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11/5/2019
1
MEDICAL MANAGEMENT OF NON-VIABLE
PREGNANCY
Prof. ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
Non-viable pregnancy
Incomplete, Silent, Delayed, missed, early fetal demise.
•Inevitable abortion
vaginal bleeding, typically accompanied by crampy pelvic pain,
and the cervix is dilated. Products of conception can often be
felt or visualized through the internal cervical os.
●Incomplete abortion
vaginal bleeding and/or pain are present, the cervix is dilated,
and products of conception are found within the cervical canal
on examination.
●Missed abortion
spontaneous abortion in a patient with or without symptoms
and with a ● closed cervical os.
ABOUBAKR ELNASHAR
11/5/2019
2
Choosing a treatment method
Surgical (dilation and curettage) or
Medication (misoprostol)
Expectant management.
All have similar efficacy
Choice depends mainly upon patient preference.
[Sotiriadis et al, 2005MA].
ABOUBAKR ELNASHAR
Medical Vs Surgical
 Both are safe and effective approaches for
appropriately selected patients.
 The choice is based upon
1.Patient preference.
Counseling of both is recommended
2. Availability
3. Gestational age:
Medical tt is less successful in the late 1st T
ABOUBAKR ELNASHAR
11/5/2019
3
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
11/5/2019
4
Alloimmunization prevention
United States and Canada, women with bleeding
during pregnancy who are
Rh(D)negative and unsensitized receive
Rh(D)immune globulin.
Other countries, guidelines vary regarding whether
Rh(D)immune globulin is required for first trimester
spontaneous abortion.
ABOUBAKR ELNASHAR
RCOG, 2006
50 mcg is effective through the 12 w of gestation {small
volume of red cells in the fetoplacental circulation (mean red
cell volume at 8 and 12w is 0.33 mL and 1.5 mL)
No harm in giving the standard 300 microgram dose
ABOUBAKR ELNASHAR
11/5/2019
5
Medical management
Misoprostol advantage: prostaglandin E1 analog
most commonly used
Cheap
not requiring refrigeration
low incidence of side effects
readily available
timing of use can be controlled by the patient.
clinical assessment and subsequent
administration can be safely performed by
appropriately trained non clinician providers
ABOUBAKR ELNASHAR
Route
Vaginal is preferable
1. mean time to expulsion is shorter
2. As effective as oral
3. Incidence of diarrhoea and fatigue: lower
Onset : 20 min
Peak concentration: 75 min
Duration: 4 -6 h
The great bioavailability explain why it is more
effective than oral routeABOUBAKR ELNASHAR
11/5/2019
6
* After oral administration, uterine tonus develops, which is not
followed by uterine contractions, unless repeated doses are given
Pharmacokinetic Profiles: Key Facts
(Tang et al., 2007)
Aboubakr Elnashar
Dose:
Single is preferred
1. Single& repeated doses of oral 600 ug
(dose repeated after 4 h to a total of 1200 ug):
 equally effective
 diarrhoea is less.
(Nguyen et al, 2005)
2. The expulsion rate:
higher
with a single dose of 600 -800 ug vaginal (70-90%)
•local effect of misoprostol on the uterine cervix,
•the high drug concentration achieved in uterine tissue, and
•the increased bioavailability with vaginal administration].ABOUBAKR ELNASHAR
11/5/2019
7
How much:
Single-dose vaginal 800 μg
more effective than 400 ug
(55.4% vs 40.2%)
more effective in delayed miscarriage compared
with cases where there was an empty sac
(50.3% vs 40.2%)
Single oral dose of 400 ug:
low rate (13%) of expulsion
same dose given multiple times:
expulsion rate of 50 to 70%ABOUBAKR ELNASHAR
Incomplete abortion
Oral: 600 ug (single dose)
[WHO, 2007]
Vaginal: 800ug
Oral : 400 μg.
ABOUBAKR ELNASHAR
11/5/2019
8
Silent, delayed, missed miscarriage or
early fetal demise
Vaginal: 800 ug or
Sublingual: 600 ug (single dose)
[WHO, 2007]
oral, sublingual or vaginal
400, 600 or 800 g in single or repeated doses
Sublingual:
400 g appears to be a safe, effective alternative to
the oral or vaginal routes.ABOUBAKR ELNASHAR
Success:
1. Dose.
2. Route
ABOUBAKR ELNASHAR
11/5/2019
9
3. Type of failed pregnancy,
but not by the duration of the pregnancy.
In medically managed patients, complete expulsion occurred in 71% of all
women by day 3 and 84% by day 8.
An anembryonic gestation had a lower success rate
than an embryonic or fetal death (81 vs 88%).
In contrast to induced medical abortion, pregnancy duration
did not affect the rate of successful expulsion in missed,
incomplete, or inevitable abortions
ABOUBAKR ELNASHAR
Medical tt and type of failed pregnancy
ABOUBAKR ELNASHAR
11/5/2019
10
ABOUBAKR ELNASHAR
Safe single doses of vaginal misoprostol for producing uterine
contractions at various gestations.
First trimester: 800µcg 24 hourly can be safely used.
