Induction of second trimester abortion with mifepristone and gemeprost

Physiology of the Endometrium and Regulation of Menstruation

The physiological functions of the uterine endometrium (uterine lining) are preparation for implantation, maintenance of pregnancy if implantation occurs, and menstruation in the absence of pregnancy. The endometrium thus plays a pivotal role in reproduction and continuation of our species. Menstruation is a steroid-regulated event, and there are alternatives for a progesterone-primed endometrium, i.e., pregnancy or menstruation. Progesterone withdrawal is the trigger for menstruation. The menstruating endometrium is a physiological example of an injured or “wounded” surface that is required to rapidly repair each month. The physiological events of menstruation and endometrial repair provide an accessible in vivo human model of inflammation and tissue repair. Progress in our understanding of endometrial pathophysiology has been facilitated by modern cellular and molecular discovery tools, along with animal models of simulated menses. Abnormal uterine bleeding (AUB), including heavy menstrual bleeding (HMB), imposes a massive burden on society, affecting one in four women of reproductive age. Understanding structural and nonstructural causes underpinning AUB is essential to optimize and provide precision in patient management. This is facilitated by careful classification of causes of bleeding. We highlight the crucial need for understanding mechanisms underpinning menstruation and its aberrations. The endometrium is a prime target tissue for selective progesterone receptor modulators (SPRMs). This class of compounds has therapeutic potential for the clinical unmet need of HMB. SPRMs reduce menstrual bleeding by mechanisms still largely unknown. Human menstruation remains a taboo topic, and many questions concerning endometrial physiology that pertain to menstrual bleeding are yet to be answered.

Effects of a prolonged, 72 hours, interval between mifepristone and gemeprost in second trimester termination of pregnancy: a retrospective analysis

OBJECTIVE

To evaluate if the 72 hours interval between mifepristone and gemeprost has a similar efficacy compared to the 48 hours interval for second trimester termination of pregnancy

STUDY DESIGN

Two-hundred and fifteen consecutive pregnant women, admitted to our hospital, for second trimester TOP, were included in this retrospective analysis. Standard protocol was followed for all patients. On the first day of the procedure oral mifepristone 200 mg was administered. After 72 (group A, n = 78) or 48 hours (group B, n = 113) women were admitted for administration of gemeprost 1 mg pessary as per protocol. The induction to abortion time was defined as the interval between the insertion of the first gemeprost pessary and the expulsion of the fetus.

RESULTS

There are no significant differences in the number of pessaries in the two groups. The induction to abortion interval was longer in group A than in group B. Twenty-one women required surgical evacuation of the uterus for retained placenta or incomplete abortion without difference between groups.

CONCLUSION

A 48-hours interval between mifepristone and gemeprost leads to better results than a 72-hours interval, with a shorter abortion length and represents the elective method for second trimester TOP.

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.

Pattern of morbidity and mortality following illegal termination of pregnancy at Nnewi, Nigeria

Seventeen women were treated for complications of illegal termination of pregnancy over a 2-year period, January 1996 to December 1997. Important characteristics of the women include a mean age of 21 years (mode 18 years) and being unmarried (100%, n=17), nulliparous (94%, n=16) and unemployed (76%, n=13). There was a tendency towards late termination as 50% of women had a termination after 13 weeks. Serious complications were cervical laceration, pelvic abscess/peritonitis, ruptured uterus, transection of the sigmoid colon and ileal/jejunal lacerations. The mortality rate was 6% (n=1). Most of the terminations were performed through instrumental cervical dilatation without prior medical or hydrophilic treatment. This study shows that illegal abortions are still commonly performed in Nigeria with an unacceptably high incidence of morbidity and mortality. Modernisation of abortion laws, wider contraceptive usage, adoption of modern methods of termination of pregnancy (RU 486 and prostaglandin E(1) analogues) and prophylactic antibiotics are recommended in order to reduce the problems of unsafe abortion in Nigeria and other developing countries.

