Middle East Fertility Society Journal

Volume 19, Issue 2, June 2014, Pages 96101

Open Access
ORIGINAL ARTICLE

Vaginal misoprostol versus vaginal surgical

evacuation of first trimester incomplete
abortion: Comparative study

Mahmoud Shokrya, , ,

Mohamed Fathallaa,

Mostafa Hussiena,

Ashraf A. Eissab

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doi:10.1016/j.mefs.2013.05.007
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Open Access funded by Middle East Fertility Society
Under a Creative Commons license

Abstract
Objectives
The aim of this study is to assess the effectiveness and acceptability of using vaginal misoprostol
for management of first trimester spontaneous incomplete abortion as an alternative to direct
vaginal surgical evacuation in our setting.

Methods
This is a prospective comparative study performed on 147 patients with first trimester
incomplete abortion between 8 and 12 weeks requesting medical management. They were
divided into two groups according to patients choice; group (I) received misoprostol tablet
400 mcg (Cytotec, Serono) every 4 h for a maximum of three doses while group (II) underwent
surgical vaginal evacuation directly under general anesthesia. Only 54 patients in group I and 51
patients in group II completed their follow up and included in the analysis.
Results
Although vaginal surgical evacuation was successful in solving the problem in 100% of cases,
misoprostol was successful in 79.6% (p = 0.0006). The overall satisfaction was slightly higher in
the surgical group but almost equal percentage of both groups mentioned that they will
recommend the method to a friend. No serious side effects or complications were reported in the
misoprostol group. The incidence of excessive post-abortive bleeding was more in the
misoprostol group than in the surgical evacuation group (p = 0.0336). Also endometrium using
transvaginal ultrasonography was significantly thicker in the misoprostol group than in group II
(p = 0.0071) but with no clinical importance as it was not associated with severe vaginal
bleeding necessitating medical or surgical interventions.
Conclusion
Although vaginal surgical evacuation is more effective than misoprostol in solving the problem
still medical treatment is effective and acceptable especially when surgical management is not
available or risky or patients refuse to do surgical management.

KEYWORDS

Incomplete abortion;

Misoprostol;

Surgical vaginal evacuation;

Vaginal bleeding

1. Introduction
Approximately 1115% of pregnancies end in spontaneous first-trimester miscarriage (1).
Vaginal surgical evacuation of retained products of conception (RPOC) was the main stay of
treatment for a long time to reduce complications such as infection and unscheduled hemorrhage.
However, surgical management may be complicated with infection, uterine perforation or bowel

damage (2). This paved way to more recourse to medical and expectant management. Expectant
management for incomplete abortion in the first trimester after use of misoprostol or after
spontaneous abortion may be practical and feasible, although it may increase anxiety associated
with the impending abortion 3 and 4. The available Cochrane systematic review evidence
suggests that expectant care as well as medical treatment with misoprostol are acceptable
alternatives to routine vaginal surgical evacuation (5).
Misoprostol as a thermostable prostaglandin E1 analogue has been previously tested in the
management of incomplete miscarriage in different regimens and settings 6, 7 and 8. Overall
results indicate efficacy, effectiveness and acceptability in most of these studies. Some other
studies used the sublingual route instead of the oral or vaginal route for uterine evacuation after
early pregnancy failure 9, 10, 11 and 12.
The aim of this study is to assess the effectiveness and acceptability of using vaginal misoprostol
for management of first trimester spontaneous incomplete abortion as an alternative to direct
vaginal surgical evacuation in our setting.

2. Patients and methods

2.1. Inclusion and exclusion criteria
This is a prospective comparative study performed in a private practice with a University
affiliation during the period from April 2009 to October 2011. This study included 147 pregnant
women between 8 and 12 week cases requesting medical management for spontaneous first
trimester incomplete abortion. Patients who are hemodynamically unstable, septic abortion,
fever, bronchial asthma or known hypersensitivity to misoprostol were excluded. All patients
signed a written informed consent before recruitment into the study.
The diagnosis of incomplete abortion was confirmed by transvaginal ultrasonography
examination using a Sono ACE 9900 Prime Multi-beam 3-D Ultrasound System (Medison,
Korea) check for the presence or absence of retained products of conception. The eligible
patients were divided into two groups according to patients choice; group (I) received
misoprostol tablet 400 mcg (Cytotec, Serono) every 4 h for a maximum of three doses while
group (II) did not receive any uterotonics and directly underwent vaginal surgical evacuation
under general anesthesia by the standard technique of the hospital. All patients were followed up
for the first 24 h for abdominal pain scores, vital signs; presence of excessive vaginal bleeding
defined as the presence of vaginal bleeding more than menstrual blood with or without presence
of blood clots. Abdominal pain was treated when necessary by oral ibuprofen, 400 mgm, single
oral dose and repeated when needed every 6 h for a maximum of 2 days.
Patients were observed for the severity of pain and passage of products of conception per vagina
as well as for severity of vaginal bleeding. Any of the patients who had vaginal bleeding more
than usual was checked by transvaginal ultrasonography. If intrauterine contents other than blood
clots were seen, vaginal evacuation of retained products of conception, under general anesthesia
was performed. If only blood clots and thickened endometrium >15 mm were noted, oral
methylergonovine (methergin tablets, Sandoz Pharmaceuticals) 0.2 mg was prescribed at a dose

