Mifepristone versus vaginally administered misoprostol for cervical priming before first-trimester termination of pregnancy: a randomized, controlled study

Cost Analysis of Surgical and Medical Uterine Evacuation Methods for First-Trimester Abortion Used in Public Hospitals in Mexico

Background:

Data on abortion procedures costs are scarce in low- and middle-income countries. In Mexico, the only known study was conducted more than a decade ago, with data from years before the abortion legislation. This study estimated the costs, from the health system’s perspective, of surgical and medical abortion methods commonly used by women who undergo first-trimester abortion in Mexico.

Methods:

Data were collected on staff time, salaries, medications, consumables, equipment, imaging, and lab studies, at 5 public general hospitals. A bottom-up micro-costing approach was used.

Results:

Surgical abortion costs were US$201 for manual vacuum aspiration and US$298 for sharp curettage. The cost of medical abortion with misoprostol was US$85. The use of cervical ripening increases the costs by up to 18%. Staff comprised up to 72% of total costs in surgical abortions. Hospitalization was the area where most of the spending occurred, due to the staff and post-surgical surveillance required.

Conclusions:

Our estimates reflect the costs of “real-life” implementation and highlight the impact on costs of the overuse of resources not routinely recommended by clinical guidelines, such as cervical ripening for surgical abortion. This information will help decision-makers to generate policies that contribute to more efficient use of resources.

Pain Associated With Cervical Priming for First-Trimester Surgical Abortion: A Randomized Controlled Trial

OBJECTIVE

To compare the effect of cervical priming with mifepristone with that of misoprostol on pain perception during surgical induced abortion under paracervical block.

METHODS

We conducted a randomized, single-blind, two-center study of women undergoing surgical induced abortion at less than 14 weeks of gestation under paracervical block. Participants were randomized to receive cervical priming with 200 mg of oral mifepristone 36 hours or 400 micrograms buccal misoprostol 3 hours before surgery. The primary outcome was pain during mechanical cervical dilation evaluated by a 100-mm visual analog scale (VAS). Secondary outcomes were pain during aspiration, preoperative and postoperative pain, participant satisfaction, duration of the procedure, occurrence of complications, and ease of performing the procedure (assessed by a 100-mm VAS). We estimated that 110 women would have to be included to have 90% power to detect a 13mm-difference of VAS for pain.

RESULTS

Between June 2017 and May 2019, 314 women were eligible and 110 were randomized (55 in each group). Patient characteristics were similar in the two groups. The mean VAS score during mechanical cervical dilation was lower in the mifepristone group (35.6±21 vs 43.5±21, P=.04) as was the mean VAS during aspiration (34±24 vs 47.8±23, P=.003). The preoperative and postoperative mean VAS, satisfaction and duration of procedures were similar between groups. The procedure was significantly easier to perform in the mifepristone group (88±16 vs 80±23, P=.004).

CONCLUSION

Cervical priming with mifepristone for surgical induced abortion under paracervical block up to 14 weeks of gestation is more effective than misoprostol in reducing pain perception.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03043014.

Cervical priming before surgical abortion up to 13+6 weeks' gestation: a systematic review and metaanalyses for the National Institute for Health and Care Excellence-new clinical guidelines for England

OBJECTIVE

This study aimed to determine the optimal cervical priming regimen before surgical abortion up to and including 13⁺⁶ weeks' gestation.

DATA SOURCES

Embase, MEDLINE, and the Cochrane Library were searched for publications up to February 2020. Experts were consulted for any ongoing or missed trials.

STUDY ELIGIBILITY CRITERIA

This study included randomized controlled trials published in English after 2000 that compared the following: (1) mifepristone and misoprostol against each other, placebo, or no priming; (2) different doses of mifepristone or misoprostol; (3) different intervals between priming and abortion; or (4) different routes of misoprostol administration.

