A retrospective study of 932 second trimester terminations using gemeprost (16,16 dimethyl-trans delta 2 PGE1 methyl ester)

An analysis of misoprostol effectiveness in second trimester pregnancy terminations

Background/Aim: Misoprostol is frequently used as a single agent in pregnancy terminations. However, it increases the risk of uterine rupture in patients who have had previous uterine surgery and terminations due to stillbirths. Therefore, it is used with concern by clinicians. The aim of this study was to evaluate the clinical features of the groups that responded and did not respond to termination treatment with misoprostol in a tertiary center and to investigate its efficacy and safety. Methods: The study design was comprised of a retrospective cohort study. A total of 114 second trimester pregnancies (between 13-24 weeks gestational age) were included in the study. These pregnancies were indicated for termination based on the prenatal diagnosis unit for fetal or maternal causes. According to the International Federation of Gynecology and Obstetrics (FIGO) directions, misoprostol was applied in the following dosages: for 13-17 weeks gestational ages, one tablet per 6 hours; for 18-26 gestational ages, ½ tablet per 6 hours; and for other indications 2 tablets per 3 hours were administered. If the patient had had a previous cesarean operation, all doses were halved. After the first 24 hours, the percentage and demographics results, such as age, body mass index (BMI), gravida, number of cesareans, number of curettages, cervical lengths, BISHOP scores, gestational age, amniotic fluid index, and fetal cardiac beat of the patients with miscarriage, were recorded. Results: The number of cases resulting in miscarriage within 24 hours were 84 (73.7%) and within 48 hours were 14 (12.2%). The total of misoprostol doses used were 8 tablets of 200 mg, mean time until the complete abortion was 17 hours. Sixteen patients required additional treatment, of whom four required Foley catheterization, five required D&E, seven required resting, and no one required a hysterectomy. Uterine rupture occurred in two patients who needed laparotomic surgery. The maternal age (P=0.340), BMI (P=0.790), gravida (P=0.270), previous cesarean history (P=0.390), previous curettage number (P=0.520), cervical length (P=0.380), Bishop score (P=0.190), gestational age (P=0.072), amniotic fluid index (P=0.470) and presence of fetal cardiac beat (P=0.350) were similar between groups Conclusion: Our results indicated that misoprostol is a safe, useful, and effective treatment option for second trimester medical terminations. Caution should be exercised in its use in patients with a history of uterine surgery.

Does feticide shorten termination duration in second trimester pregnancy terminations?

Backround

A retrospective (case-controlled) study was conducted with the aim of identifying the effect of the use of misoprostol on termination time in patients who did and did not undergo feticide procedures in second trimester pregnancy terminations.

Methods

The sampling of the study consisted of 144 pregnant women who were diagnosed as having major fetal anomalies incompatible with life, and were recommended for termination of pregnancy. The investigation showed that feticide procedures were performed for 99 women, and feticide procedures were not performed for 45 women. Misoprostol protocol was administered for 48 hours in the termination period; whether the feticide procedure directly affected the termination duration in patients who did and did not undergo feticide was evaluated.

Results

Abortion/birth was achieved in 103 (71.5%) women during the first 48 hours. There was no significant difference between the termination duration of the misoprostol protocol among the women who did and did not undergo feticide. There was no significant difference between the termination durations and fetal biometric measurements (BPD, HC) except head diameters (p=0.020 and p=0.015).

Conclusions

The misoprostol protocol is shown to be effective and safe for the termination of pregnancies during the second trimester. Feticide has no affect on the duration of termination.

Effects of parity and gestational age on second-trimester induction-abortion interval in combination with osmotic dilators and gemeprost

BACKGROUND

The true prognostic factors for induced medical abortion are unknown. We sought to investigate the effects of a patient's obstetric parameters on the induction-abortion interval in second-trimester medical abortion.

STUDY DESIGN

We studied 216 consecutive women. Pregnancy was terminated with cervical preparation using osmotic dilators followed by 1 mg vaginal gemeprost administered every 3 h for a maximum of five doses in the first 24 h. All variables are expressed in categorical form (parity, gestational age, maternal age and body mass index) and analyzed by the Cox proportional hazards model.

