Speciality
Spotlight

 




 


Obstetric & Gynaecology


 

 




Abortion

     

  • Pregnancy Complications in Women with Recurrent Miscarriage Associated with Antiphospholipid Antibodies Treated with Low Dose Aspirin and Heparin.

    M Backos, et al (St Mary’s, London), Br. J Obstet Gynaecol 106:102-107, 1999.

        

    The late pregnancy and perinatal course in 150 women treated with low dose aspirin and low-dose heparin because of recurrent miscarriage associated with antiphospholipid antibodies was prospectively examined.

       

    There were 107 live births (71%) and 41 miscarriages (27%), most of which occurred in the first trimester.

        

    Conclusion : A high birth rate was observed among women with recurrent miscarriage and antiphospholipid antibodies who underwent combined treatment with aspirin and heparin. Successful pregnancies were susceptible to a increased risk of complications during all trimesters. These high-risk pregnancies should have close antenatal surveillance, and deliveries should occur in a unit with specialist obstetric and neonatal intensive care facilities.

         

    About 15% of women with recurrent miscarriage have antiphospholipid antibodies. The current therapy for these women is administration of 75mg aspirin daily as soon as human chorionic gonadotropin is detectable in the urine, and 5000 IU of subcutaneous heparin every 12 hours beginning when fetal heart activity is first observed sonographically. With this therapy the viable pregnancy rate is about 70%, significantly greater than the 40% rate when therapy consists of aspirin alone. 

        

    The results of this study of a large group of women treated with aspirin and heparin during their pregnancies found there was little effect on bone density, and no women developed thrombocytopenia. However, because there is a high incidence of pregnancy-induced hypertension, antepartum hemorrhage, and premature and low birth weight infants, pregnant women with antiphospholipid syndrome need to be monitored closely and frequently during their gestation.

        

  • RB Ness, et al
    (Univ of Pittsburgh, Pa; Univ of Pennsylvania, Philadelphia; New York State Psychiatric Inst). 


    Cocaine and
    Tobacco Use and the Risk of Spontaenous Abortion

    N Engl J Med 340:333-339, 1999.

       


    Drug use during pregnancy was compared in a case-control study of inner city adolescents and women who had spontaneous abortions and adolescents and women who remained pregnant after 22 weeks of gestation.

        


    Questionnaires were presented to adolescent girls and women, age 14 to 40, who were screened for pregnancy in the emergency department at the Hospital of the University of Pennsylvania. Of the 1347 who were less than 22 weeks’ pregnant, 1266 consented to interviews at baseline and at 16 and 22 weeks’ of gestation and to collection of urine, blood, and hair samples. Participants were divided into 2 groups: those who had spontaneous abortions (n=400) and those who carried their pregnancies beyond 22 weeks’ gestation.

       


    Conclusion from this was that cigarette smoking and cocaine use appear to be independently associated with an increased risk of spontaneous abortion such as 24% (cocaine use 8% and smoking 16%).

       


    A major strength of this study was the objective method of evaluating use of cocaine, nicotine and marijuana by biochemical detection of their metabolites in hair and urine samples. With the use of those objective criteria, cocaine and tobacco use was found to be significantly associated with an increased risk of spontaneous abortion. This association was not confirmed when self-reporting of use of these substances was correlated with the incidence of spontaneous abortion. Pregnant women should not smoke cigarettes or use cocaine for several reasons, including an increased risk of miscarriage.

       

  • F
    Parazzini, et al (Istituto di Ricerche Farmacologiche “Mario
    Negri,” Milan, Italy; Universita di Milano, Italy; Universita di Verona, Italy). 


    Coffee consumption and risk of hospitalized miscarriage before 12 weeks of gestation.


    Hum Reprod 13:2286-2291, 1998.

