Termination of second-trimester pregnancy by mifepristone combined with misoprostol versus intra-amniotic injection of ethacridine lactate (Rivanol®): a systematic review of Chinese trials

Immediate and delayed placement of the intrauterine device after abortion: a systematic review and meta-analysis

This article aims to report the comprehensive and up-to-date analysis and evidence of the insertion rate, expulsion rate, removal rate, and utilization rate of immediate placement of intrauterine devices (IUDs) versus delayed placement after artificial abortion. PubMed, Embase, Cochrane, Web of Science, CNKI, and Wanfang databases were comprehensively searched up to January 12, 2024 for studies that compared immediate versus delayed insertion of IUDs after abortion. The evaluation metrics included the number of IUD insertion after surgical or medical abortions, the frequency of expulsion and removal at 6 months or 1 year, the number of continued usage, pain intensity scores, the number of infections, the duration of bleeding, and instances of uterine perforation during or after IUD insertion. Ten randomized controlled articles were eligible, comprising 11 research projects, of which 3 projects involved the placement of an IUD after surgical abortion, and 8 projects involved the placement of an IUD after medical abortion. This included 2025 patients (977 in the immediate insertion group and 1,048 in the delayed insertion group). We summarized all the extracted evidence. The meta-analysis results indicated that for post-surgical abortions, the immediate insertion group exhibited a higher IUD placement rate than the delayed insertion group. After medical abortions, the immediate insertion group showed higher rates of IUD placement, utilization, and expulsion at 6 months or 1 year. The two groups showed no statistically significant differences in the removal rate, post-insertion infection rate, pain scores during insertion, and days of bleeding during the follow-up period. Compared to delayed placement, immediate insertion of IUDs can not only increase the usage rate at 6 months or 1 year but also enhance the placement rate.

The Influence of Solvent on the Crystal Packing of Ethacridinium Phthalate Solvates

The synthesis, structural characterization and influence of solvents on the crystal packing of solvated complexes of ethacridine with phthalic acid: 6,9-diamino-2-ethoxyacridinium phthalate methanol solvate (1), 6,9-diamino-2-ethoxyacridinium phthalate ethanol solvate (2), 6,9-diamino-2-ethoxyacridinium phthalate isobutanol solvate (3), and 6,9-diamino-2-ethoxyacridinium phthalate tert-butanol solvate monohydrate (4) are described in this article. Single-crystal XRD measurements revealed that the compounds 1–4 crystallized in the triclinic P-1 space group, and the 6,9-diamino-2-ethoxyacridinium cations, phthalic acid anions and solvent molecules interact via strong N–H···O, O–H···O, C–H···O hydrogen bonds, and C–H···π and π–π interactions to form different types of basic structural motifs, such as: heterotetramer bis[···cation···anion···] in compound 1 and 2, heterohexamer bis[···cation···alcohol···anion···] in compound 3, and heterohexamer bis[···cation···water···anion···] in compound 4. Presence of solvents molecule(s) in the crystals causes different supramolecular synthons to be obtained and thus has an influence on the crystal packing of the compounds analyzed.

Mifepristone Followed by Misoprostol or Ethacridine Lactate and Oxytocin for Second Trimester Abortion: A Randomized Trial

Objective

To compare two medical methods for second-trimester abortion, mifepristone followed by misoprostol versus mifepristone followed by ethacridine lactate and oxytocin for success rate, induction to abortion time and acceptability.

Materials and Methods

This is a randomized trial conducted from July 2014 to May 2016 and enrolled 120 women undergoing second trimester abortion (13-20 weeks). All patients received 200mg mifepristone orally and were randomized to receive further treatment after 36 hrs. Patients in Group M (n=60) received 400 microgram of misoprostol vaginally every 3 hours (maximum - 5 doses) and Group E (n=60) had extra-amniotic ethacridine lactate instillation followed by oxytocin infusion (max-100miu).

Results

Baseline demographic characteristics were comparable in both the groups. Success rate was 100% in group M and 98.3% in group E (p=0.31). Mean induction to abortion time was significantly shorter in group M than group E (8.2+2.3hours & 10.9+2.6 hours respectively; p=0.001). Majority of women reported side effects, 96.7% women in group M and 75% women in group E (p=0.001). Fall in hemoglobin after procedure was significantly higher in group M (0.70+0.33gram %) than group E (0.52+0.23 gram %) (p=0.001). Perception of intensity of pain was significantly more in group M but patient satisfaction in both groups was similar.

