Consistency of medical abortion efficacy from 5 through 14 weeks' gestation

OBJECTIVE: To assess the efficacy of medical abortion performed according to a single protocol from 5 through 14 weeks. STUDY DESIGN: Retrospective observational study of medical abortions through 14 weeks performed from January 2000 through August 2001. The protocol combined 400mg of mifepristone orally, followed 48 h later by 800 microg of misoprostol, administered vaginally, and repeated after 4 h if the patient did not begin to abort. Outcome measures were the abortion rate, the rates of immediate manual uterine revision and of secondary vacuum aspiration, the time to expulsion, the misoprostol dose, and analgesic use. RESULTS: The study included 512 medical abortions. The abortion rate was 98.4% and the secondary vacuum aspiration rate 8.2%. The uterine exploration rate was 1.4%, but these occurred only at gestations above 13 weeks. The mean time to expulsion was 4.4+/-1.9 h (1-28), and the mean misoprostol dose 860+/-180 microg (0-2000). None of the characteristics studied differed significantly as a function of gestation. 1.6% of patients had complications. CONCLUSION: Medical abortion was consistently effective through 14 weeks and can be offered as an alternative to the surgical technique.     

Cervical priming with misoprostol before manual vacuum aspiration versus electric vacuum aspiration for first-trimester surgical abortion

Objective

To compare the efficacy of manual vacuum aspiration (MVA) with electric vacuum aspiration (EVA) and to evaluate whether cervical priming with misoprostol facilitates cervical dilation and reduces complications associated with first-trimester medical abortion performed up to 10 weeks of pregnancy.

Methods

A total of 600 women who requested termination of pregnancy were randomized into 4 groups (150 women in each group). Group I and II received a vaginal placebo 3 hours before MVA or EVA, respectively. Group III and IV received 400 μg of vaginal misoprostol 3 hours before MVA or EVA, respectively.

Results

Complete abortion rates after MVA and EVA were both 97.9%; after cervical priming with misoprostol complete abortion rates were 98.6% versus 97.3% after cervical priming with placebo (P > 0.05). Administration of misoprostol into the vagina before MVA resulted in 99.3% complete abortions (P = 0.40), and the least operative blood loss, operating time, and need for cervical dilation (P < 0.05). Overall complications and adverse effects were similar in all groups (P > 0.05).

Conclusion

For surgical evacuation, EVA and MVA did not differ in efficacy. Cervical priming 3 hours before MVA for termination of pregnancy significantly reduced the need for cervical dilation and the operative time, and improved the efficacy of the procedure. Pretreatment with vaginal misoprostol before MVA is a safe and effective method for terminating pregnancies of up to 10 weeks of gestation.Clinical Trials Registry: CTRI/2009/091/000008     

“Comparative study of medical abortion by mifepristone with vaginal misoprostol in women < 49 days versus 50–63 days of amenorrhoea”

Objectives

To compare the outcome with Mifepristone and vaginal Misoprostol combination in women having amenorrhea <-49 days (group-A) verses 50–63 days. (Group-B)

Methods

We administered 200 mg of mifepristone to 200 women willing for medical abortion within 63 days of amenorrhea. After 48 hours they were assigned to receive 400 microgram of misoprostol vaginally. At the end of 4 hours, if required, reinstillation of 400 microgram misoprostol vaginally was done.

Results

Complete abortion rate in women with amenorrhea <-49 days verses 50–63 days were 99.16% and 98.75% respectively. Average duration of bleeding was 6.26 (S, D. 2.43 days ) and 6.98 days (2.26 days)respectively and the difference is statistically significant (p<0.05). The proportion of women with induction abortion interval <-4 hours in the two groups as 83.33% and 72.25% respectively. This difference is statistically not significant (Chi-square=3.47, P>0.05). The success rate at the end of 14 days in group A and B was 99.16% and 98.75% respectively and this difference is statistically not significant. (Chi-square = 0.19, P>0.05)

Conclusions

The combination of oral mifepristone and vaginal misoprostol is currently approved for medical abortion in women with amenorrhoea up to 49 days (7 weeks gestation ). Our study has demonstrated that the use of this combination can be effectively and safely extended for inducing abortions in women with amenorrhoea up to 63 days (9 weeks gestation).     

