HDL concentration, lipid transfer to HDL, and HDL size in normolipidemic nonobese menopausal women

Objective

To determine the impact of menopause on lipid transfer from donor lipoproteins to high-density lipoproteins (HDLs)—a process that is related to the protective function of HDL—and the size of HDL particles.

Method

Plasma from 22 premenopausal and 18 postmenopausal nonobese, normolipidemic women paired for age (40-50 years) was incubated in an artificial nanoemulsion labeled with radioactive lipids. Then the HDL fraction was assessed for radioactivity; the percentage of radioactive lipids transferred from the nanoemulsion to HDL was determined; and the size of HDL particles was measured by laser light scattering.

Results

There were no differences between the 2 groups in serum concentration of HDL cholesterol (61 ± 12 mg/dL vs 61 ± 14 mg/dL) or apolipoprotein A₁ (1.5 ± 0.3 g/L vs 1.5 ± 0.2 g/L); lipid transfer to HDL; or size of HDL particles (8.8 ± 0.8 vs 9.0 ± 0.5 nm).

Conclusion

Menopause was not found to affect HDL cholesterol plasma concentration, lipid transfer to HDL, or size of HDL particles in normolipidemic nonobese women.     

Secreted cyclophilin A induction during embryo implantation in a model of human trophoblast-endometrial epithelium interaction

Objective

The aim of this study was to show glycemic and oxidative/antioxidative status (GOAS) in rats with estradiol valerate (EV)-induced polycystic ovarian syndrome.

Study design

Thirty mature female rats were randomly allocated to EV-induced PCOS, sham and control groups. Malondialdehyde, catalase and fasting blood glucose levels were determined in order to evaluate GOAS.

Results

There was a statistically significant difference between PCOS and control groups (p < 0.001) for hemolysate MDA while no difference was determined for either catalase or fasting blood glucose levels. On histopathological examination, the EV-induced PCOS group revealed disease-characteristic ovarian morphology.

Conclusion

There was an increased compensation for oxidative stress by antioxidative biologic mechanisms in EV-induced PCOS rats. Interestingly, the sole result derived from this limited study is that the sesame oil + EV combination is not appropriate for the evaluation of oxidant-antioxidant status and also glycemic condition in PCOS. This study demonstrates the need for better designed experimental studies to elucidate the aetiopathogenesis of PCOS via novel techniques.     

Doppler analysis of uterine perfusion and ovarian stromal blood flow in polycystic ovary syndrome

Objective

To investigate blood flow velocity in the ovarian stromal artery and uterine artery in women with polycystic ovary syndrome (PCOS) and to correlate these velocities with clinical and biochemical parameters.

Methods

A prospective study was carried out in 55 patients with PCOS and 42 age-matched women who did not have PCOS. Clinical, biochemical, and hormonal characteristics, and utero-ovarian Doppler ultrasound blood flow parameters were determined, and correlations between the parameters were evaluated.

Results

Ovarian stromal blood flow was higher (P < 0.01) and uterine perfusion was lower (P < 0.01) in women with PCOS compared with women who did not have PCOS. Ovarian stromal artery pulsatility index (PI) was inversely correlated with levels of dehydroepiandrosterone sulfate (DHEAS) and insulin-like growth factor-1, and with the luteinizing hormone/follicle-stimulating hormone ratio. There was a positive correlation between uterine artery PI and DHEAS level.

Conclusion

Doppler analysis of the uterine and intraovarian arteries may provide additional information about the etiopathogenesis of PCOS and partly explain the clinical implications of the condition.     

Effect of body mass index on clinical manifestations in patients with polycystic ovary syndrome

Objective

To determine whether there is a correlation between body mass index (BMI) and blood pressure or clinical features such as hirsutism in women with polycystic ovary syndrome (PCOS).

Method

In this cross-sectional study, 62 women with PCOS were allocated to one of 3 groups according to a BMI range defining normal weight, overweight, or obesity. Blood pressure, waist-to-hip ratio, Ferriman and Gallwey hirsutism score, and presence of acne were recorded for each participant and the means were compared among groups.