Conclusion

Both methods are comparable for success rate, induction interval was more for ethacridine lactate compared to misoprostol.

Effects of prophylactic uterine artery embolization on second-trimester induced abortions in patients with placenta previa

OBJECTIVE

To evaluate the effects of prophylactic uterine artery embolization (UAE) on second-trimester induced abortions in patients with placenta previa.

METHODS

The present study was a retrospective review of second-trimester induced abortions in the presence of placenta previa that conducted between January 1, 2008, and October 31, 2017, at a university hospital in Hangzhou, China. Pregnancy outcomes including intraoperative blood loss, transfusion, dilatation and evacuation, hysterotomy delivery, and hysterectomy were compared between patients with and without prophylactic UAE.

RESULTS

There were 54 patients included in the study. In patients with partial placenta previa (n=15), the volume of intraoperative blood loss and the frequency of dilatation and evacuation were not significantly different between the UAE and non-UAE groups (P>0.05). No patient had a transfusion, hysterotomy delivery, or hysterectomy. Among patients with complete placenta previa (n=39), the volumes of intraoperative blood loss (P=0.014) and transfusion (P=0.046) were significantly lower in the UAE group compared with the non-UAE group. The rates of dilatation and evacuation, and hysterotomy delivery did not differ between the groups (P>0.05), but were numerically higher in the non-UAE group. No patient was treated with hysterectomy.

CONCLUSION

Prophylactic UAE before a second-trimester induced abortion had significant advantages in women with complete placenta previa, but it did not improve the pregnancy outcome in patients with partial placenta previa.

CHINESE CLINICAL TRIAL REGISTRY

ChiCTR-OPC-14005334.

Self-induced illegal abortion with Rivanol®: A medicolegal-toxicological case report

Approximately during the 30th week of pregnancy, a woman gave birth to a still-born child in a hospital. After first citing an extraneous cause for the premature still-birth, the woman later admitted to having self-induced the abortion by injecting the antiseptic Rivanol^® (active agent: ethacridine lactate) through her abdominal wall into the amniotic cavity. The investigating authorities ordered an autopsy of the fetus along with additional toxicological investigations. To the naked eye, no obvious cause of death was apparent. The main autopsy findings were four skin defects (puncture/stabbing wounds) on the ball of the fetus's left thumb, with slight bleeding around the punctures and into the underlying fatty tissue, and a yellowish discoloration of the fetus's body surface, especially of the umbilical cord and fingernails. On basis of the results, the child would have been viable. Femoral vein blood and urine from the fetus were analyzed for ethacridine, as were an amniotic fluid sample and maternal blood and urine samples, which had been collected as evidence. The concentration of ethacridine in the amniotic fluid was 16mg/l. In the postmortem fetal blood and urine samples, the concentrations were 0.36mg/l and 0.34mg/l, respectively, while concentrations of 0.091mg/l and 0.42mg/l, respectively, were found in the serum and urine samples from the mother. In many countries, foremost in China, ethacridine lactate, to which both mother and child are exposed, is widely used as safe abortion method. Although the ethacridine concentrations found in blood and urine samples of the mother in our case are consistent with published values, we believe to be the first to report postmortem ethacridine concentrations in a fetus. While exposure to ethacridine is not toxicologically relevant for the mother, it is fatal for the fetus because it causes the placental decidua capsularis to separate from the decidua parietalis or decidua placentalis, respectively. Prostaglandins that are then produced induce labor. In medicolegal contexts, the proof for an abortion through the administration of ethacridine lactate lies in the typical yellow discoloration of the fetus in conjunction with the toxicological demonstration of the substance in fetal body fluids, and if possible also in maternal body fluids.

Is progestogen supplementation necessary to prevent abortion?