RESULTS

Parity ≥ 3 was associated with a shorter duration of the induction-abortion interval (adjusted hazards ratio 1.96; 95% confidence interval 1.13-3.40). A gestational age ≥ 16 weeks was associated with a longer duration of the induction-abortion interval (0.71; 0.52-0.98). No significant association was found in maternal age and body mass index.

CONCLUSIONS

In combination with osmotic dilators and gemeprost, gestational age and parity are independent factors that affected the induction to abortion interval of second-trimester medical abortion.

Recent advances in second-trimester abortion: an evidence-based review

The proportion of US abortions performed in the second trimester has varied little since 1992. Although 30 years of cumulative data corroborate the safety of dilation and evacuation (D&E), the most commonly used method of second-trimester abortion in the United States, both D&E and alternative induction regimens continue to evolve such that the traditional safety gap between medical and surgical regimens has narrowed. Providers now have options that allow them to either expedite D&E by diminishing the cervical-ripening period or reduce induction abortion intervals during medical induction.

Effect of placenta previa on blood loss in second-trimester abortion by labor induction using gemeprost

OBJECTIVES

The study was conducted to determine whether placenta previa increases bleeding during gemeprost-induced termination of second-trimester pregnancy.

METHODS

We carried out a retrospective study of 158 second-trimester terminations between 12 and 21 weeks' gestation. We compared the intraoperative blood loss among three groups: women without placenta previa undergoing gemeprost termination, women with placenta previa undergoing gemeprost termination and women with placenta previa undergoing dilatation and evacuation (D&E).

RESULTS

Eleven of 158 women (7.0%) had placenta previa; four underwent D&E and seven had gemeprost termination. There was no statistical difference in mean intraoperative blood loss among the three groups, although one of the seven women with placenta previa who underwent gemeprost termination developed serious bleeding requiring blood transfusion.

CONCLUSION

The use of gemeprost for second-trimester pregnancy termination in women with placenta previa seems to be relatively safe and does not increase intraoperative blood loss in the majority of cases.

Mid-trimester induced abortion: a review

Mid-trimester abortion constitutes 10-15% of all induced abortion. The aim of this article is to provide a review of the current literature of mid-trimester methods of abortion with respect to efficacy, side effects and acceptability. There have been continuing efforts to improve the abortion technology in terms of effectiveness, technical ease of performance, acceptability and reduction of side effects and complications. During the last decade, medical methods for mid-trimester induced abortion have shown a considerable development and have become safe and more accessible. The combination of mifepristone and misoprostol is now an established and highly effective method for termination of pregnancy (TOP). Advantages and disadvantages of medical versus surgical methods are discussed. Randomized studies are lacking, and more studies on pain treatment and the safety of any method used in patients with a previous uterine scar are debated, and data are scarce. Pain management in abortion requires special attention. This review highlights the need for randomized studies to set guidelines for mid-trimester abortion methods in terms of safety and acceptability as well as for better analgesic regimens.

Which factors influence the number of gemeprost pessaries used in inducing second-trimester abortions?

BACKGROUND

The course of second-trimester abortions with the intention to use gemeprost as the only abortifacient is described.

METHODS

The report is based on 278 consecutive second-trimester abortions, excluding missed abortions, during a 12-year period in a tertiary referral center. The women were treated with 1 mg gemeprost pessaries every fourth hour with a maximum of five applications during 24 h. If abortion had not occurred, a new treatment of gemeprost was prescribed after an interval of 12 h.

