Medical termination of pregnancy

Exploring the Safety and Efficacy of Medical Termination of Pregnancy: A Comprehensive Review

Medical termination of pregnancy, also known as medication abortion, is a safe and effective method of terminating pregnancies in the early stages. It involves using medications, such as mifepristone and prostaglandin, to induce a miscarriage. The success rates of medical abortion vary depending on factors such as gestational age and the specific medications used. For pregnancies that are 49 days or less, the success rates range from 92% to 98%. The choice between misoprostol and gemeprost, both prostaglandins, does not significantly impact the outcomes. It is important to note that various factors, including study design, definitions of success, and prior experience with medical abortion may influence success rates. Strict criteria for success and limited familiarity with the procedure may result in lower reported success rates. Medical termination of pregnancy should be carried out under the guidance and supervision of healthcare professionals. It is crucial to consult a healthcare provider to receive accurate information, personalized guidance, and appropriate support throughout the process. Each situation is unique, and decisions regarding medical termination of pregnancy should be made in collaboration with a trusted healthcare provider.

Association between serum progesterone levels on the day of frozen-thawed embryo transfer and pregnancy outcomes after artificial endometrial preparation

BACKGROUND

Previous studies have examined that a range of optimal serum P level during the implantation period was associated with optimal live birth rates. However, those results obtained with vaginal or intramuscular route of progesterone administration for luteal phase support (LPS) alone. Is there a relationship between the serum progesterone (P) on the day of frozen-thawed embryo transfer (FET) with the likelihood of a live birth (LB) in artificial cycles (AC) when using a combination of oral dydrogesterone and vaginal progesterone for LPS?

METHODS

This was a retrospective study of 3659 FET cycles with artificial endometrial preparation in a Chinese tertiary-care academic medical centre from January 2015 to February 2017. Endometrial preparation was performed using estradiol (E₂) valerate (Fematon-red tablets) 8 mg/d beginning on day 3 of the cycle, followed by administration of P both orally (8 mg/d Fematon-yellow tablets) and vaginally (400 mg/d; Utrogestan). The primary endpoint was live birth rate (LBR). The association between the serum P level on the embryo transfer day and pregnancy outcomes was evaluated by univariable and multivariable logistic regression analysis.

RESULTS

The LBRs according to the serum P quartiles were as follows: Q1: 35.7%; Q2: 37.4%; Q3: 39.1% and Q4: 38.9%. Logistic regression analysis showed that the odds of a LB were not significantly different between the low (P < 7.9 ng/mL) and high (P ≥ 7.9 ng/mL) progesterone groups before or after adjustment (crude OR = 0.89, 95% CI: 0.76-1.04; adjusted OR = 0.89, 95% CI: 0.75-1.04).

CONCLUSION

The present study suggests that the serum P levels on the day of embryo transfer (ET) do not correlate with the likelihood of a LB in artificial cycles when using a combination of oral dydrogesterone and vaginal progesterone for luteal phase support.

Trend of serum beta-human chorionic gonadotropin levels after medical abortion in the early first trimester of pregnancy

AIM

This study aimed to study serum beta-human chorionic gonadotropin level trends after medical abortion using mifepristone and misoprostol in the early first trimester.

METHODS

We enrolled women at ≤63 days of gestation who were indicated for pregnancy termination. We excluded women with incomplete abortions, nonviable pregnancies, extrauterine pregnancies, and contraindications for mifepristone/misoprostol use. Women received oral mifepristone (200 mg), followed by vaginal misoprostol (800 mcg) after 48 h. Serum beta-human chorionic gonadotropin levels were monitored pre-mifepristone administration (day 1); 48 h post-mifepristone, pre-misoprostol administration (day 3); day 10; and weekly after day 10, until negative beta-human chorionic gonadotropin levels (<25 mIU/mL) were achieved.

RESULTS

Among 39 enrolled women, 36 (92.3%) who underwent complete abortion without further interventions were included. The median gestational age was 51 (32-61) days. Three phases of beta-human chorionic gonadotropin levels were observed: an increase of up to 5.1% within 48 h of taking mifepristone, before misoprostol administration; a rapid decline on day 10 (by 98.5% compared with initial levels); and a slow decline after day 10 until negative results were attained within 7 weeks.

CONCLUSION

Serum beta-human chorionic gonadotropin levels minimally increased 48 h after taking mifepristone, rapidly declined within 1 week of misoprostol administration, and slowly declined until negative within 7 weeks post-abortion.

Post-abortion Complications: A Narrative Review for Emergency Clinicians

An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally “safe” (performed in a safe, clean environment with experienced providers and no legal restrictions) or “unsafe” (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.

