Vaginal misoprostol alone for medical abortion up to 9 weeks of gestation: efficacy and acceptability

Effectiveness and safety of misoprostol-only for first-trimester medication abortion: An updated systematic review and meta-analysis

OBJECTIVES

This study aimed to update our 2019 systematic review of data on the effectiveness and safety of misoprostol-only for first-trimester abortion.

STUDY DESIGN

We searched PubMed on December 18, 2022, to find published articles describing the outcomes of treatment with misoprostol-only for abortion of viable intrauterine pregnancy at ≤91 days of gestation. From each article identified, two authors independently abstracted relevant data about each group of patients treated with a distinct regimen. We assessed the risk of bias using four defined indicators. We estimated the proportion of patients with treatment failure using meta-analytic methods as well as the proportion hospitalized or transfused after treatment. We examined associations between treatment failure and selected characteristics of the groups.

RESULTS

We identified 49 papers with 66 groups that collectively included 16,354 evaluable patients, of whom 2960 (meta-analytic estimate 15%, 95% CI 12%, 19%) had treatment failures. Of 9228 patients assessed for ongoing pregnancy after treatment, 521 (meta-analytic estimate 6%, 95% CI 5%, 8%) had that condition. Failure risk was significantly associated with misoprostol dose, the total allowed number of doses, the maximum duration of dosing, and certain indicators of risk of bias. Among 11,007 patients allowed to take at least three misoprostol doses, the first consisting of misoprostol 800 mcg administered vaginally, sublingually, or buccally, the meta-analytic estimate of the failure risk was 11% (95% CI 8%, 14%). At most, 0.2% of 15,679 evaluable patients were hospitalized or received transfusions.

CONCLUSIONS

Although some studies in this updated review were adjudicated to have a high risk of bias, the results continue to support the key conclusion of our 2019 analysis: misoprostol-only is effective and safe for the termination of first-trimester intrauterine pregnancy.

IMPLICATIONS

Misoprostol-only is a safe and effective option for medication abortion in the first trimester if mifepristone is unavailable or inaccessible.

Clinical outcomes of medication abortion using misoprostol-only: A retrospective chart review at an abortion provider organization in the United States

OBJECTIVES

This study aimed to evaluate the effectiveness and safety of medication abortion with misoprostol-only among patients treated by an abortion provider organization in the United States during the COVID-19 pandemic.

STUDY DESIGN

We abstracted data from patients receiving misoprostol-only for abortion from December 2020 to December 2021. Two regimens were used, both allowing three to four doses of misoprostol 800 mcg every 3 hours but differing in the recommended administration routes (vaginal, buccal, or sublingual). We estimated the proportions of patients who had complete abortion and ongoing pregnancy in the two regimen groups in complete case analyses and after imputing missing outcomes based on pretreatment characteristics. We also estimated maximum effectiveness, assuming that all patients without known treatment failures had complete abortions. We tabulated serious adverse events.

RESULTS

We ascertained abortion outcomes for 476 (52%) of the total 911 treated patients. Of the 476 patients, 389 (82%) had complete abortion confirmed by test or history, and 45 (9%) had ongoing pregnancies detected after the provision of treatment. These proportions did not differ significantly between the two regimen groups in adjusted complete case analyses (p > 0.44). The results of imputed analyses were similar. Of the total 911 patients, at most 90% (95% confidence interval 88%, 92%) had complete abortion, and at least 5% (95% confidence interval 4%, 7%) had ongoing pregnancy. Serious adverse events were reported in three patients (0.6% of 487 patients with data for this outcome).

CONCLUSIONS

Our analysis suggests that the misoprostol-only regimens studied were safe and effective for most patients. Due to high loss to follow-up, observations from patients contacted after treatment likely somewhat underestimate true effectiveness.

IMPLICATIONS

Medication abortion with misoprostol-only was safe and produced complete abortion in most patients with follow-up. If loss to follow-up is high, effectiveness observed by clinics may misestimate true treatment efficacy.

Medical methods for first trimester abortion

BACKGROUND

Medical abortion became an alternative method of pregnancy termination following the development of prostaglandins and antiprogesterone in the 1970s and 1980s. Recently, synthesis inhibitors of oestrogen (such as letrozole) have also been used to enhance efficacy. The most widely researched drugs are prostaglandins (such as misoprostol, which has a strong uterotonic effect), mifepristone, mifepristone with prostaglandins, and letrozole with prostaglandins. More evidence is needed to identify the best dosage, regimen, and route of administration to optimise patient outcomes. This is an update of a review last published in 2011.

OBJECTIVES

To compare the effectiveness and side effects of different medical methods for first trimester abortion.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Global Health, and LILACs on 28 February 2021. We also searched Clinicaltrials.gov and the World Health Organization's (WHO) International Clinical Trials Registry Platform, and reference lists of retrieved papers.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) that compared different medical methods for abortion before the 12th week of gestation. The primary outcome is failure to achieve complete abortion. Secondary outcomes are mortality, surgical evacuation, ongoing pregnancy at follow-up, time until passing of conceptus, blood transfusion, side effects and women's dissatisfaction with the method.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected and evaluated studies for inclusion, and assessed the risk of bias. We processed data using Review Manager 5 software. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 99 studies in the review (58 from the original review and 41 new studies). 1. Combined regimen mifepristone/prostaglandin Mifepristone dose: high-dose (600 mg) compared to low-dose (200 mg) mifepristone probably has similar effectiveness in achieving complete abortion (RR 1.07, 95% CI 0.87 to 1.33; I2 = 0%; 4 RCTs, 3494 women; moderate-certainty evidence). Prostaglandin dose: 800 µg misoprostol probably reduces abortion failure compared to 400 µg (RR 0.63, 95% CI 0.51 to 0.78; I2= 0%; 3 RCTs, 4424 women; moderate-certainty evidence). Prostaglandin timing: misoprostol administered on day one probably achieves more success on complete abortion than on day three (RR 1.94, 95% CI 1.05 to 3.58; 1489 women; 1 RCT; moderate-certainty evidence). Administration strategy: there may be no difference in failure of complete abortion with self-administration at home compared with hospital administration (RR 1.63, 95% CI 0.68 to 3.94; I2 = 84%; 2263 women; 4 RCTs; low-certainty evidence), but failure may be higher when administered by nurses in hospital compared to by doctors in hospital (RR 2.69, 95% CI 1.39 to 5.22; I2 = 66%; 3 RCTs, 3056 women; low-certainty evidence). Administration route: oral misoprostol probably leads to more failures than the vaginal route (RR 2.38, 95% CI 1.46 to 3.87; I2 = 39%; 3 RCTs, 1704 women; moderate-certainty evidence) and may be associated with more frequent side effects such as nausea (RR 1.14, 95% CI 1.03 to 1.26; I2 = 0%; 2 RCTs, 1380 women; low-certainty evidence) and diarrhoea (RR 1.80 95% CI 1.49 to 2.17; I2 = 0%; 2 RCTs, 1379 women). Compared with the vaginal route, complete abortion failure is probably lower with sublingual (RR 0.68, 95% CI 0.22 to 2.11; I2 = 59%; 2 RCTs, 3229 women; moderate-certainty evidence) and may be lower with buccal administration (RR 0.71, 95% CI 0.34 to 1.46; I2 = 0%; 2 RCTs, 479 women; low-certainty evidence), but sublingual or buccal routes may lead to more side effects. Women may experience more vomiting with sublingual compared to buccal administration (RR 1.33, 95% CI 1.01 to 1.77; low-certainty evidence). 2. Mifepristone alone versus combined regimen The efficacy of mifepristone alone in achieving complete abortion compared to combined mifepristone/prostaglandin up to 12 weeks is unclear (RR of failure 3.25, 95% CI 0.81 to 13.09; I2 = 83%; 3 RCTs, 273 women; very low-certainty evidence). 3. Prostaglandin alone versus combined regimen Nineteen studies compared prostaglandin alone to a combined regimen (prostaglandin combined with mifepristone, letrozole, estradiol valerate, tamoxifen, or methotrexate). Compared to any of the combination regimens, misoprostol alone may increase the risk for failure to achieve complete abortion (RR of failure 2.39, 95% CI 1.89 to 3.02; I2 = 64%; 18 RCTs, 3471 women; low-certainty evidence), and with more diarrhoea. 4. Prostaglandin alone (route of administration) Oral misoprostol alone may lead to more failures in complete abortion than the vaginal route (RR 3.68, 95% CI 1.56 to 8.71, 2 RCTs, 216 women; low-certainty evidence). Failure to achieve complete abortion may be slightly reduced with sublingual compared with vaginal (RR 0.69, 95% CI 0.37 to 1.28; I2 = 87%; 5 RCTs, 2705 women; low-certainty evidence) and oral administration (RR 0.58, 95% CI 0.11 to 2.99; I2 = 66%; 2 RCTs, 173 women). Failure to achieve complete abortion may be similar or slightly higher with sublingual administration compared to buccal administration (RR 1.11, 95% CI 0.71 to 1.74; 1 study, 401 women).