Antifertility effects of antigestogens

Since the discovery of the structure and function of steroids over 60 years ago, it has long been recognized that synthetic antagonists of the natural hormones would have potential therapeutic uses. Antagonists of mineralocorticoids, androgens and oestrogens, for example spironolactine, cyproterone, flutamide and tamoxifen, have already found a place in the management of hormone dependent conditions. In 1982, chemists at Roussel UCLAF announced that they had synthesized mifepristone (RU486) 17β-hydroxy-11(p-(dimethylamino)phenyl)-17-(1-propynyl) estra-411, 9-dien-3-one) a derivative of norethindrone which had potent antiprogestogenic as well as antiglucocorticoid activity. Although it was immediately realised that this compound would potentially have wide clinical application, its development in the last 10 years has been dominated by its abortifacient action. In the original clinical report by Herrman and colleagues it was shown that bleeding occurred when it was given to female volunteers in the second half of the menstrual cycle. In addition, complete abortion occurred in eight of 11 women who took the drug in the early weeks of pregnancy. These findings, which demonstrated that mifepristone could be used as the basis of a medical method of inducing abortion, were immediately made the focus of groups opposed to abortion on moral grounds. Experience over the last 10 years has confirmed the promise of these early studies and mifepristone, in combination with a suitable prostaglandin, is now licensed in France, UK and Sweden for use as a medical method of inducing abortion in early pregnancy.

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.

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.

Induction of second trimester abortion (12–20 weeks) with mifepristone and misoprostol: a review of 386 consecutive cases

DESIGN

A retrospective analysis of 386 women who underwent termination of pregnancy between 12 and 24 weeks' gestation.

METHODS

Each woman received 200 mg mifepristone orally followed by vaginal misoprostol 800 microg 36 to 48 h later. Three hours after the initial misoprostol administration, 400-microg doses of vaginal misoprostol were administered every 3 h, to a maximum of four doses in 24 h. If abortion failed, 200 mg mifepristone is given again 3 h after the last misoprostol dose, followed by 12 h of rest before vaginal misoprostol administration is repeated as per previous course of treatment.

RESULTS

Overall, 97.9% and 99.5% of the women aborted within 24 and 36 h, respectively. The median induction-to-abortion interval was 6.7 h (range: 1.4-73.8 h), and nulliparous women took significantly longer time to abort (6.0 h in multiparous women compared to 7.6 h in nulliparous women; p<.0001). One woman failed to abort within 48 h. Surgical evacuation of the uterus was performed in 5% of women for incomplete abortion or retained placenta. Multiparous women were less likely to need analgesic administration for pain relief, and to experience vomiting and diarrhea, than nulliparous women.

CONCLUSION

The combination of 200 mg mifepristone and vaginally administered misoprostol is a safe, effective and noninvasive regimen for termination of pregnancy between 12 and 20 weeks.

Medical abortion at 9–13 weeks' gestation: a review of 1076 consecutive cases

OBJECTIVE

The aim of the study was to assess the use, efficacy and factors influencing the outcome of medical abortion at 9-13 weeks' gestation.

METHODS

Retrospective chart review of consecutive women undergoing medical abortion at 9-13 weeks' gestation was done.

RESULTS

A total of 1927 abortions were carried out at 9-13 weeks' gestation, of which 1076 (55.8%) were undertaken medically. Efficacy decreased with increasing gestation (p=.02). Surgical evacuation was carried out in 45 (4.2%) women including 10 (2.7%) at 64-70 days, 11 (3.3%) at 71-77 days, 10 (5.1%) at 78-84 days and 14 (8.0%) at 85-91 days of gestation (p=.02). Indications for surgery included continuing pregnancy [16 (1.5%) women], retained sac [5 (0.5%)], incomplete abortion [20 (1.9%)] and emergency curettage for bleeding [4 (0.4%)]. The number of misoprostol doses used and the induction-to-abortion interval both significantly increased with gestation (p<.001), while analgesia requirements did not vary with increasing gestation (p=.18).

CONCLUSIONS

Medical abortion at 9-13 weeks' gestation is an effective alternative to surgery. Medical methods should be offered routinely at these gestations, thus increasing women's choice.

