Nicotinic toxicity from tincture of blue cohosh (Caulophyllum thalictroides) used as an abortifacient

Numerous natural products have been used as traditional abortifacients, each with their own efficacy and adverse effects. With the continued growth of the natural products industry, clinicians are more likely to see adverse effects from attempted abortions using these agents. A 21-y-old female developed tachycardia, diaphoresis, abdominal pain, vomiting and muscle weakness and fasciculations after using blue cohosh (Caulophyllum thalictroides) in an attempt to induce an abortion. These symptoms are consistent with nicotinic toxicity and probably resulted from methylcytisine known present in blue cohosh. The patient's symptoms resolved over 24 h and she was discharged. Whether successful or not, the use of natural agents to induce abortion is frequently associated with adverse effects in the mother or fetus. Clinicians should recognize the potential toxicity of these agents.

Managing ergot-induced gangrene: the anesthesiologist as a key player

IMPLICATIONS

We discuss the successful management of gangrene of the upper and lower limbs after ergot-induced abortion by unlicensed medical charlatans in a developing country. Our purpose is to highlight the dangerous means adopted by unlicensed medical charlatans to induce abortion as well as to emphasize the key role played by anesthesiologists in the management of such cases.

Bait-delivered cabergoline for the reproductive control of the red fox (Vulpes vulpes): estimating mammalian non-target risk in south-eastern Australia

Cabergoline (CAB) is a potent dopamine agonist and an inhibitor of prolactin (PRL). In red foxes (Vulpes vulpes), a single oral dose of 100 microg kg(-1) CAB can cause abortions and postnatal cub mortality from at least Day 21 of the 52-day pregnancy. The abortifacient activity of CAB is owing to the suppression of PRL, which is essential for luteotrophic support in some eutherian species. Postnatal cub mortality probably results from a reduction in the development of the mammary ductile system, which is also partially dependant on PRL during pregnancy. This paper investigates the potential risks faced by non-target mammalian species that may consume CAB baits intended for fox control. Baiting with CAB is proposed from 1 August until 1 October each year, to correspond with the time that most vixens are pregnant in south-eastern Australia. Thirty-four endemic mammals in south-eastern Australia (9 eutherians and 25 marsupials) are considered to be potentially bait-consuming (PBC) species. The percentage overlap of pregnancy and birth periods for each PBC species was compared with the duration of the proposed CAB baiting period. Only Antechinus (3 species) and Sminthopsis leucopus have greater than 40% overlap, whereas overlap in endemic rodents ranges from 0% to 22%. Overall, most PBC rodent populations appear to face little risk from CAB baiting, as their period of pregnancy does not overlap significantly with the proposed CAB baiting period. The Antechinus species, Phascogale tapoatafa and Dasyurus maculatus, are the only PBC mammals that are seasonally mono-oestrous and are thus probably more susceptible to disruption of breeding compared with polyoestrous species that may breed many times a year. At a baiting density of 8 baits km(-2), theoretical bait availability for small dasyurids, rodents and peramelids is low. This suggests a low potential for affecting these populations if CAB was indiscriminate in affecting reproductive success in all mammal groups. Presently, studies in a limited range of marsupials suggest that, unlike eutherians, the marsupial corpus luteum is independent of pituitary control and thus suppression of PRL is not likely to cause abortions in marsupials. As yet, CAB has not been shown to be orally active in any PBC species other than rodents and carnivores. Oral doses of CAB given post partum have not been found to affect lactation in Sminthopsis crassicaudata, Trichosurus vulpecula, Macropus eugenii and Setonix brachyurus. Further studies are required in order to assess the potential for high doses of oral CAB to affect pre-partum mammary development and early lactation post partum, especially in peramelids and larger dasyurids. Highly target-specific baiting techniques, may eliminate most PBC species from being exposed to CAB and these are briefly discussed.

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.

Having an abortion using mifepristone and home misoprostol: a qualitative analysis of women's experiences

CONTEXT

Women choose medical over surgical abortion because it is more natural, more private and less painful. Whether their perceptions change during the medical abortion process has not been explored.

METHODS

A nonprobabilitysample of 43 participants in a clinical trial of abortion using mifepristone completed two open-ended questionnaires about this method, one before taking mifepristone and the second during their follow-up clinic visit 4-8 days after taking misoprostol. Thirty women participated in in-depth interviews 1-6 weeks following their abortion. Researchers analyzed transcripts to identify common themes.

RESULTS

On the first visit to the clinic, women expressed anxiety and uncertainty about the effectiveness of medical abortion, guilt or ambivalence, and a desire to avoid surgery. For most women, emotional distress decreased after their abortion. Control was the overarching theme women expressed regarding the meaning of the procedure: Women stressed the importance of being able to select the type of abortion procedure, to maintain control over their future and to preserve their family's quality of life, given the constraints of time, finances and emotional resources. In in-depth interviews, eight women remained concerned about long-term health effects; 18 said that having an abortion at home was a comfortable experience.

