Voluntary interruption of pregnancy with mifepristone (RU 486) and a prostaglandin analogue. A large-scale French experience

A validated HPLC-MS/MS method for the quantification of systemic mifepristone after subcutaneous application in mice

Mifepristone (RU486, MIF) is a synthetic steroidal hormone with progesterone and glucocorticoid receptor antagonistic characteristics. MIF is commonly used for pharmalogical abortions, but also for the treatment of endometrial and endocrine disorders. The goal of the study was to establish and validate a targeted HPLC-MS/MS method for the quantification of MIF and one of its active metabolites metapristone (MET) in plasma after subcutaneous implantation of slow-release MIF pellets in female BALB/c mice. Additionally, we aimed to apply the analytical method to tissue of several organs to understand the tissue-specific distribution of both analytes after release into systemic circulation. Sample preparation comprised a simple liquid-liquid extraction with diethylether and required 100 μl of plasma or homogenates of approximately 50 mg of tissue. The presented HPLC-MS/MS method showed high sensitivity with baseline separation of MIF, MET, and the internal standard levonorgestrel within a run time of only 8.0 minutes and comparable limits of quantification for plasma and tissue homogenates ranging from 40 pg ml-1 to 105 pg ml-1 for MIF and MET. The presented study is suitable for murine plasma and tissues and can be easily applied to human samples.

Prevention of Pregnancy Loss: Combining Progestogen Treatment and Psychological Support

Pregnancy loss can be defined as a loss before either 20 or 24 weeks of gestation (based on the first day of the last menstrual period) or the loss of an embryo or fetus less than 400 g in weight if the gestation age is unknown. Approximately 23 million pregnancy losses occur worldwide every year, equating to 15-20% of all clinically recognized pregnancies. A pregnancy loss is usually associated with physical consequences, such as early pregnancy bleeding ranging in severity from spotting to hemorrhage. However, it can also be associated with profound psychological distress, which can be felt by both partners and may include feelings of denial, shock, anxiety, depression, post-traumatic stress disorder, and suicide. Progesterone plays a key part in the maintenance of a pregnancy, and progesterone supplementation has been assessed as a preventative measure in patients at increased risk of experiencing a pregnancy loss. The primary objective of this piece is to assess the evidence for various progestogen formulations in the treatment of threatened and recurrent pregnancy loss, postulating that an optimal treatment plan would preferably include a validated psychological support tool as an adjunct to appropriate pharmacological treatment.

Obstacles to Glioblastoma Treatment Two Decades after Temozolomide

Simple Summary

Glioblastomas are the most common and aggressive brain tumors in adults, with a median survival of 15 months. Treatment is surgical removal, followed by chemotherapy and/or radiotherapy. Current chemotherapeutics do not kill all the tumor cells and some cells survive, leading to the appearance of a new tumor resistant to the treatment. These treatment-resistant cells are called tumor stem cells. In addition, glioblastoma cells have a high capacity for migration, forming new tumors in areas distant from the original tumor. Studies are now focused on understanding the molecular mechanisms of chemoresistance and controlling drug entry into the brain to improve drug performance. Another promising therapeutic approach is the use of viruses that specifically destroy glioblastoma cells, preserving the neural tissue around the tumor. In this review, we summarize the main biological features of glioblastoma and the therapeutic targets that are currently under study for new clinical trials.

Abstract

Glioblastomas are considered the most common and aggressive primary brain tumor in adults, with an average of 15 months’ survival rate. The treatment is surgery resection, followed by chemotherapy with temozolomide, and/or radiotherapy. Glioblastoma must have wild-type IDH gene and some characteristics, such as TERT promoter mutation, EGFR gene amplification, microvascular proliferation, among others. Glioblastomas have great heterogeneity at cellular and molecular levels, presenting distinct phenotypes and diversified molecular signatures in each tumor mass, making it difficult to define a specific therapeutic target. It is believed that the main responsibility for the emerge of these distinct patterns lies in subcellular populations of tumor stem cells, capable of tumor initiation and asymmetric division. Studies are now focused on understanding molecular mechanisms of chemoresistance, the tumor microenvironment, due to hypoxic and necrotic areas, cytoskeleton and extracellular matrix remodeling, and in controlling blood brain barrier permeabilization to improve drug delivery. Another promising therapeutic approach is the use of oncolytic viruses that are able to destroy specifically glioblastoma cells, preserving the neural tissue around the tumor. In this review, we summarize the main biological characteristics of glioblastoma and the cutting-edge therapeutic targets that are currently under study for promising new clinical trials.

A COVID-19 Drug Repurposing Strategy through Quantitative Homological Similarities Using a Topological Data Analysis-Based Framework

Since its emergence in March 2020, the SARS-CoV-2 global pandemic has produced more than 116 million cases and 2.5 million deaths worldwide. Despite the enormous efforts carried out by the scientific community, no effective treatments have been developed to date. We applied a novel computational pipeline aimed to accelerate the process of identifying drug repurposing candidates which allows us to compare three-dimensional protein structures. Its use in conjunction with two in silico validation strategies (molecular docking and transcriptomic analyses) allowed us to identify a set of potential drug repurposing candidates targeting three viral proteins (3CL viral protease, NSP15 endoribonuclease, and NSP12 RNA-dependent RNA polymerase), which included rutin, dexamethasone, and vemurafenib. This is the first time that a topological data analysis (TDA)-based strategy has been used to compare a massive number of protein structures with the final objective of performing drug repurposing to treat SARS-CoV-2 infection.

