Deaths and Severe Adverse Events after the use of Mifepristone as an Abortifacient from September 2000 to February 2019

OBJECTIVES

Primary: Analyze the Adverse Events (AEs) reported to the Food and Drug Administration (FDA) after use of mifepristone as an abortifacient. Secondary: Analyze maternal intent after ongoing pregnancy and investigate hemorrhage after mifepristone alone.

METHODS

Adverse Event Reports (AERs) for mifepristone used as an abortifacient, submitted to the FDA from September 2000 to February 2019, were analyzed using the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAEv3).

RESULTS

The FDA provided 6158 pages of AERs. Duplicates, non-US, or AERs previously published (Gary, 2006) were excluded. Of the remaining, there were 3197 unique, US-only AERs of which there were 537 (16.80%) with insufficient information to determine clinical severity, leaving 2660 (83.20%) Codable US AERs. (Figure 1). Of these, 20 were Deaths, 529 were Life-threatening, 1957 were Severe, 151 were Moderate, and 3 were Mild.

The deaths included: 9 (45.00%) sepsis, 4 (20.00%) drug toxicity/overdose, 1 (5.00%) ruptured ectopic pregnancy, 1 (5.00%) hemorrhage, 3 (15.00%) possible homicides, 1 (5.00%) suicide, 1 (5.00%) unknown. (Table 1).

Retained products of conception and hemorrhage caused most morbidity. There were 75 ectopic pregnancies, including 26 ruptured ectopics (includes one death).

There were 2243 surgeries including 2146 (95.68%) D&Cs of which only 853 (39.75%) were performed by abortion providers.

Of 452 patients with ongoing pregnancies, 102 (22.57%) chose to keep their baby, 148 (32.74%) had terminations, 1 (0.22%) miscarried, and 201 (44.47%) had unknown outcomes.

Hemorrhage occurred more often in those who took mifepristone and misoprostol (51.44%) than in those who took mifepristone alone (22.41%).

CONCLUSIONS

Significant morbidity and mortality have occurred following the use of mifepristone as an abortifacient. A pre-abortion ultrasound should be required to rule out ectopic pregnancy and confirm gestational age. The FDA AER system is inadequate and significantly underestimates the adverse events from mifepristone.

A mandatory registry of ongoing pregnancies is essential considering the number of ongoing pregnancies especially considering the known teratogenicity of misoprostol.

The decision to prevent the FDA from enforcing REMS during the COVID-19 pandemic needs to be reversed and REMS must be strengthened.

The "Abortion Pill" Misoprostol in Brazil: Women's Empowerment in a Conservative and Repressive Political Environment

In the aftermath of the introduction of severe restrictions on abortion in several US states, some activists have argued that providing widespread access to an abortive drug, misoprostol, will transform an induced abortion into a fully private act and therefore will empower women. In Brazil, where abortion is criminalized, the majority of women who wish to terminate an unwanted pregnancy already use the illegal, but easily accessible, misoprostol. We examine the history of misoprostol as an abortifacient in Brazil from the late 1980s until today and the professional debates on the teratogenicity of this drug. The effects of a given pharmaceutical compound, we argue, are always articulated, elicited, and informed within dense networks of sociocultural, economic, legal, and political settings. In a conservative and repressive environment, the use of misoprostol for self-induced abortions, even when supported by formal or informal solidarity networks, is far from being a satisfactory solution to the curbing of women's reproductive rights.

Label comprehension of a combined mifepristone and misoprostol product for medical abortion: A pilot study in South Africa

OBJECTIVES

As an important next step in developing an over-the-counter (OTC) misoprostol-mifepristone product, this study aims to assess the comprehension of a medical abortion label.

STUDY DESIGN

We conducted a pilot study utilizing convenience sampling to enroll women in rural and urban communities at four sites in two South African provinces. Trained, female recruiters prescreened and consented potential participants. Included women were aged 16-45 with some literacy (assessed by Rapid Estimate of Adult Literacy in Medicine). Exclusion criteria were having ever used or assisted someone with a medical abortion. Demographic data were collected after enrolment. We gave women time to read the prototype label, then asked a series of 35 questions to assess key concepts for correct use of the drug. For all questions but the indication, women could refer to the label while answering. We used descriptive, chi-square and regression analyses to assess comprehension of concepts.

RESULTS

100 women aged 16-45 years participated. Most reported prior sexual intercourse (91%), pregnancy (75%), and prior contraceptive use (male condom, 45%). Messages clear to participants (>90%) regardless of literacy were: when to consult a doctor before use (history of anemia or ectopic pregnancy), to respect the mifepristone- misoprostol interval, when to seek medical attention (heavy, prolonged or no bleeding) and that fertility returns quickly after abortion. The average scores were moderate for comprehension of all medical abortion label comprehension concepts: 79% for questions about the indication of the product; 73% for assessment of appropriate gestational age; 76% for screening out ectopic pregnancy; 80% for identifying contraindications to the medicines; 69% for instructions on use; 76% for when and for what conditions to seek medical care; and 60% for how to follow-up after abortion with a pregnancy test. Questions with lowest comprehension regarded medication timing, where women with higher literacy were significantly more likely to understand the label than among lower literacy levels.

