Role of Oral Misoprostol in First Trimester Abortion: A Prospective Study at CMH, Dhaka, Bangladesh

Background: Misoprostol has been used for medical abortion. We conducted this prospective study to see the efficacy of oral misoprostol in our tertiary Hospital. Objective: Objective of this study was to assess the efficiency, safety and compliance of misoprostol in first trimester abortion. Materials and Me-thods: This prospective study was undertaken in obstetrics and gynecology dept of CMH Dhaka, Bangladesh from July 2014 up to Dec 2014. A total 50 patients of incomplete abortion (54%), missed abortion (30%), anembryonic pregnancy (14%) and inevitable abortion (2%) of <13 weeks of gestation were the targeted population. Study population was diagnosed from history, physical examination and ultrasonogram had received 600 microgram misoprostol orally. If the pregnancy was not completely evacuated at this time another dose of misoprostol was given. All women returned for follow-up care 7 days later. If the pregnancy was not completely evacuated at this time, women un-derwent immediate surgical evacuation. Efficacy was defined as the percent of women discharged from the study without need for surgical intervention. Results: 30 patients had complete evacuation after 1 st dose, 12 cases needed 2 nd dose and only 2 cases needed 3 rd dose. Remaining 6 cases needed surgical evacuation. Efficacy was satisfactory (85%) and analysis revealed statistically significant (p < 0.05). Conclusion: Management of first trimester abortion with oral misoprostol is highly effective and highly acceptable.

Open Journal of Obstetrics and Gynecology tractions, which is responsible for its abortifacient capability and ability to promote labor and cervical ripening. First trimester abortion is one of the most common clinical problems in our daily gynecological practice. The definition of abortion is the termination of pregnancy by any means before the fetus is sufficiently developed to survive [1]. According to surveillance data from the Centers for Disease Control and Prevention (CDC), 12% of abortions occur within 13 weeks' gestation, which is known as first trimester abortion [2]. Since 1930 abortion has traditionally been managed with surgical evacuation [3]. These surgical procedures have some inadvertent complications [4]. Approximately 28,000 women in Bangladesh die each year due to abortion-related complications which are about one-fourth of total maternal mortality (1.67/1000 live birth) [5] [6]. In our country the abortion related death was found to be 5% of maternal death [6].
In years 2004 Abortion complications are responsible for the death of nearly 25% of the mothers (MOHFW 2004) [7]. The WHO estimates that about 20% -30% of unsafe abortions result in reproductive tract infections and that about 20% -40% of these result in upper-genital-tract infection and infertility. An estimated 2% of women are infertile as a reproductive age result of unsafe abortion, and 5% have chronic infections. Unsafe abortion could also increase the long-term risk of ectopic pregnancy, premature delivery, and spontaneous abortion in subsequent pregnancies [8]. It has been estimated that 13% of all maternal death worldwide are due to unsafe abortion. In recent times medical evacuation of the uterus with misoprostol is being used increasingly and rapidly replacing the surgical approach [9]. It is simple, non-invasive, less complicated, reducing the cost of service, well tolerated and acceptable for the patient [10].
Some studies showed that vaginal application of misoprostol increases the success rate and reduces the side effects [11]. A large number of studies have shown that misoprostol is highly effective in first trimester abortion [12]. In this study misoprostol has been selected as a large number of patients can be benefited and escape from surgical intervention and complications. Misoprostol interacting with prostaglandin receptors causes the cervix to soften by collagenolytic activity and uterus to contract, resulting in the expulsion of the uterine content [13].
There are some side effects of misoprostol such as nausea, vomiting, abdominal cramps, diarrhoea, vaginal bleeding, dizziness, headache, low grade fever, rashes and dose depended uterine hyperstimulation. In most cases, side effects and pelvic pain can be managed with oral analgesics [14]. "No health without reproductive health", to emphasis this motto we select and work on this topic.

Methodology
This study involved data collection by a standard data collection form, in all women admitted to CMH Dhaka, Bangladesh between July 2014 up to Dec 2014 with first trimester abortion during study period. Total 50 patients of incomplete abortion (54%), missed abortion (30%), anembryonic pregnancy (14%) and inevitable abortion (2%) of <13 weeks of gestation were the targeted population. Chi-square test to find an association between the age and parity was performed.
In this study we assess the efficacy and effectiveness of misoprostol in our institute and we satisfied with result.

Discussion
Our study indicates that treatment of early pregnancy loss with 600 microgram misoprostol orally the dose repeated after 24 hours when necessary is efficacious, a safe and effective nonsurgical option for the treatment of first trimester abortion. The success rate by 48 hours was 88%. The risk of diarrhoea and abdominal cramps were minimum and the side effects were tolerable. Misoprostol used in Open Journal of Obstetrics and Gynecology       was acceptable to most women. We found that women with incomplete or inevitable spontaneous abortion were more likely to have complete expulsion after one dose of misoprostol than were women with embryonic or fetal death or women with an anembryinic gestation. However by using a second dose, if expulsion is incomplete, a similarly high success rate. We waited 24 hours between doses in an attempt to allow sufficient time for the initial dose to be effective.
The majority of the women in our study reported satisfaction with this approach. In our study almost all women with an endometrial thickness of <20 mm by ultrasonography after misoprostol treatment complete expulsion uneventfully. It is not known whether 600 microgram of misoprostol represent the lowest effective dose for all subtypes of early pregnancy loss. Another observation in our study was that there were additional benefits of using misoprostol treatment which were not completely successful. All the patients who needed surgical evacuation had soft and dilated cervix at the time of surgical evacuation, which reduced the risk of perforation and cervical injury. From this study it is anticipated that medical management of early pregnancy loss with oral misoprostol will prove to be a good.
Our trial involved a 15 days follow up period. The vast majority of patients recovered satisfactorily within this period (88%). In some patients tissue was often seen in internal os. Who come for follow up visit, it was removed in many cases with sponge holding forceps without further treatment. Only 6 women required surgical intervention. In follow up period only few patient complaints per vaginal bleeding and USG finding showed complete evacuation of uterus. Our study included an incomplete abortion, inevitable abortion, missed abortion, anembrionic gestation less than 13 weeks size. In addition women who were having slight per vaginal bleeding, when they present to the hospital were included in our study.
Limitation of the study: we didn't face any difficulty during study. Study population may be increased in this study. Number of variables may increase.

Conclusion
We study only oral administration of misoprostol. Previous randomized trials have indicated that the effect of misoprostol is similar whether it is administered vaginally or orally, whereas the incidence of diarrhea occurred less frequently in S. K. Chowdhury, M. Z. Hussain