Parity is a major determinant of success rate in medical abortion: a retrospective analysis of 3161 consecutive cases of early medical abortion treated with reduced doses of mifepristone and vaginal gemeprost

Clinical factors associated with subsequent surgical intervention in women undergoing early medical termination of viable or non-viable pregnancies

Introduction

Mifepristone-misoprostol treatment for medical abortion and miscarriage are safe and effective. This study aimed to assess clinical factors associated with subsequent surgical intervention after medical termination of early viable or non-viable pregnancy.

Methods

This retrospective, single-center study included women who underwent medical abortion at Taipei Medical University between January 2010 and December 2019. A total of 1,561 subjects, with 1,080 viable and 481 non-viable pregnancies, who were treated with oral mifepristone 600 mg followed by misoprostol 600 mg 48 h later were included. Data of all pregnancies and medical termination of pregnancy were evaluated using regression analysis. The main outcome was successful termination of pregnancy.

Results

The success rate of medical abortion was comparable in women with viable and non-viable (92.13% vs. 92.93%) pregnancies. Besides retained tissue, more existing pregnancies with ultrasonographic findings were found in the non-viable pregnancy group than in the viable pregnancy group (29.4% vs. 14.1%, p = 0.011). Multivariate analysis showed that previous delivery was an independent risk factor for failed medical abortion among all included cases. In women with viable pregnancy, longer gestational age [adjusted odds ratio (aOR): 1.483, 95% confidence interval (CI): 1.224-1.797, p < 0.001] and previous Cesarean delivery (aOR: 2.177, 95% CI: 1.167-40.62, p = 0.014) were independent risk factors for failed medical abortion. Number of Cesarean deliveries (aOR: 1.448, 95% CI: 1.029-2.039, p = 0.034) was an independent risk factor for failed medication abortion in women with non-viable pregnancies.

Conclusion

This is the first cohort study to identify risk factors for subsequent surgical intervention in women with viable or non-viable pregnancies who had undergone early medically induced abortions. The success rate of medical abortion is comparable in women with viable and non-viable pregnancies. Previous delivery is an independent risk factor for failed medical abortion. Clinical follow-up may be necessary for women who are at risk of subsequent surgical intervention.

Predicting the likelihood of successful medical treatment of early pregnancy loss: development and internal validation of a clinical prediction model

STUDY QUESTION

What are clinical predictors for successful medical treatment in case of early pregnancy loss (EPL)?

SUMMARY ANSWER

Use of mifepristone, BMI, number of previous uterine aspirations and the presence of minor clinical symptoms (slight vaginal bleeding or some abdominal cramps) at treatment start are predictors for successful medical treatment in case of EPL.

WHAT IS KNOWN ALREADY

Success rates of medical treatment for EPL vary strongly, between but also within different treatment regimens. Up until now, although some predictors have been identified, no clinical prediction model has been developed yet.

STUDY DESIGN, SIZE, DURATION

Secondary analysis of a multicentre randomized controlled trial in 17 Dutch hospitals, executed between 28 June 2018 and 8 January 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with a non-viable pregnancy between 6 and 14 weeks of gestational age, who opted for medical treatment after a minimum of 1 week of unsuccessful expectant management. Potential predictors for successful medical treatment of EPL were chosen based on literature and expert opinions. We internally validated the prediction model using bootstrapping techniques.

MAIN RESULTS AND THE ROLE OF CHANCE

237 out of 344 women had a successful medical EPL treatment (68.9%). The model includes the following variables: use of mifepristone, BMI, number of previous uterine aspirations and the presence of minor clinical symptoms (slight vaginal bleeding or some abdominal cramps) at treatment start. The model shows a moderate capacity to discriminate between success and failure of treatment, with an AUC of 67.6% (95% CI = 64.9-70.3%). The model had a good fit comparing predicted to observed probabilities of success but might underestimate treatment success in women with a predicted probability of success of ∼70%.

LIMITATIONS, REASONS FOR CAUTION

The vast majority (90.4%) of women were Caucasian, potentially leading to less optimal model performance in a non-Caucasian population. Limitations of our model are that we have not yet been able to externally validate its performance and clinical impact, and the moderate accuracy of the prediction model of 0.67.

WIDER IMPLICATIONS OF THE FINDINGS

We developed a prediction model, aimed to improve and personalize counselling for medical treatment of EPL by providing a woman with her individual chance of complete evacuation.

STUDY FUNDING/COMPETING INTEREST(S)

The Triple M Trial, upon which this secondary analysis was performed, was funded by the Healthcare Insurers Innovation Foundation (project number 3080 B15-191).

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov: NCT03212352.

Learning from experience: cellular and molecular bases for improved outcome in subsequent pregnancies

The frequencies of preeclampsia, fetal growth restriction, fetal demise, and low birthweight are lower in subsequent pregnancies. Enhanced maternal cardiovascular adaptation, shorter first and second stages of labor, and more robust lactation also have been observed in subsequent as compared with first pregnancies. We sought to investigate the cellular and molecular bases for better outcomes in subsequent pregnancies. Based on the knowledge that specialized immune cells at the maternal-fetal interface, decidual natural killer cells, promote development of the placental bed and conversion of the spiral arteries by secreting a myriad of angiogenic and growth factors, we asked whether decidual natural killer cells differ in subsequent as compared with first pregnancies. This idea stemmed from recent studies suggesting that natural killer cells, although part of the innate immune system, possess some features of adaptive immunity, including a certain type of immune cell memory, termed trained immunity. We found that decidual natural killer cells from parous women "remember pregnancy" and differ from decidual natural killer cells of primigravidae. Compared with the decidual natural killer cells of first pregnancy, these cells, that we termed pregnancy-trained decidual natural killer cells, express greater levels of the natural killer receptors NKG2C and leukocyte immunoglobulin-like receptor B1, which interact with ligands expressed on invasive trophoblasts. Furthermore, they secrete greater levels of several growth factors, including vascular endothelial growth factor α as well as interferon-γ, augmenting remodeling of the placental bed. We propose that this pregnancy-trained memory dwells in the epigenome, where memory of stimuli is known to persist even when the stimulus is no longer present. This epigenetic memory apparently resides in endometrial natural killer cells between pregnancies. We suggest that this trained memory, which we coined pregnancy-trained decidual natural killer cells, may be the missing link in the immune basis for enhanced subsequent pregnancy. Epigenetic memory (chromatin modification) also may afford a global explanation for additional findings of enhanced maternal cardiovascular adaptation, shorter first and second stages of labor, and more robust lactation. Understanding the molecular and cellular bases of improved outcomes of subsequent pregnancy may lead to the development of treatment modalities designed for women at high risk for pregnancy disorders originating at the maternal-fetal interface.

Risk factors for surgical intervention of early medical abortion

BACKGROUND

By being noninvasive, medical termination of pregnancy has increased worldwide access to abortion and improved safety of unsafe abortion. However, secondary surgical intervention is the most frequent complication to medical abortion.

OBJECTIVE

We aimed to identify and quantify risk factors for surgical intervention in women undergoing medically induced termination of pregnancy before 9 completed weeks of gestation.

