Randomized comparison of vaginal (200 microg every 3 h) and oral (400 microg every 3 h) misoprostol when combined with mifepristone in termination of second trimester pregnancy

Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine

The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.

Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine

The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.

Medical regimens for abortion at 12 weeks and above: a systematic review and meta-analysis

Background

Mifepristone and misoprostol are recommended for second-trimester medical abortion, but consensus is unclear on the ideal regimen.

Objectives

The objectives were to systematically review randomized controlled trials (RCTs) investigating efficacy, safety and satisfaction of medical abortion at ≥ 12 weeks' gestation.

Data sources

We searched PubMed, Popline, Embase, Global Index Medicus, Cochrane Controlled Register of Trials and International Clinical Trials Registry Platform from January 2008 to May 2017.

Study eligibility participants and interventions

We included RCTs on medical abortion at ≥ 12 weeks' gestation using mifepristone and/or misoprostol. We excluded studies with spontaneous abortion, fetal demise and mechanical cervical ripening and those not reporting ongoing pregnancy (OP).

Study appraisal and synthesis methods

After extracting prespecified data and assessing risk of bias in accordance with the Cochrane handbook, we used Revman5 software to combine data and GRADE to assess certainty of evidence.

Results

We included 43 of the 1894 references identified. Combination mifepristone-misoprostol had lower rates of OP [risk ratio (RR) 0.12, 95% confidence interval (CI) 0.04-0.35] vs. misoprostol only. A 24-h interval between mifepristone and misoprostol had lower OP rate at 24 h than simultaneous dosing (RR 3.13, 95% CI 1.23-7.94). Every 3-h dosing had lower OP rate at 48 h (RR 0.39, 95% CI 0.17-0.88).

Limitations

Direct comparisons of buccal misoprostol to sublingual or vaginal routes after mifepristone were limited. Evidence from clinical trials on how to best manage women with prior uterine incisions was lacking.

Conclusion

Our analysis supports the use of mifepristone 200 mg 1 to 2 days before misoprostol 400 mcg vaginally every 3 h at ≥ 12 weeks' gestation.

Implications

Where available, providers should use mifepristone plus misoprostol for second-trimester medical abortion. Vaginal misoprostol appears to be most efficacious with fewest side effects, but sublingual and buccal routes are also acceptable.

Association between infection and fever in terminations of pregnancy using misoprostol: a retrospective cohort study

Background

Fever is a well-known side effect of misoprostol, but clinically difficult to distinguish from an intra uterine infection. The aim of this study was to determine the incidence of fever in terminations of pregnancy (TOP) using misoprostol and to evaluate fever as indication of intra uterine infection.

Methods

A retrospective cohort study was performed. Consecutive second trimester TOP with misoprostol between January 2008 and October 2012 were selected. We included 403 cases and determined the incidence of fever. To examine intra uterine infection as plausible cause of fever, pathological examination reports of placentas were reviewed for signs of infections.

Results

The incidence of fever was 42%. Logistic regression showed a dose dependent association between dosage misoprostol and degree of fever (OR 1.86; 95% CI: 1.3–2.7). There was no association between fever and epidural analgesia. Fever has a sensitivity of 55% and a specificity of 58% as a marker of intra uterine infection. The positive predictive value of fever for an intra uterine infection is 4% and the negative predictive value is 98%.

Conclusion

Administration of misoprostol for the indication TOP is strongly associated with fever during labor. Fever is a poor predictor of intra uterine infection in the context of TOP.

The combination route versus sublingual and vaginal misoprostol for the termination of 13 to 24 week pregnancies: A randomized clinical trial

OBJECTIVE

The goal of this study was to compare the effectiveness of misoprostol via sublingual and vaginal administration versus the combination route in the termination of 13 to 24 week pregnancies.

MATERIALS AND METHODS

One hundred and ninety-five patients, divided into three groups, were enrolled in this study. In the vaginal group, two 200-μg misoprostol tablets were inserted into the posterior fornix every 4 hours for 48 hours. In the sublingual group, patients took two 200-μg misoprostol tablets every 4 hours for up to 48 hours. In the combination group, two 200-μg misoprostol tablets were inserted within the posterior fornix followed by the administration of 400 μg misoprostol sublingually every 4 hours for a period of 48 hours. Efficacy was defined as a successful termination without the need for any interventions.

RESULTS

The success rate, after 24-48 hours, was not significantly different among the three groups. It was significantly higher within the first 12 hours of misoprostol administration within the sublingual group (p = 0.031). Nonetheless, the overall failure rate was not significantly different between three groups. The mean duration of abortion was shortest among the sublingual group (655 ± 46 minutes), p = 0.005, and the number of misoprostol tablets administered was lower when compared to the other groups (5.9 ± 0.3), p = 0.001. The duration of abortion and the number of misoprostol tablets used significantly varied in the cases in which the patient had a history of a previous normal vaginal delivery (NVD; p = 0.007). The average number of tablets administered was the lowest in the sublingual group. The prevalence of fever among the NVD cases were significantly higher in the combination group (p = 0.008). Overall, of all the methods, patients preferred the sublingual route (p = 0.001).

CONCLUSION

Sublingual misoprostol has a higher efficacy when compared to the vaginal and combination methods.

[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.

Comparative study of oral and vaginal misoprostol for induction of labour, maternal and foetal outcome

BACKGROUND

Misoprostol is a new promising agent for cervical ripening and induction of labour .The ideal dose, route and frequency of administration of misoprostol are still under investigation. Although, vaginal application of misoprostol has been validated as a reasonable mean of induction, there is a patient resistance to digital examination and there is a risk of ascending infection. For this reason, oral administration of misoprostol for cervical ripening and labour induction has been tried.