CONCLUSIONS

Our prototype over-the-counter label for a combined mifepristone-misoprostol product for medical abortion in early pregnancy was moderately understandable to participants. Comprehension scores were largely dependent on literacy levels. To demonstrate an understanding of at least 80% for key concepts, the prototype label for a combined medical abortion product requires revision.

Early medical abortion with self-administered low-dose mifepristone in combination with misoprostol

AIM

The aim of the present study was to investigate the safety and efficacy of low-dose mifepristone combined with self-administered misoprostol for termination of early pregnancy.

METHODS

A total of 533 women seeking medical abortion in early pregnancy (≤49 days since the last menstrual period) were divided randomly into hospital- (H-Mis, 250) and self- (S-Mis, 283) administered misoprostol groups. Women in two groups took 100 mg of oral mifepristone in hospital followed by 200 μg of sublingual misoprostol 24 h later in hospital or home. The primary outcome parameter was complete abortion without surgical intervention. Secondary outcomes were uterine bleeding, return of regular menses, side effects and patient acceptability.

RESULTS

High rates of complete abortion were observed for both the H-Mis group (243/250; 94.8%) and the S-Mis group (266/283; 94.0%). No significant differences in outcomes (complete abortion/failure rates) or side effects were observed between the two groups. General satisfaction rates were similar for the two groups (H-Mis, 231/250, 92.4%; S-Mis, 263/283, 92.9%; P > 0.05). Higher convenience of administration (H-Mis, 211/250, 84.4%; S-Mis, 270/283, 95.4%; P < 0.05) and privacy protection (H-Mis, 214/250, 85.6%; S-Mis, 267/283, 94.3%; P < 0.05) satisfaction rates were obtained for the S-Mis group than for the H-Mis group.

CONCLUSION

Self-administered sublingual misoprostol is as safe and effective as hospital-administered misoprostol following low-dose mifepristone to terminate early pregnancy (≤49 days of amenorrhoea) with fewer side effects.

Changes in the rumen bacterial microbiome of cattle exposed to ponderosa pine needles

Consumption of ponderosa pine needles, as well as needles and bark from a number of other trees, can cause abortions in cattle. The abortifacient compounds in these trees are labdane resin acids, including isocupressic acid and agathic acid. Previous research has demonstrated that cattle conditioned to pine needles metabolize the labdane resin acids more quickly than naïve cattle. The results from that study indicated that changes had occurred in the rumen of conditioned cattle. Therefore, in this study, the changes that occurred in the rumen bacterial microflora of cattle during exposure to ponderosa pine needles were evaluated. Cattle were dosed with ground pine needles twice daily for 7 d. Rumen samples were collected on d 0, 3, 7, and 14 (7 d after treatment stopped) and ruminal bacterial microbiome analyses were performed. There were 372 different genera of bacteria identified in the rumen samples. Principal coordinate analysis indicated that there was a significant difference in the rumen bacterial composition between the time points. There were 18 genera that increased in abundance from d 0 to d 7. Twenty three genera decreased in abundance from d 0 to d 7. The results from this study demonstrated that exposure of cattle to pine needles caused a clear shift in the rumen microbiome composition. In general, this shift lasted less than 1 wk post exposure, which indicates that any prophylactic treatment to manipulate the ruminal metabolism of the abortifacient compounds in pine needles would need to be continuously administered to maintain the necessary microbial composition in the rumen.

Potassium chloride-induced fetal demise: a retrospective cohort study of efficacy and safety

OBJECTIVES

Induction of fetal demise before second-trimester termination is performed for a number of reasons. One method for inducing fetal demise is via sonographically guided intracardiac potassium chloride (KCl) injection. We performed a retrospective cohort study to determine the efficacy and safety of intracardiac KCl injection as a method of second-trimester induced fetal demise.

METHODS

We reviewed records from patients who were referred for induced fetal demise from October 2002 to October 2011. We excluded patients undergoing selective fetal reduction in multiple gestations. Procedural complications, the dose of KCl, and the number of failed procedures were determined.

RESULTS

Of the 192 completed procedures, 191 were successful (99.5%). The median gestational age at termination was 22 weeks (range, 15.4-24.9 weeks), and most terminations were surgical (68.0%). Major indications for termination were fetal anomalies (41.6%), unwanted pregnancy (20.8%), and aneuploidy (15.7%). The median dose of KCl was 10 mL (range, 3-40 mL). We found a significant correlation between the dose of KCl and estimated fetal weight. There was no significant correlation between the dose of KCl and body mass index or gestational age. We had 1 maternal complication of a seizure after needle placement but before KCl injection.

CONCLUSIONS

Intracardiac KCl injection is an effective and safe method for induced fetal demise.

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.

Medical abortions in adolescent girls

According to a retrospective Finnish study, the adverse effects of medical abortion do not appear more common in girls under the age of 18 years than in adult women.

[The lowest dosages of mifepristone and misoprostol to terminate ultra-early pregnancy]

OBJECTIVE

To explore the lowest effective dosage of mifepristone combined with misoprostol in terminating ultra-early pregnancy.

METHODS

All the cases of ultra-early pregnancy classified by amenorrhea days, β-hCG and vaginal B-ultrasonic were randomly divided into two groups. One hundred cases in G1 group (minimized dosage) were orally administered 25 mg mifepristone once a day for 2 days and combined with 200 µg misoprostol 48 hours later, while 150 mg mifepristone combined with 600 µg misoprostol 48 hours later were given to 100 cases in G2 group (normal dosage). All cases were observed for 6 hours after taking misoprostol and returned for assessment three days later.