STUDY APPRAISAL AND SYNTHESIS METHODS

Risk of bias was assessed using the Cochrane Collaboration checklist for randomized controlled trials, and data were metaanalyzed in Review Manager 5.3. Dichotomous outcomes were analyzed as risk ratios using the Mantel-Haenszel method, and continuous outcomes were analyzed as mean differences using the inverse variance method. Fixed effects models were used when there was no substantial heterogeneity (I²<50%), random effects models were used for moderate heterogeneity (I²≤50% and <80%), and evidence was not pooled when there was high heterogeneity (I²≥80%). Subgroup analyses were undertaken based on parity where available. The overall quality of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

A total of 18 randomized controlled trials (n=8538) were included and showed the following: decreased incomplete abortion rate (risk ratio=0.44; 95% confidence interval, 0.21-0.9) and force required to dilate the cervix (mean difference= -7.08 N; 95% confidence interval, -11.67 to -2.49) and increased preoperative bleeding (risk ratio=5.90; 95% confidence interval, 5.08-6.86) with misoprostol compared with no priming; decreased preoperative bleeding when sublingual misoprostol was given 1 hour before abortion compared with 3 hours before (risk ratio=0.14; 95% confidence interval, 0.03-0.56); and increased force required to dilate the cervix (mean difference=14.3 N; 95% confidence interval, 2.13-26.47) when mifepristone was given 24 hours before abortion compared with 48 hours before. The quality of the evidence base was limited by low event rates and risk of bias in included studies.

CONCLUSION

Cervical priming with misoprostol decreases the force needed to dilate the cervix for first trimester surgical abortion and reduces the risk of incomplete abortion. Considered alongside clinical expertise, this evidence supports the use of routine cervical priming before first trimester surgical abortion with 400 µg misoprostol or, if misoprostol cannot be used, 200 mg oral mifepristone.

Evaluation of isosorbide-5-mononitrate as a cervical ripening agent prior to induced abortion in contrast to misoprostol- a randomized controlled trial

Objective

To determine whether vaginal application of 40 mg isosorbide-5-mononitrate (ISMN) has a comparable cervical ripening efficacy to and lesser side effects than 400 µg misoprostol in women scheduled for the first trimester induced abortion using a manual vacuum aspirator (MVA).

Methods

We conducted a prospective randomized open-label study in 70 women at 6–12 weeks of pregnancy at the R G Kar Medical College and Hospital, Kolkata, India, over a period of two years from 2015 to 2017. Forty milligrams of ISMN and 400 µg misoprostol were vaginally applied for cervical priming. The primary outcome measure was the cervical response assessed by the passage of the appropriate and largest sized MVA cannula through the internal os without resistance, at the beginning of the procedure.

Results

The base line cervical dilatation was found to be significantly higher in the misoprostol group than in the ISMN group (7.65±1.38 vs. 6.9±1.26 mm; P=0.025, 95% confidence interval, −1.4046 to −0.953). However, when the women were sub-analyzed based on parity, there was no statistically significant difference in the same parameters among the multigravid women. The need for further cervical dilatation was significantly higher in the ISMN group when the primigravid women were compared, although the multigravid women responded favorably to ISMN.

Conclusion

In the primigravid women, misoprostol appears to exert a higher efficacy as a cervical ripening agent in contrast to ISMN. However, ISMN can be used in multigravid women for the same purpose as in this group, misoprostol did not show any significant improvement in efficacy over ISMN.

A prospective study of the frequency of severe pain and predictive factors in women undergoing first-trimester surgical abortion under local anaesthesia

OBJECTIVE

To determine the frequency of severe pain among women and to identify the associated predictive factors during first-trimester surgical abortion under local anaesthesia (LA).

STUDY DESIGN

A prospective cohort study from November 2013 to January 2014 at the Department of Gynecology and Obstetrics, Rennes, France. The study population was composed of one hundred and ninety-four patients who underwent an elective first-trimester surgical abortion under LA. In an anonymized questionnaire, the participants were asked to self-record their perceived pain level 30 min after the completion of the procedure using a 10 cm visual analogue scale (VAS). The main outcome measure was the frequency of severe pain among women, defined as VAS ≥ 7. Secondary outcome measure was the risk factor(s) for severe pain.

RESULTS

Severe pain (i.e. VAS ≥ 7) was experienced by 46% (95% CI: 39%-53%) of the population. Multivariate analysis confirmed that >10 weeks of gestation (OR: 2.530 [95% CI: 1.1-5.81], p = .0287) and having 0 or 1 child (OR: 5.206 [95% CI: 1.87-14.49], p = .0016) were significant independent factors of severe pain.

