The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Miscarriage

See also:

• Grief and Loss
• Medications/Teratogens/Substance Abuse
• Getting Pregnant
• Hormones of Labor about Stress
• Need for Herbal Support after Progesterone Shots

Subsections on this page:

• General
• Possible Causes of Miscarriage
• Possible Ways to Prevent Miscarriage
• Completing A Miscarriage
• How Long to Wait Before Trying Again
• Miscellaneous

If you have recently experienced a miscarriage, you might want to start with the section on Grief and Loss since this section is more about the physical and practical aspects of miscarriage.

General

Thorstensen KA.
J Midwifery Womens Health. 2000 Nov-Dec;45(6):481-97.

Environmental Toxins Associated With Recurrent Pregnancy Loss [Medscape registration is free]

Recurrent Miscarriage - current concepts by Mr. Sushanta Bhadra, MD, MRCOG [Dec., 2004 - a PowerPoint presentation]

Early Pregnancy - Including HCG levels and ultrasound findings

Possible Causes of Miscarriage

Why do miscarriages happen?  Unfortunately, it is rare that we can ever know why a miscarriage happened?  For women who are having recurrent miscarriages, The Alan E. Beer Center for Reproductive Immunology & Genetics researches and treats couples who experience recurrent miscarriages, multiple pregnancy losses or repeated in vitro fertilization failures.  The testing can be expensive, but for couples who have experienced multiple losses, they can sometimes identify the cause and provide therapies that reduce the chance of a future miscarriage.

There's increasing evidence that the developing egg/embryo/fetus are very sensitive to environmental contaminants.

You can read more about Environmental causes of infertility and miscarriage

Anatomic Factors in Recurrent Pregnancy Loss

Raised cortisol predicts spontaneous abortion [2/21/06] Source: Proceedings of the National Academy of Sciences 2006; Early online publication

Stress and Early Miscarriage

EMF Fields

I've met a number of people who are pretty certain their history of miscarriage or infertility is related to electric blankets.

Possible Ways to Prevent Miscarriage

For a while, there was some thinking that vitamin supplementation could prevent miscarriage.  Then this Cochrane review concluded that was not true:

"Authors' conclusions: Taking vitamin supplements, alone or in combination with other vitamins, prior to pregnancy or in early pregnancy, does not prevent women experiencing miscarriage or stillbirth. However, women taking vitamin supplements may be less likely to develop pre-eclampsia and more likely to have a multiple pregnancy."

I agree that taking synthetic vitamins (which is what most pre-natals are) would not reduce the risk of miscarriage.  However, using plant based supplements to improve the body's ability to metabolize essential fatty acids - which improves the integrity of the uterine lining - that definitely helps. [from a Certified Nutritionist]

Herbal Allies for Pregnancy by Linda Woolven from Mothering Magazine - has a section on Preventing Miscarriage.

The V.I. Govallo Method for Preventing Miscarriage

Immunology of Pregnancy and Immunotherapy of Spontaneous Abortions from the author's new site.

Prednisone and Aspirin Doesn't Prevent Miscarriages

Progesterone

NOTE - if you had progesterone shots during pregnancy, your uterus will not be ready for labor when you get to term. even though your cervix may be very favorable. You may need to do something to help the uterus recruit additional oxytocin receptors so that you can have a normal, progressive labor. I find the best way to do this is to take cottonroot bark tincture . . . 1 dropperful 6 times/day once you get to 36 weeks.  See Need for Herbal Support after Progesterone Shots

Maternal Progestin Intake and Risk of Hypospadias
Suzan L. Carmichael, PhD; Gary M. Shaw, DrPH; Cecile Laurent, MS; Mary S. Croughan, PhD; Richard S. Olney, MD; Edward J. Lammer, MD; for the National Birth Defects Prevention Study
Arch Pediatr Adolesc Med. 2005;159:957-962.

Conclusion  This study found that pregnancy-related intake of progestins was associated with increased hypospadias risk.

I've heard that this study is flawed in that it lumps together synthetic progestins (which are molecules tweaked from testosterone and nor-testosterone) and bio-identical progesterone(which has a different chemical composition and different biological effects).  If you give a pregnant women something that displaces testosterone off its receptors, wouldn't you expect it to have an effect on an organism (the male fetus) that relies on having a normal level of testosterone to develop properly?

Stress really can lead to miscarriage [195th Meeting of the Society for Endocrinology; London, UK: 1-3 November, 2004]

A collection of studies on women and mice provides support for the notion that stress may lead to miscarriage in otherwise healthy individuals.

My clients let me know the following day that they miss their period. I confirm pregnancy, put them on high dose progesterone creme, squawvine mixture and extremely limited work or bedrest. They take prenatal vit/min and a B complex.  Nothing else.  Habitual aborters have carried to term...and the babes are quite healthy.

Amen to the progest application to prevent early/repeated miscarriages. I have success stories too. Best results were in conjunction with acupuncture (to get pregnant) and when early miscarriage threatened our client, the acupuncturist gave her a sub-lingual wild yam. Bleeding stopped. Healthy term pregnancy.