Mifepristone Repurposing in Treatment of High-Grade Gliomas

Glioma is the most common and aggressive primary tumor of the central nervous system. The standard treatment for malignant gliomas is surgery followed by chemoradiotherapy. Unfortunately, this treatment has not produced an adequate patient response, resulting in a median survival time of 12–15 months and a 5-year overall survival of <5%. Although new strategies have been sought to enhance patient response, no significant increase in the global survival of glioma patients has been achieved. The option of developing new drugs implies a long and costly process, making drug repurposing a more practical alternative for improving glioma treatment. In the last few years, researchers seeking more effective cancer therapy have pursued the possibility of using anti-hormonal agents, such as mifepristone. The latter drug, an antagonist for progesterone and glucocorticoid receptors, has several attractive features: anti-tumor activity, low cytotoxicity to healthy cells, and modulation of the chemosensitivity of several cancer cell lines in vitro. Hence, the addition of mifepristone to temozolomide-based glioblastoma chemotherapy may lead to a better patient response. The mechanisms by which mifepristone enhances glioma treatment are not yet known. The current review aims to discuss the potential role of mifepristone as an adjuvant drug for the treatment of high-grade gliomas.

Mifepristone for Treatment of Metabolic Syndrome: Beyond Cushing's Syndrome

A growing body of research indicates that cortisol, the glucocorticoid product of the activation of the hypothalamic-pituitary-adrenal axis, plays a role in the pathophysiology of metabolic syndrome. In this regard, chronic exposure to cortisol is associated with risk factors related to metabolic syndrome like weight gain, type 2 diabetes, hypertension, among others. Mifepristone is the only FDA-approved drug with antiglucocorticoids properties for improved the glycemic control in patients with type 2 patients secondary to endogenous Cushing’s syndrome. Mifepristone also have been shown positive effects in rodents models of diabetes and patients with obesity due to antipsychotic treatment. However, the underlying molecular mechanisms are not fully understood. In this perspective, we summarized the literature regarding the beneficial effects of mifepristone in metabolic syndrome from animal studies to clinical research. Also, we propose a potential mechanism for the beneficial effects in insulin sensitivity which involved the regulation of mitochondrial function in muscle cells.

Dydrogesterone: pharmacological profile and mechanism of action as luteal phase support in assisted reproduction

The pharmacological and physiological profiles of progestogens used for luteal phase support during assisted reproductive technology are likely to be important in guiding clinical choice towards the most appropriate treatment option. Various micronized progesterone formulations with differing pharmacological profiles have been investigated for several purposes. Dydrogesterone, a stereoisomer of progesterone, is available in an oral form with high oral bioavailability; it has been used to treat a variety of conditions related to progesterone deficiency since the 1960s and has recently been approved for luteal phase support as part of an assisted reproductive technology treatment. The primary objective of this review is to critically analyse the clinical implications of the pharmacological and physiological properties of dydrogesterone for its uses in luteal phase support and in early pregnancy.

Medical Abortion

OBJECTIVE

This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.

INTENDED USERS

Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.

TARGET POPULATION

Women with an unintended first trimester pregnancy.

EVIDENCE

Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).

BENEFITS, HARMS AND/OR COSTS

Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.

SUMMARY STATEMENTS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care

RECOMMENDATIONS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.

What is the right timing for ultrasound evaluation after pregnancy termination with mifepristone?

OBJECTIVE

To determine the timing for ultrasound evaluation after medical termination of pregnancy (MTOP).

STUDY DESIGN

The records of 301 consecutive women who underwent MTOP between July 2010 and July 2011 were studied retrospectively. The follow-up protocol included ultrasound evaluation 2 weeks after MTOP. Surgical termination was offered when pregnancy was found to be ongoing, and either hysteroscopy/curettage or a repeat ultrasound 2 weeks later was offered when the ultrasound findings were suspicious for retained products of conception. Pathology reports were used to confirm the presence of retained products of conception.

RESULTS

Women with ultrasound findings suspicious for retained products of conception were significantly older than women with negative ultrasound findings (30.9±7.7 years vs 24.8±6 years, p<0.0001). Two weeks after MTOP, ultrasound findings were negative in 236 women and suspicious in 66 women. This rate declined as the interval between ultrasound evaluation and MTOP increased (up to 10 weeks). Of the 18 women (5.98%) who underwent hysteroscopy/curettage, pathology reports indicated that 15 (83.3%) had true residua.

CONCLUSIONS

At 2 weeks after MTOP, ultrasound findings suspicious for retained products of conception do not conclusively indicate failure of the procedure. Ultrasound evaluation should be repeated 4-6 weeks later (6-8 weeks after MTOP) in women with suspected residua before diagnosing failure of the procedure.

Emerging options for emergency contraception

Emergency post-coital contraception (EC) is an effective method of preventing pregnancy when used appropriately. EC has been available since the 1970s, and its availability and use have become widespread. Options for EC are broad and include the copper intrauterine device (IUD) and emergency contraceptive pills such as levonorgestrel, ulipristal acetate, combined oral contraceptive pills (Yuzpe method), and less commonly, mifepristone. Some options are available over-the-counter, while others require provider prescription or placement. There are no absolute contraindications to the use of emergency contraceptive pills, with the exception of ulipristal acetate and mifepristone. This article reviews the mechanisms of action, efficacy, safety, side effects, clinical considerations, and patient preferences with respect to EC usage. The decision of which regimen to use is influenced by local availability, cost, and patient preference.