Oral misoprostol as an alternative to surgical management for incomplete abortion in Ghana

Objective

To investigate whether 600-μg oral misoprostol is an effective alternative to manual vacuum aspiration (MVA) for the treatment of incomplete abortion.

Methods

From June 16, 2004, to July 20, 2005, 230 women of reproductive age presenting with incomplete abortion were randomized in an open-label trial to either 600-μg oral misoprostol or MVA for the treatment of incomplete abortion.

Results

Regardless of the assigned method, more than 98% of participants experienced complete uterine evacuation following initial treatment. Efficacy, acceptability, and satisfaction ratings were similar and high for both methods.

Conclusion

600-μg oral misoprostol is a safe, effective, and acceptable alternative to MVA for the treatment of incomplete abortion.     

Oral misoprostol for the management of incomplete abortion in Ecuador

Objective

To assess the feasibility of introducing misoprostol for the treatment of incomplete abortion in Quito, Ecuador.

Methods

In a randomized prospective study conducted at a large tertiary-level maternity hospital and a private secondary-level clinic between November 2006 and November 2007, women with incomplete abortion were treated with either 600 μg of oral misoprostol (n = 122) or manual vacuum aspiration (MVA) (n = 120). All participants were requested to return for follow-up care on day 7 to determine the success of the treatment and to document their satisfaction with the method and the adverse effects experienced.

Results

Sixteen percent of women (39/242) did not return for their follow-up visit and their outcomes are unknown. Among those who did return, 94% (100/106) of women showed successful completion of abortion after treatment with misoprostol, as compared with 100% (97/97) of women treated with MVA. Most women described their adverse effects after treatment as tolerable (misoprostol, 95%; MVA, 91%). Nearly all women reported being satisfied with their treatment (196/203); there were no differences among the women's reports of satisfaction according to treatment received.

Conclusion

An oral dose of 600 μg of misoprostol was found to be an acceptable and effective non-surgical option for treating incomplete abortion. Clinical trials.gov NCT00674232.     

A randomized trial of misoprostol compared with manual vacuum aspiration for incomplete abortion

OBJECTIVE: To compare the safety, efficacy, and acceptability of misoprostol and manual vacuum aspiration for the treatment of incomplete abortion in a hospital setting in Kampala, Uganda. METHODS: Three hundred seventeen women with clinically diagnosed incomplete first-trimester abortions were randomized to treatment with either manual vacuum aspiration or 600 mug misoprostol orally to complete their abortions. All women received antibiotics posttreatment and were followed up 1-2 weeks later. RESULTS: Regardless of treatment allocation, nearly all women in this study successfully completed their abortions with either oral misoprostol or manual vacuum aspiration (96.3% versus 91.5%, relative risk 1.05, 95% confidence interval 0.98-1.14). Complications were less frequent in those receiving misoprostol than those having manual vacuum aspiration (0.9% versus 9.8%, relative risk 0.1, 95% confidence interval 0.01-0.78). In the 6 hours after treatment, women using misoprostol reported heavier bleeding but lower levels of pain than those treated with manual vacuum aspiration. Rates of acceptability were similarly high among women in the 2 treatment groups, with 94.2% and 94.7% of women reporting that their treatment was satisfactory or very satisfactory in the misoprostol and manual vacuum aspiration groups, respectively. CONCLUSION: For treatment of first-trimester uncomplicated incomplete abortion, both manual vacuum aspiration and 600 microg oral misoprostol are safe, effective, and acceptable treatments. Based on availability of each method and the wishes of individual women, either option may be presented to women for the treatment of incomplete abortion. LEVEL OF EVIDENCE: I.     

Acceptability and feasibility of medical abortion with mifepristone and misoprostol in Nigeria

Objective

To examine the acceptability and feasibility of medical abortion in Nigeria.