Mifepristone: A Safe Method of Medical Abortion and Self-Managed Medical Abortion in the Post-Roe Era

BACKGROUND

The U.S. Supreme Court's Dobbs v. Jackson Women's Health Organization decision on June 24, 2022 effectively overturned federal constitutional protections for abortion that have existed since 1973 and returned jurisdiction to the states. Several states implemented abortion bans, some of which banned abortion after 6 weeks and others that permit abortion under limited exceptions, such as if the health or the life of the woman is in danger. Other states introduced bills that define life as beginning at fertilization. As a result of these new and proposed laws, the future availability of mifepristone, one of two drugs used for medical abortion in the United States, has become the topic of intense debate and speculation.

AREAS OF UNCERTAINTY

Although its safety and effectiveness has been confirmed by many studies, the use of mifepristone has been politicized regularly since its approval. Areas of future study include mifepristone for induction termination and fetal demise in the third trimester and the management of leiomyoma.

DATA SOURCES

PubMed, Society of Family Planning, American College of Obstetrician and Gynecologists, the World Health Organization.

THERAPEUTIC ADVANCES

The use of no-touch medical abortion, which entails providing a medical abortion via a telehealth platform without a screening ultrasound or bloodwork, expanded during the COVID-19 pandemic, and studies have confirmed its safety. With the Dobbs decision, legal abortion will be less accessible and, consequently, self-managed abortion with mifepristone and misoprostol will become more prevalent.

CONCLUSIONS

Mifepristone and misoprostol are extremely safe medications with many applications. In the current changing political climate, physicians and pregnancy-capable individuals must have access to these medications.

Gynaecological management of women with inherited bleeding disorders

Women with inherited bleeding disorders (IBDs) may present to healthcare professionals in a variety of ways and commonly will be encountered by either haematology or gynaecology services. Heavy menstrual bleeding is very often the first manifestation of an IBD. There is a wide variation in severity of bleeding for women with IBD and diagnosis and subsequent management of their condition requires multidisciplinary specialised care which is tailored to the individual and includes excellent cross-specialty communication between gynaecology and haematology teams. This guideline is intended for both haematologists and gynaecologists who are involved in the diagnosis and management of women with bleeding disorders. It sets out recommendations about how to investigate heavy menstrual bleeding (HMB), the commonest presentation for women with IBD to hospital services, to guide physicians about how to diagnose an IBD and covers the management of women with known IBD and HMB. The second section sets out recommendations for patients known to have IBD and covers management of patients with IBD in the setting of gynaecological surgery and management for all other non-surgical gynaecological situations.

Mail-order pharmacy dispensing of mifepristone for medication abortion after in-person clinical assessment

OBJECTIVE(S)

To estimate the effectiveness, acceptability, and feasibility of medication abortion with mifepristone dispensed by a mail-order pharmacy after in-person clinical assessment.

STUDY DESIGN

This is an interim analysis of an ongoing prospective cohort study conducted at five sites. Clinicians assessed patients in clinic and, if they were eligible for medication abortion and ≤ 63 days' gestation, electronically sent prescriptions for mifepristone 200 mg orally and misoprostol 800 mcg buccally to a mail-order pharmacy, which shipped medications for next-day delivery. Participants completed surveys three and 14 days after enrollment, and we abstracted medical chart data.

RESULTS

Between January 2020 and April 2021 we enrolled 240 participants and obtained clinical outcome information for 227 (94.6%); 3 reported not taking either medication. Of those with abortion outcome information (N = 224), 216 (96.4%) completed day-3 and 212 (94.6%) day-14 surveys. Of the 224 that took medications, none reported taking past 70 days' gestation, and complete medication abortion occurred for 217 participants (96.9%, 95% CI 93.7%-98.7%). Most received medications within three days (82.1%, 95% CI 76.5%-86.9%). In the day-3 survey, 95.4% (95% CI 91.7%-97.8%) reported being very (88.4%) or somewhat (6.9%) satisfied with receiving medications by mail. In the day-14 survey, 89.6% (95% CI 84.7%-93.4%) said they would use the mail-order service again if needed. Eleven (4.9%, 95% CI 2.5%-8.6%) experienced adverse events; two were serious (one blood transfusion, one hospitalization), and none were related to mail-order pharmacy dispensing.

CONCLUSIONS

Medication abortion with mail-order pharmacy dispensing of mifepristone appears effective, feasible, and acceptable to patients.

IMPLICATIONS

The in-person dispensing requirement for mifepristone, codified in the drug's Risk Evaluation and Mitigation Strategy, should be removed.

What does basic science tell us about the use of uterotonics?

