random post - incomplete d & c

been in the a & e for 3 nights consecutively for pain

i have never ecxpierenced such pain before (other than the last time, the night before the d & c)

finally, on the 3 rd night, the a & e doc was able to tell me what's wrong...it's due to an incomplete d & c that causes the pain as the body is trying to expel the remaining tissue.

yes, sf loh did tell that the d & c is not thourough as it will be the second one i am doing in about less than half a year, and he said the body will expel the remaining tissues but i NEVER expected the pain to be beyond what i can bear; and i know i have a high threshold of pain.

it's been one week since the d & c, and the pain has not abated, will be seeing him again today, been reading on the net and came across this article.

i think i will ask him about this.

http://www.reproline.jhu.edu/english/2mnh/2pa/pac_proc/broek1.htm

Postabortion Care Workshop Proceedings: Workshop Presentations
Issues in Establishing Postabortion Care Services in Low-Resource
Settings: Workshop Presentations

Use of Misoprostol for the Management of Bleeding in Early Pregnancy
Fredrik F. Broekhuizen, MD University of Wisconsin

Background
Misoprostol is a synthetic PGE1 analogue which is available in tablet form. It is closely related to other prostaglandins used in obstetrical practice such as Dinoprostone (PGE2), Carboprost (15 methylPGF2alpha), Gemeprost (PGE1) and Sulprostone (PGE2 analogue). Misoprostol was developed and marketed
for prevention of peptic ulcer disease caused by prostaglandin synthetase inhibitors, but with its potent uterotonic and cervical ripening activity has found applications in the management of gynecological and obstetrical problems. In the United States it has been marketed as Cytotec, with 100 and 200 mcg tablets available.

Misoprostol:
is inexpensive (US$.36 per 100 mcg);
is easily stored (shelf life 7 years);
has, in comparison with other prostaglandins, minimal effects on
cardiovascular and bronchial tree smooth muscle (can be safely
used in hypertensive patients and asthmatics);
is not affected by ambient temperature; and
needs no refrigeration, needles or syringes for its storage and
administration.


Mechanism of Action
Misoprostol is a myometrial stimulant which binds to E-2 and E-3
prostanoid receptors. Its active plasma metabolite is misoprostolic
acid. It is rapidly absorbed after oral, vaginal and rectal
administration. With oral administration the half life is less than
30 minutes, and peak level is at 15 minutes. After vaginal
administration, there is a gradual rise to a maximum level at 60–120
minutes, but at 240 minutes the level is still at 60 percent of peak
level (see below).

Comparative Effectiveness of Vaginal and Oral Administration
of Misoprostol
More side effects with oral use
At similar dose:
95% (vaginal) success vs. 87% (oral) in first trimester
Failure 1% (vaginal) vs. 7% (oral)
Abortion within 4 hours: 93% (vaginal) vs. 78% (oral)


Source: El Refaey et al 1995.
It is assumed that rectal administration results in a similar
profile. Vaginal dosing therefore can take place with longer
intervals than oral dosing for similar desired uterine effect, and
accumulation above "safe" levels with undesirable side effects can
take place. With oral and vaginal dosing of up to 400 mg every 8
hours, no accumulation has been noted and no accumulation has been
seen with a maximum of three doses of 400 mcg 3 hours apart.
Potential hypertonus as a result of drug accumulation could lead to:
uterine rupture in the second or third trimester,
fetal distress in the third trimester, and
high rates of nausea and diarrhea in all trimesters.
For obstetrical use, the vaginal application has been studied the
most. Misoprostol in the first and second trimesters is an effective
pregnancy termination agent either as a single agent or as an
adjunct to methotrexate or mifepristone. Misoprostol will
effectively dilate the cervix prior to surgical abortion.
Misoprostol has been studied as a cervical ripening and induction
agent in the last two trimesters. Its use as an alternative to MVA
or suction curettage for management of incomplete abortion (first
trimester), as a uterotonic agent in the active management in third
stage and as a treatment of postpartum hemorrhage are currently
being studied.