Methods

In total, 250 women who were eligible for legal pregnancy termination with a gestational age of up to 63 days since last menstrual period were enrolled in Benin City and Zaria between May 2005 and October 2006. Participants received 200 mg of oral mifepristone in the clinic and then took 400 μg of oral misoprostol 2 days later—choosing to either return to the clinic or take it at home. Women returned 2 weeks later for an assessment of abortion status.

Results

The vast majority (96.3%) of women had successful complete abortions. Ultrasound was used to determine outcome in less than one-third (28.9%) of participants. Most women (83.2%) took the misoprostol at home. Almost all (96.2%) participants were satisfied or very satisfied with the abortion method.

Conclusion

The introduction of medical abortion with mifepristone and misoprostol could greatly expand current method options and improve the quality of reproductive health care in Nigeria and other settings in which access to legal abortion services is limited.     

Comparison of Mifepristone Followed by Misoprostol with Misoprostol Alone for Treatment of Early Pregnancy Failure: A Randomized Double-Blind Placebo-Controlled Trial

Objective

To compare the efficacy and safety of mifepristone followed by misoprostol with misoprostol alone in the management of early pregnancy failure (EPF).

Study Design

A randomized double-blind placebo-controlled clinical trial.

Methods

Ninety-two women with EPF ≤12 weeks were recruited and randomly allocated to receive either mifepristone 200 mg (n = 46) or placebo (n = 46). Forty-eight hours later, patients in both the groups were given 800 µg misoprostol per-vaginum. If no expulsion occurred within 4 h, repeat doses of 400 µg misoprostol were given orally at 3-hourly interval to a maximum of 2 doses in women ≤9 weeks by scan and 4 doses in women >9 weeks by scan.

Results

Pre-treatment of misoprostol with mifepristone significantly increased the complete abortion rate (86.7 vs. 57.8%, p = 0.009) and, hence, reduced the need for surgical evacuation (13.3 vs. 42.2%, p = 0.002), induction to expulsion interval (4.74 ± 2.24 vs. 8.03 ± 2.77 h, p = 0.000), mean number of additional doses of misoprostol required (0.68 vs. 1.91, p = 0.000), and side effects.

Conclusion

Use of mifepristone prior to misoprostol in EPF significantly improves the efficacy and reduces the side effects of misoprostol alone.

     

A Prospective Trial Using Mifepristone and Vaginal Misoprostol in Termination of Pregnancies up to 63 Days of Gestation

Purpose

According to the Consortium on National Consensus for Medical Abortion in India, on average about 11 million abortions take place annually, and around 20,000 women die every year due to abortion-related complications. This study was undertaken to determine the efficacy and the side effect profile of a regime of 200 mg of mifepristone administered orally followed by 800 mcg of vaginal misoprostol after 48 h.

Methods

50 cases of medical abortion meeting the inclusion criteria were included. On day 1, 200 mg of oral mifepristone was given. On day 3, the patient was called back, and 800 mcg of Misoprostol administered per vaginum and was observed for 6 h. The patients were then called back for review after two weeks to make sure that the abortion was complete. Although, in most cases, this was clinically evident, an ultrasonography was repeated to confirm the completion.

Results

Out of the 50 patients, four were lost to follow up, and of the remaining 46 patients, abortions were complete in 44 (95.65 %), while two (4.35 %) patients required surgical intervention.

Conclusions

Medical abortion with 200 mg oral mifepristone and 800 mcg vaginal misoprostol is an effective, safe, reliable, and noninvasive method with a success rate of 95.65 %. The availability of this low-cost medical treatment using agents which do not require special cold storage and transport facilities and negligible operating theater time makes this provision of safe abortion feasible in settings especially of developing countries, like India, where medical facilities are limited.     

Prospective Comparative Study of Oral Versus Vaginal Misoprostol for Second-Trimester Termination of Pregnancy

Background

Various medical methods for second-trimester medical termination of pregnancy (MTP) exist. Misoprostol alone has been used with myriad variations in route and dosage. Comparison between oral and vaginal routes of misoprostol forms the basis of this study.

