Misoprostol better than Manual vacuum aspiration for managing incomplete abortion- IJOGR
Approximately one in five recognized pregnancies are spontaneously miscarried in the first trimester and an additional 22% end in induced abortion. Incomplete abortion occurs when there are retained products of conception (POC) after induced abortion (whether by unsafe or safe methods) or after spontaneous abortion, also known as miscarriage.Incomplete abortion can be treated with...
Approximately one in five recognized pregnancies are spontaneously miscarried in the first trimester and an additional 22% end in induced abortion. Incomplete abortion occurs when there are retained products of conception (POC) after induced abortion (whether by unsafe or safe methods) or after spontaneous abortion, also known as miscarriage.
Incomplete abortion can be treated with expectant management, which allows for spontaneous evacuation of the uterus, or active management, using surgical or medical methods. Expectant management is not preferred by many providers due to its relatively low efficacy and the fact that the time interval to spontaneous expulsion is unpredictable.
Until recently, the treatment for incomplete abortion has usually been surgery of some kind (dilatation and curettage [D + C] or manual vacuum aspiration [MVA]). While these treatments are effective, they require specialised equipment and skills. Furthermore, they subject the woman to the dangers of a surgical procedure—trauma, perforations, infections, bleeding due to instrumentation, and reactions to anaesthesia.
Many studies have indicated that the uterotonic and cervical ripening properties of the prostaglandin E1 analogue misoprostol make it a safe and highly effective method of evacuating the uterus in cases of incomplete abortion, in comparison to surgical methods (such as manual vacuum aspiration).
Misoprostol stability at room temperature and low cost could make it an ideal treatment in low-resource settings, as well; it should prove safe and effective in such locales. Misoprostol is effective in emptying the uterus because of its ability to induce uterine contractions and to soften the cervix.
Misoprostol has not been associated with long-term effects on women's health, and prolonged or serious side effects are virtually nonexistent. Women and providers find misoprostol for treatment of incomplete abortion to be highly acceptable.
A study was performed by Woothvasita Mondal and team in a Durgapur Steel plant hospital, a tertiary care Hospital in West Bengal, India to compare different aspects of treatment of incomplete abortion by oral 600 µg misoprostol and manual vacuum aspiration. The institute caters a huge area, both rural and urban. The study was done between 1st January 2019 to 31st October 2020. Study population was drawn from patients attended OPD and patients admitted with incomplete abortions, either of spontaneous or, induced etiology in the Dept. Of Obst, & Gynae, Durgapur Steel plant hospital.
160 women were recruited to the trial, of which 80 women were grouped into misoprostol group & another 80 to MVA group. Immediately after abortion, all the patients were available & data collected from all the patients. But during next follow-up after 1-2 week, 33 in the MVA group & 27 in the misoprostol group did not come (Lost to follow up n=33) for follow-up. So, approximately 41% (33) of participants in MVA group & 34% (27) in the misoprostol group were lost to follow-up.
When the women who returned for follow-up at 1–2 weeks were analyzed, 92.45% of women assigned to misoprostol and 95.8% of women assigned to MVA had a completed abortion following use of their allocated treatment alone. 4 women in the misoprostol group and 1 in the manual vacuum aspiration group required an additional re-evacuation of the uterus after the initial treatment.
The rate of complications was higher in the manual vacuum aspiration group. In that group, 3 women experienced bleeding from cervical trauma during treatment (although no women needed more than a single cervical suture), and 6 women had pelvic infection at follow-up, requiring additional antibiotics. In the misoprostol group, only 5 women experienced a complication.
Bleeding ranged from mild, for about two-thirds of women, to moderate for another third. Few women enrolled in the study had severe bleeding at the first visit. In the 6 hours following treatment, bleeding was the most common symptom reported by women in the 2 study groups.
When women were asked to rate the maximum pain they experienced, most reported that the maximum pain was mild or moderate. Women in the MVA group rated their pain significantly higher than those receiving misoprostol, only 20% in the misoprostol group have experienced moderate to severe pain, as compared to 41.25% in the MVA group.
Regardless of the treatment they received, 70-80% of women indicated that they were either "very satisfied" or "satisfied" with their experience.
This study shows that 600 mg oral misoprostol is as effective as manual vacuum aspiration for the treatment of incomplete abortion and, in so doing, suggests that the medical management of this condition may be feasible and successful in less-developed countries.Irrespective of the method they received, women were generally satisfied with their treatment.
For low-resource settings, this study suggests that misoprostol may have a number of advantages over manual vacuum aspiration.
Firstly, misoprostol appears to be a much more flexible treatment. For manual vacuum aspiration, a definite diagnosis of both abortion status and gestation needs to be made. The same may not be true of misoprostol.
The second benefit of misoprostol is its ease of use. Manual vacuum aspiration requires a specific piece of equipment along with a trained operator. Manual vacuum aspiration kits or trained surgical providers may be unavailable sometimes. Misoprostol, however, is readily available at low cost (approximately Rs.50 for a 600µg tablet) in local pharmacies and could be safely administered by midlevel providers. Access to misoprostol treatment, therefore, may be greater than that of manual vacuum aspiration.
The major weakness of this trial is the low rate of attendance at the follow-up visit.
In low-resource, third world countries, such as India, where abortion rates are very high, inexpensive and easy to-use treatments are badly needed, and the introduction of misoprostol could greatly benefit both women and providers.
For treatment of first-trimester uncomplicated incomplete abortion, both manual vacuum aspiration and 600 µg oral misoprostol are safe, effective, and acceptable treatments. However, misoprostol appears to be somewhat better option than MVA, in regards to availability, low cost of therapy, less pain, less need of expert manpower or specialised instruments. Based on availability of each method and the wishes of individual women, either option may be presented to women for the treatment of incomplete abortion.
Misoprostol & MVA both methods can be safely offered to women without unnecessary recourse to ultrasound examination, which is expensive and dependent on skilled providers. For developing countries like India, both the methods can provide a solution for treatment of incomplete abortion safely and misoprostol is more suitable for use in rural health care facilities. Misoprostol for post-abortion care (PAC) would decrease the burden on tertiary health care facilities because of its low cost.
Source: Mondal, Mondal and Dutta / Indian Journal of Obstetrics and Gynecology Research 2021;8(1):20–25
MBBS, MD Obstetrics and Gynecology
Dr Nirali Kapoor has completed her MBBS from GMC Jamnagar and MD Obstetrics and Gynecology from AIIMS Rishikesh. She underwent training in trauma/emergency medicine non academic residency in AIIMS Delhi for an year after her MBBS. Post her MD, she has joined in a Multispeciality hospital in Amritsar. She is actively involved in cases concerning fetal medicine, infertility and minimal invasive procedures as well as research activities involved around the fields of interest.