[INSERT TABLE 3]
Finally, the outcomes demonstrated an 83.33% success rate in those
patients treated by misoprostol alone. While those groups treated by
misoprostol plus oxytocin and misoprostol plus methylergonovine
illustrated a success rate of 93.333%. The net results showed neither
any statistical significance in the three different medication therapies
(P=0.329) nor any adverse effects associated with them.
Discussion
The result obtained in the present study confirms an improved efficacy
of the medical therapy of misoprostol either combined with oxytocin or
with methylergonovine in successful expulsion of the RPOC. Although
treatment by misoprostol alone (83.3%) has not resulted in remarkable
statistical significance, greater therapeutic efficacy was reported in
the groups (93.33%) treated by a combination of misoprostol plus
oxytocin or misoprostol plus methylergonovine. Moreover, by designating
the degree of persistent residual tissues in the patients, it was
concluded that those patients treated with misoprostol plus oxytocin had
the best outcome compared to the other groups. Likewise, all the
patients treated with other medications showed a sufficient successful
rate of RPOC expulsion.
Kaviani et al. in 2006 concluded that ’the efficacy of methylergonovine
in the successful expulsion of retained pregnancy tissues in patients
with incomplete abortion showed to be 94.6%’. Additionally, Niroumanesh
et al. reported results similar to our findings 12.
Another study carried out by Petca et al. in 2019 compared the
effectiveness of simultaneous administration of misoprostol and oxytocin
(M&O) versus misoprostol and mifepristone (M&M) on abortion in the
second trimester in over 108 patients. Their study further illustrated
that administering M&M simultaneously resulted in greater expulsion
rates within 12 hours compared to M&O, with the latter regimen
demonstrating synergistic benefits, with lower expenses and satisfactory
I-AI 22. This study, like the previous one, is in
coherence with our study.
Misoprostol is a prostaglandin E1 analog which is a uterotonic
pharmacological agent and functions either by contracting the uterine
smooth muscles or by dilation of the uterine cervix23. On the other hand, by increasing the permeability
of uterine myofibrils to sodium, oxytocin causes uterine smooth muscle
contraction. That is why this compound is frequently used to induce
labor 24. Overall, these beneficiary medications aid
to dilate the cervix gently which results in a drastic reduction in the
subsequent complications of cervical dilation i.e. uterus perforation,
cervix rupture, hemorrhage, incomplete fetal-placental delivery and
infection, and pregnancy products expulsion. Besides, these medications
help to avoid anesthesia and its complications in cases where complete
abortion is necessary 25.
Although the mean age of all the patients in this study was 29.76±5.53
with no statistical significance in the three different groups, we
discovered that age-related physiological factors have the potential to
alter the outcomes. Niroumanesh et al. concluded that older multiparous
patients with several histories of previous pregnancies were found to
have more tendencies for surgical and curettage approaches as compared
to the other patients 26.
Another conclusive point with regards to the mean age of the patient is
that younger aged patients experiencing abortion need to be educated
thoroughly about contraceptives and preventive methods, unlike the other
age groups. However, this perspective might appear irrelevant to the
current study aim.
Abnormal weight in the mothers has a crucial impact on fertility and
sanitizations during a healthy pregnancy; that is why determining
factors like BMI like weight and height can play a substantial role in
abortion physiology. For this matter, all the patients were examined for
BMI and blood pressure, but no statistical significance in these
variables was noted that might have altered the outcomes. These findings
were compatible with a study conducted by Ghasemi et al.in 201827.
After the prescription of drugs in the different groups, hemorrhage,
pain, and spotting which are considered as pregnancy tissue expulsion
associated complications were carefully evaluated. A persistent
postpartum hemorrhage after fetus abortion signifies small fragments of
trophoblast and decidua still retained in the uterus after fetal death
or RPOC expulsion 28. There are various medical
protocols developed to prevent bleeding after surgical abortion or
labor. However, these protocols are continuously being modified to
achieve better outcomes and higher rates of success29-31. Even though there is no evidence of significant
difference regarding the severity of hemorrhage in three different
groups in our study, but those given misoprostol plus methylergonovine
showed very mild bleeding as compared to the other groups.
A causal-comparative study was conducted by Whitehouse et al. to compare
the efficacy of medical management for bleeding prevention after
surgical abortion in over 336 patients with a history of recent abortion
in 2018. Their study discovered that 72% of the patients used
contraceptive drugs to prevent bleeding, and among them, 83% preferred
vasopressin over other drugs. Likewise, scientists declared that these
patients also showed willingness for the intake of methylergonovine
during the second trimester to control severe bleeding and then
preferred misoprostol 15. Whitehouse et al’s
discoveries are consistent with our findings. A year later, they
conducted another study to illustrate oxytocin potency on the reduction
of frequency rate of hemorrhage and blood loss and concluded that
oxytocin as prophylaxis for bleeding does not result in a reduced number
of interventions required to control the bleeding during dilation and
evacuation (D&E) period between 18-24 week of gestation. However, it
does reduce the bleeding intensity and hemorrhage frequency which was
also in harmony with our study.
Methylergonovine and oxytocin are stimulators of uterine contraction
which act directly on uterine smooth muscle and peripheral vasculature,
especially uterine vessels, and thus reduce hemorrhage33,34. This topic supports our study by demonstrating
that there is no significant statistical difference between oxytocin
efficacy and other drugs used for the mentioned purpose.
Similarly, regarding spotting manifestation after abortion and
medication intake, the analysis proved no significant difference in the
manifestation of spotting between different study groups. This fact
confirms the results obtained from the degree of hemorrhage reported
from the participants.
Considering medication intake and postpartum pain followed by fetal
abortion, our study has discovered that the combination of misoprostol
plus methylergonovine showed the best efficacy in pain management. A
varied number of guidelines published for pain management by various
medical associations have recommended only a normal dosage of common
analgesics 35,36. But, most of these guidelines
describe neither specific medication type nor specific dosage in this
scope. Moreover, the efficacy of analgesic protocols is limitedly
studied in the literature, especially the protocols discussing the
prevention and treatment of pain occurring post-miscarriage.
Although the World Health Organization (WHO) strongly recommends
controlling, monitoring, and measuring the pain 37,
even then they have not specified pain measurement methods in women with
miscarriage during the first trimester.
A study conducted by Kemppainen et al. with the purpose of pain scaling
during a medical abortion in early pregnancy reported VAS score of 75,
and 91-54 for median and interquartile range respectively, in over 140
teenage and adult patients. Of all the women, 57.7% of them experienced
severe pain (VAS=70) during abortion care. Also, 93.5% of these women
needed additional opioid analgesics such as tramadol or oxycodone
despite being administered with regular analgesics for prophylactic pain
medication, like ibuprofen and paracetamol. Even though the misoprostol
administration did not reduce the risk of pain recurrence, but even
then, patients treated with misoprostol reported satisfaction38. According to Kari Braaten et al39, intravenous injections of sedatives were not
useful to reduce the pain in patients with surgical abortion during the
first trimester, in contrast to their study, due to administration of
combined misoprostol and methylergonovine, severe pain remained
uncovered and its manifestation occurred in none of the patients. It is
noteworthy to mention that, methylergometrine can be also used to
modulate the pain of origins except miscarriage; for example,
Niño-Maldonado et al. reported positive efficacy of methylergometrine
for migraine pain modulation in emergency settings 40.