STUDY DESIGN

We conducted a nationwide cohort study, including all pregnancies terminated before 63 gestational days in women aged 15-49 years during the period 2005-2015. Induction regimen was 200 mg mifepristone followed 24-48 hours later by 0.8 mg vaginal misoprostol. All included pregnancies were followed up for 8 weeks from mifepristone administration. Data were retrieved from national health registers. Multiple logistic regression provided adjusted odds ratios of surgical intervention with 95% confidence intervals. The discriminative ability of the risk factors in identifying surgical intervention was assessed by cross-validated area under the receiver operating characteristic curve.

RESULTS

Of 86,437 early medical abortions, 5320 (6.2%) underwent a surgical intervention within 8 weeks after induction. The proportion of surgical interventions increased from 3.5% in the 5th to 6th gestational week to 10.3% in week 9, odds ratio, 3.2 (95% confidence interval, 2.9-3.6). Compared with women aged 15-19 years, the risk of surgical intervention increased with increasing maternal age until the age of 30-34 years, odds ratio, 1.7 (95% confidence interval, 1.5-1.9), where after the risk decreased to an odds ratio for age group 40-49 of 1.2 (95% confidence interval, 1.0-1.4). Compared with nulliparous women, a history of only vaginal deliveries with spontaneous delivery of placenta implied an odds ratio of 1.1 (95% confidence interval, 1.0-1.2), women with a history of at least 1 cesarean delivery, an odds ratio of 1.5 (95% confidence interval, 1.3-1.6), and women having experienced a manual removal of placenta after a vaginal birth, an odds ratio of 2.0 (95% confidence interval, 1.7-2.4). Previous medically induced abortion decreased the risk of surgical intervention, odds ratio 0.84 (95% confidence interval, 0.78-0.91), whereas previous early (before 56 days of gestation) surgically induced abortion implied a 53% (95% confidence interval, 1.4-1.7) increased risk of surgical intervention. Previous surgical abortion after 55 days of gestation increased the risk by 17% (95% confidence interval, 1.1-1.3). The area under the receiver operating characteristic curve of the model including all quantified risk factors was 63% (95% confidence interval, 62-64%).

CONCLUSION

Gestational age, maternal age, previous deliveries, and history of medically and surgically induced abortions all had a significant influence on the risk of surgical intervention of early medical abortion. However, inclusion of all quantified risk factors still left most interventions unpredictable.

Drug Methods for Arteficial Termination of Unwanted Pregnancy

All medical and surgical procedures are carried out in order to premature termnination of pregnancy, can be divided on medicament and surgical methods, according to the way of procedure.

Medications used today in order to break unwanted pregnancy are inhibitors of the synthetics of progesterone and antiprogesterone, prostaglandini and antimetabolite.

Mifepristone is a derivate of norethidrone, binds to the progesterone receptor with an affinity similar progesterone, but it does not activate them so as to act as an antiprogestine.

Metotrexat is an antimetabolite and is used in gynecology practice for more indication areas. It is used the most often in conservative treatment of ectopical pregnancy. Because of low price and accessibility in order to mifepristone, it was used for application in drug methods of inducative abortions.

Misoprostol is an anlogue PGE1, used in peroral pills.

The complication are very rare at aplication of mifepristone and misoprostole in the aim to the termination the early unwanted pregnancy. The appearance of more efficient procedure of drugs called out abortions, it does not mean taht decision for the abortion is more modest. The ease and safety should not help to make a decision.

Serum β-hCG concentration is a predictive factor for successful early medical abortion with vaginal misoprostol within 24 hours

Objective

To evaluate the predictive factors associated with the success of medical abortion by misoprostol monotherapy within 24 hours in the first trimester of pregnancy.

Methods

The records of 228 women with miscarriage up to 11 weeks of gestational age who underwent medical abortion by intravaginal misoprostol monotherapy were reviewed. Success of abortion was defined as complete expulsion of the conceptus without the need for surgical intervention. Outcomes of interest were success of abortion within 24 hours following administration of misoprostol.

Results

Among 222 women who continued the process of medical abortion for 24 hours, 209 (94.1%) had a successfully completed abortion. Multivariate logistic regression showed that serum β-human chorionic gonadotropin (β-hCG) above 40,000 mIU/mL is significantly associated with failed medical abortion within 24 hours (odds ratio [OR], 7.13; 95% confidence interval [CI], 1.60–37.32; P=0.011). The area under the receiver operating characteristic curve of β-hCG level associated with successful abortion within 24 hours was 0.705 (95% CI, 0.63–0.77; P=0.007). Previous vaginal delivery seems to be significantly associated with successful abortion within 24 hours on univariate analysis (P=0.037), but the association was lost in multivariate analysis.

Conclusion

Misoprostol monotherapy has a high success rate for first trimester abortion. Women with serum β-hCG less than 40,000 mIU/mL are likely to achieve a successful abortion within 24 hours after intravaginal administration of misoprostol.

Clinical outcomes from a prospective study evaluating the role of ambulation during medical termination of pregnancy

BACKGROUND

Although induced abortion is one of the most commonly performed gynecological procedures in Great Britain and medical termination of pregnancy is being used more frequently, very little is known about the role of ambulation during the procedure. We sought to compare ambulatory and non-ambulatory groups of patients undergoing medical termination in the hospital setting and determine whether ambulation impacted clinical outcomes.

STUDY DESIGN

This was a prospective patient-preference study carried out among 130 women with pregnancies up to 63 days of gestation fulfilling the requirements of the 1967 Abortion Act and undergoing medical termination of pregnancy. The objective was to evaluate the effect of ambulation during medical termination of pregnancy. The women were given the choice to be ambulatory or non-ambulatory throughout the process of medical termination of pregnancy. They received 200 mg oral mifepristone and 800 mcg vaginal misoprostol for the termination procedure. Outcomes measured included time taken to pass the products of conception, first feeling of abdominal cramps, estimated blood loss, time to discharge from the hospital, pain scores and need for analgesia.

RESULTS

In both ambulatory and non-ambulatory groups, the mean time taken to pass the products of conception was similar: 230.7 min (118-343.4) and 233.0 min (134.5-331.5) for ambulatory and non-ambulatory patients, respectively. Time to onset of cramps was 75.6 min (29.4-121.8) for ambulatory and 91.7 min (22.2-161.2) for non-ambulatory patients, from administration of misoprostol. Mean estimated blood loss (assessed by weighing the pads as well as blood in bed pan) was less than 100 mL in both groups, and overall, approximately 85% of patients ranked their pain score as 3 or less (on a scale of 0-5). There were no statistically significant differences in the ambulatory versus non-ambulatory groups with regard to clinical outcomes.

CONCLUSION

Ambulation during medical termination of pregnancy neither appears to influence the amount of bleeding or pain nor hasten the process of medical termination of pregnancy.

Alternatives to ultrasound for follow-up after medication abortion: a systematic review

BACKGROUND

Requiring a follow-up visit with ultrasound evaluation to confirm completion after medication abortion can be a barrier to providing the service.

STUDY DESIGN

The PubMed (including MEDLINE), Cochrane Central Register of Controlled Trials and POPLINE databases were systematically searched in October and November 2009 for studies related to alternative follow-up modalities after first-trimester medication abortion to diagnose ongoing pregnancy or retained gestational sac. We calculated the sensitivity, specificity, positive predictive value and negative predictive value compared with ultrasound or clinician's exam. We also calculated the proportion of cases in each study with a positive screening test.

