Methods of Termination of First-Trimester Miscarriage: Either Medical or Surgical

Review of the literature
Chapter 3:
Methods of termination of first-trimester miscarriage
Either Medical or Surgical

Accepted treatment options for early pregnancy loss include medical treatment or
surgical evacuation. Although these options differ significantly in the process, all
have been shown to be reasonably effective and accepted by patients. (Zhang J, et ll
2005)
In women without medical complications or symptoms requiring urgent

surgical evacuation, treatment plans can safely accommodate patient treatment
preferences. (Sotiriadis A, et al 2005)
There is no evidence that any approach results in different long-term outcomes.

Patients should be counseled about the risks and benefits of each option. (Petersen
SG, et al 2013)
The following discussion applies to symptomatic and asymptomatic patients.
The women experiencing spontaneous abortion received less surgical

management compared to women that had blighted ovum and missed abortion. In
1998, 38.0% of the women that experienced spontaneous abortion were treated
surgically within the first week of miscarriage diagnosis whereas 60.7% of the
women with the blighted ovum and 70.9% with missed abortion underwent surgical
treatment. In 2016, the corresponding figures were 1.6, 9.4 and 11.2%, respectively
(P for trend <0.001). The proportion of surgical treatment within 1 month in 1998
and 2016 was 39.0 and 2.4% for spontaneous abortion, 63.3 and 15.2% for blighted
23
ovum and 72.0 and 16.1% for missed abortion (P for trend <0.001). Figure
5 displays the proportion of women undergoing surgical treatment within 1 week
according to the type of miscarriage between 1998 and 2016.
Table 4: summarizes the advantages and disadvantages of the two approaches.

If both options are suitable, the patient’s choice should be respected. 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). Dilatation and curettage is an outdated surgical technique that should be
replaced, whenever possible, by aspiration or medical (drug-induced) abortion
which are better options, as recommended by the World Health Organization and IPPF.7
• A surgical technique (preferably aspiration) should be used if:

• It is the woman’s choice
• Concurrent sterilization is anticipated
• There are contraindications to medical abortion
• A client is unable to come for follow-up after a medical abortion as
required.
24
Table 4: Advantages and disadvantages of medical and surgical abortion

Medical abortion Surgical abortion
Advantages Avoids surgery and anesthesia Quicker
More ‘natural’, like menses • More likely to have
• Emotionally easier for some a complete abortion
women • Emotionally easier
• Client controlled; more privacy for some women
and autonomy; can be home-based • Takes place in a
• Better than surgical in very early health care center,
gestation, or with severe obesity clinic or hospital
(body mass index >30) without other • Can be used up to
cardiovascular risk factors, or in the 14 weeks (12–14
case of fibroids, uterine weeks by experts
malformations or previous cervical only)
surgery • Sterilization can be
• No risk of cervical/uterine injury concurrent
Disadvantages • Bleeding, cramping, nausea, • Invasive
diarrhea, and other side-effects • Small risk of
• Waiting, uncertainty cervical or uterine
• More clinic visits injury
• Drugs are costly • Risk of infection
• Can only be used up to nine • Less privacy and
weeks autonomy
• Can be costly
25
Medical first trimester TOP
History
Over the past three decades, medical methods of abortion have been developed
throughout the world and are now a standard method of providing abortion care
in the United States.
Medical abortion, which involves the use of medications rather than a surgical
procedure to induce an abortion, is an option for women who wish to terminate
the first-trimester pregnancy. Although the method is most commonly used up to
63 days of gestation (calculated from the first day of the last menstrual period), the
treatment also is effective after 63 days of gestation.
The Centers for Disease Control and Prevention estimates that 64% of abortions
are performed before 63 days of gestation (Pazol K, et al 2012).
Medical abortions currently comprise 16.5% of all abortions in the United States
and 25.2% of all abortions at or before 9 weeks of gestation (Pazol K, et al 2012).
Mifepristone, combined with misoprostol, is the most commonly used medical

abortion regimen in the United States and Western Europe; however, in parts of
the world, mifepristone remains unavailable. We will present evidence of the
effectiveness, benefits, and risks of first-trimester medical abortion and provides a
framework for counseling women who are considering medical abortion.
PGE2 – an analog that has been connected to coronary spasm and myocardial
infarctions A further step was taken when the anti-progesterone mifepristone
became available for clinical use in the early 1990s (Tang and Ho, 2002, Fiala and Gemzel-
26
Danielsson, 2006, Bygdeman and Gemzell-Danielsson, 2008). Mifepristone boosts the effect
of PGs in MTOP (Tang and Ho, 2002, Fiala and Gemzel-Danielsson, 2006, Bygdeman and
Gemzell-Danielsson, 2008).
This method of using mifepristone and PGs was developed and first approved for
use during early pregnancy in France in 1988 (Urquhart and Templeton, 1987, Silvestre et
al., 1990, Lalitkumar et al., 2007). A few years later the method was approved for second
trimester TOP (Lalitkumar et al., 2007, Gemzell-Danielsson and Lalitkumar, 2008). However,
it was during 1999–2000 when MTOP with mifepristone and misoprostol was
approved in most European countries (Fiala and Gemzel-Danielsson, 2006, Gemzell-
Danielsson and Lalitkumar, 2008). The Food and Drug Administration approved it in the
US in 2000 and it was approved in Finland in 1999 (Bartz and Goldberg, 2009, Gemzell-
Danielsson and Lalitkumar, 2008).
Drugs used for MTOP:

In this research mifepristone is not available as it is not used in Egypt, so
misoprostol only is used for a medical termination.
Prostaglandins (PGs)
Prostaglandins are found in most human tissues and produced by almost all
nucleated cells. They are both autocrine and paracrine lipid mediators that act
upon platelets, endothelium, uterine and mast cells. PGs are synthesized in the cell
from the essential fatty acids (Figure 4) ;(Hammond and O'Donnell, 2012).
27

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Review of the literature

Methods of termination of first-trimester miscarriage

Either Medical or Surgical

In women without medical complications or symptoms requiring urgent

There is no evidence that any approach results in different long-term outcomes.

The following discussion applies to symptomatic and asymptomatic patients.

The women experiencing spontaneous abortion received less surgical

Table 4: summarizes the advantages and disadvantages of the two approaches.

• A surgical technique (preferably aspiration) should be used if:

Table 4: Advantages and disadvantages of medical and surgical abortion

Medical first trimester TOP

Mifepristone, combined with misoprostol, is the most commonly used medical

Drugs used for MTOP:

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