1
|
Iyengar K, Klingberg-Allvin M, Iyengar SD, Paul M, Essén B, Gemzell-Danielsson K. Home use of misoprostol for early medical abortion in a low resource setting: secondary analysis of a randomized controlled trial. Acta Obstet Gynecol Scand 2015; 95:173-81. [PMID: 26565074 DOI: 10.1111/aogs.12815] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/25/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Although home use of misoprostol for early medical abortion is considered to be safe, effective and feasible, it has not become standard service delivery practice. The aim of this study was to compare the efficacy, safety, and acceptability of home use of misoprostol with clinic misoprostol in a low-resource setting. MATERIAL AND METHODS This was a secondary analysis of a randomized controlled trial conducted in six primary care clinics in India. Women seeking medical abortion within up to nine gestational weeks (n = 731) received mifepristone in the clinic and were allocated either to home or clinic administration of misoprostol. Follow-up contact was after 10-15 days. RESULTS Of 731 participants, 73% were from rural areas and 55% had no formal education. Complete abortion rates in the home and clinic misoprostol groups were 94.2 and 94.4%, respectively. The rate of adverse events was similar in both groups (0.3%). A greater proportion of home users (90.2%) said that they would opt for misoprostol at home in the event of a future abortion compared with clinic users (79.7%) who would opt for misoprostol at the clinic in a similar situation (p = 0.0002). Ninety-six percent women using misoprostol at home or in the clinic were satisfied with their abortion experience. CONCLUSIONS Home-use of misoprostol for early medical abortion is as effective and acceptable as clinic use, in low resource settings. Women should be offered a choice of this option regardless of distance of their residence from the clinic and communication facilities.
Collapse
Affiliation(s)
- Kirti Iyengar
- Department of Women's and Children's Health, Karolinska Institute, WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden.,Action Research & Training for Health (ARTH), Udaipur, India
| | - Marie Klingberg-Allvin
- Department of Women's and Children's Health, Karolinska Institute, WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden.,School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
| | | | - Mandira Paul
- Department of Women's and Children's Health, Uppsala University, IMCH/Akademiska Sjukhuset, Uppsala, Sweden
| | - Birgitta Essén
- Department of Women's and Children's Health, Uppsala University, IMCH/Akademiska Sjukhuset, Uppsala, Sweden
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institute, WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
2
|
Larrea S, Palència L, Perez G. [Medical abortion provided by telemedicine to women in Latin America: complications and their treatment]. GACETA SANITARIA 2015; 29:198-204. [PMID: 25770915 DOI: 10.1016/j.gaceta.2015.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 01/30/2015] [Accepted: 02/04/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To analyze reported complications and their treatment after a medical abortion with mifepristone and misoprostol provided by a telemedicine service to women living in Latin America. METHODS Observational study based on the registry of consultations in a telemedicine service. A total of 872 women who used the service in 2010 and 2011 participated in the study. The dependent variables were overall complications, hemorrhage, incomplete abortion, overall treatments, surgical evacuation, and antibiotics. Independent variables were age, area of residence, socioeconomic deprivation, previous children, pregnancies and abortions, and week of pregnancy. We fitted Poisson regression models with robust variance to estimate incidence ratios and 95% confidence intervals (95%CI). RESULTS Complications were reported by 14.6% of the participants: 6.2% reported hemorrhage and 6.8% incomplete abortion. Nearly one-fifth (19.0%) received postabortion treatment: 10.9% had a surgical evacuation and 9.3% took antibiotics. Socioeconomic deprivation increased the risk of complications by 64% (95%CI: 15%-132%), and, among these, the risk of incomplete abortion by 82% (95%CI: 8%-206%) and the risk of surgical intervention by 62% (95%CI: 7%-144%). Previous pregnancies increased the risk of complications and, specifically, the risk of hemorrhage by 2.29 times (95%CI: 1.33-3.95%). Women with a pregnancy of 12 or more weeks had a 2.45 times higher risk of receiving medical treatment and a 2.94 times higher risk of taking antibiotics compared with women with pregnancies of 7 or less weeks. CONCLUSION Medical abortion provided by telemedicine seems to be a safe and effective alternative in contexts where it is legally restricted.