CONCLUSION

Nearly half of the women experienced severe pain. More than 10 weeks of gestation and parity were predictive factors of severe pain. These findings should be useful in counselling women undergoing surgical abortion under LA.

Cervical dilation before first-trimester surgical abortion (<14 weeks' gestation)

First-trimester surgical abortion is a common, safe procedure with a major complication rate of less than 1%. Cervical dilation before suction abortion is usually accomplished using tapered mechanical dilators. Risk factors for major complications in the first trimester include increasing gestational age and provider inexperience. Cervical priming before first-trimester surgical abortion has been studied using osmotic dilators and pharmacologic agents, most commonly misoprostol. Extensive data demonstrate that a variety of agents are safe and effective at causing preoperative cervical softening and dilation; however, given the small absolute risk of complications, the benefit of routine use of misoprostol or osmotic dilators in first-trimester surgical abortion is unclear. Although cervical priming results in reduced abortion time and improved provider ease, it requires a delay of at least 1 to 3 h and may confer side effects. The Society of Family Planning does not recommend routine cervical priming for first-trimester suction abortion but recommends limiting consideration of cervical priming for women at increased risk of complications from cervical dilation, including those late in the first trimester, adolescents and women in whom cervical dilation is expected to be challenging.

Effects of a prolonged, 72 hours, interval between mifepristone and gemeprost in second trimester termination of pregnancy: a retrospective analysis

OBJECTIVE

To evaluate if the 72 hours interval between mifepristone and gemeprost has a similar efficacy compared to the 48 hours interval for second trimester termination of pregnancy

STUDY DESIGN

Two-hundred and fifteen consecutive pregnant women, admitted to our hospital, for second trimester TOP, were included in this retrospective analysis. Standard protocol was followed for all patients. On the first day of the procedure oral mifepristone 200 mg was administered. After 72 (group A, n = 78) or 48 hours (group B, n = 113) women were admitted for administration of gemeprost 1 mg pessary as per protocol. The induction to abortion time was defined as the interval between the insertion of the first gemeprost pessary and the expulsion of the fetus.

RESULTS

There are no significant differences in the number of pessaries in the two groups. The induction to abortion interval was longer in group A than in group B. Twenty-one women required surgical evacuation of the uterus for retained placenta or incomplete abortion without difference between groups.

CONCLUSION

A 48-hours interval between mifepristone and gemeprost leads to better results than a 72-hours interval, with a shorter abortion length and represents the elective method for second trimester TOP.

Comparison of isosorbide mononitrate and misoprostol for cervical ripening in termination of pregnancy between 8 and 12 weeks: a randomized controlled trial

AIM

The present study was undertaken to compare the efficacy of isosorbide mononitrate (IMN) and misoprostol for cervical ripening in termination of pregnancy between 8 and 12 weeks.

MATERIALS AND METHODS

This prospective randomized single blind study enrolled 40 women with singleton pregnancy seeking surgical termination of pregnancy between 8 and 12 weeks of gestation. They were divided into two groups--group I received IMN 40 mg while group II received misoprostol 40 mg vaginally, 3 h prior to suction and evacuation. All women were monitored for effects of cervical ripening and adverse effects.

RESULTS

The mean sizes of dilators that could be negotiated without any resistance was 5.9 ± 1.33 in group I and 8.6 ± 0.94 in group II (p < 0.001, 95% CI 0.58, 0.41). The mean dilator sizes at which resistance was first encountered was 6.9 ± 1.37 in group I and 9.9 ± 1.23 in group II (p < 0.001, 95% CI 0.60, 0.54). The mean blood loss was 61.5 ± 13.86 ml in group I and 36.25 ± 12.80 ml in group II (p < 0.001, 95% CI 6.07, 5.63). Headache was the most common adverse effect seen with IMN use.

CONCLUSION

The results show that IMN has a definite role and better safety profile than misoprostol in first trimester cervical ripening, although misoprostol is more effective and causes less blood loss.

