Misoprostol versus cervagem for the induction of labour to terminate pregnancy in the second and third trimester: a systematic review

AIMS: to compare the benefits and harms of misoprostol to induce labour in the second and third trimester of pregnancy with cervagem. METHODS: MEDLINE was searched using the terms abortion, induced; abortifacient agents; pregnancy, second trimester; pregnancy, third trimester; misoprostol; cervagem; and gemeprost to identify randomised controlled trials in which misoprostol was compared with cervagem, for induction of labour to terminate pregnancy in the second or third trimester. Outcomes included vaginal birth not achieved within 24h; induction to delivery interval; analgesia requirements; blood loss; blood transfusion; surgical evacuation of the uterus; maternal death or serious maternal morbidity; side effects. RESULTS: Six randomised trials were included. Five compared vaginal misoprostol with cervagem [el Refaey H, Hinshaw K, Templeton A. The abortifacient effect of misoprostol in the second trimester: a randomized comparison with gemeprost in patients pre-treated with mifepristone (RU486). Hum Reprod 1993;8(10):1744-6; Ho PC, Chan YF, Lau W. Misoprostol is as effective as gemeprost in termination of second trimester pregnancy when combined with mifepristone: a randomised comparative trial. Contraception 1996;53(5):281-3; Nuutila M, Toivonen J, Ylikorkala O, Halmesmaki E. A comparison between two doses of intravaginal misoprostol and gemeprost for induction of second trimester abortion. Obstetr Gynecol 1997;90(6):896-900; Wong KS, Ngai CS, Wong AY, Tang LC, Ho PC. Vaginal misoprostol compared with vaginal gemeprost in termination of pregnancy: a randomized controlled trial. Contraception 1998;58(4):207-10; Dickinson JE, Godfrey M, Evans SF. Efficacy of intravaginal misoprostol in second trimester termination of pregnancy: a randomized controlled trial. J Mater Fetal Med 1999;7(3):115-9], and one oral misoprostol with gemeprost [Bartley J, Baird DT. A randomised study of misoprostol and gemeprost in combination with mifepristone for induction of abortion in the second trimester of pregnancy. Br J Obstetr Gynaecol 2002;109(11):1290-4]. Vaginal misoprostol compared with cervagem was associated with reduced narcotic analgesia (3 studies, 169 women, RR 0.64 95% CI 0.49-0.84), and surgical evacuation of the uterus (5 studies, 319 women, RR 0.71 95% CI 0.53-0.95). No other statistically significant differences were observed for other outcomes with reported data. In the single trial comparing oral misoprostol with gemeprost, reported outcomes were similar. CONCLUSIONS: Vaginal misoprostol for the termination of second and third trimester of pregnancy appears as effective as cervagem, but information about maternal safety is limited.     

Mifepristone and misoprostol versus Dilapan and sulprostone for second trimester termination of pregnancy

Objective. To compare two methods for second trimester termination of pregnancy: mifepristone and misoprostol versus Dilapan® and sulprostone.

Methods. This was a randomized study involving 16 patients with a singleton live fetus with congenital malformations or genetic disorders. Eight patients were treated with 200 mg mifepristone orally followed by 200 μg misoprostol vaginally 3 hourly and eight patients received a sulprostone infusion after cervical dilatation with Dilapan.

Results. Mifepristone and misoprostol had a mean induction interval of 17.8 hours and sulprostone and Dilapan 20.9 hours. The mean induction interval did not differ significantly. Mean hospital stay was shorter in the patients treated with misoprostol: 2.1 vs. 3.3 days (p = 0.02) with a 95% confidence interval of ?2.1 to 0.3.

Conclusion. Mifepristone and misoprostol did not reduce the induction interval significantly compared to the sulprostone and Dilapan treatment for second trimester pregnancy termination. Hospital admission was significantly shorter in patients treated with mifepristone and misoprostol.     

