Medical termination of pregnancy

A randomized prospective study of misoprostol or mifepristone followed by misoprostol when needed for the treatment of women with early pregnancy failure

OBJECTIVE

To compare the effectiveness and safety of misoprostol and mifepristone, followed when needed by misoprostol, for the treatment of women with early pregnancy failure.

DESIGN

Prospective randomized nonblinded controlled trial.

SETTING

University-affiliated tertiary medical center.

PATIENT(S)

One hundred fifteen consecutive women diagnosed as having a blighted ovum or missed abortion of <9 weeks of gestation enrolled.

INTERVENTION(S)

The patients received orally 600 mg mifepristone (group I) or orally 800 microg misoprostol (group II). Most patients in both groups subsequently received 48 hours later orally 800 microg misoprostol.

MAIN OUTCOME MEASURE(S)

Failure was defined as surgical intervention due to retained gestational sac 48 hours after completion of the drug protocol, severe symptoms, or suspected retained products of conception after the menstrual period.

RESULT(S)

The success rate was similar in groups I and II: 38 of 58 patients (65.5%) versus 42 of 57 patients (73.6%), respectively. No cases of severe infection or bleeding necessitating blood transfusion occurred.

CONCLUSION(S)

Misoprostol is an effective and safe treatment for early pregnancy failure and could replace surgical curettage in over two-thirds of the patients. Mifepristone offers no advantage compared with misoprostol as initial treatment.

The use of vaginal misoprostol for second-trimester pregnancy termination in women with previous single cesarean section

INTRODUCTION

This retrospective study reports of 85 women in the second trimester with one prior cesarean section undergoing medical abortion of a viable unwanted pregnancy using vaginal misoprostol. Two regimens that were selected in a nonrandomized manner were used.

MATERIALS AND METHODS

Eighty-five women treated with vaginal misoprostol in a 3-year period were retrospectively analyzed. All received 400 mug of misoprostol initially and 22 (25.8%) aborted. Then Group A (n=43) received subsequent administration of 200 microg every 6 h, whereas Group B (n=20) received 400 microg/6 h.

RESULTS

All patients aborted. The groups had no statistical difference in mean age, gravidity, parity, gestational age, and time from previous cesarean section, and there was no difference in occurrence of side effects and mean induction to abortion time interval. The lower dosage group received a median of 600 microg of vaginal misoprostol (min 600 microg to max 1000 microg). There were no uterine ruptures, need for hysterotomy, or excess bleeding in any patient.

CONCLUSIONS

This is the largest series reported to date of second-trimester pregnancy termination in cases with one previous cesarean section using only vaginal misoprostol. The study shows that both used regimens are safe and equally effective. All 85 women aborted.

Amniotic Band Syndrome with Limb Amputation after Exposure to Mifepristone in Early Pregnancy

To date, the number of cases reported after exposure to mifepristone alone in early pregnancy is limited. In 24 cases, only 1 observation of fetal malformation associated with mifepristone has previously been reported. We report a case of amniotic band syndrome with limb amputation after exposure to mifepristone in early pregnancy. This association raises the question of a possible causal relationship.

Sonographic appearance of the uterine cavity following administration of mifepristone and misoprostol for termination of pregnancy

PURPOSE

To describe the sonographic appearance of the uterine cavity in women after administration of mifepristone and misoprostol for termination of pregnancy.

METHODS

Thirty-six women treated with mifepristone 600 mg followed by misoprostol 400 mug 2 days later for termination of pregnancy were the subjects of the study. Gestational age as calculated from the last menstrual period was < or =49 days. Pretreatment sonographic parameters, including gestational sac size and crown-rump length, were measured. The sonographic appearance of the uterine cavity was recorded and documented 6 hours (T-1) and 14 days (T-2) after administration of misoprostol.

RESULTS

The mean menstrual age of the patients was 42 days (range 31-49 days). The mean gestational age according to crown-rump length was 43 days (range 40-48 days). Sonographic examination performed atT-1 revealed 23 patients (62.9%) with a well-defined echogenic mass located in the uterine cavity, 2 patients (5.5%) with an intrauterine sac containing a nonviable embryo, and 11 patients (30.5%) with an endometrium thickness of 7-14 mm with no evidence of intrauterine contents. Doppler flow signals were detected in 15 of the 23 patients (65.2%) with an echogenic intrauterine mass. Sonographic examination performed at T-2 revealed 19 patients (52.8%) with a persistent echogenic intrauterine mass; Doppler flow could be detected in 15 of these patients (78.9%). Dilatation and curettage was required in 2 patients (5.6%) due to failure of treatment; all others regained normal menses.

