A Comparative Study of Misoprostol Only and Mifepristone Plus Misoprostol in Second Trimester Termination of Pregnancy

Efficacy of pharmacologic hemorrhage prophylactics in second-trimester abortions: a systematic review

OBJECTIVE

This study aimed to evaluate prophylactic uterotonics, antifibrinolytic medications, and vasoconstrictive agents in the prevention of hemorrhage during second-trimester abortions.

DATA SOURCES

PubMed, Embase (Elsevier platform), Evidence-Based Medicine Reviews (Ovid platform), and Web of Science were searched from database creation to October 30, 2023.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials, cohort studies, case-control studies, and case series evaluating pregnant individuals (between 13 0/7 and 27 6/7 weeks of gestation) who underwent dilation and evacuation and received prophylactic uterotonics (methylergonovine, carboprost, oxytocin, or misoprostol), antifibrinolytic medications (tranexamic acid), or vasoconstrictive agents (vasopressin, lidocaine with epinephrine) were included in the study. The outcomes of interest included postprocedural bleeding, rate of medications to treat bleeding, blood transfusion, reoperation, and transfer to a higher level of care for hemorrhage.

METHODS

Of note, 2 authors independently screened the abstracts using the Systematic Review Data Repository. A third reviewer resolved discrepancies. The full text of accepted abstracts was retrieved and assessed for eligibility by 2 independent authors. Eligible studies were independently assessed for quality and bias by 3 authors. A consensus review resolved discrepancies.

RESULTS

Among 5834 abstracts screened, 11 studies met the inclusion criteria: 5 randomized controlled trials, 3 retrospective cohort studies, and 3 case series, totaling 3857 individuals. The paucity of studies combined with the heterogeneity of included trials precluded the performance of the meta-analysis. Of note, 4 studies evaluating misoprostol were of overall low-quality evidence and primarily assessed misoprostol's use for cervical dilation. Thus, its efficacy in bleeding prophylaxis remains unclear. Moreover, 2 high-quality trials evaluating oxytocin concluded that oxytocin use resulted in decreased blood loss, without a difference in interventions to control bleeding. Furthermore, 2 studies provided moderate-quality evidence that paracervical vasopressin use decreased blood loss, particularly at advanced gestational ages, but subsequent intervention outcomes were not assessed. High-quality evidence evaluating methylergonovine found that this medication increased blood loss at the time of the procedure.

CONCLUSION

Current evidence on hemorrhage prophylaxis at the time of dilation and evacuation supports the use of intravenous oxytocin or paracervical vasopressin to decrease procedural blood loss, without an associated decrease in transfusion rate or use of other interventions. Future research on outcomes by gestational age can identify subgroups with the potential to derive the most benefit.

Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine

The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.

Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine

The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.

Comparison of mifepristone plus misoprostol with misoprostol alone for first trimester medical abortion: A systematic review and meta-analysis

Objective

To compare mifepristone plus a misoprostol-combined regimen with misoprostol alone in the medical abortion of first trimester pregnancy.

Methods

An internet-based search of available literature was performed using text words contained in titles and abstracts. PubMed/Medline, Cochrane CENTRAL, EMBASE, and Google scholar were used to locate English-based articles published until December 2021. Studies fulfilling the inclusion criteria were selected, appraised, and assessed for methodological quality. The included studies were pooled for meta-analysis, and the results were presented in risk ratio at a 95% confidence interval.

Findings

Nine studies comprising 2,052 participants (1,035 intervention and 1,017 controls) were considered. Primary endpoints were complete expulsion, incomplete expulsion, missed abortion, and ongoing pregnancy. The intervention was found to more likely induce complete expulsion irrespective of gestational age (RR: 1.19; 95% CI: 1.14–1.25). The administration of misoprostol 800 mcg after 24 h of mifepristone pre-treatment in the intervention group more likely induced complete expulsion (RR: 1.23; 95% CI: 1.17–1.30) than after 48 h. The intervention group was also more likely to experience complete expulsion when misoprostol was used either vaginally (RR: 1.16; 95% CI: 1.09–1.17) or buccally (RR: 1.23; 95% CI: 1.16–1.30). The intervention was more effective in the subgroup with a negative foetal heartbeat at reducing incomplete abortion (RR: 0.45; 95% CI: 0.26–0.78) compared with the control group. The intervention more likely reduced both missed abortion (RR: 0.21; 95% CI: 0.08–0.91) and ongoing pregnancy (RR: 0.12; 95% CI: 0.05–0.26). Fever was less likely to be reported (RR: 0.78; 95% CI: 0.12–0.89), whereas the subjective experience of bleeding was more likely to be encountered (RR: 1.31; 95% CI: 1.13–1.53) by the intervention group.