Misoprostol Use in Pregnancy — An Update

Misoprostol is an inexpensive prostaglandin E₁ analogue marketed for oral prophylaxis and management of upper gastro-intestinal disorders, particularly those associated with nonsteroidal anti-inflammatory drugs.Vaginally administered misoprostol is a cost-effective medical agent for second trimester termination of pregnancy. In the first trimester, it is effective only after use of an antiprogesterone (mifepristone or methotrexate). Its use in first trimester pregnancy has been associated with newborn facial nerve paralysis if termination of the pregnancy failed to occur.In a much lower dose, vaginal misoprostol has been studied for labour induction at term. Numerous clinical trials have found vaginal misoprostol no less effective than existing approaches, but much less expensive than other prostaglandins. Though it appears to be safe for mother and newborn, there is still concern that it might provoke uterine hyperstimulation. No national body or consensus group has yet endorsed its use in clinical practice for induction of labour.The limited research with oral misoprostol suggests effectiveness with fewer problems of excessive uterine activity. Research into its use for the management of the third stage of labour and post-partum bleeding has now begun.     

Termination of 2nd and 3rd trimester pregnancies with mifepristone and misoprostol

Objective: The purpose of this study was to evaluate our use of the association of mifepristone and misoprostol for terminating second and third trimester pregnancies. Study design: One hundred and six patients undergoing termination of pregnancy between January 1993 and June 1995 in our center were studied. Each patient received 600 mg of mifepristone followed 24 h later by 400 microgrammes of misoprostol every 6 h. Results: The average interval from the first administration of misoprostol to expulsion was 12.5 ± 7.5 h (interval markedly decreased to 9.6 ± 6.3 h in cases of intrauterine fetal death). Conclusion: The efficacy of the association of mifepristone and misoprostol is comparable with that of current regimens with greater ease of utilization and at a much lower cost.     

Mifepristone and second trimester pregnancy termination for fetal abnormality in Western Australia: Worth the effort

Objective:  To determine the impact on the process of second trimester medical termination for fetal abnormality following the introduction of adjunctive mifepristone in an Australian tertiary hospital.
Methods:  All second trimester medical terminations for fetal abnormality between July 2006 and June 2009 were prospectively identified. Two temporal therapeutic cohorts were created: the first (1 July 2006 to 31 December 2007) using vaginal misoprostol alone and the second (1 January 2008 to 30 June 2009) using mifepristone priming prior to the administration of misoprostol. The primary outcome was to evaluate the impact of mifepristone priming upon the duration of pregnancy termination.
Results:  During the study period, 388 women with prenatally recognised fetal anomalies between 14 and 24 weeks gestation underwent medical termination: 189 with misoprostol alone and 199 with mifepristone priming followed by misoprostol. There was no difference between the groups for maternal age, parity or prior caesarean delivery. The median abortion duration was 15.5 h (interquartile ranges (IQR) 11.2–22.7) in the misoprostol group and 8.6 h (IQR 5.6–13.8) in the mifepristone primed group ( P  < 0.001). In both the groups, nulliparity and advancing gestation were associated with a significant prolongation of the abortion interval. Duration of hospitalisation was significantly longer in the misoprostol alone group (31.5 h (27–48.9) vs 27.2 h (22–31.5), misoprostol vs mifepristone priming, respectively, P  < 0.001).
Conclusions:  The introduction of mifepristone priming prior to second trimester medical termination with misoprostol has resulted in a significant reduction in the duration of the termination procedure and length of inpatient stay. These observed benefits of mifepristone provide objective support for the decision to permit use of this medication in Australia.     