RESULTS

None missing. Expulsion of conceptus: G1 and G2 group were 22 (22.0%, 22/100) and 25 (25.0%, 25/100; P > 0.05). Failure rate: cases with incomplete abortion were 1 (1.0%, 1/100) and 2 (2.0%, 2/100) in G1 and G2 group, hospitalization for suspected ectopic pregnancies both was 1 (1.0%). Bleeding: bleeding cases during the administration of mifepristone in G1 and G2 group were 71 (71.0%, 71/100) and 78 (78.0%, 78/100; P > 0.05); the mean bleeding time were (5.3 ± 1.4) days and (6.0 ± 1.5) days (P < 0.01). Other side effects: in G1 group, majority showed light nausea (7.0%, 7/100) and light abdominal pain (20.0%, 20/100). Menses recovery: 99 (99.0%, 99/100) for G1 group and 98 (98.0%, 98/100) for G2 group to recovery on scheduled time. Satisfactions: both were 99 (99.0%, 99/100). Except mean bleeding days and side-effects, the differences above showed no significance (P > 0.05).

CONCLUSION

It is safe and effective treatment with the lowest dosages of mifepristone and misoprostol to terminate ultra-early pregnancies.

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.

Septic shock due to Klebsiella pneumoniae after medical abortion with misoprostol-only regimen

OBJECTIVE

To report a case of a healthy woman who was admitted to the hospital with septic shock caused by a common uropathogen after self-administration of misoprostol for pregnancy termination.

DESIGN

Case report.

SETTING

Tertiary hospital.

PATIENT(S)

A 38-year-old woman, gravida 5, para 3, who developed septic shock after medical termination of pregnancy.

INTERVENTION(S)

Suction curettage, antibiotic treatment, plasma and platelet transfusions.

MAIN OUTCOME MEASURE(S)

Klebsiella pneumoniae was isolated from blood samples.

RESULT

Ten days after her admission she was discharged home in good condition on oral antibiotics.

CONCLUSION(S)

Severe infections leading to septic shock from common pathogen bacteria can occur after medical termination of pregnancy, independently of the regimen used.

Home use of two doses of misoprostol after mifepristone for medical abortion: A pilot study in Sweden and France

OBJECTIVE

To test the feasibility, safety, and efficacy of home use of two doses of misoprostol for medical abortion (MA) in European settings.

METHODS

One hundred thirty women (100 in Sweden, 30 in France) presenting for first-trimester MA were administered oral mifepristone in the clinic and sent home with two 400 microg doses of misoprostol, along with instructions to take the misoprostol at 24 h intervals. Women were also asked to complete a daily symptom diary. Outcomes of interest included effectiveness, side-effects, and adherence to and acceptability of the home-use regimen.

RESULTS

Three women (all in France) were lost to follow-up. Of the remaining 127 women, 124 (98%) had a successful MA. All women adhered successfully to the home-use regimen, and satisfaction with home use was high (98%). Most women experienced noticeable, if transitory, side effects after both the first and second doses of misoprostol (97% and 94%, respectively).

CONCLUSIONS

Misoprostol may successfully and satisfactorily be used at home as part of a MA regimen in European settings as it has been for years in the US. Further research to determine if two doses of misoprostol are more effective than a single dose would be useful.

Outpatient medical management of missed miscarriage using misoprostol

We wanted to evaluate the efficacy, safety and acceptability of misoprostol for outpatient management of missed miscarriage. This was a prospective observational study conducted in the early pregnancy unit of a university teaching hospital involving women attending the unit with a diagnosis of missed miscarriage. All women with a missed miscarriage of <12 weeks' gestation and opting to have medical management were eligible for inclusion. Women who consented to take part were given 800 microg of misoprostol in the unit and advised to take two further doses of 400 microg of misoprostol, orally, 3 h apart, the following day at home. Outcome measures included success rates, emergency admission rates, blood transfusion rates, pain scores, satisfaction scores, incidence rates of side-effects and number of women who would choose medical management in future. Of the 268 women diagnosed as having a missed miscarriage during the study period, 75 (28.0%) opted to have medical management. Over three-quarters (n = 58, 77.3%, 95% confidence interval (CI) 66.2 - 86.2) of the women achieved successful complete medical evacuation. Overall, five (6.7%; 95% CI 2.2 - 14.8) women presented for emergency admission. The mean visual analogue scale (VAS) score of all women was 6.7 (SD = 2.8) and the mean satisfaction score was 8.6 (SD = 2.1). Two-thirds of women (n = 50, 66.7%) said that they would choose to have medical evacuation in a future miscarriage, while seven (9.3%) were unsure. A total of 70 (93.3%) women said they preferred to have the treatment at home rather than in the hospital. We conclude that medical evacuation of missed miscarriage is efficacious, safe and acceptable in the outpatient setting.

Which approach for first trimester miscarriage?

