1.3 Outline
2.1.2 Constructing the Cross-Correlation Statistic
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Fever 2 1.7
No side effects 53 44.2
Table 8 showed that majority of the patients had no side effects (44.2%) and the commonest side effects seen were nausea and shivering
TABLE 9: SATISFACTION WITH MISOPROSTOL TREATMENT AMONG MISOPROSTOL GROUP
Frequency Percentage Cumulative
percentage
Highly satisfied 38 32 64
Satisfied 8 7 78
Dissatisfied 14 11 22
100.0 Would you
recommend misoprostol to a friend
Yes 46 38.3 76.7
No 14 11.7 23.3
60 50.0 100.0
Table 9, showed that 78% of the women in the misoprostol group were satisfied with misoprostol and most of whom would recommend it to a friend
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The proportion of missed abortion to that of incomplete abortion among the study groups were 50.8% and 49.2% respectively. Missed abortion was commoner probably due to the routine use of ultrasound in the evaluation of patient’s with first trimester miscarriage and hence earlier detection of it.
This study demonstrates that 600µg of misoprostol was less effective than MVA (73.3% versus 98.3%) in complete uterine evacuation, which is statistically significant, thus there is a difference between the treatment outcome of misoprostol and MVA in first trimester miscarriage. The success of misoprostol in this study was lower than similar studies done in other African countries; 96% in Mozambique, 80% in Burkina Faso and 94.5% in Tanzania respectively 18, 19,
and 29 this may be due to the fact that two types of abortions were studied unlike most studies that
compared only incomplete or missed abortion to MVA. 2,818, 20,26,29,34 The vaginal route of misoprostol used could also influence the success and so can the increased dosing. This was seen in a study by Woods et al where 800µg of misoprostol was inserted vaginally with complete abortion in 80% of cases with missed abortions.28 In another study, Pang et al compared 800µg misoprostol given vaginally or orally and found that success was 60% with either route; this was in consequence of the definition of success being radiological than clinical 8 In other studies done both oral and vaginal 800µg misoprostol were highly effective with a shorter mean time of expulsion in the vaginal group.10,60 The sublingual route of 600µg was also effective with efficacy of 86% However this success was found to be improved with repeated dosing of misoprostol within 24 to 48 hours. 1, 26, 34 The recommended regimen is 800µg vaginally or 600µg sublingually every three hours to a maximum of two doses60 The first dose may serve to ripen the cervix while the second dose to stimulate contractions. The lower success of misoprostol seen in this study was as a result of missed abortion and could be due to single dose of 600µg of misoprostol used.
Complete uterine evacuation of the uterus after misoprostol was more effective in incomplete miscarriage than in missed miscarriage. This is seen in table 6, where the group showed the comparison of complete uterine evacuation between incomplete and missed miscarriage and especially as the gestational age increases from nine weeks to 12 weeks. The rate of completion of abortion is statistically more significant (p=0.002) in patients presenting with incomplete abortion than in missed abortion. This is likely so because in incomplete abortion the process of abortion has commenced and needs only to be aided to facilitate the process unlike in missed
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abortion. This success is similar to studies done on incomplete abortion in Mozambique, Tanzania and Burkina faso.18, 19, 29
The severity of blood loss was more common in the misoprostol group though not statistically significant. The blood loss estimation was subjective as it was based on the patient for misoprostol group and the attending doctor for MVA group. The pack cell volume on day seven, by which time, most of the patients had a complete abortion was not statistically significant between the two groups. This finding is similar to studies done in some African countries and developed countries.1 2, 18,23, This was probably because women in the misoprostol group are more likely to have heavy bleeding for about 3-4 days followed by light bleeding or spotting for several weeks.10 Sixteen patients had surgical completions in the misoprostol group, two patients opted not to wait additional week and requested surgical completion at their scheduled follow up visit once it was determined that their abortion was incomplete. Three patients returned to the clinic 1-2 days after misoprostol administration (before their scheduled follow up) with heavy bleeding and cramping and had surgical evacuation. One of the three delayed presentation at the onset of heavy bleeding and presented in shock but was adequately resuscitated with intravenous fluid and two units of whole blood. The severity of pain was more in the MVA group compared to the misoprostol group and is statistically significant and similar to the study done in Mozambique, 18 even though nonsteriodal anti inflammatory drugs were administered to both groups as needed. There was no case of genital sepsis seen in both groups which may be because patients that had clinical features suggestive of genital sepsis were excluded from the study.
Majority of the women in the misoprostol group did not have any side effects with few patients reported experiencing nausea and shivering as the commonest side effect. These side effects are self limiting and do not require any treatment. This was similar to one of the findings in Mozambique.18 These side effects are well known and expected findings of misoprostol and women were counseled about them before they received the treatment.
The women in the misoprostol group were highly satisfied with the treatment given. They were also willing to recommend it to a friend in similar circumstances. However the satisfaction of patients with MVA as a treatment method was not assessed in this study to serve as a comparison to misoprostol, 18 this is a limitation of the study
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One particularly notable aspect of this study was the fact that MVA was the established and accepted form of uterine evacuation in the first trimester. There was initial reluctance in accepting misoprostol for management of first trimester abortion among colleagues and patients.
This was partly because it was a new treatment and its outcomes are untested and unknown in this environment. It could also be due to the fact that there was fear of infection of retained products of conception if not immediately evacuated. However, with counseling of patients and colleagues on the successful outcomes of research done in other African countries and the importance of harnessing this low cost technology changed their views and gained their confidence.