Pharmacotherapy with uterotonics remains the mainstay of the management for post-partum haemorrhage. Clinical studies evaluating the efficacy of these drugs are fraught with confounders, which may influence uterine contractility and blood loss. For this reason, a range of techniques have been developed to study myometrial function in vitro, allowing for the comparison of various drugs in a controlled-simulated physiological environment. In this review, we focus on the main classes of uterotonic drugs and outline their molecular and physiological basis of action. We explore the evidence related to appropriate drug dosing and relative efficacy, and compare the evidence gleaned from clinical and in vitro studies. We discuss the mechanism of oxytocin desensitisation and how basic science has helped us understand this phenomenon. We also discuss the in vitro research findings for each of the main classes of uterotonic drugs that have contributed to an improved understanding of the management of post-partum haemorrhage and, ultimately, better care for mothers.

Discovery of nano-piperolactam A: A nonsteroidal contraceptive lead acting through down-regulation of interleukins

Elevated serum interleukins (IL-6, IL-1β) over baseline concentration help in blastocyst adhesion to the uterine endometrium in the early phase of pregnancy. A nano PLA (Piperolactam A)-HPBCD (2-hydroxy-propyl-β-cyclodextrin) inclusion complex was developed as an interleukin down-regulator that exhibited 100% anti-implantation activity in rodents at a dose as low as 2.5-5.0 mg/kg. On metabolomics study, among major glyco-lipo-protein metabolites, only serum low-density lipoprotein (LDL) or very low-density lipoprotein (VLDL) levels revealed alteration by the formulation. Administration of PLA-HPBCD did not cause changes in serum estrogen and progesterone levels. However, IL-6 and IL-1β failed to increase post PLA-HPBCD administration; hence, it is assumed to be the mode of the drug's abortifacient action. In addition, absence of signs of either acute or chronic toxicity suggests the formulation was considerably non-toxic. Therefore, the nano-PLA conjugate promises as a non-steroidal contraceptive lead apart from ormeloxifene, the only non-steroidal anti-fertility agent currently available globally.

Medication abortion: Potential for improved patient access through pharmacies

OBJECTIVES

To discuss the potential for improving access to early abortion care through pharmacies in the United States.

SUMMARY

Despite the growing use of medications to induce termination of early pregnancy, pharmacist involvement in abortion care is currently limited. The Food and Drug Administration's Risk Evaluation and Mitigation Strategy (REMS) for Mifeprex® (mifepristone 200 mg), the principal drug used in early medication abortion, prohibits the dispensing of the drug by prescription at pharmacies. This commentary reviews the pharmacology of medication abortion with the use of mifepristone and misoprostol, as well as aspects of service delivery and data on safety, efficacy, and acceptability. Given its safety record, mifepristone no longer fits the profile of a drug that requires an REMS. The recent implementation of pharmacy dispensing of mifepristone in community pharmacies in Australia and some provinces of Canada has improved access to medication abortion by increasing the number of medication abortion providers, particularly in rural areas.

CONCLUSION

Provision of mifepristone in pharmacies, which involves dispensing and patient counseling, would likely improve access to early abortion in the United States without increasing risks to women.

Drug Methods for Arteficial Termination of Unwanted Pregnancy

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

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

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

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

Misoprostol is an anlogue PGE1, used in peroral pills.

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

Selective progesterone receptor modulators: current applications and perspectives

Selective progesterone receptor modulators (SPRMs) are steroid progesterone receptor ligands able to induce agonistic or antagonistic activities. Mifepristone, the class leader, was primarily used for pregnancy termination from the 1980s. Emergency contraception with extended activity was the second major development 30 years later, with mifepristone in some countries and ulipristal acetate world-wide. More recently, ulipristal acetate was released for the treatment of myoma-related uterine bleeding. In addition to a very rapid cessation of bleeding, SPRMs allow a decrease in myoma volume, as do gonadotropin releasing hormone analogs. However, estradiol secretion is not blunted by SPRMs. This offers new alternatives for myoma treatment, especially in women close to menopause. In conclusion, use of SPRMs has allowed significant progress in emergency contraception and treatment of myoma-related symptoms. Numerous future perspectives in women's health care are currently under evaluation.

The effect of sex and prematurity on the cardiovascular baroreflex response in sheep

NEW FINDINGS

What is the central question of this study? Late preterm infants are often assumed to escape long-term morbidities known to impact earlier preterm offspring. Is this true for the cardiovascular system? What is the main finding and its importance? We show that late preterm birth is a risk factor for cardiovascular dysfunction in early adulthood and is influenced by sex. Early signs of cardiovascular dysfunction might predispose to heart disease in adulthood. Very preterm infants have an increased risk of cardiovascular disease; however, the effects of a late preterm birth on future cardiovascular function are not known. We hypothesized that after a late preterm birth, the well-described impairments in heart rate variability and baroreflex sensitivity would persist into adulthood. To test this hypothesis, sheep born preterm (0.9 gestation; nine male and seven female) or term (11 male and six female) underwent surgery at 14 months of age for insertion of femoral arterial and venous catheters and a femoral flow probe. After recovery, heart rate variability was assessed, followed by a baroreflex challenge (using the vasoactive agents phenylephrine and sodium nitroprusside) in conscious adult lambs. Our data demonstrate decreased low-frequency normalised units (LFnu) and low-frequency/high-frequency ratio in female but not male ex-preterm sheep at rest. When challenged, mature male ex-preterm sheep have an increased blood pressure response but dampened heart rate baroreflex response. We show that even a late preterm birth leads to cardiovascular dysfunction in adulthood. These early signs of cardiovascular dysfunction might underpin the later hypertension and increased risk of heart disease observed in adults born preterm. These findings are particularly important because late preterm infants are often assumed to escape the long-term morbidities known to impact on very preterm and extremely preterm offspring.