Methods for Induced Abortion

We describe present methods for induced abortion used in the United States. The most common procedure is first-trimester vacuum curettage. Analgesia is usually provided with a paracervical block and is not completely effective. Pretreatment with nonsteroidal analgesics and conscious sedation augment analgesia but only to a modest extent. Cervical dilation is accomplished with conventional tapered dilators, hygroscopic dilators, or misoprostol. Manual vacuum curettage is as safe and effective as the electric uterine aspirator for procedures through 10 weeks of gestation. Common complications and their management are presented. Early abortion with mifepristone/misoprostol combinations is replacing some surgical abortions. Two mifepristone/misoprostol regimens are used. The rare serious complications of medical abortion are described. Twelve percent of abortions are performed in the second trimester, the majority of these by dilation and evacuation (D&E) after laminaria dilation of the cervix. Uterine evacuation is accomplished with heavy ovum forceps augmented by 14-16 mm vacuum cannula systems. Cervical injection of dilute vasopressin reduces blood loss. Operative ultrasonography is reported to reduce perforation risk of D&E. Dilation and evacuation procedures have evolved to include intact D&E and combination methods for more advanced gestations. Vaginal misoprostol is as effective as dinoprostone for second-trimester labor-induction abortion and appears to be replacing older methods. Mifepristone/misoprostol combinations appear more effective than misoprostol alone. Uterine rupture has been reported in women with uterine scars with misoprostol abortion in the second trimester. Fetal intracardiac injection to reduce multiple pregnancies or selectively abort an anomalous twin is accepted therapy. Outcomes for the remaining pregnancy have improved with experience.

Induction of labor with 50 and 100μg of misoprostol: comparison of maternal and fetal outcomes

OBJECTIVE

The aim of this randomized controlled study was to compare the efficacy and the safety of different regimens of misoprostol for labor induction. MATERIALS AND METHODS Eligible women received intravaginal 100 microg, every 6 h or 50 microg every 4 h. Treatment continued until: (1) dilatation >3 cm; (2) rupture of membranes (artificial); (3) signs of uterine hyperstimulation; (4) adequate contraction pattern (three contraction/10 min). Managing clinician might use oxytocin during labor. Cesarean section rate was the main outcome that was considered variably. Other outcome measures were neonatal outcome (Apgar scores, meconium staining, and umbilical artery pH) and induction to delivery interval.

RESULTS

A total number of 72 women received either misoprostol 100 microg (n=37), or 50 microg (n=35) randomly. The two groups had similar mean Bishops scores at induction (4.10+/-2.4 versus 4.2+/-2.1; P=0.85), rates of nulliparity, use of epidural anesthesia, and oxytocin augmentation. In two groups the number of doses of misoprostol used was similar (1.6+/-0.5 versus 1.7+/-0.3)

CONCLUSION

There was not any difference between the two groups in the mean+/-S.D. time to delivery (h) and cesarean rate. Likewise, there was not a significance between two groups in the rates of 5 min Apgar score, and of meconium passage.

Midtrimester medical termination of pregnancy: a review of 1002 consecutive cases

We assessed the effectiveness, safety and factors that affected the outcome of midtrimester medical termination of pregnancy at 13-21 weeks gestation. Of the 1002 women, 3 took mifepristone and decided to continue with the pregnancy, with 999 women being compliant with the regimen. Of these, 2 women aborted prior to administration of misoprostol and 970 (97.1%) aborted successfully within five doses of misoprostol. Surgical intervention was necessary to complete the abortion process in 81 (8.1%) women. Women with no previous pregnancy (p = 0.02), no previous live birth (p = 0.0001) and gestations 17-21 weeks (p = 0.001) required more prostaglandin. Younger women (p = 0.0001) and women with a previous live birth (p = 0.001) were more likely to have a successful abortion. The induction abortion interval was significantly longer with increasing gestation [95% confidence interval (CI) difference in means: -2.52 to -0.89, p = 0.0001], increasing age (p = 0.0001) and no previous live birth (95% CI difference in means: -0.25 to -1.01, p = 0.0001). Surgical intervention was more likely to be required with increasing age (p = 0.008). Mifepristone in combination with misoprostol is a safe and effective regimen for midtrimester medical abortion with younger women and those with a previous live birth more likely to have a successful abortion.

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.

Medical abortion at 64 to 91 days of gestation: a review of 483 consecutive cases

OBJECTIVE

The purpose of this study was to assess the uptake and outcome of medical abortion in the late first trimester of pregnancy.