Conclusion

The review strengthened the theory that a combined mifepristone and misoprostol regimen can be an effective medical management for inducing abortions during first trimester pregnancy in all contexts. Specifically, there is a high-level certainty of evidence on complete expulsion during the early stage and its ability to reduce both missed and ongoing pregnancies.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019134213, identifier CRD42019134213.

A comparative study of second trimester termination of pregnancy with mifepristone and misoprostol vs misoprostol alone in 50 cases

The aim: To study the efficacy and safety of combined mifepristone and misoprostol used in second-trimester abortion(≥ 12 and ≤ 20 weeks) in comparison with only vaginal misoprostol. Materials and methods: This study was a prospective comparative randomised clinical study in women attending hospitals in need of a second-trimester abortion, i.e., 12–20 weeks of pregnancy were taken up and divided as Group A – 50 women with mifeprisptone and misoprostol, Group B – 50 women with misoprostol alone Results were analysed according to age, parity, gestational age, average dose of misoprostol required for complete abortion, Induction abortion interval, completeness of abortion, side effects and mean days of hospital stay. Results: Demographic details are comparable and insignificant in the comparison. The average dose of misoprostol (mcg) required for the completeness of abortion in group A is 596±28.28 mcg, and in group B, it is 1148±160.66 mcg (p<0.001) which is statistically significant. In the present study, the induction abortion interval is significantly less in group A compared to group B, with p<0.001. In addition, 10 out of 50 patients in group A aborted within 7 hours, whereas none in group B. Mean duration of hospital stay in group A is 24 hours. In group B, it is 34.82 hours which is statistically significant with a p-value of <0.001. 12 patients in group A and 26 in group B had side effects like nausea, vomiting, fever, headache and diarrhoea. 8 % of group A and 20 % of group B had a fever. These patients were treated with antipyretics. 6 % in group A and 14 % in group B had nausea and vomiting and were treated with antiemetics. 4 % in group A and 8 % in group B had diarrhoea and were treated with antimotility drugs. 6 % in group A and 10 % in group B had a headache; these patients were treated with NSAIDs. Conclusions: The combination of mifepristone and misoprostol is a highly effective and safe method for second-trimester termination of pregnancy. The amount of misoprostol needed to accomplish the abortion, and the severity of the adverse effects are lower in the mifepristone-primed group than in the misoprostol-alone group. Since there are fewer difficulties, this approach can be employed in hospitals with high patient density.

Assessment of the Attitude and Knowledge About Abortion and Its Consequences in Women Attending Obstetrics Unit at A Public Hospital: A Prospective, Descriptive Survey-Based Study

Aim: This study aimed at assessing the attitude and knowledge about abortion and its consequences in women attending obstetrics units at a public hospital. Methods: This was a prospective, descriptive survey-based study with a purposive sampling technique involving women above 18 years attending obstetrics and gynecology unit at a public hospital. Results: A total of 209 females were approached, finally 127 respondents agreed to participate in the study. About 85.04% (n=108) of them knew about abortion. 61.42% (n=78) of respondents indicated that they did not know the methods of abortion, and among them, 63.75% (n=49) were aware of unsafe abortion practices; very few of the respondents preferred the traditional practice for abortion. 56.69% (n=72) of the respondents were not aware of the possible dangers of abortion; and 85.83% (n=109) of the respondents would seek advice on abortion (if necessary) from a qualified doctor. Conclusion: The study participants demonstrated good knowledge and attitudes towards abortion and its consequences. The study also showed the maximum number of respondents who had heard about abortion but had less knowledge of the consequences of unsafe practices. The study revealed that respondents' age, number of children, religion, and educational level had no significant influence on their knowledge and attitude. Keywords: health surveys, complications, knowledge, spontaneous abortion

Mifepristone-Misoprostol Use for Second and Third Trimester Medical Termination of Pregnancy in a Canadian Tertiary Care Centre

OBJECTIVE

This study aims to evaluate the impact of the implementation a mifepristone-misoprostol protocol (MIFE/MISO) on the induction-to-expulsion interval in the context of second- and third-trimester pregnancy termination or intrauterine fetal death (IUFD) compared with misoprostol alone (MISO), and to share the experience of a Canadian tertiary hospital concerning the feasibility and safety of such a protocol.