Progest is expensive ($30.00 for 2 oz.). We've been making our own progesterone cream using tincture of wild mexican yam (Dioscorea villosa) in a simple pure cream or moisturizer, applied transdermally. I determine my personal dosage with applied kinesiology (AK) for perimenopausal and pms symptoms.

Since becoming familiar in the early 80's with Dalton's statistics on the mutual associations of PMS, LPD, post-partum depression, and "habitual" miscarriage, I have had 4 patients with known LPD and PMS and "habitual" miscarriage who wished to attempt intervention at a next pregnancy.

All four could tell me the exact date of presumed conception, and all four had atypical temperature graphs, with chaotic ups and downs. All four had barely perceptible spotting, and in each case, spotting began on a temperature "down."

I gave each of them 50 mg progesterone I.M. daily for 2 weeks. All four carried to term.

Many of you have noted that miscarriage often occurs 4-8 weeks after fetal demise. I propose that the ineffectiveness of progesterone supplementation at time of threatened miscarriage is due to the possibility that the die was cast in the first two weeks and that it's too late to intervene at the time trouble shows up. Just on opinion-- nothing to back it up.

I wouldn't advise generalizing this story to women who don't exhibit the triad of PMS/LPD/habitual miscarriage, nor to those who aren't doing NFP/BBT monitoring of the early gestation. But within those narrow limitations, 4/4 ain't too bad, although it might have happened anyway without all the fuss.

Well, your opinion has a lot of common sense behind it! I guess the arrangement to try progesterone should be made before conception is attempted -- rather than a few weeks after the missed period or positive pregnancy test, as it is usually done.

What do you define as "habitual" .. more than one.. more than three? Would you recommend progesterone after only one miscarriage if the woman had the other symptoms?

Wild yam is supposed to be excellent in aiding the production of progesterone. You can make a tea of 2 parts wild yam, 1 part black haw and 1 part cramp bark. Another tea that might be helpful is 3 parts cramp bark, 1 part black haw and 1 part false unicorn root.

Regarding natural progesterone--wild yam is the most popular source. Tea can be used, but it is very, very bitter and hard to establish an amount. A company called the Women's Health Connection in Oregon manufactures the brand of cream that we use, but there are others available in health food stores, etc.

As to use--is we have a client who we get to before pregnancy begins, we have her begin using the cream (1/4 tsp. applied externally 2 times daily) BEFORE conception. Of course this has only happened a few times, but so far has been 100% successful in the habitual pattern we are talking about. The other clients--several (like 10-12 of them that I have documented in the last 2 years) call with complaints of heaviness, missed period and usually no morning sickness (whereas they had nausea with the babies they carried), and maybe cramping and/or spotting. These have been EARLY, like a few days to 2 weeks after missed period. They get started on the cream immediately and it works. The times it hasn't worked has been when they were farther along in their pregnancy or didn't call until a few hours of bright red bleeding had occurred. Hope this helps. Call 1-800-866-9085 to order the cream. It comes in 2 oz. jars. PLEASE REMEMBER TO TELL CLIENTS TO WEAN OFF OF IT GRADUALLY AT ABOUT 14 WEEKS, unless you do blood tests to verify progesterone levels. Did that answer the questions? Hope it works as good for you as it has for our clients (and one of my partner midwives used it too.)

I had a tape by Nora Tallman ND speaking at the Pacific NW Herb Symposium in which she says that wild yam cream applied for several months before pregnancy will diminish morning sickness in women who experienced it in previous pregnancies because it increases their progesterone. This confuses me because aren't high morning sickness pregnancies less likely to miscarry? Or is that an old wives tale?

Also interesting: Susun Weed recommends increasing progesterone in the last 2 weeks of the cycle to prevent miscarriage. However she says that taking it all the time will prevent conception. The birth control pill was originally made from wild yam.

This stuff about giving various doses of progesterone to a few women, by various routes and for various durations is all wrong. You're using a placebo !

There have been a number of RCTs of this and other interventions in recurrent miscarriage, as well as some meta-analyses. What they all show is that: a) doing nothing results in most women with previous miscarriages ( even x>3 ) don't miscarry next time; and, b) none of the pharmaceutical interventions is better than a clinician taking a great deal of interest in the woman and her problem, possibly offering weekly "reasssurance scans".

If you're interested in helping these women please do so, but don't waste money helping the pharmaceutical companies too.

Remember stilboestrol in the 1950's/60's ?

Could I respectfully point out that the evidence clearly shows that giving any form of hormonal support - hCG or prog included (outside of assisted conception programs) is completely ineffective. Low progesterones may be the result of a failing pregnancy they are certainly not a cause.

Not that long ago everyone believed estrogens were the answer - remember where all that Stilbesterol got us?

Prog supplements are at best a costly placebo - at worst they may be harmful.

The fact that they are proven of no benefit doesn't stop folks up here from prescribing it  like candy! even a lot of the Naturopathic docs prescribe if often. It's almost a fad drug.