CONCLUSIONS

An intrauterine echogenic mass with well-defined borders, with or without Doppler flow signals, can be detected 2 weeks after administration of mifepristone and misoprostol for termination of pregnancy. Because most of the women in our study regained normal menses without further surgical intervention, this finding could indicate remnants of trophoblastic tissue evacuated spontaneously from the uterine cavity. Therefore, dilatation and curettage should be avoided in these cases, unless clinical symptoms or signs necessitate surgical intervention.

Abortifacient effect of Prangos ferulacia on pregnant rats

PURPOSE

Prangos ferulacea grows in southern Iran and used in Iranian herbal medicine for gastrointestinal disorders, but it seems it has an abortifacient effect on pregnant women. To verify its potential as an abortifacient agent, we administered the leaves of this plant to pregnant rats.

MATERIAL AND METHODS

Hydroalcoholic and aqueous extract of the leaves was administered orally at different doses to 60 rats on the first 18 days of pregnancy. Group 1 (G1) was considered as control group and was given only water. Groups 2-5 (G2-G5) received 25, 50, 100 mg/g per day and Groups 6-8 (G6-G8) received 300, 500 and 1000 mg/g per day, respectively. On Day 18 of pregnancy, they were killed and laparotomized. The uterine horns of each group were opened to see whether they contained any live and degenerated/dead fetuses. We used Student's t-test to analyze the data (p < or = .05 was considered significant).

RESULTS

Of the total 504 fetuses in the studied groups, 13 fetuses (2.57%) were aborted. The abortion rate in the control group was 2 (1.94%) of 103 fetuses; the abortion rate was higher in the treated groups but not statistically significant. There was no relationship between the dose and type of extract and abortion rate in all studied groups.

CONCLUSION

This study shows that the aqueous or hydroalcoholic extract of P. ferulacea is ineffective on the rate of abortion of pregnant rats. Future studies should be performed with higher doses to test the efficacy of this agent on other animals.

Unusual case of double acute intoxication with tamoxifen complicated by miscarriage

Background: A 24-year-old female had attempted suicide twice, at the age of 20 and 24, using tamoxifen.

Case report: Subsequent to the first acute intoxication a development of bilateral ovarian cysts was observed. Cysts regressed spontaneously within 8 weeks. Five weeks after the second suicidal attempt, pregnant patient (15 weeks of gestation) was admitted to the hospital with vaginal bleeding and suspicion of miscarriage. The autopsy of the fetus did not reveal any gross abnormalities, whereas the microscopic examination demonstrated numerous foci of necrosis in the placental decidua. Other fetal membranes as well as the umbilical cord were normal.

Conclusions:1.Acute intoxication with tamoxifen may be connected with the formation of follicular ovarian cysts.2.During pregnancy, intoxication with tamoxifen, may result in delayed miscarriage.

Early Abortion in Ontario: Options and Costs

OBJECTIVE

Early abortions have been predominantly surgical for many years, but medical options with comparable efficacy and safety are now available. This study compares the costs of two medical options and two surgical options.

METHODS

We used a clinical model to compare the costs in Ontario of four options for early abortion: medical abortion using either mifepristone or methotrexate, and surgical abortion by vacuum aspiration in either a hospital or a free-standing clinic. The cost analysis was conducted from the perspectives of society, the health care system, and the patient.

RESULTS

From all perspectives, total costs were highest for hospital surgical abortion, followed by surgical abortion in a clinic. From the patient's perspective, total costs were higher for surgical abortion but direct costs (mainly for medications) were higher for medical abortion. The total cost of mifepristone and methotrexate abortion was equal if the price of mifepristone (200 mg) was $59.52. The model was robust but was sensitive to the price of mifepristone.

CONCLUSION

Early medical abortion costs less than early surgical abortion from the societal and health care system perspectives but more than surgical abortion from the patient's perspective. Surgical abortion costs more in hospitals than in free-standing clinics from the societal and health care system perspectives, but the costs are the same in both settings from the patient's perspective. No method for early abortion can be identified as best, and patients should be free to choose the option they prefer.

Determinants of physician unwillingness to offer medical abortion using mifepristone

PURPOSE

We sought to identify factors associated with contemplating versus not contemplating offering medical abortion with mifepristone among physicians not opposed to it.

METHODS

We analyzed data from a Kaiser Family Foundation survey of a nationally representative sample of 790 American obstetrician/gynecologists and primary care physicians. Our study sample consisted of 419 physicians who were not personally opposed to medical abortion and could be classified as not actively considering (precontemplation) or actively considering (contemplation) offering mifepristone. We conducted multivariate logistic regression to predict being unlikely to offer mifepristone (i.e., in the precontemplation stage of change).