The identification of nuclear receptors associated with hepatic steatosis to develop and extend adverse outcome pathways

The development of adverse outcome pathways (AOPs) is becoming a key component of twenty-first century toxicology. AOPs provide a conceptual framework that links the molecular initiating event to an adverse outcome through organized toxicological knowledge, bridging the gap from chemistry to toxicological effect. As nuclear receptors (NRs) play essential roles for many physiological processes within the body, they are used regularly as drug targets for therapies to treat many diseases including diabetes, cancer and neurodegenerative diseases. Due to the heightened development of NR ligands, there is increased need for the identification of related AOPs to facilitate their risk assessment. Many NR ligands have been linked specifically to steatosis. This article reviews and summarizes the role of NR and their importance with links between NR examined to identify plausible putative AOPs. The following NRs are shown to induce hepatic steatosis upon ligand binding: aryl hydrocarbon receptor, constitutive androstane receptor, oestrogen receptor, glucocorticoid receptor, farnesoid X receptor, liver X receptor, peroxisome proliferator-activated receptor, pregnane X receptor and the retinoic acid receptor. A preliminary, putative AOP was formed for NR binding linked to hepatic steatosis as the adverse outcome.

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.

Effectiveness and Safety of Lower Doses of Mifepristone Combined With Misoprostol for the Termination of Ultra-Early Pregnancy: A Dose-Ranging Randomized Controlled Trial

This study aimed to investigate the effectiveness and safety of lower doses of mifepristone combined with misoprostol for the termination of ultra-early pregnancy. A total of 2500 women with ultra-early pregnancy (amenorrhea ≤ 35 days) were randomly divided into 5 groups with gradually decreased dose of oral mifepristone from 150 to 50 mg followed by 200 µg of oral misoprostol 24 hours later. The primary end point was complete abortion without surgical intervention. Secondary end points were vaginal bleeding, return of menses, and side effects. Rates of complete abortion were high in all groups. Moreover, the lower doses of mifepristone led to shorter vaginal bleeding period, the return of menses on the expected date, and fewer side effects. Lower doses of mifepristone combined with 200 µg of misoprostol are as effective and safe as higher doses of this combination for the termination of ultra-early pregnancy with lower possibility of vaginal bleeding and side effects.

BAY 1002670: a novel, highly potent and selective progesterone receptor modulator for gynaecological therapies

STUDY QUESTION

Does the novel progesterone receptor (PR) modulator BAY 1002670, based on its preclinical pharmacological profile, offer a potential novel treatment option for uterine fibroids?

SUMMARY ANSWER

The newly synthesized BAY1002670 has proved to be a very potent, highly selective PR modulator in all in vitro and in vivo pharmacodynamics assays performed: it exhibits marked efficacy in an innovative humanized fibroid disease model, suggesting BAY 1002670 to be a very promising treatment option for uterine fibroids.

WHAT IS KNOWN ALREADY

PR inhibiting ligands have shown clinical utility in a range of potential indications and applications. Despite the emergence of the first PR antagonist >30 years ago, no agent of this compound class has been authorized in any indication for long-term application. Among other reasons, suboptimal selectivity and safety profiles of previous candidates have led to discontinuation and modification of development programmes.

STUDY, DESIGN, SIZE, DURATION

The preclinical studies include relevant in vitro and in vivo assays to clarify the properties of the PR modulator BAY 1002670 as well as a fibroid xenograft study to show directly the efficacy of BAY 1002670 on the human target tissue.

PARTICIPANTS/MATERIAL, SETTING, METHODS

BAY 1002670 was tested for binding and transactivational activity towards different human steroid receptors. Activity of the compound in the corresponding in vivo models (rat, rabbit) was assessed. Furthermore, BAY 1002670 was tested in a disease model for uterine fibroids utilizing primary human tumour tissues as xenograft in immunodeficient mice treated with estradiol (E2) and progesterone (P).