Induction of Labour with Misoprostol—A Review

Misoprostol is a prostaglandin E₁ analogue marketed for oral prophylaxis of non-steriodal anti-inflammatory drug induced gastric ulcers, and treatment of gastric and duodenal ulcers. Its cost per dose is one hundredth that of commercial prostaglandin gels used for labour induction. It is listed as being contra-indicated for use in pregnancy.Recent investigations have found that vaginal misoprostol is cost effective for second trimester medical termination of pregnancy. In the first trimester, it is effective only after use of another abortifacient, including mifepristone or methotrexate.Vaginal misoprostol, in a much lower dose, is now being applied as a labour induction agent at term. It is inexpensive and effective, and appears safe for mother and newborn in the reported randomized controlled trials. A concern regarding uterine hyperstimulation exists.Our group has experience with vaginal misoprostol use in the second trimester, and for labour induction. We have now looked at oral administration for labour induction. We review our experience and that in the literature.     

瘢痕子宫孕妇孕中晚期引产的方法探讨

目的 探讨瘢痕子宫孕妇孕中晚期引产的适宜方法.方法 选择2002年9月-2009年6月在首都医科大学附属北京妇产医院因医疗指征于孕中晚期引产的瘢痕子宫孕妇共90例,引产指征为胎儿畸形、严重妊娠并发症、胎死宫内.其中,孕中期72例,孕晚期18例;距离前次子宫手术的间隔时间<2年20例,≥2年70例.肝功能正常者服用米非司酮,并行利凡诺过敏试验,阴性者首选利凡诺羊膜腔注射引产法;试验阳性、羊水过少、孕周过小、利凡诺羊膜腔注射困难或注射失败者采用卡前列甲酯(卡孕栓)引产法.共有54例孕妇采用利凡诺引产(利凡诺组),36例孕妇采用卡孕栓引产(卡孕栓组).(1)记录两组孕妇入院时情况,包括年龄、孕周、孕次、产次;(2)前次导致子宫瘢痕的手术种类、手术方法、有无并发症、前次手术间隔时间;(3)此次妊娠的引产方法,并记录孕妇用药至宫缩发动的时间,用药至胎儿娩出的时间;(4)产后出血量,胎盘滞留率,引产成功率,有无子宫破裂及行全子宫切除术等情况.结果 (1)利凡诺组与卡孕栓组孕妇的年龄、孕次、产次、距前次子宫手术间隔时间比较,差异均无统计学意义(P>0.05).但两组孕妇的引产孕周比较,差异有统计学意义(P<0.01).(2)两组孕妇引产的成功率及产后出血量比较,差异无统计学意义(P>0.05),但卡孕栓组孕妇引产用药后宫缩发动的时间及分娩时间明显短于利凡诺组,两组比较,差异有统计学意义(P<0.01);卡孕栓组孕妇24 h内分娩率达到94%(34/36),明显高于利凡诺组的13%(7/54),两组分别比较,差异均有统计学意义(P<0.01).(3)卡孕栓组孕妇胎盘滞留率(31%,11/35)明显高于利凡诺组(10%,5/52);而利凡诺组胎盘胎膜残留率(54%,28/52)明显高于卡孕栓组(34%,12/35),两组分别比较,差异均有统计学意义(P<0.01).但两组孕妇总的产时并发症发生率比较,差异无统计学意义(P>0.05).不良事件发生与前次子宫手术间隔时间的关系分析显示,<2年的孕妇在胎盘滞留、胎盘胎膜残留、胎盘早剥、子宫破裂、产后出血的发生率分别与≥2年的孕妇比较,差异均无统计学意义(P>0.05).(4)卡孕栓组孕妇中有1例发生子宫破裂,利凡诺组孕妇中有1例宫缩发动1 h后发生胎盘早剥.结论 对瘢痕子宫孕妇于孕中晚期应用利凡诺羊膜腔注射引产和卡孕栓阴道用药引产均是可行的,但需在充分的术前准备及严密监护下进行,以警惕子宫破裂的发生.     