Collapse
Affiliation(s)
- Sara Larrea
- Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, España
| | - Laia Palència
- CIBER de Epidemiología y Salud Pública (CIBERESP), España; Agència de Salut Pública de Barcelona, Barcelona, España
| | - Glòria Perez
- Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, España; CIBER de Epidemiología y Salud Pública (CIBERESP), España; Agència de Salut Pública de Barcelona, Barcelona, España.
| |
Collapse
|
3
|
|
4
|
|
5
|
Tzeng CR, Hwang JL, Au HK, Chien LW. Sonographic patterns of the endometrium in assessment of medical abortion outcomes. Contraception 2013; 88:153-9. [DOI: 10.1016/j.contraception.2012.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 09/02/2012] [Accepted: 09/24/2012] [Indexed: 10/27/2022]
|
6
|
|
7
|
Liao H, Wei Q, Duan L, Ge J, Zhou Y, Zeng W. Repeated medical abortions and the risk of preterm birth in the subsequent pregnancy. Arch Gynecol Obstet 2010; 284:579-86. [DOI: 10.1007/s00404-010-1723-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 10/13/2010] [Indexed: 11/25/2022]
|
8
|
Schaff EA. Mifepristone: ten years later. Contraception 2010; 81:1-7. [DOI: 10.1016/j.contraception.2009.08.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2009] [Revised: 07/19/2009] [Accepted: 08/11/2009] [Indexed: 11/30/2022]
|
9
|
Bennett IM, Baylson M, Kalkstein K, Gillespie G, Bellamy SL, Fleischman J. Early abortion in family medicine: clinical outcomes. Ann Fam Med 2009; 7:527-33. [PMID: 19901312 PMCID: PMC2775627 DOI: 10.1370/afm.1051] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Clinical innovations have made it more feasible to incorporate early abortion into family medicine, yet the outcomes of early abortion procedures in this setting have not been well studied. We wished to assess the outcomes of first-trimester medication and aspiration abortion procedures by family physicians. METHODS Prospective observational cohort study conducted from August 2001 to February 2005 of 2,550 women who sought pregnancy termination in 4 clinical practices of family medicine departments and 1 private office/training site. RESULTS The rate of successful uncomplicated procedures for medication was 96.5% (95.5%-97.1% [corrected] confidence interval [CI], 95.5%-97.0%) and for aspiration was 99.9% (CI, 99.3%-1). Adverse events and complications of medication abortions were failed procedure (ongoing pregnancy; n = 19, 1.45%); incomplete abortion (n = 16, 1.22%); hemorrhage (n = 9, 0.69%); and patient request for aspiration (n = 1, 0.08%). One (0.08%) missed ectopic pregnancy was seen among patients receiving medication. Four types of adverse outcomes were encountered with aspiration: incomplete abortion requiring re-aspiration (n = 21, 1.83%); hemorrhage during the procedure (n = 4, 0.35%); missed ectopic pregnancy (n = 3, 0.26%); and minor endometritis (n = 1, 0.09%). Missed ectopic pregnancies were successfully treated in the inpatient setting without mortality (overall hospitalization rate of 0.16 of 100). All other complications were managed within outpatient family medicine sites. Rates of complication did not vary by experience of physician or by site of care (residency vs private practice). CONCLUSIONS Complications of medication and aspiration procedures occurred at a low rate, and most were minor and managed without incident.
Collapse
Affiliation(s)
- Ian M Bennett
- Department of Family Medicine and Community Health, University of Pennsylvania School of Medicine, 2nd Floor Gates Pavilion, 3400 Spruce St, Philadelphia, PA 19104-4283, USA.
| | | | | | | | | | | |
Collapse
|
10
|
Stojnić J, Ljubić A, Jeremić K, Radunović N, Tulić I, Bosković V, Dukanac J. Medicamentous abortion with mifepristone and misoprostol in Serbia and Montenegro. VOJNOSANIT PREGL 2006; 63:558-63. [PMID: 16796021 DOI: 10.2298/vsp0606558s] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Jelena Stojnić
- Klinicki centar Srbije, Institut za ginekologiju i akuserstvo, Beograd, Srbija i Crna Gora.
| | | | | | | | | | | | | |
Collapse
|
11
|
Machtinger R, Seidman DS, Goldenberg M, Stockheim D, Schiff E, Shulman A. Transvaginal ultrasound and operative hysteroscopy in women undergoing medical termination of pregnancy as a part of routine follow-up. Fertil Steril 2005; 84:1536-8. [PMID: 16275265 DOI: 10.1016/j.fertnstert.2005.04.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2004] [Revised: 04/27/2005] [Accepted: 04/27/2005] [Indexed: 10/25/2022]
Abstract
Follow-up of the first cohort of 191 patients who underwent medical abortion in a tertiary medical center included postmenstruation transvaginal sonography (TVS), even in asymptomatic patients. Suspected products of gestation by TVS were found in 3.7% of the asymptomatic women, and residual products of gestation were diagnosed by hysteroscopy in 85.7% of such cases.
