Sublingual versus vaginal misoprostol for second trimester termination: a randomized clinical trial

[Medical strategy for abortions between 14 and 16 weeks of gestation]

OBJECTIVE

To adapt the protocols for the management of voluntary termination of pregnancy following the new law extending the practice to 16 weeks of gestation.

MATERIAL AND METHOD

A systematic review of the literature in French and English concerning the management of patients requesting medically induced abortion was performed on PubMed, Cochrane Library and on the recommendations of international learned societies.

RESULTS

The efficacy of the medical method is greater than 95% when the protocols are adapted to the gestational age. The combination of mifepristone and misoprostol currently represents the "gold standard" of drug-based management. Mifepristone 200mg is sufficient, followed 24 to 48hours later by misoprostol 800μg administered sublingually or buccally. After the first dose, 400μg should be administered every 3hours buccally or sublingually until expulsion. Adverse effects (digestive and thermoregulatory disorders) during medical abortion are usually mild and short-lived. An anti-emetic treatment should be proposed as a prophylactic measure. For pain, ibuprofen is the analgesic treatment of choice, with the addition of level 2 analgesics if necessary.

CONCLUSION

Medical abortion is a safe and effective method up to 16 weeks of gestation, provided that the protocols, which differ according to gestational age, are respected. Women must be informed of the advantages and disadvantages of the methods according to the term and the side effects, which will allow them to choose the method that fits them best.

Methods for managing miscarriage: a network meta-analysis

BACKGROUND

Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime. An estimated 15% of pregnancies end in miscarriage. Miscarriage can lead to serious morbidity, including haemorrhage, infection, and even death, particularly in settings without adequate healthcare provision. Early miscarriages occur during the first 14 weeks of pregnancy, and can be managed expectantly, medically or surgically. However, there is uncertainty about the relative effectiveness and risks of each option.

OBJECTIVES

To estimate the relative effectiveness and safety profiles for the different management methods for early miscarriage, and to provide rankings of the available methods according to their effectiveness, safety, and side-effect profile using a network meta-analysis.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth's Trials Register (9 February 2021), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (12 February 2021), and reference lists of retrieved studies.

SELECTION CRITERIA

We included all randomised controlled trials assessing the effectiveness or safety of methods for miscarriage management. Early miscarriage was defined as less than or equal to 14 weeks of gestation, and included missed and incomplete miscarriage. Management of late miscarriages after 14 weeks of gestation (often referred to as intrauterine fetal deaths) was not eligible for inclusion in the review. Cluster- and quasi-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded non-randomised trials.

DATA COLLECTION AND ANALYSIS

At least three review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for the primary outcomes of complete miscarriage and composite outcome of death or serious complications. The certainty of evidence was assessed using GRADE. Relative effects for the primary outcomes are reported subgrouped by the type of miscarriage (incomplete and missed miscarriage). We also performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available methods.