Problem is that everyone hates to see a mom with repeated SABs miscarry again. We all want to do "SOMETHING to make this pregnancy  work for her. So folks grab for the latest 'cure". Odds being what  they are, the substance often "seems" to work  -- and so we are  convinced that it does work.

In my own time as a midwife I've seen Stibestrol (DES), thyroid medication, Vit E, vit B injections, chiropractic adjustments, reflexology, aspirin, progesterones, valium, Phenobarbital, and various  and sundry herbal combinations come into fashion as misc. preventives.  Gosh, I even remember a doc who was using liver infusions!

Lately wild yam seems to be the thing folks are trying.

I sure hope something works someday. I worry about this experimentation we are doing.

DES 'seemed" to work, even though the research was clear as early as the late fifties that it was not effective. That didn't stop folks from using it,  on the basis that it "might work, and couldn't do any harm". And obviously there was no harm to the babies who were born. they appeared perfectly normal.  Now, of course, we know that they were NOT unharmed.  I hope we don't repeat  that history with some of these other "miscarriage cures".

I agree that if a woman is a habitual aborter (had 2 in a row) she must start measures immediately upon finding she has missed a period.If they have missed 2 in a row I put them on progesterone, have them take our miscarriage remedy and even put them on complete bedrest until 3 weeks after they normally abort.  When they deliver and get pregnant again, we just have them on the creme and the miscarriage remedy.  It is a cycle and needs to be broken.  Get the hormones in balance and most women will deliver term babes.

Pregnancy management for habitual aborters is a complex issue and largely beyond the scope of the average midwife. It is useful, however, to have a working understanding of pregnancy loss; There is a big difference between someone with a single or maybe even two non-consecutive ABs and a "habitual aborter" (3 or MORE); these women need to be worked up for a wide variety of disorders such as abnormal karyotype, thrombophilias, uterine anomalies and of course, hormone "imbalances". Just giving progesterone doesn't "fix" everyone and the odds are that sooner or later you are probably going to get a "good" pregnancy anyway.

The number one cause of spontaneous AB is abnormal chromosomes or major birth defects; this is how nature cleans house. The majority of misses are going to occur between 4 & 10 weeks so some kind of heightened surveillance in this period (or prior to conception) will be needed if you are going to "save" pgs.

If the mom is bleeding, I try and determine where the blood is coming from; I take detailed hx, examine her cervix to r/o polyps, large ectropion, any other obvious condition, then do an ultrasound to see if pregnancy is viable and whether there is bleeding/clot in the uterus; ALL women are advised to go on pelvic rest until 1 to 2 weeks after ALL bleeding is resolved (at any time in pregnancy) About 25% of early pregnancies have spotting/bleeding in the first trimester and half of those will miscarry for a variety of reason, usually the ones that also have pain/cramping. The final, real cause of most miscarriages will not be determined, except perhaps in retrospect if workup identifies a condition likely to result in recurrent AB. I do not believe that putting every pregnant woman who spots or bleeds prior to 10 weeks on progesterone is necessary or appropriate. Although it is expensive, I submit POC for cytogenetic analysis in women who are habitual aborters if they desire; we sometimes confirm abnormal chromes and depending on type, can look back on mom and dad.

 I live in Silicon Valley, the stress-capitol of the country (we can all argue this I'm sure) and it is NOT going away. No matter what I do, stress will NOT be removed, its part of our culture. I am continually amazed at how much stress women try and gestate under. We have a HUGE population of  ART patients who have had all kinds of reproductive casualties and most, ultimately have IVF pregnancies (many multiple) with a majority over the age of 40 years old. Believe me, these women are getting everything; progesterone, estrogen, aspirin, heparin, blood cell infusions, you name it. I have noted that a significant portion of the progesterone supported pregnancies (intravaginal application) begin spotting as a result of cervical irritation/inflammation but of course you have to keep "throwing" everything at these cases. Oh well..........placebo affect must also be considered........

I don not have the new edition of Guide to Effective Care.... but it says progesterone supplements aren't effective (or no more so than placebo)  -- except "possibly" in the very rare group of women with short luteal phase. Those are pretty easy to figure out -- they usually have very short cycles -- under 25 days.

I use mixture of squaw vine, false unicorn, wild yam and cramp bark, bedrest, hydration, and progesterone creme.

[from ob-gyn-l]

Please respond with your up-to-date knowledge of the risks of progesterone therapy and the benefits in this pregnancy.

What is the benefit of beta mimetics as regards to premature delivery ?

As for natural micronized progesterone (sthg coming from around here) it has the agreement for early contractions but not yet for premature labour. It is widely used in this country anyway in this indication, but there is no actual evidence of its interest. Except that the most important is the side effects. Patients are always sleepy. And it's difficult to sleep standing :-) Some people said it caused cholestasis but were never able to prove it.