PRINCIPAL FINDINGS

In 2001, 1 year after U.S. Food and Drug Administration (FDA) approval, 5% of physicians surveyed were offering mifepristone. Among the 750 physicians not offering mifepristone, 57% were not opposed. Of those not opposed, 74% reported that they were unlikely to offer mifepristone in the next year (precontemplation) as compared to 23% who might offer it (contemplation). Independent predictors of being in the precontemplation stage were being a primary care versus OB/GYN physician (odds ratio [OR] 3.29, p = .02), being in private versus hospital-based practice (OR 2.40, p = .03), and lacking concerns about FDA regulations (OR 2.06, p = .01) or violence and protests (OR 1.93, p = .03) as barriers to offering mifepristone.

CONCLUSIONS

For precontemplation-stage physicians, the most efficient strategy for increasing the availability of medical abortion may be to design programs that emphasize clinical benefits and feasibility to stimulate interest in the procedure. For contemplation-stage physicians, the optimum approach may be one that helps to overcome barriers associated with FDA regulations and concerns about violence and protests.

Influence of clinical and ultrasound factors on the efficacy of misoprostol in first trimester pregnancy failure

An observational study including 276 patients with early pregnancy failure was performed to evaluate the clinical and ultrasound factors influencing the efficacy of misoprostol in the treatment of first trimester pregnancy failure. Gestational age did not influence the efficacy of this treatment and the success rate was inversely proportional to parity.

[Side effects of induced abortion: results from a population-based survey]

OBJECTIVES

This study compares the gynaecological symptoms of women who have undergone an induced abortion to those who have not. We also compare the gynaecological side effects, in particular the infectious symptoms, following an induced abortion, according to the abortion technique, medical and surgical, in the year after the abortion.

PATIENTS AND METHODS

A representative sample of 2863 women, aged 18 to 44, was interviewed by telephone between September 2000 and January 2001. Of these women, 401 declared an abortion in the last 5 years. Analysis of the gynaecological side effects according to the abortion technique was performed among the 199 women who terminated their pregnancy before the 8th week of amenorrhoea.

RESULTS

Women with a history of induced abortion had a higher sexual risk profile than those with no such history. They also more frequently reported genital infectious symptoms. The comparison between medical and surgical abortions shows that women who had a medical abortion were more likely to report heavy and prolonged bleeding. On the contrary, we found no difference of infectious symptoms between the two techniques.

DISCUSSION AND CONCLUSION

Our study does not support the idea of a reduction of infectious complications related to medical as opposed to surgical abortions. However, given the rapid diffusion of medical abortion, it seems important to carry on the investigations on the side effects related to medical abortions, in order to prevent them if necessary.

Selective progesterone receptor modulators and progesterone antagonists: mechanisms of action and clinical applications

Since the discovery of the antiprogestin mifepristone, hundreds of similar compounds have been synthesized, which can be grouped in a large family of progesterone receptor ligands. This family includes pure agonists such as progesterone itself or progestins and, at the other end of the biological spectrum, pure progesterone receptor antagonists (PA). Selective progesterone receptor modulators (SPRM) have mixed agonist-antagonist properties, and occupy an intermediate position of the spectrum. These compounds have numerous applications in female health care. Mifepristone is used to terminate pregnancy, and as such is commercially available in many countries. The negative abortion-related image of mifepristone has clearly limited the involvement of the major pharmaceutical companies in the development of PA and SPRM. Many PA and SPRM display direct antiproliferative effects in the endometrium, although with variable actions which seem product- and dose-dependent. This property justifies their use in the treatment of myomas and endometriosis. PA also suppress late follicular development, block the LH surge and retard endometrial maturation, which renders them potential estrogen-free contraceptive drugs. SPRM such as asoprisnil are not as effective in blocking the LH surge and appear to target the endometrium directly and produce amenorrhoea. Interestingly, clinical data show that treatment with these compounds is not associated with hypo-estrogenism and bone loss. The potential clinical applications of these compounds cover a broad field and are very promising in major public health areas. These include emergency contraception, long-term estrogen-free contraception (administered alone, or in association with a progestin-only pill to improve bleeding patterns), myomas (where they induce a marked reduction in tumour volume and produce amenorrhoea) and endometriosis. Further developments might also include hormone replacement therapy in post-menopausal women, as well as the treatment of hormone-dependent tumours.

Failed medical termination of twin pregnancy with mifepristone: a case report

Medical abortion with mifepristone and misoprostol is a two-step process where some women will change their minds about going through the abortion process after taking mifepristone. Of these, some pregnancies will continue. A woman with a twin pregnancy who changed her mind is presented. Twin pregnancies may need higher dosages of mifepristone than single pregnancies due to the presence of two corpora lutea and increased amount of trophoblast tissue. There is little, if any, documentation regarding congenital abnormalities after taking mifepristone. Therefore, there is little evidence to support persuasion of the patient to continue the abortion process with the prostaglandin analouge.

