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Abstract
Objective: To assess whether buccal misoprostol is effective for the treatment of intrauterine fetal death.
Study Design: This double-blind randomized trial was conducted at five tertiary-level hospitals in the United States and Vietnam. One
hundred fifty-three women with an intrauterine fetal death at 1428 weeks of pregnancy received either 100 mcg buccal misoprostol or
200 mcg buccal misoprostol every 6 h for a maximum of 8 doses. The main outcome measure was the fetal-placental delivery rate within
48 hours of prostaglandin commencement without any additional intervention.
Results: Most of the women (140/153) were recruited at the study site in Vietnam. Expulsion of both fetus and placenta within 48 hours of
prostaglandin commencement without any additional interventions occurred in 61.8% (47/76) of women receiving misoprostol 100 mcg and
77.9% (60/77) of women receiving misoprostol 200 mcg. The 200 mcg dose was significantly more effective than the 100 mcg dose at
expelling the fetus and placenta within 48 h [RR 0.68 (95% CI: 0.500.92; p=.03)]. The mean time to expulsion was significantly shorter
using the 200 mcg dose (18.511.9 h) than the 100 mcg dose (23.912.5 h) (p=.02). Most women in both groups found the procedure
satisfactory or very satisfactory (100 mcg: 76.7% (56/73); 200 mcg: 89.5% (68/76) [RR 0.86 (95% CI: 0.741.00)].
Conclusion: Buccal misoprostol is an effective method for medical induction of labor after intrauterine fetal demise. A 200 mcg dose is
significantly more effective than 100 mcg for evacuating the uterus within 48h. The treatment is highly acceptable to women.
Implications: Administration of 200 mcg buccal misoprostol every six hours is an effective and acceptable method to effect the delivery of a
demised fetus at 1428 weeks that can be feasibly implemented in a wide variety of settings.
2014 Elsevier Inc. All rights reserved.
Keywords: Buccal misoprostol; Intrauterine fetal demise
1. Introduction
0010-7824/$ see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.contraception.2013.11.014
Globally, access to healthcare and differing methodologies for the classification of fetal demise contribute to wide
variation in rates of fetal death in utero [1]. Timely evacuation can both avoid emotional distress and reduce the
possibility of developing disseminated intravascular coagulapathy (DIC) [2,3]. Intrauterine fetal demise (IUFD) may be
managed surgically with dilatation and evacuation (D&E) or
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2. Methods
This double-blind randomized trial was approved by the
institutional review boards of Montefiore Medical Center,
Stanford University, Stroger Hospital, Christiana Health
System, the Huong Vuong Hospital in Ho Chi Minh City,
Viet Nam and the Allendale Investigational Review Board,
an independent review board. Women who sought medical
care for possible fetal demise in pregnancies of between 14
and 28 weeks at the five hospitals from December 2008 to
December 2011 were screened. Confirmation of fetal demise
and final gestational age were determined by ultrasound.
Women were excluded if they had known allergies or other
contraindications to the use of misoprostol; placental
abruption with active hemorrhage, complete placenta previa,
extreme uterine structural anomalies, or other contradictions
3. Results
153 women were enrolled: 76 were randomly assigned
to receive 100 mcg buccal misoprostol, and 77 to receive
200 mcg buccal misoprostol (Fig. 1). Most of the women
were recruited at the study site in Vietnam (140 of 153). One
woman assigned to the 100 mcg group was withdrawn after
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190
Table 1
Background characteristics (n, %)
Age (y)
Mean (SD)
Range
Primiparous
Gestational age at time of demise (weeks)
mean (SD) (range)
Fetal age at time of demise
1418 weeks
1923 weeks
2428 weeks
Presentation at time of enrollment
Chorioamnionitis at time of enrollment
Vaginal bleeding
Painful contractions
Cervix dilated* (n, %)
1 cm
1.5 cm
Membranes intact
p-value
25.6 (5.6)
1741
55 (72.4)
25.8 (5.9)
1647
60 (77.9)
.93
.43
17.5 (3.4)(12.7126.43)
.14
39 (51.3)
24 (31.6)
13 (17.1)
49 (63.6)
23 (29.9)
5 (6.5)
0
0
0
5 (6.6)
4
1
71 (95.9)
0
0
0
0 (0)
.02
73 (96.1)
.97
Table 2
Delivery interval characteristics (n, %)
100 mcg (n=76)
RR (95% CI)
Fetal and placental expulsion within 48 hours with study drug alone
47 (61.8)
60 (77.9)
Fetal and placental expulsion within 24 hours with study drug alone
30 (39.5)
50 (64.9)
0.68 (0.500.92)
p=.03
0.68 (0.440.84)
p=.002
23.9 (12.5) a
20.8
(5.6747.00)
18.5 (11.9) b
14.4
(0.8347.00)
In one case, tissue was removed with forceps three days after delivery.
a
n=47.
b
n= 60.
p=.02
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4. Discussion
Fig. 2. Time from misoprostol administration to delivery of fetus and placenta. Survival curve of the percentage of pregnancies that were undelivered
for each of the two study regimens. Log rank test p=.001.
Table 3
Side effects as reported by woman after completion of treatment (n, %)
Diarrhea
Nausea
Vomiting
Chills
Headache
Pain
p-value
8 (10.7)
14 (18.7)
7 (9.5)
19 (25.3)
13 (17.3)
68 (90.7)
25 (32.5)
18 (23.4)
12 (15.6)
16 (20.8)
17 (22.1)
72 (93.5)
.001
.56
.33
.57
.54
.56
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