CONCLUSIONS

Learning whether women are concerned about personal control may help clinicians identify appropriate candidates for medical abortion. In addition, clinicians could help allay women's anxiety at their first abortion visit by explaining that the uncertainties posed by any medical procedure create similar feelings. Clinicians also should reemphasize at the follow-up visit that there are no long-term health effects related to abortion.

Can women in less-developed countries use a simplified medical abortion regimen?

BACKGROUND

Mifepristone-misoprostol abortion, consisting of oral pills, is potentially simple and safe enough for use in less-developed countries. But the labour-intensive, costly, clinic-based European protocols are not affordable or feasible in most less-developed countries.

METHODS

We prospectively tested two simplifications to the French mifepristone-misoprostol regimen in Vietnam and Tunisia. Women (n=315) with amenorrhoea 8 weeks or less since their last menstrual period received 200 mg mifepristone in the clinic and then chose whether to take 400 mg oral misoprostol 2 days later either at home or in the clinic.

FINDINGS

Despite the two-thirds reduction in mifepristone dose, success rates were high: Vietnam 93%, Tunisia 91%. About 88% of participants chose home administration of misoprostol. Most Vietnamese and Tunisian women were satisfied with their abortions, but efficacy and satisfaction rates were higher among those who used misoprostol at home.

INTERPRETATIONS

A simplified medical abortion regimen of 200 mg mifepristone followed by the option of home administration of misoprostol seems feasible.

ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Medical management of abortion

According to the U.S. Centers for Disease Control and Prevention, 1.18 million legal abortions were performed in the United States in 1997. Of these, 55.5% were performed at or before 56 days of gestation (calculated from the first day of the last menstrual period [LMP]) (I). Almost 98% of abortion procedures were performed by uterine curettage; all but 1% of these used suction curettage. There were 305 legal induced abortions per 1,000 live births, and the abortion rate was 20 per 1,000 women aged 15-44 years. For the first time in 1997, medical abortions were counted and comprised 0.25% of all abortions; 0.45% of those procedures were performed up to 56 days of gestation. Because of the lack of availability of mifepristone, these procedures mostly represent the use of a combination of methotrexate and misoprostol. Over the past two decades, medical methods of abortion have developed throughout the world and are now used clinically in the United States. This document will present evidence of effectiveness, benefits, and risks of medical methods of abortion and provide a framework for the evaluation and counseling of women who are considering such medical methods.

A comparative study of surgical and medical procedures: 932 pregnancy terminations up to 63 days gestation

The aim of this retrospective study was to compare the efficacy and complications associated with early medical and surgical pregnancy termination. The study population comprised 932 consecutive women undergoing pregnancy termination at gestations of 63 days or less. There were no age or parity differences between the study groups. Medical termination was performed with mifepristone 200 mg orally and misoprostol 800 microgram vaginally; surgical aspiration termination was performed under general anaesthesia. Outcome measures were: surgical curettage for presumed retained products of conception; ongoing pregnancy; and planned and emergency review in the unit. Early medical and surgical termination were associated with a 90.2 and 94.5% complete abortion rate respectively (P = 0.025). The complete abortion rate with medical termination decreased significantly with increasing parity; no such relationship with surgical abortion was found. Women of parity three or more were less likely to have a complete abortion following a medical (83.3%) compared to surgical procedure (97.7%) (P = 0.028). The ongoing pregnancy rate was 0.9% with medical and 0.5% with surgical termination (P = NS). Medical termination was associated with a lower complete abortion rate than surgical termination, particularly for women of higher parity. However, early medical termination allows over 90% of women to avoid the risks of surgical instrumentation of the uterus and anaesthesia.

A randomized comparison of mifepristone and self-administered oral or vaginal misoprostol for early abortion

In France, mifepristone in association with orally administered misoprostol is widely used for the early termination of pregnancy (up to 49 days' gestation). In other centers, mifepristone in association with vaginally administered misoprostol has also been used. The aim of the present study was to compare the efficacy and tolerance of mifepristone in association with misoprostol administered orally or vaginally for the termination of pregnancy of up to 49 days' gestation. A total of 237 women were enrolled in the study. All women received 600 mg mifepristone administered orally and 400 microg misoprostol administered either orally (n = 119) or vaginally (n = 118). A second dose of 400 microg misoprostol was administered if women had not expelled the pregnancy within 3 h. Women were randomized into treatment groups according to the day of their admission. The overall success rate was 98.7% and there was no significant difference in efficacy between the two groups. There was one treatment failure in the group in which misoprostol was administered orally. Of those women who aborted within 3 h of administration of the first dose ofmisoprostol, the route of administration ofmisoprostol did not influence the time to abortion. Of the women who received a second dose ofmisoprostol, the time to abortion was shorter in those who received misoprostol orally (52 min versus 77 min). Tolerance was assessed by visual analog scales and was similar for both groups. In both groups, women preferred the oral route of administration.

