Early pregnancy termination with vaginal misoprostol combined with loperamide and acetaminophen prophylaxis

Effectiveness and safety of misoprostol-only for first-trimester medication abortion: An updated systematic review and meta-analysis

OBJECTIVES

This study aimed to update our 2019 systematic review of data on the effectiveness and safety of misoprostol-only for first-trimester abortion.

STUDY DESIGN

We searched PubMed on December 18, 2022, to find published articles describing the outcomes of treatment with misoprostol-only for abortion of viable intrauterine pregnancy at ≤91 days of gestation. From each article identified, two authors independently abstracted relevant data about each group of patients treated with a distinct regimen. We assessed the risk of bias using four defined indicators. We estimated the proportion of patients with treatment failure using meta-analytic methods as well as the proportion hospitalized or transfused after treatment. We examined associations between treatment failure and selected characteristics of the groups.

RESULTS

We identified 49 papers with 66 groups that collectively included 16,354 evaluable patients, of whom 2960 (meta-analytic estimate 15%, 95% CI 12%, 19%) had treatment failures. Of 9228 patients assessed for ongoing pregnancy after treatment, 521 (meta-analytic estimate 6%, 95% CI 5%, 8%) had that condition. Failure risk was significantly associated with misoprostol dose, the total allowed number of doses, the maximum duration of dosing, and certain indicators of risk of bias. Among 11,007 patients allowed to take at least three misoprostol doses, the first consisting of misoprostol 800 mcg administered vaginally, sublingually, or buccally, the meta-analytic estimate of the failure risk was 11% (95% CI 8%, 14%). At most, 0.2% of 15,679 evaluable patients were hospitalized or received transfusions.

CONCLUSIONS

Although some studies in this updated review were adjudicated to have a high risk of bias, the results continue to support the key conclusion of our 2019 analysis: misoprostol-only is effective and safe for the termination of first-trimester intrauterine pregnancy.

IMPLICATIONS

Misoprostol-only is a safe and effective option for medication abortion in the first trimester if mifepristone is unavailable or inaccessible.

Efficacy of Misoprostol Alone for First-Trimester Medical Abortion: A Systematic Review

OBJECTIVE

To summarize available data on the effectiveness and safety of single-agent misoprostol for medical abortion in the first trimester.

DATA SOURCES

We searched MEDLINE, CABI, Cochrane, EMBASE, LILACS, the Web of Science, and ClinicalTrials.gov for English-language studies that evaluated misoprostol alone for abortion of a viable pregnancy in the first trimester.

METHODS OF STUDY SELECTION

Our search yielded 1,562 citations, of which 38 included data from 53 trial groups that met our inclusion and exclusion criteria.

TABULATION, INTEGRATION, AND RESULTS

We abstracted data about each trial group, including study characteristics, treatment regimen, clinical protocol, number of women treated and followed, and numbers with outcomes of interest. We used meta-analytic methods and logistic regression to examine factors associated with surgical intervention after treatment. Among all 12,829 evaluable women, 2,536 (meta-analytic estimate 22.0%, 95% CI 18.8-25.5%) had surgical uterine evacuation. Multiple factors were significantly associated with this proportion, including misoprostol amount per dose and route of administration, loss to follow-up rate, publication date, geographic region, number of misoprostol doses, duration of dosing, and time between dosing and evaluation. Of 6,359 evaluable women, 384 (meta-analytic estimate 6.8%, 95% CI 5.3-8.5%) had ongoing pregnancies. At most 26 of 12,184 evaluable women (meta-analytic estimate 0.7%, 95% CI 0.4-1.0%) were transfused or hospitalized for abortion-related reasons. In trials that provided satisfaction data, most women were satisfied or very satisfied with the treatment (meta-analytic estimate 78%, 95% CI 71-85%).

CONCLUSIONS

Misoprostol alone is effective and safe and is a reasonable option for women seeking abortion in the first trimester. Research is indicated to further refine the regimen and to establish efficacy in the late first trimester.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42018083589.