MAIN RESULTS

Our network meta-analysis included 78 randomised trials involving 17,795 women from 37 countries. Most trials (71/78) were conducted in hospital settings and included women with missed or incomplete miscarriage. Across 158 trial arms, the following methods were used: 51 trial arms (33%) used misoprostol; 50 (32%) used suction aspiration; 26 (16%) used expectant management or placebo; 17 (11%) used dilatation and curettage; 11 (6%) used mifepristone plus misoprostol; and three (2%) used suction aspiration plus cervical preparation. Of these 78 studies, 71 (90%) contributed data in a usable form for meta-analysis. Complete miscarriage Based on the relative effects from the network meta-analysis of 59 trials (12,591 women), we found that five methods may be more effective than expectant management or placebo for achieving a complete miscarriage: · suction aspiration after cervical preparation (risk ratio (RR) 2.12, 95% confidence interval (CI) 1.41 to 3.20, low-certainty evidence), · dilatation and curettage (RR 1.49, 95% CI 1.26 to 1.75, low-certainty evidence), · suction aspiration (RR 1.44, 95% CI 1.29 to 1.62, low-certainty evidence), · mifepristone plus misoprostol (RR 1.42, 95% CI 1.22 to 1.66, moderate-certainty evidence), · misoprostol (RR 1.30, 95% CI 1.16 to 1.46, low-certainty evidence). The highest ranked surgical method was suction aspiration after cervical preparation. The highest ranked non-surgical treatment was mifepristone plus misoprostol. All surgical methods were ranked higher than medical methods, which in turn ranked above expectant management or placebo. Composite outcome of death and serious complications Based on the relative effects from the network meta-analysis of 35 trials (8161 women), we found that four methods with available data were compatible with a wide range of treatment effects compared with expectant management or placebo: · dilatation and curettage (RR 0.43, 95% CI 0.17 to 1.06, low-certainty evidence), · suction aspiration (RR 0.55, 95% CI 0.23 to 1.32, low-certainty evidence), · misoprostol (RR 0.50, 95% CI 0.22 to 1.15, low-certainty evidence), · mifepristone plus misoprostol (RR 0.76, 95% CI 0.31 to 1.84, low-certainty evidence). Importantly, no deaths were reported in these studies, thus this composite outcome was entirely composed of serious complications, including blood transfusions, uterine perforations, hysterectomies, and intensive care unit admissions. Expectant management and placebo ranked the lowest when compared with alternative treatment interventions. Subgroup analyses by type of miscarriage (missed or incomplete) agreed with the overall analysis in that surgical methods were the most effective treatment, followed by medical methods and then expectant management or placebo, but there are possible subgroup differences in the effectiveness of the available methods.  AUTHORS' CONCLUSIONS: Based on relative effects from the network meta-analysis, all surgical and medical methods for managing a miscarriage may be more effective than expectant management or placebo. Surgical methods were ranked highest for managing a miscarriage, followed by medical methods, which in turn ranked above expectant management or placebo. Expectant management or placebo had the highest chance of serious complications, including the need for unplanned or emergency surgery. A subgroup analysis showed that surgical and medical methods may be more beneficial in women with missed miscarriage compared to women with incomplete miscarriage. Since type of miscarriage (missed and incomplete) appears to be a source of inconsistency and heterogeneity within these data, we acknowledge that the main network meta-analysis may be unreliable. However, we plan to explore this further in future updates and consider the primary analysis as separate networks for missed and incomplete miscarriage.

The efficacy of letrozole supplementation for medical abortion: a meta-analysis of randomized controlled trials

INTRODUCTION

The efficacy of letrozole supplementation for medical abortion remains controversial. We conduct a systematic review and meta-analysis to explore the influence of letrozole supplementation for medical abortion.

METHODS

We searched PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases through October 2018 for randomized controlled trials (RCTs) assessing the effect of letrozole supplementation for medical abortion. This meta-analysis is performed using the random-effect model.

RESULTS

Six RCTs involving 555 patients are included in the meta-analysis. Overall, compared with control group for pregnant women, letrozole supplementation shows significantly increased complete abortion (RR = 1.38; 95% CI = 1.07-1.78; p = .01), and decreased estradiol (std. MD = -2.86; 95% CI = -4.45 to -1.27; p = .0004), but has no remarkable effect on induction-abortion time (std. MD = -1.03; 95% CI = -2.99-0.93; p = .30), progesterone (std. MD = 0.02; 95% CI = -0.30-0.34; p = .89), vaginal hemorrhage (std. MD = 1.84; 95% CI = 0.05-70.90; p = .74), nausea and vomiting (std. MD = 073; 95% CI = 0.44-1.21; p = .22).

CONCLUSIONS

Letrozole supplementation provides benefits to medical abortion in pregnant women.

Medical treatment for early fetal death (less than 24 weeks)

BACKGROUND

In most pregnancies that miscarry, arrest of embryonic or fetal development occurs some time (often weeks) before the miscarriage occurs. Ultrasound examination can reveal abnormal findings during this phase by demonstrating anembryonic pregnancies or embryonic or fetal death. Treatment has traditionally been surgical but medical treatments may be effective, safe, and acceptable, as may be waiting for spontaneous miscarriage. This is an update of a review first published in 2006.