Methods

This was a prospective comparative study of misoprostol for second-trimester (14–20 weeks) MTP, comparing oral versus vaginal routes. Sixty patients were randomly allotted to two groups; 30 received oral misoprostol 400 µg 4 h up to a maximum of five doses (2000 µg), and 30 received vaginal misoprostol in the same dose and duration. In both groups, oxytocin infusion was started if abortion did not occur. Efficacy of oral versus vaginal misoprostol, induction–abortion interval (AI) and need for surgical intervention were analyzed.

Results

Both groups were well matched in terms of age, parity, previous LSCS, mean gestational age and indication for MTP. Overall mean induction–abortion interval was 19.59 h (21.66 vs. 18.57 h, oral vs. vaginal, respectively), with vaginal group taking lesser time (p 0.09). Sixty percentage in oral group required five doses, while 70% in vaginal group required 3–4 doses of misoprostol (p 0.010). 23.7 versus 6.7% in oral versus vaginal group required check curettage (p 0.038). There were no major complications, and there was only one failure in oral group.

Conclusions

Though both oral and vaginal misoprostol are safe, vaginal route appears to be more efficacious for second-trimester MTP.

     

Effectiveness of celecoxib for pain relief and antipyresis in second trimester medical abortions with misoprostol: a randomized controlled trial

Purpose

To evaluate the effectiveness of celecoxib for pain relief and antipyresis during second trimester abortion using sublingual misoprostol.

Methods

Fifty-six pregnant women of gestational age 14–24 weeks were randomly assigned in a double-blind randomized controlled trial to receive 400 mg of celecoxib or placebo just before sublingual administration of misoprostol 400 µg every 6 h. Pain and body temperature (BT) were assessed every 1 h until the abortion or 24 h after the first dose of misoprostol. Pain was assessed using a 10-cm Visual Analog Scale (VAS). BT was measured with an infrared thermometer.

Results

From January 2016 through September 2016, 28 patients were randomized into each study group. The mean VAS pain score at the completion of the abortion in the celecoxib group was significantly lower than in the placebo group (4.6 ± 2.8 vs. 7.3 ± 2.2) (p = 0.012). But 42.9% of patients in both groups experienced severe pain and needed equivalent amounts of morphine rescue. The overall mean BT in the celecoxib group was significantly lower than in the placebo group [? 0.09 (SD = 0.04)] (p = 0.017). The mean BTs at 1, 2 and 6 h after each repeated dose of misoprostol in the celecoxib group were also significantly lower than in the placebo group.

Conclusions

Single-dose 400 mg celecoxib had an inadequate beneficial effect on pain relief but significant antipyretic effect during second trimester abortions using sublingual misoprostol.

     

Is induced abortion with misoprostol a risk factor for late abortion or preterm delivery in subsequent pregnancies?

Objective

To examine whether a first or second trimester induced abortion with misoprostol influences the risk of late abortion or preterm delivery in subsequent pregnancies.

Study design

Case–control study in a teaching hospital from January 2005 to June 2006. The cases had singleton pregnancies delivered at 16–36 weeks of gestation after spontaneous late abortions, preterm labor or preterm premature rupture of membrane, or induction of labor for preterm premature rupture of membrane before 37 weeks. The control group was composed of the two consecutive spontaneous singleton deliveries at ≥37 weeks of gestation after each new case (ratio 2/1). The principal outcome measure was late abortion or preterm delivery. The association between late abortion or preterm delivery and a previous induced abortion with misoprostol was first assessed with the Cochran-Mantel-Haenszel chi-square test. Conditional logistic regression models adapted for clustered data were then further used to quantify the effect size, measured by estimated odds ratios (ORs) with their 95% confidence intervals (95% CI).