AUTHORS' CONCLUSIONS

Safe and effective medical abortion methods are available. Combined regimens (prostaglandin combined with mifepristone, letrozole, estradiol valerate, tamoxifen, or methotrexate) may be more effective than single agents (prostaglandin alone or mifepristone alone). In the combined regimen, the dose of mifepristone can probably be lowered to 200 mg without significantly decreasing effectiveness. Vaginal misoprostol is probably more effective than oral administration, and may have fewer side effects than sublingual or buccal. Some results are limited by the small numbers of participants on which they are based. Almost all studies were conducted in settings with good access to emergency services, which may limit the generalisability of these results.

Women's experiences using drugs to induce abortion acquired in the informal sector in Colombia: qualitative interviews with users in Bogotá and the Coffee Axis

In 2006, abortion in Colombia was decriminalised under certain circumstances. Yet some women continue to avail themselves of ways to terminate pregnancies outside of the formal health system. In-depth interviews (IDIs) with women who acquired drugs outside of health facilities to terminate their pregnancies (n = 47) were conducted in Bogotá and the Coffee Axis in 2018. Respondents were recruited when they sought postabortion care at a health facility. This analysis examines women's experiences with medication acquired outside of the health system for a termination: how they obtained the medication, what they received, how they were instructed to use the pills, the symptoms they were told to expect, and their abortion experiences. Respondents purchased the drugs in drug stores, online, from street vendors, or through contacts in their social networks. Women who used online vendors more commonly received the minimum dose of misoprostol according to WHO guidelines to complete the abortion (800 mcg) and received more detailed instructions and information about what to expect than women who bought the drug elsewhere. Common instructions were to take the pills orally and vaginally; most women received incomplete information about what to expect. Most women seeking care did not have a complete abortion before coming to the health facility (they never started bleeding or had an incomplete abortion). Women still face multiple barriers to safe abortion in Colombia; policymakers should promote better awareness about legal abortion availability, access to quality medication and complete information about misoprostol use for women to terminate unwanted pregnancies safely.

Efficacy of Misoprostol Alone for First-Trimester Medical Abortion: A Systematic Review

OBJECTIVE

To summarize available data on the effectiveness and safety of single-agent misoprostol for medical abortion in the first trimester.

DATA SOURCES

We searched MEDLINE, CABI, Cochrane, EMBASE, LILACS, the Web of Science, and ClinicalTrials.gov for English-language studies that evaluated misoprostol alone for abortion of a viable pregnancy in the first trimester.

METHODS OF STUDY SELECTION

Our search yielded 1,562 citations, of which 38 included data from 53 trial groups that met our inclusion and exclusion criteria.

TABULATION, INTEGRATION, AND RESULTS

We abstracted data about each trial group, including study characteristics, treatment regimen, clinical protocol, number of women treated and followed, and numbers with outcomes of interest. We used meta-analytic methods and logistic regression to examine factors associated with surgical intervention after treatment. Among all 12,829 evaluable women, 2,536 (meta-analytic estimate 22.0%, 95% CI 18.8-25.5%) had surgical uterine evacuation. Multiple factors were significantly associated with this proportion, including misoprostol amount per dose and route of administration, loss to follow-up rate, publication date, geographic region, number of misoprostol doses, duration of dosing, and time between dosing and evaluation. Of 6,359 evaluable women, 384 (meta-analytic estimate 6.8%, 95% CI 5.3-8.5%) had ongoing pregnancies. At most 26 of 12,184 evaluable women (meta-analytic estimate 0.7%, 95% CI 0.4-1.0%) were transfused or hospitalized for abortion-related reasons. In trials that provided satisfaction data, most women were satisfied or very satisfied with the treatment (meta-analytic estimate 78%, 95% CI 71-85%).

CONCLUSIONS

Misoprostol alone is effective and safe and is a reasonable option for women seeking abortion in the first trimester. Research is indicated to further refine the regimen and to establish efficacy in the late first trimester.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42018083589.

Sublingual vs vaginal misoprostol for completion of first trimester missed abortion: a randomised controlled trial

OBJECTIVE

The study aimed to compare the efficacy and safety of sublingual and vaginal misoprostol for termination of pregnancy in women with first trimester missed abortion.

METHODS

A single-blind, parallel group, randomised clinical trial (ClinicalTrials.gov NCT02686840) was conducted in a university hospital between 1 February 2016 and 31 January 2017. All women who presented with first trimester missed abortion were invited to participate in the study and were randomised to one of two groups: one group received sublingual misoprostol in three doses of 800 μg every 4 h, while a second group received vaginal misoprostol in the same dosage regimen. The primary outcome of the study was the rate of complete abortion within 7 days after initiation of treatment.

