A pilot study of mifepristone in combination with sublingual or vaginal misoprostol for medical termination of pregnancy up to 63 days gestation

Prophylactic Pregabalin to Decrease Pain During Medication Abortion: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether prophylactic pregabalin reduces pain experienced with medication abortion.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial of women initiating medication abortion with mifepristone and buccal misoprostol up to 70 days of gestation. Participants were randomized to 300 mg oral pregabalin or a placebo immediately before misoprostol. The primary outcome was maximum pain on an 11-point numerical rating scale, reported using real-time electronic surveys over 72 hours. Secondary outcomes included pain at each time point, ibuprofen and narcotic use, side effects, and satisfaction. We estimated that 110 women would be required to have 80% power to detect a difference in pain of 1.3 points.

RESULTS

Between June 2015 and October 2016, 241 women were screened and 110 were randomized (56 pregabalin, 54 placebo). Three were lost to follow-up. The primary outcome of mean maximum pain in the pregabalin group was 5.0±2.6 vs 5.5±2.2 in the placebo group (P=.32). Excluding medication taken before the study capsule, ibuprofen was used by 64% (35/55) of the pregabalin group vs 87% (45/52) placebo (P<.01). Narcotics were used by 29% (16/55) of the pregabalin group vs 50% (26/52) placebo (P<.03). More dizziness (P<.001), sleepiness (P<.04), and blurred vision (P<.05) occurred in the pregabalin group. Satisfaction scores for the analgesic regimen were higher in the pregabalin group (very satisfied: 47% vs 22%; P=.006).

CONCLUSION

Compared with placebo, 300 mg pregabalin coadministered with misoprostol during medication abortion did not significantly decrease maximum pain scores. Women who received pregabalin were less likely to require any ibuprofen or narcotic and were more likely to report higher satisfaction with analgesia, despite an increase in dizziness, sleepiness, and blurred vision.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02782169.

Pain during medical abortion, the impact of the regimen: a neglected issue? A review

OBJECTIVES

To evaluate pain and other early adverse events associated with different regimens of medical abortion up to nine weeks of amenorrhoea.

METHODS

The literature was searched for comparative studies of medical abortion using mifepristone followed by the prostaglandin analogue misoprostol. Publications, which included pain assessment were further analysed.

RESULTS

Of the 1459 publications on medical abortion identified, only 23 comparative, prospective trials corresponded to the inclusion criteria. Patients in these studies received different dosages of mifepristone in combination with different dosages of misoprostol administered via diverse routes or at various intervals. Information on pain level was reported in 12/23 papers (52%), information regarding systematic administration of analgesics in 12/23 articles (52%) and information concerning analgesia used was available for only 10/23 studies (43%).

CONCLUSIONS

Neither pain nor its treatment are systematically reported in clinical trials of medical abortion; this shortcoming reflects a neglect of the individual pain perception. When data are mentioned, they are too inconsistent to allow for any comparison between different treatment protocols. Standardised evaluation of pain is needed and the correlation between the dosage of misoprostol and the intensity of pain must be assessed in future studies.

Alternatives to routine ultrasound for eligibility assessment prior to early termination of pregnancy with mifepristone-misoprostol

OBJECTIVE

To test the feasibility and efficacy of an approach that foregoes the routine use of ultrasound for the determination of eligibility for medical termination of pregnancy.

DESIGN

Prospective trial.

SETTING

Ten termination of pregnancy clinics in the USA.

POPULATION

A total of 4484 women seeking termination of pregnancy with mifepristone-misoprostol.

METHODS

Women provided estimates of the date of their last menstrual period and underwent pelvic bimanual and ultrasound examinations. We compared estimates of gestational age using these three methods.

MAIN OUTCOME MEASURE

Proportion of women of ≤9 weeks' gestation by woman or provider estimate, but >9 weeks' gestation by ultrasound.

RESULTS

The reliance on women's report of their last menstrual period together with physical examination to determine their eligibility for termination of pregnancy with mifepristone-misoprostol would result in few women (63/4008 or 1.6%) accepted for treatment outside the current limits of standard mifepristone-misoprostol regimens used for early termination of pregnancy (i.e. ≤63 days' gestation on ultrasound).

CONCLUSIONS

Last menstrual period and physical examination alone, without the routine use of ultrasound, are highly effective for the determination of women's eligibility for early termination of pregnancy with mifepristone-misoprostol.