OBJECTIVES

To assess, from clinical trials, the effectiveness and safety of different medical treatments for the termination of non-viable pregnancies.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (24 October 2018) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials comparing medical treatment with another treatment (e.g. surgical evacuation), or placebo, or no treatment for early pregnancy failure. Quasi-randomised studies were excluded. Cluster-randomised trials were eligible for inclusion, as were studies reported in abstract form, if sufficient information was available to assess eligibility.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

Forty-three studies (4966 women) were included. The main interventions examined were vaginal, sublingual, oral and buccal misoprostol, mifepristone and vaginal gemeprost. These were compared with surgical management, expectant management, placebo, or different types of medical interventions were compared with each other. The review includes a wide variety of different interventions which have been analysed across 23 different comparisons. Many of the comparisons consist of single studies. We limited the grading of the quality of evidence to two main comparisons: vaginal misoprostol versus placebo and vaginal misoprostol versus surgical evacuation of the uterus. Risk of bias varied widely among the included trials. The quality of the evidence varied between the different comparisons, but was mainly found to be very-low or low quality.Vaginal misoprostol versus placeboVaginal misoprostol may hasten miscarriage when compared with placebo: e.g. complete miscarriage (5 trials, 305 women, risk ratio (RR) 4.23, 95% confidence interval (CI) 3.01 to 5.94; low-quality evidence). No trial reported on pelvic infection rate for this comparison. Vaginal misoprostol made little difference to rates of nausea (2 trials, 88 women, RR 1.38, 95% CI 0.43 to 4.40; low-quality evidence), diarrhoea (2 trials, 88 women, RR 2.21, 95% CI 0.35 to 14.06; low-quality evidence) or to whether women were satisfied with the acceptability of the method (1 trial, 32 women, RR 1.17, 95% CI 0.83 to 1.64; low-quality evidence). It is uncertain whether vaginal misoprostol reduces blood loss (haemoglobin difference > 10 g/L) (1 trial, 50 women, RR 1.25, 95% CI 0.38 to 4.12; very-low quality) or pain (opiate use) (1 trial, 84 women, RR 5.00, 95% CI 0.25 to 101.11; very-low quality), because the quality of the evidence for these outcomes was found to be very low.Vaginal misoprostol versus surgical evacuation Vaginal misoprostol may be less effective in accomplishing a complete miscarriage compared to surgical management (6 trials, 943 women, average RR 0.40, 95% CI 0.32 to 0.50; Heterogeneity: Tau² = 0.03, I² = 46%; low-quality evidence) and may be associated with more nausea (1 trial, 154 women, RR 21.85, 95% CI 1.31 to 364.37; low-quality evidence) and diarrhoea (1 trial, 154 women, RR 40.85, 95% CI 2.52 to 662.57; low-quality evidence). There may be little or no difference between vaginal misoprostol and surgical evacuation for pelvic infection (1 trial, 618 women, RR 0.73, 95% CI 0.39 to 1.37; low-quality evidence), blood loss (post-treatment haematocrit (%) (1 trial, 50 women, mean difference (MD) 1.40%, 95% CI -3.51 to 0.71; low-quality evidence), pain relief (1 trial, 154 women, RR 1.42, 95% CI 0.82 to 2.46; low-quality evidence) or women's satisfaction/acceptability of method (1 trial, 45 women, RR 0.67, 95% CI 0.40 to 1.11; low-quality evidence).Other comparisonsBased on findings from a single trial, vaginal misoprostol was more effective at accomplishing complete miscarriage than expectant management (614 women, RR 1.25, 95% CI 1.09 to 1.45). There was little difference between vaginal misoprostol and sublingual misoprostol (5 trials, 513 women, average RR 0.84, 95% CI 0.61 to 1.16; Heterogeneity: Tau² = 0.10, I² = 871%; or between oral and vaginal misoprostol in terms of complete miscarriage at less than 13 weeks (4 trials, 418 women), average RR 0.68, 95% CI 0.45 to 1.03; Heterogeneity: Tau² = 0.13, I² = 90%). However, there was less abdominal pain with vaginal misoprostol in comparison to sublingual (3 trials, 392 women, RR 0.58, 95% CI 0.46 to 0.74). A single study (46 women) found mifepristone to be more effective than placebo: miscarriage complete by day five after treatment (46 women, RR 9.50, 95% CI 2.49 to 36.19). However the quality of this evidence is very low: there is a very serious risk of bias with signs of incomplete data and no proper intention-to-treat analysis in the included study; and serious imprecision with wide confidence intervals. Mifepristone did not appear to further hasten miscarriage when added to a misoprostol regimen (3 trials, 447 women, RR 1.18, 95% CI 0.95 to 1.47).