STUDY DESIGN

We conducted a review of the cases of 483 consecutive women in a university hospital who underwent medical abortion at 64 to 91 days of gestation and who used mifepristone that was followed 36 to 48 hours later by repeated doses of misoprostol.

RESULTS

A total of 891 abortions were carried out at 64 to 91 days of gestation from October 2000 to April 2002; of these, 483 cases (54.2%) were undertaken medically. Complete abortion occurred in 458 cases (94.8%). Efficacy decreased with advancing gestational age. Surgical evacuation was carried out in 1 woman (0.9%) at 9 to 10 weeks of gestation, in 8 women (5.3%) at 10 to 11 weeks of gestation, in 7 women (6.2%) at 11 to 12 weeks of gestation, and in 9 women (7.9%) at 12 to 13 weeks of gestation. Indications for surgery included ongoing pregnancy in 8 cases (1.7%), missed abortion in 3 cases (0.6%), incomplete abortion in 13 cases (2.7%), and emergency curettage for bleeding in 1 case (0.2%). The mean number of misoprostol doses used was 2.3; of those women who had a complete abortion, 152 women (32.6%) aborted within 4 hours of receiving the misoprostol. The mean induction to abortion interval was 5.5 hours; most cases (452; 93.6%) were treated as day cases.

CONCLUSION

Medical abortion between 64 and 91 days of gestation is effective and has a high uptake. Consideration should be given to extending the availability and choice of medical abortion to women in this gestational group.

Medical termination of pregnancy at 9-12 weeks of gestation

Current RCOG guidelines advise that surgical termination should be offered to those within the 9-12 weeks gestation band. While auditing the quality of services offered for termination of pregnancy in our unit, it became apparent that many women presenting at this gestation were requesting a medical method. There has been little clinical research into medical method of abortion at this gestation. The aim of the study was to assess the efficacy of medical methods of termination at 9-12 weeks gestation. A retrospective analysis of 25 cases who underwent medical termination using a regime of mifepristone followed 48 hours later by a course of vaginal gemeprost was undertaken. Complete abortion was achieved in 96% of cases; 92% of women required no more than two pessaries to achieve complete abortion. All but one patient was suitable for discharge on the same day. One woman underwent surgical evacuation in view of heavy bleeding. We conclude that medical TOP is a safe alternative to surgical method at 9-12 weeks' gestation.

A randomised study of misoprostol and gemeprost in combination with mifepristone for induction of abortion in the second trimester of pregnancy

OBJECTIVE

To compare the effectiveness of gemeprost and misoprostol as prostaglandins used in combination with mifepristone for induction of mid-trimester termination.

DESIGN

Randomised trial.

SETTING

Scottish teaching hospital.

SAMPLE

One hundred women undergoing abortion between 12 and 20 weeks.

METHODS

Each woman received 200 mg mifepristone and 36-48 hours later either 1 mg gemeprost vaginal pessary every 6 hours for 18 hours or 4 x 200 microg misoprostol tablets vaginally followed by 2 x 200 microg misoprostol tablets orally every 3 hours for 12 hours. Success was defined as the percentage of women aborted within 24 hours of the first administration of prostaglandin.

MAIN OUTCOME MEASURES

Prostaglandin-abortion interval and side effects.

RESULTS

There were no significant differences in median prostaglandin-abortion interval between gemeprost (6.6 hours 95% CI 6.0-10.7) and misoprostol (6.1 hours 95% CI 5.5-7.5) (P = 0.22). The cumulative abortion rates at 24 hours (96% vs 94%, respectively), the surgical evacuation rates (12% and 10%) and the incidence of vomiting, diarrhoea and pain were similar.

CONCLUSION

Two hundred milligrammes of mifepristone followed 36-48 hours later by either vaginal gemeprost or misoprostol is a highly effective way of inducing abortion in the second trimester of pregnancy.

Medical abortion in the second trimester

The introduction of prostaglandin analogues and mifepristone has changed the management of second trimester abortion in the last 2 decades. Gemeprost and misoprostol are the two most extensively studied prostaglandin analogues that are used in this period. The combination of either gemeprost or misoprostol with mifepristone is most effective. With these regimens, over 90% of women abort within 24 hours and the mean induction to abortion interval is about 6 hours. Mifepristone is expensive and is not available in many countries. Therefore, prostaglandin analogue-only regimens might be the only option. These regimens are still effective with an abortion rate of >90% in 48 hours. However, the induction to abortion interval (15 hours) is much longer. Intra-cervical tents can be used to shorten the induction to abortion intervals.