Results

The overall mean age was 35.85 ± 5.03 years; BMI, 31.91 ± 6.40; systolic and diastolic blood pressure, 113.02 ± 16.10 mm Hg and 71.79 ± 10.04 mm Hg; waist-to-hip ratio, 0.82 ± 0.07; and hirsutism score, 3.63 ± 4.35. Acne was present in 24 participants. Of these, 8 (33.3%) were overweight and 13 (54.2%) obese. When groups were compared, a progressive and significant increase in systolic and diastolic blood pressure was observed from the normal weight to the obese group.

Conclusion

We observed a significant and progressive correlation between BMI and both blood pressure and clinical features in women with PCOS.     

Abdominal electromyography may predict the response to tocolysis in preterm labor

Objective

To determine whether abdominal electromyography can predict the response to tocolysis in pregnant women in preterm labor.

Study design

This study was carried out at the Department of Obstetrics and Gynecology, Menofyia University Hospital in Egypt. Fifty pregnant women in preterm labor who fulfilled the inclusion criteria were enrolled. Baseline abdominal electromyography was performed. Tocolysis in the form of hexoprenaline sulphate infusion was started for all women and electromyography was repeated after 24 h in responders but only after 6 h in non responders. The receiver operating characteristics curve was drawn to calculate specificity of the electromyography at 100% sensitivity. Results were tabulated and statistically analyzed.

Results

Forty women responded to tocolysis by delaying delivery for more than 48 h. There was a significant reduction in the frequency of uterine contractions after tocolysis (3.76 ± 0.92 versus 2.32 ± 2.05 contractions per 10 min; P < 0.001). Similar significant reductions affected the duration and amplitude of uterine action potentials (25.08 ± 9.74 versus 14.4 ± 17.16 s; P < 0.001, 40.8 ±  25.89 versus 28.32 ± 29.38 mV; P < 0.001). At a sensitivity of 100% and using ROC curve, abdominal electromyography of amplitude of 82 mV lasting for 30 s or more had a specificity of 90%, positive and negative predictive values of 67% and 95%, and a diagnostic accuracy of 88% in predicting preterm labor.

Conclusion

Abdominal electromyography may predict the response to tocolysis in preterm labor.     

Maternal serum protein S forms in pregnancies complicated by intrauterine growth restriction

Objectives

The clinical relevance of protein S deficiency in pregnant women remains controversial. Major debate exists regarding which parameter (total protein S antigen, free protein S antigen or functional protein S) should be evaluated in order to define protein S deficiency. The present study aimed to identify which of these parameters correlate with intrauterine growth restriction (IUGR).

Study design

A retrospective case-control study of women with IUGR (n = 27) and healthy controls (n = 123) in the third trimester of pregnancy.

Results

The maternal serum of women in the IUGR group had significantly lower levels of functional and free protein S compared with the control group: 54.07 ± 24.72% vs 65.20 ± 17.95% (p < 0.005) and 42.88 ± 11.01% vs 56.64 ± 13.30% (p < 0.0001), respectively. No significant correlation was found between total protein S and IUGR.

Conclusions

Levels of functional and free protein S are correlated with IUGR.     

Serum adiponectin and resistin in relation to insulin resistance and markers of hyperandrogenism in lean and obese women with polycystic ovary syndrome

Objectives

It seems that adipokines participate in disturbances of the function of the hypothalamus-pituitary-ovary axis. The aim of the study was to assess the relationship between plasma adiponectin and resistin levels and insulin resistance and markers of hyperandrogenism in lean and obese PCOS women.

Study design

Forty-one women with PCOS (22 lean and 19 obese) and 16 healthy lean women were enrolled. Body mass and height were measured and body mass index was calculated. In addition to serum glucose, lipids, androgens and insulin, adiponectin and resistin concentration were assessed in the fasting state. The insulin resistance was calculated based on the HOMA-IR.

Results

Similar serum resistin concentrations were found in both PCOS subgroups and controls. The obese PCOS subgroup was characterized by the lowest serum adiponectin level (10.8 ± 8.3, compared with 21.0 ± 15.1 in the normal weight PCOS subgroup and 26.7 ± 12.5 μg/ml in controls). There were no correlations between resistin and adiponectin levels and HOMA-IR values and serum androgen concentrations. Significant positive correlations between adiponectin to resistin ratio and plasma FSH (r = 0.49; p = 0.001) and LH (r = 0.45; p = 0.003) concentrations, and a negative correlation with free androgen index (r = −0.34; p = 0.03) in PCOS group were found.