The level of unpleasantness of pain influences the choice of home treatment during medical abortion

Background and aims

Medical abortion is often performed at outpatient clinics or gynaecological wards. Yet, some women may stay at home during medical abortion. Pain has been reported to be one of the main side effects of the procedure.

Methods

We studied whether perceived abortion pain was related to the subjectively evaluated ability to stay at home during medical abortion. The size of the study group was 29 women. We also studied how well these women remembered the intensity and unpleasantness of the abortion pain in a control visit performed 3–6 weeks after abortion.

Results

Especially, the unpleasantness associated with the pain during abortion was an important predictor when women evaluated their ability to stay at home during medical abortion. In those women who might have been able to stay at home in their own view, midwives looking after these women at the outpatient clinic estimated the pain intensity and unpleasantness also about 50% lower than in those who were not able to stay home in their own view. There were no significant differences in intensity, unpleasantness in hindsight of menstruation pain, or the area of this pain in the pain drawings in those women who considered that they might have stayed at home during medical abortion when compared with those who did not. No difference was found in age, gestational age, magnitude of previous pregnancies, miscarriages, vaginal deliveries, induced abortions, Beck’s Depression Index (BDI), Beck’s Anxiety Index (BAI) or AUDIT scores between those who could have stayed at home or those who would not have been able to stay at home during abortion. Components of abortion pain decreased significantly during the second post-abortion day. The more deliveries the subject had experienced the less pain she had during abortion. Multiparous women reported less than a fourth of the pain magnitude of the nulliparous women during abortion. Parity explained both intensity and unpleasantness of abortion pain better than the expected ability to stay at home. The remembrance of the intensity or unpleasantness of abortion pain correlated with actual pain reported at the time of abortion. However, this remembrance did not correlate with the ability to stay at home during the medical abortion.

Conclusions

The unpleasantness of pain during and immediately after abortion was recalled, not as a measure of the pain itself, but as a deciding factor in their judgement of whether or not they would be able to undergo medical abortion at home. Abortion pain is an important factor in enhancing home-based management of medical abortions. Medical staff may be able to detect those women who do not cope at home during the process by observing the intensity of pain. Therefore, proper treatment of pain might reduce the need for hospital-based medical abortions.

Implications

These patients need better care and guidelines for the care of women undergoing medical abortions should include clear recommendations for analgesic treatments, at the least adequate doses of nonopioid analgesics such as paracetamol in combination with NSAIDs like ibuprofen or diclofenac.

Antifertility effects of antigestogens

Since the discovery of the structure and function of steroids over 60 years ago, it has long been recognized that synthetic antagonists of the natural hormones would have potential therapeutic uses. Antagonists of mineralocorticoids, androgens and oestrogens, for example spironolactine, cyproterone, flutamide and tamoxifen, have already found a place in the management of hormone dependent conditions. In 1982, chemists at Roussel UCLAF announced that they had synthesized mifepristone (RU486) 17β-hydroxy-11(p-(dimethylamino)phenyl)-17-(1-propynyl) estra-411, 9-dien-3-one) a derivative of norethindrone which had potent antiprogestogenic as well as antiglucocorticoid activity. Although it was immediately realised that this compound would potentially have wide clinical application, its development in the last 10 years has been dominated by its abortifacient action. In the original clinical report by Herrman and colleagues it was shown that bleeding occurred when it was given to female volunteers in the second half of the menstrual cycle. In addition, complete abortion occurred in eight of 11 women who took the drug in the early weeks of pregnancy. These findings, which demonstrated that mifepristone could be used as the basis of a medical method of inducing abortion, were immediately made the focus of groups opposed to abortion on moral grounds. Experience over the last 10 years has confirmed the promise of these early studies and mifepristone, in combination with a suitable prostaglandin, is now licensed in France, UK and Sweden for use as a medical method of inducing abortion in early pregnancy.

Second trimester medical abortion with mifepristone-misoprostol and misoprostol alone: a review of methods and management

Second trimester abortions constitute 10-15% of all induced abortions worldwide but are responsible for two-thirds of major abortion-related complications. During the last decade, medical methods for second trimester induced abortion have been considerably improved and become safe and more accessible. Today, in most cases, safe and efficient medical abortion services can be offered or improved by minor changes in existing health care facilities. Second trimester medical abortion can be provided by a nurse-midwife with the back-up of a gynaecologist. Because of the potential for heavy vaginal bleeding and serious complications, it is advisable that second trimester terminations take place in a health care facility where blood transfusion and emergency surgery (including laparotomy) are available. This article provides basic information on regimens recommended for second trimester medical abortion. The combination of mifepristone and misoprostol is now an established and highly effective method for second trimester abortion. Where mifepristone is not available or affordable, misoprostol alone has also been shown to be effective, although a higher total dose is needed and efficacy is lower than for the combined regimen. Therefore, whenever possible, the combined regimen should be used. Efforts should be made to reduce unnecessary surgical evacuation of the uterus after expulsion of the fetus. Future studies should focus on improving pain management, the treatment of women with failed medical abortion after 24 hours, and the safety of medical abortion regimens in women with a previous caesarean section or uterine scar.

A comparison of women's, providers' and ultrasound assessments of pregnancy duration among termination of pregnancy clients in South Africa

OBJECTIVE

To compare providers' and women's estimates of duration of pregnancy with ultrasound estimates for determining medical abortion eligibility.

DESIGN

Cross-sectional study.

SETTING

Public termination of pregnancy (TOP) services in three provinces.