A prospective study was conducted to evaluate the effect of progestogens on the pregnancy outcome of threatened abortion (TA). A total of 251 pregnant women less than 20 weeks of gestational age (GA) were included. Group 1 consisted of women with vaginal bleeding who had already been under treatment with progestogens and Group 2 was composed of women with vaginal bleeding who were only followed without progestogen therapy, whereas Group 3 was the control group without any vaginal bleeding or progestogen therapy. The pregnancy outcomes and serum progesterone levels were compared among the groups. The mean serum progesterone concentrations were statistically significantly higher in Group 1 in comparison to Group 2 and 3 (p < 0.001). Abortion rates were similar among the study groups. Although progestogen supplementation leads to increased level of serum progesterone, this finding does not translate to its beneficial effect on the pregnancy outcomes in cases of TAs.

Mifepristone combined with ethacridine lactate for the second-trimester pregnancy termination in women with placenta previa and/or prior cesarean deliveries

PURPOSE

This study was aimed to evaluate the safety and efficacy of the second-trimester medical abortions using mifepristone and ethacridine lactate in women with placenta previa and/or prior cesarean deliveries.

METHODS

The patients who underwent a second-trimester pregnancy termination from January 2009 to December 2015 were retrospectively analyzed. The eligible patients were assigned to four groups based on placentation and cesarean history. The abortion interval (AI), blood loss, hospital stays, incidence of curettage, and transfusion were reviewed.

RESULTS

Two women underwent cesarean sections for placenta increta. Finally, 443 patients were enrolled in this study, including 92 with placenta previa, 153 with prior cesarean deliveries, 36 with the both factors, and 236 with normal placentation and no cesarean delivery history. All the included cases had a successful vaginal delivery. There was no significant difference in AI, hospital stay, rate of hemorrhage, and transfusion among the four groups. Patients with prior cesarean section had higher blood loss than the normal group (P = 0.0017), as well as patients with both placenta previa and prior cesarean (P = 0.0018). However, there was no obvious blood loss in patients with placenta previa when compared with normal placetal patients (P = 0.23). No uterine rupture occurred in all patients.

CONCLUSIONS

Mifepristone combined with ethacridine lactate is safe and effective for patients with low placentation or/and prior cesarean in the second-trimester pregnancy termination.

Clinical analyses of 66 cases of mid-trimester pregnancy termination in women with prior cesarean

Background:

The rate of cesarean delivery has significantly increased in China in the last decade. Women with prior cesarean history tend to have a higher risk of uterine rupture during termination of the pregnancy in mid-trimester than those without such a history. The aim of our study was to evaluate the influences of the potential risk factors on uterine rupture in women with prior cesarean.

Methods:

We conducted this retrospective study of women with prior cesarean section, who underwent mid-trimester pregnancy termination between January 2006 and December 2013 in Peking Union Medical College Hospital. The protocol was oral administration of mifepristone and misoprostol for the patients with the gestational ages below 16 weeks or intra-amniotic injection of ethacridine lactate (EL) for those with at least 16 weeks of gestational ages. The thickness of the lower uterine segment (LUS) was measured before the termination of pregnancy. Logistic regression was used to study the risk factors of uterine rupture.

Results:

The total rate of successful abortion was 93.9% (62/66). Four patients failed in induction, and one of them received curettage, whereas the other three experienced uterine rupture (4.5%). The successful rates of abortion were 85.7% (30/35) for women treated with mifepristone-misoprostol and 86.1% (31/36) for those treated with EL. There was a significant difference in the mean LUS thickness between the uterine rupture group (3.0 ± 2.0 mm) and the nonrupture group (7.0 ± 3.0 mm) (P < 0.05). The LUS thickness of <3 mm was associated with uterine rupture during mid-trimester pregnancy termination in women with prior cesarean (odds ratio, 94.0; 95% confidence interval 4.2–2106.1) after adjusted maternal age, gestational age, interdelivery interval and prior cesarean section. Severe bleeding that required transfusion occurred in one case (1.5%).

Conclusions:

Both the mifepristone-misoprostol and the EL regimens were effective and safe for the termination of mid-trimester pregnancy in women with prior cesarean. A thinner LUS is associated with a relatively high risk of uterine rupture.

