High dose misoprostol used in outpatient management of first
trimester spontaneous abortion
S. Sifakis (1), E. Vardaki (1), E. Angelakis (1), G. Koumantakis
(1), Y. Fragouli (2), E. Koumantakis (1)
Department of Obstetrics and Gynecology, University of Crete,
Heraklion, Greece (1); Department of Hygiene and Epidemiology, University of
Athens, Greece (2)
Introduction: misoprostol is effective in medical
management of 1st trimester spontaneous abortions. Various regimens have been
tested to determine the most efficacious dose. The aim of this study was to
evaluate the efficacy and tolerability of a high dose of intravavaginal
misoprostol regimen, in an outpatient management of 1st trimester spontaneous
abortions.
Design and Methods: 4 doses of 400mg misoprostol were
administered intravaginally every 4 hours at 4 daily doses for a maximum period
of 3 days. 108 women at 6–11 gestational weeks with sonographic evidence of
missed abortion (embryo 44.0mm in length, without cardiac activity) and closed
cervical os, in the absence of significant cramping or vaginal bleeding were
included in the study. Misoprostol was self-administered in the patients’ own
home after detailed instructions. Both the time of misoprostol administration
and the expulsion of gestational products, were recorded by the patient.
Transvaginal sonogram (TVS) was performed 24h after the 1st dose of misoprostol,
repeated when gestational tissues indicative of complete abortion were
discharged, or 7 days after the completion of treatment. Serum b-hCG was
determined weekly until the levels decreased below 50IU/L. 200 mg doxycycline
was given orally for chemoprophylaxis. Successful treatment was considered when
endometrial cavity thickness was 515mm, and serum b-hCG levels 550IU/L.
Results: 98 women (90.7%) were managed successfully:
68.5% within the first 24 hours, and 22.2% within the following 2 days. Mean
dose of misoprostol administered: 1257.1mg (400–4800mg); mean time required:
22hrs (7–65hrs); vaginal bleeding 1.4+1.3 days; spotting 4.9+3.9 days; total
bleeding 6.5+2.8 days; pre- and post-treatment hemoglobin levels were
11.8+0.8g/dl and 11.6+1.4 g/dl respectively (p40.05). Only 10/108 (9.3%) women
required surgical intervention as the result of retained conception products or
increased anxiety. Serum b-hCG declined to non-pregnant levels over a mean
period of 2.5 weeks. Minimal side effect occurred in 44.4% of women, included
nausea (24.1%), vomiting (14.8%), headache (7.4%), and diarrhea (3.7%). No
further intervention was required in any of the women who were successful
managed. Post-treatment infection was not observed. TVS was performed 30 days
after treatment, showed normal uterine cavity and endometrium.
Conclusions: 400mg misoprostol self-administered
intravaginally every 4 hours, to a maximum daily dose of 1600mg is effective for
the outpatient conservative management of 1st trimester missed abortions.