Conclusions

Obese but not normal weight PCOS women have lower adiponectin levels whereas resistin concentration did not differ in normal weight and obese PCOS compared to control subjects. We hypothesize that changes of the relative proportion of adiponectin to resistin, but not circulating adiponectin and resistin levels themselves, may play a role in hormonal disturbances but not in insulin resistance in PCOS.     

Brachial artery conductance during reactive hyperemia is increased in women with polycystic ovary syndrome

Objective

To examine changes in brachial artery conductance (BAC) during reactive hyperemia in women with polycystic ovary syndrome (PCOS) compared to controls.

Study design

This is a pilot case-control study performed at a single academic medical center. Changes in BAC during reactive hyperemia were evaluated in 31 women with PCOS and 11 healthy control women. Fasting glucose, insulin, lipids and androgen levels were also determined. A mixed-effects model was used to compare the PCOS curve to the control curve for change in BAC from baseline during reactive hyperemia.

Results

Body mass index (BMI) and testosterone levels were significantly increased in the PCOS group compared to controls (P < 0.05). In addition, the PCOS group had higher total and LDL cholesterol levels (P = 0.05 and 0.09, respectively). Change in BAC from baseline during reactive hyperemia was significantly increased in the PCOS group compared to controls even after adjusting for age, BMI and LDL cholesterol levels (P < 0.0001). There were no significant differences between the two groups in age, blood pressure, or fasting glucose or insulin levels.

Conclusions

Brachial artery conductance during reactive hyperemia is significantly increased in women with PCOS compared to controls and may be a novel early indicator of increased cardiovascular risk in women with PCOS.     

Polycystic ovary syndrome and abnormalities in glucose tolerance

Objectives

To compare the prevalence of abnormal glucose tolerance (AGT) among women with polycystic ovary syndrome (PCOS) and controls, and assess risk factors associated with PCOS.

Method

A fasting oral glucose tolerance test after ingestion of 75 g of glucose was administered to 264 women with and 116 without PCOS. Moreover, fasting glucose, insulin, and testosterone levels were measured in the women with PCOS. Body mass index (BMI), waist-to-hip ratio (WHR), and homeostasis model assessment-insulin resistance (HOMA-IR) were calculated for each woman with PCOS.

Results

The AGT prevalence was 14.4% in the PCOS group and 11.2% in the control group (P = 0.17). The women with both PCOS and AGT had significantly higher BMIs, WHRs, testosterone levels, and HOMA-IR values than those with normal glucose tolerance.

Conclusion

While AGT was not associated with PCOS, the women with both PCOS and AGT were significantly more obese, hyperandrogenic, and insulin resistant than those with PCOS and normal glucose tolerance.     

Assessment of bone mineral density should be considered earlier in perimenopausal women with vasomotor symptoms

Objective

To investigate the relationship between vasomotor symptoms (hot flashes) and osteopenia or osteoporosis in perimenopausal women.

Method

In this cross-sectional study 79 perimenopausal women aged between 45 and 55 years and seen at the Gynecology or Menopause Outpatient Clinic of Marmara University School of Medicine were allotted to one of 2 groups according to the presence or absence of hot flashes. The groups were then compared for bone mineral density (BMD) of the lumbar vertebrae, as measured by dual energy X-ray absorptiometry.

Results

The mean BMD measurement for vertebrae L2 to L4 was 0.32 ± 0.19 for the group with no hot flashes and  − 0.53 ± 0.21 for the group with hot flashes (P = 0.007). In the former, 6.1% of the women and in the latter, 32.6% of the women had a BMD value less than a 1.5 standard deviation from the mean (P = 0.005).

Conclusion

Women with vasomotor symptoms are more prone to have osteopenia or osteoporosis.     

The influence of body mass index on in vitro fertilization outcome

Objective

To examine whether body mass index (BMI) influences the outcome of in vitro fertilization (IVF).

Methods

We studied 516 IVF cycles, 438 undergone by nonobese (BMI ≤ 30) and 78 by obese (BMI > 30) women who all had an a priori favorable prognosis (age < 40 years and first, second, or third IVF cycle).

