Inpatient medical management

In the largest trial, 635 women were randomized to inpatient medical management (4-hourly oral 400 mg misoprostol; three doses, with surgical management the next day if no tissue was passed) or surgical management. A medical success rate of 50% was reported. The average duration of hospital stay was 2.18 days for medical management and 1.78 days for surgical management.11

A smaller trial reported a success rate of 82% following the administration of a single vaginal dose of 800 mg misoprostol. Eight to ten hours were allowed for completion of miscarriage. This time period was similar to the average time period (14 hours) from diagnosis to surgical management in the control group.4

These trials of inpatient medical management indicate that with an appropriate misoprostol regimen, success, in a similar time span to that required for surgical management, can be

Table 6.1. Suggested regimen for inpatient medical management of early fetal demise

• Admit at time convenient for patient/unit

• Obtain consent for procedure (good practice) Risks - haemorrhage, failure of complete evacuation, infection

• Administer 800 mg vaginal misoprostol

• Thereafter administer oral 400 mg misoprostol at 3 hourly intervals (maximum four oral doses)

• Offer analgesia (oral or parenterally as required). Antiemetics may also be necessary

• Anticipate passage of products of conception in an average of 8 hours (range 2-15 hrs)

• If excessive haemorrhage, remove products of conception from cervical os with sponge forceps

• Examine POC to ensure sac present and send for histological examination

• Administer Anti-D 250 IU if Rhesus negative

• If POC passed and bleeding has subsided -patient may be discharged

• If failure of passage of RPOC; offer repeat course after 12 hours, surgical curettage, allow home and await spontaneous passage of products

• Ask patient to return if bleeding is still present after 2 weeks or if symptoms of infection attained. A suggested protocol for the inpatient medical management of early fetal demise is detailed in Table 6.1.

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