Sublingual vs vaginal misoprostol for completion of first trimester missed abortion: a randomised controlled trial

OBJECTIVE

The study aimed to compare the efficacy and safety of sublingual and vaginal misoprostol for termination of pregnancy in women with first trimester missed abortion.

METHODS

A single-blind, parallel group, randomised clinical trial (ClinicalTrials.gov NCT02686840) was conducted in a university hospital between 1 February 2016 and 31 January 2017. All women who presented with first trimester missed abortion were invited to participate in the study and were randomised to one of two groups: one group received sublingual misoprostol in three doses of 800 μg every 4 h, while a second group received vaginal misoprostol in the same dosage regimen. The primary outcome of the study was the rate of complete abortion within 7 days after initiation of treatment.

RESULTS

The study included 200 women (100 in each arm). By day 7, successful complete abortion was significantly more frequent in the sublingual misoprostol group (71.4%) than in the vaginal misoprostol group (51.5%) (p = .006). By day 30, the rate of complete abortion was higher in the sublingual misoprostol group (90.6%) than in the vaginal misoprostol group (83.9%), but with no statistically significant difference (p = .164). The mean length of the induction-expulsion interval in the sublingual misoprostol group was significantly shorter compared with the vaginal misoprostol group (12.3 ± 3.1 h vs 16.4 ± 4.2 h, respectively; p = .001) and the sublingual misoprostol group had a smaller drop in haemoglobin level (p = .001). The side effects of misoprostol were significantly more frequent in the sublingual group compared with the vaginal group.

CONCLUSION

Sublingual misoprostol is more effective than vaginal misoprostol in completing first trimester missed abortion, with a shorter induction-expulsion time. Sublingual misoprostol is, however, associated with more side effects, such as unpleasant taste, gastrointestinal symptoms and fever, compared with vaginal misoprostol.

A randomized comparison of misoprostol to intrauterine instillation of hypertonic saline plus a prostaglandin F2alpha analogue for second-trimester induction termination in Uzbekistan

BACKGROUND

The study was conducted to compare the efficacy and acceptability of second-trimester induction termination using vaginal misoprostol to hypertonic saline and d-cloprostenol, a prostaglandin F(2alpha) (PGF) analogue, in Tashkent, Uzbekistan.

STUDY DESIGN

Eleven clinics providing second-trimester induction terminations were randomized to provide one of two regimens for second-trimester induction termination: vaginal misoprostol 400 mcg every 3 h or hypertonic 10% saline intrauterine instillation plus an intravenous PGF analogue, d-cloprostenol, 2.5 mg/h. Demographic information, and obstetric and medical history data were collected, and interviewers administered questionnaires to measure procedural pain and satisfaction. Differences in procedure time and complication rate, the primary outcomes, were analyzed with survival analysis and chi(2) tests.

RESULTS

Of 228 participants, 120 received misoprostol and 108 received hypertonic saline and d-cloprostenol; the groups did not significantly differ by age, parity or gestational age. Both misoprostol and saline procedures were effective, with 99.2% and 100% successful abortion rates, respectively. Median procedure time (13.1 vs. 29.2 h, p<.001), and number of women with retained placenta (2 vs. 70, p<.001) or hemorrhage (3 vs. 19, p=.001) were lower for the misoprostol group. Both provider (p<.001) and patient (p<.001) procedural satisfaction scores were higher for the misoprostol group.

CONCLUSION

While equally effective, vaginal misoprostol had a shorter time to abortion, was more acceptable to providers and patients and had fewer complications than saline instillation plus intravenous administration of a PGF analogue in Tashkent. This evidence supports change of the existing standard of care for second-trimester induction termination in Uzbekistan.