       


    In this study 1543 women were studied and they were divided into 2 groups drinkers of 1,2 or 3 and 4 or more cups of coffee per day. It was found that odds ratio per women who consumed 1,2, 3and 4 or more cups of coffee per day were 1.2 and 1.8 and 4 respectively. The estimated multivariate odds ratios of spontaneous abortion were 1.1 and 1.9 for women who reported coffee drinking for 10 years or less and for 10 years or more.

        


    Authors draw the conclusion that drinking coffee in early pregnancy increases the risk of spontaneous abortion. However, epidemiologic inference on the casualty is still debatable.

        


    Editorial comment: The epidemiologic data regarding caffeine and coffee consumption and risk of miscarriage are inconsistent. Some observational studies show no increased risk of miscarriage associated with drinking coffee, whereas others, including this case-control study, found that there was an increased risk. Because drinking coffee may be casually associated with an increased risk of miscarriage, women should be advised not to drink coffee when they become pregnant.

       

  • Thyroid Antibody titer and Avidity in Patients with Recurrent Miscarriage. 

    R Wilson, et al (Glasgow Royal Infirmary, Scotland; Glasgow Dental Hosp, Scotland; St James Univ Hosp, Leeds, England). Fertile Steril 71:558-561, 1999.

       


    Several studies have reported an increased incidence of thyroid antibodies in the sera of women with a history of recurrent miscarriage. Thyroid antibodies may serve as a marker for women at risk of miscarriage. The titers of thyroid microsomal antibodies in pregnant women with a history of recurrent miscarriage who had successful pregnancies were compared with those of women who had unsuccessful pregnancies.

        


    Conclusions: Autoimmunity plays a role in recurrent miscarriage. Among women with a history of recurrent miscarriages, the humoral response to pregnancy appears to differ between those whose pregnancies continue to term and those who miscarry again.

        


    Editorial comments: Other studies have shown that the presence of antithyroid antibodies is a risk marker for spontaneous abortion in women with and without a prior history of recurrent miscarriage. All the women in this study had a history of recurrent miscarriage, and all had antithyroid antibodies. The data indicate that there is a direct correlation between the level of thyroid peroxidase antibody titer and avidity and subsequent miscarriage. The exact relation between elevated levels of thyroid peroxidase antibody and poor pregnancy outcome has not been determined. The presence of the antibodies may be an indicator of abnormal T-cell function and not a cause of the miscarriage.

       

  • 1) B
    Jablonowska, et al (Univ Hosp, Linkoping, Sweden; Huddinge Univ Hosp, Sweden) 


    Prevention of Recurrent Spontaneous
    Abortion by Intravenous Immunoglobulin: A Double-Blind Placebo-controlled study.

    Hum Reprod. 14:838-841, 1999 and

    2) H Yamada, et al (Hokkaido Univ, Sapporo, Japan) Massive Immunoglobulin treatment in Women with four or More Recurrent Spontaneous Primary Abortions of Unexplained
    Aetiology.

    Hum Reprod.13:2620-2623, 

       


    Conclusion: Administration of intravenous immunoglobulin
    (IVIG) at intervals during early-pregnancy and mid-pregnancy as a treatment for unexplained recurrent miscarriage has been performed by several groups. In the majority of randomized controlled trials, such as the first one, the viable birth rate has not been found to be significantly greater with IVIG than when saline solution or albumin is infused in the control group. IVIG is expensive. Therefore, until its use has been shown to be significantly better than placebo, clinicians should not advise women to receive IVIG for the treatment of unexplained recurrent miscarriage.

       

  • Pregnancy Complications in Women with Recurrent Miscarriage Associated with Antiphospholipid Antibodies Treated with Low Dose Aspirin and Heparin.

    M Backos, et al (St Mary’s, London), Br. J Obstet Gynaecol 106:102-107, 1999.

        


    The late pregnancy and perinatal course in 150 women treated with low dose aspirin and low-dose heparin because of recurrent miscarriage associated with antiphospholipid antibodies was prospectively examined.

       


    There were 107 live births (71%) and 41 miscarriages (27%), most of which occurred in the first trimester.