AIMS AND OBJECTIVES

To compare 50μg of oral misoprostol versus 25μg of intravaginal misoprostol for induction of labour at term and maternal, foetal outcomes.

METHODS

Two hundred women who were at term, with indication for induction of labour and Bishop scores of ≤5 were randomly assigned to receive misoprostol 50μg or 25μg intravaginal, every 4-6 hours, for a maximum of 5 doses. In either group, pregnant females with inadequate uterine contractions despite being given maximum 5 doses of misoprostol, were augmented using oxytocin. The primary outcome measure was time-interval from induction to vaginal delivery and vaginal delivery rate within 24 hours.

RESULTS

The median induction to vaginal delivery time in oral group (12.92h) and vaginal group (14.04 h) was not significant. Oral misoprostol resulted in more number of vaginal deliveries as compared to vaginal misoprostol (94% as compared to 86%), which was not significant. There was a significantly higher incidence of uterine tachysystole in the vaginal group, as compared to oral group. There were no significant differences between the groups with respect to oxytocin augmentation, caesarean section rate, analgesic requirement and neonatal outcome.

CONCLUSION

Oral misoprostol is as efficacious as vaginal misoprostol because of shorter induction delivery interval, lower caesarean section rates, and lower incidence of failed induction rates. Lower incidence of foetal distress and easy intake are observed if the drug is administered orally.

The use of misoprostol in termination of second-trimester pregnancy

Misoprostol, a synthetic prostaglandin E1 analog, is initially used to prevent peptic ulcer. The initial US Food and Drug Administration-approved indication in the product labeling is the treatment and prevention of intestinal ulcer disease resulting from nonsteroidal anti-inflammatory drugs use. In recent two decades, misoprostol has approved to be an effective agent for termination of pregnancy in various gestation, cervical ripening, labor induction in term pregnancy, and possible management of postpartum hemorrhage. For the termination of second-trimester pregnancy using the combination of mifepristone and misoprostol seems to have the highest efficacy and the shortest time interval of abortion. When mifepristone is not available, misoprostol alone is a good alternative. Misoprostol, 400 μg given vaginally every 3-6 hours, is probably the optimal regimen for second-trimester abortion. More than 800 μg of misoprostol is likely to have more side effects, especially diarrhea. Although misoprostol can be used in women with scarred uterus for termination of second-trimester pregnancy, it is recommended that women with a scarred uterus should receive lower doses and do not double the dose if there is no initial response. It is also important for us to recognize the associated teratogenic effects of misoprostol and thorough consultation before prescribing this medication to patients regarding these risks, especially when failure of abortion occurs, is needed.

Misoprostol vs mifepristone and misoprostol in second trimester termination of pregnancy

OBJECTIVE

The present study was conducted with the aim to assess and comparatively evaluate the safety and efficacy of misoprostol alone and mifepristone with misoprostol for second trimester termination of pregnancy.

METHODS AND MATERIALS

The study was conducted on 200 selected cases, divided in two groups of 100 cases each. In the study group mifepristone was given 200 mg 12 h before intravaginal insertion of 600 μg of misoprostol followed by 400 μg every 3 h up to a maximum of 5 doses or until the abortion occurs, whichever occurs early. In the control group only misoprostol was inserted in the same dose regime. The results were analyzed.

RESULTS

The success rate in both regimens was 100%. Mean induction abortion interval from the insertion of the first misoprostol tablet was significantly shorter in the mifepristone pretreated group 6.72 ± 2.26 h as compared to 12.93 ± 3.4 h in the misoprostol alone group (P < 0.001). The mean blood loss was slightly higher in the control group. The mean dose of the misoprostol required was significantly less in the study group 1,186 ± 291.64 μg as against 1,736 ± 320.20 μg (P < 0.001). The side effects observed in both the groups were similar mainly nausea vomiting, fever, abdominal cramps.

CONCLUSION

Pretreatment with mifepristone 12 h before intravaginal misoprostol significantly improves the induction abortion interval.

Clinical guidelines. Labor induction abortion in the second trimester

Labor induction abortion is effective throughout the second trimester. Patterns of use and gestational age limits vary by locality. Earlier gestations (typically 12 to 20 weeks) have shorter abortion times than later gestational ages, but differences in complication rates within the second trimester according to gestational age have not been demonstrated. The combination of mifepristone and misoprostol is the most effective and fastest regimen. Typically, mifepristone 200 mg is followed by use of misoprostol 24-48 h later. Ninety-five percent of abortions are complete within 24 h of misoprostol administration. Compared with misoprostol alone, the combined regimen results in a clinically significant reduction of 40% to 50% in time to abortion and can be used at all gestational ages. However, mifepristone is not widely available. Accordingly, prostaglandin analogues without mifepristone (most commonly misoprostol or gemeprost) or high-dose oxytocin are used. Misoprostol is more widely used because it is inexpensive and stable at room temperature. Misoprostol alone is best used vaginally or sublingually, and doses of 400 mcg are generally superior to 200 mcg or less. Dosing every 3 h is superior to less frequent dosing, although intervals of up to 12 h are effective when using higher doses (600 or 800 mcg) of misoprostol. Abortion rates at 24 h are approximately 80%-85%. Although gemeprost has similar outcomes as compared to misoprostol, it has higher cost, requires refrigeration, and can only be used vaginally. High-dose oxytocin can be used in circumstances when prostaglandins are not available or are contraindicated. Osmotic dilators do not shorten induction times when inserted at the same time as misoprostol; however, their use prior to induction using misoprostol has not been studied. Preprocedure-induced fetal demise has not been studied systematically for possible effects on time to abortion. While isolated case reports and retrospective reviews document uterine rupture during second-trimester induction with misoprostol, the magnitude of the risk is not known. The relationship of individual uterotonic agents to uterine rupture is not clear. Based on existing evidence, the Society of Family Planning recommends that, when labor induction abortion is performed in the second trimester, combined use of mifepristone and misoprostol is the ideal regimen to effect abortion quickly and completely. The Society of Family Planning further recommends that alternative regimens, primarily misoprostol alone, should only be used when mifepristone is not available.