Results

The study included 245 cases and 490 controls. There was no significant difference in mean maternal age, number of pregnancies, parity, smoking, or history of first trimester miscarriage between cases and controls. However, a history of late abortion or previous preterm delivery was significantly more frequent among cases than controls. Forty (16.3%) cases and 56 (11.5%) controls had a history of cervical ripening with misoprostol before vacuum curettage or evacuation, or of medical abortion by misoprostol alone or with mifepristone (OR 1.51, 95% CI: 0.95–2.39; p = 0.08). After adjustment for maternal age and number of pregnancies with a multivariable conditional regression model, the adjusted OR was estimated at 1.33 (95% CI: 0.81–2.17; p = 0.25).

Conclusion

Despite the need for prudence, these results provide some reassurance that induced abortion with misoprostol during the first or second trimester of pregnancy is safe for subsequent pregnancies.     

Pre-induction with Mifepristone for Second Trimester Termination of Pregnancy

Objective

To study the efficacy and safety of combining mifepristone before misoprostol use in second trimester to considerably reduce the induction–abortion interval with the lowest possible dose and adverse reaction.

Material and methods

A prospective study was conducted which included 60 patients visiting the antenatal OPD for elective abortions between 13 and 20 weeks of gestation as per the MTP act. They were randomly divided into two groups of 30 each—the study group received mifepristone 200 mg orally before misoprostol, whereas the control group was induced with misoprostol alone. The results were analyzed.

Observation

Statistical analysis of the study was done using χ² test. The induction–abortion interval was significantly shorter in the study group, thereby decreasing the side-effects of the drug as well as duration of hospital stay.

Conclusion

This study, like many others, offers a reliable, safe, and cost-effective option by combining mifepristone before misoprostol to decrease the induction–abortion interval.     

Misoprostol in Abortion Care: Review and Update

Purpose of Review

We seek to update readers on misoprostol use in abortion care. We discuss literature on misoprostol use in first trimester medication abortion, second trimester induction abortion, management of early pregnancy loss, and first and second trimester surgical abortion. We review publications investigating efficacy, acceptability, and safety of misoprostol doses, routes of administration, use with mifepristone and osmotic dilators, and timing in relation to mifepristone or surgery.

Recent Findings

In 2016, the Food and Drug Administration approved updated labeling for medication abortion: mifepristone 200 mg oral followed in 24–48 h by misoprostol 800 mcg buccal through 70 days gestation. Intervals less than 24 h decrease efficacy. The addition of mifepristone to misoprostol for second trimester induction abortion decreases time from misoprostol to complete uterine evacuation. Misoprostol may be used alone or in combination with osmotic dilators or mifepristone for cervical preparation for surgical abortion. Routine cervical priming with misoprostol is not recommended in the first trimester. Same-day cervical preparation with misoprostol may be used from the late first trimester through 18–20 weeks, although additional mechanical dilation may be required. After 18–20 weeks, misoprostol may be used with overnight osmotic dilators, although mifepristone may be preferred to avoid misoprostol side effects and enhance ease of the surgical procedure.

Summary

Misoprostol plays an indispensable role in abortion care and may be administered in doses of 400–800 mcg by oral, buccal, vaginal, and sublingual routes. More studies are needed to assess variations in dose and timing and to determine upper gestational age limits for same-day preparation.

     

Comparison Between Sublingual and Vaginal Administration of Misoprostol in Management of Missed Abortion

Aim

The aim of the present study is to compare between sublingual administration of misoprostol and vaginal administration in the management of missed abortion.

Materials and Methods

The study was conducted in El-Shatby Maternity Hospital on 160 patients diagnosed as missed abortion by ultrasonographic examination. Cases were divided into two groups according to the methods of misoprostol administration, whether sublingual or vaginal. Patients of the two groups were observed for the times of uterine colic starting, cervical dilation, and conceptus expulsion, along with recording of any side effects.

