Treatment of early miscarriage with the drug misoprostol is a safe and effective alternative to a surgical technique called vacuum aspiration, according to a recent study. Although misoprostol has been used in the treatment of miscarriage for a number of years, there has never been a randomized study on its use in this regard, until now. The study results were published in the New England Journal of Medicine.
Early miscarriage is the loss of a baby in the first trimester of pregnancy. Miscarriage occurs in at least a quarter of all pregnancies. Approximately one in four women will have a miscarriage at some time in their lives.
Miscarriage does not usually happen all at once. "In most cases, the fertilized egg fails to develop properly. It takes a while for the woman's body to be sure that the pregnancy is not progressing properly and start the process of expulsion," says Dr. Nicolette Caccia, an obstetrician and gynaecologist at The Hospital for Sick Children. Sometimes it takes time for all the contents of the womb to come out. A number of women may have what is called an incomplete miscarriage, where remnants of the pregnancy remain in the womb, leading to increased bleeding and possible infection.
When a woman has a miscarriage, she has the option of waiting for the contents of her womb to come out naturally, or to have the cervix stretched and a vacuum aspiration to clear out the womb. This procedure is also called a dilatation & curettage (D&C). Many women are uncertain and anxious about waiting for nature to take its course, and others who do wait may still end up having very heavy bleeding or an incomplete miscarriage. As a result, vacuum aspiration has become a commonly accepted approach to the management of miscarriage.
The ulcer drug misoprostol, when inserted vaginally, is able to soften, thin, and relax the cervix. "[Misoprostol] also encourages the womb to contract to expel the failed pregnancy," says Dr. Caccia. As a result, over the last 10 years, misoprostol has been used as an alternative way to help clear out the womb during a first-trimester miscarriage.
The use of misoprostol in this fashion is done on an "off-label" basis, and is not approved by government regulatory agencies. This is largely because the pharmaceutical industry has not looked into the use of misoprostol for obstetrical purposes. As a result, many previous studies have been small. The current study is the first multicentre, randomized trial comparing misoprostol to vacuum aspiration in the treatment of miscarriage.
In the study, 652 women with a first-trimester miscarriage were randomly assigned to receive either 800 mg misoprostol vaginally or vacuum aspiration. Most women in the vacuum aspiration group received the procedure on the first day their miscarriage was diagnosed; some received it on day two or later. The women in the misoprostol group were given a first dose of the drug on the day the miscarriage was diagnosed; a second dose was given two days later if the miscarriage was not yet complete. If women in the misoprostol group still did not have a complete clearing of the womb after a week, vacuum aspiration was performed. All women in both treatment groups received follow-ups at two weeks and one month.
In the misoprostol group, 71% of women had complete clearing of their womb with one dose of misoprostol; which rose to 84% with a second dose. Vacuum aspiration was required in 16% of the misoprostol group.
In the vacuum aspiration group, 90% of women had a complete clearing of the womb by day 15 and 97% by day 30. A repeat vacuum aspiration was needed in 3% of the women in this group.
The rates of complications such as fever, infection, and excessive bleeding, and emergency room visits, were very low and similar between the two types of treatment. Women who were given misoprostol had approximately twice the incidence of nausea, vomiting, and diarrhea, compared with those who received vacuum aspiration, but these side effects were considered tolerable. Eighty-three per cent of women in the misoprostol group said they would recommend the treatment to other women.
The study concluded that treatment of first-trimester miscarriage with misoprostol, with a second dose inserted after 48 hours if necessary, is effective and safe. Misoprostol is an acceptable alternative to vacuum aspiration for most women, and many women prefer the use of misoprostol over surgery.
For more information about Miscarriage, see the Pregnancy Loss section of our Pregnancy & Babies Resource Centre.
Sherene Chen-See
Writer/editor
AboutKidsHealth