SAMPLE

A total of 673 women attending the above services for TOP.

METHODS

Women participating in a medical abortion feasibility study in South Africa provided estimates of pregnancy duration and date of last menstrual period (LMP). Each woman also had clinical and ultrasound exams. We compared estimates using the four methods, calculating the proportion of women in the 'caution zone' (< or = 8 weeks gestation by woman or provider estimate and > 8 weeks by ultrasound).

MAIN OUTCOME MEASURES

Mean gestational age by each method; difference between provider and LMP estimates and ultrasound estimates; and percentage of women in the 'caution zone'.

RESULTS

Women's estimates of pregnancy duration were 19 days fewer than ultrasound estimates (95% CI = -27 to 63). Mean provider- and LMP-based estimates were two (95% CI = -30 to 35) and less than one day(s) (95% CI = -46 to 51) fewer than ultrasound estimates. Comparing provider and ultrasound estimates, 15% of women were in the 'caution zone'; this fell to 12% if estimates of 9 weeks or fewer were considered acceptable.

CONCLUSIONS

Provider estimates of gestational age were sufficiently accurate for determining eligibility for medical abortion. LMP-based estimates were also accurate on average, but included more extreme differences from ultrasound estimates. Medical abortion could be provided in TOP facilities without ultrasound or with ultrasound on referral.

Mid-trimester induced abortion: a review

Mid-trimester abortion constitutes 10-15% of all induced abortion. The aim of this article is to provide a review of the current literature of mid-trimester methods of abortion with respect to efficacy, side effects and acceptability. There have been continuing efforts to improve the abortion technology in terms of effectiveness, technical ease of performance, acceptability and reduction of side effects and complications. During the last decade, medical methods for mid-trimester induced abortion have shown a considerable development and have become safe and more accessible. The combination of mifepristone and misoprostol is now an established and highly effective method for termination of pregnancy (TOP). Advantages and disadvantages of medical versus surgical methods are discussed. Randomized studies are lacking, and more studies on pain treatment and the safety of any method used in patients with a previous uterine scar are debated, and data are scarce. Pain management in abortion requires special attention. This review highlights the need for randomized studies to set guidelines for mid-trimester abortion methods in terms of safety and acceptability as well as for better analgesic regimens.

Simultaneous very low dose mifepristone and vaginal misoprostol for medical abortion

OBJECTIVE

This pilot study was designed to evaluate the outcome of medical abortion following simultaneous mifepristone (100 mg) and misoprostol (800 microg).

METHODS

Enrollees had gestational ages up to 56 days and desired a medical abortion. They received 100 mg of mifepristone orally and 800 microg of misoprostol vaginally. Follow-up examination occurred in 2-7 days. A phone call 3 weeks later assessed symptoms and acceptability. A 95% success rate, as seen in higher dose studies, gives a 95% confidence interval of 88-100% for 40 subjects.

RESULTS

Forty women were enrolled; 39 women had follow-up visits. Completed medical abortion was confirmed for 35 (90%) of 39 women. Four women had uterine aspiration. Two patients required repeat misoprostol. Median time from medication to abortion was 7 h. Most women (92%) strongly preferred taking all medications in the clinic.

CONCLUSIONS

The simultaneous administration of vaginal misoprostol with 100 mg of oral mifepristone had the outcome of completed abortion within the predicted confidence interval. In addition, simultaneous dosing was highly acceptable.

[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.

Comparison of misoprostol plasma concentrations following buccal and sublingual administration

BACKGROUND

New indications for misoprostol include medical abortion, cervical softening, induction of labor and treatment of postpartum hemorrhage. Various routes of misoprostol administration under study include oral, vaginal, buccal, sublingual and rectal.

MATERIALS AND METHODS

This was an open-label, randomized, cross-over study of the pharmacokinetic differences of buccal vs. sublingual misoprostol 800 mug in 10 healthy women.

RESULTS

Of the 10 women enrolled, 2 withdrew after experiencing excessive cramping from the sublingual route of misoprostol. The mean misoprostol plasma concentration-time curves at 4 h [area under the curve (AUC)0-4)] and the maximum concentration (C(max)) showed that levels were significantly higher for sublingual administration than the buccal route. Buccal misoprostol administration resulted in fewer symptoms and was found to be more acceptable.

CONCLUSIONS

Sublingual administration of misoprostol had a higher AUC and C(max) compared with buccal administration. The pharmacokinetics may help to determine the best application of misoprostol depending on the indication.

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.

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.

Methods for Induced Abortion

We describe present methods for induced abortion used in the United States. The most common procedure is first-trimester vacuum curettage. Analgesia is usually provided with a paracervical block and is not completely effective. Pretreatment with nonsteroidal analgesics and conscious sedation augment analgesia but only to a modest extent. Cervical dilation is accomplished with conventional tapered dilators, hygroscopic dilators, or misoprostol. Manual vacuum curettage is as safe and effective as the electric uterine aspirator for procedures through 10 weeks of gestation. Common complications and their management are presented. Early abortion with mifepristone/misoprostol combinations is replacing some surgical abortions. Two mifepristone/misoprostol regimens are used. The rare serious complications of medical abortion are described. Twelve percent of abortions are performed in the second trimester, the majority of these by dilation and evacuation (D&E) after laminaria dilation of the cervix. Uterine evacuation is accomplished with heavy ovum forceps augmented by 14-16 mm vacuum cannula systems. Cervical injection of dilute vasopressin reduces blood loss. Operative ultrasonography is reported to reduce perforation risk of D&E. Dilation and evacuation procedures have evolved to include intact D&E and combination methods for more advanced gestations. Vaginal misoprostol is as effective as dinoprostone for second-trimester labor-induction abortion and appears to be replacing older methods. Mifepristone/misoprostol combinations appear more effective than misoprostol alone. Uterine rupture has been reported in women with uterine scars with misoprostol abortion in the second trimester. Fetal intracardiac injection to reduce multiple pregnancies or selectively abort an anomalous twin is accepted therapy. Outcomes for the remaining pregnancy have improved with experience.

