Monitoring Medical Abortion Using Mifepristone/Misoprostol Combination with Ultrasonogram and Serum Human Chorionic Gonadotropin

Misoprostol Abortion: Ultrasonography versus Beta-hCG Testing for Verification of Effectiveness

BACKGROUND AND OBJECTIVE

Miscarriage is a common complication of early pregnancy with medical and psychological consequences. Dilation and Curettage are considered as two standard caring ways for early pregnancy failure. Alternatively misoprostol has been used as a single agent for termination of early pregnancy. Aim of the present study was to compare the usefulness of serum β-hCG measurement and ultrasound examination to predict complete abortion after medical induction.

METHODS

There were one hundred and thirty three patients experiencing missed abortion or blighted ovum. Ultrasound examination and serum β-hCG test were performed before treatment and during follow-up in all these patients.

RESULTS

Treatment was successful without any need for surgical intervention in 92.4% of the cases. Both methods could verify the complete abortion among all the patients at the end of the study (4(th) week). Kappa agreement coefficient for the two methods of diagnosis was 0.327 (P < 0.5).

CONCLUSION

Based on our results, β- hCG is as effective as ultrasound in confirming a successful medically induced abortion in early pregnancy, but it should be used as supplements to clinical assessments.

Medical abortion follow-up with serum human chorionic gonadotropin compared with ultrasonography: a randomized controlled trial

OBJECTIVE

To estimate whether follow-up with serum human chorionic gonadotropin (hCG) results in fewer unplanned visits and interventions than follow-up with ultrasonography.

METHODS

Women were randomized to either in-clinic serum hCG or ultrasound follow-up after medical abortion. The primary outcome, unplanned interventions and visits, was measured as a composite binary outcome including: additional clinic or emergency room visits, repeat dosing of misoprostol, and surgical evacuation of the uterus. Surveys were administered at initial follow-up and again 1 month after abortion to inquire about unscheduled visits, interventions, and patient satisfaction. Medical records were reviewed for evidence of additional interventions and visits.

RESULTS

A total of 376 patients was randomized. Most participants were white (56%), single (83%), nulliparous (63%), and had completed high school (96%). Average participant age was 26±6 years and average gestational age was 46±6 days. Within 2 weeks of abortion, there was no significant difference in the rate of unplanned interventions and visits between arms, 8.2% (13/159) in the serum hCG arm compared with 6.6% (10/151) in the ultrasound arm (relative risk 1.23, 95% confidence interval [CI] 0.56-2.73, P=.60). By 4 weeks postabortion, 4.4% (6/135) in the ultrasound arm and 1.4% (2/142) in the hCG arm had undergone surgical evacuation (relative risk 0.32, 95% CI 0.07-1.54, P=.16). The majority in both the serum hCG (88%) and ultrasound (95%) arms was satisfied with their assigned follow-up method.

CONCLUSION

Medical abortion follow-up with serum hCG does not reduce the rate of unplanned interventions and visits compared with ultrasonography. Overall, the number of unplanned interventions is low and both methods of follow-up are acceptable to women.

Serum angiopoietin-2 and β-hCG as predictors of prolonged uterine bleeding after medical abortion in the first trimester

OBJECTIVE

The combination of mifepristone and misoprostol is an established method for induction of early first trimester abortion, but there is no consensus about the best evaluation of treatment outcome. We evaluate serum Angiopoietin-2 (Ang-2) and β human chorionic gonadotropin (β-hCG) in women who had undergone a medical abortion as markers of prolonged uterine bleeding (PUB).

METHODS

Prospective trial involving 2843 women attending an gynecology outpatient clinic who following a medical abortion with mifepristone and misoprostol, the study cohort was divided into women with duration of uterine bleeding >14 days (PUB) and women with duration of uterine bleeding ≤14 days (normal uterine bleeding, NUB). Serum determinations of Ang-2 levels by ELISA and β-hCG levels by electrochemiluminiscence immunoassay. Receiver Operating Characteristics (ROC) analyses were calculated and plotted for the diagnostic accuracy of serum β-hCG and Ang-2 concentration to discriminate PUB and NUB.

RESULTS

Baseline characteristics for both groups were similar, Only duration of bleeding showed a significant difference between the PUB group and NUB group. Ang-2 serum levels moderately correlated with serum β-hCG levels with statistically significant correlation coefficients of 0.536. Serum β-hCG and Ang-2 levels on day 7 and on day 14 after medical abortion were signifcantly higher in PUB group than in NUB group. Plotted as ROC curves, β-hCG area under curve (AUC) was 0.65 (95% CI, 0.53-0.76) on day 7, rising to AUC = 0.83 (95% CI, 0.75-0.92) on day 14. Using Ang-2 on day 7 and day 14 as predictive parameter resulted in an analogous AUC (AUC = 0.61 on day 7, AUC = 0.78 on day 14).

CONCLUSIONS

Both parameters are clinically useful as a diagnostic test in predicting PUB after medical abortion, and can be helpful in uncertain clinical situations, but should be considered as supplementary to a general clinical evaluation.

The use of misoprostol in termination of second-trimester pregnancy

Misoprostol, a synthetic prostaglandin E1 analog, is initially used to prevent peptic ulcer. The initial US Food and Drug Administration-approved indication in the product labeling is the treatment and prevention of intestinal ulcer disease resulting from nonsteroidal anti-inflammatory drugs use. In recent two decades, misoprostol has approved to be an effective agent for termination of pregnancy in various gestation, cervical ripening, labor induction in term pregnancy, and possible management of postpartum hemorrhage. For the termination of second-trimester pregnancy using the combination of mifepristone and misoprostol seems to have the highest efficacy and the shortest time interval of abortion. When mifepristone is not available, misoprostol alone is a good alternative. Misoprostol, 400 μg given vaginally every 3-6 hours, is probably the optimal regimen for second-trimester abortion. More than 800 μg of misoprostol is likely to have more side effects, especially diarrhea. Although misoprostol can be used in women with scarred uterus for termination of second-trimester pregnancy, it is recommended that women with a scarred uterus should receive lower doses and do not double the dose if there is no initial response. It is also important for us to recognize the associated teratogenic effects of misoprostol and thorough consultation before prescribing this medication to patients regarding these risks, especially when failure of abortion occurs, is needed.