[Present and potential uses of mifepristone in gynecology, obstetrics and other medical specialties]

Mifepristone, a derivative of norethindrone, a first generation synthetic progestative, has a very potent antiprogestative activity and to a lesser degree antiandrogenic and antiglucocorticoid activities. This action makes it potentially useful in the treatment of multiple hormone dependent diseases in obstetrics-gynecology as well as in a variety of medical specialties such as neurology, ophthalmology, and oncology. Nevertheless, the label of abortive pill has incited numerous ethical and political debates concerning the permission to market this drug, and this has contributed to the delay in the assessment of the potential indications of mifepristone. Largely under-utilized in practice despite its increasing theoretical benefit, clinical studies should now de conducted. Thus, based on an international review of literature during the last ten years, we have shed light on the present and potential indications of mifepristone in medical practice.

Termination of Pregnancy in First Trimester - Medical Option

BACKGROUND

The objective of this study was to confirm the effectiveness and safety of methotrexate and misoprostol or misoprostol alone for abortion up to 12 weeks of gestation.

METHODS

A group of volunteer patients desiring MTP with gestations up to 84 days (12 weeks) were studied. The patients were divided into 2 groups. Group 1 patients with gestation up to 56 days were further subdivided as (a) Patients who received methotrexate 50 mg IM + misoprostol 800 gms intravaginal and (b) patients who only received 800 gms of misoprostol. Group 2 included the patients who were 8-12 weeks pregnant and they received same treatment as group 1 (b). Outcome measures assessed included successful abortion (complete abortion without need for surgery), side effects, decrease in hemoglobin and mean duration of vaginal bleeding.

RESULTS

Complete abortion occurred in 36 (90%) of 40 patients in group 1 (a), 10 (67%) of 15 patients in group 1(b) and 29 (83%) of 35 patients in group 2. There were only 2 patients with clinically significant decrease in hemoglobin, but none required transfusions. Vaginal bleeding lasted 15 ± 6 days in group 1 (a), 16 ± 6 days in group 1(b) and 16 ± 5 days in group 2. All the patients stopped bleeding when endometrial thickness was < 5mm. Five percent women had stomatitis after methotrexate and 44% patients had fever with chills after misoprostol administration.

CONCLUSION

Considering the low cost and availability of methotrexate and misoprostol, these drugs constitute a good alternative for medical abortion. They are safe and effective.

Mifepristone does not induce cervical softening in non-pregnant women

BACKGROUND

Many techniques have been developed to soften the cervix to reduce complications following surgical dilatation. Progesterone inhibits myometrial contractility and its secretion during pregnancy ensures cervical competence. We used the progesterone antagonist mifepristone as a cervical ripening agent and evaluated its effect prior to office hysteroscopy.

METHODS

Fifty-eight healthy non-pregnant women aged 18-50 were studied in a randomized double-blind study. They received mifepristone (200 mg) or placebo 30 h prior to hysteroscopy. A Hegar test was performed prior to drug administration and again before hysteroscopy. A visual analogue pain scale was used to assess pain.

RESULTS

Medical history, physical examination and blood tests were similar in both groups, except for serum progesterone which was higher in the study group. Hegar measurement prior to drug ingestion was similar in both groups and after a mean time of 30.3 h increased in both groups. Neither the DeltaHegar measurement nor the pain scale was different in the two groups. There was also no effect of the high progesterone levels.

CONCLUSIONS

Unlike its dramatic effect in the pregnant uterus, mifepristone administered 30 h prior to hysteroscopy was not effective in ripening the cervix of non-pregnant women.

Pharmacological properties of mifepristone: toxicology and safety in animal and human studies

Roussel Uclaf in partnership with the INSERM unit of Prof. E.E. Baulieu first discovered mifepristone (RU486) as part of a large research program on steroidal compounds with antihormone properties. Exhibiting a strong affinity to the progesterone and the glucocorticoid receptors, mifepristone exerted competitive antagonism to these hormones both in in vitro and in animal experiments. Due to its antiprogesterone activity, it was proposed that mifepristone be used for the termination of early human pregnancy. Mifepristone, at a dose of 600 mg initially used alone, was then used with a subsequent low dose of prostaglandin that led to a success rate of 95% as a medical method for early termination of pregnancy (TOP). Its use was extended to other indications, such as cervical dilatation prior to surgical TOP in the first trimester, therapeutic TOP for medical reasons beyond the first trimester, and for labor induction in case of fetal death in utero. The efficacy and safety of this treatment has been confirmed based on its use for over a decade, with close adherence to the approved recommendations. This paper describes the safety studies conducted in animals as well as the safety follow-up and side effects reported with use of the compound in various indications either approved or unapproved. The rationale for warnings and contraindications for use of the product are also explained. At lower doses, the molecule has proven promising for contraceptive purposes with few reported side effects. However, development of the product for this indication would require long-term studies. Although political and philosophical obstacles have delayed research, the use of mifepristone for other potential indications in gynecology or oncology should be investigated.