RESULTS

The median number of gemeprost pessaries used was 4 (range 1-16) and the mean number (+/-SD) 4.09 (+/-1.90). Abortion occurred within 24 h in 78% of the women and within 48 h in 96%. The efficiency of gemeprost was highly dependent on previous vaginal deliveries (p<0.001), with a mean number of applications of 4.63 (+/-2.04), 3.93 (+/-1.74), and 3.13 (+/-1.26) in those with none, one, and two or more previous vaginal deliveries, respectively. Previous spontaneous abortions were associated with a lower number of applications. Including previous vaginal deliveries and spontaneous abortions in a two-way analysis of variance (anova), only the number of spontaneous abortions was marginally significant (p=0.05). After excluding four patients with three or more spontaneous abortions from the analysis, the number of previous vaginal deliveries was significant (p=0.010) whereas that of spontaneous abortions became nonsignificant. Postprocedure complications were reported in 13% of the women.

CONCLUSION

The course of the abortions was dependent on previous vaginal deliveries and spontaneous abortions.

A short-scheme protocol of gemeprost for midtrimester termination of pregnancy with uterine scar

OBJECTIVE

The purpose of this study is to investigate the safety and effectiveness of a short-scheme protocol of gemeprost for second trimester induction of abortion in women with previous uterine surgery.

STUDY DESIGN

Retrospective review of women who underwent second trimester medical termination of pregnancy (TOP) at our hospital in a 5-year period. A short regimen of gemeprost was used: over a 24-h period, 1 mg vaginal gemeprost was given every 3 h up to three doses after which, if abortion did not occur, another course at the same dosage schedule was administered up to 4 days. Induction failure was defined as women undelivered by 96 h. A homogeneous population was identified. Statistical analysis was performed with the chi(2) test or Fisher's Exact Test for categorical data and t test for continuous variables.

RESULTS

Four hundred seventeen women underwent medical midtrimester TOP in the 5-year study period. Two hundred five patients were selected for this review, comparing 63 patients with scarred uterus to 142 women without uterine scars. There were no differences between the two groups in induction-to-abortion interval and number of pessaries given. The overall failure of induction rate was 1.5% and need for blood transfusion was 0.5%. No uterine rupture was reported.

CONCLUSION

The regimen of gemeprost proposed seems to be as safe and effective in patients with uterine scars as in women with unscarred uteri with a very low incidence of complications.

Prostaglandins for induction of second-trimester termination and intrauterine death

The introduction of synthetic prostaglandin has revolutionized the treatment protocol for induction of second-trimester abortion and intrauterine death. Gemeprost is the only licensed synthetic prostaglandin analogue for second-trimester abortion in the United Kingdom. However, it is expensive and needs to be stored in a refrigerator. Misoprostol is marketed for use in the prevention and treatment of peptic ulcer. It is inexpensive and can be stored at room temperature. It has been widely used for induction of second-trimester abortion and intrauterine death. Misoprostol, 400 microg given vaginally every 3hours, is probably the optimal regimen for second-trimester abortion. The combination of misoprostol and mifepristone significantly reduced the induction-to-abortion interval when compared with the misoprostol-only regimen. In addition, misoprostol can also be used as a cervical priming agent prior to dilatation and evacuation in second-trimester abortion.

In vitro studies of the role of CD3+ and CD56+ cells in fetal liver cell alloreactivity

BACKGROUND

Previous functional studies have suggested that fetal liver cells (FLC) are capable of responding to allogeneic stimulation and have allostimulatory capacity by early in the second trimester. The present study was designed to analyze whether the allogenic response in human FLC is restricted to HLA class II expression and to evaluate the role of CD3+ cells (T cells) and CD56+ cells (natural killer cells) in the allogenic response.

METHODS

Mixed lymphocyte culture (MLC) experiments were performed on human FLC, at 14 to 18 gestational weeks, before and after depletion of HLA class II+ cells from the stimulator FLC pool (6-11 gestational weeks) and before and after depletion of CD3+ and CD56+ cells from the responder population.

RESULTS

Depletion of HLA class II+ cells from the stimulator FLC pool resulted in a decreased response in 9 of 12 initially positive MLCs. CD3+ cell depletion from responder FLC resulted in a decreased response in four of seven experiments with peripheral blood lymphocytes as stimulators and in two of five experiments with FLC as stimulators. Depletion of CD56+ cells from responder FLC resulted in a decreased response in five of seven initially positive MLCs with peripheral blood lymphocytes as stimulators and two of five with FLC as stimulators.