RESULTS

Our search identified eight articles. The most promising modalities included serum human chorionic gonadotropin measurements, standardized assessment of women's symptoms combined with low-sensitivity urine pregnancy testing and telephone consultation. These follow-up modalities had sensitivities ≥90%, negative predictive values ≥99% and proportions of "screen-positives" ≤33%.

CONCLUSIONS

Alternatives to routine in-person follow-up visits after medication abortion are accurate at diagnosing ongoing pregnancy. Additional research is needed to demonstrate the accuracy, acceptability and feasibility of alternative follow-up modalities in practice, particularly of home-based urine testing combined with self-assessment and/or clinician-assisted assessment.

Mifepristone for induction of labour

BACKGROUND

The steroid hormone, progesterone, inhibits contractions of the pregnant uterus at all gestations. Antiprogestins (including mifepristone) have been developed to antagonise the action of progesterone, and have a recognised role in medical termination of early or mid-trimester pregnancy. Animal studies have suggested that mifepristone may also have a role in inducing labour in late pregnancy.

OBJECTIVES

To determine the effects of mifepristone for third trimester cervical ripening or induction of labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register and reference lists of relevant papers (May 2009).

SELECTION CRITERIA

Clinical trials comparing mifepristone used for third trimester cervical ripening or labour induction with placebo/no treatment or other labour induction methods.

DATA COLLECTION AND ANALYSIS

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. For this update, two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Ten trials (1108 women) are included. Compared to placebo, mifepristone treated women were more likely to be in labour or to have a favourable cervix at 48 hours (risk ratio (RR) 2.41, 95% confidence intervals (CI) 1.70 to 3.42) and this effect persisted at 96 hours (RR 3.40, 95% CI 1.96 to 5.92). They were less likely to need augmentation with oxytocin (RR 0.80, 95% CI 0.66 to 0.97). Mifepristone treated women were less likely to undergo caesarean section (RR 0.74, 95% CI 0.60 to 0.92) but more likely to have an instrumental delivery (RR 1.43, 95% CI 1.04 to 1.96). Women receiving mifepristone were less likely to undergo a caesarean section as a result of failure to induce labour (RR 0.40, 95% CI 0.20 to 0.80). There is insufficient evidence to support a particular dose but a single dose of 200 mg mifepristone appears to be the lowest effective dose for cervical ripening (increased likelihood of cervical ripening at 72 hours (RR 2.13, 95% CI 1.15 to 3.97). Abnormal fetal heart rate patterns were more common after mifepristone treatment (RR 1.85, 95% CI 1.17 to 2.93), but there was no evidence of differences in other neonatal outcomes. There is insufficient information on the occurrence of uterine rupture/dehiscence in the reviewed studies.

AUTHORS' CONCLUSIONS

There is insufficient information available from clinical trials to support the use of mifepristone to induce labour. However, the studies suggest that mifepristone is better than placebo in reducing the likelihood of caesarean sections being performed for failed induction of labour; therefore, this may justify future trials comparing mifepristone with the routine cervical ripening agents currently in use. There is little information on effects on the baby.

Medical treatment with misoprostol for early failure of pregnancies after assisted reproductive technology: a promising treatment option

OBJECTIVE

To assess the success rate of misoprostol to induce abortion in early pregnancy failure and to define the factors associated with success of treatment.

DESIGN

Prospective study.

SETTING

University-affiliated tertiary medical center.

PATIENT(S)

Two hundred twenty women with the diagnosis of blighted ovum or missed abortion with a crown-rump length (CRL) up to 25 mm (<9 w).

INTERVENTION(S)

Treatment protocol included two doses of 800 microg misoprostol given vaginally and orally in intervals of 24 to 72 hours.

MAIN OUTCOME MEASURE(S)

Failure was defined as surgical intervention because of retained gestational sac, severe pain or bleeding, or suspected retained products of gestation after menstruation.

RESULT(S)

The treatment was successful in 77.2% (170/220) of the patients. Success rate was 72.5% (121/167) for pregnancies achieved spontaneously and 92.4% (49/53) among women who conceived after assisted reproductive technology (relative risk = 3.65: 95% confidence interval 1.378 to 9.667). Multivariate analysis showed that the risk of failure of medical abortion increased significantly for patients who had had at least five previous pregnancies (of them, three or more abortions) as compared with patients with one or two previous pregnancies only, and for those who conceived spontaneously as compared with pregnancies after ovulation induction.

CONCLUSION(S)

Medical treatment in early missed abortion is recommended especially for women with low gravidity and for those who conceived after assisted reproductive technology.

Collaboration with the voluntary sector in setting up an early medical abortion service in the PCT

The 1967 Abortion Act and the 1990 Human Fertilisation and Embryology Act amendment allow abortions in acute hospitals or licensed premises only. Provision of abortions in community unlicensed premises is unlicensed and not legal. At abortion assessment, counselling, chlamydia testing and/or treatment/partner notification and a contraceptive package is included. This works towards the overall aim of reducing unwanted pregnancies and reducing the burden of sexually transmitted infections in the community, thus removing the silo approach to abortion. A 92% completed abortion outcome was achieved. Route of administration of misoprostol will be reconsidered. Efficacy could be improved by vaginal administration. The findings support the introduction of an early medical abortion service in collaboration with a partner organisation. Our experience provides useful preliminary data for others contemplating a similar service, with room for improvement.

The levonorgestrel intrauterine system in nulliparous women

The levonorgestrel intrauterine system (LNG-IUS) has been used internationally for over 15 years by 7 million women. Concern about providing the LNG-IUS to nulliparous women still exists, despite growing evidence of its safety and efficacy in this population. Expulsion rates do not vary by parity and, although evidence in nulliparas is scant, perforation rates are low in all women. Efficacy of the LNG-IUS is excellent regardless of parity, with less than 1 pregnancy per 100 woman-years of use. Efficacy with immediate post-abortal insertion is also excellent and unvaried by parity. The presence of an LNG-IUS does not increase the risk of PID or infertility in either parous or nulliparous women and the LNG may be protective against infection. Acceptability is high in nulliparous women when compared either to parous LNG-IUS users or to nulliparous users of combined oral contraceptive pills. In conclusion, LNG-IUS is both safe and extremely efficacious for use in nulliparous women.

Does methotrexate confer a significant advantage over misoprostol alone for early medical abortion? A retrospective analysis of 8678 abortions

OBJECTIVE

The objective of this study was to compare efficacy for four medical abortion regimens used in one clinic setting: (1) misoprostol alone, (2) oral methotrexate + buccal misoprostol, (3) oral methotrexate + vaginal misoprostol, and (4) intramuscular methotrexate + vaginal misoprostol.

DESIGN

Retrospective analysis of data from clinical records.

SETTING

An anonymous women's health centre in Latin America, providing medical abortion services since 2001 in a highly restrictive setting.

POPULATION

A total of 8678 women with gestations <56 days, who sought a medical abortion between April 2002 and December 2004.

