Medical termination of missed abortion

The role of mifepristone on first trimester miscarriage treatment - A double-blind randomized controlled trial - MiFirsT

OBJECTIVES

To evaluate the efficacy of combined mifepristone and misoprostol compared to misoprostol alone in outpatient medical treatment of first trimester miscarriage. Additionally, the study intends to compare the rate of complications, adverse effects, and treatment acceptability between groups.

STUDY DESIGN

Single-center double-blind randomized placebo-controlled trial including women with diagnosis of missed first trimester miscarriage up to 9 weeks of gestation.

RESULTS

Between April 2019 and November 2021, 216 women diagnosed with first trimester miscarriage up to 9 weeks of gestation were randomly assigned to mifepristone group or to misoprostol-alone group. Data from 105 women in mifepristone group and 103 women in misoprostol-alone group were analyzed, with no differences in baseline characteristics. The median time between medications (oral mifepristone/placebo and vaginal misoprostol) was nearly 43 h in both groups (p = 0.906). The median time to first follow-up was 2.6 weeks (IQR 1.0) in mifepristone group and 2.4 weeks (IQR 1.0) in misoprostol-alone group (p = 0.855). The overall success rate of medical treatment was significantly higher in the mifepristone-group comparing to misoprostol-alone group (94.3% vs. 82.5%, RR 1.14, 95% CI, 1.03-1.26; p = 0.008). Accordingly, the rate of surgical treatment was significantly lower in the mifepristone-group (5.7% vs.14.6%, RR 0.39, 95% CI, 0.16-0.97; p = 0.034). The composite complication rate was similar and lower than 4% in both groups. No case of complicated pelvic infection, hemodynamic instability or inpatient supportive treatment was reported. There were no significant differences in the rates of adverse events, median score for vaginal bleeding intensity or analgesics use. Despite the same median value, the score of abdominal pain intensity was significantly higher in the mifepristone-group (p = 0.011). In both groups, more than 65% of the women classified the treatment as "good" and 92% would recommend it to a friend on the same clinical situation.

CONCLUSION

The mifepristone plus vaginal misoprostol combined treatment for medical resolution of first trimester miscarriage resulted in significant higher success rate and lower rate of surgical uterine evacuation comparing to misoprostol-alone treatment, with no relevant differences in adverse events or treatment acceptability.

Pigment epithelium‑derived factor facilitates NLRP3 inflammasome activation through downregulating cytidine monophosphate kinase 2: A potential treatment strategy for missed abortion

A number of conditions may underlie the occurrence of missed abortion (MA), including inflammation. Pigment epithelium‑derived factor (PEDF) is a novel mediator of the inflammation‑related nucleotide‑binding oligomerization domain‑like receptor protein 3 (NLRP3) inflammasome, which is associated with several human diseases. However, the association between MA and NLRP3 inflammasome, and whether PEDF is reduced in MA, remain unknown. In the present study, the decidua and chorion tissues of patients who had suffered a MA were examined, and a lipopolysaccharide (LPS)‑induced human chorionic trophoblast HTR8/SVneo cell model was established to mimic MA in vitro. The results revealed that cytidine monophosphate kinase 2 (CMPK2) expression and NLRP3 inflammasome activation, downstream pro‑IL‑18 and pro‑IL‑1β expression, and IL‑18 and IL‑1β release, were all significantly increased in MA tissues or LPS‑induced HTR8/SVneo cells. PEDF reversed the increase in CMPK2 expression and activation of the NLRP3 inflammasome axis and, thus, downregulated the production of mitochondrial reactive oxygen species and mitochondrial DNA release, resulting in reduced lactate dehydrogenase release, and a resultant decrease in cell viability. Recovery of CMPK2 expression abolished all the effects of PEDF, indicating that CMPK2 may be an effector downstream of PEDF. PEDF reduced CMPK2 protein levels but did not affect the mRNA levels, and treatment with the proteasomal inhibitor MG132 significantly reversed this reduction in CMPK2 protein levels. Furthermore, a ubiquitination assay of immunoprecipitation demonstrated that CMPK2 was polyubiquitinated in the presence of LPS, PEDF and MG132. These results indicated that the NLRP3 inflammasome is implicated in the pathogenesis of MA, and PEDF may reduce MA through ubiquitin‑dependent proteasomal degradation of CMPK2 to inhibit NLRP3 activation, which may serve as a novel strategy for preventing or reducing the risk of MA.

Mifepristone Pretreatment for the Medical Management of Early Pregnancy Loss

BACKGROUND

Medical management of early pregnancy loss is an alternative to uterine aspiration, but standard medical treatment with misoprostol commonly results in treatment failure. We compared the efficacy and safety of pretreatment with mifepristone followed by treatment with misoprostol with the efficacy and safety of misoprostol use alone for the management of early pregnancy loss.

