Vaginal misoprostol corrected missed abortion in small study

OB/GYN News, July 1, 2002 by Betsy Bates

LOS ANGELES -- A single 800-[micro]g dose of vaginal misoprostol resulted in successful outpatient treatment of missed abortion in 21 of 28 women within 24 hours, lending credence to the notion that medical management could become a safe alternative to surgery for many women.

An initial 800-[micro]g dose was five times more likely than a 400-[micro]g dose of misoprostol to be successful in medically managing missed abortion on an outpatient basis, according to Dr. Michael J. Heard of Baylor College of Medicine, Houston.

Currently, early pregnancy failures are often treated by dilatation and curettage, a surgical procedure that poses certain risks, including hemorrhage, uterine perforation, cervical tears, retained products of conception, and infection. Outpatient management would be more convenient, less expensive, and arguably safer for patients, Dr. Heard said in an interview at the annual meeting of the American College of Obstetricians and Gynecologists, where his study was presented in poster form.

Researchers evaluated use of vaginal misoprostol in 49 women, each of whom met eligibility criteria that included absence of fetal cardiac activity, a gestational age of 8 weeks or less, a closed cervical os, and minimal vaginal bleeding.

Women were randomly assigned to receive either a single 400-[micro]g dose or a single 800-[micro]g dose of vaginal misoprostol. They returned in 24 hours to fill out a questionnaire and undergo an ultrasound and pelvic examination. Those who had not successfully passed the gestational sac were given a second dose of misoprostol in an identical dosage to the first they received.

Among 21 women who received the 400-[micro]g dose, 8 (38%) passed the products of conception within 24 hours, and 4 more were successful within 24 hours of a second dose.

At the higher dose, 21 of 28 (75%) women passed the products of conception within the first day. Two more women were successful after a second dose. One woman in the high-dose group presented to the emergency room approximately 8 hours after receiving the initial dose and was diagnosed with an incomplete abortion and dehydration. A suction curettage was performed, he said.

On average, women who received the 800-[micro]g dose of misoprostol were more likely to require prescription pain medication for moderate to severe cramping but reported less bleeding than those who received a 400-[micro]g dose.

Those patients who failed to expel the products of conception after receiving misoprostol twice over 2 days were offered a choice of expectant management or suction curettage.

The success rate after an initial failed dose was equal in both dosage groups, but side effects were higher in the high-dose cohort. Dr. Heard said that a 400-[micro]g dose might be the better option for a second dose once an 800-[micro]g dose has failed.

The use of misoprostol for missed abortion has been studied quite extensively worldwide, although Searle, the company that manufactures the drug, has not funded research for that indication.

He added that office management of missed abortion can be both effective and efficient. Women can be advised to take an over-the-counter pain reliever before introducing the medication into their vaginas at 6 a.m. on a weekday. This way, if complications develop or the products of conception are expelled, they can be seen during office hours. They are given a prescription for a narcotic pain reliever to be taken if severe cramping occurs.