This brings up a question I have had for sometime. There was a brief discussion about it 2-3 years ago on OB-Gyn-L (early in the life of the list) but I never saw a definitive answer. Here is the question: What are the effects of progesterone and estrogen on uterine perfusion? And can this have something to do with non-specific causes of miscarriage? Also, what about the effect of catecholamines like epinephrine on the vessel sizes and perfusion (i.e. how much could stress cause vessel constriction and reduction of perfusion leading to early miscarriage)? In the mid-1980's we published a couple of papers on sonographic measurements of the uterine myometrial arcuate vessel diameters and the menstrual cycle. We could see and measure change in the vessel diameters, with maximum dilation coming at mid cycle (11-17 days). We had assumed that estrogen was in control of the perfusion since progesterone has a later increase that did not seem to increase vessel size. This also seemed to be the findings of Resnik in sheep experiments, they also pointed out that catecholamines reduced perfusion. This would lead me to believe that all fertility programs should include deep-breathing relaxation and T-M just to maintain perfusion until the placenta and fetus can kick in some hormonal support. I don't mean to get too new age on this list, but when my wife and I went through a few infertility cycles (without success), it was quite stressful. A little like having the Gyn and the nurse in bed with us.

Here are the references from above:

1. DuBose TJ, Hill LW, Cunyus JA, et al.; Sonography of menstrual changes in arcuate uterine blood vessel diameters. J Cardiovascular Ultrasonography, 1985; 4:243-251.
2. DuBose TJ, Hill LW, & Hennigan HW; Sonography of arcuate uterine blood vessels. J Ultrasound Med. 1985; 4:229-233.
3. Resnik R: Anatomic alterations in the reproductive tract; In: Creasy RK & Resnik R, editors; Maternal-Fetal Medicine: Principles and Practice, 2nd ed. W.B. Saunders Co., 1989, p. 137-140.

I have read your work. There is no question, at least from sheep experiments, that the myometrium and its vascular supply are affected by the steroids you mentioned. Progesterone to prevent miscarriage, however, has been tested clinically over and over, as far back as the late 50's with absolutely no proven advantage over placebo.

This is puzzling, isn't it, given the early work by Assali and some of the material published by Donald Baron's group?

This is my impression, also. However, I routinely see women (even with normal obstetric histories) who are followed by obtaining serial progesterone levels early in pregnancy. If the levels are not "appropriate" then they are given progesterone supplementation. This seems unfair, since it gives false hope to the patient, who may have an abnormal pregnancy to begin with (nothing like stringing along a fetus with a chromosomal abnormality). Although it may make some sense theoretically, I certainly can't find data anywhere to support it.

The practice gains some momentum from in vitro fertilization procedures where patients are given IM Progesterone daily for many weeks. Or from situations where luteal phase abnormalities are suspected of causing early pregnancy loss and progesterone is given to support the luteal phase.

Although this is a completely different situation, I believe that it's one reason why the practice continues.

The only documented indications for progesterone therapy in the first trimester are it's use in patients with progesterone deficiency (luteal phase defects), in patients at risk to have an abnormal estradiol/progesterone ratio (primarily IVF patients having undergone controlled ovarian hyperstimulation), and in patients with no endogenous progesterone production (donor oocyte IVF patients, cryopreserved embryo transfer cycle patients). Even in IVF patients, I prefer to use hCG for luteal phase support (to stimulate endogenous ovarian production of progesterone) to decrease the estradiol/progesterone ratio if I am not concerned about increased risk of hyperstimulation.

I do not feel there is support for it's empiric use in a patient with a past history of twins and premature labor.

This was my understanding. However, I frequently hear of patients who spontaneously conceive, have a benign pregnancy history, but have progesterone levels checked, and if the level is below a certain level are prescribed progesterone supplementation "to prevent miscarriage"! Patients feel the former doctor was doing something to prevent a miscarriage, and are often angry that their current physician is not similarly compulsive. You just can't win.

I'm at least pleased that the discussion has confirmed my own conviction that there is no point in giving progesterone in this situation. My colleagues that do this will admit at least privately that there is more public relations benefit than true medical benefit. This also brings to mind the thread about terbutaline and nominal premature labor and the sense that a good outcome somehow proves its value.

Plant Steroids

Plant steroids are usually called phytosterols, and, when they have any hormonal effect at all, it is usually to interfere with human hormone functions. Beta sitosterol, found in lots of food, interferes with the ability to absorb cholesterol from the diet. Corn oil and legumes are two well-endowed sources that can help lower chole cholesterol is readily manufactured in the body, and elevated cholesterol in the blood is often the result of internal hormone and neurologic stimulus, not the diet. Cannabis can act to interfere with androgenic hormones, and Taraxacum phytosterols can both block the synthesis of some new cholesterol by the liver and increase the excretion of cholesterol as bile acids; but other than that, plants offer little direct hormonal implication.

The first method discovered for synthesizing pharmaceutical hormones used a saponin, diosgenin, and a five-step chemical degradation, and another, using stigmasterol and bacterial culturing, to get to cortisol. These were chemical procedures that have nothing to do with human synthesis of such hormones, and the plants used for the starting materials-Mexican Wild Yam, Agave, and Soy were nothing more than commercially feasible sources of compounds widely distributed in the plant kingdom. A clever biochemist could obtain testosterone from potato sterols, but no one would be likely to make the leap of faith that eating potatoes makes you manly (or less womanly), and there is no reason to presume that Wild Yam (Dioscorea) has any progesterone effects in humans. First, the method of synthesis from diosgenin to progesterone has nothing to do with human synthesis of the corpus luteum hormone; second, oral progesterone has virtually no effect since it is rapidly digested; and third, orally active synthetic progesterones such as norethindrone are test-tube born, and never saw a Wild Yam.