Increasing women's choices in medical abortion: a study of misoprostol 400 microg swallowed immediately or held sublingually following 200 mg mifepristone

OBJECTIVES

To assess the efficacy and acceptability of two misoprostol regimens (400 microg oral or sublingual) following mifepristone for medical abortion.

METHODS

Women seeking abortion with gestations of 56 days or less since onset of their last menstrual period were offered medical abortion as an alternative to a surgical procedure. A total of 207 eligible and consenting women were given mifepristone (200 mg oral) and the option of taking 400 microg misoprostol either orally or sublingually two days later, with the option of home-use. Two weeks later, treatment success, satisfaction, and the frequency and acceptability of side effects were assessed.

RESULTS

Most women (97.6%) opted for home use of misoprostol and almost three quarters selected the oral route. Overall efficacy, acceptability of side effects and satisfaction were high in both groups. The success rate was lower after sublingual than after oral administration but not significantly so (91.3% vs. 96.3%, p = 0.23, RR: 0.93, 95% CI = 0.85-1.02). The frequency and average duration of side effects in both groups were comparable except for pain/cramps and fever/chills, which were more frequently associated with the sublingual route.

CONCLUSIONS

This study re-emphasises the feasibility of integrating medical abortion into health services in Turkey and the potential to increase choices for women.

Acceptability and feasibility of medical abortion in Nepal

OBJECTIVE

To test the feasibility and acceptability of a simplified mifepristone-misoprostol regimen for early abortion in 2 tertiary teaching hospitals and 2 family planning clinics in Nepal.

METHODS

Consenting pregnant women (n=400) with amenorrhea of 56 days or less seeking termination of pregnancy received 200 mg of oral mifepristone followed 48 hours later with 400 microg of oral misoprostol, administered either at home or at the clinic. Prospective data were collected to determine the women's experience, abortion outcome, and the operational requirements for providing the method.

RESULTS

Most (91.3%) of the 367 women with known outcomes had successful medical abortions. Given the option, most (89.7%) women elected to administer the misoprostol at home.

CONCLUSION

A simplified medical abortion protocol, including home administration of misoprostol, can be successfully integrated into clinical services in Nepal, where abortion services were recently legalized.

A randomized controlled trial comparing powdery sublingual misoprostol and sublingual misoprostol tablet for management of embryonic death or anembryonic pregnancy

OBJECTIVES

To compare complete abortion rate, duration of abortion, and side effects between 600 microg powdery sublingual misoprostol and 600 microg sublingual misoprostol tablet for management of embryonic death or anembryonic pregnancy.

MATERIALS AND METHODS

Fifty-four pregnant women up to 13 weeks of gestation diagnosed with embryonic death or anembryonic pregnancy were randomized to receive 600 microg powdery sublingual misoprostol or 600 microg sublingual misoprostol tablet. Complete abortion was evaluated by transvaginal ultrasound at 48 h.

RESULTS

Twenty-six patients received 600 microg powdery sublingual misoprostol and 28 patients received 600 microg sublingual misoprostol tablet. Complete abortion rate was 34.6% in powdery sublingual misoprostol group and 32.1% in sublingual misoprostol tablet group (P = 0.847). Duration of abortion in powdery sublingual misoprostol group and sublingual misoprostol tablet group was similar (34.7 +/- 18.8 vs. 36.9 +/- 17.8 h, respectively, P = 0.656). There was no significant difference in the side effects between both groups.

CONCLUSIONS

Single dose of 600 microg of powdery sublingual misoprostol does not improve its efficacy for management of embryonic death or anembryonic pregnancy when compared to sublingual misoprostol tablet.

Two-pill regimens of misoprostol after mifepristone medical abortion through 63 days' gestational age: a randomized controlled trial of sublingual and oral misoprostol

BACKGROUND

A 400 mcg dose of sublingual misoprostol has high efficacy and few side effects when used with 200 mg mifepristone for medical abortion through 63 days' gestation.

STUDY DESIGN

Eligible and consenting women (n=480) were randomized to 400 mcg of misoprostol sublingually or orally, 24 h after 200 mg of mifepristone. Abortion status was assessed two weeks later.

RESULTS

Complete abortion occurred in 98.7% of the sublingual group and 94.0% of the oral group (p value=.006, RR: 1.05, 95% CI=1.01--1.09). Over 90% of women in both arms expressed high satisfaction with the method. Side effects were similar in both groups, with only fever or chills reported by significantly more women in the sublingual arm.

CONCLUSIONS

The sublingual route appears superior to the regimen of 400 mcg misoprostol used orally and may be a good option for mifepristone medical abortion.

