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Bridwell R, Long B, Montrief T, Gottlieb M. Post-abortion Complications: A Narrative Review for Emergency Clinicians. West J Emerg Med 2022; 23:919-925. [DOI: 10.5811/westjem.2022.8.57929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/23/2022] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Rachel Bridwell
- Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington
| | - Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Tim Montrief
- Jackson Memorial Health System, Department of Emergency Medicine, Miami, Florida
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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2
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The efficacy of Shenghua Decoction supplementation after early medical abortion: A meta-analysis of randomized controlled trials. Complement Ther Med 2022; 69:102848. [PMID: 35779783 DOI: 10.1016/j.ctim.2022.102848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 11/03/2022] Open
Abstract
AIMS Shenghua Decoction (SHD) is a well-known classic herbal formula documented in traditional Chinese medicine (TCM) that has been widely applied during the postpartum period in Chinese communities for several years. We conducted this systematic review and meta-analysis to explore the influence of SHD as an adjuvant treatment for early medical abortion using a combination of mifepristone followed by misoprostol. METHODS This systematic review and meta-analysis was reported using 2020 PRISMA guidelines. Eight databases were searched from their establishment to February 28, 2022, for randomized controlled trials (RCTs): PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, the Chinese BioMedical database, the Chinese Scientific Journal Database, and the Wanfang database. The Grading of Recommendations Assessment, Development, and Evaluation estimated the quality of evidence. RESULTS Sixteen RCTs involving 3016 patients were included in the meta-analysis. Overall, compared with no treatment as the control group after early medical abortion, patients treated with SHD were associated with a higher complete abortion rate (RR: 1.14; 95% CI: 1.10 - 1.18; P < 0.01, I2 = 26%, moderate quality), lower incomplete abortion rate (RR: 0.31; 95% CI: 0.24 - 0.41; P < 0.01, I2 = 0%, moderate quality), and lower viable pregnancy rate (RR: 0.26; 95% CI: 0.11 - 0.62; P < 0.01, I2 = 0%, moderate quality). Additionally, SHD supplementation was associated with reduced the induction-abortion time, duration of vaginal bleeding and menstrual recovery time. CONCLUSION Our findings suggest that SHD supplementation may be beneficial for women seeking a medical abortion before the 7-week gestational period and no adverse events in the experimental group were reported. However, the methodological quality of the included RCTs was unsatisfactory, and therefore it is necessary to further verify the effectiveness of SHD using standardized studies of rigorous design.
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Bi SJ, Yue SJ, Bai X, Feng LM, Xu DQ, Fu RJ, Zhang S, Tang YP. Danggui-Yimucao Herb Pair Can Protect Mice From the Immune Imbalance Caused by Medical Abortion and Stabilize the Level of Serum Metabolites. Front Pharmacol 2021; 12:754125. [PMID: 34867365 PMCID: PMC8636897 DOI: 10.3389/fphar.2021.754125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/01/2021] [Indexed: 11/24/2022] Open
Abstract
Unintended pregnancy is a situation that every woman may encounter, and medical abortion is the first choice for women, but abortion often brings many sequelae. Angelica sinensis Radix (Danggui) and Leonuri Herba (Yimucao) are widely used in the treatment of gynecological diseases, which can regulate menstrual disorders, amenorrhea, dysmenorrhea, and promote blood circulation and remove blood stasis, but the mechanism for the treatment of abortion is not clear. We determined the ability of Danggui and Yimucao herb pair (DY) to regulate the Th1/Th2 paradigm by detecting the level of progesterone in the serum and the expression of T-bet and GATA-3 in the spleen and uterus. Then, we detected the level of metabolites in the serum and enriched multiple metabolic pathways. The arachidonic acid pathway can directly regulate the differentiation of Th1/Th2 cells. This may be one of the potential mechanisms of DY in the treatment of abortion.