The only "precursor" the ovaries, testes and adrenal cortices EVER need (and the ONLY one that they can use if synthesising from scratch) is something almost NONE of us ever run out of...Low Density Cholesterol. Unless you are grimly fasting, anorectic, alcoholic, seriously ill or training for a triathlon, you only need blood to make steroid hormones from. If hormones are off, it isn't from any lack of building materials...and any product claiming to supply " precursors" better contain lard or butter (they don't)...or they are profoundly mistaken, or worse.

The recent gaggle of "Wild Yam" creams actually do contain some Wild Yam. (Dioscorea villosa, NOT even the old plant source of diosgenin, D. mexicana... if you are going to make these mistakes, at least get the PLANT right) This is a useful and once widely used antispasmodic herb...I have had great success using it for my three separate bouts with kidney stones...until I learned to drink more water and alkalizing teas and NEVER stay in a hot tub for three hours. What these various Wild Yam creams DO contain, is Natural Progesterone. Although this is inactive orally (oral progesterone is really a synthetic relative of testosterone), it IS active when injected...or, to a lesser degree, when applied topically. This is pharmaceutical progesterone, synthesized from stigmasterol, an inexpensive (soy-bean oil) starting substance, and, although it is identical to ovarian progesterone, it is a completely manufactured pharmaceutical. Taking advantage of an FDA loophole (to them this is only a cosmetic use...they have the misguided belief that it is not bioactive topically), coupled with some rather convincing (if irregular) studies showing the anti-osteoporotic value of topical progesterone for SOME women, a dozen or so manufacturers are marketing synthetic Natural Progesterone for topical use, yet inferring that Wild Yam is what's doing good.

I am not taking issue with the use of topical progesterone. It takes advantage of the natural slow release into the bloodstream of ANY steroid hormones that have been absorbed into subcutaneous adipose tissue. It enters the blood from general circulation the same way normal extra-ovarian estradiol is released, and this is philosophically (and physiologically) preferable to oral steroids, cagily constructed to blast on through the liver before it can break them down. This causes the liver to react FIRST to the hormones, instead of, if the source is general circulation, LAST.

My objection is both moral and herbal: the user often believes the hormonal effects are "natural", and that the Wild Yam somehow supplies "precursors" that her body can use if needed, rejected if not. This implies self-empowerment and the honoring of a woman's metabolic choice... something often lacking in medicine. This is a cheat. The creams supply a steady source of a pharmaceutical hormone (no precursor here) normally only available by prescription, but are SOLD as if the benefits come from the Wild Yam extract, seemingly formulated with the intent of having Wild Yam the most abundant substance so it can be listed first in the list of constituents. I have even seen the pharmaceutical Natural Progesterone labeled as "Wild Yam Proges- terone" or "Wild Yam Estrogen precursor" or, with utter fraud, "Wild Yam Hormone". To my knowledge, the use of Mexican Yam for its saponins ceased to be important by the early 1960's, with other processes for synthesizing steroids proving to be cheaper and more reliable. I have been unable to find ANY manufacturer of progesterone that has used the old Marker Degradation Method and/or diosgenin (from whatever Disocorea) within the last twenty years.

Just think of it as a low-tech, noninvasive and non-prescription source of progesterone, applied topically and having a slow release of moderate amounts of the hormone. Read some of the reputable monographs on its use, make your choice based solely on the presence of the synthetic hormone, and use it or don't. It has helped some women indefinitely, for others it helped various symptoms for a month or two and then stopped working, for still other women I have talked to it caused unpleasant symptoms until they ceased its use. Since marketing a product means selling as much as possible and (understandably) presenting only the product's positive aspects, it would be better to try and find the parameters of "use" or "don't use" from articles, monographs, and best of all, other women who have used it. Then ask them again in a month or two and see if their personal evaluation has changed. If you have some bad uterine cramps, however, feel free to try some Wild Yam itself...it often helps.

Unless there is organic disease, hormones are off because the whole body is making the wrong choices in the hormones it does or doesn't make. It's a constitutional or metabolic or dietary or life-stress problem, not something akin to a lack of essential amino acids or essential fatty acids that will clear up if only you supply some mythic plant-derived "precursor". End of tirade.

Hope this info helps. The creams that contain progesterone u.s.p. can be used but should be monitored by a professional. Wild yam creams without progesterone u.s.p. are useless.

See also:  Herbs/Wild Yam

Completing A Miscarriage

Study: Abortion pills don't boost later miscarriage risks - This suggests that completing a miscarriage using Cytotec  is less likely to cause a subsequent miscarriage than a D&C or any surgical intervention that forcibly opens the cervix.