Second trimester termination of pregnancy for fetal anomaly or death: comparing mifepristone/misoprostol to gemeprost

OBJECTIVE: To assess the effect of changing the regimen for second trimester induction of labour from gemeprost to mifepristone/misoprostol. DESIGN and SETTING: A retrospective study at a university teaching hospital over the 5-year period 1993-1997. SUBJECTS, METHODS and REGIMENS: 68 patients, 34 in the gemeprost group and 34 in the mifepristone/misoprostol group. The gemeprost group received 1mg vaginally every 3h to a maximum of five doses. The mifepristone/misoprostol group were pre-treated with 600 mg mifepristone orally followed by 800 microg misoprostol vaginally and then 400 microg orally every 3h to a maximum of four oral doses. MAIN OUTCOME MEASURES: Induction to abortion interval; delivery within 24h. RESULTS: The mifepristone/misoprostol group had a lower induction to abortion interval compared to the gemeprost group (median 8.9h versus 19.8h, respectively, p<0.01). The mifepristone/misoprostol regimen was more successful than the gemeprost regimen; 94% versus 68%, respectively, aborted without extra medical or surgical intervention, p=0.02. There were no significant differences in side effects, analgesia requirements or complications between the two groups. Three patients with previous Caesarean sections had a ruptured uterus; two from the gemeprost group and one from the mifepristone/misoprostol group. CONCLUSIONS: The new mifepristone/misoprostol regimen was more effective in second trimester induction of labour. Induction of labour with misoprostol or gemeprost should be used with care in patients with a previous Caesarean section.     

A randomized trial of oral and vaginal misoprostol to manage delivery in cases of fetal death

OBJECTIVE: To compare the effectiveness and side effects of oral and vaginal misoprostol for the termination of second and third trimester pregnancy with intrauterine fetal death. METHODS: Eighty pregnant women at 16-41 weeks' gestation with intrauterine fetal death were randomized in two groups to receive either 400 micro g of misoprostol orally every 4 hours (n = 40) or 200 micro g of misoprostol vaginally every 12 hours (n = 40) until the termination of pregnancy was completed. The adverse effects, progress, and outcomes of delivery were assessed. RESULTS: The groups were similar in age, weight, height, gestational age, parity, and modified Bishop scores before intervention. The mean induction-to-delivery time in the oral group (13.95 [standard deviation (SD) = 5.63] hours) was significantly shorter than the time in the vaginal group (18.87 [SD = 10.38] hours, P =.001). The number of deliveries within 24 hours after the initial drug administration in the oral group (92.5%) was significantly higher than the number in the vaginal group (67.5%, P <.001), and all delivered within 48 hours after the initial drug administration. However, the gastrointestinal side effects in the oral group was significantly higher than in the vaginal group (P =.005). CONCLUSION: Misoprostol (400 micro g given orally every 4 hours) was more effective than misoprostol (200 micro g given vaginally every 12 hours) for the termination of second and third trimester pregnancy with intrauterine fetal death, but with more gastrointestinal side effects.     

Second- and third-trimester therapeutic terminations of pregnancy in cases with complete placenta previa--does feticide decrease postdelivery maternal hemorrhage?

OBJECTIVE: To study the feasibility of second- and third-trimester termination of pregnancy (TOP) with complete placenta previa, and the impact of performing feticide before labor induction on maternal hemorrhagic morbidity. PATIENTS AND METHODS: From 1987 to 2002, the databases of two referral hospitals were reviewed. We identified 15 cases of second- or third-trimester TOP in women with complete placenta previa. Feticide was performed 2-14 days before induction in 6/15 cases. Cervical ripening was achieved in 8 cases by mifepristone alone (n = 2) or by mifepristone and dilapan (n = 6). Labor was induced by vaginal gemeprost (n = 2), intramuscular (n = 5) or intravenous (n = 4) sulprostone, vaginal misoprostol (n = 1) or a combination of misoprostol and sulprostone (n = 3). Hemorrhage was defined by the need for transfusion. The difference between the preoperative and the lowest per- or postoperative maternal hemoglobin level was also analyzed. RESULTS: Of the 9 women who underwent labor induction without previous feticide, 4 required blood transfusions, 1 of whom had a hemostat hysterectomy. The mean hemoglobin difference was 2.5 g/dl (range: 0.5-5.3). None of the 6 patients with preinduction feticide required transfusion. The hemoglobin difference was significantly smaller in this group than in terminations without previous feticide (mean: 1.0 g/dl ; range: 0.1-2.2; p = 0.03). CONCLUSION: In cases with complete placenta previa, second- or third-trimester TOP is feasible. It carries a substantial risk of hemorrhage that might be decreased by preinduction feticide.     