Around 15% of all known pregnancies miscarry during the first trimester. Historically, first trimester miscarriage was managed surgically to remove all retained products of conception, with the aim of minimising the likelihood of blood loss and infection from retained tissue. Nowadays, medical management (use of drugs such as mifepristone and misoprostol) and expectant management (i.e. allowing the miscarriage to conclude naturally) have become alternatives to a surgical procedure for managing women with early miscarriage. Here, we review the evidence on these three methods to assess the benefits and disadvantages of each.

Miscarriage and ectopic pregnancy 2: management

This two-part unit explores miscarriage and ectopic pregnancy. This part, part 2, outlines diagnosis, management and key nursing interventions. It also discusses the emotional impact of pregnancy loss.

Misoprostol and pregnancy: risk of malformations

(1) Misoprostol, a synthetic prostaglandin E1 analogue, is used to treat gastric and duodenal ulcers, and, in combination with mifepristone, for medical abortion. (2) The French and American summaries of product characteristics, based on data submitted to the relevant regulatory agencies, mention no teratogenicity in animals. However, some studies showed malformations in rats and rabbits. (3) Severe malformations have been reported in countries where misoprostol is frequently used for abortion without medical supervision despite its poor efficacy when used alone. The malformations included cranial nerve defects (especially pairs 6 and 7, characteristic of the Möbius syndrome) and various limb abnormalities. (4) Malformations, including one case of Möbius syndrome, have been reported in France after medically supervised use of misoprostol. (5) In practice, when a patient wishes to continue a pregnancy after a failed attempt at drug-induced abortion, she needs to be informed of the risk to her unborn child. Cranial nerve defects are rarely detectable by sonography, however thorough. In addition, misoprostol has a negative risk-benefit balance in the prevention or treatment of gastro-duodenal ulcers in young women.

Surgical versus medical methods for second trimester induced abortion

BACKGROUND

Determining the optimal method of performing second-trimester abortions is important, since they account for a disproportionate amount of abortion-related morbidity and mortality.

OBJECTIVES

To compare surgical and medical methods of inducing abortion in the second trimester of pregnancy with regard to efficacy, side effects, adverse events, and acceptability.

SEARCH STRATEGY

We identified trials using Pub Med, EMBASE, POPLINE, and the Cochrane Central Register of Controlled Trials (CENTRAL). We also searched the reference lists of identified studies, relevant review articles, book chapters, and conference proceedings for additional, previously unidentified studies. We contacted experts in the field for information on other published or unpublished research.

SELECTION CRITERIA

Randomised trials comparing any surgical to any medical method of inducing abortion at >/= 13 weeks' gestation were included.

DATA COLLECTION AND ANALYSIS

We assessed the validity of each study using the methods suggested in the Cochrane Handbook. Investigators were contacted as needed to provide additional information regarding trial conduct or outcomes. Two reviewers abstracted the data. Odds ratios and 95% confidence intervals were calculated for dichotomous variables using RevMan 4.2. The trials did not have uniform interventions, therefore, we were unable to combine them into a meta-analysis.

MAIN RESULTS

Two studies met criteria for this review. One compared dilation and evacuation (D&E) to intra-amniotic instillation of prostaglandin F(2) (alpha). The second study compared D&E to induction with mifepristone and misoprostol. Compared with prostaglandin instillation, the combined incidence of minor complications was lower with D&E (OR 0.17, 95% CI 0.04-0.65) as was the total number of minor and major complications (OR 0.12, 95% CI 0.03-0.46). The number of women experiencing adverse events was also lower with D&E than with mifepristone and misoprostol (OR 0.06, 95% CI 0.01-0.76). Although women treated with mifepristone and misoprostol reported significantly more pain than those undergoing D&E, efficacy and acceptability were the same in both groups. In both trials, fewer subjects randomised to D&E required overnight hospitalisation.

AUTHORS' CONCLUSIONS

Dilation and evacuation is superior to instillation of prostaglandin F(2) (alpha). The current evidence also appears to favour D&E over mifepristone and misoprostol, however larger randomised trials are needed.

Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion

OBJECTIVE

To better understand the risk of fatal toxic shock caused by Clostridium sordellii in women who had a recent medical abortion with mifepristone and misoprostol.

METHODS

We performed active and passive surveillance for cases of toxic shock associated with medical or spontaneous abortion. To identify the cause of toxic shock, immunohistochemical assays for multiple bacteria were performed on formalin-fixed surgical and autopsy tissues. We extracted DNA from tissues, performed Clostridium species-specific polymerase chain reaction assays, and sequenced amplified products for confirmation of Clostridium species.

RESULTS

We report four patients with toxic shock associated with Clostridium species infection after medical or spontaneous abortion. Two women had fatal Clostridium perfringens infections after medically induced abortions: one with laminaria and misoprostol and one with the regimen of mifepristone and misoprostol. One woman had a nonfatal Clostridium sordellii infection after spontaneous abortion. Another woman had a fatal C sordellii infection after abortion with mifepristone and misoprostol. All four patients had a rapidly progressive illness with necrotizing endomyometritis.

CONCLUSION

Toxic shock after abortion can be caused by C perfringens as well as C sordellii, can be nonfatal, and can occur after spontaneous abortion and abortion induced by medical regimens other than mifepristone and misoprostol.

LEVEL OF EVIDENCE

III.