CONCLUSIONS

The results indicate that FLC are capable of alloresponsiveness when studied in MLC and that the response seems to be HLA class II dependent. Depletion of CD3+ or CD56+ cells led to a reduction in the MLC in a majority of the experiments. The question remains how these cells interact; it is likely that both cell types exhibit complementary effects in the early allogenic response.

Medical abortion in the second trimester

The introduction of prostaglandin analogues and mifepristone has changed the management of second trimester abortion in the last 2 decades. Gemeprost and misoprostol are the two most extensively studied prostaglandin analogues that are used in this period. The combination of either gemeprost or misoprostol with mifepristone is most effective. With these regimens, over 90% of women abort within 24 hours and the mean induction to abortion interval is about 6 hours. Mifepristone is expensive and is not available in many countries. Therefore, prostaglandin analogue-only regimens might be the only option. These regimens are still effective with an abortion rate of >90% in 48 hours. However, the induction to abortion interval (15 hours) is much longer. Intra-cervical tents can be used to shorten the induction to abortion intervals.

Second trimester medical abortion with mifepristone and gemeprost: a review of 956 cases

The treatment outcomes of 956 women undergoing second trimester termination of pregnancy with mifepristone and gemeprost were studied. The median gestational age was 16 weeks (range: 12-24 weeks). All women were treated with 200 mg mifepristone orally, followed 36 h later with 1 mg vaginal gemeprost administered every 6 h to a maximum of 4 doses in the first 24 h. A second course of 1 mg vaginal gemeprost was given 3-hourly in the next 12 h, if abortion had not occurred. Overall, 96.4% and 98.8% of the women aborted within 24 and 36 h, respectively. The median induction-to-abortion interval was 7.8 h (range: 0.5-109.9 h). The induction-abortion interval was longer in nulliparous women and women with a gestation age 17 weeks or above. Surgical evacuation of the uterus was performed in 11.5% of women for incomplete abortion or retained placenta. More multiparous women (16.7%) required surgical evacuation of uterus than did nulliparous women (7.3%; p <0.001). Ten (0.1%) women failed to abort with gemeprost and required other methods for abortion. In conclusion, a combination of mifepristone and gemeprost is a safe, effective, and noninvasive method of medical abortion for second trimester pregnancy.

Mixed lymphocyte culture of human fetal liver cells

OBJECTIVE

In order to study the immunological function of the human fetus in the first and second trimesters, mixed lymphocyte culture (MLC) of fetal liver and thymic cells was performed. MLC is a functional test to determine human lymphocyte antigen-D incompatibilities.

METHODS

Human fetal liver and thymic tissue was obtained from abortions in gestational weeks 7-17.5. Forty-seven fetuses were studied with one-way MLC. The cells were stimulated by adding irradiated fetal liver cells, adult bone marrow and peripheral blood lymphocytes. The activity was measured as DNA incorporation of radiolabeled thymidine.

RESULTS

The results indicate that the human fetus is competent to react as early as 11-12 weeks of gestation and in some cases even earlier. In very immature fetal livers (< 8 weeks), the MLC seems to be inhibited.

CONCLUSIONS

Our data suggest that the human fetus can react against foreign transplantation antigens earlier than previous papers have claimed. The onset of reactivity seems to differ considerably among fetuses. The present findings may explain some of the limited success of in utero transplantations of hematopoietic stem cells in human fetuses of normal immunological status.

Oral mifepristone 600 mg and vaginal gemeprost for mid-trimester induction of abortion. An open multicenter study. UK Multicenter Study Group

This open multicenter study was performed in 20 hospital gynecological units in the UK. The effects of 600 mg oral mifepristone as pretreatment to vaginal prostaglandin induction of second trimester abortion was studied in 267 women. The primary efficacy variable was the abortion induction interval, defined as the time taken to expel the fetus from the time of administration of the first prostaglandin pessary. Induction was commenced 36 to 48 hours following mifepristone intake. The mean abortion induction interval was 7 h. A total of 81.9% of women aborted within 12 h. There was a significant relationship between abortion induction interval and age of gestation, and a significant inverse relationship between abortion induction interval and parity. Vomiting, pelvic pain, and nausea were the most frequently reported adverse events. Two patients required transfusion and one patient with a uterine scar from a previous cesarean section suffered a ruptured uterus and hysterotomy.

