الفهرس 
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Abstract
This was a randomized control trial that was conducted in the department of obstetrics and gynecology Sohag University Hospital from October 2021 to Marsh 2022on women who were referred to with missed abortion or blighted ovum with a scarred uterus at 1st trimester to evaluate the efficiency and safety of letrozole followed by misoprostol to terminate non-viable pregnancies compared with the use of misoprostol alone.
During the period of the study, 70 participants were recruited included in the study, and informed consent was obtained before the trial began.
For each patient, a thorough history was obtained and a thorough examination was performed. Before the trial, participants had essential tests such as hemoglobin level , prothrombin time and a transvaginal ultrasound scan.
Patients had been randomized into two groups as the following:
• Group-I ”Misoprostol”: women received placebo for 3 days followed by vaginal misoprostol as 2 vaginal tab (400 μg) / 4 hours for 48 hours .
• Group-II ”Letrozol + Misoprostol”: women received single daily dose of Letrozole (10 mg /day) for 3 days followed by vaginal misoprostol as 2 vaginal tab (400 μg) / 4 hours and repeated every 4 hours same like group I for 48 hours .
In both groups, women with a gestation of less than 12 weeks received outpatient treatment of either placebo or Letrozole for 3 days , then admitted to hospital before misoprostol administration or if they had severe vaginal bleeding (more than two pad changes within 1 hour), a fever for more than 24 hours, or development of a rash and after misoprostol administration were monitored every 4 hours.
On the seventh day, an ultrasound was performed, and if a bortion was missed or incomplete, an evacuation was performed.
If there was severe vaginal bleeding, surgical evacuation performed at any time, even before the seventh-day follow-up visit (inevitable abortion ).
Results showed in group-I , 34 patients were analyzed of which 14 patients had complete abortion (41.2 %) , 9 patients had incomplete abortion (26.5 %) and 11 patient failed to abort spontaneously and needed evacuation (32.4%) . In patients aborted spontaneously there was 4 cases aborted within 24 hrs , 6 cases within 36 hrs and 13 cases within 48 hrs and 21 cases more than 48 hrs .
In group-II , 36 patients were analyzed of which 23 patients had complete abortion (63.9%) , 6 patients had incomplete abortion (16.7 %) and 7 patient failed to abort spontaneously and needed evacuation (19.4%). In patients who aborted spontaneously 4 cases aborted within 24 hrs , 13 cases within 36 hrs and 21 cases within 48 hrs and 15 cases more than 48 hrs .
Results also showed higher complete abortion rate in group-II who received Letrozole (63.9%) compared to group-I received placebo (41.2%) which was statistically significant(14 vs 23 , p=0.05 ). The rate of complete abortion was higher specially within 48 hours in group-II but of no statistical significance.The rate of incomplete, and missed abortion that required surgical intervention was higher in group-I (58.8%) compared to group-II (36.1%) but the difference was not statistically significant (20 vs 13, p=0.2).
Success rate was higher in cases of blighted ova (57%) compared to (52%) cases of missed abortion but , statistically not significant .We also noticed that failed induction was more in cases of missed abortion (27%) compared to (14.2) cases of blighted ova but statistically not significant .
The most common side effects in our study were fever, nausea and/or vomiting, diarrhea, bleeding and abdominal pain. As regard fever, it occurred in 6 patients (17.6%) of group-I but it was higher in group-II as it occurred in 11 patients (30.6%), but shows no statistically significant difference.
As regard bleeding, incidence of severe bleeding was higher in group-I received placebo 7 cases (20.6%) than in group-II received Letrozole 5 cases (13.9%) which mean that combination of letrozole and misoprostole protect the patient from severe bleeding which is of clinical importance not statistically significant .
As regard abdominal pain after the administration of misoprostol, it was higher in group-II than in group-I ,but it also shows no statistically significant difference.
There were fewer women complaining of nausea and /or vomiting in group-II than those in group-I but incidence of diarrhea is higher in group-II receiving letrozol both of them not had a statistical significance.
Finally , this study found that using 10 mg (four tablets) of letrozole for three consecutive days followed by misoprostol is more successful than taking misoprostol alone for inducing the first trimester missed abortion with scarred uterus .as The letrozole group had a considerably higher complete abortion rate than the misoprostol alone group (8 percent compared to 56 percent ).
Conclusion and Recommendations
• We concluded that the use of letrozole as a pretreatment in cases of induction of 1st trimisteric missed abortion using misoprostol with scarred uterus is benificial and the complete abortion rate being greater than using misoprostol alone.
• As a result , we recoomend using letrozole followed by misoprostol for induction of abortion in cases of the first trimester missed abortion particularly with scarred uterus.