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Affiliation(s)
- Shi-Jie Bi
- Key Laboratory of Shaanxi Administration of Traditional Chinese Medicine for TCM Compatibility, and State Key Laboratory of Research and Development of Characteristic Qin Medicine Resources (Cultivation), and Shaanxi Key Laboratory of Chinese Medicine Fundamentals and New Drugs Research, and Shaanxi Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Shaanxi University of Chinese Medicine, Xi'an, China
| | - Shi-Jun Yue
- Key Laboratory of Shaanxi Administration of Traditional Chinese Medicine for TCM Compatibility, and State Key Laboratory of Research and Development of Characteristic Qin Medicine Resources (Cultivation), and Shaanxi Key Laboratory of Chinese Medicine Fundamentals and New Drugs Research, and Shaanxi Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Shaanxi University of Chinese Medicine, Xi'an, China
| | - Xue Bai
- Key Laboratory of Shaanxi Administration of Traditional Chinese Medicine for TCM Compatibility, and State Key Laboratory of Research and Development of Characteristic Qin Medicine Resources (Cultivation), and Shaanxi Key Laboratory of Chinese Medicine Fundamentals and New Drugs Research, and Shaanxi Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Shaanxi University of Chinese Medicine, Xi'an, China
| | - Li-Mei Feng
- Key Laboratory of Shaanxi Administration of Traditional Chinese Medicine for TCM Compatibility, and State Key Laboratory of Research and Development of Characteristic Qin Medicine Resources (Cultivation), and Shaanxi Key Laboratory of Chinese Medicine Fundamentals and New Drugs Research, and Shaanxi Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Shaanxi University of Chinese Medicine, Xi'an, China
| | - Ding-Qiao Xu
- Key Laboratory of Shaanxi Administration of Traditional Chinese Medicine for TCM Compatibility, and State Key Laboratory of Research and Development of Characteristic Qin Medicine Resources (Cultivation), and Shaanxi Key Laboratory of Chinese Medicine Fundamentals and New Drugs Research, and Shaanxi Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Shaanxi University of Chinese Medicine, Xi'an, China
| | - Rui-Jia Fu
- Key Laboratory of Shaanxi Administration of Traditional Chinese Medicine for TCM Compatibility, and State Key Laboratory of Research and Development of Characteristic Qin Medicine Resources (Cultivation), and Shaanxi Key Laboratory of Chinese Medicine Fundamentals and New Drugs Research, and Shaanxi Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Shaanxi University of Chinese Medicine, Xi'an, China
| | - Sai Zhang
- Key Laboratory of Shaanxi Administration of Traditional Chinese Medicine for TCM Compatibility, and State Key Laboratory of Research and Development of Characteristic Qin Medicine Resources (Cultivation), and Shaanxi Key Laboratory of Chinese Medicine Fundamentals and New Drugs Research, and Shaanxi Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Shaanxi University of Chinese Medicine, Xi'an, China
| | - Yu-Ping Tang
- Key Laboratory of Shaanxi Administration of Traditional Chinese Medicine for TCM Compatibility, and State Key Laboratory of Research and Development of Characteristic Qin Medicine Resources (Cultivation), and Shaanxi Key Laboratory of Chinese Medicine Fundamentals and New Drugs Research, and Shaanxi Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Shaanxi University of Chinese Medicine, Xi'an, China
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4
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Orlowski MH, Soares WE, Kerrigan KA, Zerden ML. Management of Postabortion Complications for the Emergency Medicine Clinician. Ann Emerg Med 2020; 77:221-232. [PMID: 33341294 DOI: 10.1016/j.annemergmed.2020.09.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 09/02/2020] [Accepted: 09/08/2020] [Indexed: 02/02/2023]
Abstract
Although induced abortion is generally a safe outpatient procedure, many patients subsequently present to the emergency department, concerned about a postabortion complication. It is helpful for emergency physicians to understand the medications and procedures used in abortion care in the United States to effectively and efficiently triage and treat women presenting with potential complications from an abortion. Furthermore, because many states are experiencing increased abortion restrictions that limit access to care, emergency medicine physicians may encounter more patients presenting after self-managed abortions, which presents additional challenges. This article reviews the epidemiology and background of abortion care, including the range of symptoms and adverse effects that are within the scope of an uncomplicated procedure. This review also offers a comprehensive overview of management of abortion complications, including algorithms for more common complications and descriptions of less common but more severe adverse events. The article concludes with a recognition of the social stigma and legal regulations unique to abortion care.