Medical methods for mid-trimester termination of pregnancy

BACKGROUND

With the improvement of ultrasound technology, the likelihood of detection of major fetal structural anomalies in mid-pregnancy has increased considerably. Upon the detection of serious anomalies, women typically are offered the option of pregnancy termination. Additionally, there are still many reasons other than fetal anomalies why women seek abortion in the mid-trimester.

OBJECTIVES

To compare different methods of second trimester medical termination of pregnancy for their efficacy and side-effects.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, Popline and reference lists of retrieved papers and other sources.

SELECTION CRITERIA

All randomised controlled trials (RCTs) examining medical regimens for termination of pregnancy of a singleton living fetus between 12-28 weeks' gestation were analysed. The outcome measures were the induction to abortion interval, abortion rate within 24 hours, need for surgical evacuation, blood loss, uterine rupture, pain, and side-effects.Trials including >20% fetal death, multiple pregnancies, previous uterine scars and regimens which involved cervical preparation were excluded.

DATA COLLECTION AND ANALYSIS

Two authors selected the trials and three authors extracted data.

MAIN RESULTS

Fourty RCTs were included, addressing various agents for pregnancy termination and methods of administration. When used alone, misoprostol was an effective inductive agent, though it appeared to be more effective in combination with mifepristone. However, the evidence from RCTs is limited.Misoprostol was preferably administered vaginally, although among multiparous women sublingual administration appeared equally effective. A range of doses of vaginally administered misoprostol has been used. No randomised trials comparing doses of misoprostol were identified; however low doses of misoprostol appear to be associated with fewer side-effects while moderate doses appear to be more efficient in completing abortion. Four RCTs showed that the induction to abortion interval with 3-hourly vaginal administration of prostaglandins is shorter than 6-hourly administration without an increase in side-effects.Many studies reported the need for surgical evacuation. Indications for surgical evacuation include retained products of the placenta and heavy vaginal bleeding. Fewer women required surgical evacuation when misoprostol was administrated vaginally compared with women receiving intra-amniotical PGF(2a) . Mild, self-limiting diarrhoea was more common among women who received misoprostol compared to other agents.

AUTHORS' CONCLUSIONS

Medical abortion in the second trimester using the combination of mifepristone and misoprostol appeared to have the highest efficacy and shortest abortion time interval. Where mifepristone is not available, misoprostol alone is a reasonable alternative. The optimal route for administering misoprostol is vaginally, preferably using tablets at 3-hourly intervals. Apart from pain, the side-effects of vaginal misoprostol are usually mild and self limiting. Conclusions from this review are limited by the gestational age ranges and variable medical regimens, including dosing, administrative routes and intervals of medication, of the included trials.

Late termination of pregnancy and foetal reduction for foetal anomaly

Late termination of pregnancy is a relatively rare procedure accounting for approximately 1% of all registered terminations in England and Wales; however, with improving detection rates for foetal anomalies, this number is increasing. Surgical dilation and evacuation (D&E) appears to be a safe and cost-effective procedure as long as the clinical expertise exists to provide this service. Medical termination appears equally safe and is best undertaken with the combined use of mifepristone and misoprostol. Foeticide, when required, should be performed from 22 weeks' gestation using strong KCl administered either by cardiocentesis or by cordocentesis. All women should be offered a post-mortem and any other appropriate investigation to allow accurate counselling regarding future pregnancies. The issue of late selective foetal reduction for foetal abnormality is complicated by the need to balance the risks to the healthy co-twin of expectant management versus selective termination.

Randomized trial of buccal versus vaginal misoprostol for induction of second trimester abortion

BACKGROUND

We evaluated the efficacy and acceptability of repeat doses of buccal misoprostol compared to vaginal misoprostol for second trimester pregnancy termination by induction.

STUDY DESIGN

Women requesting termination of a pregnancy between 18 and 22 weeks gestation were approached for participation. All women received 400 mcg misoprostol vaginally on admission. Participants were randomized to receive subsequent doses of 200 mcg misoprostol every 6 h either buccally or vaginally. All participants completed an acceptability survey.

RESULTS

Sixty-four women participated. The mean gestational age was 19.7 weeks. The median time to abortion in the buccal group was 15 h, which was not significantly different (p=0.44) from the vaginal-only group of 12 h. Most women in both groups preferred their allocated administrative route.

CONCLUSION

Repeat doses of buccal misoprostol are as effective as vaginal misoprostol in inducing abortions in the midtrimester and are highly acceptable to most women. It is reasonable to offer both options to women.

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

OBJECTIVES

To determine the efficacy of an application regimen of low-dose frequent misoprostol for second-trimester pregnancy termination.

METHODS

A total of 250 women between 12 and 20 weeks of gestation who were scheduled for second-trimester pregnancy termination received 200 microg vaginal misoprostol followed by 100 microg oral misoprostol every 2 h until expulsion of the fetus. Mechanical cervical dilatation with a 16-French Foley balloon catheter was performed if no cervical dilatation was observed after 24 h. The main outcome measures were the delivery rate within 24 h and the factors influencing the interval between the onset of induction and abortion. Secondary outcome measures were the side-effects of the regimen and the total misoprostol dose required.