Alternatives to mifepristone for early medical abortion

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

First-trimester pregnancy termination with 800 microg of vaginal misoprostol every 12 h

The objective of the study was to evaluate the efficacy and safety of 800 microg of misoprostol every 12 h, for a period of 36 h for pharmacological abortion. A group of 162 volunteer women with gestations between 50 and 63 days received misoprostol every 12 h up to a maximum of three doses for abortion. Outcome measures assessed included: successful abortion (complete abortion without requiring surgery), side effects, and a decrease in hemoglobin, mean time of vaginal bleeding, mean expulsion time and mean time of returning of menses. Complete abortion occurred in 148 of 162 (91%, 95% confidence interval 87.95) patients. The mean decrease in hemoglobin was statistically significant (p = 0.001). Vaginal bleeding lasted 8.0 +/- 3.2 days, spotting 8.0 +/- 3.5 days, and total bleeding 16 +/- 4.0 days. The mean expulsion time was 8.5 +/- 4.0 h. According to the observed outcomes, 800 microg of misoprostol vaginally could be a valid method to terminate pregnancies up to 9 weeks of gestation.

Review of medical abortion using mifepristone in combination with a prostaglandin analogue

Induced abortion is still a major health problem in the world and the most frequently performed intervention in obstetrics and gynecology with an estimated total of 46 million worldwide each year. Medical abortion with mifepristone and prostaglandin was first introduced in 1988 and is now approved in 31 countries. This combination of drugs has recently been included in the List of Essential Medicines by the World Health Organisation. The present review summarizes the development, physiology and the development of the currently used regimens.

Reaching women with instructions on misoprostol use in a Latin American country

In Latin America, where restrictive laws limit women's access to safe abortion services, misoprostol is being used to induce abortions, often without correct information on dosage or regimens. This study in an unnamed Latin American country aimed to identify appropriate channels through which instructions on misoprostol use could be disseminated to women. In-depth interviews were carried out with physicians, pharmacy staff, women who had had safe abortions and women from the community, as well as focus group discussions with advocates of safe abortion. Participants considered physicians to be the most appropriate source of information and for ensuring confidentiality for both women and provider. Participants considered midwives, pharmacists and women's groups as appropriate referral points, but not providers of information. Legal restrictions and professional risk were the primary reasons why pharmacists rejected this role, though many are selling misoprostol. There was a general lack of information about misoprostol for medical abortion among both health professionals and women. Accurate information about misoprostol use for a wide range of gynaecologic and obstetric purposes, including induced abortion, could be incorporated into training and educational materials for physicians, midwives and other appropriate mid-level providers, as well as pharmacists. Without these alternative information channels, access to information would be severely restricted, especially in rural areas.

The true cost differential between mifepristone and misoprostol and misoprostol-alone regimens for medical abortion

Our objective was to evaluate relative differences in direct and total (direct and indirect) costs for medical abortion regimens using mifepristone and misoprostol or misoprostol alone. We created formulas to evaluate relative differences in costs in the United States, Chennai (Madras), India, and a hypothetical developing country based on published protocols and efficacy data. Follow-up visits and suction aspiration procedures in the United States were evaluated over a range of costs. American indirect costs were estimated using earning data. Indirect costs in India and the hypothetical developing country were based on mifepristone cost differences between the United States and India. Although mifepristone costs US dollar 83.33 for every 200-mg tablet in the United States, the actual excess cost of using a mifepristone regimen, as compared with a misoprostol-alone regimen, is only US dollar 22 to US dollar 32. The actual cost of a mifepristone regimen is lower than that of a misoprostol-alone regimen in India. In a hypothetical developing country, a mifepristone regimen is likely to be less expensive than regimens using misoprostol alone. Because of the higher efficacy of medical abortion regimens using mifepristone and misoprostol and the need for fewer follow-up evaluations, such regimens are less expensive or only minimally more expensive than those using misoprostol alone.