Comparison of two doses and two routes of administration of misoprostol after pre-treatment with mifepristone for early pregnancy termination

Background

It is not known whether a 400 μg dose of misoprostol has a similar efficacy as an 800 μg dose when administered sublingually or vaginally 24 hours after 200 mg mifepristone.

Methods

It is proposed to undertake a placebo-controlled, randomized, non-inferiority trial (3% margin of equivalence) of the two misoprostol doses when administered sublingually or vaginally using factorial design. A total of 3008 pregnant women (< 63 days of gestational age) who request legal termination of pregnancy will be recruited for the trial at 16 clinics in ten countries providing abortion services. Eligible women willing to join the study will be allocated randomly to one of the four treatment groups within each centre. Women in all treatment groups will first receive 200 mg mifepristone, followed 24 hours later by either 400 μg or 800 μg misoprostol, administered either sublingually or vaginally. The dose and route of administration of misoprostol will be blinded to women, each woman receiving four tablets vaginally and four tablets sublingually, two or four of which are 200 μg tablets of misoprostol and the rest are placebo tablets.

The four treatment regimens will be compared in terms of: (i) their efficacy to induce complete abortion; (ii) induction-to-abortion interval when possible; (iii) the frequency of side effects; and (iv) women's perceptions. The initial judgment of the outcome of treatment is made at the follow-up visit on day 15 of the study and the final assessment four weeks later. It is estimated that the clinical phase will require 12–14 months for data collection.

To compare the two routes and two doses, relative risks (RR) of failure to achieve a complete abortion and failure to terminate pregnancy and the two-sided 95% CIs will be calculated by standard methods, as well as risk differences and two-sided 95% CIs. The latter will be used to test the non-inferiority hypotheses (at 2.5% level of significance) for achieving complete abortion. The factorial structure will be taken into account in the analysis after testing the interaction.

Trial registration

ISRCTN87811512

Mifepristone and misoprostol administered simultaneously versus 24 hours apart for abortion: a randomized controlled trial

OBJECTIVE

Mifepristone and oral misoprostol are typically used for medical abortion in women up to 49 days of gestation, with a 36- to 48-hour interval between the medications. Alternative routes of misoprostol administration allow for use beyond 49 days of gestation. We designed this randomized, noninferiority trial to compare the efficacy, adverse effects, and acceptability of misoprostol 800 mcg vaginally administered simultaneously with, or 24 hours after, mifepristone 200 mg orally for abortion in women up to 63 days of gestation.

METHODS

The 1,128 participants swallowed mifepristone 200 mg and were then randomized to self-administer misoprostol intravaginally immediately in the office (group 1) or 24 hours later at home (group 2). Subjects returned for an evaluation, including transvaginal ultrasonography, 7+/-1 days after initiating treatment. Women who had not aborted were offered a second dose of misoprostol and returned for another evaluation in approximately 1 week. A phone contact was also attempted approximately 5 weeks after treatment. Treatment was considered a failure if a suction aspiration was performed for any indication.

RESULTS

The complete abortion rate for group 1 (95.1%, 95% confidence interval [CI] 93.0-96.8%) was statistically noninferior to that for group 2 (96.9%, 95% CI 95.1-98.2%) (P=.003). The abortion rates between groups did not significantly differ by gestational age. Adverse effects were mostly similar, although nausea, diarrhea, and warmth or chills were significantly more common in group 1.

CONCLUSION

Mifepristone 200 mg and misoprostol 800 mcg vaginally used simultaneously is as effective for abortion as compared with regimens using a 24-hour dosing interval.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00269568

LEVEL OF EVIDENCE

I.

Use of Mifepristone and Sublingual Misoprostol for Early Medical Abortion

OBJECTIVE

Existing drug-induced abortion techniques involve oral administration of 200 mg of mifepristone, followed by oral administration of 600 microg of misoprostol 48 hours later, but the effects are variable. As revealed by recent research, sublingual and oral administrations of misoprostol are equally efficacious in terms of rapid absorption, but the former lasts longer in serum. Hence, in the near future, sublingual administration of misoprostol may become the most effective way to induce abortion.

MATERIALS AND METHODS

Women with intrauterine pregnancy up to 49 gestational days received vaginal ultrasonography, followed by oral administration of mifepristone 200 mg and sublingual administration of misoprostol 600 microg 48 hours later. They returned for follow-up consultations 3 and 14 days after. The definition of a successfully induced complete medical abortion was that the abortion occurred without surgery or evacuating the uterus.

