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Zwerling B, Edelman A, Jackson A, Burke A, Prabhu M. 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. Am J Obstet Gynecol 2023:S0002-9378(23)00726-3. [PMID: 37821258 DOI: 10.1016/j.ajog.2023.09.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 10/13/2023]
Abstract
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.
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Affiliation(s)
- Blake Zwerling
- Department of Gynecology & Obstetrics, Division of Family Planning, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States.
| | - Alison Edelman
- Department of Obstetrics & Gynecology, Division of Complex Family Planning, Oregon Health & Science University, Portland, OR, United States
| | - Anwar Jackson
- Department of Obstetrics & Gynecology, Aurora Health Care, Milwaukee, WI, United States
| | - Anne Burke
- Department of Gynecology & Obstetrics, Division of Family Planning, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States
| | - Malavika Prabhu
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Massachusetts General Hospital, Obstetrics and Gynecology, Yawkey Center for Outpatient Care, Boston, MA, United States
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Zwerling B, Edelman A, Jackson A, Burke A, Prabhu WTAOM. 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. Contraception 2023:110143. [PMID: 37821241 DOI: 10.1016/j.contraception.2023.110143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 10/13/2023]
Abstract
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.
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Affiliation(s)
- Blake Zwerling
- Department of Gynecology & Obstetrics, Division of Family Planning, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States.
| | - Alison Edelman
- Department of Obstetrics & Gynecology, Division of Complex Family Planning, Oregon Health & Science University, Portland, OR, United States
| | - Anwar Jackson
- Department of Obstetrics & Gynecology, Aurora Health Care, Milwaukee, WI, United States
| | - Anne Burke
- Department of Gynecology & Obstetrics, Division of Family Planning, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States
| | - With The Assistance Of Malavika Prabhu
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Massachusetts General Hospital, Obstetrics and Gynecology, Yawkey Center for Outpatient Care, Boston, MA, United States
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Bettahar K, Koch A, Deruelle P. [Medical strategy for abortions between 14 and 16 weeks of gestation]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:735-740. [PMID: 36183986 DOI: 10.1016/j.gofs.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- K Bettahar
- Service de gynecologie obstetrique, CHU de Strasbourg, 1, place de l'Hôpital, BP 426, site du CMCO, 67091 Strasbourg cedex, France.
| | - A Koch
- Service de gynecologie obstetrique, CHU de Strasbourg, 1, place de l'Hôpital, BP 426, site du CMCO, 67091 Strasbourg cedex, France.
| | - P Deruelle
- Service de gynecologie obstetrique, CHU de Strasbourg, 1, place de l'Hôpital, BP 426, site du CMCO, 67091 Strasbourg cedex, France.
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Jayaweera RT, Moseson H, Gerdts C. Misoprostol in the era of COVID-19: a love letter to the original medical abortion pill. Sex Reprod Health Matters 2020; 28:1829406. [PMID: 33111643 PMCID: PMC7887983 DOI: 10.1080/26410397.2020.1829406] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Ruvani T Jayaweera
- Senior Project Manager, Ibis Reproductive Health, Oakland, CA, USA; Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, USA
| | - Heidi Moseson
- Epidemiologist, Ibis Reproductive Health, Oakland, CA, USA
| | - Caitlin Gerdts
- Vice-President for Research, Ibis Reproductive Health, Oakland, CA, USA
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Whitehouse K, Brant A, Fonhus MS, Lavelanet A, Ganatra B. Medical regimens for abortion at 12 weeks and above: a systematic review and meta-analysis. Contracept X 2020; 2:100037. [PMID: 32954250 PMCID: PMC7484538 DOI: 10.1016/j.conx.2020.100037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 01/14/2023] Open
Abstract
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.