Intravaginal misoprostol 600 microg and 800 microg for the treatment of early pregnancy failure

OBJECTIVE

To compare the respective effectiveness and safety of 600 microg and 800 microg of intravaginal misoprostol for complete abortion in cases of early pregnancy failure (occurring in the first 12 weeks).

METHOD

A total of 114 women with a diagnosis of early pregnancy failure made by transvaginal ultrasonography at Rajavithi Hospital between November 25, 2002 and July 31, 2003, were assigned randomly to 2 groups of equal size. In one group the women received 600 microg of misoprostol and in the other 800 microg of misoprostol intravaginally.

RESULTS

The rate of complete abortion within 24 h was significantly higher in the group that received 800 microg of misoprostol (68.4%) than in the other group (45.6%) (P<0.05). There were no significant differences between the 2 groups regarding time interval between misoprostol insertion and complete abortion or side effects.

CONCLUSION

Intravaginal misoprostol 800 microg is significantly more effective than vaginal misoprostol 600 microg for the termination of an early pregnancy failure, with no significant differences in side effects.

The effect of non-steroidal anti-inflammatory drugs on medical abortion with mifepristone and misoprostol at 13–22 weeks gestation

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit the biosynthesis of prostaglandins and concerns have been expressed that they might attenuate the effects of exogenous prostaglandins. This randomized study was conducted to evaluate whether NSAID given during medical abortion with mifepristone/misoprostol in the second trimester has a negative effect on the efficacy of the abortifacient by prolonging the induction-to-abortion interval.

METHODS

Seventy-four women were treated with the anti-progesterone mifepristone, followed by repeated doses of misoprostol 36-48 h later. They were randomized to receive a prophylactic pain treatment of either paracetamol and codeine or diclofenac with the first dose of misoprostol.

RESULTS

Co-treatment of NSAID with misoprostol did not attenuate the efficacy of mifepristone and misoprostol. There was no significant difference between the NSAID and the non-NSAID group in the induction-to-abortion interval (5.4 versus 6.5 h) or the total doses of misoprostol needed (2 versus 3). The frequency of surgical intervention was similar (55.6 versus 52.6%). Women in the group treated with NSAID required significantly less opiates (P = 0.042).

CONCLUSION

Co-treatment with NSAID and misoprostol does not interfere with the action of mifepristone and/or misoprostol to induce uterine contractions and pregnancy expulsion in medical abortion. Prophylactic NSAID administration reduces the need for opiate injections.

Misoprostol Alone for Early Medical Abortion in a Latin American Clinic Setting

Misoprostol is being used widely by women throughout Latin America, often based on instructions passed along through friends, acquaintances or professionals who may have little information about safe and effective use. This paper presents the experience of a Latin American clinic working in a legally restrictive setting that offers misoprostol as one option to women seeking early pregnancy termination. Between February 2001 and June 2002, 3225 women who attended the clinic chose to use misoprostol rather than vacuum aspiration. 89.9% returned for follow-up, of whom 76.4% had had a complete abortion within 72 hours, using one, two or three doses of 800 micrograms of misoprostol administered by the woman herself vaginally every 24 hours. The first 78 women who returned for follow-up at 72 hours responded to a questionnaire regarding their experiences. Satisfaction with the abortion process was high, despite some pain, chills, diarrhoea and/or nausea. Seventy-two of the 78 women said they would use misoprostol again if they needed to terminate another pregnancy and would recommend it to a friend. Having a clinic where staff are knowledgeable and experienced in misoprostol use is particularly important in settings where abortion is stigmatised, unsafe abortion common and access to safe services limited.

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.

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.