Dilapan tent-gemeprost regimen vs. combinations of extra-amniotic Rivanol-Laminaria/Lamicel and oxytocin for second trimester abortion

OBJECTIVE

To compare a new regimen for second trimester abortion using Dilapan and vaginal gemeprost suppositories with extra-amniotic Rivanol instillation and oxytocin i.v. immediately or 16 h after instillation.

METHODS

A prospective study was performed in 153 women to analyze the induction-abortion interval, the use of analgesics and the complication rate. Wilcoxon's rank sum test was used for statistical evaluation.

RESULTS

The mean induction-abortion interval was significantly shorter in the Dilapan-gemeprost-treated women than in the immediate or 16-h Rivanol-oxytocin-treated women, 12.5 vs. 23.3 and 26.8 h, respectively. The 24-h cumulative abortion rate was 91% in the former group vs. 49% and 61%, respectively. The use of analgesics was less frequent among the Dilapan-gemeprost-treated women, whereas the complication rate did not differ.

CONCLUSIONS

The Dilapan-gemeprost treatment was advantageous with respect to a shorter induction-abortion interval and ease of handling. However a minority of women do not respond to this treatment and it is therefore necessary to employ alternative methods to complete the abortion in these cases.

Induction of second trimester abortion with mifepristone and gemeprost

OBJECTIVE

To determine the efficacy of a new regimen of the antiprogestogen mifepristone and gemeprost for midtrimester abortion.

DESIGN

Prospective study.

SETTING

Medical Termination Unit, Simpson Memorial Maternity Pavilion, Edinburgh.

SUBJECTS

One hundred women undergoing midtrimester abortion.

INTERVENTIONS

Women were pretreated with 200 mg mifepristone 36 h before prostaglandin; 1 mg gemeprost was administered every 6 h for the first 24 h. If abortion had not occurred, 1 mg gemeprost was administered 3 hourly over the next 12 h.

MEASUREMENT AND MAIN RESULTS

Ninety-six percent and 99% women aborted within 24 h and 48 h, respectively. The median prostaglandin-abortion interval was significantly shorter in multigravidae compared to primigravida (6.6 vs 8.2 h, P < 0.01). The median number of gemeprost pessaries to induce abortion was only two and 47% of women required one pessary. The incidence of vomiting and diarrhoea was 31% and 5%, respectively. Eighty-four percent of women required intramuscular diamorphine for analgesia. Thirty-three percent of women required an evacuation of the uterus following abortion.

CONCLUSIONS

The shortened induction-delivery interval following pretreatment with mifepristone makes it possible to conduct midtrimester abortion on a daycare basis.

A study of gemeprost alone, dilapan or mifepristone in combination with gemeprost for the termination of second trimester pregnancy

It is well established that abortion can be induced successfully in midtrimester of pregnancy by gemeprost vaginal pessaries. A randomised study was carried out to determine the efficacy of mifepristone and dilapan in combination with gemeprost for second trimester termination between 12-18 weeks' gestation. A contemporary group of women treated with gemeprost alone was used as a control group. A single course of 4 x 1 mg gemeprost pessaries was administered every six hours. If abortion had not occurred after 24 hours, a further course of 5 x 1 mg pessaries was administered every three hours over the next 24 hours. In the first twenty hours after administration of gemeprost, 95%, 85% and 72% of women aborted in the mifepristone, dilapan and the control group, respectively. The median induction-abortion interval in the mifepristone group (6.6h) was significantly shorter than the other two groups and fewer pessaries were required to induce abortion. The incidence of diarrhoea and vomiting was lower in the mifepristone than the other two study groups. This study demonstrated the efficacy of mifepristone in combination with gemeprost and this regimen is associated with fewer gastrointestinal side effects.