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.

Risk Factors for Legal Induced Abortion–Related Mortality in the United States

OBJECTIVE

To assess risk factors for legal induced abortion-related deaths.

METHODS

This is a descriptive epidemiologic study of women dying of complications of induced abortions. Numerator data are from the Abortion Mortality Surveillance System. Denominator data are from the Abortion Surveillance System, which monitors the number and characteristics of women who have legal induced abortions in the United States. Risk factors examined include age of the woman, gestational length of pregnancy at the time of termination, race, and procedure. Main outcome measures include crude, adjusted, and risk factor-specific mortality rates.

RESULTS

During 1988-1997, the overall death rate for women obtaining legally induced abortions was 0.7 per 100000 legal induced abortions. The risk of death increased exponentially by 38% for each additional week of gestation. Compared with women whose abortions were performed at or before 8 weeks of gestation, women whose abortions were performed in the second trimester were significantly more likely to die of abortion-related causes. The relative risk (unadjusted) of abortion-related mortality was 14.7 at 13-15 weeks of gestation (95% confidence interval [CI] 6.2, 34.7), 29.5 at 16-20 weeks (95% CI 12.9, 67.4), and 76.6 at or after 21 weeks (95% CI 32.5, 180.8). Up to 87% of deaths in women who chose to terminate their pregnancies after 8 weeks of gestation may have been avoidable if these women had accessed abortion services before 8 weeks of gestation.

CONCLUSION

Although primary prevention of unintended pregnancy is optimal, among women who choose to terminate their pregnancies, increased access to surgical and nonsurgical abortion services may increase the proportion of abortions performed at lower-risk, early gestational ages and help further decrease deaths.

LEVEL OF EVIDENCE

II-2

Emergency contraception--clinical and ethical aspects

Emergency contraception (EC) consists of either 1.5 mg of levonorgestrel (LNG) in one or two doses, or a combination of LNG with ethinylestradiol, administered for up to 5 days after unprotected intercourse. Clinical studies indicate that LNG alone is more effective and has less side effects. Its effectiveness decreases the longer after coitus it is taken. EC is indicated when there is non-compliance or accidents with the use of regular methods of contraception, or when women have had voluntary or imposed unprotected intercourse. The ethics of providing EC has been questioned by some, arguing that it acts by preventing implantation. Scientific evidence does not support this concept, but shows that EC acts mostly before fertilization. Placing obstacles to the access of EC is unethical as it transgresses the ethical principles of autonomy, non-maleficence beneficence and justice. Far from inducing abortions, EC reduces unwanted pregnancies and prevents abortion.

Mifepristone (RU486) protects Purkinje cells from cell death in organotypic slice cultures of postnatal rat and mouse cerebellum

Mifepristone (RU486), which binds with high affinity to both progesterone and glucocorticosteroid receptors (PR and GR), is well known for its use in the termination of unwanted pregnancy, but other activities including neuroprotection have been suggested. Cerebellar organotypic cultures from 3 to 7 postnatal day rat (P3-P7) were studied to examine the neuroprotective potential of RU486. In such cultures, Purkinje cells enter a process of apoptosis with a maximum at P3. This study shows that RU486 (20 microM) can protect Purkinje cells from this apoptotic process. The neuroprotective effect did involve neither PR nor GR, because it could not be mimicked or inhibited by other ligands of these receptors, and because it still took place in PR mutant (PR-KO) mice and in brain-specific GR mutant mice (GRNes/Cre). Potent antioxidant agents did not prevent Purkinje cells from this developmental cell death. The neuroprotective effect of RU486 could also be observed in pathological Purkinje cell death. Indeed, this steroid is able to prevent Purkinje cells from death in organotypic cultures of cerebellar slices from Purkinje cell degeneration (pcd) mutant mice, a murine model of hereditary neurodegenerative ataxia. In P0 cerebellar slices treated with RU486 for 6 days and further kept in culture up to 21 days, the synthetic steroid increased by 16.2-fold the survival of pcd/pcd Purkinje cells. Our results show that RU486 may act through a new mechanism, not yet elucidated, to protect Purkinje cells from death.

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.

