الفهرس 
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Abstract
This study was conducted to evaluate the efficacy of 800μg vaginal misoprostol with a 10 mg letrozole for three days pretreatment, in comparison with both saline- moistened and acetic acid moistened vaginal misoprostol for induction of first trimester missed miscarriage or abortion. The diagnosis of a missed abortion was based on pelvic ultrasound findings of a gestational sac ≥25 mm in mean diameter that does not contain a yolk sac or embryo or an embryo with a crown rump length (CRL) ≥7 mm that does not have cardiac activity. The present study included 75 patients of missed miscarriage, which were admitted to Tanta University hospital, Department of Obstetrics and Gynecology, with a diagnosis of missed abortion, in the period from December 2019 through January 2021. The study design was single blinded randomized controlled trial. The protocol was approved by the Ethical committee, Faculty of Medicine, Tanta University. Complete history taking, thorough general and abdominal examination, as well as vaginal examination were done to ensure the diagnosis, inclusion and exclusion criteria. Obstetric trans-vaginal ultrasound was done. Laboratory investigations for patient fitness, coagulopathy, some blood screening tests and vaginal pH were done. Once the diagnosis of missed abortion was confirmed and study legibility was ensured, counseling was done, all options were described, economic reasoning was also done, and the patient shared in the informed decision for selection of the different management modalities. The cases were allocated to one of the following groups: group A (Letrozole + misoprostol): Included 25 cases. They received 10 mg letrozole per day for 3 days; then they were hospitalized on the 4th day, where they received 800 μg of dry non-moistened vaginal misoprostol, as a single dose. group B (Acidified misoprostol)): Included 25 cases who received a placebo for three days, then they were hospitalized on the 4th day, where they received 800 ug of misoprostol moistened in 5% acetic acid (pH 2) and inserted digitally in the posterior vaginal fornix. group C (Misoprostol soaked with saline): Included 25 cases who received a placebo for three days, then they were hospitalized on the 4th day, where they received 800-ug misoprostol moistened with saline and inserted digitally in the posterior vaginal fornix. The cases were subjected to the following methods: All patients were monitored clinically for 24 hours. Vaginal ultrasound was after 24 hour done to confirm complete abortion. The main outcome measures were successful complete abortion and induction abortion interval in hours. The pertinent clinical (gestational age, gravidity, parity, previous modes of delivery and previous abortions) and laboratory data (CBC, coagulation profile) of all the cases were recorded and there was no statistically significant difference, between the three groups. The results can be summarized as following: o After 12 hours - Clinical significance was calculated Relative risk (RR) and its Confidence interval (CI): group A compared to group B, showed RR1=3.7, 95% CI 1.2-11.5, group A compared to group C, RR2=2.7, 95% CI 1.1-7.5 and group B compared to group C, RR3=0.8, 95% CI 0.2-3. - from these values, the most visible clinically significant difference was seen in comparing group A to group C (Narrower range of CI). o After 24 hours - Thirty-eight patients out of seventy-five patients (50.66%) had complete abortion. - The rate of complete abortion After 24 hours in group A was 68% compared to 44% and 40% in groups B and C respectively. - The rate of complete abortion in group A was significantly higher than group B (p1=0.047) also, the rate of complete in group A was significantly higher than group C (p2=0.010), while there was no statistically significantly difference between B and C (p3=0.529). - Clinical significance was calculated: group A compared to group B, showed RR1=1.5, 95% CI 0.9-2.5, group A compared to group C, RR2=1.7, 95% CI 1-2.9 and group B compared to group C, RR3=1.1, 95% CI 0.6-2.1. - from these values, the most visible clinically significant difference was seen in comparing group A to group C (CI did not cross 1, and Narrower range of CI). o Induction-abortion interval - The mean induction-abortion interval in group A was 10.88 ± 4.95hours, in group B it was 16.45 ± 6.12hours and in group C was 17.70 ± 7.29 hours. The time was statistically significantly shorter in group A than group B and C (p1=0.009) (p2=0.013) respectively, while there was no statistically significantly difference between group B and group C (p3=0.965). Failure - 31 patients (41.33%) with Failure of complete abortion, 5 patients in group A (20%), 12 patients in group B (48%) and 14 patients in group C (56%). Failed abortion was significantly higher in group C compared to group A (p2=0.009) but there was no statistically significantly difference between group B and group C (p3=0.571), while failed abortion in group B higher than group A that was statistically significantly (p1=0.037). - Clinical significance was calculated: group A compared to group B, showed RR1=0.4, 95% CI 0.2-1.0, group A compared to group C, RR2=0.35, 95% CI 0.2-0.8 and group B compared to group C, RR3=1.3, 95% CI 1.1-1.4. - from these values, the most visible clinically significant DROP was seen in comparing group A to both groups B and C. More significant DROP in comparison to group C (Narrower range of CI). o Analgesia - The need for analgesia; showed a non-significant difference between group A and group B (p= 0.208), while there was a significantly higher number in-group C; compared to group A (p=0.009). - The Amount of nalufin used also was statistically significant between A and C (p2=0.007). - Clinical significance: group A compared to group B, showed RR1=0.55, 95% CI 0.2-1.4, group A compared to group C, RR2=0.35, 95% CI 0.15- 0.84 and group B compared to group C, RR3=0.64, 95% CI 0.34-1.2. - from these values, there were clinical significant difference in comparison of all groups.