MAIN RESULT AND THE ROLE OF CHANCE

BAY1002670 in subnanomolar concentrations exhibits a highly selective binding profile and antagonistic activity for the PR. These properties are also reflected in its action in two progesterone-dependent animal models that assess the termination of pregnancy and endometrial transformation. Favourable selectivity towards other nuclear hormone receptors was demonstrated. No in vivo activity was found at the glucocorticoid, estrogenic and mineralocorticoid receptors with only weak anti-androgenic activity. In a human fibroid xenograft model BAY 1002670 showed a marked dose-dependent reduction of fibroid tumour weight gain of 95% at a dose of 3 mg/kg/day (P < 0.005).

LIMITATIONS AND REASON FOR CAUTION

Selectivity and potency of BAY 1002670 have only been determined in vitro and in animal models so far.

WIDER IMPLICATIONS OF THE FINDING

The PR modulator BAY 1002670 might offer a treatment option not only for uterine fibroids but also for other gynaecological indications.

STUDY FUNDING/COMPETING INTEREST

The studies took place at Bayer Pharma AG. All authors are employees of Bayer Pharma AG. No external funding declared.

[Cervical pregnancy: a rare case of reimplantation after abortion. A case report]

Cervical pregnancy is a rare form of ectopic pregnancy defined by the implantation of the blastocyst in the cervical canal. Most of the cervical pregnancies have been reported in patients with a history of vacuum curettage or caesarean section. The authors report a case of cervical pregnancy occurred after a failure of medical abortion. A literature review discusses the possibility of a cervical secondary implantation and describes the management of such pregnancies.

The immninent dawn of SPRMs in obstetrics and gynecology

Selective progesterone receptor modulators (SPRMs) have been developed since the late 70s when mifepristone was first described. They act through nuclear progesterone receptors and can have agonist or mixed agonist antagonist actions depending on the cell and tissue. Mifepristone has unique major antagonist properties allowing its use for pregnancy termination. Ulipristal acetate has been marketed in 2009 for emergency contraception and has been recently approved for preoperative myoma treatment. Further perspectives for SPRMs use include long term estrogen free contraception, endometriosis treatment. However long term applications will be possible only after confirmation of endometrial safety.

Medical vs. surgical abortion: the importance of women's choice

BACKGROUND

Using a large national sample of women undergoing an abortion in France, we explore the factors associated with medical or surgical abortion. We draw particular attention to the influence of women's preferences in the decision-making process.

STUDY DESIGN

The data are drawn from a nationally representative survey of 8,245 women undergoing an elective abortion in France in 2007. Analyses of factors associated with the type of abortion technique were performed among the 4,650 women who were identified as being eligible for the two techniques.

RESULTS

Sixty-eight percent of all abortions were medical procedures among women eligible for both techniques. The type of abortion technique was not dependent on women's age, parity, cohabitation status, socioeconomic circumstances nor on the type of facility providing the abortion (private or public). Conversely, women's participation in the decision-making process was strongly associated with the type of abortion method. Among the 50% of women who reported they had been given a choice, 84% underwent a medical procedure vs. 52% of those who were not offered a choice. Among the 2,286 women who were not involved in the decision, 35% indicated they trusted their doctor to make the best choice for them, while 44% were told it was too late for a medical procedure, although they had consulted before 8 weeks of amenorrhea.

CONCLUSION

In this sample of French women who participated in a national survey on abortion, those who were involved in the decision-making process as to whether to have a medical or surgical procedure showed a strong preference for the medical procedure.

Medical methods for mid-trimester termination of pregnancy

BACKGROUND

With the improvement of ultrasound technology, the likelihood of detection of major fetal structural anomalies in mid-pregnancy has increased considerably. Upon the detection of serious anomalies, women typically are offered the option of pregnancy termination. Additionally, there are still many reasons other than fetal anomalies why women seek abortion in the mid-trimester.

OBJECTIVES

To compare different methods of second trimester medical termination of pregnancy for their efficacy and side-effects.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, Popline and reference lists of retrieved papers and other sources.

SELECTION CRITERIA

All randomised controlled trials (RCTs) examining medical regimens for termination of pregnancy of a singleton living fetus between 12-28 weeks' gestation were analysed. The outcome measures were the induction to abortion interval, abortion rate within 24 hours, need for surgical evacuation, blood loss, uterine rupture, pain, and side-effects.Trials including >20% fetal death, multiple pregnancies, previous uterine scars and regimens which involved cervical preparation were excluded.

DATA COLLECTION AND ANALYSIS

Two authors selected the trials and three authors extracted data.