Use of the levonorgestrel-releasing intrauterine system: an Austrian perspective

Approximately 12 million women worldwide use the levonorgestrel-releasing intrauterine system (IUS), with approximately 180,000 users of this IUS currently reported in Austria. A patient satisfaction study of 591 women in Austria revealed a high number of 'very satisfied' (79%) and 'satisfied' (19%) patients. Reliability, comfort, excellent compatibility and less severe, shorter and less painful monthly periods were the most frequently named advantages of the levonorgestrel-releasing IUS. Medication-induced cervical priming before insertion can be carried out on a routine or selective basis (for example in nullipara, in women who have undergone cervical conisation or in women who have previously experienced painful insertion). There is, at present, no evidence of an increased rate of breast cancer through use of the levonorgestrel-releasing IUS. A directly comparative study with oral contraceptives in young nullipara showed excellent results for the levonorgestrel-releasing IUS, with no perforations, inflammation or pregnancies.

A combination of misoprostol and estradiol for preoperative cervical ripening in postmenopausal women: a randomised controlled trial

OBJECTIVE

To compare the impact of 1000 microg of self-administered vaginal misoprostol versus self-administered vaginal placebo on preoperative cervical ripening after 2 weeks of pretreatment with estradiol vaginal tablets in postmenopausal women prior to day-care operative hysteroscopy.

DESIGN

Randomised, double-blind, placebo-controlled sequential trial.

SETTING

Norwegian university teaching hospital.

POPULATION

Sixty-seven postmenopausal women referred for day-care operative hysteroscopy.

METHODS

The women were randomised to receive either 1000 microg of self-administered vaginal misoprostol or self-administered vaginal placebo on the evening before day-care operative hysteroscopy. All women had administered a 25-microg vaginal estradiol tablet daily for 14 days prior to the operation.

MAIN OUTCOME MEASURES

PRIMARY OUTCOME

preoperative cervical dilatation at hysteroscopy.

SECONDARY OUTCOMES

difference in dilatation at recruitment and before hysteroscopy, number of women who achieved a preoperative cervical dilatation of 5 mm or more, acceptability, complications and adverse effects.

RESULTS

The mean cervical dilatation was 5.7 mm (SD, 1.6 mm) in the misoprostol group and 4.7 mm (SD, 1.5 mm) in the placebo group, the mean difference in cervical dilatation being 1.0 mm (95% CI, 0.2-1.7 mm). Self-administered vaginal misoprostol of 1000 microg at home on the evening before day-care hysteroscopy is safe and highly acceptable, although a small proportion of women experienced lower abdominal pain.

CONCLUSIONS

One thousand micrograms of self-administered vaginal misoprostol, 12 hours prior to day-care hysteroscopy, after 14 days of pretreatment with vaginal estradiol, has a significant cervical ripening effect compared with placebo in postmenopausal women.

Cervical preparation for first trimester surgical abortion

BACKGROUND

Preparing the cervix prior to surgical abortion is intended to make the procedure both easier and safer. Options for cervical preparation include osmotic dilators and pharmacologic agents. Many formulations and regimens are available, and recommendations from professional organizations vary for the use of preparatory techniques in women of different ages, parity or gestational age of the pregnancy.

OBJECTIVES

To determine whether cervical preparation is necessary in the first trimester, and if so, which preparatory agent is preferred.

SEARCH STRATEGY

We searched Cochrane, Popline, Embase, Medline and Lilacs databases for randomised controlled trials investigating the use of cervical preparatory techniques prior to first trimester surgical abortion. In addition, we hand-searched key references and contacted authors to locate unpublished studies or studies not identified in the database searches.

SELECTION CRITERIA

Randomised controlled trials investigating any pharmacologic or mechanical method of cervical preparation, with the exception of nitric oxide donors (the subject of another Cochrane review), administered prior to first trimester surgical abortion were included. Outcome measures must have included the amount of cervical dilation achieved, the procedure duration or difficulty, side-effects, patient satisfaction or adverse events to be included in this review.

DATA COLLECTION AND ANALYSIS

Trials under consideration were evaluated by considering whether inclusion criteria were met as well as methodologic quality. Fifty-one studies were included, resulting in 24 different cervical preparation comparisons. Results are reported as odds ratios (OR) for dichotomous outcomes and weighted mean differences for continuous data.