Is misoprostol a safe, effective and acceptable alternative to manual vacuum aspiration for postabortion care? Results from a randomised trial in Burkina Faso, West Africa

OBJECTIVES

Previous research has demonstrated the effectiveness of misoprostol for treatment of incomplete abortion; however, few studies have systematically compared misoprostol's effectiveness with that of standard surgical care. This study documents the effectiveness of a single 600 micrograms dose of oral misoprostol versus manual vacuum aspiration (MVA) for treatment of incomplete abortion in a developing country setting.

DESIGN

Open-label randomised controlled trial.

SETTING

Two university teaching hospitals in Burkina Faso, West Africa.

POPULATION

Women of reproductive age presenting with incomplete abortion.

METHODS

From April 2004 through October 2004, 447 consenting women with incomplete abortion were randomised to either a single dose of 600 micrograms oral misoprostol or MVA for treatment of their condition.

MAIN OUTCOME MEASURE

Completed abortion following initial treatment.

RESULTS

Regardless of treatment assigned, nearly all participants had a complete uterine evacuation (misoprostol = 94.5%, MVA = 99.1%; relative risk [RR] = 0.95 [95% CI 0.92-0.99]). Acceptability and satisfaction ratings were similar and high for both misoprostol and MVA, with three out of four women indicating that the treatment's adverse effects were tolerable (misoprostol = 72.9%, MVA = 75.8%; RR = 0.96 [95% CI 0.86-1.07]). The majority of women were 'satisfied' or 'very satisfied' with the method they received (misoprostol = 96.8%, MVA = 97.7%; RR = 0.99 [95% CI 0.96-1.02]), expressed a desire to choose that method again (misoprostol = 94.5%, MVA = 86.6%; RR = 1.09 [95% CI 1.03-1.16]) and to recommend it to a friend (misoprostol = 94.5%, MVA = 85.2%; RR = 1.11 [95% CI 1.04-1.18]).

CONCLUSION

Six hundred micrograms of oral misoprostol is as safe and acceptable as MVA for the treatment of incomplete abortion. Operations research is needed to ascertain the role of misoprostol within postabortion care programmes worldwide.

Medical abortion and the risk of subsequent adverse pregnancy outcomes

BACKGROUND

The long-term safety of surgical abortion in the first trimester is well established. Despite the increasing use of medical abortion (abortion by means of medication), limited information is available regarding the effects of this procedure on subsequent pregnancies.

METHODS

We identified all women living in Denmark who had undergone an abortion for nonmedical reasons between 1999 and 2004 and obtained information regarding subsequent pregnancies from national registries. Risks of ectopic pregnancy, spontaneous abortion, preterm birth (at <37 weeks of gestation), and low birth weight (<2500 g) in the first subsequent pregnancy in women who had had a first-trimester medical abortion were compared with risks in women who had had a first-trimester surgical abortion.

RESULTS

Among 11,814 pregnancies in women who had had a previous first-trimester medical abortion (2710 women) or surgical abortion (9104 women), there were 274 ectopic pregnancies (respective incidence rates, 2.4% and 2.3%), 1426 spontaneous abortions (12.2% and 12.7%), 552 preterm births (5.4% and 6.7%), and 478 births with low birth weight (4.0% and 5.1%). After adjustment for maternal age, interval between pregnancies, gestational age at abortion, parity, cohabitation status, and urban or nonurban residence, medical abortion was not associated with a significantly increased risk of ectopic pregnancy (relative risk, 1.04; 95% confidence interval [CI], 0.76 to 1.41), spontaneous abortion (relative risk, 0.87; 95% CI, 0.72 to 1.05), preterm birth (relative risk, 0.88; 95% CI, 0.66 to 1.18), or low birth weight (relative risk, 0.82; 95% CI, 0.61 to 1.11). Gestational age at medical abortion was not significantly associated with any of these adverse outcomes.

CONCLUSIONS

We found no evidence that a previous medical abortion, as compared with a previous surgical abortion, increases the risk of spontaneous abortion, ectopic pregnancy, preterm birth, or low birth weight.

Vaginal vs. sublingual misoprostol with mifepristone for cervical priming in second-trimester abortion by dilation and evacuation: a randomized clinical trial

OBJECTIVES

The study was conducted to assess the effectiveness of mifepristone 200 mg 48 h before administering misoprostol 600 mug, sublingual vs. vaginal route, prior to dilation and evacuation (D&E) in 12- to 20-week pregnancies.

DESIGN

Randomized clinical trial.

SETTING

Clínica Mediterrania Médica, Valencia, Spain.

SUBJECTS

Women with 12- to 20-week pregnancies wanting a voluntary abortion between July 9, 2004, and February 9, 2006.

METHODS

Nine hundred women were randomized to be included in one of the following four groups: (I) mifepristone 200 mg plus sublingual misoprostol 600 microg before D&E, (II) mifepristone 200 mg plus vaginal misoprostol 600 microg before D&E, (III) sublingual misoprostol 600 microg before D&E and (IV) vaginal misoprostol 600 microg before D&E.

MAIN OUTCOMES MEASURED

The degree of cervical dilation achieved before D&E, surgical time necessary to terminate the pregnancy and side effects of misoprostol.