AUTHORS' CONCLUSIONS

Available evidence from randomised trials suggests that medical treatment with vaginal misoprostol may be an acceptable alternative to surgical evacuation or expectant management. In general, side effects of medical treatment were minor, consisting mainly of nausea and diarrhoea. There were no major differences in effectiveness between different routes of administration. Treatment satisfaction was addressed in only a few studies, in which the majority of women were satisfied with the received intervention. Since the quality of evidence is low or very low for several comparisons, mainly because they included only one or two (small) trials; further research is necessary to assess the effectiveness, safety and side effects, optimal route of administration and dose of different medical treatments for early fetal death.

Comparison of Effectiveness of Sublingual and Vaginal Misoprostol for Second-Trimester Abortion

OBJECTIVE

The aim of this study was to compare the efficacy and safety of sublingual and vaginal misoprostol in second-trimester termination of pregnancy in 24 and 48 h.

STUDY DESIGN

This is a retrospective study of 240 pregnant women seeking termination in second trimester (13-18.5 weeks), in which the patients are subdivided into two groups-first group received 400 mcg of misoprostol sublingually (n = 120), and second group received 400 mcg of misoprostol vaginally (n = 120) every 4 h for a maximum of five doses. The course of misoprostol was repeated if the patient did not abort within 24 h.

RESULTS

The mean induction-to-abortion interval was shorter in sublingual group (10.28 ± 3.1 h) versus 14.68 ± 4.2 h in vaginal group in 24 h (p = 0.0001), and 36.9 ± 4.4 h in sublingual versus 29.7 ± 14 in vaginal group in 48 h (p = 0.0933). Mean dose requirement for misoprostol by sublingual route was low as compared to vaginal misoprostol (1048 ± 301 mg versus 1250 ± 375 mg; p = 0.0001 in 24 h and 1110 ± 833 mg versus 1325 ± 536 mg; p = 0.0231 in 48 h). No significant difference was found in the success rate (both at 24 and 48 h) and in side effects among the two comparison groups.

CONCLUSION

Misoprostol as such by any route has been proven as an effective abortifacient in second trimester. Both sublingual and vaginal routes are effective for medical abortion. But shorter induction-to-abortion interval in sublingual route, less dose requirement and higher acceptability makes sublingual route as a better choice.

Current and potential methods for second trimester abortion

Medical and surgical methods can both be recommended for second trimester abortion (after 12-weeks of gestational age). Induced abortion with a mifepristone and misoprostol regimen is the preferred approach; where mifepristone is not available, misoprostol alone for medical abortion is also effective. Dilation and evacuation (D&E) is the procedure of choice for surgical abortions, and adequate cervical preparation contributes significantly to safety. Availability of drugs and instruments, ability to provide pain control, provider skill and comfort, client preference, cultural considerations, and local legislation all influence the method of abortion likely to be performed in a given setting. Both surgical and modern medical methods are safe and effective when provided by a trained, experienced provider.

Prospective Comparative Study of Oral Versus Vaginal Misoprostol for Second-Trimester Termination of Pregnancy

Background

Various medical methods for second-trimester medical termination of pregnancy (MTP) exist. Misoprostol alone has been used with myriad variations in route and dosage. Comparison between oral and vaginal routes of misoprostol forms the basis of this study.

Methods

This was a prospective comparative study of misoprostol for second-trimester (14-20 weeks) MTP, comparing oral versus vaginal routes. Sixty patients were randomly allotted to two groups; 30 received oral misoprostol 400 µg 4 h up to a maximum of five doses (2000 µg), and 30 received vaginal misoprostol in the same dose and duration. In both groups, oxytocin infusion was started if abortion did not occur. Efficacy of oral versus vaginal misoprostol, induction-abortion interval (AI) and need for surgical intervention were analyzed.

Results

Both groups were well matched in terms of age, parity, previous LSCS, mean gestational age and indication for MTP. Overall mean induction-abortion interval was 19.59 h (21.66 vs. 18.57 h, oral vs. vaginal, respectively), with vaginal group taking lesser time (p 0.09). Sixty percentage in oral group required five doses, while 70% in vaginal group required 3-4 doses of misoprostol (p 0.010). 23.7 versus 6.7% in oral versus vaginal group required check curettage (p 0.038). There were no major complications, and there was only one failure in oral group.

