1. Misoprostol and early pregnancy loss i.e. < 13 weeks Types of miscarriage Missed miscarriage - intact sac. Incomplete - heterogenous mass of tissue Complete

2. Dedicated EPAU 1.Staff 2.Transvaginal scanning 3.Direct access for GPs and some patient subgroups Miscarriage Scan findings Intact mean sac diameter >20mm with no contents or Fetal pole > 6mm with no FH Rescan in 1 week.

3. Management options for Miscarriage < 13 weeks 1.Surgical ERPC – Risk perforation Risk G.A Risk retained products Risk infection 2.Medical (Misoprostol) Risk retained products Risk infection 3. Expectant - Risk Retainied products - Risk of infection

4. Review of Misoprostol in Missed Miscarriage Cervix closed Slight bleeding FIGO 2007 800ug vaginally 3 hourly( max x 2) or 600ug Sublingual 3 hourly ( max x 2) Follow-up 2 weeks Sublingual associated more frequently with diarrhoea than vaginal administration but similar efficacy

5. Misoprostol in incomplete miscarriage FIGO review – Advise 600mg oral single dose 2 studies compared 1 vs 2 doses – no difference in efficacy ( 90%) Take care not to over –diagnose failed medical management

6. Contra - indications Haemodynamically unstable Suspected ectopic Known allergy to Misoprostol Previous uterine rupture Signs of intrauterine infection Trophoblastic Disease Precautions –? 2 previous Caesarean Sections ? Previous myomectomy ? Taking Anti-coagulants

7. Predictors of success Higher for incomplete Lower for anembryonic pregnancy 2 RCTS of pretreatment with Mifepristone conflicting results many studies poorly defined ultrasound / clinical criteria Does not increase risk of infection vs surgery (Trinder MIST et al BMG 2006) No effect on future fertility (Blohm et al Lancet 1997)

8. Information sheets for patients Uterine contractions usually start within a few hours Routine antibiotics not necessary Tylex + or – Difene At 2 week check a further course of Misoprostol or ERPC or expectant management Bleeding lasts for up to 2 weeks If syncopal or presyncopal – emergency room Transient chills are common Fever less common if persists > 24 hours may have infection Nausea / vomiting 2 – 6 hours Diarrhoea < 1 day Taste / numbness of tongue

9. Differences 1 st Trimester vs 2 nd Trimester +3 rd Trimester management Hospitalisation not necessary. Expulsion of tissue hours to weeks Extremely low rates of uterine rupture.

10. In Summary < 13weeks gestation Willing patient Haemodynamically stable Sac size <5cm 600ug X 2 for missed miscarriage (subling.) 600ug X 1 for incomplete miscarriage (oral) See for scan 2 weeks later