acarreta sérias repercussões sociais, psicológicas e clínicas para as pacientes. Perda gestacional retida é definida como a visualização do saco gestacional vazio até a décima segunda semana de gestação, gestação intrauterina no primeiro trimestre com perda da atividade cardíaca ou a estabilização da medida comprimento crânio-nádega (CCN) em avaliações ecográficas sucessivas. Historicamente, a conduta cirúrgica tem sido o tratamento de escolha para esse quadro clínico. No entanto, há novas tendências baseadas em estudos recentes que sugerem alternativas terapêuticas válidas como a conduta expectante ou a conduta farmacológica. Esta revisão apresentou a evidência científica atual das diferentes possibilidades de tratamento da perda gestacional, sua eficácia e a relação com possíveis complicações.

Miscarriage is the most common complication of pregnancy which causes serious social, psychological and clinical consequences for patients. Missed miscarriage is defined as the visualization of a gestational sac empty until 12th week of pregnancy, 1st trimester intrauterine pregnancy with loss of heart activity or stabilization of the cranial-rump length measurement (CRL) in successive sonographic evaluations. Historically the surgical approach has been the treatment of choice for this clinical event. However, the new trends based on recent studies suggest that alternative therapies are valid as expectant treatment or pharmacological treatment. This review presented the current scientific evidence of the different possibilities for the treatment of pregnancy loss, its efectiveness and relation to possible complications.

Glyceryl trinitrate versus misoprostol for termination of first trimester missed miscarriage

Missed abortion refers to a pregnancy that can manifest as an anembryonic gestation or fetal demise prior to 20 week's gestation. Medical management has been used as a treatment options. A common medical regimen used to evacuate the uterus is vaginal misoprostol [Cytotec] in single or multiple doses. To compare the therapeutic efficacy and adverse effects of intravaginal administration of a nitric oxide donor [glyceryl trinitrate] with that of a prostaglandin [misoprostol] to induce cervical changes in women with missed miscarriages to terminate their pregnancies. A prospective, randomized comparative trial conducted at Al-Yarmouk Teaching Hospital, Department of Obstetrics and Gynaecology/Baghdad-Iraq, enrolled Sixty women with first trimester missed miscarriages that requested pregnancy termination. They were randomly selected to receive either two tablets of 500 microg. glyceryl trinitrate vaginally [n = 30] or 200 microg misoprostol tablet vaginally [n = 30], every 3 hours to a maximum of four doses or until reaching desirable cervical changes. Baseline vital signs were recorded and repeated with monitoring for adverse side effects every 3 hours until finishing therapy. The difference in cervical changes between the two groups was statistically not significant [p > 0.05]. The successful outcome taken as cervical dilatation >/= 10 mm, incomplete, or complete miscarriage was achieved in 30% of women in the glyceryl trinitrate and in 53% of women in the misoprostol group which was statistically not significant [p>0.05]. Systolic and diastolic blood pressure, temperature and heart rate were lower with glyceryl trinitrate than misoprostol, but the differences were not significant [v > 0.05]. The most frequent side effect associated with glyceryl trinitrate administration was headache, which occurred in 27/30 women, compared with only 5/30 women in misoprostol group; relative risk 5.42 [p < 0.05]. Women treated with misoprostol reported mainly lower abdominal pain; relative risk 4.2 [p < 0.05]. Although glyceryl trinitrate was less effective than misoprostol when used prior to termination of missed miscarriage, the difference was statistically not significant. Moreover glyceryl trinitrate caused less adverse effects than misoprostol and it could have a role in the management of this obstetrical problem

Management of first trimester missed miscarriage with minimal surgical intervention

To observe the efficacy of Prostaglandin E1 analogue [misoprostol] in management of 1st trimester missed miscarriage. Observational study The study was done from June 2005 to June 2007 at Pakistan Railway Hospital Rawalpindi All patients presenting with 1st trimester missed miscarriage excluding suspected ectopic pregnancy, massive vaginal bleeding at admission, previous 3 scars, severe anaemia, history of handling before and history of bleeding disorders were subjected to the 1000 microgram regime of oral misoprotol in divided doses in 6 hours 400 micrograms orally stat and then 200 microgram 2 hourly 3 doses. After informed counselling and consent of the patient, a detailed Pelvic scan, blood complete picture, Hepatitis screening, blood sugar random and blood group was done. The patients were hospitalized and counselled as soon as first dose was given. The main outcome measures which were evaluated were complete abortion, incomplete abortion, severe haemorrhage, gastro-intestinal disturbances like nausea / Vomiting and any surgical intervention, if required like dilatation and curettage and evaculation and curettage. A total of 100 women were recruited to this study, 97% patients completed the 6 hours dosage regime and 3% patients expelled completely after initial doses. In 30% patients' evacuation was done which means that no cervical dilatation was required and the time of surgery/general anaesthesia was less than 6 minutes on average. Nausea and vomiting were seen in only 6% patients but considered as tolerable and transient. Only 1% patient had heavy bleeding and required an emergency evacuation, histopathology of which revealed molar tissue. None of them required blood transfusion. Majority of patients had no side effects. Patient satisfaction with oral misoprostol treatment was high, as many participants reported that they would prefer the same treatment if they have another miscarriage. Medical management of missed abortion is effective, reduces the need of dilatation and curettage, and is associated with high levels of patient satisfaction