        


    Conclusion : A high birth rate was observed among women with recurrent miscarriage and antiphospholipid antibodies who underwent combined treatment with aspirin and heparin. Successful pregnancies were susceptible to a increased risk of complications during all trimesters. These high-risk pregnancies should have close antenatal surveillance, and deliveries should occur in a unit with specialist obstetric and neonatal intensive care facilities.

        


    About 15% of women with recurrent miscarriage have antiphospholipid antibodies. The current therapy for these women is administration of 75mg aspirin daily as soon as human chorionic gonadotropin is detectable in the urine, and 5000 IU of subcutaneous heparin every 12 hours beginning when fetal heart activity is first observed
    sonographically. With this therapy the viable pregnancy rate is about 70%, significantly greater than the 40% rate when therapy consists of aspirin alone. 

        


    The results of this study of a large group of women treated with aspirin and heparin during their pregnancies found there was little effect on bone density, and no women developed
    thrombocytopenia. However, because there is a high incidence of pregnancy-induced hypertension, antepartum hemorrhage, and premature and low birth weight infants, pregnant women with antiphospholipid syndrome need to be monitored closely and frequently during their gestation.

       

  • TKH Chung, et al (Chinese Univ of Hong Kong, China) 


    Spontaneous Abortion: A Randomized, Controlled Trial Comparing Surgical Evacuation With Conservative Management Using Misoprostol.


    Fertil Steril 71:1054-1059, 1999.

       


    Six hundred thirty-five women who aborted spontaneously were randomized to receive routine surgical evacuation or medical evacuation of the uterus using misoprostol at 400 mg every 4 hours up to a total dose of 1200 mg. If patients had severe blood loss, sepsis, or a known allergy to
    prostaglandins, they were excluded from the randomization.

       


    Results: The group treated with misoprostol had significantly more blood loss. Surgical evacuation was required in about 50% of the medically treated group.

       


    Conclusion: In women with spontaneous abortion, treatment with misoprostol can reduce the demand for surgical evacuation, and its use is associated with fewer medical
    compliations. It is worthwhile to have initial treatment with
    misoprostol, because it reduced the number of evacuation of retained products of conception by 50%.

       


    Editor D.R.Mishell Jr, does not seem to agree with it. According to him sonograph examination of the uterine cavity after a spontaneous abortion indicates that a little gestational tissue ramins in about one third of the uteri. Women with these findings can usually be managed without surgical evacuation. If gestational tissue is present in the cavity, the standard practice is to remove the tissue with a surgical procedure to prevent excessive uterine blood loss and infection. It may be possible to treat incomplete abortion with the prostaglandin misoprostol to avoid the need of a surgical procedure. However, the necessity for hospitalization of 1 day as in this study may be more costly and inconvenient than a curettage performed in an outpatient surgical environment. Studies with the use of vaginal misoprostol administered to outpatients to treat incomplete abortion should be undertaken.

       

  • Vaginal Misoprostol Alone is Effective in the Treatment of Missed Abortion.

    S Zalanyi (Municipal Hosp, Keszthely, Hungary) Br J Obstet Gynaecol 105:1026-1035, 1998

       


    Twenty five women were included in the prospective, observational trial. Misoprostol in 200 mg tablets was placed intravaginally and repeated every 4 hours, for a total dose of 800 mg or until expulsion of the gestational sac.

       


    The vaginal administration of 200 mg of misoprostol, repeated for up to 3 doses or until the products of conception are expelled, is effective treatment for missed abortion in most women. In this current study the majority had complete expulsion of the products of conception after the second dose, resulting in a mean induction-to-abortion time of 6.1 hours.

       


    Previous studies have shown that the vaginal administration of misoprostol is an effective way to empty the uterine cavity of fetal components during the second trimester in women who have either a live or a dead fetus. Vaginal administration of 800 mg of misoprostol causes abortion to occur in about 90% of women with a viable pregnancy in the first trimester. This study indicates that vaginal administration of 200 mg of misoprostol every 4 hours causes expulsion of the products of conception in about 90% of women with embryonic or fetal death in the first trimester. Thus, women with evidence of embryonic or fetal death in the first or second trimester can have their pregnancies terminated by surgical evacuation or vaginal administration of
    misoprostol.