RESULTS

A total of 356 women underwent medical abortion; the complete abortion rate was 98.3% (350 women). Medical abortion was unsuccessful in five (1.7%) women, who eventually had to undergo dilation and curettage. Patients found the side effects to be bearable; the reported satisfaction rate was 89.9% (325 women).

CONCLUSION

Medical abortion for early termination of pregnancy should be achieved by oral administration of mifepristone, followed by sublingual administration of misoprostol.

The pharmacokinetics and different regimens of misoprostol in early first-trimester medical abortion

Misoprostol is a synthetic prostaglandin E(1) analogue that is commonly used for medical abortion. It can be given orally, vaginally and sublingually. A pharmacokinetic study has shown that sublingual misoprostol has the shortest onset of action, the highest peak concentration and the greatest bioavailability among the three routes of administration. Earlier clinical trials have shown that vaginal misoprostol is superior to oral misoprostol when combined with mifepristone for early first-trimester medical abortion. Recent studies on the clinical efficacy of sublingual misoprostol have demonstrated that it is as effective as vaginal misoprostol. Further studies are required to determine the optimal dose and route of administration of misoprostol that can give the highest complete abortion rate, lowest ongoing pregnancy rate and least side effects.

A systematic review of more than one dose of misoprostol after mifepristone for abortion up to 10 weeks of gestation

OBJECTIVES

This review aimed to assess the effectiveness, acceptability and safety of regimens that include mifepristone and multiple misoprostol doses for abortion up to 10 weeks of gestation.

METHODS

We searched MEDLINE and reference lists for English-language reports (published between January 1990 and September 2005) of trials evaluating a medication abortion regimen consisting of mifepristone and multiple doses of misoprostol. Eligible trials had to either be restricted to women with less than 10 weeks' gestation or report stratified results that allowed the extraction of data for this subset.

RESULTS

Although we identified 26 eligible studies, only 3 were randomized controlled trials (RCTs), comparing regimens that differed in the repeat-dose misoprostol component. These trials did not detect differences in effectiveness between the randomized groups. One RCT found evidence of higher effectiveness from repeat misoprostol doses among a subgroup of women with more advanced gestations.

CONCLUSIONS

Although clinicians often prescribe a repeat dose of misoprostol to increase effectiveness in medication abortion, the effect of the repeat dose has not been established. Because mifepristone followed by a single misoprostol dose is highly effective in inducing abortion, determining the effect of a repeat misoprostol dose would require a large sample size. The resource expenditure on such large trials might not be warranted. Any future studies should use induction-to-completion time to measure effectiveness and should assess acceptability and side effects.

Review of medical abortion using mifepristone in combination with a prostaglandin analogue

Induced abortion is still a major health problem in the world and the most frequently performed intervention in obstetrics and gynecology with an estimated total of 46 million worldwide each year. Medical abortion with mifepristone and prostaglandin was first introduced in 1988 and is now approved in 31 countries. This combination of drugs has recently been included in the List of Essential Medicines by the World Health Organisation. The present review summarizes the development, physiology and the development of the currently used regimens.

Medicamentous abortion with mifepristone and misoprostol in Serbia and Montenegro

Background/Aim. Medicamentous abortion was first introduced in Serbia and Montenegro in September 2001. The aim of this study was to assess the efficiency, side effects, and acceptability of medicamentous abortion using mifeprostone orally (600 mg), and 48 hours later, misoprostol both orally and vaginally in different regiments in our population (400 mcg, 600 mcg, 800 mcg). Methods. A total of 235 consecutive women with pregnancies up to 49 days of gestational age were assigned to 4 groups according to the different misoprostol regiment (group I 400 mcg, group II 600 mcg, group III 800 mcg orally, and group IV 800 mcg both orally and vaginally). The principal outcome measure was a successful abortion defined as a complete expulsion of intrauterine contents without a need for surgical intervention 14 days after the procedure. Other outcome measures were the following: drug related effects, and adverse effects related to the abortion process. Results. In general, the success rate was 50%, 89.48%, 75% and 92.11% in the groups I, II, III, and IV, respectively, as judged by the complete expulsion of the intrauterine contents without surgical intervention (t1:4 = 7.005; t2:4 = 0.3872, t3:4 = 2.9784, p < 0.01). The incidence of adverse effects (vomiting, abdominal pain, bleeding, and fever) was low in general, but among our groups it occurred mostly with the higher doses of orally applied misoprostol (800 and 600 mcg). Only one case required urgent curettage for heavy vaginal bleeding, and two blood transfusions, as well. No cases of intact pregnancies were recorded in the study. Conclusion. Our study showed that a mifepristone dose of 600 mg orally, and misoprostol 400 mcg orally and 400 mcg vaginally were most effective. Thus, a combination of mifepristone and misoprostol for medicamentous abortion should take a higher proportion in the termination of early pregnancy in our population.

