Sublingual misoprostol for preabortion cervical ripening in first-trimester pregnancy termination

The objective of this prospective randomized placebo-controlled study was to determine the efficacy of sublingual misoprostol in facilitating cervical dilatation before surgical abortion in first trimester pregnancy. Sixty healthy pregnant women between 6 and 11 weeks of gestation opting for voluntary medical termination of pregnancy at All India Institute of Medical Sciences hospital were included in this study. Women were randomized to two groups, the study group (n = 30) received 400 micro g of sublingual misoprostol and the control group (n = 30) received placebo, 2 h prior to surgical abortion. Using Hegar's dilators, cervical dilatation prior to vacuum aspiration was measured. Other parameters assessed included the total time required for the procedure, intraoperative blood loss and associated side effects. The mean cervical dilatation in the misoprostol group was 7.7 mm as compared to 3.4 mm for placebo group. The average time required for pregnancy termination was significantly shorter (p < 0.001) in the misoprostol group. The procedure-related blood loss was also significantly decreased in the misoprostol group. However, side effects including pre-evacuation vaginal bleeding, lower abdominal pain, nausea and vomiting were significantly higher in the misoprostol group than in placebo group (p < 0.005). There was no case of hemorrhage or uterine perforation in either group. Sublingual misoprostol is effective in facilitating cervical dilatation prior to surgical abortion. Its usage significantly decreased the time of surgical evacuation and minimized blood loss during the procedure.     

Buccal misoprostol as cervical preparation for second trimester pregnancy termination

The objective of the study was to assess the efficacy of cervical preparation with misoprostol or laminaria suction abortion up to 18 weeks gestation. The study was conducted among a consecutive case series of patients presenting for dilatation and evacuation at a single center. Cervical preparation was effected by either 600 mg buccal misoprostol (n = 32) or laminaria (n = 78). Dilatation and evacuation was then performed using vacuum aspiration, with fetal parts or placenta removed as necessary with appropriate forceps. The principle outcome of interest was procedure time.

Complete abortion was effected in 100% of the cases. In all cases, the cervix was adequately prepared to allow either the introduction of a size 14-mm suction cannula or was easily dilated to this diameter. Group size was sufficient for detection of a 20% difference in mean procedure time with 80% power (calculated with two separate standard deviations for procedure time). Procedure times were not significantly different when misoprostol was used compared to laminaria for cervical preparation.

It is concluded that the use of misoprostol to provide cervical preparation in second trimester abortion procedures appeared effective and offers an alternative to laminaria. Buccal misoprostol should be more widely investigated for this purpose.     

A Gemeprost vaginal suppository for cervical priming prior to termination of first trimester pregnancy

A randomized, double-blind, placebo-controlled, multicentre study was conducted to assess the efficacy and tolerance of a single 1.0 mg Gemeprost (16, 16-dimethyl-trans-delta 2PGE1 methyl ester) vaginal suppository for dilatation of the cervix uteri prior to vacuum aspiration termination of first trimester pregnancy in nulliparous women. The suppository was inserted three hours before vacuum aspiration. In the six centres involved, the preoperative cervical diameter was significantly greater in women treated with Gemeprost. Further mechanical dilatation was either unnecessary or significantly easier than in placebo-treated women. A significant reduction in operative blood loss was noted in the Gemeprost group.     

A comparison of two stable prostaglandin E analogues for termination of early pregnancy and for cervical dilatation

Termination of pregnancy with prostaglandin E analogues is in general associated with a lower frequency of gastrointestinal side effects than if corresponding F analogues are used. Their clinical use has, however, been limited by stability problems. In the present study the efficacy of different dose schedules of two new stable E analogues for termination of early pregnancy and for preoperative dilatation of the cervical canal was evaluated in 389 women. In early pregnant patients vaginal administration of 75 mg of 9-deoxo-16, 16-dimethyl-9-methylene PGE₂ repeated after six hours or three intramuscular injections of 0.5 mg 16-phenoxy-ω-17, 18, 19, 20-tetranor PGE₂ methyl sulfonylamide administered in three hour intervals resulted in a complete abortion in 94 to 100 per cent of the patients. Both treatments were associated with a low frequency of side effects. The 9-methylene analogue had the advantage of causing less uterine pain than 16-phenoxy -ω-17, 18, 19, 20-tetranor PGE₂ methyl sulfonylamide with the dose schedules used. Single vaginal administration of 30 mg of 9-deoxo-16, 16-dimethyl-9-methylene PGE₂ and one intramuscular injection of 0.5 mg of the methyl sulfonylamide analogue 12 hours prior to vacuum aspiration were equally effective in dilating the cervix in late first trimester pregnant patients. For both compounds, the frequency of side effects were lower than that previously reported for different PGF analogues administered by non-invasive routes.     