Applications of Misoprostol
Cervical priming prior to surgical abortion
Labor induction 24 weeks to term
Alone/adjunct for medical abortion
Management of spontaneous abortion?
Management of uterine atony


Misoprostol offers a potentially inexpensive treatment for life
threatening bleeding in pregnancy in developing countries in the
hands of frontline healthcare workers.

Research Results
The following section summarizes the status of misoprostol use in
early pregnancy.
Fong et al (1998) demonstrated that 400 mcg vaginal misoprostol
will dilate the cervix to more than 8 mm in 96.7 percent of
patients when it is given up to 3 hours or more prior to suction
curettage in the first trimester.
Carbonell et al (1997b) demonstrated that for gestations less than
63 days, misoprostol, given in a dose of 800 mcg vaginally and
repeated at 48 and 96 hours, resulted in a 92 percent complete
abortion rate, with 77 percent complete after one dose and an
additional 13.7 percent after the second dose; there was a failure
rate of 8 percent. Hausknecht (1995), Creinin et al (1995) and
Carbonell et al (1997a) all reported a 90–96 percent complete
abortion rate with methotrexate followed by misoprostol at 3, 5
and 7 days in a dose of 800 mcg; 20 percent of patients required
two or three doses.
In a review of the literature, Grimes (1997) concluded that class
I evidence and class A recommendations for first trimester
abortion existed for misoprostol as the most effective
prostaglandin, either as a single agent or as an adjunct (most
effective at the seventh day) to mifepristone or methotrexate.
El Refaey et al (1995) compared oral and vaginal doses and found
vaginal misoprostol use resulted in fewer failures.
These studies clearly establish misoprostol as an effective agent to
"empty" the pregnant uterus in the first trimester. One could assume
similar effectiveness when it is given for a "failed" pregnancy or
missed abortion. Blood loss in all of these studies was acceptable
and comparable to blood loss during surgical abortion.
Misoprostol is associated with birth defects in "continuing
pregnancies," and this is an obvious concern with unsupervised use.

Failed Induction Using Misoprostol
Congenital defect
Moebius Syndrome
Limb reduction defect
Mechanism of action
Placental bed ischemia
Embryonic vascular disruption


Source: Gonzalez et al 1998; Hofmeyr et al 1998; Pastuszak et al
1998.
This association is confirmed by several studies in Brazil, where
misoprostol is readily available over the counter. Moebius syndrome,
characterized by equinovarus, cranial nerve defects, arthrogryposis
and terminal limb defects, has been described with exposure to a
failed single dose of 800 mcg. Localized ischemia in the placental
bed and vascular disruption in the embryo are postulated as the
operational mechanism for causing the congenital anomalies.

Misoprostol Use in Incomplete Abortion
So far, only five studies regarding the use of misoprostol for
incomplete abortion have appeared in the peer review literature.
Studies regarding the management of incomplete abortion must be
considered against the natural history and expectant management of
this condition and its complications. Nielsen and Hahlin (1995),
comparing surgical evacuation and expectant management over a
72-hour period, reported that completed abortion occurred in 70
percent of cases in the expectant management group. The complication
rate was also lower in the expectant management group (3 percent)
compared to the surgical treatment group (11 percent). In a pilot
study of 20 patients, Creinin, Moyer and Guido (1997) found an 800
mcg vaginal dose more effective than a 400 mcg oral dose, with 88
percent complete evacuation. As shown in Table 1 below, Chung et al
(1997) in two prospective observational studies (none prospectively
randomized) found that 66 percent and 79 percent of patients managed
over a 48-hour period with 400 mcg misoprostol orally in three doses
did not require a curettage. A reference group had immediate sharp
curettage (D&C) and the complication rates (infection, repeat
curettage) were higher in the curettage group. Blood loss was not
systematically evaluated.

Table 1. Misoprostol for Incomplete Abortion
PROTOCOLRESULTS
354 cases by ultrasound
225 products of conception (POC)
102 empty uterus
137 reference cases
Misoprostol
Orally
400 mcg every 4 hours for three doses
D&C if incomplete after 48 hoursCompletion rate: 70.6%
101 in <>

so many things have happened since....

it has been a while since i updated this blog, so many things have happened since. i am totally numb, emotionally as well as mentally

i came across something that strike me just and i thought i post it here