BACKGROUND: Little is known about the effectiveness of misoprostol treatment in women with early pregnancy failure who have been managed expectantly. We therefore performed a randomized trial on this subject. METHODS: Women with early pregnancy failure, who had been managed expectantly for at least 1 week, were assigned randomly (using a computer-generated list) to receive either vaginal misoprostol 800mg or curettage. If, after 24 h, there had not been complete evacuation, a further 800mg of misoprostol was administered. In the absence of complete evacuation after >3 days, curettage was performed. The primary end-point was the complete evacuation of the products of conception, with secondary end-points being the occurrence of side effects, pain intensity, need for analgesics, and intensity and duration of bleeding. RESULTS: In the misoprostol group, 47% (37/79) required curettage due to incomplete evacuation. After 1 week, evacuation was complete in 85% (67 out of 79) of the misoprostol group and 93% (70 out of 75) of the curettage group. Severity of pain, bleeding and emergency evacuation was higher in the misoprostol group. The complication rate was 0% for misoprostol and 4% for curettage. CONCLUSIONS: Curettage is superior to misoprostol in the evacuation of early pregnancy failure after failed expectant management. However, misoprostol could be clinically useful since it reduces the need for curettage by half and has a lower complication rate, at the expense of increased pain, vaginal bleeding and emergency evacuation.

Misoprostol versus curettage in women with early pregnancy failure after initial expectant management: A randomized trial

Approximately one of five pregnant women will experience bleeding during the first trimester of pregnancy. Of these women, about half will go on to have a spontaneous abortion. Comfort with triaging this common problem assists the midwife in providing quality, cost-effective care without eliminating continuity. This article reviews the causes of early pregnancy bleeding, offers strategies to differentiate between these causes, and identifies emergent from nonemergent presentations. Triage and management strategies for women with an impending or threatened spontaneous abortion are reviewed, exploring the alternative of expectant management.

Midwifery triage of first trimester bleeding.

The pharmacological management of early pregnancy loss reduced substantially the need for dilation and curettage. However, prognostic markers of successful outcome were not established. Thus the major purpose of this study was to determine the sensitivity and specificity of the uterine artery pulsatility (PI) and resistance (RI) indices to detect early pregnancy loss patients requiring dilation and curettage after unsuccessful management. A cohort prospective observational study was undertaken to include women with early pregnancy loss, ≤ 12 weeks of gestation, managed with mifepristone (200 mg) and misoprostol (1600 μg) followed by PI and RI evaluation of both uterine arteries 2 weeks after. At this time, in 173/315 patients, incomplete miscarriage was diagnosed. Among them, 32 underwent uterine dilatation and curettage at 8 weeks of follow-up. The cut-off points for the uterine artery PI and RI, leading to the maximum values of sensitivity (69.5%, CI95%: 61.5%-76.5% and 75.0%, CI95%: 57.9%-86.8%, respectively) and specificity (75.0%, CI95%: 57.9%-86.8% and 65.6%, CI95%: 48.3%-79.6%, respectively), for the discrimination between the women who needed curettage from those who resolved spontaneously were 2.8 and 1, respectively. The potential usefulness of uterine artery Doppler evaluation to predict the need for uterine curettage in patients submitted to medical treatment for early pregnancy loss was demonstrated.

/pdf/uterine-artery-doppler-in-the-management-of-early-pregnancy-38ir2yiilr.pdf

Uterine artery Doppler in the management of early pregnancy loss: a prospective, longitudinal study

SummaryWe report a prospective study to determine the efficacy and acceptability of two mifepristone regimens administered in combination with misoprostol for the management of missed abortion. Fifty women each received 400 mg or 600 mg of mifepristone followed 48 hours later by 600 μg of misoprostol if abortion had not already occurred. There was no difference in efficacy between the two mifepristone regimens. Overall 34 (68 per cent) aborted successfully although 11 (32 per cent) were troubled by haemorrhage or pain, particularly when the abortion occurred at home before misoprostol. The remaining 16 (32 per cent) required surgical evacuation of the uterus. Thirty-one women who aborted medically attended for review; 13 of these (42 per cent) would opt for surgical management should a similar event arise in the future. Medical management offers an additional option in missed abortion, but women should be warned of possible complications and advised that the failure rate may be higher than previous report...

The efficacy and acceptability of managing missed abortion medically

SummaryThe results of the first 67 women who chose a medical termination of an early pregnancy after the introduction of the service in East Somerset are presented The initial failure rate of the technique was 35 per cent in the first year Failure was defined as needing surgical intervention The failure rate dropped to 8 percent as clinicians became familiar with the procedure Reasons for the unacceptably high failure rate are discussed and advice is offered to units considering offering this service

Medical termination of pregnancy in a district general hospital

EDrroR,-I am evaluating the factors that contributed to the delay in the recognition and acknowledgment of the health hazard of exposure to asbetos dust and the consequent delay in the implementation of effective intervention. Scientists have had an important role in this history and in the study of dose-response relations-none more pominently than the members of the subcommittee on asbetos of the British Occupational Hygiene Society. The society's reports and related literature show that an account would be incomplete without a review of the data handled by members of this committee and of the details of their methods of working and decision making. This can be found only in their working papers, correspondence, and minutes, which extend over a quarter of a century. In May 1990 I wrote to the president of the British Occupational Hygiene Society, requesting access to the files of the committee on asbestos. The reply stated that this was not possible on two counts: that there was no central archive and that much of the material had been made available on a confidential basis and it would not be acceptable for later councils to break that confidence. I wrote more recently to the society, requesting its permission for access to files containing its records that were preserved elsewhere, but I was informed that the society is still unable to allow anyone access to these data. If commercial confidentiality ever applied to the data it must have lapsed after some 20 years and more. Medical confidentiality would never have applied to data from which individual subjects could notbe identified. This experience raises certain matters of principle in relation to scientific work and publication. Should it be a condition that data and analyses that have formed the basis of a publication be preserved and kept accessible for further study? What constraints of confidentiality are unacceptable in the field of scientific publication? If the accessibility of data constitutes part of the scientific ethic whose ultimate responsibility is it to ensure this-the author's or the editor's?

https://www.bmj.com/content/bmj/307/6898/259.2.full.pdf

Management of uncomplicated miscarriage. Randomized trials are possible.

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Management of uncomplicated miscarriage. Randomized trials are possible.