Second trimester medical abortion with mifepristone and gemeprost: a review of 956 cases

The treatment outcomes of 956 women undergoing second trimester termination of pregnancy with mifepristone and gemeprost were studied. The median gestational age was 16 weeks (range: 12-24 weeks). All women were treated with 200 mg mifepristone orally, followed 36 h later with 1 mg vaginal gemeprost administered every 6 h to a maximum of 4 doses in the first 24 h. A second course of 1 mg vaginal gemeprost was given 3-hourly in the next 12 h, if abortion had not occurred. Overall, 96.4% and 98.8% of the women aborted within 24 and 36 h, respectively. The median induction-to-abortion interval was 7.8 h (range: 0.5-109.9 h). The induction-abortion interval was longer in nulliparous women and women with a gestation age 17 weeks or above. Surgical evacuation of the uterus was performed in 11.5% of women for incomplete abortion or retained placenta. More multiparous women (16.7%) required surgical evacuation of uterus than did nulliparous women (7.3%; p <0.001). Ten (0.1%) women failed to abort with gemeprost and required other methods for abortion. In conclusion, a combination of mifepristone and gemeprost is a safe, effective, and noninvasive method of medical abortion for second trimester pregnancy.

Vaginal misoprostol in termination of second trimester pregnancy

OBJECTIVE

To study the effectiveness and complications of 600 micrograms of intravaginal misoprostol for terminating second trimester pregnancies.

STUDY DESIGN

One hundred and seventy-two patients undergoing termination of pregnancy between March 1997 and April 1999 were studied. Each patient received 600 micrograms of intravaginal misoprostol every 12 hours until abortion occurred.

RESULTS

The mean induction to abortion time was 24.1 +/- 21.6 hours. The percentage of women aborting within 24 and 48 hours was 68.6 and 89.5 respectively. There was no significant difference in the mean induction to abortion time and the percentage of women aborted within 48 hours between nulliparous and multiparous women. The mean amount of misoprostol used was 1405.5 +/- 1084.6 micrograms. Incomplete abortion occurred in 23.3% of women. The most common complication was temperature of more than 38 degrees C occurred in 41% followed by diarrhoea (20%), nausea and vomiting (15%).

CONCLUSION

Six hundred micrograms of vaginal misoprostol is effective, but whether the 48 hours abortion rate can be improved with a large dose or shortened the time interval between doses, requires further study.

Second trimester therapeutic abortion using mifepristone and oral misoprostol in a woman with two previous caesarean sections and a cone biopsy

Most regimes for medical termination use an antiprogesterone and a vaginal prostaglandin. Concern remains about its safety in women with previous caesarean births. We present a case of successful therapeutic mid-trimester termination in a woman with two previous caesarean births and cervical surgery using an antiprogesterone and an oral prostaglandin.

Nonsurgical mid-trimester termination of pregnancy: a review of 500 consecutive cases

OBJECTIVE

To assess the effectiveness of a regimen comprising mifepristone followed by a combination of the vaginal and oral administration of misoprostol for mid-trimester medical termination of pregnancy.

DESIGN

Retrospective analysis of prospectively collected data in women undergoing mid-trimester medical termination of pregnancy.

SETTING

Aberdeen Royal Infirmary, Scotland.

SAMPLE

A consecutive series of 500 women with pregnancies of 13-21 weeks of amenorrhea undergoing legally induced abortion in one Scottish NHS hospital.

METHODS

Each woman received a single oral dose of mifepristone 200 mg and 36-48 h later vaginal misoprostol 800 microg. Three hours following the first dose of misoprostol, 400 microg doses were administered orally at three hourly intervals, to a maximum of four doses. Success was defined as abortion occurring with five doses of prostaglandin, or within 15 h of administration of the first dose of prostaglandin.