MAIN RESULTS

Fourty RCTs were included, addressing various agents for pregnancy termination and methods of administration. When used alone, misoprostol was an effective inductive agent, though it appeared to be more effective in combination with mifepristone. However, the evidence from RCTs is limited.Misoprostol was preferably administered vaginally, although among multiparous women sublingual administration appeared equally effective. A range of doses of vaginally administered misoprostol has been used. No randomised trials comparing doses of misoprostol were identified; however low doses of misoprostol appear to be associated with fewer side-effects while moderate doses appear to be more efficient in completing abortion. Four RCTs showed that the induction to abortion interval with 3-hourly vaginal administration of prostaglandins is shorter than 6-hourly administration without an increase in side-effects.Many studies reported the need for surgical evacuation. Indications for surgical evacuation include retained products of the placenta and heavy vaginal bleeding. Fewer women required surgical evacuation when misoprostol was administrated vaginally compared with women receiving intra-amniotical PGF(2a) . Mild, self-limiting diarrhoea was more common among women who received misoprostol compared to other agents.

AUTHORS' CONCLUSIONS

Medical abortion in the second trimester using the combination of mifepristone and misoprostol appeared to have the highest efficacy and shortest abortion time interval. Where mifepristone is not available, misoprostol alone is a reasonable alternative. The optimal route for administering misoprostol is vaginally, preferably using tablets at 3-hourly intervals. Apart from pain, the side-effects of vaginal misoprostol are usually mild and self limiting. Conclusions from this review are limited by the gestational age ranges and variable medical regimens, including dosing, administrative routes and intervals of medication, of the included trials.

Mifepristone: pharmacology and clinical impact in reproductive medicine, endocrinology and oncology

IMPORTANCE OF THE FIELD

Mifepristone is a synthetic selective progesterone-receptor modulator (SPRM) that is widely used around the globe in the field of reproductive medicine. At present mifepristone is approved in a number of countries for early termination of pregnancy (TOP), cervical dilatation before surgical TOP, and management of early embryonic loss or fetal death. A number of new clinical applications are being developed in gynecology, endocrinology and oncology. Mifepristone has also served as an invaluable tool in the study of steroid hormone biology.

AREAS COVERED IN THIS REVIEW

Current indications for mifepristone are reviewed. New applications for mifepristone under clinical investigation are discussed. In addition, the unique molecular and cellular effects of mifepristone are described.

WHAT THE READER WILL GAIN

The reader will understand the mechanisms of action of mifepristone and the underlying steroid hormone biology. The reader will know the approved clinical indications for mifepristone and appreciate the ongoing basic and clinical research into new applications.

TAKE HOME MESSAGE

Mifepristone is the first-discovered and still most widely used antiprogestin. It has several indications in reproductive medicine and is under investigation for a variety of potential applications in other fields of medicine. The molecular and cellular effects of mifepristone illuminate important aspects of steroid hormone biology.

Early abortion in family medicine: clinical outcomes

PURPOSE

Clinical innovations have made it more feasible to incorporate early abortion into family medicine, yet the outcomes of early abortion procedures in this setting have not been well studied. We wished to assess the outcomes of first-trimester medication and aspiration abortion procedures by family physicians.

METHODS

Prospective observational cohort study conducted from August 2001 to February 2005 of 2,550 women who sought pregnancy termination in 4 clinical practices of family medicine departments and 1 private office/training site.

RESULTS

The rate of successful uncomplicated procedures for medication was 96.5% (95.5%-97.1% [corrected] confidence interval [CI], 95.5%-97.0%) and for aspiration was 99.9% (CI, 99.3%-1). Adverse events and complications of medication abortions were failed procedure (ongoing pregnancy; n = 19, 1.45%); incomplete abortion (n = 16, 1.22%); hemorrhage (n = 9, 0.69%); and patient request for aspiration (n = 1, 0.08%). One (0.08%) missed ectopic pregnancy was seen among patients receiving medication. Four types of adverse outcomes were encountered with aspiration: incomplete abortion requiring re-aspiration (n = 21, 1.83%); hemorrhage during the procedure (n = 4, 0.35%); missed ectopic pregnancy (n = 3, 0.26%); and minor endometritis (n = 1, 0.09%). Missed ectopic pregnancies were successfully treated in the inpatient setting without mortality (overall hospitalization rate of 0.16 of 100). All other complications were managed within outpatient family medicine sites. Rates of complication did not vary by experience of physician or by site of care (residency vs private practice).

CONCLUSIONS

Complications of medication and aspiration procedures occurred at a low rate, and most were minor and managed without incident.

Medical abortion in the first trimester: The use of serum hCG and endometrial thickness as markers of completeness

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 assessed endometrial thickness, determined by ultrasound and serum-human chorionic gonadotropin (s-hCG) as markers of successful management.

METHODS

Prospective trial involving 255 women, with a gestation of 62 days or less, who were to undergo medical abortion. In addition to our established routines of performing clinical and ultrasound examinations, we also determined the s-hCG level prior to treatment and at follow-up.