Second trimester: 200µcg 12 hourly is a common dose
Beyond 24 w 25µcg 6 hourly is usually used. If a higher dose
than this is used, then uterine hyperstimulation with uterine
rupture or fetal distress might be the result

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MEDICAL MANAGEMENT OF NON-VIABLE PREGNANCY

  • 1. 11/5/2019 1 MEDICAL MANAGEMENT OF NON-VIABLE PREGNANCY Prof. ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR Non-viable pregnancy Incomplete, Silent, Delayed, missed, early fetal demise. •Inevitable abortion vaginal bleeding, typically accompanied by crampy pelvic pain, and the cervix is dilated. Products of conception can often be felt or visualized through the internal cervical os. ●Incomplete abortion vaginal bleeding and/or pain are present, the cervix is dilated, and products of conception are found within the cervical canal on examination. ●Missed abortion spontaneous abortion in a patient with or without symptoms and with a ● closed cervical os. ABOUBAKR ELNASHAR
  • 2. 11/5/2019 2 Choosing a treatment method Surgical (dilation and curettage) or Medication (misoprostol) Expectant management. All have similar efficacy Choice depends mainly upon patient preference. [Sotiriadis et al, 2005MA]. ABOUBAKR ELNASHAR Medical Vs Surgical  Both are safe and effective approaches for appropriately selected patients.  The choice is based upon 1.Patient preference. Counseling of both is recommended 2. Availability 3. Gestational age: Medical tt is less successful in the late 1st T ABOUBAKR ELNASHAR
  • 4. 11/5/2019 4 Alloimmunization prevention United States and Canada, women with bleeding during pregnancy who are Rh(D)negative and unsensitized receive Rh(D)immune globulin. Other countries, guidelines vary regarding whether Rh(D)immune globulin is required for first trimester spontaneous abortion. ABOUBAKR ELNASHAR RCOG, 2006 50 mcg is effective through the 12 w of gestation {small volume of red cells in the fetoplacental circulation (mean red cell volume at 8 and 12w is 0.33 mL and 1.5 mL) No harm in giving the standard 300 microgram dose ABOUBAKR ELNASHAR
  • 5. 11/5/2019 5 Medical management Misoprostol advantage: prostaglandin E1 analog most commonly used Cheap not requiring refrigeration low incidence of side effects readily available timing of use can be controlled by the patient. clinical assessment and subsequent administration can be safely performed by appropriately trained non clinician providers ABOUBAKR ELNASHAR Route Vaginal is preferable 1. mean time to expulsion is shorter 2. As effective as oral 3. Incidence of diarrhoea and fatigue: lower Onset : 20 min Peak concentration: 75 min Duration: 4 -6 h The great bioavailability explain why it is more effective than oral routeABOUBAKR ELNASHAR
  • 6. 11/5/2019 6 * After oral administration, uterine tonus develops, which is not followed by uterine contractions, unless repeated doses are given Pharmacokinetic Profiles: Key Facts (Tang et al., 2007) Aboubakr Elnashar Dose: Single is preferred 1. Single& repeated doses of oral 600 ug (dose repeated after 4 h to a total of 1200 ug):  equally effective  diarrhoea is less. (Nguyen et al, 2005) 2. The expulsion rate: higher with a single dose of 600 -800 ug vaginal (70-90%) •local effect of misoprostol on the uterine cervix, •the high drug concentration achieved in uterine tissue, and •the increased bioavailability with vaginal administration].ABOUBAKR ELNASHAR
  • 7. 11/5/2019 7 How much: Single-dose vaginal 800 μg more effective than 400 ug (55.4% vs 40.2%) more effective in delayed miscarriage compared with cases where there was an empty sac (50.3% vs 40.2%) Single oral dose of 400 ug: low rate (13%) of expulsion same dose given multiple times: expulsion rate of 50 to 70%ABOUBAKR ELNASHAR Incomplete abortion Oral: 600 ug (single dose) [WHO, 2007] Vaginal: 800ug Oral : 400 μg. ABOUBAKR ELNASHAR
  • 8. 11/5/2019 8 Silent, delayed, missed miscarriage or early fetal demise Vaginal: 800 ug or Sublingual: 600 ug (single dose) [WHO, 2007] oral, sublingual or vaginal 400, 600 or 800 g in single or repeated doses Sublingual: 400 g appears to be a safe, effective alternative to the oral or vaginal routes.ABOUBAKR ELNASHAR Success: 1. Dose. 2. Route ABOUBAKR ELNASHAR
  • 9. 11/5/2019 9 3. Type of failed pregnancy, but not by the duration of the pregnancy. In medically managed patients, complete expulsion occurred in 71% of all women by day 3 and 84% by day 8. An anembryonic gestation had a lower success rate than an embryonic or fetal death (81 vs 88%). In contrast to induced medical abortion, pregnancy duration did not affect the rate of successful expulsion in missed, incomplete, or inevitable abortions ABOUBAKR ELNASHAR Medical tt and type of failed pregnancy ABOUBAKR ELNASHAR
  • 10. 11/5/2019 10 ABOUBAKR ELNASHAR Safe single doses of vaginal misoprostol for producing uterine contractions at various gestations. First trimester: 800µcg 24 hourly can be safely used. Second trimester: 200µcg 12 hourly is a common dose Beyond 24 w 25µcg 6 hourly is usually used. If a higher dose than this is used, then uterine hyperstimulation with uterine rupture or fetal distress might be the result