A comparison of 600 and 200 mg mifepristone prior to second trimester abortion with the prostaglandin misoprostol

Objective To compare the use of 600 and 200 mg mifepristone prior to second trimester termination of pregnancy with the prostaglandin misoprostol.
Design A randomised study. Setting A Scottish teaching hospital.
Participants Seventy women undergoing legal induced abortion between 13 and 20 weeks of gestation.
Intervention Administration of either 600 or 200 mg mifepristone 36 to 48 hours prior to prostaglandin.
Main outcome measure Induction-abortion interval.
Results The geometric mean induction abortion interval was 6.9 (95 % CI 5.8–8.4) h and 6.9 (95 % CI 5.8–8.2) h in the 600 and 200 mg groups, respectively (no significant difference). The median dose of misoprostol was 1600 pg (three doses) in each group. Analgesic requirements and prostaglandin-related side effects were similar between groups. Overall, 11-4% of women required surgical evacuation of the uterus as a result of retained placenta.
Conclusions The dose of mifepristone used in second trimester abortion can be reduced from 600 to 200 mg.     

Misoprostol for second trimester pregnancy termination in women with prior caesarean section

OBJECTIVE: To examine whether a previous caesarean section increases the risk for complications in women undergoing a mid-trimester pregnancy termination by labour induction. DESIGN: Retrospective analysis of case records between 1997 and 2002. SETTING: Fetal Medicine Unit of a large teaching hospital. POPULATION: One hundred and eight women with a previous caesarean section (study group) and 216 women without such a history (controls), who underwent a second trimester termination of pregnancy. METHODS: All the terminations were performed between 17 and 24 weeks of gestation by using 400 mug of oral administration of misoprostol in combination with 400 mug of intravaginal misoprostol. The same dose of intravaginal misoprostol was repeated every 6 hours for a maximum of five doses. MAIN OUTCOME MEASURES: Severe haemorrhage requiring blood transfusion, post-abortal infection, retained placenta and uterine rupture. RESULT: Complications occurred in 16 out of 108 women of the study group (15%) and in 26 out of 216 of the controls (12%), with only one ruptured uterus in the control group. CONCLUSION: We found no evidence that a previous caesarean delivery affects the incidence of complications when women with such a history undergo a mid-trimester pregnancy termination with misoprostol.     

Second and third medical termination of pregnancy with misoprostol without mifepristone

BACKGROUND: Advances in prenatal diagnosis make it possible to detect many fetal pathologies for which a termination of pregnancy (TOP) is possible in France. In pregnancies which go beyond 3 months, the use of prostaglandins combined with mifepristone has simplified this procedure. Since mifepristone must be taken 48 h before using prostaglandins, we have used only misoprostol intravaginally. METHODS: Our report deals with a continuous series of terminated pregnancies in the second and third trimesters. The time period in question is January 1, 1996 through July 31, 2001. When this treatment was used within the first 30 weeks of gestation, four tablets (800 microg) of misoprostol were administered intravaginally. When there were no contractions, two additional tablets (400 microg) of misoprostol were given orally every 3 h, not exceeding 3 times. Beyond 30 weeks of amenorrhoea, because of the risk of uterine rupture, the initial dose was lower: 1/4 tablet (50 microg) of misoprostol intravaginally was increased to 100 microg (1/2 tablet) every 3 h until expulsion. RESULTS: In the second and third trimesters, 55 pregnancies were terminated medically; only 1 case was not successful. In the other 54 cases, the average time interval between administering misoprostol intravaginally and expulsion was 12.7 +/- 8 h. Side effects included nausea or vomiting for 12 patients (22%) and hyperthermia for 11 patients (20%). Thirty-three patients (60%) had no side effects at all. In 10 cases (18%), the fetus and the placenta were removed in one movement. In 11 cases (20%), the placenta had to be removed by artificial means. In 7 cases (13%), a curettage with a curette foam was done. In the long run perspective, only 1 patient needed a curettage to remove placental residue. CONCLUSION: Treatment by misoprostol without mifepristone during the second and third trimesters makes it possible to terminate a pregnancy easily and quickly without significant complications.     