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Affiliation(s)
- Katherine Whitehouse
- The UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Department of Reproductive Health and Research, Avenue Appia 20, 1211 Geneva, Switzerland
| | - Ashley Brant
- MedStar Washington Hospital Center, 110 Irving St., Washington, DC, 20010, USA
| | | | - Antonella Lavelanet
- The UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Department of Reproductive Health and Research, Avenue Appia 20, 1211 Geneva, Switzerland
| | - Bela Ganatra
- The UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Department of Reproductive Health and Research, Avenue Appia 20, 1211 Geneva, Switzerland
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Barinov SV, Tirskaya YI, Shamina IV, Medyannikova IV, Kadcyna TV, Shkabarnya LL, Lazareva OV. The use of an osmotic dilator for induction of miscarriage in patients with the second trimester missed miscarriage. J Matern Fetal Neonatal Med 2019; 34:2778-2782. [PMID: 31570024 DOI: 10.1080/14767058.2019.1671331] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AIM The aim of this study was to assess the outcomes of combined use of dilapan-S and pharmacological induction of miscarriage with mifepristone and misoprostol versus mifepristone and misoprostol only in patients with a second-trimester pregnancy loss. MATERIALS AND METHODS Our study included 74 patients with a second-trimester antenatal death who were randomized into two groups to receive pharmacological induction of miscarriage combined with intracervical insertion of dilapan-S (n = 37) or pharmacological induction of miscarriage only (n = 37). Efficacy endpoints included: blood loss volume, length of time between the procedure initiation and complete miscarriage, and the number of complications. RESULTS The use of dilapan-S together with mifepristone and misoprostol for induction of miscarriage in the second trimester in women with antenatal fetal death reduced the time from the start of the procedure to complete miscarriage by 1.98-fold. However, the use of dilapan-S did not significantly reduce the odds of such post-procedural complications as hematometra and retention of the products of conception in the uterus (p = .2501). CONCLUSIONS Combined management of antenatal pregnancy loss in the second trimester including intracervical insertion of dilapan-S and conventional induction with miscarriage may be considered a valuable clinical strategy. However, future studies should focus on ways to prevent postprocedural complications in this group of women.
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Affiliation(s)
- Sergey V Barinov
- 2nd Department of Obstetrics and Gynecology, Omsk State Medical University, Omsk, Russia
| | - Yuliya I Tirskaya
- 2nd Department of Obstetrics and Gynecology, Omsk State Medical University, Omsk, Russia
| | - Inna V Shamina
- 2nd Department of Obstetrics and Gynecology, Omsk State Medical University, Omsk, Russia
| | - Irina V Medyannikova
- 2nd Department of Obstetrics and Gynecology, Omsk State Medical University, Omsk, Russia
| | - Tatiana V Kadcyna
- 2nd Department of Obstetrics and Gynecology, Omsk State Medical University, Omsk, Russia
| | | | - Oksana V Lazareva
- 2nd Department of Obstetrics and Gynecology, Omsk State Medical University, Omsk, Russia
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Louie KS, Chong E, Tsereteli T, Avagyan G, Abrahamyan R, Winikoff B. Second trimester medical abortion with mifepristone followed by unlimited dosing of buccal misoprostol in Armenia. EUR J CONTRACEP REPR 2016; 22:76-80. [DOI: 10.1080/13625187.2016.1258461] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | | | | | - Gayane Avagyan
- Department of Obstetrics and Gynaecology No2, Yerevan State Medical University, Yerevan, Armenia
| | - Ruzanna Abrahamyan
- Republican Institute of Reproductive Health, Perinatology, Obstetrics and Gynaecology, Yerevan, Armenia