MAIN RESULTS

When compared to placebo, misoprostol (400-600 microg given vaginally or sublingually), gemeprost, mifepristone (200 or 600 mg), prostaglandin E and F(2alpha) (2.5 mg administered intracervically) demonstrated larger cervical preparation effects. When misoprostol was compared to gemeprost, misoprostol was more effective in preparing the cervix and was associated with fewer gastrointestinal side-effects. For vaginal administration, administration 2 hours prior was less effective than administration 3 hours prior to the abortion. Compared to oral misoprostol administration, the vaginal route was associated with significantly greater initial cervical dilation and lower rates of side-effects; however, sublingual administration 2-3 hours prior to the procedure demonstrated cervical effects superior to vaginal administration.When misoprostol (600 microg oral or 800 microg vaginal) was compared to mifepristone (200 mg administered 24 hours prior to procedure), misoprostol had inferior cervical preparatory effects. Compared to day-prior laminaria tents, 200 or 400 microg vaginal misoprostol showed no differences in the need for further mechanical dilation or length of the procedure; similarly, the osmotic dilators Lamicel and Dilapan showed no differences in cervical ripening when compared to gemeprost, although gemeprost had cervical effects which were superior to laminaria tents. Older prostaglandin regimens (sulprostone, prostaglandin E(2) andF(2alpha)) were associated with high rates of gastrointestinal side-effects and unplanned pregnancy expulsions. Few studies reported women's satisfaction with cervical preparatory techniques.

AUTHORS' CONCLUSIONS

Modern methods of cervical ripening are generally safe, although efficacy and side-effects between methods vary. Reports of adverse events such as cervical laceration or uterine perforation are uncommon overall in this body of evidence and no published study has investigated whether cervical preparation impacts these rare outcomes. Cervical preparation decreases the length of the abortion procedure; this may become increasingly important with increasing gestational age, as mechanical dilation at later gestational ages takes longer and becomes more difficult. These data do not suggest a gestational age where the benefits of cervical dilation outweigh the side-effects, including pain, that women experience with cervical ripening procedures or the prolongation of the time interval before procedure completion. Mifepristone 200 mg, osmotic dilators and misoprostol, 400microg administered either vaginally or sublingually, are the most effective methods of cervical preparation.

Two mifepristone doses and two intervals of misoprostol administration for termination of early pregnancy: a randomised factorial controlled equivalence trial

OBJECTIVE

To compare the efficacy of 100 mg and 200 mg of mifepristone and 24- and 48-hour intervals to administration of 800 microg vaginal misoprostol for termination of early pregnancy.

DESIGN

Placebo-controlled, randomized, equivalence trial, stratified by centre.

SETTING

13 departments of obstetrics and gynecology in nine countries.

POPULATION

2,181 women with 63 days or less gestation requesting medical abortion.

METHODS

Two-sided 95% CI for the risk differences of failure to complete abortion were calculated and compared with 5% equivalence margin between two doses of mifepristone and two intervals to misoprostol administration. Proportions of women with adverse effects were compared between the regimens using standard testes for proportions.

OUTCOME MEASURES

Rates of complete abortion without surgical intervention and adverse effects associated with the regimens.

RESULTS

Efficacy outcome was analysed for 2,126 women (97.5%) excluding 55 lost to follow up. Both mifepristone doses were found to be similar in efficacy. The rate of complete abortion was 92.0% for women assigned 100 mg of mifepristone and 93.2% for women assigned 200 mg of mifepristone (difference 1.2%, 95% CI: -1.0 to 3.5). Equivalence was also evident for the two intervals of administration: the rate of complete abortion was 93.5% for 24-hour interval and 91.7% for the 48-hour interval (difference -1.8%, 95% CI: -4.0 to 0.5). Interaction between doses and interval to misoprostol administration was not significant (P = 0.92). Adverse effects related to treatments did not differ between the groups.

CONCLUSIONS

Both the 100 and 200 mg doses of mifepristone and the 24- and 48-hour intervals have a similar efficacy to achieve complete abortion in early pregnancy when mifepristone is followed by 800 micrograms of vaginally administered misoprostol.