Oral and vaginal misoprostol 800 microg every 8 h for early abortion

The objective of the study was to evaluate the efficacy and safety of 800 microg misoprostol (Cytotec) every 8 h for 24 h for pharmacological abortion; the treatment was repeated if abortion did not occur in the first 24-h interval. The first misoprostol doses were always self-administered into the vagina; the second and third doses could be administered orally or vaginally depending on the amount of bleeding. Four-hundred and fifty-two women with gestations between 36 and 63 days were recruited into the study. The main outcomes assessed were: successful abortion (complete abortion without surgery), side effects, mean drop in hemoglobin, vaginal bleeding and mean time of return of menstruation. Complete abortion occurred in 409/452 (90.5%; 95% confidence interval [CI] 87%, 93%) patients. Medication to relieve symptoms was administered to all women before the first misoprostol dose. Vaginal bleeding lasted 15.9 +/- 4.4 days. The mean drop in hemoglobin, measured 14 days after abortion, was statistically significant (p = 0.0001) but without clinical relevance. According to the results obtained, 800 microg of misoprostol administered every 8 h for 24 h could be a valid method for abortion for up to 9 weeks of gestation.

A study of co-treatment of nonsteroidal anti-inflammatory drugs (NSAIDs) with misoprostol for cervical priming before suction termination of first trimester pregnancy

This double-blind randomized control study was conducted to evaluate whether a nonsteroidal anti-inflammatory drug (NSAID) could act as an effective pain control method during first trimester suction abortion, and whether co-treatment of NSAID with misoprostol will decrease the efficacy of the cervical ripening effect of misoprostol. Subjects were randomized to receive misoprostol alone or misoprostol together with diclofenac sodium. Both groups of subjects suffered from similar incidence of preoperative side effects. Co-treatment of NSAID with misoprostol did not attenuate the cervical ripening efficacy of misoprostol. There was no significant pain reduction in the group treated with NSAID, except that a marginal benefit was found in the subgroup of multiparous women. About two thirds of the subjects in both treatment groups found that this was a satisfactory pain relief method during the procedure.

A prospective randomized, double-blinded, placebo-controlled trial comparing mifepristone and vaginal misoprostol to vaginal misoprostol alone for elective termination of early pregnancy

BACKGROUND

Vaginal misoprostol has been shown to be an effective single agent for medical abortion. This randomized, double-blinded, placebo-controlled trial compared a regimen of mifepristone and misoprostol with misoprostol alone for termination of early pregnancy.

METHODS

250 women with gestations < or = 56 days were randomized by a random number table to receive either 200 mg mifepristone orally or placebo followed 48 h later by 800 microg vaginal misoprostol. Administration of misoprostol was repeated every 24 h up to three doses if abortion failed to occur. Abortion success was defined as complete abortion without the use of surgical aspiration.

RESULTS

Successful medical abortions occurred in 114 out of 119 subjects (95.7%) after mifepristone followed by vaginal misoprostol. In all, 110 out of 125 subjects (88.0%) successfully aborted after placebo and vaginal misoprostol. The higher success rate of complete abortion with the mifepristone and misoprostol regimen was statistically significant compared with the placebo and misoprostol regimen (P < 0.05).

CONCLUSIONS

A regimen of mifepristone and misoprostol was significantly more effective for termination of pregnancies < or = 56 days than misoprostol alone. The 88% efficacy obtained with vaginal misoprostol alone may be clinically acceptable when mifepristone is not available.

Borage oil reduction of rheumatoid arthritis activity may be mediated by increased cAMP that suppresses tumor necrosis factor-alpha

Recent double blind studies have shown some benefit of borage oil in treatment of rheumatoid arthritis. Tumor necrosis factor-alpha has been shown to be a central mediator of inflammatory and joint destructive processes in rheumatoid arthritis. In this paper, evidence from published research is reviewed that indicates gamma linolenic acid component of borage oil increases prostaglandin E levels that increase cAMP levels that in turn suppress tumor necrosis factor-alpha synthesis. If this biochemical path of borage oil is correct then (1) concomitant non-steroidal anti-inflammatory drug use would tend to undermine borage oil effects, and (2) borage oil would be contraindicated in pregnancy given the teratogenic and labor inducing effects of prostaglandin E agonists.