Misoprostol and first trimester pregnancy termination

OBJECTIVE: To investigate the efficacy of vaginal administration of 800 microg misoprostol as a single dose without performing post expulsion systematic curettage in first trimester pregnancy termination. METHOD: 113 women, aged 16-44, who requested first trimester pregnancy termination, received 800 microg of vaginal misoprostol. All examined women were divided into two groups depending on gestation age. The first group included of 67 women with up to nine weeks and the second of 46 with up to 12 weeks of pregnancy. RESULTS: Abortion occurred within 24 hours and was completed in 74.3% of the cases. The mean induction-abortion interval was 5.9 +/- 1.7 hours (median 5.5 hours). Side-effects were experienced by 24 women (21.2%). There was no significant difference between groups in the success rate, induction-abortion interval, number of previous deliveries and side-effects. CONCLUSION: Misoprostol is an effective agent for first trimester medical termination.     

Management of first trimester pregnancy termination failures

Suction curettage is the procedure of choice for first trimester abortion. The basic preevaluation and follow-up standards for this operation have been adopted by most physicians. In some instances, however, follow-up assessment may be inadequate, particularly regarding the histopathologic evaluation of uterine contents. As a result, recognition of serious conditions such as ectopic pregnancy may be delayed. When a first trimester abortion fails, when scanty tissue is obtained, or when histopathologic examination demonstrates only decidual tissue, an extrauterine pregnancy or pregnancy in an anomalous uterus must be considered. Ultrasonography and endoscopic methods such as laparoscopy and hysteroscopy are invaluable in locating the site of the pregnancy and in preventing serious sequelae. The authors report the outcome of 25 women in whom abortion by suction curettage failed. A protocol outlining the methods used for diagnosis and therapeutic management is presented.     

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.     

Intra-amniotic pressures following vaginal gemeprost prior to first and second trimester termination of pregnancy.

Intra-amniotic pressures were measured following 1 mg gemeprost for cervical preparation before first trimester vacuum aspiration (n = 10) and following 2 mg gemeprost before second trimester dilatation and evacuation (n = 15). Twenty-five women, matched for gestational age and parity, who did not receive gemeprost served as controls. Compared to control values (2-8 mmHg), basal intra-amniotic pressure (IAP) was significantly increased after 1 mg and 2 mg of gemeprost (median 20.0, range 4-45 mmHg, median 20.0, range 8-60 mmHg, respectively). Uterine contractions were recorded in 8 of 10 subjects after 1 mg (median delta IAP 28.0, 95% CI 10.0-42.6 mmHg) and 14 of 15 subjects after 2 mg (median delta IAP 52.5, 95% CI 26.7-60.3 mmHg). Gemeprost produces an increase in uterine contractility which may be additional to cervical softening properties and which may be responsible for the adverse effects of pain and bleeding experienced by some women prior to termination.     

Comparison of paracervical block techniques during first trimester pregnancy termination.

OBJECTIVES: To determine whether variations in chloroprocaine placement in paracervical blocks influence effectiveness, whether chloroprocaine is superior to saline, and what factors influence pain perception. METHOD: Eighty-two women undergoing first trimester aspiration abortions were randomized to receive 1% chloroprocaine or saline at 3-5-7-9 or 4-8 o'clock positions. Using a 0--10 scale, women rated anxiety, dysmenorrhea, and pain associated with laminaria insertion, paracervical block, and aspiration. RESULTS: All four groups were similar in medical and demographic characteristics. Injection position did not influence pain ratings, but women who received chloroprocaine had less pain than those who received saline (6.3+/-2.3 vs. 7.8+/-2.0, P=0.002). Paracervical pain and dysmenorrhea were independently associated with aspiration pain scores (respective regression coefficients 0.49 and 0.26, P<0.008). CONCLUSIONS: There is no advantage to using a four-site paracervical block over a two-site technique, but chloroprocaine is superior to saline. Paracervical block may not provide adequate anesthesia during first trimester abortion, especially for women with significant dysmenorrhea.     

Voluntary pregnancy termination over the first trimester. A five-year observation

AIM: The law for legalising abortion was approved by the Italian Government in May 1978. In regulating legal abortion this law identifies two different scenarios: one where legal abortion is performed within 90 days of gestational age, and the second where it can be performed beyond this term but within 120 days: 'when pregnancy or delivery can cause a severe damage to the woman's life, in case of severe pathologies, as fetal relevant anomalies or malformations which can cause a severe damage to the woman's physical or psychological health'. Since during the last years an increase of requests for voluntary pregnancy termination (VPT) over 90 days of gestational age has been observed in Italy, it was decided to carry out a retrospective study on the reasons for requesting such an operation. METHODS: All interventions for VPT over 90 days of gestational age performed in the Department of Obstetrics and Gynecology in the University of Rome 'La Sapienza' between January 2003 and December 2007 have been re-assessed, analysing age of women, obstetric anamnesis, reasons for VPT request, gestational age, mode of intervention, complications due to intervention and days of inpatient admission. RESULTS: During five years 255 women demanded to terminate a pregnancy over the first trimester. In all cases requested have been authorized following a psychological consult assessing a severe damage on psychological health by the Clinical Psychology Service of 'La Sapienza' University, that in all cases was subsequent to a diagnosis of fetal anomalies, ascertained by a genetic test and/or ultrasound scan. Anomalies were genetic in 112 of cases (43.2%) and morphological, both single and multiple, in 143 of cases (56.8%). In most of the cases (65%) these anomalies have been assessed by ultrasound scan, while in 35% by cariotype analysis. CONCLUSION: After the legalisation in 1978, cases of abortion have constantly increased. More detailed data would be helpful to better understand and face this event.     