RESULTS

With application of this protocol, 245 women (98%) delivered within 24 h of induction. The mean (+/-standard deviation) misoprostol dose used was 728+/-297 microg (200-2100 microg). Cox regression analysis revealed that vaginal spotting or nulliparity do not effect the induction-abortion time. On the other hand, using this regimen induction to abortion time tends to be longer in the presence of live fetuses (odds ratio (OR) = 0.45; confidence interval (CI) =0.2-0.8; p=0.008) and pregnancies with gestational age > 16 weeks (OR= 0.59; CI = 0.4-0.8; p= 0.003) when compared with cases of in utero death and pregnancies with a gestational age of 12-13 weeks, respectively. Twenty-seven women (10.8%) experienced one or more side-effects attributable to misoprostol.

CONCLUSION

The 100-microg oral misoprostol every 2 h following 200 microg vaginal misoprostol is a highly effective protocol for inducing abortion at 12-20 weeks of pregnancy. Cases with live fetuses or pregnancies with older gestational age (> 16 weeks) deliver in a longer time period.

Second trimester medical abortion with mifepristone-misoprostol and misoprostol alone: a review of methods and management

Second trimester abortions constitute 10-15% of all induced abortions worldwide but are responsible for two-thirds of major abortion-related complications. During the last decade, medical methods for second trimester induced abortion have been considerably improved and become safe and more accessible. Today, in most cases, safe and efficient medical abortion services can be offered or improved by minor changes in existing health care facilities. Second trimester medical abortion can be provided by a nurse-midwife with the back-up of a gynaecologist. Because of the potential for heavy vaginal bleeding and serious complications, it is advisable that second trimester terminations take place in a health care facility where blood transfusion and emergency surgery (including laparotomy) are available. This article provides basic information on regimens recommended for second trimester medical abortion. The combination of mifepristone and misoprostol is now an established and highly effective method for second trimester abortion. Where mifepristone is not available or affordable, misoprostol alone has also been shown to be effective, although a higher total dose is needed and efficacy is lower than for the combined regimen. Therefore, whenever possible, the combined regimen should be used. Efforts should be made to reduce unnecessary surgical evacuation of the uterus after expulsion of the fetus. Future studies should focus on improving pain management, the treatment of women with failed medical abortion after 24 hours, and the safety of medical abortion regimens in women with a previous caesarean section or uterine scar.

Effect of vaginal pH on the efficacy of vaginal misoprostol for induction of midtrimester abortion

AIM

To evaluate the effect of vaginal pH on the efficacy of misoprostol for induction of midtrimester abortion.

METHODS

The study comprised 110 women, with a gestational age of 14-26 weeks, with a missed abortion as an indication for the induction of abortion. On admission, the vaginal pH was measured and two groups were generated: (A) those with pH<5 (n=63); and (B) those with pH >or= 5 (n=47). All of the women received intravaginal misoprostol tablets moistened with 3 mL of 5% acetic acid, 200 microg every 4 h for a maximum of 5 doses within 24 h. If the patient did not have adequate uterine contractions, the same regimen was repeated over the following 24 h and if no response was achieved, this was considered a failure of therapy.

RESULTS

All patients aborted within 48 h. A significant positive correlation between vaginal pH and the misoprostol application-abortion interval was found. The mean induction-abortion interval was significantly shorter in group A compared to group B (12.1 vs 23.6 h, P<0.001), with abortion rates at 24 h being 100% and 63.8%, respectively. Moreover, a significantly lower dose of misoprostol was used in group A with a lower incidence of fever and abdominal pain.

CONCLUSION

Vaginal pH influences the efficacy of misoprostol administered vaginally for the induction of midtrimester abortion. The presence of this relationship, despite premoistening misoprostol with an acidifying agent, suggests that the effect of vaginal pH might extend beyond affecting the pharmacokinetics of the drug.

Oral mifepristone and buccal misoprostol administered simultaneously for abortion: a pilot study

BACKGROUND

Simultaneous oral mifepristone and vaginal misoprostol has a 24-h expulsion rate of approximately 90% when used for abortion through 63 days' gestation. This pilot study sought to determine if a simultaneous regimen using buccal misoprostol would be similarly effective and merit further investigation.

STUDY DESIGN

One hundred twenty women were enrolled into three equal groups by gestational age: < or =49 days (Group 1), 50-56 days (Group 2) and 57-63 days (Group 3). After swallowing 200 mg of mifepristone, subjects received 800 mcg buccal misoprostol. Participants returned in 24+/-1 h for evaluation of expulsion by ultrasonography. Women with a persistent gestational sac received 800 mcg vaginal misoprostol. Further follow-up occurred at 1, 2 and 5 weeks by telephone or in person, as appropriate. Sample sizes for each group were estimated with the aim of establishing a 24-h expulsion rate of 90% (95% CI=76-95).

RESULTS

The 24-h expulsion rates for Groups 1, 2 and 3 were 73% (95% CI=56-85), 69% (95% CI=52-83) and 73% (95% CI=56-85), respectively. Common side effects were nausea (62%), vomiting (33%) and diarrhea (48%), which did not differ by gestational age. Forty-three percent of subjects found the taste of buccal misoprostol objectionable; 30% found buccal retention uncomfortable or inconvenient, and 10% reported oral irritation, sensitivity, numbness or oral ulcers.

CONCLUSIONS

Simultaneous oral mifepristone and buccal misoprostol had a lower-than-hypothesized expulsion rate at 24 h. Although overall success rates at 7 or 15 days could have been higher than those observed at 24 h, we believe that this regimen does not warrant further study.

A randomised trial of two regimens of vaginal misoprostol to manage termination of pregnancy of up to 16 weeks

OBJECTIVE

The purpose of this study was to compare the efficacy and side-effects of two regimens of vaginal misoprostol for pregnancy termination of up to 16 weeks.