First trimester abortion with mifepristone and three doses of sublingual misoprostol: a pilot study

OBJECTIVE

To evaluate the efficacy and safety of a medical abortion regimen with multiple doses of sublingual misoprostol 24 h after mifepristone.

METHODS

The regimen was designed on the basis of pharmacokinetics of various routes of administration of misoprostol. Forty women < or = 8 weeks' gestation were given mifepristone 200 mg orally, followed 24 h later by three doses of misoprostol 200 microgm sublingually 6 h apart. They were followed up on day 3 and day 14 with transvaginal ultrasound. Pain and bleeding were assessed using a visual analogue scale and acceptability, by a questionnaire.

RESULTS

Abortion outcome was assessed in terms of onset of pain and vaginal bleeding, time of expulsion of products and duration of vaginal bleeding. Seventy-five per cent of women experienced pain within 2 h after first dose of misoprostol. Bleeding began at a mean of 1.41 h after pain and expulsion at a mean of 6.1 h after first dose of misoprostol. Complete expulsion was confirmed in all women (100%) by ultrasound on day 14. The longest duration of bleeding was 12 days (mean 7.2 days) with 87.5% bleeding for < 10 days. Acceptability was 100% but 70% perceived pain to be moderate and 67.5% bleeding to be light or slightly more than menses.

CONCLUSIONS

Medical abortion using three doses of sublingual misoprostol administered 24 h after mifepristone appears to be the most appropriate in terms of pharmacokinetics of the drugs. This pilot study associates the regimen with a short abortion process, which appears to be safe, highly efficacious and acceptable.

Home self-administration of misoprostol for medical abortion up to 56 days' gestation

OBJECTIVE

Studies from the USA have suggested the feasibility and acceptability of home medical abortion, however the issue has not been addressed in the UK. This study aimed to assess the feasibility, efficacy and acceptability of home self-administration of misoprostol for medical abortion up to 56 days' gestation.

METHODS

Mifepristone 200 mg was given orally in hospital under nursing supervision. Women were provided with misoprostol tablets 600 microg and advised to take them sublingually 36-48 hours later. The main outcome measures were (1) feasibility, assessed through successful completion of abortion at home without the need for hospital admission, (2) efficacy, assessed through complete uterine evacuation without the need for further medical or surgical intervention and (3) women's acceptability of the procedure as assessed by questionnaire.

RESULTS

A total of 49 women participated in this study. Of these, 48 women aborted at home while one opted to be admitted to hospital after receiving misoprostol at home. One woman underwent surgical evacuation 5 weeks following abortion for excessive bleeding and retained products of conception. A total of 43/44 (98%) women were satisfied with having the abortion at home. Side effects experienced by women included nausea [32/40 (80%], vomiting [17/41 (42%)], diarrhoea [17/41 (42%)], shivering [26/40 (65%)], tiredness [32/40 (80%)], headache [12/39 (31%)], hot flushes [14/40 (35%)], dizziness [24/39 (62%)] and unpleasant mouth taste [19/38 (50%)].

CONCLUSIONS

This study suggests the feasibility and acceptability of home self-administration of misoprostol for medical abortion up to 56 days' gestation. These findings need to be assessed in the context of a randomised trial.

A randomised controlled trial of mifepristone in combination with misoprostol administered sublingually or vaginally for medical abortion up to 13 weeks of gestation

OBJECTIVE

To assess women's acceptability, the efficacy and side effects of sublingual versus vaginal administration of misoprostol in combination with mifepristone for medical abortion up to 13 weeks of gestation.

DESIGN

Randomised controlled trial.

SETTING

Aberdeen Royal Infirmary.

POPULATION

Women undergoing medical abortion under the terms of the 1967 Abortion Act.

METHODS

Mifepristone (200 mg) was given orally followed 36-48 hours later by misoprostol administration (sublingual: 600 microg; vaginal: 800 microg). A second dose of misoprostol 400 microg was given 3 hours later (sublingually or vaginally). Women between 9 and 13 weeks of gestation received a further (third) dose of misoprostol 400 microg (sublingually or vaginally), 3 hours later if abortion had not occurred.

MAIN OUTCOME MEASURES

Women's acceptability, efficacy of the regimen and side effects experienced.