Results

Pregnancy was achieved in 122 (27.9%) nonobese and 12 (15.4%) obese women. The obese women required significantly longer stimulation and more gonadotropin ampoules, and had lower peak estradiol levels and a significantly lower fertilization rate; obese poor responders had a significantly lower pregnancy rate than nonobese poor responders; and the prevalence of poor responders was significantly higher among obese than nonobese women (28.2% vs 16.9%, P < 0.04).

Conclusion

While the likelihood of poor responders was increased among obese women, reasonable conception rates were achieved in nonobese poor responders, and were comparable to the rates in nonobese and obese normal responders.     

Efficacy of transient abdominal ovariopexy in patients with severe endometriosis

Objective

To assess adhesion formation and fertility outcome after transient abdominal ovariopexy performed in patients with severe endometriosis.

Study design

Retrospective study including 218 patients who underwent surgery for severe endometriosis from 1997 to 2009. One hundred and thirty-nine (64%) patients were infertile. The initial ASRM stage was IV in 139 cases, III in 43 cases and II in 36 cases. Adnexal adhesions were scored by using the Operative Laparoscopy Study Group (OLSG) and modified AFS scoring systems. Unilateral or bilateral transient abdominal ovariopexy of 336 ovaries was performed to prevent adhesion formation or reformation for extensive surgery. In patients who underwent a second operation, adnexal adhesion scores were reported. Fertility outcome was evaluated by a questionnaire.

Results

Second-look surgery was performed after 11.7 ± 2.4 months in 24 patients (11%) who had undergone 38 ovariopexies. Transient abdominal ovariopexy significantly decreased adnexal adhesion scores (p < 0.05). Regarding fertility outcome, the median follow up was 19.6 ± 1.5 months. Fifty-eight patients, out of 105 infertile women who actively tried to conceive after surgery, conceived, 21 (36%) spontaneously and 37 (64%) after ART. The median time interval for conception was 8.6 ± 1 months.

Conclusion

In patients with severe endometriosis, transient abdominal ovariopexy is an effective technique in preventing postoperative adhesion formation and in improving fertility outcome.

Condensation

In 218 patients with severe endometriosis, transient abdominal ovariopexy was an effective technique in preventing adhesion formation and improving fertility outcome.     

Negative correlation between D-dimer and homocysteine levels during pregnancy and the postpartum period: a prospective study

Objective

There have been conflicting data about the role of increased levels of homocysteine (Hcy) on haemostatic system. We aim to investigate prospectively the relation between serum Hcy levels and changes in haemostatic system in pregnancy and postpartum period.

Study design

Sixty-eight healthy pregnant women were included in the study. Blood samples were obtained in the 11th gestational week, 25th gestational week, 32nd gestational week and postpartum 4th week. The haemoglobin levels, white blood cell count (WBC), platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), fibrinogen, D-dimer, Hcy, vitamin B12, and folate levels were measured.

Results

Serum Hcy levels were negatively correlated with D-dimer levels (r = −0.57, p < 0.0001). The highest levels of D-dimer (1046.62 ± 322.01 ng/ml) were achieved in the third trimester and the lowest levels of serum Hcy (4.45 ± 1.23 mmol/l) were detected in the same trimester. In postpartum fourth week, D-dimer levels were decreased to normal levels (238.27 ± 198.59 ng/ml) while the serum Hcy levels were reached to the highest levels (7.99 ± 1.36 mmol/l).

Conclusion

The negative correlation between Hcy and D-dimer levels may be a compensatory mechanism to maintain the normal haemostatic balance in pregnancy. Hence, possible advantage of low Hcy levels in pregnancy may be to prevent undesired thrombosis.     

Urodynamic findings in women with pelvic organ prolapse and obstructive voiding symptoms

Objective

To determine whether obstructive voiding symptoms in women with advanced pelvic organ prolapse (POP) were associated with objective bladder outflow tract obstruction.

Methods

We reviewed preoperative data from patients with advanced POP who underwent surgical correction at the Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel, between December 1, 2005, and November 30, 2007. Obstructive voiding symptoms were recorded from Pelvic Floor Distress Inventory-20 questionnaires.