of two tablets per day for three successive days. Patients with no excessive bleeding were
discharged home 12 h after vaginal surgical evacuation in group II or after confirming complete
uterine emptying using transvaginal ultrasonography in the misoprostol group.
All participants were requested to come for a follow-up visit after one week. The patients were
asked about the amount and duration of vaginal bleeding, fever, pelvic pain (using visual
analogue score), or passage of fleshy parts per vagina. They were asked also about their
satisfaction for the method they chose for the management of their condition, whether they will
recommend this method to a friend as well as about any experienced side effects. Transvaginal
ultrasonography examination was performed to all patients who came for the follow up visit, to
measure the endometrial thickness at the maximum anteroposterior diameter on the long-axis
view of the uterus. An incomplete abortion is associated with a prominent endometrial echo
(thickness greater than 5 mm) round or oval echogenic intra-cavitary lesion, high-intensity
echogenic foci associated with acoustic shadowing, fluid in the uterine cavity, and is stippled
echo pattern (Fig. 1).

Figure 1.
An incomplete abortion is associated with a prominent endometrial echo (thickness
greater than 5 mm) round or oval echogenic intra-cavitary lesion, high-intensity
echogenic foci associated with acoustic shadowing, fluid in the uterine cavity, and is
stippled echo pattern (Fig. 1).
Figure options
Endometrial cavity after complete abortion showed no content with normal thickness (Fig. 2).

Figure 2.
Endometrial cavity after complete abortion showing no content with normal thickness
(Fig. 2).
Figure options

2.2. Pain scoring

Pain was assessed during the hospital stay four hourly and during the follow up visit, visual
analogue scoring (VAS) was used by means of a 10-cm line with verbal anchors saying no pain
at one end and excruciating pain at the other end.
The primary outcome measure was the effectiveness of misoprostol for completion of evacuation
in cases of incomplete abortion. Secondary outcomes included the proportion of patients
reporting severe pain or bleeding within and after 10 days, and the presence of any adverse
effects or major complications and patient satisfaction with the method.

2.3. Statistical analysis

Data were statistically described in terms of mean and standard deviation (SD). Comparison of
the studied groups was done using students t test. Chi square test was used to compare
categorical variables. A p-value less than 0.05 was considered statistically significant. All
statistical calculations were performed using computer programs Microsoft Excel version 7
(Microsoft Corporation, NY, USA) and SPSS version 13 (Statistical Package for the Social
Science; SPSS Inc., Chicago, IL, USA) statistical program. Fig. 3 shows a flowchart of study
procedure including patients enrollment, allocation, follow up and analysis.

Figure 3.
A flowchart of study procedure including patients enrollment, allocation, follow up and
analysis.
Figure options

3. Results

Demographic characteristics of both groups were comparable as regards age (years), height
(cms), weight (kgs) body mass index (BMI, in kg/m2) gestational age at the time of pregnancy
termination in weeks, gravidity, parity as well as number of primiparous patients. No statistically
significant differences were recorded between both groups as regards history of previous
abortions as shown in (Table 1).
Table 1.
Demographic characteristics of the study population.

Age (years)
Height (cm)
Weight (kg)
Body mass index
Gestational age (weeks)
Range (weeks)
Parity
Primiparous {No. (%)]
Multiparous {No. (%)]
History of previous abortion {No.
(%)}

Misoprostol group
(N = 54)
26.9 4.6
159.4 5.4
66.4 11.3
25.9 3.6
8.4 1.3
712

ERPC group
(N = 51)
27.1 5.4
160.7 4.5
64.8 11.8
25.4 3.2
8.2 1.2
711

11 (20.4%)
43 (79.6%)

12 (23.5%)
39 (76.5%)

0.6956
0.6956

8 (14.8%)

6 (11.8%)

0.6458

P-value
0.8938
0.1968
0.4845
0.3623
0.3986

ERPC = Evacuation of retained products of conception.

