Mifepristone followed by home administration of buccal misoprostol for medical abortion up to 70 days of amenorrhoea in a general practice in Curaçao

Brief of over 300 reproductive health researchers as Amici Curiae in FDA v. Alliance for Hippocratic Medicine

On January 30, 2024, over 300 researchers filed an amicus brief in FDA v. Alliance for Hippocratic Medicine, a United States (US) Supreme Court case that could have severely impacted access to mifepristone, one of the two drugs commonly used in medication abortion. The researchers summarize the legal challenges to the US Food and Drug Administration's (FDA's) original approval of mifepristone in 2000 and its 2016 and 2021 decisions modifying mifepristone's Risk Evaluation and Mitigation Strategy (REMS) Program and label, the responses from the FDA and drug manufacturer to the challenges, and the potential implications of the Court's decision on access to mifepristone in the US. The researchers detail how the FDA relied on a robust scientific record analyzing tens of thousands of patient experiences that conclusively demonstrated the safety and effectiveness of the changes to the mifepristone REMS Program and label and urge the Supreme Court to rely on the clear scientific record and preserve access to mifepristone without reimposing restrictions. What follows is a reprint of this brief.

Misoprostol-Induced Fever and Unnecessary Antibiotic Prescribing: A Retrospective Study

INTRODUCTION

Misoprostol is widely used for medication abortion and postpartum hemorrhage. However, it has been associated with the adverse effect of fever, which can pose challenges in management and potentially contribute to unnecessary antibiotic use. The incidence of misoprostol-induced fever in the context of medical abortion has not been extensively studied.

METHODS

This retrospective cohort study aimed to determine the incidence of fever following misoprostol administration at a tertiary care hospital in Saudi Arabia. The study included female patients who received misoprostol for pregnancy termination or management of missed or incomplete abortion between January 2017 and December 2019. Data on demographics, misoprostol dosage and route, fever characteristics, outcome of abortion, and antibiotic use were collected. Statistical analysis was preformed using appropriate tests.

RESULTS

A total of 213 patients were included in the study. The incidence of fever post-misoprostol administration was 8%. Patients who developed fever had a higher gestational age and received higher doses of misoprostol. However, no significant associations were found between other patient variables and fever incidence. Antibiotic therapy was administered to a almost half of the patients who developed fever post-misoprostol but was determined to be unnecessary in all cases.

CONCLUSION

This study contributes to the understanding of misoprostol-induced fever in the context of medical abortion. Further research is needed to explore strategies for reducing unnecessary antibiotic use in this population.

First trimester abortion protocols by facility type in Switzerland and potential barriers to accessing the service

Simplified first-trimester abortion protocols are well established. However, data on the use of medical or surgical abortion protocols across Switzerland is lacking. We report protocol characteristics in abortion care for two different facility types, hospital vs private practices (office-based) in Switzerland. Furthermore, we investigate an association between protocol characteristics and the likelihood of following through with the abortion at the same facility. We also report abortion outcomes of an office-based cohort where doctors use simplified abortion protocols. This study consists of two parts. (i) Between April and July, 2019, we collected data regarding medical and surgical abortion protocols of institutions offering abortions, in a nationwide survey. We assessed whether the proportion of patients who followed through with the abortion (primary outcome) after first appointment was associated with predefined protocol characteristics, considered to complicate access to abortion services, using generalised estimating equations. (ii) We analysed abortion outcomes of six selected office-based facilities from January, 2008, to December, 2018, using simplified abortion protocols in accordance with the Worlds Health Organisation (WHO) guidelines. (i) We included a total of 39 institutions. Hospitals showed more protocol-based barriers to abortion access compared with office-based facilities. The odds of undergoing an abortion after the first appointment were increased using protocols with minimal barriers. Overall, office-based facilities applied higher gestational age limits, required fewer appointments, and administered mifepristone more often after the first visit than did hospitals. (ii) We included a total of 5274 patients with an incidence of complications requiring surgery of 2.5% in line with rates reported in published literature. Only a few hospitals provide abortion care with easy access to medical and surgical abortion, whereas most office-based facilities do. Access to abortion services is generally crucial, and should be provided in a single visit whenever clinically permissible.