METHODS

We randomly assigned 300 women who had an anembryonic gestation or in whom embryonic or fetal death was confirmed to receive pretreatment with 200 mg of mifepristone, administered orally, followed by 800 μg of misoprostol, administered vaginally (mifepristone-pretreatment group), or 800 μg of misoprostol alone, administered vaginally (misoprostol-alone group). Participants returned 1 to 4 days after misoprostol use for evaluation, including ultrasound examination, by an investigator who was unaware of the treatment-group assignments. Women in whom the gestational sac was not expelled were offered expectant management, a second dose of misoprostol, or uterine aspiration. We followed all participants for 30 days after randomization. Our primary outcome was gestational sac expulsion with one dose of misoprostol by the first follow-up visit and no additional intervention within 30 days after treatment.

RESULTS

Complete expulsion after one dose of misoprostol occurred in 124 of 148 women (83.8%; 95% confidence interval [CI], 76.8 to 89.3) in the mifepristone-pretreatment group and in 100 of 149 women (67.1%; 95% CI, 59.0 to 74.6) in the misoprostol-alone group (relative risk, 1.25; 95% CI, 1.09 to 1.43). Uterine aspiration was performed less frequently in the mifepristone-pretreatment group than in the misoprostol-alone group (8.8% vs. 23.5%; relative risk, 0.37; 95% CI, 0.21 to 0.68). Bleeding that resulted in blood transfusion occurred in 2.0% of the women in the mifepristone-pretreatment group and in 0.7% of the women in the misoprostol-alone group (P=0.31); pelvic infection was diagnosed in 1.3% of the women in each group.

CONCLUSIONS

Pretreatment with mifepristone followed by treatment with misoprostol resulted in a higher likelihood of successful management of first-trimester pregnancy loss than treatment with misoprostol alone. (Funded by the National Institute of Child Health and Human Development; PreFaiR ClinicalTrials.gov number, NCT02012491 .).

Misoprostol for medical treatment of missed abortion: a systematic review and network meta-analysis

The efficacy and safety of misoprostol alone for missed abortion varied with different regimens. To evaluate existing evidence for the medical management of missed abortion using misoprostol, we undertook a comprehensive review and meta-analysis. The electronic literature search was conducted using PubMed, the Cochrane Library, Embase, EBSCOhost Online Research Databases, Springer Link, ScienceDirect, Web of Science, Ovid Medline and Google Scholar. 18 studies of 1802 participants were included in our analysis. Compared with vaginal misoprostol of 800 ug or sublingual misoprostol of 600 ug, lower-dose regimens (200 ug or 400 ug) by any route of administration tend to be significantly less effective in producing abortion within about 24 hours. In terms of efficacy, the most effective treatment was sublingual misoprostol of 600 ug and the least effective was oral misoprostol of 400 ug. In terms of tolerability, vaginal misoprostol of 400 ug was reported with fewer side effects and sublingual misoprostol of 600 ug was reported with more side effects. Misoprostol is a non-invasive, effective medical method for completion of abortion in missed abortion. Sublingual misoprostol of 600 ug or vaginal misoprostol of 800 ug may be a good choice for the first dose. The ideal dose and medication interval of misoprostol however needs to be further researched.

Comparison Between Sublingual and Vaginal Administration of Misoprostol in Management of Missed Abortion

AIM

The aim of the present study is to compare between sublingual administration of misoprostol and vaginal administration in the management of missed abortion.

MATERIALS AND METHODS

The study was conducted in El-Shatby Maternity Hospital on 160 patients diagnosed as missed abortion by ultrasonographic examination. Cases were divided into two groups according to the methods of misoprostol administration, whether sublingual or vaginal. Patients of the two groups were observed for the times of uterine colic starting, cervical dilation, and conceptus expulsion, along with recording of any side effects.

RESULT

During the follow-up of our cases we found that sublingual route is more effective than vaginal route in the management of missed abortion. The difference between the two groups in percentage of conceptus expulsion was statistically significant. The most common side effects were nausea which was present in 55 % of cases in group I (sublingual) and in 40 % of cases in group II (vaginal) then severe pain in 25 % of cases in group I (sublingual) and in 20 % of cases in group II (vaginal) and hyperpyrexia in 15 % of cases in group I (sublingual) and in 5 % of cases in group II (vaginal).

CONCLUSION

Sublingual administration of misoprostol is more effective than its vaginal administration in missed abortion management. Side effect of misoprostol as nausea, vomiting, fever is more common with sublingual administration in comparison with its vaginal administration.