Result

During the follow-up of our cases we found that sublingual route is more effective than vaginal route in the management of missed abortion. The difference between the two groups in percentage of conceptus expulsion was statistically significant. The most common side effects were nausea which was present in 55 % of cases in group I (sublingual) and in 40 % of cases in group II (vaginal) then severe pain in 25 % of cases in group I (sublingual) and in 20 % of cases in group II (vaginal) and hyperpyrexia in 15 % of cases in group I (sublingual) and in 5 % of cases in group II (vaginal).

Conclusion

Sublingual administration of misoprostol is more effective than its vaginal administration in missed abortion management. Side effect of misoprostol as nausea, vomiting, fever is more common with sublingual administration in comparison with its vaginal administration.

     

Comparison of sequential vaginal and sublingual misoprostol after a vaginal loading dose for second-trimester abortion

Objective

To evaluate the effects of sequential vaginal and sublingual misoprostol after a vaginal loading dose for second-trimester abortion.

Quantitative assessment of medical students' clinical practical learning in department of obstetrics and gynecology of Brest Hospital University

Objective

The main objective of this study was to describe how medical students got progressively trained to perform the most frequent medical procedures in obstetrics and gynecology. The secondary objective was to rationalize and plan the training.

Methods

The medical students in our University Hospital were contacted either directly or by e-mail. They were given an anonymous simple choice questionnaire relating to eight most important acts in the specialty.

Results

Three hundred and eighty-two medical students have been consulted. We got 173 answers which means a participation rate of 45.3%. The survey showed up that the considered procedures were progressively put into practice with the exception of two: the insertion of an intrauterine contraceptive device (coil) and of an implant.

Conclusion

The study showed off some insufficiency in the training in two of the considered procedures. An amendment was proposed with simulated performances of the acts and the setting up of a training course booklet.     

Effects of leonurine hydrochloride on medically induced incomplete abortion in early pregnancy rats

Objectives

To determine the effect of leonurine hydrochloride (LH) on abnormal bleeding induced by medical abortion.

Study design

Rats had incomplete abortions induced in early pregnancy using mifepristone in combination with misoprostol. After abortion, rats were treated with LH for 7 days, and the duration and volume of uterine bleeding were observed. Approximately 30 min after the last treatment, the animals were killed and the uterine shape was observed. The sinistro-uteri were suspended in organ baths to record the contraction curves, including the frequency and tension for 10 min; the dextro-uteri were fixed with formaldehyde for pathologic evaluation. In addition, blood samples were collected from the femoral artery for the measurement of estradiol (E₂) and progesterone (P) levels by radioimmunoassay.

Results

In in vivo experiments, compared with the model group, LH treatment markedly reduced the volume of bleeding and intrauterine residual, and significantly shortened the duration of bleeding. From the contraction curve, LH notably reinforced the frequency and tension of uterine contractions. LH remarkably elevated the serum estradiol level in rats, but had no obvious effect on progesterone level.

Conclusions

LH has an inhibitory effect on bleeding caused by incomplete abortion; the mechanism may be related to up-regulation of the E₂ level, leading to an increase in uterine contractions and evacuation of intrauterine residuum.     

Buccal Versus Vaginal Misoprostol Administration for the Induction of First and Second Trimester Abortions

Objectives

To compare the effectiveness, side effects, and patient satisfaction of buccal versus vaginal misoprostol administration in first and second trimester induced abortions.

Methods

In first trimester, women received oral mifepristone followed by misoprostol either by buccal or vaginal route. In second trimester, women received oral mifepristone followed by repeated doses of misoprostol either by buccal or vaginal route. A comparative analysis using SPSS was done.

Results

In first trimester, success rate of medical abortion was 96 % in buccal group and 88 % in vaginal group. Nausea was the most common adverse effect which was similar in both groups. In second trimester, success rate was 96 % in buccal group and 80 % in vaginal group. A statistically higher incidence of nausea was noticed in buccal group. Patient satisfaction level was almost similar in both the groups in both trimesters.

Conclusions

Buccal and vaginal routes of misoprostol administration have similar efficacy and patient satisfaction level for first and second trimester induced abortions. Hence, buccal route may serve as an alternative to vaginal misoprostol.