Treatment Method After a Miscarriage Does Not Affect Subsequent Pregnancies CME - Actually, it doesn't affect fertility rates.  They didn't measure how treatment methods affected labor and birth, i.e. whether a stenotic cervix complicated labor and necessitated a c-section.

Cytotec Safe and Effective for Management of Early Pregnancy Failure - Medical management of early pregnancy failure with 800 µg of Cytotec (misoprostol) is a safe and effective alternative to vacuum aspiration, researchers reported today. [Medscape registration is free]

A comparison of medical management with misoprostol and surgical management for early pregnancy failure.
Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C, Frederick MM; National Institute of Child Health !Human Development (NICHD) Management of Early Pregnancy Failure Trial.
N Engl J Med. 2005 Aug 25;353(8):761-9.

CONCLUSIONS: Treatment of early pregnancy failure with 800 microg of misoprostol vaginally is a safe and acceptable approach, with a success rate of approximately 84 percent. Copyright 2005 Massachusetts Medical Society.

Medical treatment of missed abortion using misoprostol. [Full text article]
Ngoc NT, Blum J, Westheimer E, Quan TT, Winikoff B.
Int J Gynaecol Obstet. 2004 Nov;87(2):138-42.

[Summary from www.obgynworld.com] - The worldwide use of misoprostol for a variety of therapeutic indications in our specialty continues to increase. This randomized study from Vietnam compares oral and vaginal adminstration of the same dose (800 mcg) of misoprostol for medical termination of pregnancy in 200 women presenting with a confirmed missed abortion. Both the efficacy of the therapy and patient satisfaction was high in both groups, indicating that either oral or vaginal administration of misoprostol is appropriate for the medical management of missed abortion. The widespread availability of misoprostol, and its ease of storage and administration, may allow this drug to be especially useful to women in low resource settings.

"Medical abortion" is the use of pharmaceuticals rather than surgery to empty the uterus.  For women who have had a miscarriage, having a D&C may increase their chances of a repeat miscarriage.  A "medical abortion" is a superior option because there's no trauma to the cervix.

Reproductive Health 2002: Update on Contraception and Medical Abortion From the ARHP Annual Meeting September 11-14, 2002
[Medscape registration is free]

MEDICAL ABORTION: OVERVIEW AND MANAGEMENT - This article focuses on the FDA-approved regimen for medical abortion, discusses other regimens in current clinical use, and reviews the management of patients receiving medical abortion regimens.  [Medscape registration is free]

Surgical treatment or expectant management for miscarriage?

Herbal Suggestions for Completing Miscarriage

Many of the herbs used to cause a miscarriage can also be used to complete a miscarriage and avoid unnecessary surgery that may traumatize the uterus.  A D&C can increase the risk of future miscarriages, so many women having fertility difficulties may prefer to use herbs as the most appropriate initial treatment after miscarriage.

Here's another site with lots of great information about fertility.  It also has a subsection on terminating a pregnancy with herbs.

Pharmaceutical Methods for Completing a Miscarriage

2. Methotrexate and Misoprostol vs Misoprostol Alone for Early Abortion (A randomized controlled trial). Mitchell D. Creinin, M.D., and Eric Vittinghoff, PhD. JAMA, October 19, 1994 - Vol 272, No. 15 p 1190.

This info may muddy the discussion waters by introducing the drug "methotrexate". To help with any resulting cloudiness I offer the following:

The authors wrote:

"Methotrexate is cytotoxic to trophoblast and, in low doses, has minimal side effects. It is used to treat both gestational trophoblastic meoplasia and ectopic pregnancy. The cytotoxic effects of methotrexate on intrauterine trophoblasts should be equivalent."

To put this in more understandable terms: The drug methotrexate inhibits growth of rapidly dividing cells (ie: the egg shortly after fertilization). It is currently accepted for use in cases of hydatidiform molar pregnancies and also in tubal pregnancies. Therefore, the authors hypothesized that this drug would also be effective in early (as in < or = 56 days from 1st day of last menses) medical abortions.

The dosage of cytotec (misoprostol) used in these studies was 400 mcg. The route was vaginal.

Cytotec 800 mcg (yes you read it right) intravag and repeat in 4 hours since there is no baby there is no limit on the number of repetitions.  It is quite normal to have 0 ctx for several applications then to have one or two tetanic ctx with evacuation of the POC.  WATCH FOR BLEEDING...be ready to give pit or po methergine.  Save POC and if you have access to an abortion facility you can have them check for completeness.

Place with as little lubricant as possible.  Helps also if a couple of ccs of vinegar is introduced after cytotec placed.  follow by a 4x4 gauze tampon.  Keep woman in bed for 30 minutes after placing tabs.

Expect: mild n/v (ginger tea for this) and diarrhea (not so mild) ---try Miso soup for electrolyte replacement.

I seldom see big pain with this procedure except for several long strong ones at the end.  You can do a paracervical block or use viscous lidocaine (lido mixed with KY) periodically as a cx massage to relieve pain.  It is OK to use sterile water papules or a tens unit also...but...NO Aspirin or Motrin until the POC are evacuated.