Conclusions

Though both oral and vaginal misoprostol are safe, vaginal route appears to be more efficacious for second-trimester MTP.

Update on second trimester medical abortion

PURPOSE OF REVIEW

To review recent literature on second trimester abortion with medical methods.

RECENT FINDINGS

Across studies published in the recent past, it is apparent that women prefer shorter procedures and procedure times. Several randomized controlled trials have confirmed adding mifepristone to the second trimester medication abortion regimen results in shorter abortion intervals from first misoprostol administration to complete fetal expulsion. A study of simultaneous administration of mifepristone and misoprostol yielded shorter mean 'total' abortion times, presenting several logistical advantages. Recent studies on the continuous dosing of misoprostol have produced critical evidence to support continued dosing until expulsion. These studies had a more practical design compared with previous protocols that capped the number of misoprostol doses.

SUMMARY

Second trimester surgical abortion is well tolerated and increasingly expeditious. Further research is needed to refine second trimester medical abortion methods, specific to the mifepristone, misoprostol dosing interval. A 12-hour mifepristone to misoprostol interval may be the optimal interval balancing patient preferences and logistical considerations. Pragmatic dosing, including continuous dosing of misoprostol, could yield results that better inform clinical guidelines and reduce burden on patient, provider, and health facility.

Effectiveness of celecoxib for pain relief and antipyresis in second trimester medical abortions with misoprostol: a randomized controlled trial

PURPOSE

To evaluate the effectiveness of celecoxib for pain relief and antipyresis during second trimester abortion using sublingual misoprostol.

METHODS

Fifty-six pregnant women of gestational age 14-24 weeks were randomly assigned in a double-blind randomized controlled trial to receive 400 mg of celecoxib or placebo just before sublingual administration of misoprostol 400 µg every 6 h. Pain and body temperature (BT) were assessed every 1 h until the abortion or 24 h after the first dose of misoprostol. Pain was assessed using a 10-cm Visual Analog Scale (VAS). BT was measured with an infrared thermometer.

RESULTS

From January 2016 through September 2016, 28 patients were randomized into each study group. The mean VAS pain score at the completion of the abortion in the celecoxib group was significantly lower than in the placebo group (4.6 ± 2.8 vs. 7.3 ± 2.2) (p = 0.012). But 42.9% of patients in both groups experienced severe pain and needed equivalent amounts of morphine rescue. The overall mean BT in the celecoxib group was significantly lower than in the placebo group [- 0.09 (SD = 0.04)] (p = 0.017). The mean BTs at 1, 2 and 6 h after each repeated dose of misoprostol in the celecoxib group were also significantly lower than in the placebo group.

CONCLUSIONS

Single-dose 400 mg celecoxib had an inadequate beneficial effect on pain relief but significant antipyretic effect during second trimester abortions using sublingual misoprostol.

The combination route versus sublingual and vaginal misoprostol for the termination of 13 to 24 week pregnancies: A randomized clinical trial

OBJECTIVE

The goal of this study was to compare the effectiveness of misoprostol via sublingual and vaginal administration versus the combination route in the termination of 13 to 24 week pregnancies.

MATERIALS AND METHODS

One hundred and ninety-five patients, divided into three groups, were enrolled in this study. In the vaginal group, two 200-μg misoprostol tablets were inserted into the posterior fornix every 4 hours for 48 hours. In the sublingual group, patients took two 200-μg misoprostol tablets every 4 hours for up to 48 hours. In the combination group, two 200-μg misoprostol tablets were inserted within the posterior fornix followed by the administration of 400 μg misoprostol sublingually every 4 hours for a period of 48 hours. Efficacy was defined as a successful termination without the need for any interventions.

RESULTS

The success rate, after 24-48 hours, was not significantly different among the three groups. It was significantly higher within the first 12 hours of misoprostol administration within the sublingual group (p = 0.031). Nonetheless, the overall failure rate was not significantly different between three groups. The mean duration of abortion was shortest among the sublingual group (655 ± 46 minutes), p = 0.005, and the number of misoprostol tablets administered was lower when compared to the other groups (5.9 ± 0.3), p = 0.001. The duration of abortion and the number of misoprostol tablets used significantly varied in the cases in which the patient had a history of a previous normal vaginal delivery (NVD; p = 0.007). The average number of tablets administered was the lowest in the sublingual group. The prevalence of fever among the NVD cases were significantly higher in the combination group (p = 0.008). Overall, of all the methods, patients preferred the sublingual route (p = 0.001).