Short-term efficacy and safety of early medical abortion in Japan: A multicenter prospective study

Purpose

To evaluate the short-term efficacy and safety of a combined mifepristone-misoprostol regimen in individuals seeking medical abortion at up to 63 days of gestational age.

Methods

This open-label, multicenter, prospective study evaluated the short-term efficacy and safety of medical abortion, with the primary outcome being the abortion success rate 24 h after misoprostol administration. The participants received 200 mg of mifepristone orally and 800 μg of misoprostol buccally in the hospital/clinic 36-48 h later. Bleeding and lower abdominal pain, which are the main symptoms associated with medical abortion, were recorded.

Results

The abortion success rate was 93.3% (95% confidence interval [CI]: 87.3-97.1%) within 24 h of misoprostol administration, 63.3% (95% CI: 54.05-71.94%) within 4 h, and 90.0% (95% CI: 83.18-94.73%) within 8 h. The median time from misoprostol administration to a successful abortion was 3.93 h. Bleeding was most commonly observed 0-4 h prior to the confirmation of gestational sac (GS) expulsion. The most intense lower abdominal pain occurred 0-1 h before the confirmation of GS expulsion.

Conclusion

The combined regimen of mifepristone and buccal misoprostol for medical abortion showed short-term efficacy and a favorable safety profile.

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.

Outcomes During Early Implementation of Mifepristone-Buccal Misoprostol Abortions up to 63 Days of Gestation in a Canadian Clinical Setting

OBJECTIVE

In January 2017, mifepristone became available in Canada. The goal of this study was to determine the effectiveness and safety of mifepristone-misoprostol abortion during its early implementation in a Canadian setting.

METHODS

This retrospective chart review included the first 477 patients who had a mifepristone-misoprostol abortion from March 13 to October 31, 2017, in an urban sexual health clinic. Women with pregnancies up to 63days of gestation had an initial dating ultrasound and β-human chorionic gonadotropin determination. They were provided mifepristone 200 mg orally in clinic, followed 24-48hours later with misoprostol 800 µg buccally at home. Follow-up, 7-14days later, in clinic or by telephone, used symptom review and follow-up β-human chorionic gonadotropin or ultrasound. The primary outcome was successful abortion, defined as expulsion of pregnancy without uterine aspiration.

RESULTS

Of 477 consecutive mifepristone abortions, 422 women (88.5%) had documented follow-up, with 408 (96.7%) successful abortions, including eight in women who had a repeat dose of misoprostol. Fourteen (3.3%) unsuccessful abortions required uterine aspiration, two (0.5%) for ongoing pregnancy and 12 (2.8%) for incomplete abortion or persistent bleeding. Seventeen women (4.0%) had emergency department visits, one (0.2%) of whom was hospitalized and three (0.7%) of whom received blood transfusion. Four women (1.0%) were treated for infection.

CONCLUSION

Mifepristone-misoprostol medical abortion was safe and effective during early implementation in Canada, comparable to previously published outcomes.

Safety, efficacy and acceptability of outpatient mifepristone-misoprostol medical abortion through 70 days since last menstrual period in public sector facilities in Mexico City

Extensive evidence exists regarding the efficacy and acceptability of medical abortion through 63 days since last menstrual period (LMP). In Mexico City's Secretariat of Health (SSDF) outpatient facilities, mifepristone-misoprostol medical abortion is the first-line approach for abortion care in this pregnancy range. Recent research demonstrates continued high rates of complete abortion through 70 days LMP. To expand access to legal abortion services in Mexico City (where abortion is legal through 12 weeks LMP), this study sought to assess the efficacy and acceptability of the standard outpatient approach through 70 days in two SSDF points of service. One thousand and one women seeking pregnancy termination were enrolled and given 200 mg mifepristone followed by 800 μg misoprostol 24-48 hours later. Women were asked to return to the clinic one week later for evaluation. The great majority of women (93.3%; 95% CI: 91.6-94.8) had complete abortions. Women with pregnancies ≤ 8 weeks LMP had significantly higher success rates than women in the 9th or 10th weeks (94.9% vs. 90.5%; p = 0.01). The difference in success rates between the 9th and 10th weeks was not significant (90.0% vs. 91.2%; p = 0.71). The majority of women found the side effects (82.9%) and the use of misoprostol (84.4%) to be very acceptable or acceptable. This study provides additional evidence supporting an extended outpatient medical abortion regimen through 10 weeks LMP.

