Comparing Buccal and Vaginal Misoprostol in Management of Early Pregnancy Loss
Condition: Spontaneous Abortion in First Trimester
MeSH terms: Abortion, Spontaneous
Study type: Interventional
Phase: Phase 2/Phase 3

Summary: 
      First trimester miscarriages are common. When the failed pregnancy does not pass
      spontaneously on its own, it is called a missed abortion. There are several ways in which
      missed abortions are managed, one of which involves administering a medication called
      misoprostol which causes uterine contractions inducing expulsion of the failed pregnancy.
      Misoprostol can be administered in multiple ways but has been traditionally inserted
      vaginally when used for management of missed abortions. Some studies have shown that some
      women are not comfortable with vaginal insertion of misoprostol and prefer oral
      administration. Buccal misoprostol is a way of administering misoprostol by having the
      patients insert the tablets of misoprostol between their gum and cheek, letting it dissolve
      for 30 minutes, then swallowing the remaining remnants. Buccal misoprostol is used safely in
      medical abortion. In fact a study by Fjerstad et al (2009), found a decrease in infection
      rate for medical abortion when misoprostol administration was switched from vaginal to buccal
      route combined with routine administration of doxycycline. The efficacy of using buccal
      misoprostol to treat missed abortions has not been studied previously to the investigators'
      knowledge. In this pilot study, investigators aim to test the hypotheses that buccal
      misoprostol is equally effective as vaginal misoprostol in the medical management of early
      pregnancy loss. As secondary outcomes, investigators suspect that buccal misoprostol may be
      associated with higher rates of gastrointestinal side effect but that patient satisfaction
      will remain equally as high for buccal misoprostol as for vaginal misoprostol.
    

Detailed description: 
      Randomization:

      Women who present to University of California, San Diego (UCSD) Medical Offices South clinic
      for evaluation and management of missed abortion will all be sent to the lab prior to the
      clinic visit for a type and screen and hemogram to determine blood type and hemoglobin level
      as is the current standard of care. Each woman will then be screened by a physician. The
      physician will notify a co-investigator of eligible patients who are interested in
      participating in the study. The co-investigator will consent the patient for the study. Once
      the written consent is obtained, patient will be asked to fill out an intake survey to obtain
      demographic information. Participants will be randomized into either the vaginal or buccal
      misoprostol group with a block size of four. Assignments will be concealed in sequentially
      numbered sealed opaque envelope. The envelope will be opened by the co-investigator who will
      reveal the route of misoprostol to the patient and review the written instructions on how to
      take the medication appropriately. Given the different routes of administration, neither the
      patient nor the provider will be blinded. Given that one of the secondary outcomes of
      interest was patient satisfaction based on the different route of administration, decision
      was made to not use placebo pills which could have been used to do a double-blinded study.

      Intervention:

      Dose of Misoprostol for both treatment groups: 800 micrograms administered as four tablets of
      200 micrograms.

      Currently, the standard of care is to prescribe vaginal misoprostol 800 mcg for women with an
      early pregnancy failure desiring medical management. The only "intervention" in this study is
      to change the route of administration from vaginal to buccal for the women randomized to this
      group. The dose of misoprostol, follow up plan (including ultrasound) and prescription for
      pain medications (described below) is unchanged from the current standard of care.
      Participants randomized to the vaginal misoprostol group will be instructed to insert four
      misoprostol tablets (total of 800 micrograms) deeply into the vagina with their fingers.
      Participants randomized to the buccal misoprostol group will be instructed to place two
      tablets of misoprostol between their gum and cheek on each side (total 800 micrograms), then
      swish and swallow the remnants after 30 minutes. If the patient is Rh negative, the patient
      will be given a dose of rhogam 300 mcg at the initial visit which is the current standard of
      care.

      Patients will be prescribed an additional dose of misoprostol 800 mcg that they can take at
      their own discretion in the absence of vaginal bleeding 48 hours from initial dose using the
      same route of administration as the first dose. All participants will be prescribed ibuprofen
      with instructions to take 600 mg every 6 hours as needed for pain and a narcotic medication
      for breakthrough pain. The cost of these medications will be fully covered by the
      participant's insurance with no additional cost to the participant.

      Follow up will be a clinic visit scheduled one week from the from the initial visit at UCSD
      Medical Offices South Clinic which time the participant will fill out a follow up survey
      assessing the participant's satisfaction and side effects experienced. The provider will also
      fill out a survey at this 1-week follow up visit assessing the success of the misoprostol in
      achieving a complete abortion. The participant's involvement in the study will conclude at
      this end of this one-week follow up visit.

      Participant Commitment:

      The research will require the following additional time commitment from participant in
      addition to the standard clinic visit:

        1. Initial Visit: An additional 20 minutes will be required to review the study consent,
           randomize to the vaginal or buccal misoprostol group, and have the patient fill out a
           short intake survey.

        2. Follow-up visit: The follow up visit will take one week from time of initial visit. An
           additional 10 minutes will be required to fill out the follow up survey. The
           participant's involvement in the study will conclude with this visit.
    

Intervention name(s): Vaginal Misoprostol; Buccal Misoprostol
Intervention type(s): Drug; Drug
Intervention description(s): Misoprostol inserted into vagina; Misoprostol placed between the gum and cheek and allowed to dissolve for 30 minutes with the remnants swallowed after this time.
Other intervention name(s): Vaginal Cytotec; Buccal Cytotec
Intervention MeSH terms: Misoprostol
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: misoprostol, early pregnancy loss, missed abortion