A study of the efficacy of cervical ripening with nitric oxide donor versus placebo for cervical priming before second-trimester termination of pregnancy

This was a double-blind randomized control study to evaluate the efficacy of cervical priming by nitric oxide donor before second-trimester induced abortion. One-hundred healthy women with a singleton pregnancy between 14 and 20 weeks of gestation were randomized into either 40 mg isosorbide mononitrate or placebo, given intravaginally 12 h before induction. This was followed by intravaginal misoprostol induction. The induction-abortion interval, abortion rate, side effects and the woman's acceptability of the priming agent were recorded. All women completed the study and there was no severe complication recorded. There was no significant difference in the induction-abortion interval and abortion rate between the two groups. Isosorbide mononitrate group reported significantly more side effects of headache. More than 90% of the women in both groups found the priming agent acceptable. The application of intravaginal nitric oxide donors prior to the prostaglandins induction did not significantly improve the second-trimester induced-abortion process.     

A randomized comparison of sublingual and vaginal misoprostol for cervical priming before suction termination of first-trimester pregnancy

This randomized trial compares the efficacy and side effects of sublingual and vaginal misoprostol for cervical priming before first-trimester pregnancy termination. One-hundred pregnant women between 6 and 12 weeks of gestation opting for termination of pregnancy by suction evacuation were included in this study. The women were randomly allocated into two groups. Group 1 received 400 microg of sublingual misoprostol and group 2 received 400 microg of vaginal misoprostol 2 h prior to suction evacuation. The abortion was carried out by suction evacuation using a Karman's cannula attached to an electrically operated suction machine under intravenous analgesia. Baseline cervical dilatation, duration of the procedure, operative blood loss, side effects and complications were noted in both groups. There was a significant difference between the sublingual and vaginal misoprostol groups with respect to mean cervical dilatation (8.6 mm vs. 6.8 mm, p < 0.05). However, the duration of the procedure (3.03 min vs. 3.16 min) and the amount of blood loss (29 mL vs. 31.2 mL) were not significantly different between the two groups. The women in the sublingual group experienced significantly more shivering and preoperative vaginal bleeding (68% vs. 56%, p < 0.05). None of the women in the two groups had either uterine perforation or excessive hemorrhage. In our study, sublingual misoprostol (400 microg) was significantly more effective in facilitating cervical dilation prior to surgical abortion than vaginal misoprostol.     

Randomized trial of the effect of drugs on cervical dilatation for termination of first trimester pregnancy

A randomized triple-blind and placebo-controlled clinical trial on the effect of lidocaine and Anodyne-lubricant jelly (ALJ) containing dicaine on cervical dilatation is reported. Three-hundred-seventy-two consecutive cases were randomly allocated to 4 groups. The four groups were given: ALJ and placebo (placebo 1); and lidocaine and placebo (placebo 2). ALJ and placebo 1 treatment was by topical application, and lidocaine and placebo 2 by injection. In parous women, a significant difference was found for satisfactory dilatation (SD) rate (p less than 0.01) among four groups. It was unexpected that there were no significant differences between drug and placebo groups, neither between ALJ treatment group and placebo 1 group (p greater than 0.5), nor between lidocaine and placebo 2 (p greater than 0.75). However, the combined SD rate was 60.9% for the topical groups compared with 39.0% for the injection groups (p less than 0.005). The findings suggested that the effect of ALJ on cervical dilatation was not mainly due to dicaine, but associated with the lubricant and the topical treatment.     

A new method for treating ectopic pregnancy with methotrexate

Due to diagnostic methods of the last decades, such as laparoscopy, ultrasonography and radioimmunoassays, early diagnosis of pregnancy and also of ectopic pregnancy became available. Management of ectopic pregnancy has been conservative tubal surgery so far. Local Methotrexate treatment of ectopic pregnancy was reported only recently. The authors treated successfully two cases of ectopic tubal pregnancy with locally administered 50 mg Methotrexate. One of the tubal pregnancies occurred after IVF, and the other one following GIFT. After local Methotrexate treatment both patients are without any complaints or symptoms. This new method in the treatment of early diagnosed ectopic pregnancy is emphasized and prosed.     

A psychosocial profile of adolescent pregnancy termination patients

This study examined the psychosocial problems of a sample of adolescent women who presented for a pregnancy termination appointment at a family planning clinic located in the southeastern region of the United States. The sample consisted of 120 adolescent women, age 14-21 who were administered the Multidimensional Adolescent Assessment Scale (MAAS) while waiting for their pregnancy termination procedure. The MAAS is a self-administered instrument with multiple subscales that measure a variety of psychosocial problems. Results indicated that most subjects did not score in the clinical range on the various subscales, thus indicating respondents as overall being stable and healthy. This paper reviews the specific findings from the study and discusses implications for practice and future research directions on this understudied population.     