Misoprostol treatment for early pregnancy failure does not impair future fertility

AIMS

To examine whether misoprostol treatment for first trimester missed abortion affects future fertility.

PATIENTS AND METHODS

In a historical prospective approach, we analyzed our database for patients treated with misoprostol. All eligible patients underwent an interview according to a questionnaire, which includes their demographic characteristics, obstetric, gynecologic and infertility history. They were asked about the side effects, intention and subsequent ability to conceive. Their future pregnancy rates were calculated and compared to the acceptable figures in the literature.

RESULTS

The infertility rates among our patients were similar to those reported in the general population. Pregnancy rates 2 years after treatment were similar to the previously published reports, except for lower rates during the first three months post-treatment. Although no between-group differences were observed in the subsequent pregnancy rates, 2 years following misoprostol treatment in ≤35 versus >35 years old patients, primi- versus multigravida and nulli- versus parous women, higher pregnancy rates were observed in patients ≤35 versus >35 years old, primi- versus multigravida and nulli- versus, parous, during the first 3 months following misoprostol treatment.

CONCLUSION

Misoprostol treatment, for women with first trimester missed abortion and favorable reproductive history, is an acceptable treatment with no detrimental effect on future fertility.

Mifepristone and misoprostol for early pregnancy failure: a cohort analysis

OBJECTIVE

We sought to examine outcomes of mifepristone and misoprostol for early pregnancy failure (EPF) treatment in a nonresearch setting.

STUDY DESIGN

A protocol was developed for physicians to use mifepristone 200 mg orally and misoprostol 800 μg vaginally for EPF. Success rates were analyzed and an adjusted multivariable regression was used to identify factors predictive of success.

RESULTS

Treatment success occurred in 99 (80%; 95% confidence interval, 72-87%) of 123 patients after mifepristone and a single dose of misoprostol and 102 (83%; 95% confidence interval, 75-89%) patients overall. The odds of successful medical treatment were increased in women with a diagnosis of intrauterine embryonic/fetal demise (odds ratio, 3.80) and decreased in women who made additional emergency department visits (odds ratio, 0.12).

CONCLUSION

Patients and clinicians may be more likely to intervene surgically with an EPF when a strict study protocol is not being followed.

A Study of Efficacy of Misoprostol in Missed Abortion

BACKGROUND

Missed abortion is a common emergency where uterine evacuation is performed by surgical means.

METHOD

A total of 30 patients were included in this study to evaluate the efficacy of tablet misoprostol for uterine evacuation in cases of missed abortion. The gestational age ranged from 8-22 weeks. 21 out of 30 patients were primigravidae and the rest multigravidae. Tablet misoprostol (200mcg) was applied vaginally in the posterior fornix every eight hours to a maximum of five tablets. Success rate, complications and side effects were the main outcome measures.

RESULTS

The procedure was successful in all cases. Two out of 30 cases required check curettage. Gastrointestinal side effects like vomiting and diarrhoea were seen in few cases.

CONCLUSION

The use of tablet misoprostol is effective for uterine evacuation in cases of missed abortion.

Bleeding patterns after misoprostol vs surgical treatment of early pregnancy failure: results from a randomized trial

OBJECTIVE

The purpose of this study was to describe bleeding patterns after misoprostol or curettage for early pregnancy failure (EPF).

STUDY DESIGN

This was a randomized trial that included women (n = 652) with EPF. Participants were assigned to vaginal misoprostol (800 microg) or curettage in a 3:1 ratio. Participants completed a bleeding diary. We measured hemoglobin levels at baseline and 2 weeks after the treatment.

RESULTS

Decreases in hemoglobin levels were greater after misoprostol (-0.7 g/dL; SD, 1.2) than curettage (-0.2 g/dL; SD, 0.9; P < .001). Large changes in hemoglobin levels (at least 2 g/dL) or low nadir hemoglobin levels (< 10 g/dL) were more frequent after misoprostol (55/428 women; 12.8%) than after curettage (6/135 women; 4.4%; P = .02). More participants in the misoprostol group reported "any bleeding" or "heavy bleeding" every study day. Four women who were treated with misoprostol required blood transfusion.

CONCLUSION

Bleeding is heavier and more prolonged after medical treatment with misoprostol than with curettage for EPF; however, bleeding rarely requires intervention.

Mifepristone and misoprostol for the treatment of early pregnancy failure: a pilot clinical trial

BACKGROUND

In an attempt to improve efficacy for women who desire medical management of early pregnancy failure (EPF), we studied the efficacy and acceptability of mifepristone 200 mg, orally (po), followed 24 h later by misoprostol 800 microg, vaginally (pv), for the treatment of EPF.