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Vaginal Misoprostol Compared With Buccal Misoprostol for Termination of Second-Trimester Pregnancy: A Randomized Controlled Trial. Obstet Gynecol 2015; 126:593-598. [PMID: 26181087 DOI: 10.1097/aog.0000000000000946] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the efficacy of vaginal misoprostol with buccal misoprostol for second-trimester termination of pregnancies. METHODS In a randomized trial, we compared 400 micrograms vaginal and buccal misoprostol every 3 hours for up to six doses for induction of labor at 13-24 weeks of gestation with a live fetus and intact membranes. Women who had a uterine scar were excluded from the study. The primary outcome of the study was induction-to-abortion interval. Based on a two-tailed α of 0.05, we planned to include 65 patients per group to detect a 50% difference in the primary outcome with a power of 80%. RESULTS From January 2014 to December 2014, 172 women were screened and 130 were randomized: 65 vaginal and 65 buccal misoprostol. Characteristics of patients were similar between groups. Patients administered vaginal misoprostol compared with buccal misoprostol had a shorter induction-to-abortion interval (25±17 hours compared with 40±29 hours, P=.001) and a higher abortion rate within both 24 hours (41 [63%] compared with 27 [42%] P=.014) and 48 hours (59 [91%] compared with 44 [68%], P=.001). Complete abortion rates were similar in both groups (vaginal 51 [78%] compared with buccal 54 [83%]). The incidence of side effects was similar for both groups. The perceived pain was higher in the buccal group, but the small difference did not appear to be clinically meaningful. CONCLUSION Vaginal compared with buccal misoprostol administration has a shorter induction-to-abortion interval for second-trimester termination of viable pregnancies. However, both administration routes are equally effective for induction of termination. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT02048098. LEVEL OF EVIDENCE I.
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A double-blind randomized controlled trial of mifepristone or placebo before buccal misoprostol for abortion at 14-21 weeks of pregnancy. Int J Gynaecol Obstet 2015; 130:40-4. [PMID: 25896965 DOI: 10.1016/j.ijgo.2015.02.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 01/27/2015] [Accepted: 03/27/2015] [Indexed: 11/22/2022]
Abstract
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.
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Patil E, Edelman A. Medical Abortion: Use of Mifepristone and Misoprostol in First and Second Trimesters of Pregnancy. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015. [DOI: 10.1007/s13669-014-0109-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Second-trimester postabortion care for ruptured membranes, fetal demise, and incomplete abortion. Int J Gynaecol Obstet 2015; 129:98-103. [PMID: 25660084 DOI: 10.1016/j.ijgo.2014.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 11/05/2014] [Accepted: 01/09/2015] [Indexed: 11/21/2022]
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Buccal versus vaginal misoprostol administration for the induction of first and second trimester abortions. J Obstet Gynaecol India 2014; 65:111-6. [PMID: 25883442 DOI: 10.1007/s13224-014-0605-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 09/15/2014] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES To compare the effectiveness, side effects, and patient satisfaction of buccal versus vaginal misoprostol administration in first and second trimester induced abortions. METHODS In first trimester, women received oral mifepristone followed by misoprostol either by buccal or vaginal route. In second trimester, women received oral mifepristone followed by repeated doses of misoprostol either by buccal or vaginal route. A comparative analysis using SPSS was done. RESULTS In first trimester, success rate of medical abortion was 96 % in buccal group and 88 % in vaginal group. Nausea was the most common adverse effect which was similar in both groups. In second trimester, success rate was 96 % in buccal group and 80 % in vaginal group. A statistically higher incidence of nausea was noticed in buccal group. Patient satisfaction level was almost similar in both the groups in both trimesters. CONCLUSIONS Buccal and vaginal routes of misoprostol administration have similar efficacy and patient satisfaction level for first and second trimester induced abortions. Hence, buccal route may serve as an alternative to vaginal misoprostol.