METHODS

Chi-square test was performed to compare patient characteristics by abortion outcome (success/failure). The impact of selected variables on method success was explored through logistic regression. A second regression analysis was conducted with a subsample (n = 4022), for which data on parity and previous abortion(s) were available.

MAIN OUTCOME MEASURE

Abortion outcome (success/failure) at 2-week follow up.

RESULTS

Success rates for the three methotrexate regimens ranged from 81.7 to 83.5% and did not differ significantly; misoprostol-alone regimen had a success rate of 76.8%. Efficacy was significantly higher for the three combined methotrexate regimens compared with misoprostol alone and remained so in the multivariate model (OR = 1.35). In the final regression, lower gestational age, being nulliparous, and having no previous abortions were positively correlated with method success.

CONCLUSIONS

In this real-use setting, methotrexate appears to confer a significant advantage over misoprostol alone for early medical abortion. This finding is important for settings where mifepristone remains unavailable. Additional factors such as gestational age limits and patient preference should be considered in regimen selection.

Sonographic appearance of the uterine cavity following administration of mifepristone and misoprostol for termination of pregnancy

PURPOSE

To describe the sonographic appearance of the uterine cavity in women after administration of mifepristone and misoprostol for termination of pregnancy.

METHODS

Thirty-six women treated with mifepristone 600 mg followed by misoprostol 400 mug 2 days later for termination of pregnancy were the subjects of the study. Gestational age as calculated from the last menstrual period was < or =49 days. Pretreatment sonographic parameters, including gestational sac size and crown-rump length, were measured. The sonographic appearance of the uterine cavity was recorded and documented 6 hours (T-1) and 14 days (T-2) after administration of misoprostol.

RESULTS

The mean menstrual age of the patients was 42 days (range 31-49 days). The mean gestational age according to crown-rump length was 43 days (range 40-48 days). Sonographic examination performed atT-1 revealed 23 patients (62.9%) with a well-defined echogenic mass located in the uterine cavity, 2 patients (5.5%) with an intrauterine sac containing a nonviable embryo, and 11 patients (30.5%) with an endometrium thickness of 7-14 mm with no evidence of intrauterine contents. Doppler flow signals were detected in 15 of the 23 patients (65.2%) with an echogenic intrauterine mass. Sonographic examination performed at T-2 revealed 19 patients (52.8%) with a persistent echogenic intrauterine mass; Doppler flow could be detected in 15 of these patients (78.9%). Dilatation and curettage was required in 2 patients (5.6%) due to failure of treatment; all others regained normal menses.

CONCLUSIONS

An intrauterine echogenic mass with well-defined borders, with or without Doppler flow signals, can be detected 2 weeks after administration of mifepristone and misoprostol for termination of pregnancy. Because most of the women in our study regained normal menses without further surgical intervention, this finding could indicate remnants of trophoblastic tissue evacuated spontaneously from the uterine cavity. Therefore, dilatation and curettage should be avoided in these cases, unless clinical symptoms or signs necessitate surgical intervention.

Mifepristone dose in the regimen with misoprostol for medical abortion

Medical abortion with the antiprogesterone mifepristone followed by a prostaglandin is highly effective and widely used. The mifepristone dose registered is a single dose of 600 mg followed by a suitable prostaglandin analogue 36-48 h later. The 600-mg dose was chosen arbitrarily, and later studies have proven one third of this dose to be equally effective when combined with a prostaglandin analogue. This report reviews published data on the efficacy of mifepristone in different doses and demonstrates that there are no differences neither clinically nor in pharmacokinetics if the dose is reduced to 200 mg.

Induction of second trimester abortion (12–20 weeks) with mifepristone and misoprostol: a review of 386 consecutive cases

DESIGN

A retrospective analysis of 386 women who underwent termination of pregnancy between 12 and 24 weeks' gestation.

METHODS

Each woman received 200 mg mifepristone orally followed by vaginal misoprostol 800 microg 36 to 48 h later. Three hours after the initial misoprostol administration, 400-microg doses of vaginal misoprostol were administered every 3 h, to a maximum of four doses in 24 h. If abortion failed, 200 mg mifepristone is given again 3 h after the last misoprostol dose, followed by 12 h of rest before vaginal misoprostol administration is repeated as per previous course of treatment.

RESULTS

Overall, 97.9% and 99.5% of the women aborted within 24 and 36 h, respectively. The median induction-to-abortion interval was 6.7 h (range: 1.4-73.8 h), and nulliparous women took significantly longer time to abort (6.0 h in multiparous women compared to 7.6 h in nulliparous women; p<.0001). One woman failed to abort within 48 h. Surgical evacuation of the uterus was performed in 5% of women for incomplete abortion or retained placenta. Multiparous women were less likely to need analgesic administration for pain relief, and to experience vomiting and diarrhea, than nulliparous women.

CONCLUSION

The combination of 200 mg mifepristone and vaginally administered misoprostol is a safe, effective and noninvasive regimen for termination of pregnancy between 12 and 20 weeks.

Home self-administration of misoprostol for medical abortion up to 56 days' gestation

OBJECTIVE

Studies from the USA have suggested the feasibility and acceptability of home medical abortion, however the issue has not been addressed in the UK. This study aimed to assess the feasibility, efficacy and acceptability of home self-administration of misoprostol for medical abortion up to 56 days' gestation.

METHODS

Mifepristone 200 mg was given orally in hospital under nursing supervision. Women were provided with misoprostol tablets 600 microg and advised to take them sublingually 36-48 hours later. The main outcome measures were (1) feasibility, assessed through successful completion of abortion at home without the need for hospital admission, (2) efficacy, assessed through complete uterine evacuation without the need for further medical or surgical intervention and (3) women's acceptability of the procedure as assessed by questionnaire.

RESULTS

A total of 49 women participated in this study. Of these, 48 women aborted at home while one opted to be admitted to hospital after receiving misoprostol at home. One woman underwent surgical evacuation 5 weeks following abortion for excessive bleeding and retained products of conception. A total of 43/44 (98%) women were satisfied with having the abortion at home. Side effects experienced by women included nausea [32/40 (80%], vomiting [17/41 (42%)], diarrhoea [17/41 (42%)], shivering [26/40 (65%)], tiredness [32/40 (80%)], headache [12/39 (31%)], hot flushes [14/40 (35%)], dizziness [24/39 (62%)] and unpleasant mouth taste [19/38 (50%)].

CONCLUSIONS

This study suggests the feasibility and acceptability of home self-administration of misoprostol for medical abortion up to 56 days' gestation. These findings need to be assessed in the context of a randomised trial.

A randomised controlled trial of mifepristone in combination with misoprostol administered sublingually or vaginally for medical abortion up to 13 weeks of gestation

OBJECTIVE

To assess women's acceptability, the efficacy and side effects of sublingual versus vaginal administration of misoprostol in combination with mifepristone for medical abortion up to 13 weeks of gestation.

DESIGN

Randomised controlled trial.

SETTING

Aberdeen Royal Infirmary.

POPULATION

Women undergoing medical abortion under the terms of the 1967 Abortion Act.

METHODS

Mifepristone (200 mg) was given orally followed 36-48 hours later by misoprostol administration (sublingual: 600 microg; vaginal: 800 microg). A second dose of misoprostol 400 microg was given 3 hours later (sublingually or vaginally). Women between 9 and 13 weeks of gestation received a further (third) dose of misoprostol 400 microg (sublingually or vaginally), 3 hours later if abortion had not occurred.

