Missed Abortion and Application of Misoprostol

Missed Abortion and Application of

Misoprostol
Fehmi Zeqiri, Myrvete Paarada, Niltene Kongjeli, Vlora Zeqiri, Gyltene Kongjeli
Gynecology/Obstetrics Clinic, University Clinical Centre of Kosova, Prishtina, Kosovo

Original paper
SUMMARY
Background: Spontaneous abortion is categorized
as threatened, inevitable, incomplete, complete,
or missed. Abortion can be further categorized as
sporadic or recurrent. By definition, a missed abortion is an in utero death of the embryo or fetus before
the 20th week of gestation with retained conception
products. Missed abortions may also be referred
to as blighted ovum or an anembryonic pregnancy.
Materials and methods: A prospective-pathological
analysis of 100 missed abortion pregnancies that
were diagnosed and treated at the obstetricsgynecology clinic in Pristina were included. Patients
were analyzed based on age, parity, gestational age,
method of misoprostol application, effective duration
from the moment of application to abortion, and
adverse effects from applying misoprostol. Results:

In 25 (25%) pregnancies (15 at the end of week 10

pregnant Vlll and IX of the week until the end of the
week XII) one tablet of misoprostol was applied to
the rear vaginal fornix for 3 h, and the effect was
achieved in a mean of 10 h for the first group, while
it was achieved in 11 h in the second group. Thus, the
average efficiency was 10.5h. After applying three
tablets of misoprostol to the rear vaginal fornix,
11 abortions occurred (44%), with the use of four
tablets seven (28%) aborted, and with five tablets
three (12%) aborted. There was average bleeding in
60 (67.41%) aborted pregnancies, and bleeding of
the package in 15 (16.85%). Conclusion: Administration of misoprostol to women with a missed abortion
produced spontaneous expulsion and reduced the
need for surgical treatment.
Key words: missed abortion, Misoprostol.

Corresponding author: Fermi Zeqiri, MD, Ph.D. Gynecology/Obstetrics Clinic, University Clinical Centre of
Kosovo, 10 000 Prishtina, Phone: +377 44 17 34 92, E-mail: fehmizeqiri@gmail.com

1. Introduction
Spontaneous abortion is categorized as threatened, inevitable, incomplete, complete, or missed. Abortion
can be categorized further as sporadic
or recurrent. By definition, a missed
abortion is an in utero death of the
embryo or fetus before the 20th week
of gestation with retained conception
products. Missed abortions also may
be referred to as blighted ovum, anembryonic pregnancy, or fetal demise (1).
Causes of missed abortion are generally the same as those causing spontaneous abortions or early pregnancy
failure and include anembryonic gestation (blighted ovum), fetal chromosomal abnormalities, maternal disease,
embryonic anomalies, placental abnormalities, and uterine anomalies. Virtually all spontaneous abortions are preceded by a missed abortion. A rare ex-

ception is expulsion of a normal foetus

because of a uterine abnormality (2).
An ultrasound diagnosis of a dead
fetus during early pregnancy is based
on the absence of movements of the
fetal heart. Movements of a dead fetus
are a result of passive fluctuation. Secondary changes in the dead fetus may
occur later and indicate a complication
of pregnancy. All of these depend on
the time that passes from the moment
of intrauterine death until the moment
of diagnosis (3).
If a dead fetus remains in the womb
for a long time then followed with clinical bleeding tendency emptying scarce
with the burden of uterine pathology
spontaneously.
However, in rare cases a spontaneous abortion may not occur after the
death of the fetus. Several weeks after
death, trophoblastic substances seep