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Affiliation(s)
| | - William E Soares
- University of Massachusetts Medical School at Baystate Medical Center, Springfield, MA
| | - Kathleen A Kerrigan
- University of Massachusetts Medical School at Baystate Medical Center, Springfield, MA
| | - Matthew L Zerden
- Planned Parenthood South Atlantic, Chapel Hill, and WakeMed Health & Hospitals, Raleigh, NC
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Gambir K, Garnsey C, Necastro KA, Ngo TD. Effectiveness, safety and acceptability of medical abortion at home versus in the clinic: a systematic review and meta-analysis in response to COVID-19. BMJ Glob Health 2020; 5:e003934. [PMID: 33380413 PMCID: PMC7780419 DOI: 10.1136/bmjgh-2020-003934] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Increased access to home-based medical abortion may offer women a convenient, safe and effective abortion method, reduce burdens on healthcare systems and support social distancing during the COVID-19 pandemic. Home-based medical abortion is defined as any abortion where mifepristone, misoprostol or both medications are taken at home. METHODS A systematic review and meta-analysis of randomised controlled trials (RCTs) and non-randomised studies (NRSs) were conducted. We searched databases from inception to 10 July 2019 and 14 June 2020. Successful abortion was the main outcome of interest. Eligible studies were RCTs and NRSs studies with a concurrent comparison group comparing home versus clinic-based medical abortion. Risk ratios (RRs) and their 95% CIs were calculated. Estimates were calculated using a random-effects model. We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess risk of bias by outcome and to evaluate the overall quality of the evidence. RESULTS We identified 6277 potentially eligible published studies. Nineteen studies (3 RCTs and 16 NRSs) were included with 11 576 women seeking abortion up to 9 weeks gestation. Neither the RCTs nor the NRS found any difference between home-based and clinic-based administration of medical abortion in having a successful abortion (RR 0.99, 95% CI 0.98 to 1.01, I2=0%; RR 0.99, 95% CI 0.97 to 1.01, I2=52%, respectively). The certainty of the evidence for the 16 NRSs was downgraded from low to very low due to high risk of bias and publication bias. The certainty of the evidence for the three RCTs was downgraded from high to moderate by one level for high risk of bias. CONCLUSION Home-based medical abortion is effective, safe and acceptable to women. This evidence should be used to expand women's abortion options and ensure access to abortion for women during COVID-19 and beyond. PROSPERO REGISTRATION NUMBER CRD42020183171.
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Affiliation(s)
- Katherine Gambir
- Poverty, Gender and Youth Program, Population Council, New York, New York, USA
| | - Camille Garnsey
- Poverty, Gender and Youth Program, Population Council, New York, New York, USA
| | - Kelly Ann Necastro
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thoai D Ngo
- Poverty, Gender and Youth Program, Population Council, New York, New York, USA
- The GIRL Center, Population Council, New York, New York, USA
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Fiala C, Agostini A, Bombas T, Cameron S, Lertxundi R, Lubusky M, Parachini M, Saya L, Trumbic B, Gemzell Danielsson K. Management of pain associated with up-to-9-weeks medical termination of pregnancy (MToP) using mifepristone–misoprostol regimens: expert consensus based on a systematic literature review. J OBSTET GYNAECOL 2019; 40:591-601. [DOI: 10.1080/01443615.2019.1634027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- C. Fiala
- Gynmed Clinic, Vienna, Austria
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynaecology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - A. Agostini
- Obstetric and Gynecology Department, La Conception Hospital, Marseille, France
| | - T. Bombas
- Obstetric Service, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - S. Cameron
- Chalmers Centre, NHS Lothian, Edinburgh, Scotland
| | | | - M. Lubusky
- Department of Obstetrics and Gynaecology, Palacky University Hospital, Olomouc, Czech Republic
| | | | - L. Saya
- Altius Pharma CS, Paris, France
| | | | - K. Gemzell Danielsson
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynaecology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Detection of Illegal Abortion-Induced Drugs Using Rapid and Simultaneous Method for the Determination of Abortion-Induced Compounds by LC–MS/MS. Chromatographia 2019. [DOI: 10.1007/s10337-019-03758-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Bettahar K, Pinton A, Boisramé T, Cavillon V, Wylomanski S, Nisand I, Hassoun D. Interruption volontaire de grossesse par voie médicamenteuse. ACTA ACUST UNITED AC 2016; 45:1490-1514. [DOI: 10.1016/j.jgyn.2016.09.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
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Soon JA, Costescu D, Guilbert E. Medications Used in Evidence-Based Regimens for Medical Abortion: An Overview. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:636-45. [DOI: 10.1016/j.jogc.2016.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 03/15/2016] [Indexed: 12/27/2022]
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Abstract
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.
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12
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Patil E, Edelman A. Medical Abortion: Use of Mifepristone and Misoprostol in First and Second Trimesters of Pregnancy. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015. [DOI: 10.1007/s13669-014-0109-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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13
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Clark W, Shannon C, Winikoff B. Misoprostol for uterine evacuation in induced abortion and pregnancy failure. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.2.1.67] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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14
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Makenzius M, Tydén T, Darj E, Larsson M. Autonomy and dependence - experiences of home abortion, contraception and prevention. Scand J Caring Sci 2012; 27:569-79. [DOI: 10.1111/j.1471-6712.2012.01068.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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15
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Timing and indication for curettage after medical abortion in early pregnant women with prior uterine incision. Contraception 2010; 81:62-6. [DOI: 10.1016/j.contraception.2009.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Revised: 09/23/2009] [Accepted: 09/24/2009] [Indexed: 11/24/2022]
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Bennett IM, Baylson M, Kalkstein K, Gillespie G, Bellamy SL, Fleischman J. Early abortion in family medicine: clinical outcomes. Ann Fam Med 2009; 7:527-33. [PMID: 19901312 PMCID: PMC2775627 DOI: 10.1370/afm.1051] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Ian M Bennett
- Department of Family Medicine and Community Health, University of Pennsylvania School of Medicine, 2nd Floor Gates Pavilion, 3400 Spruce St, Philadelphia, PA 19104-4283, USA.
