Misoprostol for treatment of early pregnancy failure in women with previous uterine surgery.

OBJECTIVE: Misoprostol use in early pregnancy may incur a risk of uterine rupture in women with previous uterine surgery. STUDY DESIGN: We analyzed 488 women who received misoprostol 800 microg vaginally in a study that evaluated medical and surgical management of early pregnancy failure. Subjects received a repeat misoprostol dose if expulsion was not confirmed 2 days after treatment. We compared efficacy, acceptability, and safety in subjects with a history (n = 78 women) or absence (n = 410 women) of uterine surgery, defined as cesarean delivery or myomectomy. RESULTS: Expulsion rates after a single misoprostol dose (69% vs 72%; P = .64) and overall success at 30 days (82% vs 85%; P = .50) were comparable. Pain, bleeding, complications, and acceptability did not differ. No uterine ruptures occurred (95% CI, 0, 3.8%). CONCLUSION: Misoprostol treatment for early pregnancy failure had similar success, acceptability, and complications in women with and without previous uterine surgery.

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.

Factors related to successful misoprostol treatment for early pregnancy failure.

OBJECTIVE: To identify potential predictors for treatment success in medical management with misoprostol for early pregnancy failure. METHODS: We conducted a planned secondary analysis of data from a multicenter trial that compared medical and surgical management of early pregnancy failure. Medical management consisted of misoprostol 800 mug vaginally on study day 1, with a repeat dose if indicated on day 3. Women returned on days 3 and 15, and a telephone interview was conducted on day 30. Failure was defined as suction aspiration for any reason within 30 days. Demographic, historical, and outcome variables were included in univariable analyses of success. Multivariable analyses were conducted using clinical site, gestational age, and variables for which the univariable analysis resulted in a P < .1 to determine predictors of overall treatment success and first-dose success. RESULTS: Of the 491 women who received misoprostol, 485 met the criteria for this secondary analysis. Lower abdominal pain or vaginal bleeding within the last 24 hours, Rh-negative blood type, and nulliparity were predictive of overall success. However, only vaginal bleeding within the last 24 hours and parity of 0 or 1 were predictive of first-dose success. Overall success exceeds 92% in women who have localized abdominal pain within the last 24 hours, Rh-negative blood type, or the combination of vaginal bleeding in the past 24 hours and nulliparity. CONCLUSION: Misoprostol treatment for early pregnancy failure is highly successful in select women, primarily those with active bleeding and nulliparity. Clinicians and patients should be aware of these differences when considering misoprostol treatment. LEVEL OF EVIDENCE: II-2.

Sickle cell anemia in the female patient.

UNLABELLED: Seventy-two thousand Americans are homozygous for the sickle cell gene and 2 million are carriers. The gene offers protection against malaria but can be a cause of chronic pain and early death. Life expectancy is 48 years for females. Some people with sickle cell anemia live into their 60s and beyond. The purpose of this article is to review and summarize evidence from clinical, translational, and epidemiologic studies that have examined the clinically relevant aspects of sickle cell anemia as it relates to the female patient. Studies were identified through a MEDLINE search for articles in English between the years 1966 and 2005. References from identified reports were also used to identify additional articles. Women with sickle cell disease experience multiple complications. These complications can affect each and every organ system and are often worse in pregnant women. Progestins, hydroxyurea, and bone marrow transplant appear to ameliorate sickle cell anemia. Other therapies being evaluated include those that increase fetal hemoglobin concentration and prevent dehydration of the sickle red blood cells. More than one third of pregnancies in women with sickle syndromes terminate in abortion, stillbirth, or neonatal death. Recently, a number of genes modifying the clinical severity of sickle cell anemia have been identified. Sickle anemia is associated with immense suffering and multisystemic complications. In addition to the now-established therapy with hydroxyurea and bone marrow transplants, there are multiple investigational treatments that offer the hope of extending life expectancy while diminishing associated morbidities. Whether any of these new agents are safe in pregnancy has yet to be determined. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to summarize the multiple complications that women with sickle cell anemia (SCA) endure, explain that many of the complications worsen during pregnancy and increase the risk of an adverse pregnancy outcome, and state that there are treatment modalities that extend life and diminish morbidities.

A comparison of medical management with misoprostol and surgical management for early pregnancy failure.

BACKGROUND: Misoprostol is increasingly used to treat women who have a failed pregnancy in the first trimester. We assessed the efficacy, safety, and acceptability of this treatment in a large, randomized trial. METHODS: A total of 652 women with a first-trimester pregnancy failure (anembryonic gestation, embryonic or fetal death, or incomplete or inevitable spontaneous abortion) were randomly assigned to receive 800 microg of misoprostol vaginally or to undergo vacuum aspiration (standard of care) in a 3:1 ratio. The misoprostol group received treatment on day 1, a second dose on day 3 if expulsion was incomplete, and vacuum aspiration on day 8 if expulsion was still incomplete. Surgical treatment (for the misoprostol group) or repeated aspiration (for the vacuum-aspiration group) within 30 days after the initial treatment constituted treatment failure. RESULTS: Of the 491 women assigned to receive misoprostol, 71 percent had complete expulsion by day 3 and 84 percent by day 8 (95 percent confidence interval, 81 to 87 percent). Treatment failed in 16 percent of the misoprostol group and 3 percent of the surgical group (absolute difference, 12 percent; 95 percent confidence interval, 9 to 16 percent) by day 30. Hemorrhage or endometritis requiring hospitalization was rare (1 percent or less in each group), with no significant differences between the groups. In the misoprostol group, 78 percent of the women stated that they would use misoprostol again if the need arose and 83 percent stated that they would recommend it to others. CONCLUSIONS: Treatment of early pregnancy failure with 800 microg of misoprostol vaginally is a safe and acceptable approach, with a success rate of approximately 84 percent.

A randomized trial of saline solution-moistened misoprostol versus dry misoprostol for first-trimester pregnancy failure.

OBJECTIVE: The purpose of this study was to estimate whether the efficacy of treatment with intravaginal misoprostol for first-trimester pregnancy failure is enhanced by the addition of saline solution. STUDY DESIGN: Eighty women with embryonic/fetal death or anembryonic pregnancy were assigned randomly to receive either 800 microg of misoprostol with saline solution (group I, 41 women) or without (group II, 39 women). Treatment was repeated on day 3 if the gestational sac remained. Curettage was performed if the gestational sac remained on day 8 or as necessary during at least 30 days of follow-up. Data were analyzed with the Student t test and the chi(2) or Fisher exact test. RESULTS: By the first follow-up visit, 73% (group I) and 64% (group II) of women passed the gestational sac (P=.38). By the second follow-up visit, expulsion rates were 83% and 87%, respectively (P=.59). Five subjects in each group underwent curettage. CONCLUSION: Misoprostol is effective for the treatment of failed first-trimester pregnancy. The expulsion rate is not improved by adding saline solution.