RESULTS

The study included 200 women (100 in each arm). By day 7, successful complete abortion was significantly more frequent in the sublingual misoprostol group (71.4%) than in the vaginal misoprostol group (51.5%) (p = .006). By day 30, the rate of complete abortion was higher in the sublingual misoprostol group (90.6%) than in the vaginal misoprostol group (83.9%), but with no statistically significant difference (p = .164). The mean length of the induction-expulsion interval in the sublingual misoprostol group was significantly shorter compared with the vaginal misoprostol group (12.3 ± 3.1 h vs 16.4 ± 4.2 h, respectively; p = .001) and the sublingual misoprostol group had a smaller drop in haemoglobin level (p = .001). The side effects of misoprostol were significantly more frequent in the sublingual group compared with the vaginal group.

CONCLUSION

Sublingual misoprostol is more effective than vaginal misoprostol in completing first trimester missed abortion, with a shorter induction-expulsion time. Sublingual misoprostol is, however, associated with more side effects, such as unpleasant taste, gastrointestinal symptoms and fever, compared with vaginal misoprostol.

Moistening the new vaginal misoprostol tablets: does it increase the efficacy of cervical priming before manual vacuum aspiration in first-trimester miscarriage? A randomised clinical trial

OBJECTIVES

The primary objective of our study was to ascertain whether moistening the Brazilian formulation of vaginal misoprostol tablets increases cervical dilation before manual vacuum aspiration (MVA), compared with use of dry misoprostol, in first-trimester miscarriage. The secondary objective was to ascertain whether there was any correlation between vaginal pH and the degree of cervical dilation using a moistened or dry misoprostol tablet.

METHODS

In a single-centre, double-blind, randomised trial, 46 patients with first-trimester miscarriage were randomly allocated to treatment with dry or moistened (with 200 µl distilled water) 2 × 200 μg misoprostol tablets.

RESULTS

The median (range) cervical dilation in the wet and dry groups was 8 mm (6-12 mm) and 7 mm (5-10 mm), respectively (p = .06). The median time between misoprostol insertion and carrying out the procedure did not differ between the dry (406 min, range 180-550 min) and wet (448 min, range 180-526 min) groups (p = .1). No correlation was found between vaginal pH and cervical dilation using continuous data (p = .57; r= 0.08; 95% confidence interval -0.02, 0.3) or dichotomous data (pH ≤5/>5; cervical dilation ≥8 mm or <8 mm; p = .8).

CONCLUSION

No difference was observed in cervical dilation between moistened and non-moistened misoprostol use prior to MVA.

Cervical dilation before first-trimester surgical abortion (<14 weeks' gestation)

First-trimester surgical abortion is a common, safe procedure with a major complication rate of less than 1%. Cervical dilation before suction abortion is usually accomplished using tapered mechanical dilators. Risk factors for major complications in the first trimester include increasing gestational age and provider inexperience. Cervical priming before first-trimester surgical abortion has been studied using osmotic dilators and pharmacologic agents, most commonly misoprostol. Extensive data demonstrate that a variety of agents are safe and effective at causing preoperative cervical softening and dilation; however, given the small absolute risk of complications, the benefit of routine use of misoprostol or osmotic dilators in first-trimester surgical abortion is unclear. Although cervical priming results in reduced abortion time and improved provider ease, it requires a delay of at least 1 to 3 h and may confer side effects. The Society of Family Planning does not recommend routine cervical priming for first-trimester suction abortion but recommends limiting consideration of cervical priming for women at increased risk of complications from cervical dilation, including those late in the first trimester, adolescents and women in whom cervical dilation is expected to be challenging.

The effect of 7 days of letrozole pretreatment combined with misoprostol on the expression of progesterone receptor and apoptotic factors of placental and decidual tissues from first-trimester abortion: a randomized controlled trial

OBJECTIVE

To evaluate if letrozole-induced suppression of estradiol reduces progesterone receptor expression and apoptosis in the first-trimester placenta.

STUDY DESIGN

We performed a double-blinded, randomized, placebo-controlled trial. We randomized 20 women requesting first-trimester abortion with gestation up to 63 days to receive either letrozole 10 mg daily or placebo pretreatment for 7 days before administrating 400 mcg of vaginal misoprostol followed by suction abortion. We collected the placental and decidual tissues on which we performed immunohistochemical staining for progesterone receptor and apoptotic markers (active caspase 3, caspase 3, Bcl2, CD95, fas ligand) and determined H-scores of each based on the intensities of staining. We performed terminal deoxynucleotidyl transferase-mediated dUTP-digoxigenin nick end labeling (TUNEL) assay for apoptosis in the samples of four women to confirm the findings from apoptotic markers.

RESULTS

We excluded one woman in the letrozole group from the analysis because she had passage of abortus after taking letrozole, leaving 19 women (9 in the letrozole group, 10 in the placebo group) for analysis. There was no significant difference in the H-scorings of progesterone receptor and apoptotic markers, as well as proportion of apoptotic cells on TUNEL assay between the two groups. The H-scores for the progesterone receptor were 8.17 ± 2.67 (mean ± SD) in the letrozole group and 9.01 ± 2.82 in the placebo group (p=0.36).

CONCLUSION

We did not detect a difference in the expression of progesterone receptor and apoptotic markers in placental and decidual tissues after letrozole pretreatment for 7 days in first-trimester abortion.

IMPLICATIONS

We did not confirm the hypothesis that letrozole reduces progesterone receptor expression and induces apoptosis in the first-trimester placenta. Further studies are required to allow better understanding of the mechanism by which estrogen suppression following the use of letrozole can lead to improved abortion rate in the first trimester.

Effectiveness of a single dose of oral misoprostol 600 μg for treatment in early pregnancy failure

The purpose of this study was to examine the effectiveness, side-effects and acceptability of a single dose of oral misoprostol 600 μg for treatment of 1st trimester pregnancy failure. A prospective descriptive study was conducted on pregnant women of < 13 weeks' gestation, diagnosed as 1st trimester pregnancy failure. Patients were assigned to receive a single dose of misoprostol 600 μg orally and then evaluated 48 h after drug administration for complete abortion. A total of 55 women were recruited to the study. The complete abortion rate was 65.5%. Pain and diarrhoea were the most common side-effects. Acceptability and satisfactory rates were 70.9% and 70.9%, respectively. In conclusion, a single dose of oral misoprostol 600 μg is a fair method for the management of 1st trimester pregnancy failure. Side-effects are tolerable and satisfaction is high. Thus, this method may be used as an alternative treatment.

Improving care of women at risk of unsafe abortion: implementing a risk-reduction model at the Uruguayan-Brazilian border

OBJECTIVE

To describe the initial stages of the implementation of a risk-reduction model designed by Iniciativas Sanitarias to shield women from unsafe abortion in a traditional community on the Uruguay-Brazil border.