METHODS

We enrolled 30 women with EPF in this pilot clinical trial. All women used misoprostol 800 microg, pv, 24 h after ingesting 200 mg mifepristone. Follow-up evaluations with transvaginal ultrasonography occurred at 24 h and 1 week after treatment. Participants were offered a repeat dose of misoprostol if the pregnancy had not been expelled at the first follow-up.

RESULTS

The expulsion rate with one dose of misoprostol was 90% (95% CI=79-100%). The overall success rate of the treatment was 93% (95% CI=84-100%).

CONCLUSION

This regimen of mifepristone followed by vaginal misoprostol appears to be an efficacious and acceptable treatment for EPF and may have improved results over a single dose of misoprostol alone.

Mifepristone-induced nitric oxide release and expression of nitric oxide synthases in the human cervix during early pregnancy

BACKGROUND

Nitric oxide (NO) is a factor in cervical ripening, perhaps under the control of progesterone. We studied the effects of the antiprogesterone mifepristone on the release of NO and on the expression of inducible NO synthase (iNOS) and endothelial NO synthase (eNOS) in the uterine cervix of women in early pregnancy.

METHODS

Thirteen women were treated with oral mifepristone (200 mg), and 15 women were studied as controls. Cervical fluid samples were collected before treatment then hourly up to 3 h, and the samples were assayed for the concentration of nitric oxide metabolites (NOx). In addition, cervical biopsy samples from six women treated with mifepristone and from six controls were assessed for iNOS and eNOS by immunohistochemistry and Western blotting.

RESULTS

In 1-3 h, mifepristone induced 7.4- to 17.2-fold elevations in cervical fluid NOx concentrations; no change was seen in the controls. The expression of both iNOS and eNOS was detected in the cervical cells. The expression of cervical iNOS was strong in five of the six women treated with mifepristone but was not strong in any of the six control women.

CONCLUSION

This is the first study to show that mifepristone stimulates the release of NO and the expression of iNOS in cervical cells of women in early pregnancy. This may be one mechanism by which mifepristone initiates cervical ripening.

Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis

OBJECTIVE

To quantify the relative benefits and harms of different management options for first-trimester miscarriage.

DATA SOURCES

MEDLINE, EMBASE, and Cochrane Controlled Trials Register searches (1966 to July 2004), including references of retrieved articles.

METHODS OF STUDY SELECTION

Randomized trials assigning women with first-trimester missed or incomplete miscarriage to surgical, medical, or expectant management were included. Primary outcomes were successful treatment and patient satisfaction. Secondary outcomes included moderate or severe bleeding, blood transfusion, emergency curettage, pelvic inflammatory disease, nausea, vomiting, and diarrhea. Comparisons used the risk difference. Between-study heterogeneity and random effects summary estimates were calculated.

TABULATION, INTEGRATION, AND RESULTS

Complete evacuation of the uterus was significantly more common with surgical than medical management (risk difference 32.8%, number needed to treat 3, success rate of medical management 62%) and with medical than expectant management (risk difference 49.7%, number needed to treat 2). Success rate with expectant management was spuriously low (39%) in the latter comparison. Analysis of cases with incomplete miscarriage only showed that medical management still had two thirds the chance to induce complete evacuation compared with surgical management, but it was better than expectant management. Data from studies that evaluated outcome at 48 hours or more after allocation indicated again that medical management had a better success rate than expectant management but a worse success rate than surgical management; expectant management probably had much lower success rates than surgical evacuation, but data were very sparse. Patient satisfaction data were sparse. Moderate or severe bleeding was less common with medical than expectant management (risk difference 3.2%) and possibly surgical management (risk difference 2.1%). There was a considerable amount of missing information, in particular for secondary outcomes.

CONCLUSION

One additional success can be achieved among 3 women treated surgically rather than medically. Expectant management has had remarkably variable success rates across these studies, depending probably on the type of miscarriage. Greater standardization of outcomes should be a goal of future research.

The role of ultrasound in pregnancy-related emergencies

Most complications of pregnancy allow time for transfer to specialized obstetric ultrasound units, but many women present to the emergency room or the labor and delivery unit with signs and symptoms suggesting genuine acute medical emergencies, where successful outcome depends on prompt diagnosis of the disorder and rapid appropriate medical management. The use of ultrasound technology in obstetric emergencies is well established. Ultrasonography plays a major role in such cases as the most important tool clinicians are using to identify the correct etiology and diagnosis, whereas in other cases it helps limit the differential diagnosis. One of the goals of any advanced training program in obstetrics and gynecology and radiology is to allow the skilled physician to perform the proper ultrasound study in case of an obstetric emergency to facilitate the proper diagnosis, enabling the medical team to provide the best possible care.