Comparison of gemeprost and vaginal misoprostol in first trimester mifepristone-induced abortion

Evaluation of Pain and Use of Analgesics during Medical Termination of Pregnancy in Real-Life Settings

INTRODUCTION

Women frequently report pain associated with medical termination of pregnancy (MToP), and its management can differ largely between centres. This study aimed at evaluating in real-life settings pain related to MToP and its management in France.

METHODS

This was a non-interventional prospective, longitudinal study run in 23 centres between 2015 and 2016 that included 893 pregnant women. Pain was reported by women prior any curative analgesic intake (CAI) through a five-level Likert scale (absence, mild, moderated, severe, extreme). Modalities of analgesic prophylaxis prescription (APP) and intake (API) and CAI were collected. Risk factors were investigated using ordinal logistic regression (for pain) or logistic regression (for CAI) with stepwise selection of variables.

RESULTS

APP was prescribed to 657 (73.7%) women irrespective of the gestational age, among whom 386 (73.7%) took the treatment. Out of 740 women who documented their pain symptoms prior to any CAI, few declared no pain (n = 94, 12.7%) or intense pain (n = 88, 11.9%). The majority reported mild or moderate pain (n = 558, 75.4%). On multivariate analysis adjusted on gestational age, increasing initial [odds ratio (OR) 1.25, 95% confidence interval (CI) 1.06-1.47] or total dose (OR 1.15, 95% CI 1.05-1.26) of misoprostol taken were independent factors associated with risk of more pain. When adjusting for gestational age, initial dose of misoprostol (OR 1.69, 95% CI 1.45-2.66) and pain experienced (OR 3.58, 95% CI 2.82-4.55) were significantly associated with higher risk of CAI while API (OR 0.52, 95% CI 0.36; 0.75) was negatively associated.

CONCLUSIONS

Most of the women received an APP, but not all used it. API and gestational age were not related to different risks of more pain following MToP, whereas history of at least one child showed a negative association. Higher doses of misoprostol were strongly associated with both pain and CAI. API was associated with a decreased risk of CAI.

Efficacy of mifepristone - Prostaglandin analogue combination in medical termination of pregnancy up to and beyond 7 weeks of amenorrhea: The RYMMa study

OBJECTIVE

To assess, in real-life conditions, the success rate of the protocol mifepristone 600 mg / prostaglandin analogue (PG) in women requesting medical termination of pregnancy (MToP) either up to or beyond 7 weeks of amenorrhea (WA).

STUDY DESIGN

The study was performed between 2015 and 2016. This was a non-interventional prospective, multicentre, longitudinal study conducted in France, among a sample of public and/or private centres dealing with MToP. Characteristics of women, term of Mtop, modality of PG used were reported. The primary outcome was success of MToP, defined as complete abortion without surgical procedure.

RESULTS

A total of 893 pregnant women with less than the legal term of 14 WA were included in this study: 490 (54.9 %) ≤7 WA and 403 (45.1 %) >7 WA comprising 29 > 9 WA. The mean age of women was 28.1 ± 6.8 years and the one of pregnancy was 7.0 WA ± 1.3 WA. The most frequently used PG combined to mifepristone 600 mg was misoprostol 400 μg (57.0 % ≤7 WA and 35.1 % >7 WA) or 800 μg per os (oral or oral transmucosal) (27.5 % ≤7 WA and 40.1 % >7 WA). Vaginal misoprostol (6.4 %, N = 48) and gemeprost (5.2 %, N = 39) were less used. In women ≤7 WA (N = 422) and women >7 WA (N = 354) for whom result of the MToP was collected, success rates were 94.5 % (95 %CI 91.9 %-96.5 %) and 92.4 % (95 %CI 89.1 %-94.9 %), respectively (p = 0.219). In multivariate regression analysis, three factors were significantly associated with a higher risk of MToP failure: increased number of previous pregnancies (OR = 1.233; 95 %CI 1.086-1.401 for one pregnancy), increased number of previous surgical ToPs (OR = 1.563; 95 %CI 1.036-2.359 for one ToP) and increased interval between mifepristone and PG intake (OR = 1.061; 95 %CI 1.012-1.112 for one hour). Term of pregnancy (OR = 1.497; 95 %CI 0.833-2.690 for ≤7 WA vs >7WA), administration route (OR = 1.553; 95 %CI 0.488-4.936 for oral vs oral transmucosal; and OR = 1.216; 95 %CI 0.625-2.366 for vaginal vs oral transmucosal), and dose of misoprostol (OR = 1.000; 95 %CI 0.999-1.001), were not associated with the risk of failure. Overall, tolerance was good.