Progesterone antagonists and progesterone receptor modulators: an overview

Since the original description of the structure of the antiprogestin, mifepristone, was published, numerous related compounds have been synthesized which may function as progesterone antagonists (PAs) or progesterone receptor modulators (PRMs). The latter are mixed agonists-antagonists. Both PAs and PRMs have therapeutic applications in female health care. Mifepristone is predominantly a PA and displays only minimum agonist activity in certain systems. Together with a prostaglandin, mifepristone can terminate pregnancies of less than 9 weeks duration, and it may also be used at later gestational ages. Mifepristone causes expulsion of the uterine contents following intrauterine fetal death. A mifepristone-prostaglandin combination has been shown to be very effective treatment in women with menses delay of 11 days or less. Many PAs and PRMs display antiproliferative effects in the endometrium. Serum estradiol levels however remain in the early to mid-follicular phase range. For this reason, they have application in the treatment of endometriosis and myoma without being associated with bone loss and hypoestrogenism. PRMs may also find application in the treatment of dysfunctional bleeding as well as an adjunct to estrogens in hormone replacement therapy in postmenopausal women. Many PAs have contraceptive potential by suppressing follicular development and blocking the LH surge. Low doses may also be potential contraceptives by retarding endometrial maturation without affecting ovulation or inducing bleeding. Mifepristone is an excellent agent for use as an emergency "postcoital" contraceptive. PAs may also be useful in IVF programs to prevent a premature LH surge and to delay the emergence of the implantation window. In addition to their use in women's health care, mifepristone and several other PAs are potent antiglucocorticoid agents and may be used to treat ACTH-independent Cushing's syndrome. They may also be used in the treatment of tumors containing steroid receptors and in other situations which require suppression of the ACTH-cortisol axis.

Prostaglandin inhibitors in preterm labour

Prematurity accounts for the majority of neonatal morbidity and mortality in the developed world. The process of labour resembles inflammation, with prostaglandin and cytokine production both before and during labour. Anti-inflammatory drugs therefore have the potential to prevent preterm delivery. Indomethacin is the only tocolytic drug proven to delay delivery beyond 37 weeks and to reduce the incidence of low birth weight (<2500 g). There are, however, fetal side-effects such as ductal constriction and impaired renal function associated with its use. It is the type 2 isoform of cyclo-oxygenase (COX-2), which is important for the production of prostaglandins within intrauterine tissues and that up-regulation of COX-2 is associated with labour. Although indomethacin is currently the most common non-steroidal anti-inflammatory drug (NSAID) used in the treatment of preterm labour, it was hoped that COX-2-selective drugs, used as tocolytics, would target COX-2 activity and potentially spare COX-1-specific fetal side-effects. Experience with sulindac and nimesulide has been linked with both constriction of the ductus arteriosus and oligohydramnios. It is unclear whether this is due to COX-2-dependent side-effects, or due to accumulation of drug in the fetal circulation leading to levels that would cause COX-1 inhibition. Currently, the use of COX-2-selective drugs should therefore be confined to randomized controlled trials.

Early medical termination pregnancy with methotrexate and misoprostol in lower segment cesarean section cases

AIM

The aim of the study was to investigate the efficacy of methotrexate and misoprostol for the medical termination of early pregnancy with previous cesarean section.

METHODS

Sixty-six pregnant women of 60 days or less in duration with previous one or two cesarean sections were selected. Each woman received intramuscularly a dose of methotrexate (50mg). Two to 3 days later, 800 microg of misoprostol was administered intravaginally. Repeat doses were used if there was no significant bleeding. An ultrasonography was done in each case after seven days. Subjects with continuing pregnancies or excessive bleeding had a surgical abortion. A successful medical abortion was defined by vaginal bleeding without surgical intervention and a negative transvaginal ultrasound. Side-effects were noted.

