Carole P, a 35-year-old project manager, has just suffered
a failed pregnancy at nine weeks. Besides coping with
the attendant emotional pain, she's also been waiting
for a week for the miscarriage to complete spontaneously.
Now she has a difficult choice to make. Carole could either
opt for curettage, the traditional approach where the
lining of the uterus is scraped out, or she could take
the drug route and try misoprostol, a synthetic prostaglandin
E1 analogue most commonly used in gastric ulcer prevention,
but also employed (somewhat controversially) to induce
labour and early abortions. Since both treatments carry
risks, she and her doctor are finding the decision far
from easy.
A Dutch team based at the St Antonius
Hospital in Nieuwegein, the Netherlands, recently set
out to make the process a little simpler by comparing
the two treatments in 154 women suffering from miscarriage,
measuring outcomes and patient satisfaction. Their study
was made available April 14 online in the journal Human
Reproduction.
SUCCESS
HIGHS AND LOWS
The researchers determined that misoprostol is successful
in only 53% of patients where expectant management had
failed. In contrast, curettage was successful in 96%
of these cases.
Despite the lower efficacy of misoprostol,
according to the article "some women are willing to
trade a treatment burden and possible failure of misoprostol
for the benefit of a non-invasive management" when the
wait and see approach fails.
The study looked at 154 women aged
18 to 45, recruited from three teaching Dutch hospitals
from November 2001 to June 2003. All were identified
as having a gestational sac (with or without embryonic
pole) through ultrasonography and had completed at least
one week of unsuccessful expectant management after
miscarriages occurring between six and 14 weeks gestation.
Seventy-five of the women were treated with curettage,
while 79 had four 200mg misoprostol tablets placed intravaginally
(repeated after 24hrs if necessary). The women's satisfaction
with their treatment and measures of quality of life
related to their health were assessed by questionnaires.
While women in both groups were
at their worst two days after treatment, the women in
the misoprostol group experienced more pain than those
in the curettage group, and perceived their general
health to be poorer two and six weeks after treatment.
"The rather high failure rate for
misoprostol treatment in our study remains a considerable
problem," says Dr Giuseppe Graziosi, a gynecologist
and one of the study's authors. But he adds, "Our somewhat
low evacuation rate could partially be due to strict
criteria on ultrasonographic evaluation."
BOTH
HAVE A PLACE
Despite the findings, an equal percentage of women (58%)
in either treatment group would undergo the same treatment
in the future. However the authors note that for women
in the misoprostol group "this choice depended on the
initial success of misoprostol: in cases where misoprostol
had caused complete evacuation, 76% of the women would
opt for the same treatment, whereas only 38% of women
who needed curettage after unsuccessful misoprostol
would do so."
Dr Graziosi thinks that at the
end of the day, the drug has its place in the array
of treatments available. "When balancing the disadvantages
of misoprostol (lesser effectiveness, higher chance
of emergency curettage and overall lower health related
quality of life) and advantages (higher satisfaction
in case of complete evacuation and lower costs), there
is a place for it in treating early pregnancy failure
after unsuccessful expectant management." At present,
however, "there are no clinical prognostic factors identified
that are predictive for complete evacuation using misoprostol
after failed expectant management."
He emphasizes counselling and shared
decision-making for this traumatic experience. The negative
psychological impact in terms of anxiety and depression
of early pregnancy failure on a significant proportion
of women is well documented, according to Dr Graziosi.
"Counselling of the pros and cons of misoprostol treatment
is of the utmost importance and the woman should make
the final choice."
Hum Reprod published online
Apr 14
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