Management of side effects and complications in medical abortion

Side effects are an expected part of medical abortion; some, such as pain and bleeding, result from the abortion process itself and are generally managed with orally administered analgesics and counseling. True medication side effects most commonly include nausea, vomiting, diarrhea, and warmth or chills. Complications of medical abortion usually represent an extreme or severe side effect. Large series have reported transfusion rates of <1%. Because of the infrequency of uterine instrumentation, postabortal endometritis appears to be rare with medical abortion. As with early surgical abortion, the clinician must remain aware of the possibility for ectopic pregnancy. Overall approximately 2% to 10% of patients will require surgical intervention for control of bleeding, resolution of incomplete expulsion, or termination of a continuing pregnancy. Understanding the types of side effects and complications that can occur will enable the clinician to counsel patients properly as well as to understand when medical intervention is necessary during the medical abortion process.

Induced second trimester abortion by extra-amniotic prostaglandin infusion in patients with a cesarean scar: is it safe?

BACKGROUND

One result of the advancement in prenatal diagnosis is an increase in the need for second trimester pregnancy terminations. Extra-amniotic infusion of prostaglandins is a common technique used for such pregnancy termination. Since prostaglandins cause strong uterine contractions, many practitioners are hesitant to use this technique on women with a uterine scar. In this study we tried to evaluate the effectiveness and safety of the technique for women with a previous uterine scar.

METHODS

This retrospective study included all women with a complete medical record who underwent a second trimester pregnancy termination at our institution by extra amniotic prostaglandin E2, during a 6 year period. The study group included all women with a previous uterine scar. The group of women without such a scar served as the control group.

RESULTS

Three hundred and forty women had their pregnancy terminated, but only in 282 cases was the medical information complete (research population). The study group (35 women) characteristics were similar to those of the control group (247 women). We found no difference in the abortion interval, the need to use an additional method, the need for curettage and in bleeding complication between the two groups. There was no case of uterine rupture. The group of women with multiple uterine scars was too small for analysis.

CONCLUSIONS

Our results suggest that extra amniotic prostaglandin infusion is an effective and safe technique in women with a uterine scar.

Side effects of mifepristone-misoprostol abortion versus surgical abortion. Data from a trial in China, Cuba, and India

Although serious adverse events of early abortion have been studied, little attention has been paid to the more common side effects experienced by early medical or surgical abortion clients. Using data from a multicenter comparative trial of women < or = 56 days' gestation in China, Cuba, and India (n = 1373), side effects experienced by mifepristone-misoprostol medical abortion and surgical abortion clients were analyzed at the different stages of their abortions. Data on side effects came from women's reports at each clinic visit, providers' observations during the clinic visits, and symptom diaries maintained during the study period. Medical abortion clients at all sites experienced more side effects than their surgical counterparts. The disparity between the two groups was particularly pronounced for bleeding and pain. Despite more reports of side effects among medical abortion clients, however, assessments of well-being and reports of satisfaction at the exit interview were similar in both treatment groups.

[Acute myocardial infarction following administration of a synthetic analog of prostaglandin E2 in a subject with an intramural course of the anterior intraventricular artery]

We report a case of acute myocardial infarction which occurred after administration of a synthetic analog of prostaglandin E2 (PGE2) for the voluntary interruption of pregnancy in a 31-year-old woman who had previously been asymptomatic, with myocardial bridging of the left anterior descending artery. The pathogenesis of the severe ischemia causing myocardial infarction and left ventricle aneurysm is quite unclear. The temporal connection is highly indicative of a causal relationship between the pharmacological effects of a synthetic PGE2 analog and coronary spasm responsible for severe ischemia. The hypothesis of endothelial dysfunction proximal to the intramyocardial artery tract and paradoxical vasoconstriction with platelet activation should be taken into consideration. A possible additional effect seems to be a horizontal coronary steal produced by the administration of PGE2 in the myocardium below the intramyocardial artery tract. It cannot be excluded that pharmacological doses of a synthetic analog of PGE2 may have inverted the vasoactive effects of the substance due to direct stimulation on the delivery of constrictive agonist factors.

Adult and two children with fetal methotrexate syndrome

The folic acid antagonists, methotrexate and aminopterin, are known to be teratogenic in humans. The critical period for their teratogenecity is suspected to be between 6 to 8 weeks post-conception. Fetal exposure from 10 to 32 weeks weeks post-conception to methotrexate alone or in combination with other anti-cancer drugs has not resulted in obvious teratogenic effects. Methotrexate is often used to treat cancers but is occasionally used as an abortifacient. The long-term outcome of the fetal aminopterin syndrome has been published in only four adults. We report on a 28-year-old man with fetal methotrexate syndrome and two children with mild manifestations of the syndrome. One child was inadvertently exposed to methotrexate from 7 1/2 through 30 weeks post-conception because his mother was receiving it for treatment of breast cancer. The other was exposed from 11 weeks and 5 days through 25 weeks in an attempt to induce abortion. The 28-year-old man has craniofacial and digital anomalies, growth retardation but normal intelligence as noted in the previously reported cases. These cases remind us of the teratogenicity of methotrexate and should serve as a warning that if methotrexate is used as an abortifaciant and an abortion does not ensue, there is a teratogenic risk.