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Description : MISCARRIAGE - EXP & MEDICAL MX

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EXPECTANT & MEDICAL MX OF MISCARRIAGE DR MALINI MAT NAPES HSNZKT
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 A 28 year old woman presents to you and you diagnose her as having a missed abortion. Do you schedule her for an ERPOC OR Are there other options
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OUTLINE INTRODUCTION EXPECTANT MANAGEMENT MEDICATION USED FOR MEDICAL MANAGEMENT MEDICAL MANAGEMENT OF FIRST TRIMESTER MISCARRIAGE SECOND TRIMESTER MEDICAL MANAGEMENT PAIN CONTROL OUTPATIENT MANAGEMENT CONTRAINDICATIONS OF MEDICAL MANAGEMENT
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INTRODUCTION Miscarriage is a common event in women of reproductive age and the incidence of clinically recognized miscarriage remains around 10-20%. The majority of miscarriages occur early, before 12 weeks of pregnancy. Second trimester pregnancy loss contributes to less than 4% of pregnancy losses.
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INTRODUCTION Bleeding in early pregnancy is the most common reason for women to present to the gynaecology emergency department. In a study done in a rural hospital in Kebbi State, 189 patients were admitted for gynaecological problems within a 10 month period. 148 (78.3%) of those women were admitted for spontaneous abortion.
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INTRODUCTION A miscarriage is the spontaneous loss of a fetus before the period of viability. An incomplete miscarriage is one in which some of the products of conception have been passed out but some remain in utero. A complete miscarriage is one in which all the products of conception have been expelled.
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INTRODUCTION An inevitable miscarriage describes a condition in which the cervix has already dilated open, but the fetus has yet to be expelled. A missed miscarriage is a nonviable intrauterine pregnancy that has been retained within the uterus without spontaneous abortion.
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INTRODUCTION Traditionally, surgical curettage was the gold standard for the management of miscarriage because of the fear of uterine infection and bleeding. However, it is now clear that the risk of infection or haemorrhage is low with spontaneous miscarriage, even if no treatment is given (in contrast to miscarriages that are induced unsafely).
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INTRODUCTION The introduction of medical and expectant management of miscarriage has increased options for women and clinicians alike for the management of this common condition. Surgery is the method of choice for excessive bleeding, if vital signs are unstable or the woman has either suspected infection or gestational trophoblastic disease.
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INTRODUCTION  Where suitable, patients choice should be taken into consideration for the management of miscarriage.
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Choosing a treatment method Surgical (dilation and curettage) or Medication (misoprostol) or Expectant management. All have similar efficacy Choice depends mainly upon patient preference. [Sotiriadis et al, 2005MA].
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Options for the management of early pregnancy failure Surgical evacuation of the uterus Medical evacuation of the uterus Wait and see Recommended as first line by NICE
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Expectant Vs Medical Women prefer to avoid surgery and anesthesia. {concern about risks or may be due to a preference to pass the pregnancy without instrumentation} Expectant management criteria: Miscarriage <14 w stable vital signs no evidence of infection.
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Medical Vs Surgical Both are safe and effective approaches for appropriately selected patients. The choice is based upon Patient preference. Counseling of both is recommended Availability Gestational age: Medical tt is less successful in the late 1st T
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Medical management is recommended when: There are fetal parts >14 weeks in size Surgical evacuation is unsafe There is contraindication to surgery or anaesthesia
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MEDICATION USED FOR MEDICAL MANAGEMENT It is only over the last two decades that the medical methods of managing miscarriage have become popular. The chief pharmacological agents include prostaglandins (misoprostol, gemeprost) used alone or in combination with the anti-progestogen mifepristone.
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What is the role of mifepristone in miscarriage?  By competitive inhibition of natural progesterone, this steroid increases the sensitivity of the myometrium to prostaglandins up to five times. Maximal effect of this is on uterine contractility and cervical ripening at 36 – 48 hours following treatment.
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GEMEPROST OR MISOPROSTOL  Misoprostol and gemeprost are synthetic prostaglandin analogues which when used in high doses will cause expulsion of products of conception.  They have a high incidence of gastrointestinal side effects.
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GEMEPROST OR MISOPROSTOL There is now a large body of evidence to show that misoprostol has a similar efficacy and safety profile at all gestations to gemeprost. Unlike the gameprost pessary, misoprostol is stable at room temperature and therefore does not require stringent storage conditions. It is also considerably cheaper, thus providing a cost- effective alternative to gemeprost.
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MISOPROSTOL ADMINISTRATION Routes of misoprostol administration include: Oral Vaginal Sublingual Buccal Rectal
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MISOPROSTOL ADMINISTRATION Pharmacokinetic studies comparing oral and vaginal administration have shown that vaginal misoprostol is associated with slower absorption , lower peak plasma levels, and slow clearance, similar to an extended- release preparation. Vaginal misoprostol is also associated with greater local effects on the cervix and uterus.
