High dose misoprostol used in outpatient management of first trimester spontaneous abortion

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


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.

Scroll to Top