Medical Termination of Delayed Miscarriage: Four-Year Experience with an Outpatient Protocol

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 or misoprostol allergy; no more 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 de misoprostol 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.

Keywords

delayed miscarriage - vaginal misoprostol - outpatient management

Palavras-chave

aborto retido - misoprostol vaginal - tratamento em ambulatório

• References

• 1 National Institute for Health and Clinical Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Clinical guideline. Manchester: NICE; 2012
• 2 Coughlin LB, Roberts D, Haddad NG, Long A. Medical management of first trimester miscarriage (blighted ovum and missed abortion): is it effective?. J Obstet Gynaecol 2004; 24 (01) 69-71
• 3 Ayres-de-Campos D, Teixeira-da-Silva J, Campos I, Patrício B. Vaginal misoprostol in the management of first-trimester missed abortions. Int J Gynaecol Obstet 2000; 71 (01) 53-57
• 4 Sotiriadis A, Makrydimas G, Papatheodorou S, Ioannidis JP. Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis. Obstet Gynecol 2005; 105 (5 Pt 1): 1104-1113
• 5 Barceló F, De Paco C, López-Espín JJ, Silva Y, Abad L, Parrilla JJ. The management of missed miscarriage in an outpatient setting: 800 versus 600 μg of vaginal misoprostol. Aust N Z J Obstet Gynaecol 2012; 52 (01) 39-43
• 6 Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C, Frederick MM. ; National Institute of Child Health Human Development (NICHD) Management of Early Pregnancy Failure Trial. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med 2005; 353 (08) 761-769
• 7 Shankar M, Economides DL, Sabin CA, Tan B, Kadir RA. Outpatient medical management of missed miscarriage using misoprostol. J Obstet Gynaecol 2007; 27 (03) 283-286
• 8 Petersen SG, Perkins AR, Gibbons KS, Bertolone JI, Mahomed K. The medical management of missed miscarriage: outcomes from a prospective, single-centre, Australian cohort. Med J Aust 2013; 199 (05) 341-346
• 9 Ng BK, Annamalai R, Lim PS, Aqmar Suraya S, Nur Azurah AG, Muhammad Abdul Jamil MY. Outpatient versus inpatient intravaginal misoprostol for the treatment of first trimester incomplete miscarriage: a randomised controlled trial. Arch Gynecol Obstet 2015; 291 (01) 105-113
• 10 Kulier R, Kapp N, Gülmezoglu AM, Hofmeyr GJ, Cheng L, Campana A. Medical methods for first trimester abortion. Cochrane Database Syst Rev 2011; (11) CD002855
• 11 Sifakis S, Angelakis E, Vardaki E, Fragouli Y, Koumantakis E. High-dose misoprostol used in outpatient management of first trimester spontaneous abortion. Arch Gynecol Obstet 2005; 272 (03) 183-186
• 12 Wu HL, Marwah S, Wang P, Wang QM, Chen XW. Misoprostol for medical treatment of missed abortion: a systematic review and network meta-analysis. Sci Rep 2017; 7 (01) 1664
• 13 Reynolds A, Ayres-de-Campos D, Costa MA, Montenegro N. How should success be defined when attempting medical resolution of first-trimester missed abortion?. Eur J Obstet Gynecol Reprod Biol 2005; 118 (01) 71-76
• 14 Black KI, de Vries BS, Moses F, Pelosi M, Cong A, Ludlow J. The impact of introducing medical management on conservative and surgical management for early pregnancy miscarriage. Aust N Z J Obstet Gynaecol 2017; 57 (01) 93-98
• 15 Bord I, Gdalevich M, Nahum R, Meltcer S, Anteby EY, Orvieto R. Misoprostol treatment for early pregnancy failure does not impair future fertility. Gynecol Endocrinol 2014; 30 (04) 316-319
• 16 Vejborg TS, Nilas L, Rørbye C. Medical management of first trimester miscarriage according to ultrasonographic findings. Acta Obstet Gynecol Scand 2007; 86 (05) 604-609