Collapse
Affiliation(s)
- Ronit Machtinger
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | | | | | | | | | | |
Collapse
|
12
|
Fiala C, Winikoff B, Helström L, Hellborg M, Gemzell-Danielsson K. Acceptability of home-use of misoprostol in medical abortion. Contraception 2005; 70:387-92. [PMID: 15504378 DOI: 10.1016/j.contraception.2004.06.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2004] [Accepted: 06/30/2004] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Home-use of misoprostol would reduce the number of visits and improve access to medical abortion. We evaluated acceptance of home-use of misoprostol among women and their partners. MATERIALS AND METHODS One hundred women with up to 49 days of amenorrhea were given mifepristone, followed by misoprostol taken at home. RESULTS Women chose home-use of misoprostol because it felt more natural, private and allowed the presence of a partner/friend. Two women had a vacuum aspiration due to incomplete abortion. Five unscheduled visits occurred. Ninety-six women were satisfied with their choice of home-use. The male partners were generally satisfied with their partner's choice of home-use and felt that their presence and support had been valuable. DISCUSSION Our study shows a high acceptability among women and their partners and confirms the safety and efficacy of home-use of misoprostol. Women should be offered this choice to allow more flexibility and privacy in their abortions.
Collapse
Affiliation(s)
- Christian Fiala
- Division for Obstetrics and Gynaecology, Department of Woman and Child Health, Karolinska Hospital/Institute, S-171 76 Stockholm, Sweden
| | | | | | | | | |
Collapse
|
13
|
Weingertner AS, Hamid D, Baldauf JJ, Nisand I. [Present and potential uses of mifepristone in gynecology, obstetrics and other medical specialties]. ACTA ACUST UNITED AC 2005; 33:692-702. [PMID: 15687940 DOI: 10.1016/s0368-2315(04)96630-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- A-S Weingertner
- Département de Gynécologie-Obstétrique, CHU de Hautepierre, avenue Molière, 67098 Strasbourg Cedex
| | | | | | | |
Collapse
|
14
|
Borgatta L, Mullally B, Vragovic O, Gittinger E, Chen A. Misoprostol as the primary agent for medical abortion in a low-income urban setting. Contraception 2004; 70:121-6. [PMID: 15288216 DOI: 10.1016/j.contraception.2004.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2003] [Revised: 01/10/2004] [Accepted: 03/04/2004] [Indexed: 11/20/2022]
Abstract
The purpose of this study was to assess the outcomes of early medical abortion in an inner-city hospital abortion service, using misoprostol as the primary agent. This was a retrospective chart review from July 2001 through December 2002. Women were eligible if they had a viable pregnancy with gestational age 8 weeks or less by transvaginal ultrasound and no medical contraindications. Two doses of 800 microg misoprostol were administered vaginally, 24 h apart. Initial follow-up was scheduled 2-3 days later. Of the 440 women who underwent medical abortion, 373 (90.8%, 95% confidence interval (CI) 88-94%) completed abortion medically, 38 (9.2%) had uterine aspiration and the remainder had incomplete or no follow-up. Of uterine aspirations, 11 were medically indicated, giving a rate of indicated aspiration of 2.7%. Gestational age, age, gravidity, parity, past abortion history, ethnic group and payer did not significantly correlate with overall rate of aspiration or rate of follow-up, but gestational age was correlated with medically indicated aspiration. Among 57 women who reported a time of tissue passage, the mean time from initial misoprostol dose was 8.5 h (95% CI 6.5-13 h).
Collapse
Affiliation(s)
- Lynn Borgatta
- Department of Obstetrics and Gynecology, Boston University School of Medicine and Boston Medical Center, 85 East Concord Street, 6th Floor, Boston, MA 02118, USA.
| | | | | | | | | |
Collapse
|
15
|
Hamoda H, Ashok PW, Dow J, Flett GMM, Templeton A. A pilot study of mifepristone in combination with sublingual or vaginal misoprostol for medical termination of pregnancy up to 63 days gestation. Contraception 2003; 68:335-8. [PMID: 14636936 DOI: 10.1016/j.contraception.2003.07.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Of the total women included in the study, 96 women chose to receive misoprostol 600 microg sublingually while 53 women received misoprostol 800 microg vaginally 36-48 h after receiving mifepristone 200 mg. Complete abortion occurred in 93 women (98.9%) in the sublingual and 51 women (96.2%) in the vaginal group (p = 0.27). The mean induction-to-abortion interval was 3.2 h (SD = 1.4) in the sublingual and 4.1 h (SD = 1.5) in the vaginal group (p = 0.02). The mean gestation at abortion in weeks was 7.1 (SD = 1.0) in the sublingual and 7.7 (SD = 1.3) in the vaginal group (p = 0.003). Women in the sublingual group experienced more vomiting (p = 0.03), diarrhea (p = 0.02) and unpleasant taste in their mouth (p = 0.0001) while those in the vaginal group experienced more headache (p = 0.002). Of women in the sublingual group, 77% were satisfied with the route of misoprostol administration compared to 68% in the vaginal group (p = 0.25). These findings now need to be assessed in the context of a randomized controlled trial.