MAIN OUTCOME MEASURES

Women's acceptability, efficacy of the regimen and side effects experienced.

RESULTS

A total of 340 women were recruited (171 sublingual and 169 vaginal). A total of 70% of women in the sublingual group expressed satisfaction with the route of misoprostol administration; 18% answered 'Don't know' while 12% were dissatisfied, compared with 68%, 28% and 4%, respectively, in the vaginal group (P= 0.02). There was no significant difference in the need for surgical evacuation for women in the sublingual (3/158, 1.9%) and vaginal groups (4/156, 2.6%) (P= 0.70). Women receiving misoprostol sublingually were more likely to experience diarrhoea (P < 0.01), shivering (P < 0.01) and unpleasant mouth taste (P < 0.01).

CONCLUSIONS

Sublingual administration of misoprostol is an effective alternative to vaginal administration for medical abortion up to 13 weeks of gestation. The prevalence of prostaglandin-related side effects, however, was higher with this route of administration.

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

BACKGROUND

The aim of this study was to compare efficacy and side effects of gemeprost and vaginal misoprostol in mifepristone-induced abortions in women up to 63 days of gestation.

METHODS

A retrospective study of 833 consecutive patients admitted for medical termination of first trimester pregnancy was conducted. Four-hundred ten patients received mifepristone 600 mg, followed 48 h later by gemeprost 1 mg (regimen I), and 423 patients received mifepristone 200 mg followed by vaginal misoprostol 800 microg (regimen II). Success rates were evaluated after 2 weeks and after 3 months. The severity of bleeding and side effects (pain, nausea, vomiting and diarrhea) was scored by the patients, and requests for supplementary analgesic treatment were recorded by the attending nurse.

RESULTS

Success rates were 99% in both groups after 2 weeks of follow-up. At 3 months of follow-up, success rates had declined to 94% for regimen I and 96% for regimen II. The frequency of severe pain was higher in regimen I compared to regimen II (72% vs. 60%, p < .001), but the severity of bleeding and gastrointestinal side effects was similar in the two regimens.

CONCLUSION

When combined with mifepristone, gemeprost and vaginal misoprostol are equally effective for termination of first trimester abortion, but may be associated with varying intensity of side effects.

The acceptability of home medical abortion to women in UK settings

OBJECTIVE

To assess the acceptability of home medical abortion to women in UK settings.

DESIGN

Questionnaire survey.

SETTING

Four NHS gynaecology units in England and Scotland.

SUBJECTS

Women undergoing conventional, hospital-based, medical abortion up to nine weeks of gestation.

METHODS

A self-complete questionnaire explored the acceptability of abortion in hospital (including pain and bleeding experienced) and at home. Comparisons were made between centres (English and Scottish).

MAIN OUTCOME MEASURE

Women's views on home administration of misoprostol for medical abortion; perceived acceptability and perceived ability to cope with the process at home.

RESULTS

Sixty-six percent (366/553) of the questionnaires were returned: Edinburgh, 204 (56%); London, 92 (25%); Hull, 43 (12%); and Glasgow, 27 (7%). Individual questionnaire items were answered by varying numbers of women: 228/320 (71%; 95% CI: 66-76%) said there was nothing that happened during abortion in the hospital that they would have been unable to cope with at home; 123/342 (36%; 95% CI: 31-41%) said they would have opted to have home abortion, had that choice been available. However, 219/342 (64%; 95% CI: 59-69%) indicated that they would prefer to have abortion in the hospital. The majority of women said they would have coped at home with bleeding (280/355, 79%; 95% CI: 74-83%) and with pain if given analgesia (203/268, 76%; 95% CI: 70-81%).

CONCLUSION

This study suggests that most women would welcome being offered the choice of having medical abortion at home or in hospital. The development of home abortion must be seen as complementary, not an alternative, to hospital services.

Medical abortion at 9–13 weeks' gestation: a review of 1076 consecutive cases

OBJECTIVE

The aim of the study was to assess the use, efficacy and factors influencing the outcome of medical abortion at 9-13 weeks' gestation.

METHODS

Retrospective chart review of consecutive women undergoing medical abortion at 9-13 weeks' gestation was done.

RESULTS

A total of 1927 abortions were carried out at 9-13 weeks' gestation, of which 1076 (55.8%) were undertaken medically. Efficacy decreased with increasing gestation (p=.02). Surgical evacuation was carried out in 45 (4.2%) women including 10 (2.7%) at 64-70 days, 11 (3.3%) at 71-77 days, 10 (5.1%) at 78-84 days and 14 (8.0%) at 85-91 days of gestation (p=.02). Indications for surgery included continuing pregnancy [16 (1.5%) women], retained sac [5 (0.5%)], incomplete abortion [20 (1.9%)] and emergency curettage for bleeding [4 (0.4%)]. The number of misoprostol doses used and the induction-to-abortion interval both significantly increased with gestation (p<.001), while analgesia requirements did not vary with increasing gestation (p=.18).

CONCLUSIONS

Medical abortion at 9-13 weeks' gestation is an effective alternative to surgery. Medical methods should be offered routinely at these gestations, thus increasing women's choice.

Randomized, double-blind, controlled trial of mifepristone in capsule versus tablet form followed by misoprostol for early medical abortion

OBJECTIVE

To compare the efficacy and side-effects of mifepristone 75 mg in capsule form versus 150 mg in tablet form followed by misoprostol for medical termination of early pregnancy.

STUDY DESIGN

In a prospective randomized, double-blind, placebo-controlled trial, a total of 480 women who were 49 days or less pregnant were randomized by means of a random number table to receive either two tablets in the morning and one tablet 12 h later for 2 days (group A) or three capsules orally twice daily for 2 days, the first dose being double all subsequent doses (group B). After a further 48 h, 600 microg misoprostol was given orally. Successful abortion was defined as complete abortion with no need for surgical aspiration.

RESULTS

There were no significant differences between the two study groups in the rates of complete abortion (95.4% in group A versus 96.3% in group B), incomplete abortion (3.8% in group A, 3.3% in group B) and continued pregnancy (0.8% in group A, 0.4% in group B). No significant difference in the duration and amount of vaginal bleeding was observed. The incidence of side-effects, such as vomiting, nausea, headache, diarrhea and lower abdominal pain was similar in the two groups.

CONCLUSIONS

Our results indicate that 75 mg mifepristone in capsule form combined with 600 microg misoprostol is as effective and safe as 150 mg mifepristone in tablet form for the termination of pregnancy up to 49 days.

A short-scheme protocol of gemeprost for midtrimester termination of pregnancy with uterine scar

OBJECTIVE

The purpose of this study is to investigate the safety and effectiveness of a short-scheme protocol of gemeprost for second trimester induction of abortion in women with previous uterine surgery.

STUDY DESIGN

Retrospective review of women who underwent second trimester medical termination of pregnancy (TOP) at our hospital in a 5-year period. A short regimen of gemeprost was used: over a 24-h period, 1 mg vaginal gemeprost was given every 3 h up to three doses after which, if abortion did not occur, another course at the same dosage schedule was administered up to 4 days. Induction failure was defined as women undelivered by 96 h. A homogeneous population was identified. Statistical analysis was performed with the chi(2) test or Fisher's Exact Test for categorical data and t test for continuous variables.

