A medical approach to management of spontaneous abortion using misoprostol. Extending misoprostol treatment to a maximum of 48 hours can further improve evacuation of retained products of conception in spontaneous abortion

Abstract

Background: To compare a 48 hour non surgical policy in the management of spontaneous abortion with a policy of routine, universal uterine curettage.

Methods: A prospective, observational study on 354 women admitted to hospital with spontaneous abortion. Of these, 225 who had retained products of conception were treated with misoprostol for up to 48 hours after 101 were excluded because they had an empty uterus on transvaginal scan (TVS) and another 28 women because they were unsuitable for conservative management. Follow-up was conducted over a 3 week period to assess morbidity. A reference group of 137 women, all of whom had an evacuation of retained products of conception (ERPC) as a routine after they had a TVS documenting retained products of conception (POCs), was used for comparison.

Results: Evacuation of the uterus occurred within 24 hours in 107 women and in 148 at 48 hours after misoprostol treatment was started. There were three uterine curettages up to 14 days after discharge from hospital for persistent bleeding and two cases of pelvic infection. An ectopic pregnancy was diagnosed at follow-up in one woman. In the reference group, there were nine women who had complications, four requiring another ERPC and five had infection, an overall complication rate of 6.6% in the reference group and 1.7% in the protocol treatment group.

Conclusion: A 48 hour regimen using transvaginal ultrasound and misoprostol for the management of spontaneous abortion was successful in avoiding surgery in 249 out of a possible 354 (70.6%) women with spontaneous abortion, with a low rate of subsequent morbidity.

PIP: A prospective, observational study of 354 women admitted to a Hong Kong hospital with a confirmed diagnosis of spontaneous abortion confirmed the effectiveness of a non-surgical 48-hour regimen using transvaginal ultrasound and misoprostol administration. 101 women were excluded because they had an empty uterus on transvaginal scan and another 28 were considered unsuitable for conservative management. The 225 remaining women were treated with up to 1200 mcgs of misoprostol administered orally in 3 divided doses per day for up to 48 hours; a comparison group of 137 women underwent surgical evacuation of retained products of conception. Evacuation of the uterus occurred within 24 hours of misoprostol administration in 107 women and by 48 hours after misoprostol administration in 148 women. The cumulative success rate was 69.6%. There were 3 uterine curettages for persistent bleeding up to 14 days after discharge, 2 cases of pelvic infection, and 1 ectopic pregnancy. In the reference group, 4 women required a repeat evacuation and 5 had infection. The overall complication rate in up to 3 weeks of follow-up was 6.6% in the surgical reference group and 1.7% in the medical treatment group.