RESULTS

Of the 255 subjects treated during the study, 20 (7.8%) were lost to follow-up. The overall complete abortion rate was 94.0%. Fourteen subjects required vacuum aspiration, nine of them prior to the scheduled follow-up and five thereafter. None of the pregnancies were ongoing. A decrease of 99% in s-hCG levels was noted in 99% of the women, when levels determined prior to mifepristone intake and those measured 15-71 days post-abortion were compared.

CONCLUSION

This study confirms that s-hCG levels drop sharply after medical abortion. To assess the completeness of medical abortion, we recommend that clinical examination to be combined with determination of s-hCG. Ultrasonography should be carried out only when indicated.

Nuclear receptors CAR and PXR: Molecular, functional, and biomedical aspects

Nuclear receptors (NRs) are ligand-activated transcription factors sharing a common evolutionary history and having similar sequence features at the protein level. Selective ligand(s) for some NRs is not known, therefore these NRs have been named "orphan receptors". Whenever ligands have been recognized for any of the orphan receptor, it has been categorized and grouped as "adopted" orphan receptor. This group includes the constitutive androstane receptor (CAR) and the pregnane X receptor (PXR). They function as sensors of toxic byproducts derived from endogenous metabolites and of exogenous chemicals, in order to enhance their elimination. This unique function of CAR and PXR sets them apart from the steroid hormone receptors. The broad response profile has established that CAR and PXR are xenobiotic sensors that coordinately regulate xenobiotic clearance in the liver and intestine via induction of genes involved in drug and xenobiotic metabolism. In the past few years, research has revealed new and mostly unsuspected roles for CAR and PXR in modulating hormone, lipid, and energy homeostasis as well as cancer and liver steatosis. The purpose of this review is to highlight the structural and molecular bases of CAR and PXR impact on human health, providing information on mechanisms through which diet, chemical exposure, and environment ultimately impact health and disease.

Relationship of obesity to outcome of medical abortion

OBJECTIVE

The purpose of this study was to compare the outcome of medical abortion for obese women and nonobese women.

STUDY DESIGN

We conducted a chart review of women having medical abortions in 2005-2007. Outcomes were classified as surgical intervention, need for additional visits, and complete abortion. The rate of surgical intervention was compared for women with BMI less than 30 to women with BMI greater than 30.

RESULTS

Of the 1202 eligible procedures using mifepristone and misoprostol, there were 861 women with BMI less than 30 and 341 women with BMI greater than 30. Women with BMI less than 30, and women with BMI greater than 30 had identical rates of surgical intervention, 5% and 6%, respectively (P = .72).

CONCLUSION

In light of the additional risks of surgical abortion to obese women, medical abortion should be considered for these women.

Endometrial Thickness- a Practical Prospective Marker for the Risk of Surgical Intervention after RU486 Induced Abortion

Background

Medical termination of pregnancy [TOP] during the early first trimester is commonly used. However, treatment failure which warrants surgical intervention occurs in small proportion of patients. Our objective was to examine the effectiveness and predictive value of sonographic measurement of endometrial thickness during a follow up visit after medical abortion as an accurate predictor of the necessity of curettage for completion of pregnancy termination.

Methods

Women who opted for medical TOP where treated by single dose of RU486 followed by a single dose of misoprostol. Endometrial thickness was evaluated by transvaginal U.S. at 14 days after misoprostol tretament. The data was collected prospectively for this cohort study which includes all the women undergoing medical abortion in the first seven weeks of gestation.

Results

In 34.7% of the patients the endometrial width was > 11 mm on the follow-up visit. Surgical intervention was performed in 18% of these patients, for a failure rate of the medical termination of pregnancy [TOP] of 6.25%, as compared with no failure rate in those with endometrium < 11 mm, P < 0.001. In the patients where the endometrium was 11-12 mm on follow-up, the failure rate was 5%, and if > 12 mm the failure was 5.9%. In cases where the endometrium was 12-13 mm the failure rate was 27.3%, and if >13 mm the failure was 18.9%. When the endometrium was 13-14 mm the failure rate was 10%, and when >14 mm the failure was 23.7%. Half of the 18 patients who had undergone dilatation and curettage [D&C] for completion of the TOP, had endometrium > 14 mm, one to two weeks after the medical abortion.

Conclusion

Measurement of endometrial width after medical TOP is beneficial in segregating patient to low or high risk for surgical treatment of retained product of conception [POC]. Using a cutoff of 11 mm during the follow-up visit after medical TOP, 18% of the patients may need dilatation and curettage to complete the pregnancy termination, and if it is >14 mm, half of them may need surgical intervention. There is no difference between 11 and 14 mm regarding the risk of surgical intervention after medical TOP.