RESULTS

Four hundred seventeen women underwent medical midtrimester TOP in the 5-year study period. Two hundred five patients were selected for this review, comparing 63 patients with scarred uterus to 142 women without uterine scars. There were no differences between the two groups in induction-to-abortion interval and number of pessaries given. The overall failure of induction rate was 1.5% and need for blood transfusion was 0.5%. No uterine rupture was reported.

CONCLUSION

The regimen of gemeprost proposed seems to be as safe and effective in patients with uterine scars as in women with unscarred uteri with a very low incidence of complications.

[Present and potential uses of mifepristone in gynecology, obstetrics and other medical specialties]

Mifepristone, a derivative of norethindrone, a first generation synthetic progestative, has a very potent antiprogestative activity and to a lesser degree antiandrogenic and antiglucocorticoid activities. This action makes it potentially useful in the treatment of multiple hormone dependent diseases in obstetrics-gynecology as well as in a variety of medical specialties such as neurology, ophthalmology, and oncology. Nevertheless, the label of abortive pill has incited numerous ethical and political debates concerning the permission to market this drug, and this has contributed to the delay in the assessment of the potential indications of mifepristone. Largely under-utilized in practice despite its increasing theoretical benefit, clinical studies should now de conducted. Thus, based on an international review of literature during the last ten years, we have shed light on the present and potential indications of mifepristone in medical practice.

Medical termination of pregnancy in the early first trimester

Surgical abortion using vacuum aspiration or dilatation and curettage has been the method of choice for termination of pregnancy up to 63 days' gestation since the 1960s. Over the last three decades many studies have explored the use of medical methods for inducing abortion at these gestations. Earlier regimens assessed the systemic and intrauterine injection of prostaglandins. This was followed in the 1980s by the introduction of the antiprogesterone, mifepristone. Since its introduction, the uptake of medical abortion has been steadily increasing in countries where it has been available for routine use. Most current clinical protocols require the use of prostaglandins in combination with anti-progesterones or antimetabolites. The safety, efficacy and acceptability of the medical regimen are now well established at all gestations of pregnancy. Provision of medical abortion increases the choice available to women, in particular those wishing to avoid surgery.

Medical versus surgical abortion efficacy, complications and leave of absence compared in a partly randomized study

To provide optimal information to women choosing between early medical and surgical abortion, rigorous comparisons of the two methods are warranted. We compared the outcome of 1135 consecutive women with gestational age (GA) < or = 63 days receiving either a medical (600 mg mifepristone and 1 mg gemeprost) or a surgical abortion (vacuum aspiration in general anesthesia). One hundred eleven of these women were randomized for abortion method. Surgical interventions and complications leading to readmission within the following 15 weeks were identified through a computer system. Information about antibiotic treatment, leave of absence and number of contacts to the health care system were obtained from mailed questionnaires. The number of complications was identical after the two methods, but surgical abortion was associated with a higher success rate [97.7% (708/725) vs. 94.1% (386/410), p < .01] and also with a higher risk of antibiotic treatment than medical abortion [7.8% (37/467) vs. 3.7% (13/356), p < .05]. The median leave of absence was shorter in women choosing a medical (1 day) than a surgical termination (2 days), p < .05. On average, one third of all the women requested at least one extra unscheduled consultation apart from a routine follow-up visit. We conclude that the chance of a primary successful termination at GA < or = 63 days is higher after a surgical abortion in general anesthesia compared to a medical abortion induced with 600 mg mifepristone and 1 mg gemeprost. A surgical abortion is associated with an increased risk of antibiotic treatment compared to medical abortion. The women's need for follow-up might be higher than we expect.

Analgesia requirements and predictors of analgesia use for women undergoing medical abortion up to 22 weeks of gestation

OBJECTIVE

To assess analgesia use and the predictors for requiring analgesia in women undergoing medical abortion at all gestations up to 22 weeks.

DESIGN

Retrospective observational study.

SETTING

Aberdeen Royal Infirmary, Scotland.

POPULATION

Consecutive women undergoing medical abortion under the terms of the 1967 Abortion Act.

METHODS

Analgesia requirements and characteristics of women undergoing abortion were analysed using logistic regression.

MAIN OUTCOME MEASURES

The effect of age, gestation, reproductive history, route and dose of misoprostol administration on analgesia requirements.

RESULTS

Of the total 4343 women included in this review, 3139 women (72%) required analgesia. Of these, 3054 women (97%) used oral analgesia, 75 women (2.4%) used opiates while 10 women (0.3%) had diclofenac sodium given rectally. There was no significant difference in analgesia use whether women used the vaginal or sublingual route of misoprostol administration. Logistic regression showed a significant positive association with gestation at termination (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.05-1.12), number of misoprostol doses used (OR 1.31, 95% CI 1.13-1.51) and induction to abortion interval (OR 1.08, 95% CI 1.03-1.12) and a negative association with the age of women undergoing abortion (OR 0.98, 95% CI 0.97-0.99) and previous live birth (OR 0.43, 95% CI 0.33-0.56).

CONCLUSIONS

Analgesia requirement was significantly higher in women of younger age, higher gestation, longer induction to abortion interval and with increased number of misoprostol doses used while women with previous live birth were significantly less likely to use analgesia.

Infection after medical abortion: A review of the literature

Medical abortion regimens have become widely used, but the frequency of infection after medical abortion is not well documented. This systematic review provides data on infectious complications after medical abortion. We searched Medline for articles written before July 2003 to determine the frequency of infection after medical abortion up to 26 weeks of gestation. We reviewed all articles and extracted data on the frequency of infection from 65 studies. The frequency of diagnosed and/or treated infection after medical abortion was very low (0.92%, N = 46,421) and varied among regimens. Results of this review confirm that, with respect to infectious complications, medical abortion is a safe and effective option for first- and second-trimester pregnancy termination. After accounting for regional variations in diagnosis, there is little difference in frequency of infection among the regimens reviewed. Future studies should report clear diagnosis and treatment standards for infection so that more precise information becomes available.

Ectopic Pregnancy and Medical Abortion

OBJECTIVE

Medical abortion regimens have become more widely used to terminate early pregnancies. Medical abortion providers are concerned to diagnose and exclude women with ectopic pregnancy before initiating treatment, as with any early pregnancy termination. Yet, there is little information about whether the various pretreatment screening methods used are adequate. We reviewed published literature to determine the overall success of screening for ectopic pregnancy before medical abortion treatment.

DATA SOURCES

We searched MEDLINE for articles on medical abortion regimens published before July 2003.

METHODS OF STUDY SELECTION

We selected English language articles of studies of medical abortion with sample sizes greater than 100, which reported on ectopic pregnancy diagnosed after medical abortion treatment. Fifty-seven of 85 prospective studies and randomized trials (69%) met these inclusion criteria. We also included data from 2 unpublished studies because they were large and well-controlled and because they included serious adverse events known to us, which we did not deem fair to exclude from our analysis.

