Glyceryl Trinitrate Versus Misoprostol for Termination of First Trimester Missed Miscarriage


ABSTRACT:BACKGROUND:Missed abortion refers to a pregnancy that can manifest as an anembryonic gestation or fetal demise prior to 20 weeks' gestation. Medical management has been used as a treatment options.A common medical regimen used to evacuate the uterus is vaginal misoprostol (Cytotec) in single or multiple doses.OBJECTIVE:To compare the therapeutic efficacy and adverse effects of intravaginal administration of a nitric oxide donor (glyceryl trinitrate) with that of a prostaglandin (misoprostol) to induce cervical changes in women with missed miscarriages to terminate their pregnancies.METHODS:A prospective, randomized comparative trial conducted at Al-Yarmouk Teaching Hospital, Department of Obstetrics & Gynaecology/ Baghdad-Iraq, enrolled Sixty women with first trimester missed miscarriages that requested pregnancy termination. They were randomly selected to receive either two tablets of 500 μg glyceryl trinitrate vaginally (n = 30) or 200 μg misoprostol tablet vaginally (n = 30), every 3 hours to a maximum of four doses or until reaching desirable cervical changes. Baseline vital signs were recorded and repeated with monitoring for adverse side effects every 3 hours until finishing therapy.RESULT:The difference in cervical changes between the two groups was statistically not significant (p > 0.05). The successful outcome taken as cervical dilatation ≥ 10 mm, incomplete, or complete miscarriage was achieved in 30% of women in the glyceryl trinitrate and in 53% of women in the misoprostol group which was statistically not significant ( p>0.05).Systolic & diastolic blood pressure, temperature & heart rate were lower with glyceryl trinitrate than misoprostol, but the differences were not significant (p>0.05).The most frequent side effect associated with glyceryl trinitrate administration was headache, which occurred in 27/30 women, compared with only 5/30 women in misoprostol group; relative risk 5.42 (p <0.05). Women treated with misoprostol reported mainly lower abdominal pain; relative risk 4.2 (p <0.05).CONCLUSION:Although glyceryl trinitrate was less effective than misoprostol when used prior to termination of missed miscarriage, the difference was statistically not significant. Moreover glyceryl trinitrate caused less adverse effects than misoprostol and it could have a role in the management of this obstetrical problem.