The prince and the pauper. A tale of anticancer targeted agents

Cancer rates are set to increase at an alarming rate, from 10 million new cases globally in 2000 to 15 million in 2020. Regarding the pharmacological treatment of cancer, we currently are in the interphase of two treatment eras. The so-called pregenomic therapy which names the traditional cancer drugs, mainly cytotoxic drug types, and post-genomic era-type drugs referring to rationally-based designed. Although there are successful examples of this newer drug discovery approach, most target-specific agents only provide small gains in symptom control and/or survival, whereas others have consistently failed in the clinical testing. There is however, a characteristic shared by these agents: -their high cost-. This is expected as drug discovery and development is generally carried out within the commercial rather than the academic realm. Given the extraordinarily high therapeutic drug discovery-associated costs and risks, it is highly unlikely that any single public-sector research group will see a novel chemical "probe" become a "drug". An alternative drug development strategy is the exploitation of established drugs that have already been approved for treatment of non-cancerous diseases and whose cancer target has already been discovered. This strategy is also denominated drug repositioning, drug repurposing, or indication switch. Although traditionally development of these drugs was unlikely to be pursued by Big Pharma due to their limited commercial value, biopharmaceutical companies attempting to increase productivity at present are pursuing drug repositioning. More and more companies are scanning the existing pharmacopoeia for repositioning candidates, and the number of repositioning success stories is increasing. Here we provide noteworthy examples of known drugs whose potential anticancer activities have been highlighted, to encourage further research on these known drugs as a means to foster their translation into clinical trials utilizing the more limited public-sector resources. If these drug types eventually result in being effective, it follows that they could be much more affordable for patients with cancer; therefore, their contribution in terms of reducing cancer mortality at the global level would be greater.

Manual versus electric vacuum aspiration for first-trimester abortion: a systematic review

BACKGROUND

As an alternative to electric vacuum aspirations (EVA), there is an increasing interest in using manual vacuum aspiration (MVA).

OBJECTIVE

To compare the safety, efficacy and acceptability of MVA with those of EVA for first-trimester abortion.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Cochrane Library and Chinese Biomedical Database in all language, together with reference lists of retrieved papers.

SELECTION CRITERIA

Randomised controlled trials comparing MVA with EVA for first-trimester abortion were included. The outcomes are complete abortion rate, uterine perforation rate, blood loss, pain perception and acceptability.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted the data. Results from the trials were combined to calculate relative risks (RRs) or risk differences for dichotomous outcomes and weighted mean differences (WMDs) for continuous outcomes, together with 95% CIs.

MAIN RESULTS

Ten trials were included, involving 1660 women. Generally, the methodological quality was poor. There were no statistically significant differences, comparing MVA with EVA, in complete abortion rate (RR 1.00; 95% CI 0.99-1.02) and participants' satisfaction (RR 1.02; 95% CI 0.87-1.20). In participants with less than 50 days of gestational age, less blood loss (WMD -1.84; 95% CI -2.45 to -1.23) and less severe pain perception (RR 0.04; 95% CI 0.01-0.12) were reported during the MVA procedure, whereas the operation time was shorter (WMD 0.32; 95% CI 0.02-0.63) in the EVA procedure.

AUTHOR'S CONCLUSIONS

There is some evidence that MVA is as effective and acceptable as EVA and might be safer than EVA.

Inhibitory effect of alprostadil against sevoflurane-induced myometrial relaxation in rats

PURPOSE

For anesthetic management of cesarean sections, regardless of the use of regional or general anesthesia, it is crucial to achieve sufficient uterine contraction immediately following the delivery of an infant in order to reduce excessive bleeding. No previous study has investigated the ability of alprostadil, a synthesized prostaglandin, to inhibit myometrial relaxation induced by volatile anesthetics. The aim of the present study was to investigate the inhibitory effects of alprostadil on sevoflurane-induced myometrial relaxation using myometrial strips isolated from pregnant rats.

METHODS

Myometrial strips were isolated from Sprague-Dawley rats (300-400 g) in the late stage of gestation (19-21 days). The time course of changes in spontaneous myometrium contraction was studied in the presence and absence of sevoflurane. Additionally, alprostadil was titrated at three different concentrations during continuous introduction of sevoflurane 2%, and myometrium contraction was studied. As an index of contraction, the area under the contraction curve was used, and data were analyzed by repeated measure one-way analysis of variance.

RESULTS

We have shown a significant decrease in myometrium contraction as a result of the use of sevoflurane (2%). Additionally, alprostadil has been shown to inhibit myometrial relaxation induced by sevoflurane in a dose-dependent manner. The areas under the contraction curve were 87%, 87%, 129%, and 172% of the baseline value for the control and at low, medium, and high concentrations of alprostadil, respectively.

CONCLUSION

The ability of alprostadil to inhibit myometrial relaxation induced by sevoflurane suggests that the use of alprostadil during general anesthesia for cesarean section may be advantageous for the reduction of postpartum bleeding.

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.