TABULATION, INTEGRATION, AND RESULTS

Each article was reviewed by one author. Data from selected studies were compiled, and the frequency of ectopic pregnancy diagnosed after medical abortion treatment was calculated. Ectopic pregnancy was diagnosed very infrequently following medical abortion procedures, occurring in only 10 of 44,789 (0.02%) women.

CONCLUSION

The very low frequency of ectopic pregnancies diagnosed after medical abortion treatment demonstrates that the various pretreatment screening methods that providers use to exclude patients with ectopic pregnancies are successful. Further, there is no evidence to suggest that medical abortion treatment leads to unusual complications for women with ectopic pregnancies.

Progesterone antagonists and progesterone receptor modulators: an overview

Since the original description of the structure of the antiprogestin, mifepristone, was published, numerous related compounds have been synthesized which may function as progesterone antagonists (PAs) or progesterone receptor modulators (PRMs). The latter are mixed agonists-antagonists. Both PAs and PRMs have therapeutic applications in female health care. Mifepristone is predominantly a PA and displays only minimum agonist activity in certain systems. Together with a prostaglandin, mifepristone can terminate pregnancies of less than 9 weeks duration, and it may also be used at later gestational ages. Mifepristone causes expulsion of the uterine contents following intrauterine fetal death. A mifepristone-prostaglandin combination has been shown to be very effective treatment in women with menses delay of 11 days or less. Many PAs and PRMs display antiproliferative effects in the endometrium. Serum estradiol levels however remain in the early to mid-follicular phase range. For this reason, they have application in the treatment of endometriosis and myoma without being associated with bone loss and hypoestrogenism. PRMs may also find application in the treatment of dysfunctional bleeding as well as an adjunct to estrogens in hormone replacement therapy in postmenopausal women. Many PAs have contraceptive potential by suppressing follicular development and blocking the LH surge. Low doses may also be potential contraceptives by retarding endometrial maturation without affecting ovulation or inducing bleeding. Mifepristone is an excellent agent for use as an emergency "postcoital" contraceptive. PAs may also be useful in IVF programs to prevent a premature LH surge and to delay the emergence of the implantation window. In addition to their use in women's health care, mifepristone and several other PAs are potent antiglucocorticoid agents and may be used to treat ACTH-independent Cushing's syndrome. They may also be used in the treatment of tumors containing steroid receptors and in other situations which require suppression of the ACTH-cortisol axis.

Prostaglandins for first-trimester termination

Since the 1980s, when mifepristone combined with a prostaglandin was found to be safe and effective for early abortion, many studies have refined the regimens and investigated alternatives such as methotrexate plus misoprostol, and misoprostol alone. Evidence now demonstrates that more than 200 mg of mifepristone provides no additional benefit, that vaginal misoprostol is superior to oral, especially between 7 and 9 weeks' gestation, and that misoprostol may be safely self-administered at home. Buccal and sublingual routes of administration of misoprostol also are promising. Absolute contraindications to medical abortion arise infrequently. Gastrointestinal and other side-effects occur in about one-third of women, primarily after administration of the prostaglandin. Careful assessment before and after medical abortion is essential and can be accomplished in various ways, depending on the skills of the clinician.

WHO multinational study of three misoprostol regimens after mifepristone for early medical abortion. I: Efficacy

OBJECTIVES

To compare the efficacy of oral and vaginal administration of misoprostol after a single oral dose of 200 mg of mifepristone and to investigate whether the efficacy can be improved and the duration of bleeding shortened by continuing oral misoprostol for one week.

DESIGN

Double blind, randomised controlled trial.

SETTING

Fifteen gynaecological clinics in 11 countries.

POPULATION

A total of 2219 healthy pregnant women requesting medical abortion with < or =63 days of amenorrhoea.

METHODS

Mifepristone 200 mg administered orally on day one, followed by 0.8 mg misoprostol either orally or vaginally on day three. The oral group and one of the vaginal groups continued with 0.4 mg of oral misoprostol twice daily for seven days.

MAIN OUTCOME MEASURES

Complete abortion was the main outcome. Secondary outcomes were side effects, timing of expulsion and duration of bleeding.

RESULTS

The crude complete abortion rate was 92.3% in the oral plus continued oral misoprostol group, in the vaginal-only group it was 93.5%, and it was 94.7% in the vaginal group that continued with oral misoprostol, when considering undetermined cases as failures. Among women with amenorrhoea length > or =57 days, the risk of failure of complete abortion was almost three times higher in the oral plus continued oral misoprostol group (RR = 2.8, 95% CI 1.3 to 5.8), and over two times higher in the vaginal-only group (RR = 2.2, 95% CI 1.0 to 4.7), when compared with the vaginal plus continued oral misoprostol group. Among women with amenorrhoea length < 57 days, the differences were not significant. Timing of expulsions and duration of bleeding were similar in the three groups.

CONCLUSIONS

For amenorrhoea length > or =57 days, vaginal misoprostol is more effective than oral when continued with 0.4 mg oral misoprostol twice daily for seven days. Misoprostol continuation improved the efficacy in this amenorrhoea group compared with a single dose of vaginal misoprostol on day three, but it did not shorten the duration of bleeding. No differences in efficacy were observed when amenorrhoea length was < 57 days.

Mifepristone and misoprostol for early medical abortion: 18 months experience in the United States

In the first 18 months since mifepristone was approved by the Food and Drug Administration (FDA) for use with misoprostol for early medical abortion, approximately 80,000 women have been treated. One-hundred thirty-nine adverse events were reported to Danco Laboratories LLC and subsequently reported to the FDA. Thirteen patients required blood transfusions, 10 patients were treated with antibiotics for infection and 6 had a generalized allergic reaction. Fifty patients had an ongoing pregnancy, with 48 having suction curettage, leaving 2 ongoing pregnancies. Thirty-nine patients had a suction curettage for heavy or prolonged vaginal bleeding. The overall national experience has been highly favorable.

The learning curve is rapid in medical termination of pregnancy--first-year results from the Helsinki area

Medical termination of pregnancy by means of mifepristone and prostaglandin became available in Finland in May 2000. We summarize the first year results of medical abortion in a large tertiary care unit in Helsinki. A regimen of 200 mg of mifepristone followed by 0.4 mg vaginally administered misoprostol 2 days later was used. The maximum duration of pregnancy was 56 days. Four hundred and seventeen women, 47% of those with a pregnancy duration of up to 56 days, chose medical instead of surgical abortion. The monthly percentage of medical abortions varied from 27% to 63%. The percentage of complete terminations increased from 92% among the first quarter of the subjects to 97% among the fourth quarter, the overall success rate being 95%. Subject satisfaction, duration and self-estimated amount of bleeding, as well as analgesia needs were similar to those reported elsewhere. Most subjects (61%) chose combined oral contraceptive (COC) pills for future contraception; 75% of the COCs were started around the day of misoprostol administration. The reported amounts and duration of bleeding were not influenced by the immediate start of oral contraceptives. Intrauterine contraception was planned for 28% of the subjects, and 16% of them chose a levonorgestrel-releasing intrauterine device. We conclude that the learning curve in medical termination of pregnancy is rapid, and results comparable to those in centers with extensive experience with the method can be reached within the first year.