CONCLUSION

Sublingual misoprostol has a higher efficacy when compared to the vaginal and combination methods.

The effectiveness of using misoprostol with and without letrozole for successful medical abortion: A randomized placebo-controlled clinical trial

Background:

In developing countries it is important to the exploration of available and safe regimens for medical abortion. The present study was designed to assess the effect of letrozole compared to placebo pretreatment followed by sublingual misoprostol for therapeutic abortion in eligible women with gestational age less than 17 weeks.

Materials and Methods:

In this randomized control trail, 130 women eligible for legal abortions were randomly divided into two groups of case and controls. Cases received daily oral dose of 10 mg letrozole 10 mg letrozole for three days followed by sublingual misoprostol. Controls received daily oral dose of placebo followed by sublingual misoprostol. The dose of misoprostol was administrated according to ACOG guidelines based on patients’ gestational age. The rate of complete abortion, induction-of-abortion time, and side-effects were assessed as main outcomes.

Results:

Complete abortion was observed in 46 (76.7%) letrozole group and 26 (42.6%) controls (P < 0.0001). Also, in 14 subjects of letrozole group and 35 subjects in placebo group, the placenta was not delivered during follow-up and curettage was performed. The mean interval induction-to-abortion was 5.1 h in letrozole group and 8.9 h in control (P < 0.0001). The cumulative rates of the induction-of-abortion time were a significant difference between the two groups (P < 0.0001). The incidence and severity of side-effects was comparable for the two groups (P = 0.9).

Conclusion:

Letrozole could be a quite beneficial adjuvant to misoprostol for induction of complete abortion in those who are candidates for legal medical abortion.

Comparison of two misoprostol regimens for mid-trimester pregnancy terminations after FIGO's misoprostol dosage recommendation in 2012

OBJECTIVE

To compare the safety and efficacy of two misoprostol regimens for mid-trimester pregnancy terminations.

METHODS

Retrospective analysis of 263 cases of pregnancy terminations with misoprostol between 12 and 24 weeks was performed. Group 1 (total 129 patients) consisted of patients who were given 200 mcg vaginal misoprostol every 4 h until the abortion, whereas Group 2 patients (total 134 patients) were given misoprostol as in International Federation of Gynecology and Obstetrics's (FIGO) 2012 recommendation. In case of a previous cesarean section doses were halved in both groups. Primary outcomes of the study were the time to abortion and the total drug dose used. Secondary outcome was the rate of complications.

RESULTS

Total dose and time to abortion did not differ between the groups. As for complications, one patient (%0.8) in group 1 developed HELLP syndrome and had hysterotomy. One patient (%0.8) in group 2 had uterine rupture and had total hysterectomy. Two patients in both groups considered failure of induction and terminated with surgery (hysterotomy). Groups did not show difference in induction failure rates.

CONCLUSIONS

We respect the presence of dose recommendation stated by the FIGO and found similar results with our recent protocol. Other misoprostol regimens used worldwide should also be compared with this guideline in order to improve its efficacy.

A double-blind randomized controlled trial of mifepristone or placebo before buccal misoprostol for abortion at 14-21 weeks of pregnancy

OBJECTIVE

To assess differences in outcomes of misoprostol with or without mifepristone for second-trimester abortion.

METHODS

A randomized, double-blind, placebo-controlled trial of buccal misoprostol following placebo or 200mg mifepristone was done in Tunisia among women presenting for abortions at 14-21 weeks of pregnancy between August 2009 and December 2011. Women with a live fetus, a closed cervical os, no cervical bleeding, and no contraindications to study drugs were eligible and underwent randomization (block size 10). Participants returned 24 hours later to receive 400 μg buccal misoprostol every 3 hours until complete fetal and placental expulsion (maximum 10 doses, five per 24-hour period). The primary outcomes were rates of complete uterine evacuation at 48 hours and time to expulsion.