Efficacy, Safety, and Acceptability of Low-Dose Mifepristone and Self-Administered Misoprostol for Ultra-Early Medical Abortion: A Randomized Controlled Trial

The aim of this study was to investigate the efficacy, safety, and acceptability of low-dose mifepristone combined with self-administered misoprostol for ultra-early medical abortion. A total of 744 women with ultra-early pregnancy (amenorrhea ≤35 days) who fulfilled the inclusion criteria were enrolled in the study. Equal numbers of participants were allocated randomly to the hospital administration and self-administration groups. All participants took 75 mg mifepristone at the initial visit and 400 µg oral misoprostol 24 hours later in the hospital or by self-administration. The primary end point was complete abortion. Secondary end points were rates of unscheduled reattendance, time required for and cost of hospital observation and follow-up, vaginal bleeding, adverse effects, menstrual disturbance in the posttreatment period, and satisfaction rating. No differences in the rates of complete abortion, unscheduled reattendance, vaginal bleeding, adverse effects, or return of posttreatment menstruation were observed. The time required for (and costs of) hospital observation and follow-up per participant was 557.82 minutes (and US$40.12) in the hospital administration group and 18.46 minutes (and US$1.96) in the self-administration group (both P < .001). Satisfaction rates were similar in both groups, but the rates of "very satisfied" responses (87.60% vs 25.41%) and follow-up compliance (loss to follow-up, 0.45% vs 7.70%) were higher in the self-administration group (both P < .001). Low-dose mifepristone combined with self-administered misoprostol for ultra-early pregnancy termination was as effective and safe as hospital administration, with greater acceptability and lower cost to the women.

Medical Abortion

OBJECTIVE

This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.

INTENDED USERS

Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.

TARGET POPULATION

Women with an unintended first trimester pregnancy.

EVIDENCE

Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).

BENEFITS, HARMS AND/OR COSTS

Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.

SUMMARY STATEMENTS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care

RECOMMENDATIONS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.

Mifepristone With Buccal Misoprostol for Medical Abortion: A Systematic Review

OBJECTIVE

To summarize clinical outcomes and adverse effects of medical abortion regimens consisting of mifepristone followed by buccal misoprostol in pregnancies through 70 days of gestation.

DATA SOURCES

We used PubMed, ClinicalTrials.gov, and reference lists from published reports to identify relevant studies published between November 2005 and January 2015 using the search terms "mifepristone and medical abortion" and "buccal and misoprostol."

METHODS OF STUDY SELECTION

Studies were included if they presented clinical outcomes of medical abortion using mifepristone and buccal misoprostol through 70 days of gestation. Studies with duplicate data were excluded.

TABULATION, INTEGRATION, AND RESULTS

We included 20 studies with a total of 33,846 women through 70 days of gestation. We abstracted efficacy and ongoing pregnancy rates as an overall rate and by gestational age in days in reference to completed weeks (eg, 49 days or less, 50-56 days, 57-63 days, 64-70 days) and adverse effects when reported. The overall efficacy of mifepristone followed by buccal misoprostol is 96.7% (95% confidence interval [CI] 96.5-96.8%) and the continuing pregnancy rate is 0.8% (95% CI 0.7-0.9%) in approximately 33,000 pregnancies through 63 days of gestation. Only 332 women with pregnancies between 64 and 70 days of gestation are reported in the literature with an overall efficacy of 93.1% (95% CI 89.6-95.5%) and a continuing pregnancy rate of 2.9% (95% CI 1.4-5.7%). Currently available data suggest that regimens with a 24-hour time interval between mifepristone and buccal misoprostol administration are slightly less effective than those with a 24- to 48-hour interval. Rates of surgical evacuation for reasons other than ongoing pregnancy range from 1.8% to 4.2%. Severe adverse events like blood transfusion (0.03-0.6%) and hospitalization (0.04-0.9%) are uncommon.