METHODS

This mixed-design study was conducted first between 22 and 26 March 2010, and then between 2 and 7 May 2011, in Rivera, Uruguay, to gather information from women seen at health centers, healthcare providers, and local policy makers before the project started and midway through the project.

RESULTS

At baseline most women and providers considered abortion justifiable only on narrow grounds, yet favored the implementation of a risk-reduction model that would include preabortion as well as postabortion counseling, the former providing information on different abortion methods and their risks. By the midterm assessment, the counseling service had assisted 87 women with unwanted pregnancies. Of the 52 who came for a postabortion visit, 50 had self-administered misoprostol, with no complications. Women were highly satisfied with the counseling. At baseline, misoprostol seemed to be available from both pharmacists and informal sellers. At midterm, it was still available from informal vendors but pharmacists said they did not provide misoprostol. The risk-reduction initiative heightened public attention to the abortion issue but the controversy it generated did not seriously impede its implementation.

CONCLUSION

It is feasible to implement the proposed risk-reduction model in a traditional community such as Rivera, not only in Uruguay but in any country irrespective of its abortion laws.

Medical methods for first trimester abortion

BACKGROUND

Surgical abortion by vacuum aspiration or dilatation and curettage has been the method of choice for early pregnancy termination since the 1960s. Medical abortion became an alternative method of first trimester pregnancy termination with the availability of prostaglandins in the early 1970s and anti-progesterones in the 1980s. The most widely researched drugs are prostaglandins (PGs) alone, mifepristone alone, methotrexate alone, mifepristone with prostaglandins and methotrexate with prostaglandins.

OBJECTIVES

To compare different medical methods for first trimester abortion.

SEARCH METHODS

The Cochrane Controlled Trials Register, MEDLINE and Popline were systematically searched. Reference lists of retrieved papers were also searched. Experts in WHO/HRP were contacted.

SELECTION CRITERIA

Types of studies Randomised controlled trials comparing different medical methods for abortion during first trimester (e.g. single drug, combination) were considered. Trials were assessed and included if they had adequate concealment of allocation, randomisation procedure and follow-up. Women, pregnant during the first trimester, undergoing medical abortion were the participants. The outcomes were mortality, failure to achieve complete abortion, surgical evacuation, ongoing pregnancy at follow-up, time until passing of conceptus, blood transfusion, side effects and women's dissatisfaction with the procedure.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion from the results of the search strategy described previously.The selection of trials for inclusion in the review was performed independently by two reviewers after employing the search strategy described previously. Trials under consideration were evaluated for appropriateness for inclusion and methodological quality without consideration of their results. Data were processed using Revman software.

MAIN RESULTS

Fifty-eight trials were included in the review. The effectiveness outcomes below refer to 'failure to achieve complete abortion' with the intended method unless otherwise stated. 1) Combined regimen mifepristone/prostaglandin: Mifepristone 600 mg compared to 200 mg shows similar effectiveness in achieving complete abortion (4 trials, RR 1.07, 95% CI 0.87 to 1.32). Misoprostol administered orally is less effective (more failures) than the vaginal route (RR 3.00, 95% CI 1.44 to 6.24) and may be associated with more frequent side effects such as nausea and diarrhoea. Sublingual and buccal routes were similarly effective compared to the vaginal route, but had higher rates of side effects. 2) Mifepristone alone is less effective when compared to the combined regimen mifepristone/prostaglandin (RR 3.76 95% CI 2.30 to 6.15). 3) Five trials compared prostaglandin alone to the combined regimen (mifepristone/prostaglandin). All but one reported higher effectiveness with the combined regimen. The results of these studies could not be combined but the RR of failure with prostaglandin alone is reportedly between 1.4 to 3.75 with the 95% confidence intervals indicating statistical significance. 4) In one trial comparing gemeprost 0.5 mg with misoprostol 800 mcg, misoprostol was more effective (failure with gemeprost: RR 2.86, 95% CI 1.14 to 7.18). 5) There was no difference in effectiveness with use of a divided dose compared to a single dose of prostaglandin. 6) Combined regimen methotrexate/prostaglandin demonstrates similar rates of failure to complete abortion when comparing intramuscular to oral methotrexate administration (RR 2.04, 95% CI 0.51 to 8.07). Similarly, day 3 vs. day 5 administration of prostaglandin following methotrexate administration showed no significant differences (RR 0.72, 95% CI 0.36 to 1.43). One trial compared the effect of tamoxifen vs. methotrexate and no statistically significant differences were observed in effectiveness between the groups.

AUTHORS' CONCLUSIONS

Safe and effective medical abortion methods are available. Combined regimens are more effective than single agents. In the combined regimen, the dose of mifepristone can be lowered to 200 mg without significantly decreasing the method effectiveness. Vaginal misoprostol is more effective than oral administration, and has less side effects than sublingual or buccal. Some results are limited by the small numbers of participants on which they are based. Almost all trials were conducted in settings with good access to emergency services, which may limit the generalizability of these results.

How commonly do US abortion patients report attempts to self-induce?

OBJECTIVE

This study measures the extent to which women who access clinical abortion services in the United States report having ever used misoprostol or other substances to self-induce.

STUDY DESIGN

A random sample of 107 US abortion providers was asked to distribute questionnaires to abortion patients.

RESULTS

Information was gathered from 9493 patients at 95 facilities, and weights were constructed to make the data nationally representative of all US abortion patients. Only 1.2% of women obtaining abortions report having ever used misoprostol on their own to "bring back" their period or end a pregnancy. A similarly small proportion of women, 1.4%, reported using other substances, such as vitamin C or herbs, to attempt to end a pregnancy.

CONCLUSION

Media reports of self-induced abortions using misoprostol may be exaggerated, but further research is needed to estimate the incidence of self-induced abortion among women who do not access clinical abortion services.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Cervical dilation before first-trimester surgical abortion (<14 weeks' gestation). SFP Guideline 20071

