Frequent low-dose misoprostol for termination of second-trimester pregnancy

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.

[Use of misoprostol for induction of labor in case of fetal death or termination of pregnancy during second or third trimester of pregnancy: Efficiency, dosage, route of administration, side effects, use in case of uterine scar]

OBJECTIVE

Study, based on the literature, of the use of misoprostol for induction of labor in cases of second or third trimester fetal death or termination of pregnancy and define the different mode of administration.

MATERIALS AND METHODS

Bibliographic review using the Medline and Pubmed databases and the guidelines of the international professional societies. Selection of papers in French and English. Keywords used: misoprostol, termination of pregnancy, mid and third trimester, scarred uterus, previous cesarean section, uterine rupture.

RESULTS

Misoprostol is effective for induction of labor in case of second or third fetal death or termination of pregnancy. Comparing to oral route, vaginal route reduces the induction-expulsion time and the rate of patients remaining undelivered in the first 24 hours without increasing side effects. Oral route is a possible alternative if preferred by the patient. Sublingual route seems interesting but data are limited. The use of moderate doses (800-2400 μg/day) every 3 to 6 hours seems to be the best compromise between efficiency and tolerance. It is not possible to recommend a specific dosing schedule. The risk of uterine rupture in case of previous cesarean section justifies the use of minimum effective dose for these patients. In this case, it is recommended not to exceed a dose of 100 μg for each dose. The induction-birth period and doses of misoprostol required to induce labor are reduced when combined with mifepristone administered 36 to 48 hours before.

CONCLUSION

Misoprostol is effective and safe for induction of labor in case of second or third trimester fetal death or termination of pregnancy.

Effect of cervical length on second trimester pregnancy termination

AIM

To evaluate the value of sonographic measurement of cervical length as a predictor of abortion or delivery within 24 h by misoprostol in second trimester termination of pregnancy (TOP).

MATERIAL AND METHODS

One hundred and sixty-three women underwent TOP between 14 and 26 weeks of pregnancy due to various indications. The primary outcome was abortion within 24 h. Cervical length was measured before transvaginal administration of misoprostol. The effects of cervical length, total misoprostol dose, parity, and gestational age at diagnosis on successful TOP were evaluated.

RESULTS

  One hundred and sixty-three women were eligible who met the inclusion criteria. TOP occurred in 80.5% of patients within 24 h. Parous women had shorter prolonged induction to expulsion period over 24 h (14.1% vs 28.6%, P = 0.061). Total misoprostol dose and history of abortion were parameters that affected induction to delivery period (P = 0.002 and P = 0.041). Using an optimum cutoff of 36 mm, 58.2% sensitivity and 68.2% specificity were obtained. In addition, positive and negative predictive values were 85.36% and 33.3%, respectively. Pregnant women whose preinduction cervical length was shorter than 36 mm had a shorter induction time and needed a lower total misoprostol dose to achieve TOP than women with a cervical length longer than 36 mm (P = 0.027 and P = 0.011, respectively).

CONCLUSION

Transvaginal measurement of cervical length before administration of prostaglandin analogue was not correlated with successful TOP within 24 h. It cannot be used as a predictor in light of our findings.

A randomized comparison of misoprostol to intrauterine instillation of hypertonic saline plus a prostaglandin F2alpha analogue for second-trimester induction termination in Uzbekistan

BACKGROUND

The study was conducted to compare the efficacy and acceptability of second-trimester induction termination using vaginal misoprostol to hypertonic saline and d-cloprostenol, a prostaglandin F(2alpha) (PGF) analogue, in Tashkent, Uzbekistan.

STUDY DESIGN

Eleven clinics providing second-trimester induction terminations were randomized to provide one of two regimens for second-trimester induction termination: vaginal misoprostol 400 mcg every 3 h or hypertonic 10% saline intrauterine instillation plus an intravenous PGF analogue, d-cloprostenol, 2.5 mg/h. Demographic information, and obstetric and medical history data were collected, and interviewers administered questionnaires to measure procedural pain and satisfaction. Differences in procedure time and complication rate, the primary outcomes, were analyzed with survival analysis and chi(2) tests.

RESULTS

Of 228 participants, 120 received misoprostol and 108 received hypertonic saline and d-cloprostenol; the groups did not significantly differ by age, parity or gestational age. Both misoprostol and saline procedures were effective, with 99.2% and 100% successful abortion rates, respectively. Median procedure time (13.1 vs. 29.2 h, p<.001), and number of women with retained placenta (2 vs. 70, p<.001) or hemorrhage (3 vs. 19, p=.001) were lower for the misoprostol group. Both provider (p<.001) and patient (p<.001) procedural satisfaction scores were higher for the misoprostol group.

CONCLUSION

While equally effective, vaginal misoprostol had a shorter time to abortion, was more acceptable to providers and patients and had fewer complications than saline instillation plus intravenous administration of a PGF analogue in Tashkent. This evidence supports change of the existing standard of care for second-trimester induction termination in Uzbekistan.