Clinicians' perception of sonogram indication for mifepristone abortion up to 63 days

One barrier in the US to wider acceptance of mifepristone for abortion is the additional cost of the routine use of two sonograms, that is, for pregnancy dating and confirmation of a complete abortion. The purpose of this study is to document how the accuracy of medical abortion clinicians experienced with pelvic exams and dating pregnancies in assessing gestational age at the first visit compared with sonograms, and to identify the factors influencing whether they perceive that sonograms are desired or indicated at the first and follow-up visits. This was a prospective study of 1016 women wanting to participate in a medical abortion trial. After informed consent, clinicians (1) dated the pregnancy before routine sonography and (2) determined whether a sonogram was indicated. Women with sonographic pregnancies of less than 63 days were eligible for mifepristone followed by misoprostol 48 h later. Women returned on Day 4 to Day 8, and clinicians performed a clinical assessment of whether the abortion was complete and determined whether a sonogram was indicated. Fifteen sites participated. Advanced-level providers performed 56% of the assessments. When clinicians assessed a pregnancy under 43 days gestation, they perceived that a sonogram was "not indicated" in 60% of these women. This percentage increased to 66% at 43-49 days gestation, and declined to 46% of women assessed at more than 49 days. Clinicians correctly assessed gestational age as no more than 63 days in 87% of women. In only 1% (14/1013) of their assessments did clinicians underestimate gestational age. In 7/24 (29%) women with a persistent gestational sac, clinicians did not indicate the need for sonography when it was likely indicated. We conclude that the clinicians in our study felt confident in not using sonography in most cases. If clinicians monitor hCG levels to identify any ectopic or continuing pregnancies, medical abortion can be safely performed without sonography.

Acceptability of mifepristone for early pregnancy interruption

It is the purpose of this article to review the current status of early pregnancy interruption with mifepristone (RU 486) combined with a prostaglandin analogue from the standpoint of its acceptability to women. Also discussed are the need for uniform terminology in acceptability studies, observations from clinical trials in California, France, and the United Kingdom, and comments on eventual utilization in developing countries.

Mifepristone and misoprostol for early abortion when no gestational sac is present

The study was conducted to determine whether the administration of mifepristone followed by vaginal misoprostol can induce an abortion in early pregnancy when no gestational sac is present on sonogram. This report presents a prospective, pilot study of 30 healthy adult women, pregnant and seeking an abortion, and with no gestational sac on sonogram. All women had a baseline serum chorionic gonadotropin (hCG) level measured prior to using mifepristone 200 mg orally followed by misoprostol 800 mcg vaginally 48 h later, and then returned up to 4 days later for a repeat sonogram and serum hCG level. Women with initial hCG levels > 2000 IU/L were evaluated for ectopic pregnancy. At the first follow-up visit, if the hCG decreased by >50%, the women were followed with home pregnancy (25 IU/L) tests weekly until negative. If the levels did not decrease by 50%, a second dose of misoprostol was given. Surgical intervention was indicated for persistent hCG levels or excessive bleeding. Of the 30 women enrolled, the mean number of days of amenorrhea was 40 (SD 9) days. Two women had surgical intervention for continuing pregnancy, 2 had ectopic pregnancies, and 1 was lost to follow-up. Complete medical abortions occurred in 25/30 (88%) women, but when recalculated, in 25/27 (93%) women who completed the protocol and who did not have an ectopic pregnancy. There was 1 adverse event in a woman with an ongoing pregnancy who then received methotrexate. She was hospitalized a day later with a complicated pelvic infection and likely methotrexate-induced pneumonitis. Twenty-three women had a decrease in hCG at first follow-up visit of >50%. All 27 women who completed the protocol found the overall regimen acceptable. Mifepristone followed at 48 h by vaginal misoprostol were effective and acceptable in inducing an abortion in very early pregnancy. There may be a higher incidence of failure in very early pregnancies. Documentation of a complete abortion by hCG level is necessary to ensure the pregnancy is neither ongoing nor ectopic.

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

The objectives of this prospective non-concurrent cohort study were to confirm the efficacy of vaginal misoprostol for early pregnancy termination and to determine whether the incidence of side effects is lower with prophylactic loperamide and acetaminophen. Two-hundred women with an intrauterine pregnancy < or =56 days gestational age seeking medical pregnancy termination in an ambulatory research clinic were enrolled in the study. One-hundred participants (group 1) ingested 4 mg of loperamide and 500 mg of acetaminophen before the vaginal placement of 800 mirog of misoprostol moistened with 2 mL of saline. If abortion had not occurred, the same regimen was repeated every 24 h (maximum three doses). One-hundred participants (group 2) from the same clinic who previously underwent the same misoprostol regimen without prophylactic medication served as a control group for comparison with respect to abortion success and the incidence of side effects. The rate of successful abortion was not statistically significantly different between the two groups (group 1 93%, group 2 89%). The incidence of opiate analgesic use was significantly less in group 1 (4%) compared with group 2 (16%) (OR 0.22, 95% CI 0.06-0.73, p = 0.01). There was a significantly lower incidence of diarrhea in group 1 (23%) compared with group 2 (44%) (OR 0.38, 95% CI 0.20-0.73, p = 0.003). There was no difference in the incidence of fever/chills or the incidence of emesis between the two groups. Vaginal misoprostol is effective for termination of pregnancy < or = 56 days and the incidence of diarrhea and the use of opiate analgesia is significantly reduced with prophylactic loperamide and acetaminophen.

Timing of pain and bleeding after mifepristone-induced abortion

Previous studies of medical abortion with mifepristone and a prostaglandin have reported percentages of subjects who experience cramping and/or bleeding relative to prostaglandin use. This is the first analysis of cramping and bleeding onset patterns in subjects treated with low-dose (200 mg) mifepristone and 800 microg vaginal misoprostol at 24, 48, or 72 h after mifepristone. We analyzed the cramping and bleeding onset patterns in subjects up to 8 weeks pregnant who used 800 microg vaginal misoprostol at 24, 48, or 72 h after 200 mg of oral mifepristone. We collected data from subjects' symptom diaries and divided symptom onset into 3 categories: before misoprostol use, 0--12 h following misoprostol, and more than 12 h after misoprostol. Of the 2,302 subjects, cramping and bleeding onset data were available for 2,030 (88%) and 2,123 (92%), respectively. Across all groups, 230 (11%) experienced cramping and 445 (21%) experienced bleeding before misoprostol use. There was a significantly higher percentage of subjects who experienced early cramping and/or early bleeding between the three treatment groups, and this was related to the interval between mifepristone and misoprostol. In the 12 h following misoprostol administration, cramping and bleeding patterns were similar in the three groups. The longer subjects waited to insert misoprostol, the more likely they were to experience early cramping and/or bleeding. After misoprostol insertion, cramping and bleeding patterns are similar regardless of treatment group. Patients and providers cannot rely on symptom onset to predict treatment success.