RESULTS

Complete abortion occurred in 87.9% cases after first dose of misoprostol, and 6.1% cases had complete abortion after second dose, so out of 66 cases 62 (94%) had a successful medical abortion. Four (6%) subjects required surgical intervention; one for continued pregnancies, one for missed abortion, and two for excessive bleeding. The complete abortion rate was higher for early gestations: 30/30 (100%) at < or = 45 days gestation, 28/30 (93.3%) at 46-50 days gestation, and 2/6 (33.3%) from 50 to 63 days gestation. Vaginal bleeding lasted 15 +/- 7 days. Gastrointestinal side-effects were uncommon, mild, and brief. There was no case of uterine rupture.

CONCLUSION

Medical abortion using methotrexate with misoprostol is safe, cheap, and effective for early pregnancy termination through 8 weeks' gestation even with previous cesarean section.

Progesterone represses interleukin-8 and cyclo-oxygenase-2 in human lower segment fibroblast cells and amnion epithelial cells

Labor is preceded by cervical ripening through upregulation of interleukin (IL)-1beta, IL-8, and increased prostaglandin synthesis via inducible type 2 cyclooxygenase (COX-2). Progesterone maintains myometrial quiescence during pregnancy. In this study, we examined the effects of IL-1beta and progesterone on IL-8 and prostaglandin E2 (PGE2) synthesis and IL-8 and COX-2 mRNA and promoter activity in amnion cells and lower segment fibroblast (LSF) cells. In both cell types, progesterone had no effect on basal IL-8 or PGE2 synthesis. In LSF cells, IL-1beta significantly increased IL-8 and PGE2 synthesis and COX-2 and IL-8 mRNA expression, but progesterone significantly attenuated these effects. In prelabor amnion cells, IL-1beta also increased IL-8 and PGE2 synthesis and both COX-2 and IL-8 mRNA and promoter expression; however, progesterone significantly attenuated these effects on IL-8 and PGE2 synthesis and COX-2 expression. In postlabor amnion cells, IL-1beta increased IL-8 and PGE2 synthesis and COX-2 expression, but progesterone did not attenuate the effect of IL-1beta upon IL-8 synthesis. Progesterone repression of IL-8 and COX-2 in LSF cells suggests that IL-8 and COX-2 have similar regulatory mechanisms in LSF cells and that progesterone may play a role in maintenance of cervical competence. The lack of effect of progesterone on IL-8 in postlabor cells may be the result of downregulation of the progesterone receptor during labor.

Pharmacoeconomics of medical abortion: a review of cost in the United States, Europe and Asia

Procedures for the termination of pregnancy have existed for many years. Vacuum aspiration, otherwise referred to as 'surgical' abortion, is a very common and safe procedure. Its efficacy and acceptability has been established and its complication rate is low. Medical abortion is a much more recent phenomenon. It is defined as early pregnancy termination with the use of abortion inducing medications, without surgery [1]. In contrast to surgical abortion, medical abortion is not as routinely offered, nor are many providers comfortable with its use. Medical abortion regimens currently available throughout the world include mifepristone (Mifeprex trade mark, Aventis Pharma AG) and a prostaglandin analogue (usually misoprostol), methotrexate and misoprostol and misoprostol (Cytotec trade mark, CD Searle & Co.) alone. In the US, minimal information exists directly comparing medical to surgical abortion. Most abortion surveillance data was collected by the Centers for Disease Control prior to the approval of mifepristone. In contrast, there is over a decade's worth of experience from Europe with both the use and provision of medical abortion. A complete review of these issues must include background information on the history and incidence of abortion, who chooses to get an abortion, who provides that service and at what cost. The cost issue is discussed using three different viewpoints: cost to the patient, cost to the provider, cost to society - mainly in the form of government expenditure and savings. Following the cost analysis, there is a summary of relevant information from countries in Europe, primarily the UK, France, Sweden and countries in Asia, mainly China and India.

Early abortion services in the United States: a provider survey

The objective of this study was to describe the availability of early surgical and medical abortion among members of the National Abortion Federation (NAF) and to identify factors affecting the integration of early abortion services into current services. Telephone interviews were conducted with staff at 113 Planned Parenthood affiliates and independent abortion providers between February and April 2000, prior to FDA approval of mifepristone. Early abortion services were available at 59% of sites, and establishing services was less difficult than or about what was anticipated. Sites generally found it easier to begin offering early surgical abortion than early medical abortion. Physician participation was found to be critical to implementing early services. At sites where some but not all providers offered early abortion, variations in service availability resulted. Given the option of reconsidering early services, virtually all sites would make the same decision again. These data suggest that developing mentoring relationships between experienced early abortion providers/sites and those not offering early services, and training physicians and other staff, are likely to be effective approaches to expanding service availability.