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El-Baradie SM, El-Said MH, Ragab WS, Elssery KM, Mahmoud M. Endometrial Thickness and Serum β-hCG as Predictors of the Effectiveness of Oral Misoprostol in Early Pregnancy Failure. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2008; 30:877-881. [DOI: 10.1016/s1701-2163(16)32966-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Gan C, Zou Y, Wu S, Li Y, Liu Q. The influence of medical abortion compared with surgical abortion on subsequent pregnancy outcome. Int J Gynaecol Obstet 2008; 101:231-8. [PMID: 18321519 DOI: 10.1016/j.ijgo.2007.12.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Revised: 12/07/2007] [Accepted: 12/18/2007] [Indexed: 11/18/2022]
Affiliation(s)
- Changping Gan
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
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19
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Shannon C, Winikoff B. How much Supervision is Necessary for Women Taking Mifepristone and Misoprostol for Early Medical Abortion? WOMENS HEALTH 2008; 4:107-11. [DOI: 10.2217/17455057.4.2.107] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Caitlin Shannon
- Gynuity Health Projects, 15 East 26th Street, Suite 1617, NY 10010, USA, Tel.: +1 212 448 1230; Fax: +1 212 448 1260
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Abstract
BACKGROUND The long-term safety of surgical abortion in the first trimester is well established. Despite the increasing use of medical abortion (abortion by means of medication), limited information is available regarding the effects of this procedure on subsequent pregnancies. METHODS We identified all women living in Denmark who had undergone an abortion for nonmedical reasons between 1999 and 2004 and obtained information regarding subsequent pregnancies from national registries. Risks of ectopic pregnancy, spontaneous abortion, preterm birth (at <37 weeks of gestation), and low birth weight (<2500 g) in the first subsequent pregnancy in women who had had a first-trimester medical abortion were compared with risks in women who had had a first-trimester surgical abortion. RESULTS Among 11,814 pregnancies in women who had had a previous first-trimester medical abortion (2710 women) or surgical abortion (9104 women), there were 274 ectopic pregnancies (respective incidence rates, 2.4% and 2.3%), 1426 spontaneous abortions (12.2% and 12.7%), 552 preterm births (5.4% and 6.7%), and 478 births with low birth weight (4.0% and 5.1%). After adjustment for maternal age, interval between pregnancies, gestational age at abortion, parity, cohabitation status, and urban or nonurban residence, medical abortion was not associated with a significantly increased risk of ectopic pregnancy (relative risk, 1.04; 95% confidence interval [CI], 0.76 to 1.41), spontaneous abortion (relative risk, 0.87; 95% CI, 0.72 to 1.05), preterm birth (relative risk, 0.88; 95% CI, 0.66 to 1.18), or low birth weight (relative risk, 0.82; 95% CI, 0.61 to 1.11). Gestational age at medical abortion was not significantly associated with any of these adverse outcomes. CONCLUSIONS We found no evidence that a previous medical abortion, as compared with a previous surgical abortion, increases the risk of spontaneous abortion, ectopic pregnancy, preterm birth, or low birth weight.
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Affiliation(s)
- Jasveer Virk
- Department of Epidemiology, University of California, Los Angeles, USA
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21
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Abstract
This article provides an overview of medication abortion in the United States 6 years after the approval of mifepristone (RU486; Mifeprex; Danco Laboratories, LLC, New York, NY) by the US Food and Drug Administration (FDA). The adoption of mifepristone is considered in the context of epidemiologic data on abortion, abortion access, and the safety of abortion. The risks of medication and aspiration abortion are discussed in the context of abortion-related mortality, recent experience with obstetric and gynecologic infection with Clostridium sordellii, and the limits of scientific knowledge on the incidence of this infection in women. Innovative protocols studied since FDA approval of mifepristone are presented, and implications for clinical practice are discussed.
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Affiliation(s)
- Margaret W Beal
- Yale University School of Nursing, 100 Church Street South, PO Box 9740, New Haven, CT 06536-0740, USA.