RESULTS

The average cervical dilation in the mifepristone groups was 12.5+/-2.8 mm (SD) [95% confidence interval (CI), 12.3-12.8] vs. 8.5+/-3.2 mm (SD) (95% CI, 8.2-8.8) in those receiving only misoprostol. Surgical time in the mifepristone sublingual misoprostol group was 11.9+/-4.3 min (SD) vs. 13.0+/-5.3 min (SD) in the sublingual misoprostol group without mifepristone (p=.007); in the mifepristone vaginal misoprostol group, the average surgical time was 12.3+/-5.0 min (SD) vs. 13.0+/-6.2 (SD) in the vaginal misoprostol group without mifepristone (p=.031).

CONCLUSIONS

Administering mifepristone before D&E with misoprostol in second-trimester abortions makes surgery easier and shorter and, to a certain extent, lessens the risk of cervical injuries, especially in D&E in advanced gestational periods.

Update on medication abortion

This article provides an overview of medication abortion in the United States 6 years after the approval of mifepristone (RU486; Mifeprex; Danco Laboratories, LLC, New York, NY) by the US Food and Drug Administration (FDA). The adoption of mifepristone is considered in the context of epidemiologic data on abortion, abortion access, and the safety of abortion. The risks of medication and aspiration abortion are discussed in the context of abortion-related mortality, recent experience with obstetric and gynecologic infection with Clostridium sordellii, and the limits of scientific knowledge on the incidence of this infection in women. Innovative protocols studied since FDA approval of mifepristone are presented, and implications for clinical practice are discussed.

Mifepristone and misoprostol for the treatment of early pregnancy failure: a pilot clinical trial

BACKGROUND

In an attempt to improve efficacy for women who desire medical management of early pregnancy failure (EPF), we studied the efficacy and acceptability of mifepristone 200 mg, orally (po), followed 24 h later by misoprostol 800 microg, vaginally (pv), for the treatment of EPF.

METHODS

We enrolled 30 women with EPF in this pilot clinical trial. All women used misoprostol 800 microg, pv, 24 h after ingesting 200 mg mifepristone. Follow-up evaluations with transvaginal ultrasonography occurred at 24 h and 1 week after treatment. Participants were offered a repeat dose of misoprostol if the pregnancy had not been expelled at the first follow-up.

RESULTS

The expulsion rate with one dose of misoprostol was 90% (95% CI=79-100%). The overall success rate of the treatment was 93% (95% CI=84-100%).

CONCLUSION

This regimen of mifepristone followed by vaginal misoprostol appears to be an efficacious and acceptable treatment for EPF and may have improved results over a single dose of misoprostol alone.

Silent rupture of unscarred uterus: an unusual presentation at second trimester abortion

Rupture of unscarred uterus during the second trimester is rare. A case of ruptured uterus in a multiparous woman is presented. To our knowledge, this might be the first reported case in the English literature of uterine rupture during second trimester termination of pregnancy using ethacridine lactate. This case is also rare as uterine rupture is presented with an insidious course rather than acute, thus delaying the diagnosis.

Mifepristone and misoprostol sequential regimen side effects, complications and safety

Exhibiting a strong affinity to the progesterone and the glucocorticoid receptors, mifepristone exert competitive antagonism to these hormones both in in vitro and in animal experiments. Due to its antiprogesterone activity, it was proposed that mifepristone be used for the termination of early human pregnancy. Mifepristone, at a dose of 600 mg initially used alone, was then used with a subsequent low dose of prostaglandin that led to a success rate of 95% as a medical method for early termination of pregnancy (TOP), and the occurrence of continuing pregnancy was reduced to <or=1%. Its use was extended to other indications, such as cervical dilatation prior to surgical TOP in the first trimester, therapeutic TOP for medical reasons beyond the first trimester and for labor induction in case of fetal death in utero. The efficacy and safety of this treatment have been confirmed based on its use for over 15 years since its first approval in France and with close adherence to the approved recommendations. This article describes the toxicology studies conducted in animals as well as the safety follow-up and side effects reported with use of the compound when used with misoprostol in the main indication that is currently approved in 31 countries. Special emphasis is given to the rare but relevant safety issues, that is, heavy uterine bleeding, pelvic infections and continuing pregnancies. The rationale for warnings and contraindications for use of the product are also explained.

[Study on Meta analysis regarding the acceptability of medical abortion compared with surgical abortion]

OBJECTIVE

To analyze and evaluate the acceptability of mifepristone compatible with misoprostone versus conventional surgical abortion among women under unwanted early pregnancy, so as to help the unexpected pregnant women to choose the satisfactory abortion, and to provide the evidence for clinicians to make a proper clinical decision.

METHODS

Six medical databases were searched, including MEDLINE, EMBASE, Cochrane library, CBMdisc, CNKI and VIP, together with twelve journals hand-searched, and references of included studies additionally searched. Two qualified reviewers reviewed the original articles, evaluating qualities of articles, and extracting data independently. After heterogeneity test, the data was pooled using Revman software if capable, or descriptive analysis was applied.

RESULTS

In total, nine original clinical controlled trials were included, containing 3565 cases. Before abortion, more unwanted pregnant women chose the medical abortion because they believed medical abortion was less painful than surgical abortion (OR = 466.51, 95% CI: 91.37 - 2381.88), but medical abortion was less time-consuming than surgical abortion (OR = 0.02, 95% CI: 0.01 - 0.06). After abortion, satisfaction with medical abortion was similar to that with surgical abortion, with insignificant difference (P = 0.89). However, second choice and recommendation rates of medical abortion were much higher than those of surgical abortion with OR and 95% CI as 2.72, 2.13 - 3.47 and 4.19, 2.16 - 11.16, respectively.