       

  • A Randomized Controlled Trial of Laminaria, Oral Misoprostol and Vaginal Misoprostol Before Abortion.

    L Macisaac, et al (Univ of California, San Francisco) Obstet Gynecol 93: 766-70.

       


    One hundred six women at 7 to 14 weeks’ gestation who were requesting abortion were included in the study. Oral
    misoprostol, 400 mg, vaginal misoprostol, 400 mg or one medium laminaria was administered more than 4 hours before surgery.

       


    Conclusions- Vaginal administration of misoprostol is an acceptable alternative to laminaria tents for cervical dilation before surgical abortion in women at 7 to 14 weeks’ gestation. Vaginal misoprostol is inexpensive and easy to administer, and it produces dilation equal to or greater than that produced by
    laminaria, with less pain and no increase in adverse effects. The vaginal route is superior to the oral route.

       


    The results of this randomized controlled trial indicate that vaginal administration of 400 mg of misoprostol is as effective as laminaria for dilating the cervix before surgical evacuation of the uterine cavity in pregnancies of 7 to 14 weeks’ gestation. Clinicians who perform elective abortion in the first and early second trimesters may wish to use misoprostol instead of laminaria to dilate the cervix before surgical evacuation of the uterine contents to avoid the discomfort produced by laminaria placement.

       

  • EA
    Schaff, et al (Univ of Rochester, NY; Univ of California, San Francisco; Univ of Washington, Seattle) 


    Low-Dose Mifepristone 200mg and Vaginal Misoprostol for Abortion.


    Contraception 59:1-6, 1999

       


    The research subjects were 933 women 18 years or older who had a singleton pregnancy of upto 8 weeks gestation and who sought an abortion. In the office, the women were given 200mg mifepristone orally and 48 hours later it was followed by 800mg misoprostol vaginally (4 tablets) introduced in the office or administered by the patient herself. The participants returned to the office 1 to 4 days after the misoprostol dose for ultrasound evaluation to determine whether the pregnancy had aborted or not. 

       


    An adiditional 800 mg dose of misoprostol was inserted vaginally and the participant returned for evaluation within a week in case the pregnancy was not aborted with the first dose. If this additional dose failed to terminate the procedure, then a surgical procedure was performed. At the initial ultrasound, participants were asked about their side effects and their satisfaction with the protocol.

       


    Findings : Neither gestational age, participant age, nor prior pregancy or abortion had a signfiicant influence on the failure rate. The most common reason for failure was heavy bleeding (8 participants, or 30%), 16 i.e.2% required a second dose. Bleeding started a mean of 3.2 hours after misoprostol administration and lasted a mean of 10.8 days. Most participants (95%) passed the pregnancy by day 7. At least one third of subjects experienced cramping, nausea, and fever or chills and 85% found the side effects to be acceptable, and 94% found the procedure to be acceptable.

       


    Conclusion: Low-dose oral mifepristone followed by vaginal misoprostol was highly effective, safe, and acceptable as an abortifacient up to 8 weeks’ gestation. The option to use misoprostol at home was very popular, and less than 1% of patients experienced acute hemorrhage, which is the problem most likely to benefit from a 4-hour office observation period after misoprostol administration.

       


    Editorial comments say that the optimal type and dose of medication for medical termination of early pregnancy as well as the optimal route of administration and interval of therapy remain to be determined. The results of this large multicenter trial indicate that use of only 200mg of mifepristone is as effective as the standard 600-mg dose currently being used in Europe. The administration of misoprostol intravaginally by the subjects themselves at home is more convenient and acceptable than remaining in the clinic for 4 hours after receiving an oral dose of
    misoprostol. The efficacy of 97% achieved in this study is equivalent or superior to other trials of mifepristone and
    misoprostol.