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22
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Stockheim D, Machtinger R, Wiser A, Dulitzky M, Soriano D, Goldenberg M, Schiff E, Seidman DS. A randomized prospective study of misoprostol or mifepristone followed by misoprostol when needed for the treatment of women with early pregnancy failure. Fertil Steril 2006; 86:956-60. [PMID: 17027362 DOI: 10.1016/j.fertnstert.2006.03.032] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2005] [Revised: 03/10/2006] [Accepted: 03/10/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To compare the effectiveness and safety of misoprostol and mifepristone, followed when needed by misoprostol, for the treatment of women with early pregnancy failure. DESIGN Prospective randomized nonblinded controlled trial. SETTING University-affiliated tertiary medical center. PATIENT(S) One hundred fifteen consecutive women diagnosed as having a blighted ovum or missed abortion of <9 weeks of gestation enrolled. INTERVENTION(S) The patients received orally 600 mg mifepristone (group I) or orally 800 microg misoprostol (group II). Most patients in both groups subsequently received 48 hours later orally 800 microg misoprostol. MAIN OUTCOME MEASURE(S) Failure was defined as surgical intervention due to retained gestational sac 48 hours after completion of the drug protocol, severe symptoms, or suspected retained products of conception after the menstrual period. RESULT(S) The success rate was similar in groups I and II: 38 of 58 patients (65.5%) versus 42 of 57 patients (73.6%), respectively. No cases of severe infection or bleeding necessitating blood transfusion occurred. CONCLUSION(S) Misoprostol is an effective and safe treatment for early pregnancy failure and could replace surgical curettage in over two-thirds of the patients. Mifepristone offers no advantage compared with misoprostol as initial treatment.
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Affiliation(s)
- David Stockheim
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Israel.
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23
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Markovitch O, Tepper R, Klein Z, Fishman A, Aviram R. Sonographic appearance of the uterine cavity following administration of mifepristone and misoprostol for termination of pregnancy. JOURNAL OF CLINICAL ULTRASOUND : JCU 2006; 34:278-82. [PMID: 16788959 DOI: 10.1002/jcu.20232] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
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.
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Affiliation(s)
- Ofer Markovitch
- Ultrasound Unit, Department of Obstetrics and Gynecology, Meir Medical Center, Tel Aviv University, Ramat Aviv, Israel
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Arvidsson C, Hellborg M, Gemzell-Danielsson K. Preference and acceptability of oral versus vaginal administration of misoprostol in medical abortion with mifepristone. Eur J Obstet Gynecol Reprod Biol 2006; 123:87-91. [PMID: 16260342 DOI: 10.1016/j.ejogrb.2005.02.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2004] [Revised: 02/22/2005] [Accepted: 02/23/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To compare the experience of pain, need of analgesic interventions, preference and acceptability in medical abortion up to 49 days of amenorrhea with mifepristone and orally versus vaginally administered misoprostol. STUDY DESIGN Ninety-seven women were randomised to oral misoprostol, n=48, or vaginal misoprostol, n=49. On day 1 of the study, both the groups received 600 mg of mifepristone. On day 3 of the study, one group received 0.4 mg of misoprostol orally and the other group received 0.8 mg of misoprostol vaginally. RESULTS Even though oral administration of misoprostol seemed to be associated with a higher rate of gastrointestinal side effects, women in both the groups showed a clear preference towards the oral route of administration. The willingness to administer the misoprostol at home was also higher among the women in the oral group, which may in part depend on a more positive/less negative experience of the abortion. CONCLUSION A majority of women prefer oral administration of misoprostol in early medical abortion.
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Affiliation(s)
- Caroline Arvidsson
- Department of Obstetrics and Gynecology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
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Limacher JJ, Daniel I, Isaacksz S, Payne GJ, Dunn S, Coyte PC, Laporte A. Early Abortion in Ontario: Options and Costs. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2006; 28:142-8. [PMID: 16643717 DOI: 10.1016/s1701-2163(16)32065-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Early abortions have been predominantly surgical for many years, but medical options with comparable efficacy and safety are now available. This study compares the costs of two medical options and two surgical options. METHODS We used a clinical model to compare the costs in Ontario of four options for early abortion: medical abortion using either mifepristone or methotrexate, and surgical abortion by vacuum aspiration in either a hospital or a free-standing clinic. The cost analysis was conducted from the perspectives of society, the health care system, and the patient. RESULTS From all perspectives, total costs were highest for hospital surgical abortion, followed by surgical abortion in a clinic. From the patient's perspective, total costs were higher for surgical abortion but direct costs (mainly for medications) were higher for medical abortion. The total cost of mifepristone and methotrexate abortion was equal if the price of mifepristone (200 mg) was $59.52. The model was robust but was sensitive to the price of mifepristone. CONCLUSION Early medical abortion costs less than early surgical abortion from the societal and health care system perspectives but more than surgical abortion from the patient's perspective. Surgical abortion costs more in hospitals than in free-standing clinics from the societal and health care system perspectives, but the costs are the same in both settings from the patient's perspective. No method for early abortion can be identified as best, and patients should be free to choose the option they prefer.