Factors affecting the outcome of early medical abortion: a review of 4132 consecutive cases

OBJECTIVE

To assess the outcome of a regimen of a reduced dose of mifepristone followed by one or two doses of vaginal misoprostol as a non-surgical method for termination of pregnancy.

DESIGN

Prospective observational study.

SETTING

Aberdeen Royal Infirmary, Aberdeen, Scotland.

POPULATION

Women seeking abortion under the 1967 Abortion Act.

METHODS

Factors influencing the outcome in a consecutive series of 4132 women undergoing early medical abortion in one Scottish teaching hospital since 1994.

MAIN OUTCOME MEASURES

Complete abortion rates following one or two doses of misoprostol. The effect of age, gestation, previous pregnancy and previous termination on complete abortion rates following the medical regimen.

RESULTS

Of the 4132 women, 95 (2.3%) aborted within 48 hours of mifepristone and a further 3942 (95.4%) achieved complete abortion following administration of one or two doses of misoprostol. Thus, the overall complete abortion rate was 97.7% (4037/4131). A total of 94 (2.3%) women required surgical intervention of whom 13 (0.3%) had a continuing pregnancy. Following change of the regimen to include the possibility of two doses of misoprostol the continuing pregnancy rates were significantly reduced (OR = 5.88) and gestation ceased to have an effect on overall efficacy. Women who had a previous abortion were more likely to have a failed medical abortion (OR = 2.09), while women with no previous termination, but a previous live birth were more likely to have a failed abortion (OR = 2.03).

CONCLUSION

Mifepristone in combination with one to two doses of vaginal misoprostol is an effective regimen for early medical abortion. The option of administering two doses of misoprostol significantly reduced the ongoing pregnancy rates and abolished the effect of gestation on overall efficacy. Previous termination was the strongest predictor of failed medical abortion.

Mifepristone: contraceptive and non-contraceptive uses

Mifepristone is an orally active progesterone antagonist. It can be used for both contraceptive and non-contraceptive clinical indications. It is a very effective drug for emergency contraception with a low incidence of side effects. There is a potential for mifepristone to be used as a once-a-month pill. There is a need, however, for a simple, inexpensive and accurate method to identify the luteinizing hormone surge before this method can be used in clinical practice. The daily administration of mifepristone offers promise as an effective method of contraception but more studies need to be done. The combination of mifepristone with a prostaglandin analogue is a well-established method for termination of pregnancy of up to 9 weeks. Recent data suggest that this combination may also be used up to 9-13 weeks of pregnancy. Although mifepristone is effective in dilating the cervix before vacuum aspiration, misoprostol is probably the drug of choice in most situations. In the second trimester, mifepristone is effective in shortening the abortion process induced by prostaglandin analogues. The combination of mifepristone and prostaglandin also offers a medical method for management of miscarriages. Mifepristone has been used for a number of other indications, but further studies are needed before such treatment can be recommended.

Medical abortion in the first trimester

Pregnancy can be terminated safely by inducing abortion medically at any stage of gestation. Antagonists such as mifepristone block the action of progesterone and hence result in uterine contractions and increase the sensitivity of the uterus to prostaglandins. In the last 15 years the combination of a single dose of mifepristone (600 mg) followed 48 hours later with a suitable prostaglandin (1 mg gemeprost vaginal pessary or 400 microg oral misoprostol) has been licensed in most countries in Europe and the USA for induction of abortion in the early weeks of pregnancy. The safety and efficacy of these methods is comparable to vacuum aspiration at the same gestation. The complete abortion rate is related to the type and dose of prostaglandin, the route of administration as well as the gestation and parity. Published data suggest that the dose of mifepristone can be reduced from 600 mg to 200 mg without loss of efficacy. Although misoprostol tablets are formulated for oral use, extensive clinical experience has demonstrated vaginal administration is more effective and is associated with fewer side-effects. Successful abortion using medical methods requires a well organized service which includes referral without delay and a robust system of follow up to identify failures. The failure rate as reflected by the number of women who require surgical intervention falls with increasing experience. In those countries where medical abortion has been freely available for about 10 years, such as France, Scotland and Sweden, about 60-70% of eligible women elect for this method.

Double-blind randomized trial of mifepristone in combination with vaginal gemeprost or misoprostol for induction of abortion up to 63 days gestation

BACKGROUND

Gemeprost and misoprostol are two of the most widely used prostaglandins in combination with mifepristone for medical abortion in early pregnancy. However, the efficacy and side-effects of those two drugs given vaginally have not been assessed in a randomized trial.

METHODS

Randomized double-blind controlled trial involving 999 women undergoing an abortion at gestational age < or =63 days who received either 0.5 mg gemeprost (group I, n = 499) or 800 microg misoprostol (group II, n = 500) vaginally approximately 48 h after taking 200 mg mifepristone by mouth. The rate of complete abortion and the side-effects were compared between the groups.

RESULTS

A total of 89 cases was excluded from full analysis of outcome because either they aborted after mifepristone alone (n = 2), had an ectopic pregnancy (n = 1), or because the outcome was uncertain as they failed to attend their follow-up appointment (n = 86). The rate of complete abortion was very high (>95%) in both groups but significantly higher after treatment with misoprostol than with gemeprost [436/453 (98.7%) versus 451/457 (96.2%), P = 0.019, difference 2.5%, confidence interval 0.4-4.7%] and there were fewer ongoing pregnancies (n = 1 versus n = 8, P < 0.018). Surgical intervention rose significantly with gestation in women who received gemeprost (P < 0.03) but not with misoprostol. The incidence of side-effects such as diarrhoea (13.7 versus 16.4%) and vomiting (27.8 versus 29.7%) was similar in women who received misoprostol or gemeprost respectively, as was the duration and amount of bleeding.

CONCLUSIONS

(i) Both regimens using a reduced dose of mifepristone are highly effective methods of inducing abortion in early pregnancy; (ii) vaginal misoprostol is the preferred prostaglandin because it is it is associated with fewer failures than low-dose gemeprost, particularly at gestation > or =49 days.

Second trimester medical abortion with mifepristone and gemeprost: a review of 956 cases

The treatment outcomes of 956 women undergoing second trimester termination of pregnancy with mifepristone and gemeprost were studied. The median gestational age was 16 weeks (range: 12-24 weeks). All women were treated with 200 mg mifepristone orally, followed 36 h later with 1 mg vaginal gemeprost administered every 6 h to a maximum of 4 doses in the first 24 h. A second course of 1 mg vaginal gemeprost was given 3-hourly in the next 12 h, if abortion had not occurred. Overall, 96.4% and 98.8% of the women aborted within 24 and 36 h, respectively. The median induction-to-abortion interval was 7.8 h (range: 0.5-109.9 h). The induction-abortion interval was longer in nulliparous women and women with a gestation age 17 weeks or above. Surgical evacuation of the uterus was performed in 11.5% of women for incomplete abortion or retained placenta. More multiparous women (16.7%) required surgical evacuation of uterus than did nulliparous women (7.3%; p <0.001). Ten (0.1%) women failed to abort with gemeprost and required other methods for abortion. In conclusion, a combination of mifepristone and gemeprost is a safe, effective, and noninvasive method of medical abortion for second trimester pregnancy.