Results

Of the 81 women aged 44-80 years who were included in the study, 40 (49.4%) reported incomplete bladder emptying preoperatively. There was no significant difference between these women and asymptomatic women in terms of demographic and clinical parameters such as age, parity, and stage of prolapse. Furthermore, there was no significant difference with regard to postvoid residual bladder volume (52.8 ± 65.8 vs 41.6 ± 41.2 mL), maximal (23.8 ± 11 vs 21.9 ± 9.6 mL/second) and average (10.3 ± 6.2 vs 9.3 ± 4 mL/second) urinary flow velocities, prevalence of increased postvoid residual volume (10.0% vs 4.8%), or obstructive urinary flow (17.5% vs 7.3%).

Conclusion

Almost half of all women with advanced POP experienced incomplete bladder emptying; however, this symptom did not correlate with objective urodynamic bladder outflow tract obstruction.     

Induction of labor with vaginal misoprostol plus oxytocin versus oxytocin alone

Objective

To compare the effect of an oxytocin infusion alone or preceded by an intravaginal application of misoprostol for labor induction in women with term pregnancies and a low Bishop score.

Methods

This study randomized 100 multiparous women with singleton pregnancies over 38 weeks and a Bishop score less than 6 to receive either a single 50-µg dose of misoprostol intravaginally 3 hours before initiation of the oxytocin infusion or only an oxytocin infusion. The time from induction to delivery, the route of delivery, and maternal and fetal outcomes were analyzed.

Results

The mean time from induction to delivery was 9.36 ± 1.97 hours in the misoprostol plus oxytocin group and 11.08 ± 3.23 in the oxytocin alone group (P = 0.002). The rates of vaginal delivery, 1- and 5-minute Agpar scores, placental abruption, and postpartum hemorrhage were similar between the 2 groups, as were the rates of admission to the neonatal intensive care unit. There were no cases of perinatal asphyxia.

Conclusion

A 50-µg intravaginal application of misoprostol before starting the oxytocin infusion is a more effective method of labor induction than an oxytocin infusion alone for our study population.     

Determinants of fertility and reproductive success after hysteroscopic septoplasty for women with unexplained primary infertility: a prospective analysis of 88 cases

Objective

To evaluate prospectively the effect of hysteroscopic septoplasty as therapy for unexplained primary infertility in women with uterine septum as a sole cause for reproductive failure and to define the factors influencing reproductive success.

Study design

In a prospective comparative study, we enrolled 103 infertile women with uterine septum as a sole cause for reproductive failure. They had had unexplained primary infertility >2 years and a follow-up >12 months. Uterine anomalies were diagnosed by means of hysterosalpingography (HSG) and 2D-transvaginal sonography (TVS) with intrauterine saline infusion. Hysteroscopic septoplasty was performed in the early follicular phase. Pregnancy rates (PR) according to patient and septum characteristics (septum size) were the main outcome measures.

Results

Follow-up was complete for 88 patients. The mean (±SD) age of the patients was 36.1 ± 2.1 years. Forty-two patients became pregnant (40.7%). The mean (±SD) delay in conception was 7.5 ± 2.6 months. Nearly 80% of the pregnant women conceived spontaneously. Of 44 pregnancies in 42 women, 36 live newborns were delivered. The PR was significantly higher in women <35 years of age or with <3 years of unexplained primary infertility. Moreover, in women with a septum size larger than one-half of their uterine length the PR was significantly higher than those with septum size <1/2 of their uterus (P = .12).

Conclusion

Fertility and pregnancy after hysteroscopic septoplasty in women with unexplained primary infertility and uterine septum as a sole cause for reproductive failure seems to depend on patient age, duration of infertility before septoplasty, and septum size. Women with a septum size larger than one-half of their uterine length have a higher chance of successful pregnancy after hysteroscopic septoplasty.     

Single-port laparoscopic myomectomy using transumbilical GelPort access

Objective

To describe our initial experience with single-port laparoscopic myomectomy (SP-LM) using transumbilical GelPort access and the surgical technique used, and to evaluate the safety and feasibility of this procedure.

Study design

A prospective observational study was performed at a university teaching hospital from January 2009 to December 2009. Fifteen patients with symptomatic subserosal or superficial intramural myomas (≤8 cm) underwent SP-LM.

Results

The mean age and body mass index were 35.0 ± 8.6 years and 22.6 ± 2.6 kg/m². Two patients had a history of previous abdominal surgery, consisting of one and two cesarean deliveries. The mean operating time, hemoglobin change, return of bowel activity, and length of hospital stay were 81 ± 21.5 min, 1.1 ± 0.5 g/dL, 34.3 ± 5.9 h, and 3.1 ± 0.5 days, respectively. In one patient (6.7%), SP-LM was converted to two-port LM. There were no surgical or wound complications in any patient, and the histopathological result was leiomyoma in all the cases.