Visualization also helps a lot....but keep it non morbid...bless and release the little spirit and the dreams for that child rather than thinking of dead tissue.

Dr. Richard U. Hausknecht of Mount Sinai School of Medicine in New York published a study of the use of the combination of methotrexate and misoprostol to induce abortion in the Aug. 31 in the New England Journal of Medicine.

Methotrexate is FDA-approved for use against cancer; Misoprostol is FDA approved to treat ulcers. Because both are FDA-approved, they can be prescribed by physicians today and together, they produce abortions at a better rate than the RU-486 pill.

[from ob-gyn-l]

About Mifepristone, It is called Mifegyne in France, you can utilize it for abortion until 49 days of amenorrhea. You have to give 600 mg. Once and use prostaglandins analog from 36 to 48 hours after the RU. In the pratique, women have to take orally RU in your presence and come back to clinic 2 days after, have the prosta, injection or orally. Then often the abortion occurs, with bleeding. She can have a antalgique. She goes back home accompanied, 2 hours later. It works in more than 95%. You must verify the vacuity of uterus maximum 9 days after. You have to give a contraception. Excluded to this technique, hemostat troubles, cortosurrenal insufficiency, people with corticotherapy. Until now, we did not propose this to smokers. Because of cardio-vasc problems seen with another prostaglandin analog on smokers. This year it seems not to be an motif of exclusion. I think that women who goes to this RU must be strong in her mind with the decision of abortion. The does all by herself so she feels completely responsible. Most of M.D. in France consider that it is a complication compared to the surgical way. Easier for us. The public hospitals goes on this technique, private breaks on it. RU is used to prepare cervix for surgical abortion, as we done before with laminaires. RU is used for Abortion in the second and third trimester. To prepare the cervix. It works very well. It is also used, in selected areas for the preparation of the cervix on declenchement of post term pregnancy, normal pregnancy. But no one will say that to you. It is experientially done.

It has been a great product for all of us here in India. we have been combining the product with misoprostol for terminations up to 9 weeks as a domiciliary therapy. Beyond up to 20 weeks we have combined it again as a multidose vagino-oral therapy with misoprostol. Our Success has been terrific with this regimen . Up to 9 weeks :

complete Abortion rate: 99.2 % . No Incompletes, no excessive post abortal bleeds . We have had only 0.8% complete failures.

The regimen we use is called a Mifepristone with Multi-dose Misoprostol therapy. The key to this regimen is that once you have given 200 mg Mifepristone on Day 1 of the therapy . On Day 2 we give no treatment until unless they have an bleed on that day itself in that case we treat as a day3 case. This premature abortion occurs in around 20 % of the cases. On day 3 we give a stat dose of 400mcg of Misoprostol orally then in 90% of cases the bleeding starts in about 30 mins and abortion process is completed in about 2 hours . We then follow it up with additional 200 mcg of misoprostol after 3 hours of the first dose. This ensures that uterus is completely emptied & prevents incompletes.

In case they fail to bleed within 3 hours of the first dose we repeat 200mcg misoprostol every 3 hours till abortion process is initiated after which we give the final 200mcg of misoprostol to complete the process.

We have published details in " Kini P & Rajagopal N (1996): Medically Induced (non-surgical)early first trimester abortion with mifepristone (Ru-486) and multidose misoprostol. J.obstet gynecol India. Vol 46 No 1 pg 470. The journal of Obstetrics & Gynecology, Cama & Albless Hospital, New Building , 6th Floor, Mahapalika Marg, Bombay 400 001 India for reprints.

I tend to agree with the view that surgical TOP is an easier option for T1 terminations. But the main issue here is women's choice and an increasing number of women in the UK chose the medical option after honest discussions. A lot depends on what they've heard from their peers too. In Glasgow the uptake is much less than in the east of Scotland where much pioneering work on mifepristone has been done.

As far 2nd trimester TOP and intrauterine fetal death mifepristone is streets ahead as far as I'm concerned. I wouldn't want a relative of mine treated with anything else.

I've seen women hold onto non-viable pregnancies for weeks, finally ending in a D & C.

I am not sure where I read this, so I cannot produce any documentation but maybe someone else can, but I had read that the normal time to hold onto a non-viable pregnancy is 4 weeks. This source said that once we finally lose the pregnancy that the baby has probably been dead a month. With the age of US we may be seeing this change a lot since D&Cs are being done once a dead baby is detected with a routine US. And if you think about it, how many times have you seen a 10 weeker miscarry a 6 week size baby.

Some References

"Methotrexate and misoprostol for early abortion." Family Medicine 28(3):198-203, 1996 March.

Brief synopsis: 8 wk or less pregnant, 50 mg/m2 methotrexate, 800 mcg misoprostol oral or vaginal day 3-4 or day 5-7. repeat 800 mcg if no bleed and < 12 weeks preg. results: 97% (274/282) had medical abortion, 3% (8 subjects) required surgical intervention--4 for failure to abort and 4 for continued bleeding.

"Evaluation of the effectiveness of vaginal misoprostol to induce first trimester abortion." Contraception 53(4):244-6, 1996 Apr.