The roles of clinical assessment, human chorionic gonadotropin assays, and ultrasonography in medical abortion practice

The clinical assessment of patients who request early medical abortion includes confirmation of the diagnosis of pregnancy and estimation of gestational age. Accurate gestational dating is essential, because the efficacies of medical abortion regimens decline as pregnancy advances. Whereas medical abortion researchers in the United States have relied on routine ultrasonography for gestational dating, abortion providers experienced with mifepristone and prostaglandin regimens outside the United States have reported high efficacy and safety primarily with clinical dating parameters. Diligent follow-up of patients allows clinicians to confirm that complete abortion has occurred without complications. In cases of uncertain outcome or suspected ectopic pregnancy, transvaginal ultrasonography and beta-human chorionic gonadotropin assays can assist in prompt diagnosis and management. As medical abortion with mifepristone and misoprostol becomes more prevalent in the United States, studies will be needed to further evaluate the effects of these modalities on medical abortion outcomes.

Management of side effects and complications in medical abortion

Side effects are an expected part of medical abortion; some, such as pain and bleeding, result from the abortion process itself and are generally managed with orally administered analgesics and counseling. True medication side effects most commonly include nausea, vomiting, diarrhea, and warmth or chills. Complications of medical abortion usually represent an extreme or severe side effect. Large series have reported transfusion rates of <1%. Because of the infrequency of uterine instrumentation, postabortal endometritis appears to be rare with medical abortion. As with early surgical abortion, the clinician must remain aware of the possibility for ectopic pregnancy. Overall approximately 2% to 10% of patients will require surgical intervention for control of bleeding, resolution of incomplete expulsion, or termination of a continuing pregnancy. Understanding the types of side effects and complications that can occur will enable the clinician to counsel patients properly as well as to understand when medical intervention is necessary during the medical abortion process.

Medical abortion regimens: historical context and overview

Medical abortion offers an important alternative to surgical abortion for women with early pregnancies who wish to avoid a surgical procedure. More than 3 million women worldwide have had medical abortions in the past decade alone. The best-studied regimens include mifepristone orally followed 36 to 48 hours later by a prostaglandin analog administered either orally or intravaginally. Because of political and social restrictions related to mifepristone, however, researchers have investigated alternative regimens, most notably methotrexate and misoprostol. Mifepristone regimens are approximately 95% effective for abortion at </=49 days' gestation. Efficacy between 50 and 63 days' gestation varies according to the type and route of administration of the prostaglandin analog. Complete abortion rates among these later gestations are clinically acceptable when mifepristone is followed by intravaginally administered misoprostol or gemeprost. This report reviews the development, efficacy, and side effects of mifepristone regimens.

Acceptability of suction curettage and mifepristone abortion in the United States: a prospective comparison study

OBJECTIVE

We sought to compare the acceptability of suction curettage abortion with that of medical abortion with mifepristone and misoprostol in American women.

STUDY DESIGN

We performed a prospective, serially enrolled, cohort analysis. The study population consisted of 152 subjects receiving mifepristone and misoprostol and 174 subjects undergoing suction curettage abortion aged > or =18 years with intrauterine pregnancies of up to 63 days' estimated gestation. Questionnaires regarding expectations and experiences were administered before the abortion and at the 2-week follow-up visit.

RESULTS

Subjects undergoing medical abortions reported significantly greater satisfaction than those undergoing surgical abortions (mean rank, 121 vs 149; P <.01) but were no more likely to recommend the method they had just experienced to a friend (97% vs 93.3%). If a future abortion was required, however, 41.7% of subjects undergoing surgical abortions indicated they would opt for a medical abortion, whereas only 8.6% of subjects receiving medical abortions would choose a surgical abortion (P <.001). Failure of the abortion decreased satisfaction in the medical group and increased the likelihood of choosing a surgical abortion for a subsequent procedure (P <.001). Surgical subjects who experienced more anxiety than expected during the abortion were more likely to choose a medical procedure for a subsequent abortion (P <.01).

CONCLUSION

Women receiving mifepristone and misoprostol were more satisfied with their method and more likely to choose the same method again than were subjects undergoing surgical abortion. Failure of a medical abortion and increased anxiety during surgical abortion were associated with preference for the alternative technique in a future procedure.

Predictors of analgesia use during supervised medical abortion. The Mifepristone Clinical Trials Group

The object of this analysis was to identify predictors of narcotic analgesic use during medical abortion. A total of 2121 women with pregnancies of </=63 days gestational age received 600 mg mifepristone followed 48 h later by 400 microg oral misoprostol in a single arm clinical trial perfomed at 17 centers in the US. We tested the effects of subject characteristics at baseline and study centers on the use of any narcotic analgesics on the day of misoprostol use. Overall, 27% of subjects received narcotic analgesics. The main determinant of narcotic analgesic use was the study center. The relative risk of using narcotic analgesics increased with gestational age; the relative risk decreased in women with previous births, and also decreased with increasing age of the woman receiving treatment. It is concluded use of narcotic analgesia during medical abortion is least likely among older, parous women at low gestational ages; however, the clinic providing care for the patient was the most important determinant of who received narcotic analgesia.