into the maternal circulation and may

cause intravascular clotting dissemination, so maternal blood fibrinogen levels should be checked (4).
Evacuation of a missed abortion
should be performed only if the maternal blood fibrinogen level is greater
than 1 g /L. This can be achieved with
parenteral fibrinogen or heparin, which
prevents further coagulation and allows
intravascular improvement in fibrinogen values.
Currently, pregnancy termination is
mainly performed by so-called drug curettage using misoprostol (5). Cytotec is
a synthetic analog of E1-featured prostaglandins that can be administered at
any time during the pregnancy, but its
effectiveness is best in early termination
of pregnancies at no later than week 12
(6). The Cytotec administration modes
in these cases are sublingual, vaginal, or
combined. Complete removal of uterine cavity products may be delayed after applying misoprostol.
Vaginal application is more difficult
than oral application, and many countries hesitate to use misoprostol vaginally for social and religious reasons.
Although the surgical curettage efficiency is 98%, the possibility of complications such as pelvic infection after abortion, a performing uterus, injury of the neck, and Ashermans syndrome favor a medical method for pregnancy termination in the first quarter
of the load.
The purpose of this study:
This study analyzed the priority for
applying misoprostol for a missed abortion, success in application, method of
application, optimal misoprostol effi-

MED ARH 2010; 64(3) Original papers

151

Missed Abortion and Application of Misoprostol

this week XII. The misoprostol efficacy

of sublingual use was 90.6%.

Cases
Regarding the misoprostol impact
of our research in termination of pregResults
nancy appears that from his application
1 tablet of
Rear vaginal
misoprostol
in Of the 100 pregnancies, 89 (89%) re25
10.5
21
4
84%
In both 16%
groups of pregnant women, misoprostol was administered sublingually or in th
fornix
every (h)
sulted in termination, while 11 (11%)
3h
rear of the vaginal fornix.
In 25 (25%)
of the
pregnancies
(15 pregnant at the end of we
women
did not
react
to the misoprostol.
tablet of
On
Figure
3
and
4.
is
presentation
Sublingual
misoprostol
10) one9.33%
tablet of misoprostol was applied to the rear vaginal fornix for 3 h, and the effe
11.75
68
7
90.6%
75
of all cases administered misoprostol in
every
2h
was achieved after 10 hthe
in the
firstfornix
group, while
the vagina
effect wasand
recognized
rear
of the
sub- in the second
lingually. The general efficacy of misoTable 1. The two misoprostol application methods and the results obtained
group after 11 h.
prostol was 89%.
ciency after application, and basic difto the rear vaginal fornix, 11 pregnanWe applied misoprostol during the
ferences in management. Misoproscies were aborted (44%), with the use
first pregnancy in 25 pregnant women.
The seven
averagewere
efficiency
10.5 hefficiency
(Fig. 1). After
applying
three tablets
tol actions were analyzed in primipara
of four misoprostol tablets
Thewas
average
time for
sublinand multipara pregnant women, and
aborted (28%), and with five tablets
gual and vaginal use was 9.3 h after adfornix, 11 pregnancies
were aborted
(44%),
with the tablets,
use of four misopr
the side effects and preference for surthree were aborted (12%).
ministering
three
misoprostol
gical curettage were evaluated.
From this, it appears that in 25 pregwhile in 64 second pregnancies the avwere aborted (28%), and with five tablets three were aborted (12%).
nant with missed abortion efficiency
erage efficiency time was 11.4 h with
2. Materials and methods
has been pregnant 21 or From this, it appears that in 25 pregnant with missed abortion efficie
One-hundred missed-abortion
84%. While application 11 h
pregnancies who were diagnosed and
of 5 misoprostol tabletspregnant
in the
11
21 or 84%. While application of 5 eApplication
misoprostol
tablets not have
rear vaginal fornix
treated at the obstetric-gynecology
not have aborted 4 of 10.9
until the end of
clinic in Pristina were included. Pathem (16%), these werethem10.8
(16%), these were 2 with gestative ageweek
end 8.of the week that VIII,
tients were analyzed based on age, par2 with gestative age end 10.7
in the
10.6 by the beginning of the week IX toApplication
ity, gestational age, method of misoof the week that VIII,pregnant
XIIvaginal
weekfornix
end. This was su
rear
10.5
prostol application, the effective durawhile 2 have been preguntil the end of
10.4
12.
the vacuum
cavity followe
tion from the moment of application to
nant by the beginning ofbeen done in four pregnancies aspirations ofweek
10.3
abortion, and adverse effects from apthe week IX to XII week 10.2
plying misoprostol.
end. This was supposedcurettage.
1
The patients ranged in age from 18
to be have been done in Figure 1. Average efficiency for the misoprostol time of application to
to 42 years. We divided the patients into
four pregnancies aspira- the rear vaginal fornix in both groups of pregnant woman.
two groups based on gestational week.
tions of the vacuum cavThe first group included pregnancies
ity followed by a uterine
(n = 66) with missed abortions up to
curettage.
Figure 1. Average efficiency for the misoprostol time of application to the rear vaginal
the end of week 8 of gestation, while
In 75 (75%) pregnanthe second group included pregnancies we applied miso- fornix in both groups of pregnant woman.
cies through week 12 (44%). The followprostol sublingually (in
ing criteria were considered: diagnostic
50 by the end of week 8
ultrasound for a missed abortion and a
of pregnancy, and in 25
clinical examination, a medical disorby the end of week 12).
der that contraindicated misoprostol,
Of the 75 pregnancies,
adverse effects from the misoprostol,
one-half tablet was supgynecological status, cervical status
plied sublingually every
(length, consistency, dilatation), and
2 h. The average effec- Figure 2. Abortion-achieving efficiency, expressed as a percentage
inflammatory changes.
tive time was 11 h for the of applications to the rear vaginal fornix after administering 3.4 to 5
week-8 group, and 12.5 misoprostol tablets every 3 h.
3. Results
h for the week-12 group.
In both groups of pregnant women,
The average ef f imisoprostol was administered sublinciency for both groupsFigure
92.00%
2 Abortion-achieving efficiency, expressed as a percentage of ap
gually or in the rear of the vaginal forfollowing the sublingual 90.00%
Subling applic
nix. In 25 (25%) of the pregnancies (15
use of misoprostol wasrear 88.00%
vaginal fornix after administering 3.4 to755 cases
misoprostol tablets every
pregnant at the end of week 10) one tab11.75 h. By sublingual 86.00%
Application in rear
let of misoprostol was applied to the
application of misopro- 84.00%
of fornix
rear vaginal fornix for 3 h, and the efstol to 75 pregnant have 82.00%
25 cases
75 (75%) pregnancies we applied misoprostol sublingually (in 50
fect was achieved after 10 h in the first
failed only have 7 preg- In
80.00%
1
group, while the effect was recognized nant. (9.33%), of which 2
in the second group after 11 h.
have met the first groupweek 8 of pregnancy, and in 25 by the end of week 12). Of the 75 pregn
3. Percent efficiency for sublingual and rear vaginal fornix
The average efficiency was 10.5 h
have met while 5 of preg- Figure
applications of misoprostol
(Figure 1). After applying three tablets
nancy until the end of
Application
method