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Affiliation(s)
- James J Limacher
- Department of Health Policy, Management and Evaluation, University of Toronto, Toronto ON
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Fischer M, Bhatnagar J, Guarner J, Reagan S, Hacker JK, Van Meter SH, Poukens V, Whiteman DB, Iton A, Cheung M, Dassey DE, Shieh WJ, Zaki SR. Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion. N Engl J Med 2005; 353:2352-60. [PMID: 16319384 DOI: 10.1056/nejmoa051620] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Endometritis and toxic shock syndrome associated with Clostridium sordellii have previously been reported after childbirth and, in one case, after medical abortion. We describe four deaths due to endometritis and toxic shock syndrome associated with C. sordellii that occurred within one week after medically induced abortions. Clinical findings included tachycardia, hypotension, edema, hemoconcentration, profound leukocytosis, and absence of fever. These cases indicate the need for physician awareness of this syndrome and for further study of its association with medical abortion.
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Affiliation(s)
- Marc Fischer
- Centers for Disease Control and Prevention, Atlanta, USA.
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Shand C, Rose SB, Simmons A, Sparrow MJ. Introduction of early medical abortion in New Zealand: An audit of the first 67 cases. Aust N Z J Obstet Gynaecol 2005; 45:316-20. [PMID: 16029300 DOI: 10.1111/j.1479-828x.2005.00419.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In New Zealand, mifepristone became available in 2001, but because of uncertainty about the law, the first 67 cases were carried out under a very strict protocol. Once the prostaglandin had been administered it was necessary that the woman remain in the unit until the products of conception (POC) had been passed and, if this had not occurred within 8 h, she underwent suction curettage. AIMS To demonstrate that an early medical termination of pregnancy (EMTOP) service could be offered as a safe option for women, despite the constraints of the law. METHODS An audit of patient notes was carried out on the first 67 patients undergoing an EMTOP at the Level J Unit (LJU), Wellington Hospital. Data collected included age, ethnicity, parity, previous abortions, gestational age, length of time between the administration of mifepristone and misoprostol, length of time after administration of misoprostol to the completion of abortion, whether a fetal sac was seen, analgesia required, extent of heavy bleeding and any adverse effects. Patient characteristics were compared with those of the 3052 women who underwent surgical termination during the same time period. Data were analysed using EpiInfo 2000 (Centers for Disease Control and Prevention, Atlanta, GA) and Chi square tests for significance. RESULTS Successful completion of EMTOP occurred in 63 of 67 cases (94%). Only four cases (6%) required completion by suction curettage and this was performed for legal and financial reasons, rather than for medical reasons. Clinical events requiring management, mainly bleeding problems, occurred in 11 patients (16%). CONCLUSIONS EMTOP with mifepristone and misoprostol was successfully introduced and the experience provides useful data for others contemplating a similar service.
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Affiliation(s)
- Carol Shand
- Level J Unit, Wellington Hospital, Capital & Coast Health Ltd, Wellington, New Zealand.
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Lamarche-Vadel A, Moreau C, Warszawski J, Bajos N. [Side effects of induced abortion: results from a population-based survey]. ACTA ACUST UNITED AC 2005; 33:113-8. [PMID: 15848082 DOI: 10.1016/j.gyobfe.2005.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2004] [Accepted: 02/17/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This study compares the gynaecological symptoms of women who have undergone an induced abortion to those who have not. We also compare the gynaecological side effects, in particular the infectious symptoms, following an induced abortion, according to the abortion technique, medical and surgical, in the year after the abortion. PATIENTS AND METHODS A representative sample of 2863 women, aged 18 to 44, was interviewed by telephone between September 2000 and January 2001. Of these women, 401 declared an abortion in the last 5 years. Analysis of the gynaecological side effects according to the abortion technique was performed among the 199 women who terminated their pregnancy before the 8th week of amenorrhoea. RESULTS Women with a history of induced abortion had a higher sexual risk profile than those with no such history. They also more frequently reported genital infectious symptoms. The comparison between medical and surgical abortions shows that women who had a medical abortion were more likely to report heavy and prolonged bleeding. On the contrary, we found no difference of infectious symptoms between the two techniques. DISCUSSION AND CONCLUSION Our study does not support the idea of a reduction of infectious complications related to medical as opposed to surgical abortions. However, given the rapid diffusion of medical abortion, it seems important to carry on the investigations on the side effects related to medical abortions, in order to prevent them if necessary.
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Affiliation(s)
- A Lamarche-Vadel
- Inserm-INED U 569, 82, avenue du Général-Leclerc, 94276 Le-Kremlin-Bicêtre cedex, France.