First-trimester surgical abortion is a common, safe procedure with a major complication rate of less than 1%. Cervical dilation before suction aspiration is usually accomplished using tapered mechanical dilators. Risk factors for major complications in the first trimester are increasing gestational age and provider inexperience. Use of laminaria for cervical priming reduces the risk of cervical laceration and, to a lesser extent, uterine perforation. While pharmacological priming agents may potentially have the same effects, no published studies to date have been large enough to assess these outcomes. Given an experienced provider, the risk of these injuries during suction aspiration is very small. Cervical priming can be achieved with osmotic dilators or pharmacological agents. The advantages of osmotic dilators such as laminaria, Dilapan-S and Lamicel are their ability to produce wide cervical dilation, and for the synthetic types, their advantages include predictable effects and rapid onset of action. A disadvantage of osmotic dilators is that they require a speculum examination and a trained clinician to perform the insertion. When cervical priming is performed, misoprostol is the prostaglandin analogue most commonly used worldwide. Compared to laminaria, vaginal misoprostol requires a shorter period of time to achieve the same dilatation, is associated with less discomfort and is preferred by women. The sublingual route appears as effective as vaginal administration and requires less time for priming (2 h), but it is associated with more side effects. Oral administration can produce equivalent dilation to vaginal or sublingual administration, but higher doses and longer treatment periods (8 to 12 h) are required. Buccal administration of misoprostol appears to have a pharmacokinetic and physiologic profile similar to vaginal administration; however, there are no published studies of buccal misoprostol prior to first-trimester suction abortion. While extensive data demonstrate that a variety of agents are safe and effective at causing cervical softening and dilation preoperatively, there are not enough data to conclude that routine cervical priming is necessary to reduce complications of first-trimester surgical abortion. Cervical priming increases preoperative cervical dilation, making the procedure easier and quicker for the physician. However, in order to preoperatively dilate the cervix, the woman must receive the agent at least 3 to 4 h prior to her procedure. Besides the additional waiting, the woman might experience bleeding and cramping prior to the procedure. There are insufficient data evaluating how cervical priming affects women's quality of life in relation to abortion. Based on existing evidence, the Society of Family Planning does not recommend routine cervical priming for suction aspiration procedures. The Society of Family Planning further recommends that providers consider cervical priming only for women who may be at increased risk of complications from cervical dilation, including those late in the first trimester, adolescents and women in whom cervical dilation is expected to be difficult due to either patient factors or provider experience.

Efficacy of two intervals and two routes of administration of misoprostol for termination of early pregnancy: a randomised controlled equivalence trial

BACKGROUND

The most effective route and best interval between several doses of misoprostol to induce abortion have not been defined. Our aim was to assess the effects of the interval between multiple doses of misoprostol and the route of administration to terminate pregnancy.

METHODS

2066 healthy pregnant women requesting medical abortion with 63 days or less of gestation were randomly assigned within 11 gynaecological centres in six countries to the four treatment groups (three doses of 0.8 mg misoprostol given sublingually at 3-h intervals, vaginally 3 h, sublingually 12 h, and vaginally 12 h), stratifying by gestational age. This was an equivalence trial with a 5% margin of equivalence. The primary endpoints were efficacy of treatment to achieve complete abortion and to terminate pregnancy. The main efficacy analysis excluded women lost to follow-up. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN10531821.

FINDINGS

Efficacy outcomes were analysed for 2046 women (99%), excluding 20 lost to follow-up. Complete abortion rates at 2-week follow-up were recorded for 431 (84%) in the sublingual and for 434 (85%) women in the vaginal group when misoprostol was given at 3-h intervals (difference 0.4%, 95% CI -4.0 to 4.9, p=0.85 equivalence shown), and for 399 (78%) in the sublingual and for 425 (83%) in the vaginal 12-h groups (4.6%, -0.2 to 9.5, p=0.06, equivalence not shown). In the 3-h groups, pregnancy continued in 29 (6%) women after sublingual and in 20 (4%) women after vaginal administration (difference 1.8%, 95% CI -0.8 to 4.4, p=0.19, equivalence shown); in the 12-h groups it continued in 47 (9%) after sublingual and in 25 (5%) after vaginal administration (4.4%, 1.2-7.5, p=0.01, vaginal better than sublingual). Differences for complete abortion between intervals for sublingual and vaginal routes were 6% (95% CI 1.0-10.6, p=0.02, 3 h better than 12 h) and 2% (-2.9 to 6.1, p=0.49, equivalence not shown), respectively; for continuing pregnancies they were 4% (0.4-6.8, p=0.03, 3 h better than 12 h) and 1% (-1.5 to 3.5, p=0.44, equivalence shown), respectively.

INTERPRETATION

Administration interval can be chosen between 3 h and 12 h when misoprostol is given vaginally. If administration is sublingual, the intervals between misoprostol doses need to be short, but side-effects are then increased. With 12-h intervals, vaginal route should be used, whereas with 3-h intervals either route could be chosen.

Alternatives to mifepristone for early medical abortion

OBJECTIVE

To review published reports of first-trimester medical abortion regimens that do not include mifepristone.

METHODS

Reports listed in Pubmed and Medline on prospective and controlled trials of the efficacy of misoprostol, alone or associated with methotrexate, for first-trimester abortion were analyzed if they included more than 100 participants and were published since 1990.

RESULTS

The efficacy of regimens using misoprostol alone ranged from 84% to 96%, and when misoprostol was used with methotrexate the efficacy ranged from 70% to 97%. Efficacy rates were influenced by follow-up interval. Treatment for infection, bleeding, and incomplete abortion were infrequent with both methods (0.3%-5%).

CONCLUSION

Alone or in combination with methotrexate, misoprostol is an efficacious alternative to mifepristone for the medical termination of pregnancy.

Misoprostol alone for early abortion: an evaluation of seven potential regimens

INTRODUCTION

A growing body of literature has shown that misoprostol alone could be effective for early medical abortion. We evaluated seven potential regimens in women up to 56 days of gestation in order to potentially identify an optimal regimen.

METHODS

In phase I of the study, women requesting early abortion were randomized to one of three misoprostol regimens (4x400 microg po every 3 h, 2x800 microg po every 6 h, 1x600 pv microg); in phase II, women were randomized to one of two regimens (2x800 microg po every 3 h, 1x800 pv microg). In phase III, we consecutively tested two regimens (800 microg pv wetted with saline repeated after 24 h if intact gestational sac, 2x800 microg pv wetted with saline) to validate previously published results.

RESULTS

Although most women experienced some side effects, all regimens were tolerable and acceptable. Five of the seven regimens resulted in complete abortion rates of 60% or less. Only repeated doses of 800 microg pv misoprostol resulted in efficacy exceeding 60%.

DISCUSSION

Misoprostol-alone abortion regimens using oral misoprostol are too ineffective for clinical use or further investigation. Regimens with repeated dosing of misoprostol 800 microg pv warrant further study to find the optimal treatment protocol.

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.

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.

Misoprostol and pregnancy: ever-increasing indications of effective usage

PURPOSE OF REVIEW

The subject of misoprostol in the field of reproductive health care has courted much controversy. The aim of this review is to survey the literature published in this field over the past year, and to evaluate developments in this area. This article will cover termination of pregnancy, induction of labor and the issue of postpartum hemorrhage.

RECENT FINDINGS

The use of misoprostol as a single agent remains of clinical value when mifepristone is unavailable. The sublingual and rectal routes are alternative modes of administration. For induction of labor, the optimum dose and route of misoprostol is still undetermined. Lower doses of between 20 microg to 40 microg may increase the safety profile for labor induction. Misoprostol may be a useful adjunct to the therapeutic options available for the prevention and treatment of postpartum hemorrhage.