Target-controlled sedation-analgesia using propofol and remifentanil in women undergoing late termination of pregnancy

Twenty-one women undergoing termination of pregnancy for severe fetal abnormality received remifentanil and propofol using a target-controlled infusion system and were studied prospectively. Target concentrations were initially set at 1 ng.mL(-1) for remifentanil and 0.8 microg.mL(-1) for propofol. Remifentanil concentration was adjusted to obtain visual analog scores <50 mm with preservation of ventilation. Visual analog scores assessed by the patients and physiologic data were recorded every 15 min until delivery. The median duration of administration was 150 min [10th-90th centiles: 42-282 min). Visual analog scores decreased within the first 5 min (P < 0.05) and remained under 50 mm for 91.7% of time. The median rate of infusion of remifentanil was 0.056 microg.kg(-1) min(-1) [10th-90th centiles: 0.037-0.15 ng.mL(-1)]. At delivery, the median target concentration was 2.2 ng.mL(-1) [10th-90th centiles: 1.25-4 ng.mL(-1)] for remifentanil and 0.8 microg.mL(-1) [10th-90th centiles: 0.32-1.12 microg.mL(-1)] for propofol. Remifentanil requirements were statistically correlated to gestational age, parity and duration of labor. No episodes of ventilatory depression, nausea, vomiting or pruritus were noted. Patients scored analgesia as excellent in 12 cases, good in 7 cases and moderate in 2 cases. Further studies are required to determine the place and the best regimen of remifentanil infusion for pain management in labor in those cases when epidural analgesia is contraindicated.

In vitro and in vivo characterization of novel nonsteroidal progesterone receptor antagonists derived from the fungal metabolite PF1092C

We studied the pharmacological effects of novel nonsteroidal progesterone receptor antagonists CP8661 and CP8754, which were synthesized from the fungal metabolite PF1092C. CP8661 possess a tetrahydrobenzindolone skeleton and CP8754 possess a tetrahydronaphthofuranone skeleton. In binding assays for steroid receptors, CP8661 and CP8754 inhibited [(3)H]-progesterone binding to human progesterone receptors (hPR), though they are less potent than RU486. CP8661 also showed moderate affinity to rat androgen receptors (rAR), although CP8754 did not. Neither compound showed affinity to human glucocorticoid receptors (hGR) or human estrogen receptors (hER). In exogeneous and endogeneous PR-dependent enzyme expression assays using human mammary carcinoma T47D, CP8661 and CP8754 showed pure antagonistic activity. In a rabbit endometrial transformation test, CP8661 and CP8754 showed anti-progestational activity by s.c. administration in a dose-dependent manner; meanwhile, these compounds showed no progestational activity at the same dose. These results suggested that CP8661 and CP8754 are in vivo effective pure progesterone receptor antagonists and presented the possibility of synthesizing pure progesterone receptor antagonists from both tetrahydronaphthofuranone and tetrahydrobenzindolone skeletons.

Fetal methotrexate and misoprostol exposure: the past revisited

BACKGROUND

Fetal aminopterin/methotrexate syndrome was described nearly 50 years ago when these agents were first used as abortifacients. Physicians essentially stopped using these agents when the associated anomalies were recognized. Over the last several years the use of methotrexate with or without misoprostol for management of ectopic pregnancy and medical terminations of pregnancy has increased.

METHODS

A 23-year-old female sought a termination at eight weeks gestation. She was given methotrexate followed by misoprostol.

RESULTS

The medical termination was unsuccessful. The patient elected to continue the pregnancy secondary to financial considerations. She presented at 39 weeks without intervening prenatal care. She was diagnosed with severe preeclampsia. At delivery the infant was hypotonic and growth restricted with multiple anomalies.

CONCLUSIONS

Physicians are increasingly using methotrexate with or without misoprostol for treatment of ectopic pregnancies and medical terminations. Clinicians need to be aware of the characteristic teratologic effects of these two agents.

A prospective randomized, double-blinded, placebo-controlled trial comparing mifepristone and vaginal misoprostol to vaginal misoprostol alone for elective termination of early pregnancy

BACKGROUND

Vaginal misoprostol has been shown to be an effective single agent for medical abortion. This randomized, double-blinded, placebo-controlled trial compared a regimen of mifepristone and misoprostol with misoprostol alone for termination of early pregnancy.

METHODS

250 women with gestations < or = 56 days were randomized by a random number table to receive either 200 mg mifepristone orally or placebo followed 48 h later by 800 microg vaginal misoprostol. Administration of misoprostol was repeated every 24 h up to three doses if abortion failed to occur. Abortion success was defined as complete abortion without the use of surgical aspiration.