Gynaecological uses of a new class of steroids: the selective progesterone receptor modulators

Selective progesterone receptor modulators (SPRM) represent a new class of synthetic steroids, which can interact with the progesterone receptor (PR) and can exert agonist, antagonist or mixed effects on various progesterone target tissues in vivo. This review evaluates the actual and potential usefulness of SPRMs in gynaecology.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

[Pregnancy termination between 12 and 14 weeks gestation: practices and early complications in comparison with termination between 8 and 12 weeks]

OBJECTIVES

To describe and compare practices and complications of induced abortions (IA) between 12 and 14 gestational weeks (GW) with those performed at lower terms (8-10 and 10-12 GW).

PATIENTS AND METHODS

Cohort study enrolled in two IA centers 411 women, 147 of them with 12-14 weeks gestation. Comparisons were made according to pregnancy term (8-10, 10-12 and 12-14 GW).

RESULTS

Pregnancy term influenced the technical conditions of IA. Number and diameter of dilators and suction cannula as well as surgery time increase with gestational age--whether priming agents were used or not. Pain felt during surgery and early complications (within 15 days post IA) did not increase with gestational age.

CONCLUSION

Results of this study show that IA between 12 and 14 GW are as feasible as with lower terms.

Comparison of oral and vaginal misoprostol for cervical ripening before manual vacuum aspiration of first trimester pregnancy under local anesthesia: a randomized placebo-controlled study

The objective of this prospective randomized placebo-controlled study was to determine the effectiveness of 400 mug oral and 400 mug vaginal misoprostol administration for cervical priming 3 h prior to manual vacuum aspiration (MVA) under local anesthesia for voluntary termination of pregnancy before 10 weeks of gestation in comparison with placebo oral or placebo vaginal administration (n=40 in each group). Postmedication cervical dilatation was similar in the oral (mean, 6.6+/-1.5) and vaginal (mean, 7.2+/-0.8) misoprostol groups but significantly higher compared with the oral (mean, 3.4+/-0.2) and vaginal (mean, 3.6+/-1.9) placebo groups. Duration of the procedure was also significantly shorter in the misoprostol groups in comparison with their placebo counterparts. Preoperative bleeding and side effects were more common in the misoprostol groups, but none required medical intervention. Intraoperative bleeding was less in the vaginal misoprostol group compared with the placebo groups. There was no significant difference in terms of visual analogue scores during the procedure, patient satisfaction, days of postoperative bleeding and rate of postoperative complications among the groups. Cervical priming with misoprostol administered orally or vaginally 3 h before MVA for termination of pregnancy under local anesthesia facilitates the procedure by decreasing the need for cervical dilatation and by shortening its duration without improving patients' pain perception and satisfaction mainly due to side effects.

Oral versus vaginal misoprostol administered one hour before surgical termination of pregnancy: a randomised controlled trial

OBJECTIVE

To assess the efficacy of oral and vaginal misoprostol as cervical priming agents administered 1 hour before first trimester surgical termination of pregnancy.

DESIGN

A randomised controlled trial.

SETTING

Chelsea and Westminster Hospital, London.

POPULATION

Pregnant women of 10 weeks or less gestation attending the termination of pregnancy clinic.

METHODS

Ninety eligible women were recruited to the study during September 2001 and September 2002. Women were randomised to one of the three groups: misoprostol administered orally (400 microg), misoprostol administered vaginally (800 microg) and standard care (no cervical priming agent) administered prior to surgical termination of pregnancy. Under general anaesthesia, and prior to the operation, a cervical tonometer was used to determine the main outcome measures.

MAIN OUTCOME MEASURES

Baseline cervical dilatation and the cumulative force required to dilate the cervix from 3 to 9 mm.

RESULTS

There was no significant difference in the mean baseline cervical dilation (P= 0.16) or the cumulative force required to dilate the cervix (P= 0.12) between the three randomised groups.

CONCLUSION

No cervical priming effects were detectable with oral or vaginal misoprostol administered 1 hour before first trimester surgical termination of pregnancy.

Mifepristone does not induce cervical softening in non-pregnant women

BACKGROUND

Many techniques have been developed to soften the cervix to reduce complications following surgical dilatation. Progesterone inhibits myometrial contractility and its secretion during pregnancy ensures cervical competence. We used the progesterone antagonist mifepristone as a cervical ripening agent and evaluated its effect prior to office hysteroscopy.