SUMMARY

There are many potential uses for misoprostol in pregnancy. However clinicians must judge the evidence and the emotive debate surrounding this field and decide how it will influence their clinical practice depending on the priorities of their own clinical circumstances.

Medical methods for first trimester abortion

BACKGROUND

Surgical abortion up to 63 days by vacuum aspiration or dilatation and curettage has been the method of choice since the 1960s. Medical abortion became an alternative method of first trimester pregnancy termination with the availability of prostaglandins in the early 1970s and anti-progesterones in the 1980s. The most widely researched drugs are prostaglandins (PGs) alone, mifepristone alone, methotrexate alone, mifepristone with prostaglandins and methotrexate with prostaglandins.

OBJECTIVES

To compare different medical methods for first trimester abortion.

SEARCH STRATEGY

The Cochrane Controlled Trials Register, MEDLINE and Popline were systematically searched. Reference lists of retrieved papers were also searched. Experts in WHO/HRP were contacted.

SELECTION CRITERIA

Types of studies. Randomised controlled trials comparing different medical methods (e.g. single drug, combination), ways of application, or different dose regimens, single or combined, for medical abortion, were considered. Trials were assessed and included if they had adequate concealment of allocation, randomisation procedure and follow-up. Women, pregnant in the first trimester, undergoing medical abortion were the participants. Different medical methods used for first trimester abortion, compared with each other or placebo were included. The outcomes sought include mortality, failure to achieve complete abortion, surgical evacuation (as emergency procedure, non-emergency procedure, or undefined), ongoing pregnancy at follow-up, time until passing of conceptus (> 3-6 hours), blood transfusion, blood loss (measured or clinically relevant drop in haemoglobin), days of bleeding, pain resulting from the procedure (reported by the women or measured by use of analgesics), additional uterotonics used, women's dissatisfaction with the procedure, nausea, vomiting, diarrhoea.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion from the results of the search strategy described previously. The selection of trials for inclusion in the review was performed independently by two reviewers after employing the search strategy described previously. Trials under consideration were evaluated for appropriateness for inclusion and methodological quality without consideration of their results. A form was designed to facilitate the data extraction. Data were processed using Revman software.

MAIN RESULTS

Thirty-nine trials were included in the review. The effectiveness outcomes below refer to 'failure to achieve complete abortion' with the intended method unless otherwise stated. 1) Combined regimen mifepristone/prostaglandin: Mifepristone 600 mg compared to 200 mg shows similar effectiveness in achieving complete abortion (4 trials, RR 1.07, 95% CI 0.87 to 1.32). Misoprostol administered orally is less effective (more failures) than the vaginal route (RR 3.00, 95% CI 1.44 to 6.24) and may be associated with more frequent side effects such as nausea and diarrhoea. 2) Mifepristone alone is less effective compared to the combined regimen mifepristone/prostaglandin (RR 3.76 95% CI 2.30 to 6.15). 3) Similarly, the 5 trials included in the comparison of prostaglandin compared to the combined regimen reported in all but one higher effectiveness with the combined regime compared to prostaglandin. The results of these studies were not pooled but the RR of failure with prostaglandin alone is between 1.4 to 3.75 and the 95% confidence intervals indicate statistical significance. 4) In one trial comparing gemeprost 0.5 mg with misoprostol 800 mcg, misoprostol was more effective (failure with gemeprost: RR 2.86, 95% CI 1.14 to 7.18). 5) There was no difference when using split dose compared to single dose of prostaglandin. 6) Combined regimen methotrexate/prostaglandin: there was no statistically significant difference in failure to achieve complete abortion comparing methotrexate administered intramuscular to oral (RR 2.04, 95% CI 0.51 to 8.07). Similarly, early (day 3) vs late (day 5) administration of prostaglandin showed no significant of prostaglandin showed no significant difference (RR 0.72, 95% CI 0.36 to 1.43). One trial compared the effect of tamoxifen vs methotrexate and no statistically significant differences were observed in effectiveness between the groups.

REVIEWER'S CONCLUSIONS

Safe and effective medical abortion methods are available. Combined regimens are more effective than single agents. In the combined regimen, the dose of mifepristone can be lowered to 200 mg without significantly decreasing the method effectiveness. Misoprostol vaginally is more effective than orally. Some of the results are based on small studies only and therefore carry some uncertainty. Almost all trials were conducted in hospital settings with good access to support and emergency services. It is therefore not clear if the results are readily applicable to under-resourced settings where such services are lacking even if the agents used are available.

Medical methods for first trimester abortion

BACKGROUND

Surgical abortion up to 63 days by vacuum aspiration or dilatation and curettage has been the method of choice since the 1960s. Medical abortion became an alternative method of first trimester pregnancy termination with the availability of prostaglandins in the early 1970s and anti-progesterones in the 1980s. The most widely researched drugs are prostaglandins (PGs) alone, mifepristone alone, methotrexate alone, mifepristone with prostaglandins and methotrexate with prostaglandins.

OBJECTIVES

To compare different medical methods for first trimester abortion.

SEARCH STRATEGY

The Cochrane Controlled Trials Register, MEDLINE and Popline were systematically searched. Reference lists of retrieved papers were also searched. Experts in WHO/HRP were contacted.

SELECTION CRITERIA

Types of studies. Randomised controlled trials comparing different medical methods (e.g. single drug, combination), ways of application, or different dose regimens, single or combined, for medical abortion, were considered. Trials were assessed and included if they had adequate concealment of allocation, randomisation procedure and follow-up. Women, pregnant in the first trimester, undergoing medical abortion were the participants. Different medical methods used for first trimester abortion, compared with each other or placebo were included. The outcomes sought include mortality, failure to achieve complete abortion, surgical evacuation (as emergency procedure, non-emergency procedure, or undefined), ongoing pregnancy at follow-up, time until passing of conceptus (> 3-6 hours), blood transfusion, blood loss (measured or clinically relevant drop in haemoglobin), days of bleeding, pain resulting from the procedure (reported by the women or measured by use of analgesics), additional uterotonics used, women's dissatisfaction with the procedure, nausea, vomiting, diarrhoea.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion from the results of the search strategy described previously. The selection of trials for inclusion in the review was performed independently by two reviewers after employing the search strategy described previously. Trials under consideration were evaluated for appropriateness for inclusion and methodological quality without consideration of their results. A form was designed to facilitate the data extraction. Data were processed using Revman software.