METHODS

A randomised clinical trial of medical pregnancy termination of up to 16 weeks was conducted. A hundred pregnant women requesting legal termination of pregnancy were randomised into two groups to receive either 200 microg (50 women) or 400 microg (50 women)--vaginal misoprostol every six hours up to four doses. Outcome of abortion and side-effects were assessed.

RESULTS

The groups were similar in maternal age, gestational age, parity and indication for pregnancy termination. There were no statistically significant differences between the two groups in abortion (P = 0.084) and mean induction to abortion time (P = 0.35). However, the side-effects in the 400 microg group were significantly higher than in the 200 microg group (P = 0.000).

CONCLUSION

In pregnancy termination of up to 16 weeks, 200 microg vaginal misoprostol every six hours up to four doses was as effective as 400 microg, but side-effects were more common in 400 microg regimen.

Randomized comparison of second trimester pregnancy termination utilizing saline moistened or dry misoprostol

OBJECTIVE

The aim of this randomized prospective study was to compare efficacy and side effects of saline moistened misoprostol with dry misoprostol, administered 800 mug intravaginally every 6 h up to a maximum of 3 doses in 24 h for second trimester pregnancy termination.

MATERIALS AND METHODS

A total of 81 women seeking termination of second trimester pregnancy (55 fetal death, 17 fetal structural anomaly, 5 chromosomal abnormality, 4 other reasons) were randomly assigned to one of two treatment groups: (1) intravaginal non-moistened (dry) misoprostol in group A (n = 40) or (2) misoprostol moistened with 3 ml of saline in group B (n = 41).

RESULTS

All of the patients in either group aborted within 48 h (100% success rate). Delivery was achieved in a median (interquartile range) of 13 (40) h with the group A protocol and 12 (36) h with the group B protocol (P = 0.652). Delivery with first dose, delivery within 12 h and delivery within 24 h were similar (P > 0.05) in group B (34.1, 87.5 and 60%, respectively) and group A (25, 82.9, 46.3, respectively). Both treatment regimens were tolerable and with similar side effects.

CONCLUSION

Misoprostol moistened with saline was not more effective than dry misoprostol for second trimester pregnancy termination.

Mifepristone- and misoprostol-induced mid-trimester termination of pregnancy: A review of 272 cases

BACKGROUND

Mifepristone became available in New Zealand in 2001, and was first used for second trimester terminations at the Level J Unit, Wellington Hospital. The protocol is based on that published by Ashok et al. in Aberdeen.

AIMS

To describe the use of mifepristone prior to misoprostol induction of labour for mid-trimester termination and to compare outcomes with the published data.

METHODS

A retrospective audit of prospectively collected notes for 272 women presenting for mid-trimester termination of pregnancy in a hospital termination clinic. Data collection included age, ethnicity, previous pregnancies, gestational age, induction-to-abortion interval, analgesia, and complications. Data were entered into an Access database and imported into Excel and Epi Info for the computation of descriptive statistics.

RESULTS

Data on completed abortion were available for 271 women (one chose not to continue the abortion following mifepristone). The median time to abortion was 6 h, and mean number of doses of misoprostol was three. The proportion of women who aborted within 24 h was 95.9%. Immediate surgical evacuation of retained placenta was required in 22 women (8.1%). Heavy bleeding occurred in 22 women (8.1%), and seven required a transfusion (2.6%). The proportion of women who required parenteral narcotics was 78.2%.

CONCLUSIONS

Outcomes for women in the present review were comparable with those for previous publications using the same regimen, with the exception of a higher transfusion rate. Our experience supports the finding that the use of mifepristone as pretreatment to misoprostol results in a shorter induction-to-delivery interval than the use of misoprostol alone as has been reported by other groups.

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.

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.

Preference and acceptability of oral versus vaginal administration of misoprostol in medical abortion with mifepristone

OBJECTIVES

To compare the experience of pain, need of analgesic interventions, preference and acceptability in medical abortion up to 49 days of amenorrhea with mifepristone and orally versus vaginally administered misoprostol.

STUDY DESIGN

Ninety-seven women were randomised to oral misoprostol, n=48, or vaginal misoprostol, n=49. On day 1 of the study, both the groups received 600 mg of mifepristone. On day 3 of the study, one group received 0.4 mg of misoprostol orally and the other group received 0.8 mg of misoprostol vaginally.

RESULTS

Even though oral administration of misoprostol seemed to be associated with a higher rate of gastrointestinal side effects, women in both the groups showed a clear preference towards the oral route of administration. The willingness to administer the misoprostol at home was also higher among the women in the oral group, which may in part depend on a more positive/less negative experience of the abortion.

CONCLUSION

A majority of women prefer oral administration of misoprostol in early medical abortion.

Cervical preparation using laminaria with adjunctive buccal misoprostol before second-trimester dilation and evacuation procedures: a randomized clinical trial

OBJECTIVE

This study was undertaken to determine whether buccal misoprostol improves cervical preparation achieved with laminaria before second-trimester dilation and evacuation procedures.

STUDY DESIGN

A randomized, double blind, placebo-controlled trial of preoperative cervical preparation with overnight laminaria and either buccal placebo or 400 microg buccal misoprostol approximately 90 minutes before second-trimester surgical abortion. Block randomization was used to provide balanced enrollment into 2 separate gestational age study groups: early (13-15(6/7)) and mid (16-20(6/7)) second trimester. Surgeons tested maximal cervical dilation by inserting the largest dilator that could be passed through the cervical os without force. Subject demographics and preprocedure symptoms were tracked.