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Scioscia M, Pontrelli G, Vimercati A, Santamato S, Selvaggi L. A short-scheme protocol of gemeprost for midtrimester termination of pregnancy with uterine scar. Contraception 2005; 71:193-6. [PMID: 15722069 DOI: 10.1016/j.contraception.2004.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2004] [Revised: 10/25/2004] [Accepted: 10/27/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this study is to investigate the safety and effectiveness of a short-scheme protocol of gemeprost for second trimester induction of abortion in women with previous uterine surgery. STUDY DESIGN Retrospective review of women who underwent second trimester medical termination of pregnancy (TOP) at our hospital in a 5-year period. A short regimen of gemeprost was used: over a 24-h period, 1 mg vaginal gemeprost was given every 3 h up to three doses after which, if abortion did not occur, another course at the same dosage schedule was administered up to 4 days. Induction failure was defined as women undelivered by 96 h. A homogeneous population was identified. Statistical analysis was performed with the chi(2) test or Fisher's Exact Test for categorical data and t test for continuous variables. RESULTS Four hundred seventeen women underwent medical midtrimester TOP in the 5-year study period. Two hundred five patients were selected for this review, comparing 63 patients with scarred uterus to 142 women without uterine scars. There were no differences between the two groups in induction-to-abortion interval and number of pessaries given. The overall failure of induction rate was 1.5% and need for blood transfusion was 0.5%. No uterine rupture was reported. CONCLUSION The regimen of gemeprost proposed seems to be as safe and effective in patients with uterine scars as in women with unscarred uteri with a very low incidence of complications.
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Affiliation(s)
- Marco Scioscia
- Department of Obstetrics and Gynaecology, University of Bari, 70125 Bari, Italy.
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Wiebe E, Guilbert E, Jacot F, Shannon C, Winikoff B. A Fatal Case of Clostridium sordellii Septic Shock Syndrome Associated With Medical Abortion. Obstet Gynecol 2004; 104:1142-4. [PMID: 15516429 DOI: 10.1097/01.aog.0000142738.68439.9e] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clostridia bacteria are infrequent human pathogens. In the obstetric and gynecologic literature, Clostridium sordellii infections have been very rarely reported. This is a case of infection following medical termination of early pregnancy with mifepristone and misoprostol. CASE A 27-year-old woman presented for termination of pregnancy at 5.5 weeks from her last menstrual period. She received mifepristone 200 mg orally followed by 800 microg vaginal misoprostol. Three days after administration of misoprostol, she complained of dizziness, pelvic pain, and bleeding. The next day, she experienced worsening of symptoms and was hospitalized. She developed pulmonary edema, ascites, and heart failure. Despite supportive measures, antibiotics, and hysterectomy, she died 3 days later. The post mortem examinations indicated that death was caused by shock secondary to C sordellii infection. CONCLUSION The frequency of infection following medical abortion is low. The rapid and fatal course of this infection is similar to other obstetric and gynecologic cases reported in the literature. Although providers should remain vigilant to the possibility of infection following medical abortion, the overall proven safety of medical abortion remains the same.
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Affiliation(s)
- Ellen Wiebe
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
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Grossman D, Ellertson C, Grimes DA, Walker D. Routine follow-up visits after first-trimester induced abortion. Obstet Gynecol 2004; 103:738-45. [PMID: 15051567 DOI: 10.1097/01.aog.0000115511.14004.19] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Routine follow-up visits after abortion are intended to confirm that the abortion is complete and to diagnose and treat complications. Many clinicians also take advantage of the follow-up visit to provide general reproductive health care: discussing contraceptive plans and providing family planning services; diagnosing sexually transmitted infections; performing a Pap test or discussing abnormal Pap results. We reviewed the evidence related to the routine postabortion follow-up visit. Other than mifepristone medical abortion performed at 50 days of gestation or later and methotrexate medical abortion, we found little evidence that mandatory follow-up visits typically detect conditions that women themselves could not be taught to recognize. In addition, the natural history of the most severe complications after abortion-infection and unrecognized ectopic pregnancy-have time courses inconsistent with the usual timing of the follow-up visit. Costs associated with this visit can be great. These include travel expenses, lost wages, child-care expenses, privacy and emotional burdens for women, and scheduling disruptions and the related opportunity costs caused by "no-shows" for the provider. Follow-up appointments should be scheduled for those women likely to benefit from a physical examination. For the remainder of women, simple instructions and advice about detecting complications, possibly coupled with telephone follow-up, might suffice. Although arguably valuable in their own right, counseling, family planning services, or sexually transmitted infection diagnosis and treatment should not be so inflexibly bundled with postabortion care. Protocols that require in-person follow-up after abortion may not make the best use of a women's time or abilities, or of the medical system.