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Drey EA, Benson LS, Sokoloff A, Steinauer JE, Roy G, Jackson RA. Buccal misoprostol plus laminaria for cervical preparation before dilation and evacuation at 21-23 weeks of gestation: a randomized controlled trial. Contraception 2014; 89:307-13. [PMID: 24560477 DOI: 10.1016/j.contraception.2013.10.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 10/23/2013] [Accepted: 10/26/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To describe the effectiveness of buccal misoprostol as an adjunct to laminaria for cervical ripening before later second-trimester abortion by dilation and evacuation (D&E). METHODS A randomized, double-blinded, placebo-controlled trial of 196 women undergoing D&E between 21 and 23 weeks of gestation. Subjects had overnight laminaria and 400 mcg buccal misoprostol or placebo 3-4 h before the abortion. We used logarithmic transformation of the primary outcome--D&E procedure duration--to achieve a normal distribution. RESULTS Mean D&E duration was 1.7 min shorter with misoprostol (p=.02). The median duration was 9.7 versus 10.4 min in the misoprostol and placebo groups, respectively (p=.09). Cervical dilation was slightly greater with misoprostol (median 75 mm vs. 73 mm, p=.04); however, physicians did not find the misoprostol D&Es easier to complete. Half of subjects reported severe pain after misoprostol vs. 11% with placebo (p<.001). CONCLUSION Adjuvant buccal misoprostol results in slightly shorter D&Es at the cost of more side effects.
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Affiliation(s)
- Eleanor A Drey
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, USA
| | - Lyndsey S Benson
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, USA
| | - Abby Sokoloff
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, USA
| | - Jody E Steinauer
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, USA
| | - Geneviève Roy
- Department of Obstetrics and Gynecology, University of Montreal, Montréal, Québec, Canada
| | - Rebecca A Jackson
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, USA.
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Bracken H, Ngoc NTN, Banks E, Blumenthal PD, Derman RJ, Patel A, Gold M, Winikoff B. Buccal misoprostol for treatment of fetal death at 14–28 weeks of pregnancy: a double-blind randomized controlled trial. Contraception 2014; 89:187-92. [DOI: 10.1016/j.contraception.2013.11.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 11/06/2013] [Accepted: 11/15/2013] [Indexed: 10/26/2022]
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Abstract
Labor induction abortion is effective throughout the second trimester. Patterns of use and gestational age limits vary by locality. Earlier gestations (typically 12 to 20 weeks) have shorter abortion times than later gestational ages, but differences in complication rates within the second trimester according to gestational age have not been demonstrated. The combination of mifepristone and misoprostol is the most effective and fastest regimen. Typically, mifepristone 200 mg is followed by use of misoprostol 24-48 h later. Ninety-five percent of abortions are complete within 24 h of misoprostol administration. Compared with misoprostol alone, the combined regimen results in a clinically significant reduction of 40% to 50% in time to abortion and can be used at all gestational ages. However, mifepristone is not widely available. Accordingly, prostaglandin analogues without mifepristone (most commonly misoprostol or gemeprost) or high-dose oxytocin are used. Misoprostol is more widely used because it is inexpensive and stable at room temperature. Misoprostol alone is best used vaginally or sublingually, and doses of 400 mcg are generally superior to 200 mcg or less. Dosing every 3 h is superior to less frequent dosing, although intervals of up to 12 h are effective when using higher doses (600 or 800 mcg) of misoprostol. Abortion rates at 24 h are approximately 80%-85%. Although gemeprost has similar outcomes as compared to misoprostol, it has higher cost, requires refrigeration, and can only be used vaginally. High-dose oxytocin can be used in circumstances when prostaglandins are not available or are contraindicated. Osmotic dilators do not shorten induction times when inserted at the same time as misoprostol; however, their use prior to induction using misoprostol has not been studied. Preprocedure-induced fetal demise has not been studied systematically for possible effects on time to abortion. While isolated case reports and retrospective reviews document uterine rupture during second-trimester induction with misoprostol, the magnitude of the risk is not known. The relationship of individual uterotonic agents to uterine rupture is not clear. Based on existing evidence, the Society of Family Planning recommends that, when labor induction abortion is performed in the second trimester, combined use of mifepristone and misoprostol is the ideal regimen to effect abortion quickly and completely. The Society of Family Planning further recommends that alternative regimens, primarily misoprostol alone, should only be used when mifepristone is not available.
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