CONCLUSIONS

Medical abortion was less painful than surgical abortion and the rate of second choice and recommendation to others were all also higher than those of surgical abortion. However, the process of medical abortion was not as quick as surgical abortion but the satifacation of both methods seemed similar. Therefore, the two artificial abortion methods were not recommended to replace each other at the present time.

Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion

Endometritis and toxic shock syndrome associated with Clostridium sordellii have previously been reported after childbirth and, in one case, after medical abortion. We describe four deaths due to endometritis and toxic shock syndrome associated with C. sordellii that occurred within one week after medically induced abortions. Clinical findings included tachycardia, hypotension, edema, hemoconcentration, profound leukocytosis, and absence of fever. These cases indicate the need for physician awareness of this syndrome and for further study of its association with medical abortion.

Pathophysiology of Mifepristone-Induced Septic Shock Due toClostridium sordellii

OBJECTIVE:

To explain the role of mifepristone in medical abortions that results in fulminant and lethal septic shock due to Clostridium sordellii.

DATA SOURCES:

MEDLINE, PubMed, and Google Scholar databases were searched (1984–March 2005%). Key search terms were mifepristone, RU38486, RU486, Mifeprex, medical abortion, septic shock, innate immune system, cytokines, and Clostridium sordellii.

STUDY SELECTION AND DATA EXTRACTION:

All articles identified from the data sources were evaluated and all information deemed relevant was included for the information related to the development of the understanding of the pathophysiology of mifepristone-induced septic shock due to C. sordellii.

DATA SYNTHESIS:

The mechanisms of action of mifepristone were incorporated into the pathophysiology of septic shock due to C. sordellii. Mifepristone, by blocking both progesterone and glucocorticoid receptors, interferes with the controlled release and functioning of cortisol and cytokines. Failure of physiologically controlled cortisol and cytokine responses results in an impaired innate immune system that results in disintegration of the body's defense system necessary to prevent the endometrial spread of C. sordellii infection. The abnormal cortisol and cytokine responses due to mifepristone coupled to the release of potent exotoxins and an endotoxin from C. sordellii are the major contributors to the rapid development of lethal septic shock.

CONCLUSIONS:

Theoretically, it appears that the mechanisms of mifepristone action favor the development of infection that leads to septic shock and intensifies the actions of multiple inflammatory cytokines, resulting in fulminant, lethal septic shock.

Centers for Disease Control and Prevention (CDC). Clostridium sordellii toxic shock syndrome after medical abortion with mifepristone and intravaginal misoprostol--United States and Canada, 2001-2005

On July 19, 2005, the Food and Drug Administration (FDA) issued a public health advisory regarding the deaths of four women in the United States after medical abortions with Mifeprex (mifepristone, formerly RU-486; Danco Laboratories, New York, New York) and intravaginal misoprostol. Two of these deaths occurred in 2003, one in 2004, and one in 2005. Two of these U.S. cases had clinical illness consistent with toxic shock and had evidence of endometrial infection with Clostridium sordellii, a gram-positive, toxin-forming anaerobic bacteria. In addition, a fatal case of C. sordellii toxic shock syndrome after medical abortion with mifepristone and misoprostol was reported in 2001, in Canada. All three cases of C. sordellii infection were notable for lack of fever, and all had refractory hypotension, multiple effusions, hemoconcentration, and a profound leukocytosis. C. sordellii previously has been described as a cause of pregnancy-associated toxic shock syndrome.

[Side effects of induced abortion: results from a population-based survey]

OBJECTIVES

This study compares the gynaecological symptoms of women who have undergone an induced abortion to those who have not. We also compare the gynaecological side effects, in particular the infectious symptoms, following an induced abortion, according to the abortion technique, medical and surgical, in the year after the abortion.

PATIENTS AND METHODS

A representative sample of 2863 women, aged 18 to 44, was interviewed by telephone between September 2000 and January 2001. Of these women, 401 declared an abortion in the last 5 years. Analysis of the gynaecological side effects according to the abortion technique was performed among the 199 women who terminated their pregnancy before the 8th week of amenorrhoea.

RESULTS

Women with a history of induced abortion had a higher sexual risk profile than those with no such history. They also more frequently reported genital infectious symptoms. The comparison between medical and surgical abortions shows that women who had a medical abortion were more likely to report heavy and prolonged bleeding. On the contrary, we found no difference of infectious symptoms between the two techniques.

DISCUSSION AND CONCLUSION

Our study does not support the idea of a reduction of infectious complications related to medical as opposed to surgical abortions. However, given the rapid diffusion of medical abortion, it seems important to carry on the investigations on the side effects related to medical abortions, in order to prevent them if necessary.

Medical termination of pregnancy in the early first trimester

Surgical abortion using vacuum aspiration or dilatation and curettage has been the method of choice for termination of pregnancy up to 63 days' gestation since the 1960s. Over the last three decades many studies have explored the use of medical methods for inducing abortion at these gestations. Earlier regimens assessed the systemic and intrauterine injection of prostaglandins. This was followed in the 1980s by the introduction of the antiprogesterone, mifepristone. Since its introduction, the uptake of medical abortion has been steadily increasing in countries where it has been available for routine use. Most current clinical protocols require the use of prostaglandins in combination with anti-progesterones or antimetabolites. The safety, efficacy and acceptability of the medical regimen are now well established at all gestations of pregnancy. Provision of medical abortion increases the choice available to women, in particular those wishing to avoid surgery.