RESULTS

Successful medical abortions occurred in 114 out of 119 subjects (95.7%) after mifepristone followed by vaginal misoprostol. In all, 110 out of 125 subjects (88.0%) successfully aborted after placebo and vaginal misoprostol. The higher success rate of complete abortion with the mifepristone and misoprostol regimen was statistically significant compared with the placebo and misoprostol regimen (P < 0.05).

CONCLUSIONS

A regimen of mifepristone and misoprostol was significantly more effective for termination of pregnancies < or = 56 days than misoprostol alone. The 88% efficacy obtained with vaginal misoprostol alone may be clinically acceptable when mifepristone is not available.

Ligand-inducible transgene regulation for gene therapy

A synthetic ligand regulable system for gene transfer and expression has been developed in our laboratory based on mechanistic studies of steriod hormone receptor and transcriptional regulation. This gene switch system possesses most of the important features that are required for application of the system in biological research and clinical gene therapy in the future. As the primary ligand tested in this system, mifepristone can effectively turn on the regulatory circuit at doses much lower than those used in the clinic. By modification of the chimeric regulator and its feedback regulatory mode, this system has been optimized to produce very low basal activity with high inducibility in the presence of mifepristone. Also, improvements in regulator composition have been made to minimize immunogenicity and make the system more amenable to human gene therapy. Moreover, incorporation of this gene switch system into the HC-Ad vector system has further enhanced the efficiency of gene transfer and the long-term inducible expression of transgenes. However, for each application within a different biological system, the gene switch needs to be optimized to achieve appropriate inductions. In particular, the method used to deliver the transgenes and adjustment of ligand dosage are critical for in vivo gene expression.

Expression of PGT in MDCK cell monolayers: polarized apical localization and induction of active PG transport

The PG transporter (PGT) is expressed in subapical vesicles in the kidney collecting duct. To gain insight into the possible function of the PGT in this tubule segment, we tagged rat PGT with green fluorescent protein at the COOH terminus and generated stable PGT-expressing Madin-Darby canine kidney cell lines. When grown on permeable filters, green fluorescent protein-PGT was expressed predominantly at the apical membrane. Although the basal-to-apical transepithelial flux of [(3)H]PGE(2) was little changed by PGT expression, the apical-to-basolateral flux was increased 100-fold compared with wild-type cells. Analysis of driving forces revealed that this flux represents PGT-mediated active transepithelial PGE(2) transport. We propose that endogenous PGT is exocytically inserted into the collecting duct apical membrane, where it could control the concentration of luminal PGs.

Early medical abortion with methotrexate and misoprostol: outcomes and satisfaction among women aged 15-21 years

STUDY OBJECTIVE

To compare the outcomes of women aged 15-21 yr to those of older women in a multicenter case series of early medical abortion.

DESIGN, SETTING, PARTICIPANTS

We enrolled 1973 women at 34 outpatient Planned Parenthood sites in a case series for medical abortion in the first seven weeks of pregnancy. We used methotrexate (50 mg/m(2)) and misoprostol (800 mg vaginally, repeated as needed). We compared women who started the abortion prior to their 22(nd) birthday to older women. Outcomes of abortion were classified as documented or presumed complete medical abortion, and documented or presumed suction curettage. During the first half of the study, we did an exit interview assessing patient satisfaction.

RESULTS

A total of 330 women were under 22 yr and 1641 women over 21 yr. Younger women presented for abortion at the same gestational ages. Overall, younger women had a higher rate of complete medical abortion than did older women (89.4% vs 83%). However, the multiple regression model demonstrated a significant adverse effect of prior live birth (P = 0.006), but not patient age, on outcome. Younger women were less likely to have had prior live births. Younger women were more likely to return for follow-up (96.4% vs 92.9%); the regression model demonstrated a significant effect (P = 0.001) of prior birth on rates of follow-up. Side effects and satisfaction were similar for older and younger women.

CONCLUSIONS

Younger women having medical abortion with methotrexate and misoprostol have better outcomes and similar satisfaction levels as do older women.

The scope and limits of conscientious objection

Principles of religious freedom protect physicians, nurses and others who refuse participation in medical procedures to which they hold conscientious objections. However, they cannot decline participation in procedures to save life or continuing health. Physicians who refuse to perform procedures on religious grounds must refer their patients to non-objecting practitioners. When physicians refuse to accept applicants as patients for procedures to which they object, governmental healthcare administrators must ensure that non-objecting providers are reasonably accessible. Nurses' conscientious objections to participate directly in procedures they find religiously offensive should be accommodated, but nurses cannot object to giving patients indirect aid. Medical and nursing students cannot object to be educated about procedures in which they would not participate, but may object to having to perform them under supervision. Hospitals cannot usually claim an institutional conscientious objection, nor discriminate against potential staff applicants who would not object to participation in particular procedures.