METHODS

Fifty-eight healthy non-pregnant women aged 18-50 were studied in a randomized double-blind study. They received mifepristone (200 mg) or placebo 30 h prior to hysteroscopy. A Hegar test was performed prior to drug administration and again before hysteroscopy. A visual analogue pain scale was used to assess pain.

RESULTS

Medical history, physical examination and blood tests were similar in both groups, except for serum progesterone which was higher in the study group. Hegar measurement prior to drug ingestion was similar in both groups and after a mean time of 30.3 h increased in both groups. Neither the DeltaHegar measurement nor the pain scale was different in the two groups. There was also no effect of the high progesterone levels.

CONCLUSIONS

Unlike its dramatic effect in the pregnant uterus, mifepristone administered 30 h prior to hysteroscopy was not effective in ripening the cervix of non-pregnant women.

Oral misoprostol vs. vaginal gemeprost prior to surgical termination of pregnancy in nulliparae

BACKGROUND

To compare the efficacy and side-effects of intravaginal gemeprost with those of oral misoprostol for cervical ripening prior to first-trimester pregnancy termination in nulliparous women.

METHODS

Retrospective analysis of surgical terminations of pregnancy performed before 90 days of gestation. Intravaginal gemeprost 1 mg or oral misoprostol 800 micro g was administered 2 h before the procedure.

RESULTS

In total, 746 women were enrolled into the study, 84 received intravaginal gemeprost and 662 oral misoprostol. Median baseline cervical dilatation was significantly greater in women who received misoprostol before the operation than in those who received gemeprost (7 mm vs. 3 mm; p < 0.0001). The incidence of fever, vomiting and diarrhea was not different between the two groups. The incidence of abdominal pain with request for pain medication, emergency admission to operating room due to vaginal bleeding, hospital stay longer than 24 h and surgical repair of cervical injury due to Hegar dilatation was significantly higher among the gemeprost group than the misoprostol group.

CONCLUSIONS

In cervical priming prior to first-trimester pregnancy termination in nulliparous women, oral misoprostol is more effective and is associated with fewer side-effects and complications than intravaginal gemeprost.

A randomized controlled comparison of sublingual and vaginal administration of misoprostol for cervical priming before first-trimester surgical abortion

OBJECTIVE

The purpose of this study was to compare the effectiveness of the sublingual and vaginal administration of misoprostol for cervical priming before surgical termination of pregnancy.

STUDY DESIGN

In a randomized controlled trial, 74 primigravid women who were undergoing surgical abortion were assigned randomly to receive misoprostol (400 microg) sublingually or vaginally.

RESULTS

There was no statistically significant difference in the cumulative force that was required to dilate the cervix to 9 mm, for baseline cervical dilatation, for priming to abortion interval, for operating time, or for intraoperative blood loss between the two groups. Women in the sublingual group had more nausea (P=.008), vomiting (P=.01), diarrhea (P=.01), and unpleasant mouth taste (P=.0001) compared with the women in the vaginal group. In the sublingual group, 65% of women were satisfied with the route of misoprostol administration compared with 78% in the vaginal group (P=.11). Most of the staff members (84%) said that they would recommend the sublingual administration of misoprostol (P=.0001).

CONCLUSION

The sublingual administration of misoprostol is an effective alternative to vaginal administration for cervical priming before surgical abortion; despite a higher incidence of side effects, there was high patient and staff acceptability.

Mifepristone: contraceptive and non-contraceptive uses

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

Surgical abortion

This review of surgically-induced abortion focuses on conventional first trimester suction evacuation. Manual vacuum aspiration at early gestations and dilatation and evacuation at more advanced gestation are also considered. The place of surgical abortion in contemporary abortion practice is reviewed alongside developments in medical abortion. There is still debate about the best method for later abortions. Patient choice and pre-procedure assessment are considered fundamental to practice. The importance of antibiotic prophylaxis or infection screening is highlighted. The value of ultrasound emerges. The need for cervical priming is considered along with choice of suitable pharmacological agents. Current practice and the procedure of surgical abortion is outlined. Complications and strategies to minimize risk are detailed. The overview concludes with consideration of the impact on future reproductive health.