Collapse
Affiliation(s)
- H Hamoda
- Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen, United Kingdom.
| | | | | | | | | |
Collapse
|
16
|
Abstract
Medical abortion was performed in 461 consecutive women with gestational age </= 63 days using a regimen of mifepristone 600 mg followed 2 days later by gemeprost 1 mg vaginally. Success, defined as no surgical intervention, declined from 98.7% after 2 weeks to 94.6% after 15 weeks. The difference in short- and long-term success rates increased with increasing gestational age. The majority of failures (76%) were diagnosed more than 2 weeks after initiation of the abortion. At a 2-week follow-up visit, the women who turned out to be failures had a larger endometrial width, higher beta-hCG values and smaller reductions of beta-hCG than those treated successfully. To optimize comparison of success rates after different medical abortion regimens, we suggest that the criteria for success are stated clearly, that the success rates are stratified according to gestational age and that the indications for secondary intervention are categorized.
Collapse
Affiliation(s)
- Christina Rørbye
- Department of Obstetrics and Gynecology, H:S Hvidovre Hospital, University of Copenhagen, Kettegaard Alle 30, 2650 Hvidovre, Denmark.
| | | | | | | |
Collapse
|
17
|
Hausknecht R. Mifepristone and misoprostol for early medical abortion: 18 months experience in the United States. Contraception 2003; 67:463-5. [PMID: 12814815 DOI: 10.1016/s0010-7824(03)00049-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In the first 18 months since mifepristone was approved by the Food and Drug Administration (FDA) for use with misoprostol for early medical abortion, approximately 80,000 women have been treated. One-hundred thirty-nine adverse events were reported to Danco Laboratories LLC and subsequently reported to the FDA. Thirteen patients required blood transfusions, 10 patients were treated with antibiotics for infection and 6 had a generalized allergic reaction. Fifty patients had an ongoing pregnancy, with 48 having suction curettage, leaving 2 ongoing pregnancies. Thirty-nine patients had a suction curettage for heavy or prolonged vaginal bleeding. The overall national experience has been highly favorable.
Collapse
Affiliation(s)
- Richard Hausknecht
- Department of Obstetrics, Gynecology and Reproductive Medicine, The Mount Sinai School of Medicine and Danco Laboratories, LLC, 131 East 65th Street, New York, NY 10021, USA.
| |
Collapse
|
18
|
Abstract
Mifepristone is an orally active progesterone antagonist. It can be used for both contraceptive and non-contraceptive clinical indications. It is a very effective drug for emergency contraception with a low incidence of side effects. There is a potential for mifepristone to be used as a once-a-month pill. There is a need, however, for a simple, inexpensive and accurate method to identify the luteinizing hormone surge before this method can be used in clinical practice. The daily administration of mifepristone offers promise as an effective method of contraception but more studies need to be done. The combination of mifepristone with a prostaglandin analogue is a well-established method for termination of pregnancy of up to 9 weeks. Recent data suggest that this combination may also be used up to 9-13 weeks of pregnancy. Although mifepristone is effective in dilating the cervix before vacuum aspiration, misoprostol is probably the drug of choice in most situations. In the second trimester, mifepristone is effective in shortening the abortion process induced by prostaglandin analogues. The combination of mifepristone and prostaglandin also offers a medical method for management of miscarriages. Mifepristone has been used for a number of other indications, but further studies are needed before such treatment can be recommended.
Collapse
Affiliation(s)
- Pak Chung Ho
- Department of Obstetrics and Gynaecology, University of Hong Kong, Hong Kong.
| | | | | |
Collapse
|
19
|
Curettage After Mifepristone-Induced Abortion. Obstet Gynecol 2001. [DOI: 10.1097/00006250-200112000-00034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
20
|
Curettage After Mifepristone-Induced Abortion. Obstet Gynecol 2001. [DOI: 10.1097/00006250-200112000-00033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|