Table options
Success of the method of treatment in completely solving the medical problem was different
between the two study groups (Table 2). Despite that the vaginal surgical evacuation method was
successful in solving the medical problem in 100% of cases, the medical management using
misoprostol was successful in 79.6% (p = 0.0006), so it was needed to have vaginal surgical
evacuation in 11 cases of the misoprostol group.
Table 2.
Clinical outcomes of the study groups.
Misoprostol group
(N = 54) {No. (%)}
43 (79.6%)
46 (85.2%)

Success of the treatment method

Patient method satisfaction
Patient recommendation to a friend of
42 (77.8%)
the treatment method

ERPC group
p-value
(N = 51) {No. (%)}
51 (100%)
0.0006
47 (92.2%)
0.2617
43 (84.3%)

0.3939

Misoprostol group
(N = 54) {No. (%)}
Incidence of side effects
11 (20.4%)
Tolerability of the method of treatment 46 (85.2%)
Incidence of significant lower
5 (9.3%)
abdominal cramps (within 7 days)
Incidence of excessive post-abortive
7 (12.96%)
bleeding
Endometrial thickness (mm) (within
8.43 0.49
7 days) [Mean (SD)]

ERPC group
p-value
(N = 51) {No. (%)}
6 (11.8%)
0.2315
45 (88.2%)
0.6458
3 (5.9%)

0.5144

1 (1.96%)

0.0336

6.03 0.39

0.0071

ERPC = Evacuation of retained products of conception.

Table options
Patient satisfaction was significantly higher in the surgical evacuation group (Table 2). However,
almost the same percent of patients in each group reported they will recommend the method to a
friend. In the meantime the incidence of side effects and tolerability of the method of treatment
were comparable in both of the study groups (Table 2).
The incidence of excessive post-abortive bleeding defined as bleeding anytime more than
menstrual bleeding was more in the misoprostol group than in the surgical evacuation group
(p = 0.0336). Also endometrial thickness using transvaginal ultrasonography was significantly
thick in the misoprostol group than in group II (p = 0.0071).
Regarding pain scores, both groups were comparable regarding pain score at their first
presentation to the clinic. Both groups were comparable regarding their complaint of significant
painful lower abdominal cramps (VAS score >4) during their follow up visit one week after
discharge (p = 0.514) (Table 2).

4. Discussion
In this study, we compared the effectiveness of vaginal misoprostol 400 mcg (Cytotec, Serono)
every 4 h for a maximum of three doses versus direct vaginal surgical evacuation of spontaneous
first trimester incomplete abortion in a population that is more familiar with surgical evacuation.
Misoprostol was comparable regarding effectiveness. The overall satisfaction was slightly higher
in the surgical group but equal percentage of both groups mentioned that they will recommend
the method to a friend. No serious side effects or complications were reported in the misoprostol
group. Also, there was no difference in post abortive endometrial thickness or prolonged
bleeding but more women in the misoprostol group reported heavy bleeding.
We tested the effectiveness of misoprostol to ensure complete evacuation of the uterine contents
and to lessen the need for vaginal surgical evacuation in cases of incomplete abortion. The use of
misoprostol to facilitate complete uterine expulsion of products of conception was mentioned

repeatedly in the literature either to ripen the cervix facilitating manual vacuum aspiration (13) or
to help complete expulsion of the retained intrauterine conception products.
Home self-administration of doses as small as 400 mcg sublingually was feasible and acceptable
for medical abortion up to 56 days gestation (14). The high efficacy, safety, and acceptability of
400-g sublingual misoprostol indicate that it is an alternative to surgery for incomplete
abortion. Hence, misoprostol might improve post-abortion care when surgical treatment is
unavailable (15).
The side effects reported in our study were transient and tolerable, which agrees with findings of
other studies. It was reported that cramping usually starts within the first few hours after
misoprostol administration (16). Pain scores, 6 and 24 h after evacuation, were significantly
higher among misoprostol patients compared to controls. Severe abdominal pain was recorded
when administering misoprostol for pregnancy termination in the late first and early second
trimesters 17 and 18 and consequently significantly higher analgesia requirement in women who
require increased number of misoprostol doses.
Our results are also in agreement with the results of Neilson and colleagues 2010; who reported
that the administration of misoprostol to women with incomplete abortion appears to be safe and
can avoid vaginal surgical evacuation in 80% of cases. It was also considered as an acceptable
choice by a subset of women. However, women should be given proper analgesia and advice
about possible occurrence of more than average bleeding. Given the availability of health service
resources to support all expectant, medical and surgical management of spontaneous first
trimester incomplete abortions, women experiencing miscarriage at less than 13 weeks should be
offered these three choices (5).

5. Conclusion
Although vaginal surgical evacuation is more effective than misoprostol in solving the problem
still medical treatment is effective and acceptable especially when surgical management is not
available or risky or patients refuse to undergo surgical management.

6. Conflicts of interest
None.