      



 

 

Speciality Spotlight

 

 

Abortion
     

  • Pregnancy Complications in Women with Recurrent Miscarriage Associated with Antiphospholipid Antibodies Treated with Low Dose Aspirin and Heparin.
    M Backos, et al (St Mary’s, London), Br. J Obstet Gynaecol 106:102-107, 1999.
        
    The late pregnancy and perinatal course in 150 women treated with low dose aspirin and low-dose heparin because of recurrent miscarriage associated with antiphospholipid antibodies was prospectively examined.
       
    There were 107 live births (71%) and 41 miscarriages (27%), most of which occurred in the first trimester.
        
    Conclusion : A high birth rate was observed among women with recurrent miscarriage and antiphospholipid antibodies who underwent combined treatment with aspirin and heparin. Successful pregnancies were susceptible to a increased risk of complications during all trimesters. These high-risk pregnancies should have close antenatal surveillance, and deliveries should occur in a unit with specialist obstetric and neonatal intensive care facilities.
         
    About 15% of women with recurrent miscarriage have antiphospholipid antibodies. The current therapy for these women is administration of 75mg aspirin daily as soon as human chorionic gonadotropin is detectable in the urine, and 5000 IU of subcutaneous heparin every 12 hours beginning when fetal heart activity is first observed sonographically. With this therapy the viable pregnancy rate is about 70%, significantly greater than the 40% rate when therapy consists of aspirin alone. 
        
    The results of this study of a large group of women treated with aspirin and heparin during their pregnancies found there was little effect on bone density, and no women developed thrombocytopenia. However, because there is a high incidence of pregnancy-induced hypertension, antepartum hemorrhage, and premature and low birth weight infants, pregnant women with antiphospholipid syndrome need to be monitored closely and frequently during their gestation.
        

  • RB Ness, et al (Univ of Pittsburgh, Pa; Univ of Pennsylvania, Philadelphia; New York State Psychiatric Inst). 
    Cocaine and
    Tobacco Use and the Risk of Spontaenous Abortion
    N Engl J Med 340:333-339, 1999.
       
    Drug use during pregnancy was compared in a case-control study of inner city adolescents and women who had spontaneous abortions and adolescents and women who remained pregnant after 22 weeks of gestation.
        
    Questionnaires were presented to adolescent girls and women, age 14 to 40, who were screened for pregnancy in the emergency department at the Hospital of the University of Pennsylvania. Of the 1347 who were less than 22 weeks’ pregnant, 1266 consented to interviews at baseline and at 16 and 22 weeks’ of gestation and to collection of urine, blood, and hair samples. Participants were divided into 2 groups: those who had spontaneous abortions (n=400) and those who carried their pregnancies beyond 22 weeks’ gestation.
       
    Conclusion from this was that cigarette smoking and cocaine use appear to be independently associated with an increased risk of spontaneous abortion such as 24% (cocaine use 8% and smoking 16%).
       
    A major strength of this study was the objective method of evaluating use of cocaine, nicotine and marijuana by biochemical detection of their metabolites in hair and urine samples. With the use of those objective criteria, cocaine and tobacco use was found to be significantly associated with an increased risk of spontaneous abortion. This association was not confirmed when self-reporting of use of these substances was correlated with the incidence of spontaneous abortion. Pregnant women should not smoke cigarettes or use cocaine for several reasons, including an increased risk of miscarriage.
       

  • F Parazzini, et al (Istituto di Ricerche Farmacologiche “Mario Negri,” Milan, Italy; Universita di Milano, Italy; Universita di Verona, Italy). 
    Coffee consumption and risk of hospitalized miscarriage before 12 weeks of gestation.

    Hum Reprod 13:2286-2291, 1998.
       