RESULTS

Groups were similar in regard to age, gravity, parity, delivery type, and gestational age. Data were analyzed from 125 women in the 13 to 15(6/7) (30 misoprostol, 32 placebo) and 16 to 20(6/7) (31 misoprostol, 32 placebo) gestational age groups. Overall, misoprostol treatment did not improve the initial mean dilation achieved with laminaria alone in either the 13 to 15(6/7) (46.0 fr +/- 5.0; placebo 45.0 fr +/- 6.2, P = .68) or 16 to 20(6/7) (50.9 fr +/- 5.6, placebo 48.9 fr +/- 5.2, P = .16) groups. However, a subanalysis of gestations 19 weeks or more demonstrated significantly greater dilation in the misoprostol group (53.6 fr fr +/- 5.3, placebo 48.5 fr +/- 5.0, P = .01). Subjects receiving misoprostol reported significantly more cramping than those receiving placebo (13-15(6/7) weeks misoprostol 25/30, 83%; placebo 17/32, 53%, P = .02; 16-20(6/7) week misoprostol 25/31, 81%, placebo 16/32, 50%, P = .02).

CONCLUSION

Cervical dilation with laminaria is augmented by 400 microg buccal misoprostol in gestations 19 weeks or more, but not in earlier gestations. Misoprostol causes more abdominal cramping.

Efficacy of two regimens of misoprostol for early second-trimester pregnancy termination

OBJECTIVE

To compare the efficacy of a combined regimen of misoprostol with vaginal misoprostol for early 2nd-trimester pregnancy termination.

METHODS

This is a prospective study that includes 79 pregnant women who requested legal termination of 2nd-trimester pregnancy between 13 and 22 weeks. Two regimens of misoprostol were used. Group 1: 400 microg of oral plus 400 microg vaginal misoprostol every 8 h (combined regimen) and group 2: 400 microg of vaginal misoprostol every 3 h up to a maximum of five doses (vaginal regimen).

RESULTS

The induction-to-abortion interval was significantly longer in group 1 (25.5 +/- 24.45 h) than in group 2 (15 +/- 7.14 h) (p = 0.016). The abortion rate within 24 h in group 1 was of 56.8 vs. 85.7% in group 2 (p = 0.006). The hazard rate for vaginal delivery within 24 h was found to be 2.277-fold greater in the group with the combined therapy once controlled for plausible confounders.

CONCLUSIONS

Our study suggests that oral misoprostol combined with vaginal misoprostol does not reduce the induction-to-abortion interval compared to an exclusively vaginal route when used for early 2nd-trimester pregnancy termination.

A randomized trial comparing oral misoprostol with intra-amniotic prostaglandin F2alpha for second trimester terminations

OBJECTIVE

To compare the efficacy of oral misoprostol with that of intra-amniotic prostaglandin F2alpha (PGF2alpha) for second trimester pregnancy termination.

METHODS

One hundred seventeen women with pregnancies of between 16 and 22 weeks' gestation were randomly assigned after insertion of laminaria to receive either oral misoprostol 400 microg every 4 hours (to a maximum of four doses) or intra-amniotic PGF2alpha 40 mg. The rate of complete abortion within 24 hours was the primary outcome for power analysis. Secondary outcome measures were the rate of dilatation and curettage (D&C) for retained placenta and the rates of fever and gastrointestinal complications.

RESULTS

Patient characteristics were similar in both groups. The rate of complete abortion within 24 hours was similar in the misoprostol (63%) and PGF2alpha (66%) groups. The rate of retained placenta requiring D&C was significantly greater in the PGF2alpha group (22.4% vs. 3.4%, P = 0.002). There were no differences in other maternal morbidities. Parous patients treated with oral misoprostol had a significantly greater rate of complete abortion than nulliparous patients (84% vs. 57%, P = 0.04).

CONCLUSIONS

Oral misoprostol is as effective as intra-amniotic PGF2alpha for second trimester pregnancy termination when laminaria is inserted before treatment. Parous patients have a higher success rate than nulliparous patients with use of oral misoprostol. Oral misoprostol is associated with a very low rate of placental retention.

Uterine Rupture during Second Trimester Abortion with Misoprostol

BACKGROUND

Data are limited regarding the use of misoprostol in the midtrimester, therefore few cases with uterine rupture during the second trimester with a previous uterine scar have been reported in the literature.

CASE REPORT

A 23-year-old woman with a prior low transverse cesarean section presented at 26 weeks' gestation for pregnancy termination for a fetal abnormality. She was given 200 microg misoprostol intravaginally every 3 h until regular contractions began. After the fourth dose, she had vaginal bleeding and severe contractions. She aborted completely 2 h later after the last dose. Uterine rupture was diagnosed at the previous cesarean section scar by manual vaginal examination. She underwent emergency laparotomy and the uterus was repaired.

CONCLUSION

Misoprostol use in the second trimester in a woman with a uterine scar can trigger severe contractions that can lead to uterine rupture.

A prospective randomized comparison of sublingual and oral misoprostol when combined with mifepristone for medical abortion at 12–20 weeks gestation

BACKGROUND

Sublingual misoprostol has been shown to be effective in medical abortion. A prospective double-blinded placebo-controlled trial was done to compare the efficacy and side-effects of sublingual to oral misoprostol when used with mifepristone for medical abortion from 12 to 20 weeks gestation.

METHODS

A total of 120 women at 12-20 weeks of gestation were randomized to receive 200 mg oral mifepristone followed by either sublingual or oral misoprostol 400 mg every 3 h for a maximum of five doses 36-48 h later. The course of misoprostol was repeated if the woman did not abort within 24 h.