CONCLUSION

Outpatient medical abortion regimens with mifepristone followed in 24-48 hours by buccal misoprostol are highly effective for pregnancy termination through 63 days of gestation. More data are needed to evaluate clinical outcomes with regimens containing mifepristone followed in 24 hours by buccal misoprostol and in pregnancies beyond 63 days of gestation.

Adolescent Girls and Abortion

Abortion is an extremely common procedure in the United States, with approximately 2% of women having an abortion before age 19 years. Although most pediatricians do not provide abortions, many will care for a young woman who is either considering an abortion or has already had one; therefore, the pediatrician should be able to provide accurate and appropriate counseling about this option. To provide the best care for adolescent patients considering abortion, pediatricians must be knowledgeable of aspects of abortion that are universal to all women and have an understanding of considerations specific to the adolescent patient. The purpose of this article is to (1) review recent statistics about teenagers and abortion, (2) explain the different types of abortion available to teenagers who desire to terminate an unwanted pregnancy, (3) discuss aspects of abortion unique to the adolescent population, such as insurance coverage and parental involvement laws, and (4) address common misconceptions about abortion. [Pediatr Ann. 2015;44(9):384-385,388,390,392.].

Reaching women where they are: eliminating the initial in-person medical abortion visit

The requirement that every woman desiring medical abortion must come in person to a clinical facility to obtain the drugs is a substantial barrier for many women. To eliminate this requirement in the United States, two key components of the standard initial visit would need to be restructured. First, alternatives to ultrasound and pelvic exam would need to be identified for ensuring that gestational age is within the limit for safe and effective treatment. This is probably feasible: for example, data from a large study suggest that in selected patients menstrual history is highly sensitive for this purpose. Second, the Food and Drug Administration would need to remove the medically unwarranted restriction on distribution of mifepristone. These two changes could allow provision of the service by a broader range of providers in nontraditional venues or even by telemedicine. Such options could have profound benefits in reducing cost and expanding access to abortion.

An overview of medical abortion for clinical practice

Medical abortion is a safe, convenient, and effective method for terminating an early unintended pregnancy. Medical abortion can be performed up to 63 days from the last menstrual period and may even be used up to 70 days for women who prefer medical abortion over surgical abortion. Counseling on the adverse effects and expectations for medical abortion is critical to success. Medical abortion can be performed in a clinic without special equipment, and it is perceived as more "natural" than a surgical abortion by many women. Follow-up for medical abortion can be simplified to include only serum human chorionic gonadotropin measurements when necessary, although obtaining an ultrasound remains the criterion standard. Pain associated with medical abortion is best treated with nonsteroidal anti-inflammatory medications, possibly in combination with opioid analgesics. Medical abortion can contribute to continuity of care for women who wish to remain with their primary care providers for management of their abortion.

Women's satisfaction with early home medical abortion with telephone follow-up: a questionnaire-based study in the U.K

A questionnaire-based study was undertaken to assess women's satisfaction with the home medical abortion service. Over a 15-month period, questionnaires were conducted at 24 h and 2 weeks following the procedure. A total of 127 women took part in the study and filled in a questionnaire at 24 h, with 77 completing the questionnaire at 2 weeks. At 24 h, over 95% of women who responded, agreed or strongly agreed that they felt prepared for the pain and bleeding that they experienced at home. At 2 weeks, 97.3% of respondents felt that they had had enough information and knew what to expect, and were therefore satisfied with the procedure. Only 15% of women were lost to clinical follow-up at 2 weeks. The majority of women are satisfied with the home medical abortion service. These high satisfaction rates are maintained at 2 weeks. Telephone follow-up 2 weeks after the abortion was safe and effective.