The effect of gestational age on the outcome of second-trimester termination of pregnancies for foetal abnormalities

OBJECTIVE: To explore the effect of gestational age on the outcome of second-trimester termination of pregnancies for foetal abnormalities. METHOD: A retrospective study was conducted on 280 pregnancies terminated for foetal abnormalities in the second trimester using vaginal misoprostol. The gestational age at termination was divided into three groups: 13-16 weeks, 17-20 weeks and 21-23 weeks. The likelihood of (1) abortion within 24 h of commencement of misoprostol, (2) incomplete abortion and (3) experiencing significant side effects was compared among these three gestational groups after adjusting for maternal age, parity and body mass index (BMI). RESULTS: Compared to termination after 20 weeks, pregnancy termination for foetal abnormality before 17 weeks of gestation was associated with higher chance of incomplete abortion (OR 2.2, 95% CI 1.07-4.61, p = 0.032) and lower chance of experiencing significant side effects (OR 0.11, 95% CI 0.01-0.91, p = 0.041). CONCLUSION: Women undergoing pregnancy termination for foetal abnormalities in the early second trimester should be informed of possible higher chance of incomplete abortion.     

Second- and third-trimester management of medical termination of pregnancy and fetal death in utero after prior caesarean section

Objectives

To evaluate the results and risks of a protocol for second- and third-trimester termination of pregnancy after prior caesarean section.

Study design

This is a retrospective study, conducted in a level 3 (university hospital) maternity unit between January 2001 and September 2008. 67 women with a history of caesarean section underwent second- and third-trimester termination of pregnancy. The protocol was administration of 600 mg mifepristone the first day and application of laminaria tents the second day. One the third day, 48 h after mifepristone, two 200 μg tablets of misoprostol were given orally every 3 h until delivery. Epidural analgesia was performed routinely. Complications analysed were uterine rupture, labour lasting over 12 h, and bleeding requiring blood transfusion.

Results

Delivery was vaginal in 64 cases (95.5%), a median 4 h 20 min (P25: 3 h 5 min, P75: 7 h 7 min) after administration of misoprostol (median number of tablets 2; P25: 2, P75: 4). The median number of tablets of misoprostol was significantly higher for termination of pregnancy than for fetal death in utero (4 vs. 2; p = 0.002). The rate of uterine rupture was 4.8% [95% CI: 1.2-14.2]. Bleeding during delivery requiring a transfusion occurred in 2 cases (3.0%; 95% CI: 0.5-11.3).

Conclusion

A high rate of vaginal delivery was achieved at low doses of misoprostol, with a short median induction-to-delivery interval, and a rate of uterine rupture higher than that observed during attempted vaginal delivery at term in a caesarean scar pregnancy. The rate of severe bleeding during delivery was low.     

Nonsurgical mid-trimester termination of pregnancy: a review of 500 consecutive cases.