RESULTS

Ninety-seven percent aborted successfully. The median dose of misoprostol required was 1200 microg and the median induction-to-abortion interval after first prostaglandin administration was 6.5 h. The median number of doses of misoprostol required to induce abortion, and the induction-to-abortion interval, was statistically significantly higher among women at gestations 17-21 weeks than among those at 13-16 weeks (P = 0.0001). A total of 9.4% required surgical evacuation of the uterus under general anaesthesia and 66.4% of the women were managed as day cases.

CONCLUSIONS

The combination of oral mifepristone 200 mg followed by vaginally and orally administered misoprostol provides a noninvasive and effective regimen for second trimester termination of pregnancy.

Second trimester abortion using intravaginal misoprostol

OBJECTIVE

To find the effective dose of intravaginal misoprostol to induce second trimester abortion.

METHODS

Intravaginal misoprostol in 200-microg, 400-microg and 600-microg doses were applied at 12-h intervals in 150 consecutive pregnancies.

RESULTS

The 48-h successful abortion rate was 70.6%, 82% and 96%, respectively, and these rates were unaffected by parity. The mean induction to abortion interval was 45.0 +/- 41.5, 33.4 +/- 34.9 and 22.3 +/- 14.3 h, respectively. The mean dose of misoprostol required to induce abortion was 416.7 microg, 772.8 microg and 1296 microg. The rate of nausea and vomiting was 3.9%, 12% and 20%. The diarrhea occurrence rate was 0%, 6% and 22% with temperature elevation 0%, 2% and 28%, respectively. The rate of incomplete abortion was 35.3%, 28% and 22%, respectively.

CONCLUSION

The 600-microg dose is more effective as an abortifacient agent for second trimester abortion in terms of 48-h success rate and the rate of incomplete abortion but with more side effects. However, the side effects were mild and did not warrant any specific treatment.

Termination of 2nd and 3rd trimester pregnancies with mifepristone and misoprostol

OBJECTIVE

The purpose of this study was to evaluate our use of the association of mifepristone and misoprostol for terminating second and third trimester pregnancies.

STUDY DESIGN

One hundred and six patients undergoing termination of pregnancy between January 1993 and June 1995 in our center were studied. Each patient received 600 mg of mifepristone followed 24 h later by 400 microgrammes of misoprostol every 6 h.

RESULTS

The average interval from the first administration of misoprostol to expulsion was 12.5 +/- 7.5 h (interval markedly decreased to 9.6 +/- 6.3 h in cases of intrauterine fetal death).

CONCLUSION

The efficacy of the association of mifepristone and misoprostol is comparable with that of current regimens with grealer ease of utilization and at a much lower cost.

Impact of the introduction of new medical methods on therapeutic abortions at the Royal Infirmary of Edinburgh

OBJECTIVE

To assess the impact of the introduction of new medical methods on the provision of therapeutic abortions at the Royal Infirmary Edinburgh.

DESIGN

A review of the total number of abortions performed by medical and surgical means between 1989 and 1995 (inclusive); a prospective survey of the terminations of pregnancy (< or = 9 weeks of gestation) performed over the six-month period of January to June 1994; and a questionnaire of the reasons why women chosen a particular method.

SETTING

Large teaching hospital in Scotland.

SUBJECTS

One thousand and seven women seeking early pregnancy termination between January and June 1994.

MAIN OUTCOME MEASURES

Proportion of pregnancies terminated by medical means; comparison of complete abortion rate, incidence of complications and morbidity following both medical and surgical methods (< or = 9 weeks of gestation); reasons for preference of the method of abortion.

RESULTS

Since 1991 there has been a progressive increase in the number of medical abortions performed at the Royal Infirmary of Edinburgh, and by 1994 the majority of women (57%) seeking abortion at < or = 9 weeks chose a medical method. Women who chose medical abortion had more years at full-time education and were less likely to smoke (P < 0.04). Both medical and surgical methods were highly effective (> 96% complete abortion) with a low incidence of complications and morbidity. However, women who had chosen the medical method were less likely to receive antibiotics for suspected endometritis than their surgical counterparts (chi 2, P = 0.0001).

CONCLUSIONS

If this trend towards medical methods in Edinburgh is repeated elsewhere, it will inevitably have an impact on gynaecological services by releasing staff and operating time for other purposes.