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MISOPROSTOL ADMINISTRATION  There is no clinical significant difference between vaginal misoprostol that is administered dry and vaginal misoprostol moistened with water, saline or acetic acid.
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MISOPROSTOL ADMINISTRATION The sublingual route has a more rapid absorption and higher peak levels than either vaginal or oral administration. This translates into higher rates of gastrointestinal side effects. Nevertheless , the sublingual route causes uterine contractions at a rate equivalent to vaginal administration.
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MISOPROSTOL ADMINISTRATION The absorption rate after the buccal administration is the same as after vaginal administration but the serum drug levels attained are much lower. The rectal route of administration shows a similar pattern to vaginal administration but has a significantly lower maximum peak concentration.
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MISOPROSTOL ADMINISTRATION Vaginal bleeding can adversely affect the absorption of misoprostol. Both sublingual and buccal routes avoid the inconvenience of vaginal administration. On the other hand, in cases where women vomit after the administration of oral medications, it can be difficult to determine if the dose should be repeated. This is not an issue with the vaginal route.
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MODE OF ACTION & ADVERSE EFFECTS WITH MISOPROSTOL Misoprostol has uterotonic and cervical softening effects. Various studies on uterine contractility have demonstrated that a sustained level, rather than a high serum level, is required for the development of regular uterine contractions. While a single dose increases uterine clonus, repeated doses are required to maintain sustained contractions.
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MODE OF ACTION & ADVERSE EFFECTS WITH MISOPROSTOL  These regular uterine contractions are sustained for a longer period after vaginal than after sublingual administration, with decreased activity occurring only after 4 hours (compared to 3 hours with sublingual).
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MODE OF ACTION & ADVERSE EFFECTS WITH MISOPROSTOL Side effects of misoprostol are generally limited to the GIT, including nausea, diarrhea, vomiting, fever and chills. Some women experience an unpleasant taste when it is taken sublingually or bucally. There are no known drug interactions with misoprostol.
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MEDICAL MANAGEMENT OF FIRST TRIMESTER MISCARRIAGE Various medical methods have been described using prostaglandin analogues (gemeprost or misoprostol) with or without anti progesterone priming (mifepristone). There is however a lack of consensus as to whether the addition of the mifepristone confers any benefit for the management of miscarriage.
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MEDICAL MANAGEMENT OF FIRST TRIMESTER MISCARRIAGE  A study carried out by Wagaarachchi proposed that although incomplete miscarriage may be managed with misoprostol alone, in the presence of an intact sac and closed cervix, priming with mifepristone makes the regimen more effective with success rates above 80%.
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MEDICAL MANAGEMENT OF FIRST TRIMESTER MISCARRIAGE  A cochrane review suggested that non-viable pregnancies may contain viable trophoblast tissue which produces hormones, which may in theory make these pregnancies more susceptible to anti-hormone therapy and more resistant to uterotonic therapy than pregnancies in which (incomplete) miscarriages have taken place.
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MEDICAL MANAGEMENT OF FIRST TRIMESTER MISCARRIAGE However , more recent trials report that mifepristone may not be necessary for medical management of miscarriage as the pregnancy is non-viable and the progesterone level is already low. Other recent trials have shown that addition of mifepristone does not improve the overall success rate compared with regimens using misoprostol alone.
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MEDICAL MANAGEMENT OF FIRST TRIMESTER MISCARRIAGE  Mifepristone is expensive and not available in many countries. As such regimens using prostaglandins alone would be a more practical approach to the problem.
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MEDICAL MANAGEMENT OF FIRST TRIMESTER MISCARRIAGE Higher success rates for medical management of miscarriage are seen in women with incomplete miscarriage when compared to missed miscarriage. Higher success rates are also seen with high-dose misoprostol, prostaglandins administered vaginally and clinical follow-up without routine ultrasound.
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MEDICAL MANAGEMENT OF FIRST TRIMESTER MISCARRIAGE Many studies have been performed to investigate the best regimen for medical treatment of miscarriage. The optimal regimen is yet to be determined. Recent NICE guidance recommend that: For women with missed miscarriage, a single dose of 800 micrograms (oral or vaginal) of misoprostol seems to be the most effective regimen. For women with an incomplete miscarriage, the evidence suggests that a single dose of 600 micrograms of misoprostol is effective.
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MEDICAL MANAGEMENT OF FIRST TRIMESTER MISCARRIAGE For women with missed miscarriage, used at the same dose, both vaginal and oral routes of administration have similar effectiveness, and both are more effective than sublingual administration.