CONCLUSION

This study showed, in real-life settings, a high rate of success for MToP using mifepristone 600 mg, independent of the pregnancy term and the therapeutic protocol used. MToP was safe and well tolerated however only a small number of women beyond 9 WA have been included.

Do women with a repeat termination of pregnancy prefer a medical or a surgical regimen?

We compared the risk of a repeat termination and the method of termination in women with a prior medical or surgical termination, or both, in a cohort study of women with a pregnancy termination at gestational age ≤63 days in 1999-2001. Within 5 years, 24% (330/1379) had a repeat abortion, and repeat terminations were more frequent in the surgical [27% (159/588)] than the medical group [22% (171/791)] (p < 0.05). The method used at the repeat termination was medical in 49% (83/171) of women with an earlier medical termination, compared with 13% (21/159) (p < 0.01) in women with an earlier surgical termination. In 125 women who had experienced both procedures, 37% (46/125) of the next terminations were performed medically and 63% (79/125) surgically (p < 0.01). Women in our study with a repeat termination tended to choose the same method as used before, and more often a surgical termination.

Service provision for women undergoing termination of pregnancy: progress in Wales, UK

BACKGROUND

This audit established a recent picture of termination of pregnancy services in Wales, UK using the Royal College of Obstetricians and Gynaecologists' Guidelines as a baseline. The context of abortion is rapidly changing and services need to be adaptable to meet women's needs.

METHODS

A questionnaire survey was sent to all National Health Service (NHS) Trusts in Wales; 10 out of 13 responded.

RESULTS

In the nine Trusts performing abortions in Wales, medical abortions accounted for 57% and surgical abortions for 43%. Doctors in training were involved in six Trusts. All but one Trust complied with referral times. Five Trusts provided a dedicated clinic. Written information provided prior to abortion varied in accessibility and quality. Choice of abortion within gestation bands was limited in some Trusts with some only providing medical termination. Essential abortion aftercare was performed by Trusts, whereas follow-up and counselling were less comprehensive.

DISCUSSION

Trusts are willing to adapt to new methods of working with an increasing number of medical terminations, although this advantage was offset by a lack of choice of abortion methods offered by some Trusts. Doctors in training should be offered exposure to abortion procedures in all Trusts as this has been shown elsewhere to improve attitudes. Providing dedicated abortion clinics, quality written information and comprehensive abortion aftercare should improve compliance with the guidelines.

CONCLUSION

Overall, in Wales there is compliance with national guidelines, although for a number of the guideline recommendations there remains room for improvement.

A review of developments in medical termination of pregnancy

AIM

This literature review aims to supplement guidelines by providing an overview of recent evidence relevant to medical termination of pregnancy.

BACKGROUND

Termination of pregnancy is available to women in the UK within legal parameters. Although guidelines form a strong body of evidence on which nurses and midwives can base their practice, there is a need to supplement them with up-to-date robust research findings.

METHOD

A systematic search of the literature with high sensitivity and low specificity was undertaken on five databases using medical subject headings (MeSH) terms including (medical) induced abortion, therapeutic abortion and termination of pregnancy.

RESULTS

The literature search revealed articles under the following headings: The importance of choice for the women involved the need for the optimal medication type, dose, route and interval between stages one and two, and the optimum place for medical termination to take place.

CONCLUSION

It was found that women attach a great deal of importance to the opportunity to choose their method of termination. The first stage of mifepristone is now a standard practice and an optimum dose has been determined. Several studies examined misoprostol used in the second stage of medical termination. There was some evidence for repeated doses of misoprostol, particularly in later gestation, with conflicting evidence on the optimal route. There were some grounds for reducing the interval between stages. Consideration should be given to home medical termination based on individual circumstances and choice. Gestation and previous obstetric history is an important factor to take into account when determining optimal regimen. Relevance to clinical practice. The number of medical termination of pregnancies performed has risen in recent years together with the nurses' involvement. As new research is published, it is imperative that nurses adapt to base their involvement on the best available evidence.

Alternatives to mifepristone for early medical abortion

OBJECTIVE

To review published reports of first-trimester medical abortion regimens that do not include mifepristone.

METHODS

Reports listed in Pubmed and Medline on prospective and controlled trials of the efficacy of misoprostol, alone or associated with methotrexate, for first-trimester abortion were analyzed if they included more than 100 participants and were published since 1990.

RESULTS

The efficacy of regimens using misoprostol alone ranged from 84% to 96%, and when misoprostol was used with methotrexate the efficacy ranged from 70% to 97%. Efficacy rates were influenced by follow-up interval. Treatment for infection, bleeding, and incomplete abortion were infrequent with both methods (0.3%-5%).

CONCLUSION

Alone or in combination with methotrexate, misoprostol is an efficacious alternative to mifepristone for the medical termination of pregnancy.