Prolonged induction to delivery time in termination of pregnancy using 16, 16-dimethyl-PGE1-methyl ester (gemeprost) for fetuses with a neural tube defect or hydrocephalus

A retrospective study is reported comparing the induction to delivery interval using gemeprost for termination of pregnancy, in the second trimester, in 3 groups of patients. It was observed that the mean induction to delivery interval was significantly longer in 75 pregnancies where there was a fetus with a neural tube defect and or hydrocephalus (31.7 hours) compared with 88 pregnancies with other fetal abnormalities (19.7 hours) and 84 pregnancies where there was an intrauterine death (11.3 hours). There was also an increase in the requirements for further intervention to obtain delivery in the group with a neural tube defect or hydrocephalus (n = 33) compared with where there was an intrauterine fetal death (n = 4) and other abnormality (n = 14). We believe these results should be considered when counselling patients who have requested termination of pregnancy for fetal abnormalities.

A randomised study of two doses of gemeprost in combination with mifepristone for induction of abortion in the second trimester of pregnancy

Two regimens of the prostaglandin E1 analogue, gemeprost, in combination with mifepristone were compared in a randomised trial for termination of pregnancy between 12-19 weeks. Thirty-six hours after treatment with 200 mg mifepristone, women were allocated at random to receive either 4 x 1 mg (Group I) or 4 x 0.5 mg (Group II) gemeprost by vaginal pessary every 6 hours (n = 50 in each group). If abortion had not occurred after 24 h, 5 x 1 mg of gemeprost was administered every 3 h to both groups of women. Although the median abortion interval was slightly shorter in the 1 mg group (7.8 h vs. 8.4 h, p = 0.5), the cumulative abortion rates at 24 h were similar (98% vs. 96%). Women in Group I required significantly more gemeprost to induce abortion than Group II (p < 0.0001). Parous women in both groups required significantly less of the prostaglandin to induce abortion. In Group II, the median abortion interval was significantly longer in primigravidae than multigravidae (9.5 h vs. 6.1 h; p < 0.02). There were no significant differences between the groups in the incidence of vomiting, diarrhoea or the request for analgesia. The results suggest that in parous women, the dose of gemeprost can be reduced to 0.5 mg every 6 h within the first 24 h without loss of clinical efficacy.

Termination of second trimester pregnancy with gemeprost and misoprostol: a randomized double-blind placebo-controlled trial

A prospective randomized double-blind placebo-controlled trial was conducted in 70 subjects to determine whether pre-treatment with misoprostol could facilitate termination of second trimester pregnancy by gemeprost. The women received either 400 micrograms oral misoprostol or placebo tablets 12 hours before the administration of vaginal pessary of gemeprost 1 mg every 3 hours. There were no significant differences in induction-abortion interval and the amount of gemeprost required between the misoprostol and the placebo group. There was no significant difference in the incidence of side effects or analgesic requirement between the two groups. We conclude that oral misoprostol is not useful in facilitating termination of second trimester pregnancy by gemeprost.

A comparison of 600 and 200 mg mifepristone prior to second trimester abortion with the prostaglandin misoprostol

OBJECTIVE

To compare the use of 600 and 200 mg mifepristone prior to second trimester termination of pregnancy with the prostaglandin misoprostol.

DESIGN

A randomised study.

SETTING

A Scottish teaching hospital.

PARTICIPANTS

Seventy women undergoing legal induced abortion between 13 and 20 weeks of gestation.

INTERVENTION

Administration of either 600 or 200 mg mifepristone 36 to 48 hours prior to prostaglandin.

MAIN OUTCOME MEASURE

Induction-abortion interval.

RESULTS

The geometric mean induction abortion interval was 6.9 (95% CI 5.8-8.4) h and 6.9 (95% CI 5.8-8.2) h in the 600 and 200 mg groups, respectively (no significant difference). The median dose of misoprostol was 1600 micrograms (three doses) in each group. Analgesic requirements and prostaglandin-related side effects were similar between groups. Overall, 11.4% of women required surgical evacuation of the uterus as a result of retained placenta.

CONCLUSIONS

The dose of mifepristone used in second trimester abortion can be reduced from 600 to 200 mg.