MAIN RESULTS

Thirty-nine trials were included in the review. The effectiveness outcomes below refer to 'failure to achieve complete abortion' with the intended method unless otherwise stated. 1) Combined regimen mifepristone/prostaglandin: Mifepristone 600 mg compared to 200 mg shows similar effectiveness in achieving complete abortion (4 trials, RR 1.07, 95% CI 0.87 to 1.32). Misoprostol administered orally is less effective (more failures) than the vaginal route (RR 3.00, 95% CI 1.44 to 6.24) and may be associated with more frequent side effects such as nausea and diarrhoea. 2) Mifepristone alone is less effective compared to the combined regimen mifepristone/prostaglandin (RR 3.76 95% CI 2.30 to 6.15). 3) Similarly, the 5 trials included in the comparison of prostaglandin compared to the combined regimen reported in all but one higher effectiveness with the combined regime compared to prostaglandin. The results of these studies were not pooled but the RR of failure with prostaglandin alone is between 1.4 to 3.75 and the 95% confidence intervals indicate statistical significance. 4) In one trial comparing gemeprost 0.5 mg with misoprostol 800 mcg, misoprostol was more effective (failure with gemeprost: RR 2.86, 95% CI 1.14 to 7.18). 5) There was no difference when using split dose compared to single dose of prostaglandin. 6) Combined regimen methotrexate/prostaglandin: there was no statistically significant difference in failure to achieve complete abortion comparing methotrexate administered intramuscular to oral (RR 2.04, 95% CI 0.51 to 8.07). Similarly, early (day 3) vs late (day 5) administration of prostaglandin showed no significant of prostaglandin showed no significant difference (RR 0.72, 95% CI 0.36 to 1.43). One trial compared the effect of tamoxifen vs methotrexate and no statistically significant differences were observed in effectiveness between the groups.

REVIEWERS' CONCLUSIONS

Safe and effective medical abortion methods are available. Combined regimens are more effective than single agents. In the combined regimen, the dose of mifepristone can be lowered to 200 mg without significantly decreasing the method effectiveness. Misoprostol vaginally is more effective than orally. Some of the results are based on small studies only and therefore carry some uncertainty. Almost all trials were conducted in hospital settings with good access to support and emergency services. It is therefore not clear if the results are readily applicable to under-resourced settings where such services are lacking even if the agents used are available.

Prostaglandins for first-trimester termination

Since the 1980s, when mifepristone combined with a prostaglandin was found to be safe and effective for early abortion, many studies have refined the regimens and investigated alternatives such as methotrexate plus misoprostol, and misoprostol alone. Evidence now demonstrates that more than 200 mg of mifepristone provides no additional benefit, that vaginal misoprostol is superior to oral, especially between 7 and 9 weeks' gestation, and that misoprostol may be safely self-administered at home. Buccal and sublingual routes of administration of misoprostol also are promising. Absolute contraindications to medical abortion arise infrequently. Gastrointestinal and other side-effects occur in about one-third of women, primarily after administration of the prostaglandin. Careful assessment before and after medical abortion is essential and can be accomplished in various ways, depending on the skills of the clinician.

Pharmacokinetics of prostaglandins

Naturally occurring prostaglandins (PGs) are rapidly metabolized in the human circulation. For clinical use a number of PG analogues have therefore been developed which are resistant to rapid inactivation. Among these are carboprost, gemeprost and misoprostol. Following intramuscular injection of carboprost, plasma levels peaked after 20 minutes and declined slowly thereafter. In amniotic fluid the half-life was between 31 and 37 hours. Gemeprost is administered vaginally, and maximum plasma levels were reached after 2-3 hours, with detectable levels for at least 6-8 hours. Pharmacokinetic data on misoprostol are available following oral, vaginal and sublingual administration. Following oral treatment, plasma levels peaked at about 30 minutes, while after vaginal administration of the tablets the levels increased gradually and reached maximum levels after 70-80 minutes, but remained detectable for a significantly longer time. After sublingual administration the peak concentration was the same as for oral treatment but declined significantly more slowly. Endocervical administration of PGE(2) might be regarded as a local therapy, while following vaginal administration increased plasma levels of metabolites can generally be found. The plasma profile varies with the vehicle used.

Pharmacoeconomics of medical abortion: a review of cost in the United States, Europe and Asia

Procedures for the termination of pregnancy have existed for many years. Vacuum aspiration, otherwise referred to as 'surgical' abortion, is a very common and safe procedure. Its efficacy and acceptability has been established and its complication rate is low. Medical abortion is a much more recent phenomenon. It is defined as early pregnancy termination with the use of abortion inducing medications, without surgery [1]. In contrast to surgical abortion, medical abortion is not as routinely offered, nor are many providers comfortable with its use. Medical abortion regimens currently available throughout the world include mifepristone (Mifeprex trade mark, Aventis Pharma AG) and a prostaglandin analogue (usually misoprostol), methotrexate and misoprostol and misoprostol (Cytotec trade mark, CD Searle & Co.) alone. In the US, minimal information exists directly comparing medical to surgical abortion. Most abortion surveillance data was collected by the Centers for Disease Control prior to the approval of mifepristone. In contrast, there is over a decade's worth of experience from Europe with both the use and provision of medical abortion. A complete review of these issues must include background information on the history and incidence of abortion, who chooses to get an abortion, who provides that service and at what cost. The cost issue is discussed using three different viewpoints: cost to the patient, cost to the provider, cost to society - mainly in the form of government expenditure and savings. Following the cost analysis, there is a summary of relevant information from countries in Europe, primarily the UK, France, Sweden and countries in Asia, mainly China and India.

Options for early therapeutic abortion: a comparative review

Vacuum aspiration, either manual or electric, has for many years been the most commonly used method for termination of an early pregnancy. More recently, new medical methods have been developed which for many women are attractive alternatives to the surgical procedure. The compounds mainly used are prostaglandin analogues, methotrexate, and mifepristone in combination with a suitable prostaglandin analogue. However, only the last method has been registered for routine clinical use. The treatment schedule mainly used is mifepristone 200 to 600 mg followed 36 to 48 hours later by oral misoprostol 0.4 to 0.6 mg in pregnancies up to 49 days and vaginal gemeprost 1.0mg or misoprostol 0.8 mg if the treatment period is extended to 63 days of amenorrhoea. The ability to compare medical and surgical methods is limited by the fact that there are few randomised studies and the definitions of successful outcome (complete abortion), adverse effects and complications vary from one study to the other. Experience with the method used is also important for the outcome. However, it seems adequate to state that the medical method is equally, or almost equally, as effective as vacuum aspiration. Duration of bleeding and amount of blood loss is greater following medical abortion. Also the frequency of uterine pain, vomiting and diarrhoea is higher following medical abortion than following vacuum aspiration. On the other hand, the frequency of major complications such as excessive bleeding, blood transfusion and pelvic infection does not seem to differ between the two procedures. Surgical complications, for example, uterine perforation and cervical tears, are obviously not a risk associated with medical abortion. Both methods are equally well accepted provided the woman is allowed to choose. It is not possible to state which method is best. Medical termination of early pregnancy will not replace, but is an alternative to, vacuum aspiration and ideally both methods should be available to give the woman a choice.

[Spontaneous abortions of first trimester pregnancy: is uterine aspiration still in line?]