RESULTS

A total of 120 women were evenly randomized to treatment. Complete uterine evacuation at 48 hours was recorded in 55 (91.7%) women in the combined group versus 43 (71.7%) in the misoprostol alone group (relative risk 1.28; 95% confidence interval 1.07-1.53). Mean time to complete abortion was 10.4±6.6 hours in the group who received mifepristone versus 20.6±9.7 hours in the misoprostol alone group (P<0.001). Side effects were similar in both groups.

CONCLUSION

Adding mifepristone before misoprostol can improve the quality of second-trimester abortion care by making the process faster.

Comparative Study of Misoprostol in First and Second Trimester Abortions by Oral, Sublingual, and Vaginal Routes

OBJECTIVE

To identify an effective misoprostol-only regimen for termination of pregnancy between 12 and 20 weeks of gestation, a prospective randomized study comparing sublingual, vaginal, and oral routes of administration of misoprostol was done.

METHODS

One hundred and fifty women (12-20 weeks gestation) were randomly divided into three groups and given 400 mcg misoprostol sublingually, vaginally, and orally every 4 h up to a maximum of four doses. Primary outcome was the success rate at 24 h. Secondary outcomes were failure rate, induction-abortion interval, and need for surgical intervention. Various side effects and patients' subjective assessment of comfort with the route of administration were also studied.

RESULTS

Success rate at 24 h of sublingual (86 %) group was higher compared to oral (64 %) group (P = 0.011). Complete abortion rate of sublingual (76 %) group was higher than that of oral (48 %) group (P = 0.004). There was no significant difference in the failure rate and need for surgical intervention in the three groups. Induction-abortion interval in sublingual (9.8 ± 3.6 h) and vaginal (10.6 ± 2.9 h) groups was shorter than that in oral group (14.3 ± 3.3). Diarrhea occurred significantly more in the oral group (28 %) and sublingual (22 %) compared to vaginal group (6 %). Fever was significantly higher in vaginal (36 %) than that in the oral group (12 %). Oral route of administration was most comfortable.

CONCLUSION

Sublingual route results in significantly higher abortion rate compared to oral route. Vaginal route has efficacy similar to sublingual route.

Misoprostol versus High Dose Oxytocin and Laminaria in Termination of Pregnancy in Second Trimester Pregnancies

BACKGROUND

In 2 recent decades, found drug regimen to induce abortion that are more effective than surgery. Prostaglandins especially misoprostol, oxytocin and osmotic dilators such as laminaria use for termination but the best method is unknown. Therefore we aimed to assess the comparison between the Misoprostol regimen and the highly concentrated oxytocin with laminaria regimen in second trimester of pregnancy termination.

METHODS

In this randomized clinical trial, 100 women with gestational age 14 to 24 week coming to hospital due to termination of pregnancy in the absence of uterine contractions and items of exclusion criteria enrolled to study and randomly assign to 2 groups and received misoprostol (group 1) or oxytocin (group 2). Data collected with use of observation, examination and demographic checklist. In group 1, in admission time and then every 6 hour patients received 200 µgr misoprostol until start the pain or vaginal bleeding or abortion in 48 hr. in group 2, patients first received laminaria in cervix with duration of 6 hr and then oxytocin 50 unit in 500 cc normal saline in 3 hr. after 1 hr rest, oxytocin dosage elevated as multiple into 2 and continue until termination or maximum dose of 300 u in 500 cc normal saline. Data entered to SPSS software version 16 and analyzed with use of descriptive methods and also Chi-square and T-test.

RESULTS

In each group enrolled 50 women that approximately no different in baseline characteristic. Number of abortion in misoprostol group was more than oxytocin group (P<0.001) and duration of abortion also was shorter than oxytocin in misoprostol group (P<0.001). Side effects in 23 (46%) women in misoprostol group were seen but no side effect seen in oxytocin group. Complementally interventions was seen in 31 women (60%) in misoprostol group versus 32 women (62%) in oxytocin group but this difference was not significant (P>0.05).

CONCLUSION

This study demonstrated that misoprostol is effective than oxytocin in termination of pregnancy but with attention to limitation of this study include of limited abortion causes due to legal laws, additional studies on different doses of misoprostol and oxytocin due to achieve to suitable regimen with lower side effects recommended.