OBJECTIVE: To assess the effectiveness of a regimen comprising mifepristone followed by a combination of the vaginal and oral administration of misoprostol for mid-trimester medical termination of pregnancy. DESIGN: Retrospective analysis of prospectively collected data in women undergoing mid-trimester medical termination of pregnancy. SETTING: Aberdeen Royal Infirmary, Scotland. SAMPLE: A consecutive series of 500 women with pregnancies of 13-21 weeks of amenorrhea undergoing legally induced abortion in one Scottish NHS hospital. METHODS: Each woman received a single oral dose of mifepristone 200 mg and 36-48 h later vaginal misoprostol 800 microg. Three hours following the first dose of misoprostol, 400 microg doses were administered orally at three hourly intervals, to a maximum of four doses. Success was defined as abortion occurring with five doses of prostaglandin, or within 15 h of administration of the first dose of prostaglandin. RESULTS: Ninety-seven percent aborted successfully. The median dose of misoprostol required was 1200 microg and the median induction-to-abortion interval after first prostaglandin administration was 6.5 h. The median number of doses of misoprostol required to induce abortion, and the induction-to-abortion interval, was statistically significantly higher among women at gestations 17-21 weeks than among those at 13-16 weeks (P = 0.0001). A total of 9.4% required surgical evacuation of the uterus under general anaesthesia and 66.4% of the women were managed as day cases. CONCLUSIONS: The combination of oral mifepristone 200 mg followed by vaginally and orally administered misoprostol provides a noninvasive and effective regimen for second trimester termination of pregnancy.     

Randomized comparison of second trimester pregnancy termination utilizing saline moistened or dry misoprostol

Objective The aim of this randomized prospective study was to compare efficacy and side effects of saline moistened misoprostol with dry misoprostol, administered 800 μg intravaginally every 6 h up to a maximum of 3 doses in 24 h for second trimester pregnancy termination. Materials and methods A total of 81 women seeking termination of second trimester pregnancy (55 fetal death, 17 fetal structural anomaly, 5 chromosomal abnormality, 4 other reasons) were randomly assigned to one of two treatment groups: (1) intravaginal non-moistened (dry) misoprostol in group A (n = 40) or (2) misoprostol moistened with 3 ml of saline in group B (n = 41). Results All of the patients in either group aborted within 48 h (100% success rate). Delivery was achieved in a median (interquartile range) of 13 (40) h with the group A protocol and 12 (36) h with the group B protocol (P = 0.652). Delivery with first dose, delivery within 12 h and delivery within 24 h were similar (P > 0.05) in group B (34.1, 87.5 and 60%, respectively) and group A (25, 82.9, 46.3, respectively). Both treatment regimens were tolerable and with similar side effects. Conclusion Misoprostol moistened with saline was not more effective than dry misoprostol for second trimester pregnancy termination.     

Low-dose vaginal misoprostol in the management of intrauterine fetal death

Objectives.?To assess the effectiveness and side effects of vaginal misoprostol (Vagiprost® tablet) termination of second and third trimester pregnancy complicated with intrauterine fetal death (IUFD).

Design.?A prospective observational cohort study.

Setting.?Tanta University Hospital.

Patients.?The study carried out on 324 women with fetal demise in the second and third trimesters, from January 2008 to December 2009.

Intervention.?All patients were subjected to history taking, physical examination, and the Bishop Scoring. Application of 25?μg misoprostol in the posterior fornix of the vagina, this was repeated every 4 h over 24 h. We assessed the adverse effects, progress, and outcomes.

Results.?The success rate was 90% and 45% in women in the third and second trimesters, respectively. The mean induction-termination interval was 8.95?±?2.63 and 15.3?±?5.37 h for women in the third and second trimesters, respectively. The induction termination interval correlated negatively with the duration of gestation. Approximately, 90% of second trimester and 55% of third trimester women required oxytocin augmentation. The mean value of total required dose of misoprostol was 166.3?±?7.5 and 120?±?28.79?μg for women in the second and third trimesters, respectively.

Conclusion.?Vagiprost appears to be a safe, effective, practical, and inexpensive method for termination of third trimester pregnancy complicated with of IUFD.