Conclusion

SP-LM is feasible in selected patients with symptomatic myoma.     

Endometrial ablation with the NovaSure system in Iran

Objective

To evaluate the rate of response to treatment with the NovaSure endometrial ablation device among Iranian women with menorrhagia.

Methods

Twenty 35-50-year-old women with menorrhagia who were referred to Arash Hospital, Tehran, Iran, in 2008 were enrolled. They underwent endometrial ablation via the NovaSure system and were followed-up for 2 years.

Results

The incidence of amenorrhea was 30.0% at the end of the 2-year follow-up period. Hypomenorrhea was reported by 40.0% of women. The mean number of days of bleeding per month decreased significantly, from 30.0 ± 6.4 days before treatment to 3.1 ± 2.6 days after 2 years (P < 0.001). The severity of bleeding decreased significantly within 2 years after treatment (P < 0.001). In total, 85.0% of women were satisfied and 90.0% had responded to treatment—as defined by amenorrhea, hypomenorrhea, or return to normal menstruation.

Conclusion

The NovaSure system is effective and should be considered by gynecologists for the treatment of menorrhagia.     

Circulating ghrelin levels and the polycystic ovary syndrome: correlation with the clinical, hormonal and metabolic features

Objectives

Dysregulation of ghrelin levels may lead to physiological problems including obesity and polycystic ovary syndrome (PCOS). The aim of the study was to compare ghrelin levels in women with and without PCOS.

Study design

Serum ghrelin levels (pre- and post-prandial) were compared between 30 Saudi women suffering from PCOS and 30 healthy controls. The relationship between circulating ghrelin levels and other hormones was investigated. Anthropometric measurements were made for all subjects. Biochemical and hormonal investigations included plasma glucose, insulin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), 17β-estradiol (E2), progesterone, testosterone and sex hormone binding globulin (SHGB), and serum ghrelin levels. The data were statistically analyzed using independent T-test and ANOVA. Correlation studies were performed between ghrelin levels and other variables.

Results

No differences were observed in the levels of ghrelin during fasting and the postprandial period in the PCOS (p = 0.487) and control groups (p = 0.378). A significant inverse correlation was observed in ghrelin levels (fasting and postprandial) levels and BMI (PCOS: r = −0.529; p = 0.009, controls: r = −0.670; p = 0.005); PCOS: r = −0.421; p = 0.007, controls: r = −0.491; p = 0.004 respectively). No correlations between ghrelin levels and other parameters were observed.

Conclusion

The findings of the study suggest that circulating plasma ghrelin levels were found to be normal and were inversely related to BMI in women with PCOS. No relationship between circulating ghrelin levels and the abnormal hormonal pattern of the PCOS were observed.     

Sublingual misoprostol for first trimester termination of pregnancy

Objectives

To compare blood loss, efficiency, and acceptability of repeated doses of sublingual misoprostol with the standard Tunisian regimen of mifepristone-misoprostol for first trimester medical abortion.

Methods

A prospective randomized trial of 252 healthy pregnant women requesting medical abortion in the first trimester (up to 56 days). Participants were randomized to receive 200 mg of oral mifepristone followed by 400 µg of oral misoprostol (group 1) or 800 µg of sublingual misoprostol repeated every 4 hours for up to a maximum of 3 doses (group 2). Primary outcome was blood loss assessed by decrease in hematocrit.

Results

Mean decrease in hematocrit at follow-up was significantly greater in group 1 than in group 2 (3.65% ± 1.18% vs 2.69% ± 1.89%, respectively; P = 0.02). There was no difference in efficiency rates between groups 1 and 2 (94.5% vs 92.1%; P = 0.7). Comparable proportions of women experiencing at least one adverse effect after misoprostol administration were reported in groups 1 and 2 (81.7% vs 79.4%; P = 0.75).

Conclusion

Compared with the most widely used regimen in Tunisia (mifepristone-misoprostol), sublingual misoprostol alone induces less blood loss (although not clinically significant); it is less expensive and offers reduced interval time to expulsion.