METHODS

This is a single-centre retrospective pre-post cohort study carried out at the Centre Hospitalier Universitaire (CHU) Sainte-Justine between 2017 and 2019. Women in the MIFE/MISO group were instructed to take mifepristone 24-48 hours before induction. Induction in the MIFE/MISO group was performed with misoprostol dosages adjusted to gestational age and the presence of previous uterine scars, while, in the MISO group, all patients received 400 μg of misoprostol vaginally every 4 hours.

RESULTS

Ninety-four patients were included in the MIFE/MISO group and 103 patients, in the MISO group. Median time to expulsion was significantly lower in the MIFE/MISO group than the MISO group (13.5 and 19.5 h respectively; P < 0.001). The total dose of misoprostol administered was significantly lower in the MIFE/MISO group than the MISO group, and adverse effects were reported in 60% and 82% of patient records, respectively (P < 0.001). Complication rates were similar between the two groups.

CONCLUSION

The MIFE/MISO protocol is highly effective for second- and third-trimester induction for pregnancy termination or IUFD, without increasing complication rates and with fewer reported adverse effects. Its implementation is safe and feasible in a tertiary medical centre.

When there is only one patient: Induction of labour for termination of pregnancy

Induction of labour when no live birth is anticipated presents a number of unique considerations for members of the healthcare team. The main indication for Induction of Labour for Termination of Pregnancy (iTOP) is intrauterine fetal death (IUFD) beyond a gestational age where surgical management is available, but may also be indicated in the setting of induction abortion (with or without feticide), and termination of pregnancy (with or without infant palliation) for pregnancies where a lethal fetal anomaly is diagnosed. In tertiary care centres, iTOP may represent a significant proportion of labouring patients. Despite this, there are few guidelines dedicated specifically to iTOP in either obstetrical or family planning specialties. In this article, we will consider four main themes from an evidence-informed perspective: method selection; pre-induction preparation; clinical considerations during and after iTOP; and complications management.

Medical regimens for abortion at 12 weeks and above: a systematic review and meta-analysis

BACKGROUND

Mifepristone and misoprostol are recommended for second-trimester medical abortion, but consensus is unclear on the ideal regimen.

OBJECTIVES

The objectives were to systematically review randomized controlled trials (RCTs) investigating efficacy, safety and satisfaction of medical abortion at ≥ 12 weeks' gestation.

DATA SOURCES

We searched PubMed, Popline, Embase, Global Index Medicus, Cochrane Controlled Register of Trials and International Clinical Trials Registry Platform from January 2008 to May 2017.

STUDY ELIGIBILITY PARTICIPANTS AND INTERVENTIONS

We included RCTs on medical abortion at ≥ 12 weeks' gestation using mifepristone and/or misoprostol. We excluded studies with spontaneous abortion, fetal demise and mechanical cervical ripening and those not reporting ongoing pregnancy (OP).

STUDY APPRAISAL AND SYNTHESIS METHODS

After extracting prespecified data and assessing risk of bias in accordance with the Cochrane handbook, we used Revman5 software to combine data and GRADE to assess certainty of evidence.

RESULTS

We included 43 of the 1894 references identified. Combination mifepristone-misoprostol had lower rates of OP [risk ratio (RR) 0.12, 95% confidence interval (CI) 0.04-0.35] vs. misoprostol only. A 24-h interval between mifepristone and misoprostol had lower OP rate at 24 h than simultaneous dosing (RR 3.13, 95% CI 1.23-7.94). Every 3-h dosing had lower OP rate at 48 h (RR 0.39, 95% CI 0.17-0.88).

LIMITATIONS

Direct comparisons of buccal misoprostol to sublingual or vaginal routes after mifepristone were limited. Evidence from clinical trials on how to best manage women with prior uterine incisions was lacking.

CONCLUSION

Our analysis supports the use of mifepristone 200 mg 1 to 2 days before misoprostol 400 mcg vaginally every 3 h at ≥ 12 weeks' gestation.

IMPLICATIONS

Where available, providers should use mifepristone plus misoprostol for second-trimester medical abortion. Vaginal misoprostol appears to be most efficacious with fewest side effects, but sublingual and buccal routes are also acceptable.

No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods

OBJECTIVE

This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care.

INTENDED USERS

Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs.

TARGET POPULATION

Women with an unintended or abnormal first or second trimester pregnancy.

EVIDENCE

PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched.

VALUES

The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request.

BENEFITS, HARMS, AND/OR COSTS

IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.