    In this study 1543 women were studied and they were divided into 2 groups drinkers of 1,2 or 3 and 4 or more cups of coffee per day. It was found that odds ratio per women who consumed 1,2, 3and 4 or more cups of coffee per day were 1.2 and 1.8 and 4 respectively. The estimated multivariate odds ratios of spontaneous abortion were 1.1 and 1.9 for women who reported coffee drinking for 10 years or less and for 10 years or more.
        
    Authors draw the conclusion that drinking coffee in early pregnancy increases the risk of spontaneous abortion. However, epidemiologic inference on the casualty is still debatable.
        
    Editorial comment: The epidemiologic data regarding caffeine and coffee consumption and risk of miscarriage are inconsistent. Some observational studies show no increased risk of miscarriage associated with drinking coffee, whereas others, including this case-control study, found that there was an increased risk. Because drinking coffee may be casually associated with an increased risk of miscarriage, women should be advised not to drink coffee when they become pregnant.
       

  • Thyroid Antibody titer and Avidity in Patients with Recurrent Miscarriage. 
    R Wilson, et al (Glasgow Royal Infirmary, Scotland; Glasgow Dental Hosp, Scotland; St James Univ Hosp, Leeds, England). Fertile Steril 71:558-561, 1999.
       
    Several studies have reported an increased incidence of thyroid antibodies in the sera of women with a history of recurrent miscarriage. Thyroid antibodies may serve as a marker for women at risk of miscarriage. The titers of thyroid microsomal antibodies in pregnant women with a history of recurrent miscarriage who had successful pregnancies were compared with those of women who had unsuccessful pregnancies.
        
    Conclusions: Autoimmunity plays a role in recurrent miscarriage. Among women with a history of recurrent miscarriages, the humoral response to pregnancy appears to differ between those whose pregnancies continue to term and those who miscarry again.
        
    Editorial comments: Other studies have shown that the presence of antithyroid antibodies is a risk marker for spontaneous abortion in women with and without a prior history of recurrent miscarriage. All the women in this study had a history of recurrent miscarriage, and all had antithyroid antibodies. The data indicate that there is a direct correlation between the level of thyroid peroxidase antibody titer and avidity and subsequent miscarriage. The exact relation between elevated levels of thyroid peroxidase antibody and poor pregnancy outcome has not been determined. The presence of the antibodies may be an indicator of abnormal T-cell function and not a cause of the miscarriage.
       

  • 1) B Jablonowska, et al (Univ Hosp, Linkoping, Sweden; Huddinge Univ Hosp, Sweden) 
    Prevention of Recurrent Spontaneous
    Abortion by Intravenous Immunoglobulin: A Double-Blind Placebo-controlled study.
    Hum Reprod. 14:838-841, 1999 and
    2) H Yamada, et al (Hokkaido Univ, Sapporo, Japan) Massive Immunoglobulin treatment in Women with four or More Recurrent Spontaneous Primary Abortions of Unexplained Aetiology.
    Hum Reprod.13:2620-2623, 
       
    Conclusion: Administration of intravenous immunoglobulin (IVIG) at intervals during early-pregnancy and mid-pregnancy as a treatment for unexplained recurrent miscarriage has been performed by several groups. In the majority of randomized controlled trials, such as the first one, the viable birth rate has not been found to be significantly greater with IVIG than when saline solution or albumin is infused in the control group. IVIG is expensive. Therefore, until its use has been shown to be significantly better than placebo, clinicians should not advise women to receive IVIG for the treatment of unexplained recurrent miscarriage.
       

  • Pregnancy Complications in Women with Recurrent Miscarriage Associated with Antiphospholipid Antibodies Treated with Low Dose Aspirin and Heparin.
    M Backos, et al (St Mary’s, London), Br. J Obstet Gynaecol 106:102-107, 1999.
        
    The late pregnancy and perinatal course in 150 women treated with low dose aspirin and low-dose heparin because of recurrent miscarriage associated with antiphospholipid antibodies was prospectively examined.
       
    There were 107 live births (71%) and 41 miscarriages (27%), most of which occurred in the first trimester.
        