Cervagem®/dilapan® for preoperative cervical dilatation prior to vacuum aspiration for termination of first trimester pregnancy A prospective randomized study

The present study included 40 healthy nulliparous women admitted to the hospital for termination of first trimester pregnancy. The patients were randomly allocated to two study groups. One group was treated for 4 hours with one 1 mg Cervagem vaginal suppository prior to vacuum aspiration, the other was treated 4 hours with a Dilapan osmotic dilator intracervically. The patients were continuously supervised during treatment and after operation. Side effects and analgesic consumption were recorded. At operation the degree of cervical dilatation, blood loss and operative complications was registered. Dilapan was more effective and more uniform in dilating the cervix (p<0.05) and eventual further dilatation was easier (p<0.05). The blood loss was higher in the Dilapan-treated group (p<0.05). Side effects of postoperative pain and use of analgesic injections were higher in the Cervagem group (p<0.05). It is concluded that both methods are effective in dilating the cervix prior to vacuum aspiration, with Dilapan being the more effective dilator with the lower frequency of side effects.     

Self-administration of prostaglandin for termination of early pregnancy

The possibility of terminating early pregnancy by self-administration at home was evaluated in the present study. Forty women with a positive pregnancy test and an amenorrhea of less than 50 days and at least one previous pregnancy were selected from the patients coming to the hospital for a legal termination of their pregnancy. Each patient accepted after thorough explanation that a non-surical procedure was to be used and to perform the treatment at home. The patients treated themselves with two suppositories at 6-hour intervals. The first suppository contained 75 mg and the second 30 mg 9-deoxo-16, 16-dimethyl-9-methylene PGE₂. They were allowed to take non-narcotic oral analgesics. All patients but one (98%) aborted completely as judged from clinical course, gynecological examination and plasma β-hCG. In one patient, ultrasound examination two weeks after treatment showed a missed abortion and curettage was performed. In another patient, he expulsion of the conceptus was delayed until the 12th day after start of treatment. Two patients (5%) were brought to the hospital during treatment due to strong uterine pain which was effectively treated with one intramuscular injection of pethidin® (meperidine hydrochloride). Other side effects, mainly vomiting and diarrhea, were so limited that all patients regarded them as acceptable although troublesome in one case. The results of the present study indicate that termination of early pregnancy by self-administration at home starts to be a reality, at least in selected patients.     

Sulprostone (Nalador) versus gemeprost (Cervagem) for cervical priming in the termination of pregnancy during the first trimester

The activity and side-effects of the prostaglandin derivatives, sulprostone and gemeprost were compared, 188 patients were studied, 90 receiving sulprostone 500 micrograms intramuscularly 16 hours pre-operatively and 98 receiving gemeprost 1 mg intravaginally 4 hours pre-operatively. Dilatation of the cervix of more than Hegar 8 was obtained in 80 per cent of the sulprostone group and in about 50 per cent in the gemeprost group. On dilatation before vacuum aspiration, little or no resistance was detected in nearly 80 per cent of both groups. Side-effects occurred in 39.3 per cent of the sulprostone group (usually abdominal pain), and in 22.6 per cent of the gemeprost group and here again abdominal pain was predominant. The results showed that with both sulprostone and gemeprost satisfactory dilatation of the cervix could be obtained. The somewhat better results with sulprostone are obtained at the expense of a higher incidence of side-effects. The administration of gemeprost was also better tolerated by the patients.     

Support following pregnancy termination for genetic indications: experiences of involved women and their partners]

By means of semistructured interviews with 40 women and their partners data were collected concerning on the one hand the care and support and on the other the grieving after termination of pregnancy performed because the child appeared to be genetically affected. Crucial in the grieving process is having to choose personally for or against termination of the pregnancy. This grieving process can be complicated by factors such as uncertainty concerning either the evidence of the disease or its prognosis, high recurrence risk, negative self-esteem, feelings of failure and pre-existent relational or personal problems. Clear and complete counselling, combined with structural support during the hospital stay, proves to be the basis of adequate care. Follow-up interviews after the hospital stay play a supporting part, both for the hospital workers and for the couple involved.     

A study of co-treatment of nonsteroidal anti-inflammatory drugs (NSAIDs) with misoprostol for cervical priming before suction termination of first trimester pregnancy

This double-blind randomized control study was conducted to evaluate whether a nonsteroidal anti-inflammatory drug (NSAID) could act as an effective pain control method during first trimester suction abortion, and whether co-treatment of NSAID with misoprostol will decrease the efficacy of the cervical ripening effect of misoprostol. Subjects were randomized to receive misoprostol alone or misoprostol together with diclofenac sodium. Both groups of subjects suffered from similar incidence of preoperative side effects. Co-treatment of NSAID with misoprostol did not attenuate the cervical ripening efficacy of misoprostol. There was no significant pain reduction in the group treated with NSAID, except that a marginal benefit was found in the subgroup of multiparous women. About two thirds of the subjects in both treatment groups found that this was a satisfactory pain relief method during the procedure.