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SECOND TRIMESTER MEDICAL MANAGEMENT The optimal medical management of second trimester miscarriage continues to be debated. Medical induction of labour in the second trimester is a safe and effective alternative to dilation and evacuation, particularly in situations where fetal autopsy is desirable, due to patient’s preference, or more commonly, simply because of the lack of trained late dilation and evacuation providers.
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SECOND TRIMESTER MEDICAL MANAGEMENT Protocols using misoprostol with or without mifepristone appear to be safe and effective with minimal side effects. Vaginal and oral misoprostol are equally effective. Nynde et al compared oral and vaginal administration of 200 micrograms of misoprostol given 6 hourly for up to 4 doses. The induction to delivery time was significantly shorter in the vaginal group by nealry 8 hours.
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SECOND TRIMESTER MEDICAL MANAGEMENT  The dose of misoprostol needs to be modified according to the gestational age.
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SECOND TRIMESTER MEDICAL MANAGEMENT Although there is a large body of evidence on the use of misoprostol for first trimester miscarriage, the literature is scarce with regard to second trimester miscarriage. Thus the optimal regimen for management of second trimester miscarriage is yet to be determined.
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SECOND TRIMESTER MEDICAL MANAGEMENT The review by Gomez Ponce recommends the following regimen: Fetal demise from 13 to 17 weeks: vaginal misoprostol 200 micrograms every 6 to 12 hours for a total of 4 doses. If the first dose does not lead to effective contractions, the subsequent dose could be doubled to 400 micrograms. The maximum daily dose should not exceed 1600 micrograms.
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SECOND TRIMESTER MEDICAL MANAGEMENT Fetal demise from 18 to 26 weeks: Vaginal misoprostol 100 micrograms every 6 to 12 hours for a total of 4 doses. If the first dose does not lead to effective contractions the subsequent dose should be doubled to 200 micrograms. The maximum daily dosing should not exceed 800 micrograms.
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SECOND TRIMESTER MEDICAL MANAGEMENT Other methods for the management of second trimester miscarriage include: Extra-amniotic instillation of ethacridinelactate Intra cervical administration of PGE2 gel Intravenous infusion of concentrated oxytocin or Insertion of laminaria tents.
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SECOND TRIMESTER MEDICAL MANAGEMENT Traditionally, oxytocin has been the most commonly used induction agent at later gestational ages. However, oxytocin fails to induce labour effectively as a single-agent therapy at mid-trimester as the number of myometrial oxytocin receptors only increase significantly in the third trimester.
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PAIN CONTROL Abdominal pain is the most common adverse effect of the medical methods of managing miscarriage. In routine clinical practice, analgesia should be offered to all women. Most women have period-like cramps that can be very painful.
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PAIN CONTROL Pain is most likely to be felt in the first few hours after prostaglandin analogue administration. Studies have shown that analgesic requirements and the perception of pain are significantly higher in women of younger age and those at a higher gestational age, with a longer induction to expulsion of products interval and with a greater number of misoprostol doses.
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PAIN CONTROL  NSAIDs are a potential first-line treatment and do not appear to mitigate the action of misoprostol or mifepristone.
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OUTPATIENT MANAGEMENT Medical management can be undertaken successfully on an outpatient basis. Zhang et al reported that complications with misoprostol treatment occur at a rate of less than 1 in 70 treated patients thus suggesting that hospitalization of patients is unnecessary. Allowing women to go home soon after they have received misoprostol may therefore be a plausible option and incur less cost for the patient.
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OUTPATIENT MANAGEMENT  However it may not be feasible at an advanced gestational age where more than one dose of misoprostol and narcotic analgesics may be required.
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OUTPATIENT MANAGEMENT Medical management with misoprostol carries a risk of heavy bleeding in a small proportion of women. In a study done, 3% of women visited the gynaecology emergency units within 24 hours after treatment with misoprostol.
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OUTPATIENT MANAGEMENT  The Royal College of Obstetricians and Gynaecologists advice that expectant and medical management should be offered only in units where patients have access to 24 hour telephone advice and immediate admission can be arranged
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CONTRAINDICATIONS OF MEDICAL MANAGEMENT Suspected molar pregnancy Ectopic pregnancy or pregnancy of unknown location Haemodynamically unstable with significant anaemia ie Hb < 10 Uncontrolled severe asthma Chronic adrenal failure Known or suspected heart disease Glaucoma Haemoglobinopathies Haemorrhagic disorders and anti-coagulation therapy (aspirin accepted) Adrenal suppression and long term glucocorticoid therapy (may require corticosteroid) Patient living in remote areas with difficulty in accessing hospital
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CONCLUSION Expectant management – is an option to offer Medical management of miscarriage is a safe and effective way of miscarriage It is an alternative technique that complements but does not replace surgical management. Its availability has led to an improvement in choice for women who miscarry.
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THANKS FOR LISTENING