الفهرس 
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Abstract
Miscarriage or spontaneous abortion is the involuntary termination of pregnancy before 20 weeks of gestation or a fetus born weighting less than 500 grams. (Schorge et al., 2008).
First trimester miscarriage is defined as the loss of pregnancy within the first 12 weeks and 6 days of gestation. (NICE, 2012).
Missed miscarriages in the first trimester are characterized by the arrest of embryonic or fetal development with ultrasound findings of an empty gestational sac or an embryo/fetus without cardiac activity. (Danielson et al., 2007). The cervix is closed and there is no or only slight bleeding. (Silver 2010).
Misoprostol is a synthetic prostaglandin El (PGE1) analogue, and because of its cervical ripening and uterotonic properties, misoprostol has begun to be abused for illegal abortion since late 1980s. After serial trials in recent two decades, misoprostol became one of the most useful drugs in termination of pregnancy and also for induction of labor. (Lin et al., 2011).
Estrogen is important in the maintenance of pregnancy. Aromatase inhibitors, such as Letrozole, suppress the peripheral conversion of androgens to estrogens. (Yeunget al., 2012).
Letrozole is a selective and reversible aromatase inhibitor used to treat estrogen-dependent breast cancer. (Gibson et al., 2009).
One study has shown that Letrozole 7.5 mg given daily for two days and then followed by 800 mcg of vaginal misoprostol induces complete abortion in 80% of patients. (Kallner, 2012).
This study was conducted at outpatient Obstetric clinic of Ain Shams maternity hospital in the period between June 2017 and December 2018.
The patients who were fulfilling the inclusion criteria, were recruited in the study, then an informed consent was taken before starting the trial.
Detailed history was taken and careful examination was done for all patients.
Also necessary investigations as hemoglobin, blood group, RH and trans-vaginal ultrasound scan were done for patients before the study.
88 patients were divided randomly into two equal in number groups:
First group:
The patients received 800 mcg of misoprostol (four tablets, each tablet 200 mcg) vaginally as a single dose.
Second group:
The patients received letrozole 10 mg (4 tablets, each one 2.5 mg) as a single dose for 3 days followed by 800 mcg misoprostol vaginally.
In both groups women were allowed to go home 4-hour after administration of misoprostol if bleeding was not heavy and abdominal pain was not severe. Upon discharge from hospital, participants were given diary cards to record days and amount of vaginal bleeding and side effects.
The patients were informed to return to the hospital if sever pain or bleeding had occurred, intolerable side effects, on the third and seventh day after the first dose of misoprostol for follow up.
At the third day ultrasound was done, second dose of misoprostol 800 mcg was given vaginally if missed or incomplete miscarriage.
At the seventh day ultrasound was done, and evacuation was done if missed or incomplete miscarriage.
Surgical evacuation was also allowed at any time even before the seventh day follow up visit if there was sever vaginal bleeding (inevitable miscarriage).
The primary outcome of this study is the complete abortion rate without need for surgical evacuation which was reached by complete expulsion of products of conception and can be diagnosed by ultrasound examination that showed empty endometrial cavity.
This study demonstrated that 10 mg (four tablets) of letrozole orally for three days followed by 800 mcg (four tablets) of misoprostol vaginally is more effective than misoprostol alone for induction of first trimesteric missed miscarriage.
In the total of 88 patients who were recruited in the study, 3 patients dropped from the study, 2 patients from the first group and 1 patient from the second group, so 85 patients were analyzed, the complete abortion rate of the letrozole group was significantly higher than that of the misoprostol only group (83.72% compared to 64.29%).