RESULTS

A total of 340 women were recruited (171 sublingual and 169 vaginal). A total of 70% of women in the sublingual group expressed satisfaction with the route of misoprostol administration; 18% answered 'Don't know' while 12% were dissatisfied, compared with 68%, 28% and 4%, respectively, in the vaginal group (P= 0.02). There was no significant difference in the need for surgical evacuation for women in the sublingual (3/158, 1.9%) and vaginal groups (4/156, 2.6%) (P= 0.70). Women receiving misoprostol sublingually were more likely to experience diarrhoea (P < 0.01), shivering (P < 0.01) and unpleasant mouth taste (P < 0.01).

CONCLUSIONS

Sublingual administration of misoprostol is an effective alternative to vaginal administration for medical abortion up to 13 weeks of gestation. The prevalence of prostaglandin-related side effects, however, was higher with this route of administration.

Comparison of gemeprost and vaginal misoprostol in first trimester mifepristone-induced abortion

BACKGROUND

The aim of this study was to compare efficacy and side effects of gemeprost and vaginal misoprostol in mifepristone-induced abortions in women up to 63 days of gestation.

METHODS

A retrospective study of 833 consecutive patients admitted for medical termination of first trimester pregnancy was conducted. Four-hundred ten patients received mifepristone 600 mg, followed 48 h later by gemeprost 1 mg (regimen I), and 423 patients received mifepristone 200 mg followed by vaginal misoprostol 800 microg (regimen II). Success rates were evaluated after 2 weeks and after 3 months. The severity of bleeding and side effects (pain, nausea, vomiting and diarrhea) was scored by the patients, and requests for supplementary analgesic treatment were recorded by the attending nurse.

RESULTS

Success rates were 99% in both groups after 2 weeks of follow-up. At 3 months of follow-up, success rates had declined to 94% for regimen I and 96% for regimen II. The frequency of severe pain was higher in regimen I compared to regimen II (72% vs. 60%, p < .001), but the severity of bleeding and gastrointestinal side effects was similar in the two regimens.

CONCLUSION

When combined with mifepristone, gemeprost and vaginal misoprostol are equally effective for termination of first trimester abortion, but may be associated with varying intensity of side effects.

A randomized trial of mifepristone in combination with misoprostol administered sublingually or vaginally for medical abortion at 13–20 weeks gestation

BACKGROUND

Several studies have now reported the successful use of the sublingual administration of misoprostol for medical abortion in the first trimester. The objective of this study was to assess the acceptability to women, the efficacy of the regimen, as well as the acceptability to staff of sublingual versus vaginal administration of misoprostol following mifepristone for medical abortion at 13-20 weeks gestation.

METHODS

Women were randomized by opening consecutive sealed envelopes generated using random number tables. Mifepristone (200 mg) was followed 36-48 h later by sublingual administration of misoprostol 600 microg or vaginal misoprostol 800 microg. This was followed by 3 hourly doses of misoprostol 400 microg administered sublingually or vaginally.

RESULTS

A total of 76 women were randomized. Of women in the sublingual group, 24 (66.7%) expressed satisfaction with the route of misoprostol administration compared with 25 (62.5%) in the vaginal group. A higher proportion in the sublingual group used intramuscular opiates. There was no significant difference in the surgical evacuation rate between the sublingual (three out of 36 women, 8.3%) and vaginal groups (one out of 40, 2.5%), (P=0.26) and acceptability to staff was the same for both methods.

CONCLUSIONS

Sublingual administration of misoprostol following mifepristone is an acceptable and effective alternative to vaginal administration for medical abortion at 13-20 weeks gestation. However, women should be advised about the greater likelihood of requiring stronger analgesia.

Medical termination of pregnancy in the early first trimester

Surgical abortion using vacuum aspiration or dilatation and curettage has been the method of choice for termination of pregnancy up to 63 days' gestation since the 1960s. Over the last three decades many studies have explored the use of medical methods for inducing abortion at these gestations. Earlier regimens assessed the systemic and intrauterine injection of prostaglandins. This was followed in the 1980s by the introduction of the antiprogesterone, mifepristone. Since its introduction, the uptake of medical abortion has been steadily increasing in countries where it has been available for routine use. Most current clinical protocols require the use of prostaglandins in combination with anti-progesterones or antimetabolites. The safety, efficacy and acceptability of the medical regimen are now well established at all gestations of pregnancy. Provision of medical abortion increases the choice available to women, in particular those wishing to avoid surgery.