Knowledge and provision practices regarding medical abortion among public providers in Hanoi, Khanh Hoa, and Ho Chi Minh City, Vietnam

OBJECTIVE

To assess public service providers' knowledge of medical abortion (MA) and practices, and perspectives on expanding the use of MA to primary and secondary health facilities in Vietnam.

METHODS

A cross-sectional study was conducted via an interviewer-administered questionnaire among abortion providers (n=905) from public health facilities between August 2011 and January 2012.

RESULTS

Overall, 31.1% of providers performed both surgical and medical abortions; 68.9% offered only surgical abortion. Providers were knowledgeable about the regimen/dosage of mifepristone plus misoprostol regimen; however, knowledge scores were low for gestational age limits for MA, adverse effects of the combined drug regimen, and safety and effectiveness of MA compared with surgical abortion. Knowledge scores were significantly lower among providers in rural areas than among those in urban settings. A large proportion of providers (82.9%) thought that MA should be expanded to primary and secondary health facilities. Perceived barriers to MA expansion included lack of knowledge and training, qualified staff, adequate drug supplies, equipment, or facilities, guidelines and protocols on MA, and patient awareness.

CONCLUSION

Provision of MA in Vietnam was found to be disproportionate to surgical abortion provision and to vary by region. Knowledge of MA was moderate, but poorer among providers in rural settings.

Efficacy and acceptability of early mifepristone-misoprostol medical abortion in Ukraine: results of two clinical trials

BACKGROUND

Abortion services are legally available in Ukraine although there are issues in quality and access. Two studies were conducted in Ukraine to expand options for women, and to determine the efficacy and acceptability of medical abortion.

STUDY DESIGN

Two open-label clinical trials were conducted at six clinics in Ukraine. Women were given 200 mg mifepristone followed after 48 hours by 400 μg oral misoprostol (Study One) and mifepristone followed after 24 hours by 400 μg sublingual misoprostol (Study Two). Follow-up visits were scheduled for two weeks after mifepristone administration to assess whether complete uterine evacuation had occurred.

RESULTS

Success rates were 97% in the first study and 98% in the second one. The vast majority of participants were satisfied or very satisfied with their abortion method (Study One: 94%; Study Two: 98%).

CONCLUSIONS

The two studies demonstrate high rates of success and acceptability of early medical abortion in Ukraine.

Medical abortion service in rural areas of Henan Province, China: a provider survey

AIM

The aim of this study was to explore the knowledge, attitudes and practices on medical abortion of abortion service providers in rural areas of China.

MATERIAL AND METHODS

A cross-sectional study via self-administered questionnaire was conducted among 362 abortion service providers from family planning service centers (FPSC) and hospitals in rural areas of Henan Province, China, between November 2009 and May 2010.

RESULTS

Most of the providers were female (99.4%) and obstetricians/gynecologists (63.3%). The knowledge score achieved ranged from 9.4 to 78.1 points, with both the median and the mode of 56.3 points. Of the 52.2% (189/362) of providers having a preference on abortion method, 30.2% (57/189) preferred medical abortion, while 69.8% (132/189) preferred surgical abortion. In total, 50.7% (174/343) of the providers indicated the provision of medical abortion should be expanded, with the three biggest challenges in its further expansion being increased complications/failures, poor client knowledge/awareness, and problems with drug/equipment supplies. Of all the providers, 81.7% and 92.2% reported they had experience in providing medical abortion and surgical abortion, respectively. Medical abortion providers were mainly experienced in misoprostol with oral (81.8%)/vaginal (79.6%) prostaglandin (misoprostol/gemeprost).

CONCLUSION

Knowledge on medical abortion of providers working in rural China was at a moderate level. Providers preferred surgical abortion to medical abortion. Providers have more experience in providing surgical abortion than medical abortion. Efforts should be made to overcome the perceived challenges in future expansion of medical abortion.

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.