    Conclusion : A high birth rate was observed among women with recurrent miscarriage and antiphospholipid antibodies who underwent combined treatment with aspirin and heparin. Successful pregnancies were susceptible to a increased risk of complications during all trimesters. These high-risk pregnancies should have close antenatal surveillance, and deliveries should occur in a unit with specialist obstetric and neonatal intensive care facilities.
        
    About 15% of women with recurrent miscarriage have antiphospholipid antibodies. The current therapy for these women is administration of 75mg aspirin daily as soon as human chorionic gonadotropin is detectable in the urine, and 5000 IU of subcutaneous heparin every 12 hours beginning when fetal heart activity is first observed sonographically. With this therapy the viable pregnancy rate is about 70%, significantly greater than the 40% rate when therapy consists of aspirin alone. 
        
    The results of this study of a large group of women treated with aspirin and heparin during their pregnancies found there was little effect on bone density, and no women developed thrombocytopenia. However, because there is a high incidence of pregnancy-induced hypertension, antepartum hemorrhage, and premature and low birth weight infants, pregnant women with antiphospholipid syndrome need to be monitored closely and frequently during their gestation.
       

  • TKH Chung, et al (Chinese Univ of Hong Kong, China) 
    Spontaneous Abortion: A Randomized, Controlled Trial Comparing Surgical Evacuation With Conservative Management Using Misoprostol.

    Fertil Steril 71:1054-1059, 1999.
       
    Six hundred thirty-five women who aborted spontaneously were randomized to receive routine surgical evacuation or medical evacuation of the uterus using misoprostol at 400 mg every 4 hours up to a total dose of 1200 mg. If patients had severe blood loss, sepsis, or a known allergy to prostaglandins, they were excluded from the randomization.
       
    Results: The group treated with misoprostol had significantly more blood loss. Surgical evacuation was required in about 50% of the medically treated group.
       
    Conclusion: In women with spontaneous abortion, treatment with misoprostol can reduce the demand for surgical evacuation, and its use is associated with fewer medical compliations. It is worthwhile to have initial treatment with misoprostol, because it reduced the number of evacuation of retained products of conception by 50%.
       
    Editor D.R.Mishell Jr, does not seem to agree with it. According to him sonograph examination of the uterine cavity after a spontaneous abortion indicates that a little gestational tissue ramins in about one third of the uteri. Women with these findings can usually be managed without surgical evacuation. If gestational tissue is present in the cavity, the standard practice is to remove the tissue with a surgical procedure to prevent excessive uterine blood loss and infection. It may be possible to treat incomplete abortion with the prostaglandin misoprostol to avoid the need of a surgical procedure. However, the necessity for hospitalization of 1 day as in this study may be more costly and inconvenient than a curettage performed in an outpatient surgical environment. Studies with the use of vaginal misoprostol administered to outpatients to treat incomplete abortion should be undertaken.
       

  • Vaginal Misoprostol Alone is Effective in the Treatment of Missed Abortion.
    S Zalanyi (Municipal Hosp, Keszthely, Hungary) Br J Obstet Gynaecol 105:1026-1035, 1998
       
    Twenty five women were included in the prospective, observational trial. Misoprostol in 200 mg tablets was placed intravaginally and repeated every 4 hours, for a total dose of 800 mg or until expulsion of the gestational sac.
       
    The vaginal administration of 200 mg of misoprostol, repeated for up to 3 doses or until the products of conception are expelled, is effective treatment for missed abortion in most women. In this current study the majority had complete expulsion of the products of conception after the second dose, resulting in a mean induction-to-abortion time of 6.1 hours.
       
    Previous studies have shown that the vaginal administration of misoprostol is an effective way to empty the uterine cavity of fetal components during the second trimester in women who have either a live or a dead fetus. Vaginal administration of 800 mg of misoprostol causes abortion to occur in about 90% of women with a viable pregnancy in the first trimester. This study indicates that vaginal administration of 200 mg of misoprostol every 4 hours causes expulsion of the products of conception in about 90% of women with embryonic or fetal death in the first trimester. Thus, women with evidence of embryonic or fetal death in the first or second trimester can have their pregnancies terminated by surgical evacuation or vaginal administration of misoprostol.
       