[Study on the influence of medical abortion and surgical abortion on subsequent pregnancy]

OBJECTIVE

To evaluate and compare medical abortion versus surgical abortion in respect of their influence on the safety of the mother and baby in the subsequent pregnancy and parturition.

METHODS

Based on the principle of informed consent of subjects, 150 healthy pregnant women with a past history of having experienced medical abortion once were included in the study group (also called medical abortion group), and in the same period, 150 healthy pregnant women with a past history of having experienced surgical abortion once were enrolled into the comparison group (also called surgical abortion group). From then on, all the pregnant women in the two groups were followed up till a week after labor. The baseline data of the two groups were comparable (P>0.05). The rates of complications observed in these women during pregnancy and labor were evaluated.

RESULTS

The incidence rates of miscarriage, placental abnormality, premature delivery and postpartum hemorrhage in the study group were significantly lower than those in the comparison group (P<0.05). No significant differences on other variables were observed between the two groups.

CONCLUSION

Medical abortion is probably safer than surgical abortion in respect of their influence on subsequent pregnancy. So, provided there is less contraindication, medical abortion may be the choice for terminating unwanted pregnancy, especially for those women without a child.

[Side effect of mifepristone in combination with misoprostol for medical abortion]

OBJECTIVE

To assess the safety of mifepristone in combination with misoprotol for medical abortion.

METHOD

Literatures on the safety of medical abortion were searched in 9 databases worldwide and 9 Chinese medical journals.

RESULTS

A total of 101 articles and 1364 women were collected. Severe side effects including allergic or hemorrhagic shock, arrhythmia, convulsion and newborn deformities were observed in 115 cases. A total of 1015 cases appeared vaginal bleeding, mild or moderate allergic reaction. Systematic review found the relative risks (95% confidence interval, CI) of bleeding, abdominal pain, fever and dizziness in the medical abortion population were 3.27 (1.14 - 9.38), 1.63 (1.14 - 2.34), 1.58 (1.03 - 2.44) and 1.36 (1.06 - 1.75), respectively. These were higher in the medical abortion population than that in the surgical abortion population. In addition, the duration of bleeding caused by medical abortion was longer than that caused by surgical abortion. Its weighted mean difference was 6.49 and 95% CI was 6.08 - 7.80.

CONCLUSIONS

The incidence of side effects caused by this medical abortion was low. However, attention should be paid in clinical practice to the rare, but severe adverse events caused by this treatment. It is necessary to establish a comprehensive nationwide reporting system for these adverse events.

[Evaluation of maternal morbidity after drug-induced termination of pregnancy (TOP) after 12 gestation weeks]

OBJECTIVE

The number of TOP for medical indications has increased regularly over the last ten years. At the same time, the methods used for TOP have evolved. The purpose of this study was to assess the frequency of complications after drug-induced termination of pregnancy in order to determine whether using this method for interrupting pregnancy during the second or third trimester adds further danger for the mother in terms of early severe risk (uterine rupture, hysterectomy) or less severe long-term risk (infection).

MATERIAL AND METHODS

This metaanalysis included all articles devoted to pregnancy interruption from 12 gestation weeks retrieved from the Medline database and published between 1989 and 1999 in the United States, Canada, Australia, New Zealand, or the European Union. After excluding articles that included in utero death (n=8), isolated case reports and series involving a high-risk of maternal somatic complications (n=16), and surgical methods for pregnancy termination (n=4), we retained 23 articles for analysis. These articles had included 58,891 drug-induced terminations of pregnancy. For each article, we recorded the following complications: bleeding requiring transfusion, uterine rupture, ovular or placentar retention, and infection. A classical homogenicity test was performed for each type of complication. When this test was not significant, a mean rate, weighing by size of the study, was calculated.

RESULTS

One study reported maternal deaths (3/143000). The weighted mean rate for late retention (>24 hr) was 1.5 [CI95: 1.1%-1.9%]. For infections, the rates were very variable between studies (from 0.7% to 3.6% with one study reporting 8%). For bleeding with transfusion, the weighted mean rate was 0.7% [CI95: 0.5%-0.9%]. This rate was significantly higher than the rate observed in 1999 in France after delivery excepting medically terminated pregnancy (p<10(-3)) but probably is a reflection of the variable transfusion practices during the eighties in these different countries. Th rate of uterine rupture after medically terminated pregnancy was 0.1% [CI95: 0.07%-0.17%] and would be higher after delivery (excepting terminations) but not significantly (p=0.07).

CONCLUSION

This metaanalysis demonstrates that the risk of severe complications (uterine rupture and bleeding requiring transfusion) are rare but are more prevalent than after delivery except pregnancy termination. The metaanalysis approach is justified due to the low incidence of these severe complications. A prospective multicentric study of the complications using a geographical base would be useful to obtain unbiased data on risk level. A risk analysis by gestational age, maternal age, parity, and product used would thus be possible, as would long-term monitoring of maternal outcome.