Danazol mimics antigestagen action in first trimester termination of pregnancy

BACKGROUND: Based on steroid receptor binding and biologic activity, danazol was suspected to be an antigestagen. OBJECTIVE: To compare with placebo test in first trimester termination of pregnancy (TOP) as a method for predilatation of the cervix prior to application of misoprostol. METHODS: 52 patients were randomised into two groups. Thereby, 26 women received 200 mg danazol vaginal suppositories three times during 2 days before administering 200 microg misoprostol and undergoing mechanical dilatation and vacuum aspiration 5h later. The other 26 received placebo suppositories and the same treatment otherwise. RESULT: The uterine cervix was wider and less dilatation and time was needed for the surgical termination in the group pretreated with danazol. There were six cases of complete abortion within 5h of administering misoprostol in the danazol group; and none in the placebo group. After danazol treatment, 16 women exhibited signs of abortion versus four receiving the inert suppositories. CONCLUSION: Pretreatment with 200mg danazol suppositories three times starting 36 h before administering misoprostol for cervical dilatation enhances the effect of prostaglandin on cervical dilatation and uterine contractions in a manner similar to antigestagens.     

First trimester termination of pregnancy

First trimester termination of pregnancy (TOP) is a safe and effective procedure. The complete abortion rates of surgical and medical abortion are approximately 97% and 95%, respectively. Vacuum aspiration (VA) either by electrical suction or manual aspiration is the method of choice for surgical TOP. Risk of significant bleeding is ≤ 5% in VA, while major complications occur in <1%. The risk of infection after VA can be reduced significantly by using prophylactic antibiotics or by the screen-and-treat strategy. Pre-operative administration of misoprostol can also reduce the risk of complications. The combination of 200 mg mifepristone followed by 800 μg misoprostol 24–48 h later is recommended for first trimester medical TOP. If mifepristone is not available, misoprostol can also be used alone, but repeated doses may be required and the complete abortion rate may be lower. Due to the reduced efficacy in more advanced gestation, repeated doses of misoprostol may be required for medical TOP over 9 weeks of gestation. The complete abortion rate with this regimen is 95% or more. Gastrointestinal upsets can occur in up to 50% of women, but major complications are rare. There was no lower limit of gestational week for TOP, although extra precaution is required for the confirmation of completion of procedures and exclusion of ectopic pregnancy.     

Successful pregnancy outcome following first trimester pelvic inflammatory disease

Pelvic inflammatory disease rarely complicates pregnancy. Although few in number, most of the previously reported cases have resulted in spontaneous abortion or intrauterine fetal demise. At 5 weeks gestation, a 20 year old gravida 2 para 1 underwent uterine curettage and diagnostic laparoscopy for a suspected ectopic gestation. Seventeen days later, she presented with severe bilateral lower abdominal pain, cervical motion tenderness, uterine tenderness, and bilateral adnexal tenderness. After 84 hours of intravenous cefazolin, gentamycin, and clindamycin, the patient had resolution of all symptoms. She then completed 14 days of outpatient antibiotic therapy with oral cephalexin. At 39 weeks gestation, she delivered a 3611 g male fetus via spontaneous vaginal delivery. Successful pregnancy outcome can occur after first trimester pelvic inflammatory disease.     

Changes in circulating alphafetoprotein following administration of mifepristone in first trimester pregnancy.

The occurrence of fetomaternal haemorrhage was investigated in 30 women by measuring maternal serum alphafetoprotein (AFP) levels before and after the administration of mifepristone (RU 486) for termination of first trimester pregnancy. A significant rise in AFP levels was seen in 21 women (70%), the increase ranging from 6 to 660% of baseline levels. The apparent frequency of fetomaternal haemorrhage was similar to that reported previously for surgical termination of first trimester pregnancies.     

Vaginal misoprostol in termination of second trimester pregnancy

OBJECTIVE: To study the effectiveness and complications of 600 micrograms of intravaginal misoprostol for terminating second trimester pregnancies. STUDY DESIGN: One hundred and seventy-two patients undergoing termination of pregnancy between March 1997 and April 1999 were studied. Each patient received 600 micrograms of intravaginal misoprostol every 12 hours until abortion occurred. RESULTS: The mean induction to abortion time was 24.1 +/- 21.6 hours. The percentage of women aborting within 24 and 48 hours was 68.6 and 89.5 respectively. There was no significant difference in the mean induction to abortion time and the percentage of women aborted within 48 hours between nulliparous and multiparous women. The mean amount of misoprostol used was 1405.5 +/- 1084.6 micrograms. Incomplete abortion occurred in 23.3% of women. The most common complication was temperature of more than 38 degrees C occurred in 41% followed by diarrhoea (20%), nausea and vomiting (15%). CONCLUSION: Six hundred micrograms of vaginal misoprostol is effective, but whether the 48 hours abortion rate can be improved with a large dose or shortened the time interval between doses, requires further study.