Average
time for
an effect
(h)

# of
# of
pregnant
pregnant
woman
woman that
with no
terminated
effect

Efficiency

Inefficiency

0.45

0.4

0.35

0.3

0.25

0.2

Series1

0.15

0.1

0.05

After 3 tbl

S1

After 4 tbl

After 5 tbl

Figure 5. Percent efficiency for sublingual and rear vaginal fornix applications of

152

MED ARH 2010; 64(3) Original papers

misoprostol

Missed Abortion and Application of Misoprostol

after 1 to 2 weeks.
three tablets. In the 11
We concluded that selective use of
other pregnancies that 70
Rapid bleeding in
misoprostol is a primary method of
did not fail, there were 60
13 cases
terminating an early pregnancy with
five primipara and six 50
Average bleeding
missed abortion pathology.
multipara.
40
in
T h i r t e e n c a s e s 30
60 cases
(14 . 6 %) p r e s e n t e d 20
5. Conclusion
Bleeding of the
with rapid bleeding, 10
Vaginal administration of misopropackage in 15 cases
60 (67.41%) with averstol
to women with a missed abortion
0
1
age bleeding, and 15
produced spontaneous expulsion of the
(16.85%) with bleeding. Figure 4. Bleeding following misoprostol application by two methods
fetus and reduced the need for surgical
(sublingual
and
rear
vaginal
fornix).
Rapid onset of bleed- Fig.
7. Bleeding following misoprostol application by two methods (sublingual treatment.
and rear
ing occurred mostly in
late-gestation pregnan- vaginal fornix).
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153