Misoprostol en el manejo del aborto retenido y óbito fetal / Misoprostol in the management of missed abortion and fetal death

Se evalúa en forma prospectiva la acción del misoprostol en el manejo del aborto no séptico del primer trimestre (52 abortos retenidos y 13 huevos anembrionados) y en el óbito fetal de segundo trimestre (11 pacientes). Los compromisos de misoprostol de 200 microgramos se colocaron en la vagina y/o endocervix en 1 a 4 dosis (1 dosis por día) en un total de 76 pacientes, hospitalizados en el Servicio de Obstetricia y Ginecología del Hospital del Salvador en el período comprendido entre el 1 de Septiembre de 1995 y el 29 de Febrero de 1996. En 56 de los 76 pacientes (73,7 porciento) se desencadenó y se completó el trabajo de aborto. En las restantes 20 hubo modificaciones significativas del cuello uterino que hicieron notablemente más fácil la dilatación y vaciamiento. No hubo complicaciones atribuibles al método. Se concluye que el misoprostol puede formar parte del arsenal terapéutico en el manejo del aborto retenido y del óbito fetal por la comodidad, seguridad, economía y eficacia de su uso

Periovular: método válido para la interrupción del embarazo no viable de 2§-3§ trimestre / Periovular: accepted method for the non viable pregnancy interruption of 2§-3§ trimester

Se inducen 41 pacientes gestantes, con fetos muertos entre la 24 y 40 semanas de embarazo, mediante la administración extraamniótica de soluciones salinas isotónicas. El éxito fue de 90 por ciento de partos vaginales. Las complicaciones fueron 9,7 por ciento

Experiencia con prostaglandinas E2 en gel intracervicales y tabletas intravaginales en óbitos fetales / Experience with E2 prostaglandins in intracervical gel and intravaginal pills in death fetus

Se presenta nuestra experiencia clínica con el uso de prostaglandinas E2 en gel intracervicales y en tabletas intravaginales en la inducción del parto o abortos en fetos muertos. Considerados globalmente las 50 pacientes, el éxito fue de 70 por ciento, excluídos los 9 casos de fetos acráneos; esta proporción de éxito asciende a 77,7 por ciento en los casos de aborto retenido y a 78,26 por ciento en los casos de feto muerto in utero

Necessidade discutível de esvaziamento uterino de rotina em abortamento espontâneo em clínica privada / Discussible need of routine uterine emptying in spontaneous abortion in private clinic

Os autores apresentam 410 casos de abortamento espontâneos em clínica de esterilidade conjugal, dos quais apenas 32 (7,8//) necessitaram esvaziamento uterino cirúrgico. Destes 9 (nove) obedecendo protocolo da fertilizaçäo assistida com transferência de embriäo, e tendo evoluído para o abortamento. Oito (n=8) por suspeita de manuseio ginecológico, cinco (n=5) por suspeita de mola hidatiforme, nove (n=9) por fatores psicossomáticos envolvidos e apenas um (n=1) devido a sangramenteo uterino abundante. As eliminaçöes espontâneas (n=378) e "loquiaçöes" ocorreram em prazo máximo de 4 semanas näo ocorrendo qualquer complicaçäo neste grupo, levando em consideraçäo que näo houve exame ginecológico em momento algum. A administraçäo de medicamentos estro-progestativos e uterolíticos durante a gestaçäo näo mudaram a evoluçäo. Discutem os autores a necessidade de dosagem de beta-HCG e exames ecográficos frequentes, principalmente visando excluir neoplasia trofoblástica gestacional, e além disso, de boa relaçäo médico-paciente. Acreditam estarem evitando assim "stress" físico local, emocional e complicaçöes dos fatores de abortamentos espontâneos de repetiçäo ou näo pré-existentes. Resta considerar os problemas em adaptar-se esta conduta ás condiçöes dos serviços-escolas ou ambulatórios ginecológicos gerais. Neles, o atendimento médico tem características peculiares quanto a relato médico-paciente, além dos problemas nas repetiçöes de exames instrumentais e laboratoriais. Em trabalho em evoluçäo em nosso ambulatório-escola discute-se estes aspectos