MEDICAL VERSUS SURGICAL METHODS FOR

FIRST TRIMESTER TERMINATION OF

PREGNANCY
COMPARATIVE STUDY
SUBMITTED BY: MERVAT MALAKA

SUPERVISED BY: PROF. DR. HOSSAM THABET SALEM

PROF. OF GYNECOLOGY AND OBSTETRICS DEPARTMENT

DR. ESRAA YOUSSEF BADRAN

LECTURER OF GYNECOLOGY AND OBSTETRICS DEPARTMENT
INTRODUCTION
First trimester miscarriage is termination of pregnancy
(up to 14 week of gestation since the first day of the last
menstrual period),
First trimester abortion can be provided using either
medical drug-induced abortion, or surgical techniques.
(1)

Surgical abortion can be performed by aspiration (using

an electric pump or a manual syringe) or by dilatation
and curettage (sometimes called dilation and curettage
or D&C). (2)
INTRODUCTION
Medical abortion by misoprostol
> Misoprostol is a prostaglandin E-1 analogue which
induces uterine contractions, cervical dilatation and
ripening. It has been widely used overseas for
pregnancy termination. It is the drug of choice as it is
cheap, stable at room temperature, readily available,
and can be given orally, vaginally or sublingually. (3)
> The optimal dose of misoprostol is not known and
different regimens are in use.
INTRODUCTION
>Misoprostol alone can induce abortion in the early first
trimester, although repeated doses may be required. In one
study, misoprostol 800 g placed vaginally every 48 hours up
to three doses, had a complete abortion rate of 93%. (4 ,5, 6)
>When used alone in the first trimester it is reported to be >
83 % effective in expelling the products of conception from
the uterus. (7)
> Misoprostol usually acts quickly and the women can expect
to pass products of conception within the next few hours, but
bleeding usually continues for several weeks
INTRODUCTION
Precautions A woman treated by medical abortion should
have access to a medical facility equipped to provide
emergency treatment of incomplete abortion, including
aspiration (or dilatation and curettage), blood transfusion,
treatment of shock and emergency resuscitation.
Nevertheless, medical abortion is always safer than abortion
induced by personnel who do not have the necessary skills
or in an environment without the minimum medical
standards.
A follow-up visit, usually two weeks later, is essential to
confirm termination of pregnancy: bleeding is not proof of
complete evacuation
AIM OF will
This study THEbe a WORK
cross sectional observational
study to compare the outcomes of abortion by
vaginal misoprostol tablets and surgical evacuation
in the first trimester of pregnancy.
The primary outcome: complete evacuation of the
uterus as detected by ultrasound after 6 weeks after
termination.
The secondary outcome: postoperative bleeding,
infection, perforation of the uterus, and medically
related complications, and return of menstrual
pattern
SAMPLE SIZE
Number of cases: 121 case
Sample size calculated using G power program
version 3.1.3
Prevalence 87 %
Type one error (alpha) =0.05
With confidence level 95 %
1_beta error =0.95
the expected frequency is 87% with worst level 81%
at the confidence level 95%
SETTINGS

Study patients will be recruited from the outpatient

obstetric clinic of Obstetrics and Gynecology hospital
in Assuit.
PATIENTS

The study will include 121 pregnant women allocated

into 2 groups (under 14 weeks gestational age) who
are candidate for termination of pregnancy.
Patients will undergo either treatment with, 600 g
vaginal misoprostol in one side and in the other side
by Suction curettage or dilatation and curettage
PATIENT EVALUATION WILL INCLUDE:

History taking,
Physical examination,
Ultrasound evaluation.
POST TREATMENT FOLLOW UP WILL INCLUDE:
side effects of the treatment,
intra-operative findings, complications of surgical treatment,
clinical success,
duration of bleeding, interval to return of menses,
interval between misoprostol insertion to passage of tissue
mass (timed from the first dose),
histology of the product of conception (POC),
products of gestation being retained and treated by suction
evacuation, presumed infection treated by antibiotics,
severe bleeding and abdominal pain resulting in
readmission, and the duration of follow-up.
EXCLUSION CRITERIA:

1- Patients with contraindications to misoprostol

(asthma, glaucoma, mitral stenosis)
2- Patients with severe vaginal bleeding requiring
immediate evacuation
3- Patients who are hemodynamically unstable
needing immediate termination
4- sepsis, pelvic infection, or fever (>37.6C)
INCLUSION CRITERIA

Both inevitable (dilated cervix and minimal vaginal

bleeding) and missed miscarriage will be included
REFERENCES
1. Nielsen S, Hahlin M. Expectant management of first trimester
spontaneous abortion. Lancet 1995; 345:84-6.
2. Chung TK, Cheung LP, Sahota DS, et al. Spontaneous abortion:
short-term complications following either conservative or surgical
management. Aust N Z J Obstet Gynaecol 1998; 38:61-4.
3. 10-Mufftey PE, Stitely ML, Gherman RB. Early intrauterine pregnancy
failure: a randomized trial of medical versus surgical treatment. Am J
Obstet Gynecol 2002;187(2):321-5.
4. Carbonell JLL, Varela L, Velazco A, Fernandez C. The use of
misoprostol for the termination of early pregnancy. Contraception
1997;55:1658.
5. Ngai SW, Tang OS, Chan YM, Ho PC. Vaginal misoprostol alone for
medical abortion up to 9 weeks of gestation: efficacy and acceptability.
Hum Reprod 2000;15:22058.
REFERENCES
6. Bugalho A, Faundes A, Jamisse L, Usfa M, Maria E, Bique C.
Evaluation of vaginal misoprostol to induce first trimester abortion.
Contraception 1996;53:2436.
7. International Planned Parenthood Federation (IPPF). First trimester
abortion guidelines and protocols: Surgical and medical procedures.
London: IPPF; 2008 [cited 2012 Dec 17]. Available from URL:
http://ippf.org/resources/publications/abortion-guidelines-and-protocol.
8.Borgatta L, Burnhill MS, Tyson J, Leonhardt KH, Hausknect RU, Haskell
S. Early medical abortion with methotrexate and misoprostol. Obstet
Gynecol. 2001; 97(1):6-11.
9 -Dahiya K, Madan S, Hooda R, Sangwan K, Khosla AH. Evaluation of
the efficacy of mifepriston/ misoprostol and methotrexate/misoprostol
for medical abortion. Indian J Med Sci 2005;59(7):301-6.
THANK YOU