RESULTS

There was no significant difference (P = 0.43) in the success rate at 24 h [relative risk = 1.075; 95% confidence interval (CI): 0.94-1.19]. Abortion occurred in 91.4% in the sublingual group (95% CI: 81.0-96.7%) as compared to 85.0% (95% CI: 73.7-92.1%) in the oral group. The median induction-to-abortion interval was significantly shorter (P = 0.009) in the sublingual group (5.5 h) as compared to the oral group (7.5 h). The incidence of fever was higher in the sublingual group (P < 0.0001). The incidences of other side-effects were similar.

CONCLUSION

Sublingual misoprostol, when combined with mifepristone, is effective for medical abortion in the second trimester. The induction-to-abortion interval is shorter when sublingual misoprostol is used when compared to oral misoprostol.

Misoprostol moistened with acetic acid or saline for second trimester pregnancy termination: a randomized prospective double-blind trial

BACKGROUND

This study was conducted to evaluate the efficacy and side effects of a new regimen of 800 microg misoprostol administered intravaginally every 6 h up to a maximum of three doses in 24 h for second trimester pregnancy termination.

METHODS

A total of 66 women seeking termination of second trimester pregnancy (30 fetal structural anomaly, six chromosomal abnormality and 30 fetal death) were randomly assigned to one of two treatment groups: (i) intravaginal misoprostol moistened with 3 ml of 5% acetic acid in group A (n = 33); or (ii) intravaginal misoprostol moistened with 3 ml of saline in group B (n = 33).

RESULTS

The overall median (range) induction-abortion interval was 10 h (2-46) [10 h (4-35) in 36 live fetuses and 9 h (2-46) in 30 dead fetuses, P = 0.515]. All of the patients in both groups aborted within 48 h (100% success rate). The median (range) induction-abortion interval revealed a significantly faster delivery time (P < 0.001) in group A [8 h (2-24)] than in group B [14 h (3-46)].

CONCLUSIONS

This new regimen of 800 microg of vaginal misoprostol every 6 h for a maximum of three doses in 24 h was an effective alternative method for second trimester abortion. In addition, misoprostol moistened with acetic acid was significantly more effective than misoprostol moistened with saline.

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.

Infection after medical abortion: A review of the literature

Medical abortion regimens have become widely used, but the frequency of infection after medical abortion is not well documented. This systematic review provides data on infectious complications after medical abortion. We searched Medline for articles written before July 2003 to determine the frequency of infection after medical abortion up to 26 weeks of gestation. We reviewed all articles and extracted data on the frequency of infection from 65 studies. The frequency of diagnosed and/or treated infection after medical abortion was very low (0.92%, N = 46,421) and varied among regimens. Results of this review confirm that, with respect to infectious complications, medical abortion is a safe and effective option for first- and second-trimester pregnancy termination. After accounting for regional variations in diagnosis, there is little difference in frequency of infection among the regimens reviewed. Future studies should report clear diagnosis and treatment standards for infection so that more precise information becomes available.

WHO multinational study of three misoprostol regimens after mifepristone for early medical abortion

OBJECTIVES

To compare the side effect profiles of regimens of oral and vaginal administration of misoprostol after a single oral dose of 200 mg of mifepristone and to investigate patients' perceptions of medical abortion.

DESIGN

Double-blind, randomised controlled trial.

SETTING

Fifteen gynaecological clinics in 11 countries.

POPULATION

A total of 2219 healthy pregnant women requesting medical abortion with < or =63 days of amenorrhoea. Two thousand women were asked about their perceptions of the method.

METHODS

Mifepristone 200 mg orally on day one, followed by 0.8 mg misoprostol either orally or vaginally on day three. The oral group (O/O group) and one of the vaginal groups (V/O group) continued with 0.4 mg of oral misoprostol, and the vaginal-only group (V-only group) with oral placebo, twice daily for seven days. Side effects were recorded daily by women and reported at each visit. After misoprostol administration at the clinic, side effects were recorded at 1-hour interval up to 3 hours. Patients' perceptions were asked at the second follow up visit, six weeks after treatment.

MAIN OUTCOME MEASURES

The outcome measures were the following: pregnancy-related symptoms (nausea, vomiting, breast tenderness, fatigue, dizziness, headache), drug-related side effects (diarrhoea, fever, rash and blood pressure change), side effects related to the abortion process (lower abdominal pain) and women's perceptions of the method.

RESULTS

The pregnancy-related symptoms decreased in all groups after misoprostol, and breast tenderness decreased already after mifepristone. Oral administration of misoprostol was associated with a higher frequency of nausea and vomiting than vaginal administration at 1 hour after administration. With oral misoprostol, diarrhoea was more frequent at 1, 2 and at 3 hours after administration than with vaginal administration. Misoprostol induced fever during at least 3 hours after administration in up to 6% of the women, this peak being slightly higher and taking place later with the vaginal route. Lower abdominal pain peaked at 1 and 2 hours after oral misoprostol, while it did so at 2 and 3 hours after vaginal misoprostol. In the two groups that continued misoprostol, 27% of women had diarrhoea between the misoprostol visit and the two-week follow up visit, compared with 9% in the placebo group. Among the women studied, 84% would choose medical abortion again, 9% would choose surgical abortion and 7% did not know. Twenty-three percent of the women would choose to have a possible future abortion at home, 70% at a health facility and 7% did not know.

CONCLUSIONS

The pregnancy-related symptoms decrease significantly with time during medical abortion. Nausea, vomiting and diarrhoea were more frequent after oral administration of misoprostol. Pain related to the abortion process occurs earlier after oral misoprostol. Should a need arise, a majority of women would choose medical abortion again and would prefer to have it at a health facility rather than at home.

Randomized controlled trial of misoprostol for second-trimester pregnancy termination associated with fetal malformation

OBJECTIVE

Our purpose was to compare the effectiveness, women's views of the termination procedure, and success of umbilical cord culture for vaginal and oral misoprostol versus intra-amniotic prostaglandin PGF(2alpha) for second-trimester pregnancy termination (STPT).

