Mifepristone Followed in 24 Hours to 48 Hours by Misoprostol for Late First-Trimester Abortion

A repeat dose of misoprostol 800 mcg following mifepristone for outpatient medical abortion at 64-70 and 71-77 days of gestation: A retrospective chart review

OBJECTIVE

To compare the effectiveness of outpatient medical abortion with mifepristone 200 mg and two misoprostol 800 mcg doses at 64-70 and 71-77 days of gestation.

STUDY DESIGN

We conducted a retrospective chart review of medical abortion outcomes among clients with 64-77 day gestations at a Mexico City public clinic between February 2014 and November 2016 who took mifepristone 200 mg followed 24-48 h later by two doses of misoprostol 800 mcg four hours apart (first dose buccally, second dose sublingually). The primary outcome was successful medical abortion, defined as pregnancy expulsion without surgical intervention. We also assessed additional management and visits to other facilities. We compared outcomes by gestational age (64-70 vs 71-77 days).

RESULTS

Of 602 charts reviewed, we analyzed 232 and 218 in the respective groups for effectiveness; nearly 25% of clients were lost to follow up. Treatment success occurred in 231 (99.6%, 95% CI 97.6-100%) clients at 64-70 days and 213 (97.7%, 95% CI 94.7-99.3%) clients at 71-77 days (p = 0.11). Ongoing pregnancy occurred in 1 (0.4%, 95% CI 0-2.4%) and 3 (1.4%, 95% CI 0.3-4.0%) clients, respectively (p = 0.36). Two charts from the 71-77 days group documented visits to other facilities: one bleeding concern prior to scheduled follow up and a hemorrhage during an aspiration intervention.

CONCLUSIONS

Regimen effectiveness was high at 64-70 and 71-77 days among clients who attended follow up. However, with 25% attrition, it is difficult to draw definitive conclusions about effectiveness and associated safety.

IMPLICATIONS

Mifepristone 200 mg followed by two doses of misoprostol 800 mcg four hours apart is a promising medical abortion regimen to improve efficacy in pregnancies from 64-77 days of gestation as compared to regimens with an initial single misoprostol dose. Prospective research is recommended to achieve more robust efficacy estimates.

Clinic-level introduction of medical abortion in Vietnam

OBJECTIVE

To assess the efficacy of medical abortion and patient satisfaction in the clinic setting, in addition to determining healthcare providers' views.

METHODS

From 2006 to 2008, 2400 women were enrolled at 10 Vietnam Family Planning Association (VINAFPA) clinics in an operations research project. Participants took 200mg of oral mifepristone in the clinic and 400 μg of oral misoprostol 2 days later at home or in the clinic. Abortion status was assessed at follow-up. Furthermore, in 2006, 900 clinicians at 45 health facilities answered a knowledge, attitudes, and practices survey to capture providers' views.

RESULTS

In total, 93.8% of participants had successful medical abortions. The majority (84.5%) administered misoprostol at home. Adverse effects included bleeding, pain/cramps, and nausea. Most women (92.6%) were satisfied/very satisfied with the method. Most providers who took the survey (85.6%) recommended that medical abortion be introduced at VINAFPA clinics.

CONCLUSION

The operations research data demonstrate the safety, efficacy, and acceptability of medical abortion at VINAFPA clinics. The majority of surveyed providers endorsed adding medical abortion at their own facilities. Developing national guidelines for providing medical abortion at the clinic level is an important step in expanding access to services in Vietnam.

Trends in use of medical abortion in the United States: reanalysis of surveillance data from the Centers for Disease Control and Prevention, 2001-2008

BACKGROUND

With changing patterns and increasing use of medical abortion in the United States, it is important to have accurate statistics on the use of this method regularly available. This study assesses the accuracy of medical abortion data reported annually to the Centers for Disease Control and Prevention (CDC) and describes trends over time in the use of medical abortion relative to other methods.

STUDY DESIGN

This analysis included data reported to CDC for 2001-2008. Year-specific analyses included all states that monitored medical abortion for a given year, while trend analyses were restricted to states that monitored medical abortion continuously from 2001 to 2008. Data quality and completeness were assessed by (a) examining abortions reported with an unspecified method type within the gestational age limit for medical abortion (med-eligible abortions) and (b) comparing the percentage of all abortions and med-eligible abortions reported to CDC as medical abortions with estimates based on published mifepristone sales data for the United States from 2001 to 2007.

RESULTS

During 2001-2008, the percentage of med-eligible abortions reported to CDC with an unspecified method type remained low (1.0%-2.2%); CDC data and mifepristone sales estimates for 2001-2007 demonstrated strong agreement [all abortions: intraclass correlation coefficient (ICC)=0.983; med-eligible abortions: ICC=0.988]. During 2001-2008, the percentage of abortions reported to CDC as medical abortions increased (p<.001 for all abortions and for med-eligible abortions). Among states that reported medical abortions for 2008, 15% of all abortions and 23% of med-eligible abortions were reported as medical abortions.

CONCLUSION

CDC's Abortion Surveillance System provides an important annual data source that accurately describes the use of medical abortion relative to other methods in the United States.

Two medical abortion regimens for late first-trimester termination of pregnancy: a prospective randomized trial

BACKGROUND

Medical abortion regimens based on the use of either misoprostol alone or in association with mifepristone have shown high efficacy and excellent safety profile in early pregnancy abortion. However, no clear recommendation is available for late first-trimester termination of pregnancy.

STUDY DESIGN

A prospective randomized controlled trial included 122 women seeking medical abortion at 9 to 12 weeks of gestation. Seventy-three patients were given a fixed protocol of 200 mg of mifepristone followed 48 h later by 400 mcg oral misoprostol (Group 1). The second group of 49 patients was administered 800-mcg intravaginal single-dose misoprostol (Group 2). This study sought to compare safety, efficacy and acceptability of these two nonsurgical abortion regimens.

RESULTS

Fifty-nine (80.8%) women in Group 1 had complete abortion vs. 38 (77.4%) women in Group 2 (p=.66). Abdominal pain was observed significantly more often in Group 2 (35/49 (71.4%) vs. 32/73 (43.8%) in Group 1, p<.0001. Medical abortion was equally acceptable among the two groups [37/49 (75.5%) and 55/73 (75.7%), p=.89].

CONCLUSION

For late first-trimester termination, a single 800-mcg vaginal dose of misoprostol seems to be as effective as the mifepristone+misoprostol regimen, with acceptable side effects.

Medication abortion

Medical methods for pregnancy termination in early gestation offer women an alternative to surgical evacuation and have the potential to improve access globally to safe abortion. Several drug regimens are used with varying efficacy including mifepristone plus misoprostol, misoprostol alone, and methotrexate plus misoprostol. Where available, a mifepristone plus misoprostol regimen is most frequently used and is highly effective for early abortion. We review these drug regimens along with clinical practice recommendations including patient counseling and selection, regimen administration location, expected side effects, and follow-up procedures. Overall, women who choose medical abortion report high levels of satisfaction.