Brief: two groups, one 200 mcg q6h and one 400 mcg q6h, both vaginal. with 48 hrs of treatment, 46% of 200 mcg group and 66% of 400 mcg group aborted (there were 101 and 133 patients in the groups).

"The use of misoprostol for termination of early pregnancy." Contraception 53(4) 238-42, 1996 Apr.

Brief: 58 women, < 10 weeks pregnant, varying doses. 61% abortion rate, all within 24 hours. They used laminaria in some and tamoxifen in some but found no difference in success.

"Medical management of miscarriage: non-surgical uterine evacuation of incomplete and inevitable spontaneous abortion." BMJ 306(6882): 894-5, 3 Apr 1993.

Brief: 42 women received sulprostone 0.5 mg IM (20 subjects) or misoprostol 400 mcg orally. 2 failures, both for incomplete Ab.

"Misoprostol in the management of spontaneous abortion." Br J Ob Gyn 102(10):832-5, Oct 1995.

No abstract.

I researched this for a paper I did over a year ago. Three of the sources I used are:

CONTRACEPTION 48, October (p 339 -348)

JAMA vol 272, no. 15, October 19, 1994 (p 1190 - 1195)

THE MEDICAL LETTER vol. 38, issue 973, April 26, 1996 (p 39 -40)

The dosage protocol in the randomized controlled trial reported in the above cited JAMA article were as follows:

Intramuscular administration of 50 mg of methotrexate PER SQUARE METER OF BODY SURFACE AREA.

followed three days later by:

Vaginal administration of 800 mcg of misoprostol (cytotec)
NOTE! the misoprostol (cytotec) dosage is MICROgrams, not MILLIgrams!

Second trimester pregnancy termination including fetal death: comparison of five different methods.

Abstract

OBJECTIVE: To compare the efficacy of methods for second trimester pregnancy termination.

METHODS: A prospective randomized study of women undergoing pregnancy termination between 14 and 28 weeks gestation. Three hundred and forty patients with poor cervical condition (Bishop score < or = 4) in whom one of five termination methods were used were assessed: (i) extraamniotic administration of ethacridine lactate (82 patients); (ii) intracervical prostaglandin (PG) E2 gel (100 patients); (iii) intravenous infusion of concentrated oxytocin (36 patients); (iv) vaginal misoprostol (49 patients); and (v) balloon insertion (73 patients). Oxytocin infusion was used in all but concentrated oxytocin group to augment labor, when necessary. Patients in whom effective uterine contractions and cervical dilatation was not obtained within 48 h with the primary termination method were registered as failures.

RESULTS: The efficacy of each method were evaluated in terms of abortion within time. Abortion within 48 h were achieved in 98.8% (81/82) of the patients in ethacridine group; 97.3% (35/36) of the patients in concentrated oxytocin group; 90.0% (90/100) of the patients in PGE2 group; 97.2% (71/73) of the patients in balloon group; 77.5% (38/49) of the patients in misoprostol group (P = 0.000, P < 0.01, Wilcoxon (Gehan) statistic). The overall median induction-abortion interval +/- S.D. (in h) in each group were as follows: ethacridine lactate: 15.7 +/- 9.6, PGE2 gel: 20.0 +/- 14.5, concentrated oxytocin: 12.2 +/- 14.4, misoprostol: 24.0 +/- 22.2, balloon: 16.0 +/- 15.4 (one way ANOVA, P = 0.003, P < 0.01).

CONCLUSION: In comparison with the five methods, the use of extraamniotic ethacridine, intravenous concentrated oxytocin, and balloon was found to provide more effective treatment than intracervical PGE2 and misoprostol in terms of achievement of abortion within 24 and 48 h.

There is randomized prospective study for termination using cytotec in the NEJM. The dosage was 200ug in the posterior fornix. I would be very hesitant to use 600ug for an IUFD. Unless you have been associated with a ruptured uterus from too much of an oxytocic and you like to revisit that occurrence in a new patient, use of the 200ug on a q12hr basis works well. If one wants to use another effective medication then Hemabate 0.25mg IM q2hrs will usually initiate delivery and complete it in the IUFD population. After the 3rd dose, the majority of patients will experience one or more GI side effects.

In our hospital we are using very successfully Misoprostol in preparing cervix after diagnosis of missed abortion. We are beginning a randomized study comparing Dinoprostone (Prepidil) vs. Misoprostol, bur our previous experience using 800 mcg (4 comp) in posterior vaginal sac leads to spontaneous expulsion and/or cervix ripening enough to do a very easy curettage.

Methotrexate for Ectopic Pregnancy

In general, the dose is 50 mg/m2 IM and close following on hCG is the rule. If you have any doubts of the patient's compliance, it is not a suitable option.

How Long to Wait Before Trying Again

How Long to Wait Before Trying Again from Frequently Asked Questions about Miscarriage

How Long Should You Wait After a Pregnancy Loss before Trying Again?

Miscellaneous

How to Counsel Pregnant Women after Previous Pregnancy Losses