Low-dose mifepristone followed by vaginal misoprostol at 48 hours for abortion up to 63 days

The aim of this study was to compare the effectiveness, side effects, and acceptability of one-third the standard dose of mifepristone, i.e., 200 mg, and vaginal misoprostol 800 microg to induce abortion in subjects < or =56 days pregnant with subjects 57-63 days pregnant. A prospective multicenter trial enrolled healthy women > or =18 years, < or =63 days pregnant, and wanting an abortion. Women received mifepristone 200 mg orally, followed by misoprostol 800 microg vaginally, and returned 1-4 days later for ultrasound evaluation. A second dose of misoprostol was administered, if necessary. Surgical intervention was indicated for continuing pregnancy, excessive bleeding, or persistent products of conception 5 weeks later. Of 1137 subjects, 829 were in the < or =56 days pregnant group and 308 in the 57-63 days pregnant group. In all, 34 subjects had surgical intervention and 16 were lost to follow-up. Complete medical abortions occurred in 97% of subjects < or =56 days pregnant and 96% in the 57-63 days pregnant group. In all, 88% of subjects in the < or =56 days pregnant and 92% in the 57-63 days pregnant group bled within 4 h of using vaginal misoprostol. Comparing subjects < or =56 days pregnant with 57-63 days pregnant, there was less diarrhea (20% vs 29%, p = 0.002) and vomiting (33% vs 44%, p = 0.001), although side effects were acceptable to 82% of subjects in both groups. One subject in the < or =56 day group required a transfusion for delayed excessive bleeding. Although bleeding (p = 0.01) and pain (p = 0.02) were less acceptable in the 57-63 day group, 91% of subjects in both groups reported that the overall procedure was acceptable. In summary, low-dose mifepristone 200 mg and home administration of vaginal misoprostol 800 microg at 48 h were highly effective and acceptable to women < or =63 days pregnant, thereby expanding the number of women who can access a medical abortion.

The efficacy of medical abortion: a meta-analysis

Multiple clinical studies demonstrate the efficacy of medical abortion with mifepristone or methotrexate followed by a prostaglandin analogue. However, assessing predictors of success, including regimen, is difficult because of regimen variability and a lack of direct comparisons. This meta-analysis estimates rates of primary clinical outcomes of medical abortion (successful abortion, incomplete abortion, and viable pregnancy) and compares them by regimen and gestational age. We identified 54 studies published from 1991 to 1998 using mifepristone with misoprostol (18), mifepristone with other prostaglandin analogues (23), and methotrexate with misoprostol (13). Data abstracted from studies included regimen details and clinical outcomes by gestational age. We found that efficacy decreases with increasing gestational age (p<0.001), and differences by regimen are not statistically significant except at gestational age > or =57 days. For gestations < or =49 days, mean rates of complete abortion were 94-96%, incomplete abortion 2-4%, and ongoing (viable) pregnancy 1-3%. For gestations of 50-56 days, the mean rate of complete abortion was 91% (same for all regimens), incomplete abortion 5-8%, and ongoing pregnancy 3-5%. For > or =57 days, success was lower for mifepristone/misoprostol (85%, 95% confidence interval 78-91%) than for mifepristone/other prostaglandin analogues 95% (CI 91-98%, p = 0.006). For mifepristone/misoprostol, using > or =2 prostaglandin analogue doses seems to be better than a single dose for certain outcomes and gestational ages. We conclude that both mifepristone and methotrexate, when administered with misoprostol, have high levels of success at < or =49 days gestation but may have lower efficacy at longer gestation.

Early pregnancy termination with intravaginally administered sodium chloride solution-moistened misoprostol tablets: historical comparison with mifepristone and oral misoprostol

OBJECTIVE

The purpose of this study was to compare the abortifacient effect of intravaginally administered moistened misoprostol tablets with that of the combination regimen of mifepristone and oral misoprostol.

STUDY DESIGN

One hundred women at </=56 days' gestation received 800 microg misoprostol intravaginally in the form of sodium chloride solution-moistened tablets. The dose was repeated 24 hours later if a gestational sac persisted on ultrasonographic examination. These 100 subjects (group 1) were then matched with 100 subjects who had received 600 mg mifepristone followed by 400 microg misoprostol orally as part of a large multicenter American trial (group 2). Subjects were monitored for abortion success, adverse side effects, and bleeding characteristics. Abortion failure was defined as persistence of an intrauterine sac or the need to perform a surgical evacuation of the uterus for hemorrhage, for incomplete abortion, or at the subject's request.

RESULTS

In 88 of the 100 women in group 1 and 94 of the 100 women in group 2, abortion occurred and a surgical procedure was not required. Abortion rates were not influenced by gestational age in either group. Prostaglandin-related side effects of fever and chills, vomiting, diarrhea, and uterine pain were all significantly higher in group 1. Excessive uterine bleeding was uncommon in both groups, and no subjects received blood transfusions.

CONCLUSION

The abortion rate with intravaginally administered moistened misoprostol tablets is similar to that with the combination of mifepristone and oral misoprostol. However, intravaginal administration of misoprostol is associated with significantly more prostaglandin-related side effects.