  • A Randomized Controlled Trial of Laminaria, Oral Misoprostol and Vaginal Misoprostol Before Abortion.
    L Macisaac, et al (Univ of California, San Francisco) Obstet Gynecol 93: 766-70.
       
    One hundred six women at 7 to 14 weeks’ gestation who were requesting abortion were included in the study. Oral misoprostol, 400 mg, vaginal misoprostol, 400 mg or one medium laminaria was administered more than 4 hours before surgery.
       
    Conclusions- Vaginal administration of misoprostol is an acceptable alternative to laminaria tents for cervical dilation before surgical abortion in women at 7 to 14 weeks’ gestation. Vaginal misoprostol is inexpensive and easy to administer, and it produces dilation equal to or greater than that produced by laminaria, with less pain and no increase in adverse effects. The vaginal route is superior to the oral route.
       
    The results of this randomized controlled trial indicate that vaginal administration of 400 mg of misoprostol is as effective as laminaria for dilating the cervix before surgical evacuation of the uterine cavity in pregnancies of 7 to 14 weeks’ gestation. Clinicians who perform elective abortion in the first and early second trimesters may wish to use misoprostol instead of laminaria to dilate the cervix before surgical evacuation of the uterine contents to avoid the discomfort produced by laminaria placement.
       

  • EA Schaff, et al (Univ of Rochester, NY; Univ of California, San Francisco; Univ of Washington, Seattle) 
    Low-Dose Mifepristone 200mg and Vaginal Misoprostol for Abortion.

    Contraception 59:1-6, 1999
       
    The research subjects were 933 women 18 years or older who had a singleton pregnancy of upto 8 weeks gestation and who sought an abortion. In the office, the women were given 200mg mifepristone orally and 48 hours later it was followed by 800mg misoprostol vaginally (4 tablets) introduced in the office or administered by the patient herself. The participants returned to the office 1 to 4 days after the misoprostol dose for ultrasound evaluation to determine whether the pregnancy had aborted or not. 
       
    An adiditional 800 mg dose of misoprostol was inserted vaginally and the participant returned for evaluation within a week in case the pregnancy was not aborted with the first dose. If this additional dose failed to terminate the procedure, then a surgical procedure was performed. At the initial ultrasound, participants were asked about their side effects and their satisfaction with the protocol.
       
    Findings : Neither gestational age, participant age, nor prior pregancy or abortion had a signfiicant influence on the failure rate. The most common reason for failure was heavy bleeding (8 participants, or 30%), 16 i.e.2% required a second dose. Bleeding started a mean of 3.2 hours after misoprostol administration and lasted a mean of 10.8 days. Most participants (95%) passed the pregnancy by day 7. At least one third of subjects experienced cramping, nausea, and fever or chills and 85% found the side effects to be acceptable, and 94% found the procedure to be acceptable.
       
    Conclusion: Low-dose oral mifepristone followed by vaginal misoprostol was highly effective, safe, and acceptable as an abortifacient up to 8 weeks’ gestation. The option to use misoprostol at home was very popular, and less than 1% of patients experienced acute hemorrhage, which is the problem most likely to benefit from a 4-hour office observation period after misoprostol administration.
       
    Editorial comments say that the optimal type and dose of medication for medical termination of early pregnancy as well as the optimal route of administration and interval of therapy remain to be determined. The results of this large multicenter trial indicate that use of only 200mg of mifepristone is as effective as the standard 600-mg dose currently being used in Europe. The administration of misoprostol intravaginally by the subjects themselves at home is more convenient and acceptable than remaining in the clinic for 4 hours after receiving an oral dose of misoprostol. The efficacy of 97% achieved in this study is equivalent or superior to other trials of mifepristone and misoprostol.

      

 

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