Small-molecule screening of PC3 prostate cancer cells identifies tilorone dihydrochloride to selectively inhibit cell growth based on cyclin-dependent kinase 5 expression

Cyclin-dependent kinase 5 (CDK5) is a potential target for prostate cancer treatment, the enzyme being essential for prostate tumor growth and formation of metastases. In the present study, we identified agents that target prostate cancer cells based on CDK5 expression. CDK5 activity was suppressed by transfection of PC3 prostate cancer cells with a dominant-negative construct (PC3 CDK5dn). PC3 CDK5dn and PC3 control cells were screened for compounds that selectively target cells based on CDK5 expression, utilizing the Johns Hopkins Drug Library. MTS proliferation, clonogenic and 3D growth assays were performed to validate the selected hits. Screening of 3,360 compounds identified rutilantin, ethacridine lactate and cetalkonium chloride as compounds that selectively target PC3 control cells and a tilorone analog as a selective inhibitor of PC3 CDK5dn cells. A PubMed literature study indicated that tilorone may have clinical use in patients. Validation experiments confirmed that tilorone treatment resulted in decreased PC3 cell growth and invasion; PC3 cells with inactive CDK5 were inhibited more effectively. Future studies are needed to unravel the mechanism of action of tilorone in CDK5 deficient prostate cancer cells and to test combination therapies with tilorone and a CDK5 inhibitor for its potential use in clinical practice.

Mifepristone: a potential clinical agent based on its anti-progesterone and anti-glucocorticoid properties

Nowadays, unwanted pregnancy is a major globe tragedy for millions of women, associated with significant direct and indirect costs, no matter for individuals or society. The progesterone receptor antagonist steroid, mifepristone has been widely and effectively using throughout the world for medical abortion, but to a lesser extent for emergency contraception. In this review, we hope to explore the role of mifepristone as a contraceptive, particularly for emergency contraception. Studies of mifepristone have also been expanding to the fields of endometriosis and uterine fibroids. Furthermore, this initially considered reproductive medicine has been investigated in some psychotic diseases and various disorders of hypercortisolism, because of its glucocorticoid receptor antagonism. Mifepristone was approved suitable for patients with hyperglycemia secondary to Cushing's syndrome by the United States Food and Drug Administration (FDA) in 2012. The aim of this article is to review published reports on the anti-progesterone and anti-glucocorticoid properties of mifepristone as a clinical agent. There is a new insight into systematically describing and evaluating the potential efficiency of mifepristone administrated in the field of endocrine and neuroendocrine, not only in obstetrics and gynecology.

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.

Progestogen for treating threatened miscarriage

BACKGROUND

Miscarriage is a common complication encountered during pregnancy. The role of progesterone in preparing the uterus for the implantation of the embryo and its role in maintaining the pregnancy have been known for a long time. Inadequate secretion of progesterone in early pregnancy has been linked to the aetiology of miscarriage and progesterone supplementation has been used as a treatment for threatened miscarriage to prevent spontaneous pregnancy loss.

OBJECTIVES

To determine the efficacy and the safety of progestogens in the treatment of threatened miscarriage.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2011) and bibliographies of all located articles for any additional studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compare progestogen with placebo, no treatment or any other treatment given in an effort to treat threatened miscarriage.

DATA COLLECTION AND ANALYSIS

At least two authors assessed the trials for inclusion in the review, assessed trial quality and extracted the data. Data were checked for accuracy.

MAIN RESULTS

We included four studies (421 participants) in the meta-analysis. In three studies all the participants met the inclusion criteria and in the fourth study, we included only the subgroup of participants who met the inclusion criteria in the meta-analysis. There was evidence of a reduction in the rate of spontaneous miscarriage with the use of progestogens compared to placebo or no treatment (risk ratio (RR) 0.53; 95% confidence interval (CI) 0.35 to 0.79). There was no increase in the rate of antepartum haemorrhage (RR 0.76; 95% CI 0.30 to 1.94), or pregnancy-induced hypertension (RR 1.00; 95% CI 0.54 to 1.88) for the mother. The rate of congenital abnormalities was no different between the newborns of the mothers who received progestogens and those who did not (RR 0.70; 95% CI 0.10 to 4.82).

AUTHORS' CONCLUSIONS

The data from this review suggest that the use of progestogens is effective in the treatment of threatened miscarriage with no evidence of increased rates of pregnancy-induced hypertension or antepartum haemorrhage as harmful effects to the mother, nor increased occurrence of congenital abnormalities on the newborn. However, the analysis was limited by the small number and the poor methodological quality of eligible studies (four studies) and the small number of the participants (421), which limit the power of the meta-analysis and hence of this conclusion.