STUDY DESIGN

We randomized 217 women, 15 to 24 weeks' gestation, into 3 groups. Oral (OM) and vaginal (VM) misoprostol groups received 400 microg of misoprostol every 4 hours for 24 hours. The intra-amniotic PGF(2alpha) (IAPG) group received 40 mg of PGF(2alpha) followed by oxytocin infusion. Women completed self-administered questionnaires 3 weeks after the termination procedure. Umbilical cord samples were collected at delivery for karyotype analysis. The primary outcome was the time from start of the procedure to placental delivery. Secondary outcomes were maternal complications, women's acceptance of the termination procedure, and success rates of umbilical cord culture.

RESULTS

The time was longer for the OM group (30.5+/-14.4 hours) compared with the VM group (18.3+/-8.2 hours) and the IAPG group (21.1+/-10.2 hours), P<.001 for both comparisons. Women in the VM group reported being more willing to repeat the termination method in the future and reported fewer side effects than those in the other groups, P<.001. Failure rates for umbilical cord cultures were 9.6%, 17.0%, and 45.6% for the VM, OM, and IAPG groups, respectively.

CONCLUSION

Oral misoprostol is less effective than intra-amniotic PGF(2alpha) or vaginal misoprostol for STPT. Women report vaginal misoprostol more acceptable than other methods. Umbilical cord culture failure rate is highest in the IAPG group.

Misoprostol: A Quarter Century of Use, Abuse, and Creative Misuse

Misoprostol is a prostaglandin E1 analog originally intended for use to prevent NSAID-induced gastric ulcers. However, because of its cervical ripening and uterotonic property, misoprostol has become one of the most useful drugs in obstetrics and gynecology. Misoprostol has proven to be a very convenient and flexible drug because of its formulation as a tablet that is stable and that can be administered orally, rectally, vaginally and by the sublingual route. Beginning with its abuse for illegal abortion in the late 1980s, misoprostol has quickly become established as one of the most effective drugs for terminating pregnancies in the first and second trimesters, as well as for inducing labor in the third trimester. Its use for routine prevention of postpartum hemorrhage has not been so successful, partly as the high doses required for this indication often result in troublesome side effects. Despite the large body of medical evidence about its efficacy and relative safety, the use of misoprostol in pregnant women remained off-label until the spring of 2002.

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.

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.

WHO multinational study of three misoprostol regimens after mifepristone for early medical abortion. I: Efficacy

OBJECTIVES

To compare the efficacy of oral and vaginal administration of misoprostol after a single oral dose of 200 mg of mifepristone and to investigate whether the efficacy can be improved and the duration of bleeding shortened by continuing oral misoprostol for one week.

DESIGN

Double blind, randomised controlled trial.

SETTING

Fifteen gynaecological clinics in 11 countries.

POPULATION

A total of 2219 healthy pregnant women requesting medical abortion with < or =63 days of amenorrhoea.

METHODS

Mifepristone 200 mg administered orally on day one, followed by 0.8 mg misoprostol either orally or vaginally on day three. The oral group and one of the vaginal groups continued with 0.4 mg of oral misoprostol twice daily for seven days.

MAIN OUTCOME MEASURES

Complete abortion was the main outcome. Secondary outcomes were side effects, timing of expulsion and duration of bleeding.

RESULTS

The crude complete abortion rate was 92.3% in the oral plus continued oral misoprostol group, in the vaginal-only group it was 93.5%, and it was 94.7% in the vaginal group that continued with oral misoprostol, when considering undetermined cases as failures. Among women with amenorrhoea length > or =57 days, the risk of failure of complete abortion was almost three times higher in the oral plus continued oral misoprostol group (RR = 2.8, 95% CI 1.3 to 5.8), and over two times higher in the vaginal-only group (RR = 2.2, 95% CI 1.0 to 4.7), when compared with the vaginal plus continued oral misoprostol group. Among women with amenorrhoea length < 57 days, the differences were not significant. Timing of expulsions and duration of bleeding were similar in the three groups.

CONCLUSIONS

For amenorrhoea length > or =57 days, vaginal misoprostol is more effective than oral when continued with 0.4 mg oral misoprostol twice daily for seven days. Misoprostol continuation improved the efficacy in this amenorrhoea group compared with a single dose of vaginal misoprostol on day three, but it did not shorten the duration of bleeding. No differences in efficacy were observed when amenorrhoea length was < 57 days.

A randomized comparison of two regimens of misoprostol for second-trimester pregnancy termination

OBJECTIVE

The purpose of this study was to compare the efficacy and side effects of two different misoprostol regimens for second-trimester pregnancy termination.

STUDY DESIGN

We performed a randomized clinical trial in patients who were at 14 to 23 weeks of gestation and who were admitted for medical termination of pregnancy. All patients received 800 microg of vaginal misoprostol and were assigned randomly to 400 microg of oral misoprostol or 400 microg of vaginal misoprostol every 8 hours. Efficacy and side effects were compared. The mean induction time of the study group was compared with that of an historic control group that had received 400 microg vaginally every 12 hours.

RESULTS

Forty-three women were assigned randomly, 22 women to vaginal misoprostol and 21 women to oral misoprostol. Induction time and hospital stay were slightly shorter for the oral group; however, the differences were not significant. Side effects were similar for both groups.

CONCLUSION

After an initial 800 microg dose of vaginal misoprostol, a regimen of 400 microg of oral misoprostol every 8 hours is as effective as the same dose of vaginal misoprostol with no additional side effects, which provides a convenient alternative for midtrimester pregnancy termination.