Spontaneous abortions of first trimester pregnancy is a frequent pathology in gynecology (more than 10% of clinical pregnancy). Since the mid of twentieth century, the gold standard of evacuation of spontaneous abortion is manual vacuum aspiration most of the time under general anesthesia. This method is used in France for all miscarriages after 7 weeks' gestation at the sonography (about 40,000 women in 1999) but complications are not rare. The vaginal sonography and new medical management changes the view. We can now use expectative management or medical management with misoprostol and/or mifepristone. We summarise the current literature and propose a randomised multicentric control trial.

Pilot study on the use of sublingual misoprostol with mifepristone in termination of first trimester pregnancy up to 9 weeks gestation

BACKGROUND

A combination of mifepristone and misoprostol provides an effective method of medical abortion for early pregnancy. A new route of administration of misoprostol, the sublingual route, was investigated in this study.

METHODS

One hundred women who requested legal termination of pregnancy up to 63 days were given 200 mg of oral mifepristone followed 48 h later by 800 microg (4 x 200 microg tablets) of sublingual misoprostol.

RESULTS

Ninety-four women (94%) had a complete abortion with this regimen. There was one ongoing pregnancy. The median duration of vaginal bleeding was 15 days. There were no serious complications. However, lower abdominal pain, diarrhoea, chills and fever were the commonest side-effects with incidences of 89, 42, 38 and 79% respectively.

CONCLUSIONS

The combination of mifepristone and sublingual misoprostol is effective for medical abortion up to 63 days gestation. Randomized trials are required to compare its efficacy and side-effect profile with vaginal misoprostol.

A prospective randomized, double-blinded, placebo-controlled trial comparing mifepristone and vaginal misoprostol to vaginal misoprostol alone for elective termination of early pregnancy

BACKGROUND

Vaginal misoprostol has been shown to be an effective single agent for medical abortion. This randomized, double-blinded, placebo-controlled trial compared a regimen of mifepristone and misoprostol with misoprostol alone for termination of early pregnancy.

METHODS

250 women with gestations < or = 56 days were randomized by a random number table to receive either 200 mg mifepristone orally or placebo followed 48 h later by 800 microg vaginal misoprostol. Administration of misoprostol was repeated every 24 h up to three doses if abortion failed to occur. Abortion success was defined as complete abortion without the use of surgical aspiration.

RESULTS

Successful medical abortions occurred in 114 out of 119 subjects (95.7%) after mifepristone followed by vaginal misoprostol. In all, 110 out of 125 subjects (88.0%) successfully aborted after placebo and vaginal misoprostol. The higher success rate of complete abortion with the mifepristone and misoprostol regimen was statistically significant compared with the placebo and misoprostol regimen (P < 0.05).

CONCLUSIONS

A regimen of mifepristone and misoprostol was significantly more effective for termination of pregnancies < or = 56 days than misoprostol alone. The 88% efficacy obtained with vaginal misoprostol alone may be clinically acceptable when mifepristone is not available.

Unsafe abortion: an avoidable tragedy

An estimated 60 000-70 000 women die annually from complications of unsafe abortion and hundreds of thousands more suffer long-term consequences which include chronic pelvic pain and infertility. The reasons for the continuing high incidence of unwanted pregnancy leading to unsafe abortion include lack of access to, or misuse of and misinformation about, effective contraceptive methods, coerced sex which prohibits women from protecting themselves, and contraceptive failure. Unsafe abortion is closely associated with restrictive legal environments and administrative and policy barriers hampering access to existing services. Vacuum aspiration and medical methods combining mifepristone and a prostaglandin for early abortion are simple and safe. For second trimester abortion, the main choices are repeat doses of prostaglandin with or without prior mifepristone, and dilatation and evacuation by experienced providers. Strategies for preventing unsafe abortion include: upgrading providers' skills; further development of medical methods for pregnancy termination and their introduction into national programmes; improving the quality of contraceptive and abortion services; and improving partner communication.

Pilot study on the use of repeated doses of sublingual misoprostol in termination of pregnancy up to 12 weeks gestation: efficacy and acceptability

BACKGROUND

A sublingual misoprostol-alone regimen was used in 50 women requesting medical abortion at up to 12 weeks gestation. The efficacy and acceptability of this regimen were studied.

METHODS

The women were given 600 microg misoprostol sublingually every 3 h for a maximum of 5 doses.

RESULTS

The overall complete abortion rate was 86% (95% confidence interval: 74-93). The mean number of doses of misoprostol required was 4.1 +/- 1.1. There was no significant change in haemoglobin concentration and the median duration of vaginal bleeding was 15 days (range: 7-56). Diarrhoea, fever and chills were the most common side-effects. The acceptability of this regimen of misoprostol was good: 97.7% of the women who had a complete abortion would choose this method again and 88.4% would recommend it to others. They preferred sublingual misoprostol as it is convenient to take, avoids the painful vaginal administration and gives more privacy during the abortion process.

CONCLUSION

This regimen of sublingual misoprostol is an effective and acceptable method of medical abortion. Randomized controlled trials are required to compare the efficacy of various misoprostol-alone regimens of medical abortion. Pharmacokinetic studies and clinical trials are needed to find out the most appropriate dose, dosing interval and route of administration of misoprostol.

Early pregnancy termination with vaginal misoprostol combined with loperamide and acetaminophen prophylaxis

The objectives of this prospective non-concurrent cohort study were to confirm the efficacy of vaginal misoprostol for early pregnancy termination and to determine whether the incidence of side effects is lower with prophylactic loperamide and acetaminophen. Two-hundred women with an intrauterine pregnancy < or =56 days gestational age seeking medical pregnancy termination in an ambulatory research clinic were enrolled in the study. One-hundred participants (group 1) ingested 4 mg of loperamide and 500 mg of acetaminophen before the vaginal placement of 800 mirog of misoprostol moistened with 2 mL of saline. If abortion had not occurred, the same regimen was repeated every 24 h (maximum three doses). One-hundred participants (group 2) from the same clinic who previously underwent the same misoprostol regimen without prophylactic medication served as a control group for comparison with respect to abortion success and the incidence of side effects. The rate of successful abortion was not statistically significantly different between the two groups (group 1 93%, group 2 89%). The incidence of opiate analgesic use was significantly less in group 1 (4%) compared with group 2 (16%) (OR 0.22, 95% CI 0.06-0.73, p = 0.01). There was a significantly lower incidence of diarrhea in group 1 (23%) compared with group 2 (44%) (OR 0.38, 95% CI 0.20-0.73, p = 0.003). There was no difference in the incidence of fever/chills or the incidence of emesis between the two groups. Vaginal misoprostol is effective for termination of pregnancy < or = 56 days and the incidence of diarrhea and the use of opiate analgesia is significantly reduced with prophylactic loperamide and acetaminophen.