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Cowett AA, Cohen LS, Lichtenberg ES, Stika CS. Ultrasound Evaluation of the Endometrium After Medical Termination of Pregnancy. Obstet Gynecol 2004; 103:871-5. [PMID: 15121559 DOI: 10.1097/01.aog.0000124782.69622.48] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine ultrasound parameters associated with the need for clinical intervention after mifepristone and misoprostol termination of pregnancy. METHODS Charts of patients undergoing medical termination according to a standard protocol in a 13-month period were reviewed. Endometrial thickness and the presence of gestational sac, fluid interface, or complex echoes on postprocedure ultrasonogram were recorded. Repeat doses of medication, surgical intervention, and complications were noted. Success was defined as an abortion completed after a single course of medical therapy. RESULTS Postprocedure ultrasonograms were available for 525 of 684 patients. Endometrial thickness was measurable in 437 cases. The observed mean endometrial thickness was 4.10 +/- 1.80 mm (range 0.67-13.4 mm). Endometrial thickness was inversely proportional to the number of days after initiation of therapy when ultrasonography was performed (r = -0.22; P <.001). The endometrium was thicker in the women who had failed than in those who had a successful medical abortion (6.15 +/- 1.95 mm [range 3.35-10.0 mm] versus 4.01 +/- 1.75 mm [range 0.67-13.4 mm], respectively; P <.001), but the wide overlap in endometrial thicknesses nullified the clinical usefulness of this difference. CONCLUSION Endometrial thickness after administration of a single dose of mifepristone and misoprostol for medical termination should not dictate clinical intervention. The decision to treat should be based on the presence of a persistent gestational sac or compelling clinical signs and symptoms.
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Affiliation(s)
- Allison A Cowett
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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Acharya G, Haugen M, Bråthen A, Nilsen I, Maltau JM. Role of routine ultrasonography in monitoring the outcome of medical abortion in a clinical setting. Acta Obstet Gynecol Scand 2004; 83:390-4. [PMID: 15005788 DOI: 10.1111/j.0001-6349.2004.00368.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinical methods generally used to evaluate the completeness of medical abortion are not accurate. There are no published reports evaluating the role of routine ultrasonography in monitoring the outcome of medical abortion. The purpose of this study was to investigate whether routine transvaginal ultrasonography (TVS) at the follow-up visit after medical abortion can accurately identify women who will require surgical intervention. DESIGN Retrospective review of medical records and charts of all women undergoing medical abortion in the first trimester of pregnancy between January 1999 and December 2001. METHODS Medical abortion was performed using oral mifepristone and a vaginal prostaglandin analog before 63 days gestation. All women had an initial TVS to confirm intrauterine pregnancy and gestational age, and another TVS at the follow-up visit 2-3 weeks later to assess the completeness of abortion. Surgical evacuation of the uterus was allowed as indicated on clinical grounds but not on the basis of ultrasound findings only. RESULTS A total of 690 women consented to medical abortion during the study period. Eleven of these women were excluded from the study for various reasons. Of the remaining 679 cases, 95% (645/679) had a documented follow-up at the hospital. The pregnancy termination rate among these women was 99.2% (640/645) and TVS identified all five cases of continuing pregnancy at the follow-up. A total of 66 (10.2%) patients had complications. The uterine cavity was empty on TVS at the follow-up visit in 84.8% (547/645) of cases and only 3.1% (17/547) of them required surgical aspiration/curettage due to excessive or prolonged vaginal bleeding. In the remaining 15.2% (98/645) the uterine cavity was not empty, and 43.9% (43/98) of them had a curettage. The risk of requiring a surgical intervention was significantly higher [odds ratio (OR) 24.4; 95% confidence interval (95% CI) 14.9-39.7] when the uterine cavity was not demonstrated to be empty at the follow-up visit 2-3 weeks after medical abortion. However, 59.1% (55/93) of women did not require surgical intervention despite ultrasound evidence of thick endometrial echo-complex. CONCLUSION Routine TVS 2-3 weeks after medical abortion appears to be an efficient means of accurately identifying the cases of ongoing pregnancy and diagnosing a complete abortion. Although TVS could be used as an adjunct to clinical examination to diagnose an incomplete expulsion, it does not accurately differentiate those women who require surgical intervention from those who do not.
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Affiliation(s)
- Ganesh Acharya
- Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway.
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Taylor D, Hwang AC. Mifepristone for medical abortion. Exploring a new option for nurse practitioners. ACTA ACUST UNITED AC 2004; 7:524-9. [PMID: 14753095 DOI: 10.1177/1091592303261927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Diana Taylor
- Department of Family Health Care Nursing, University of California, San Francisco, USA
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Abdel-Aziz E, Hassan I, Al-Taher HM. Assessment of pain associated with medical abortion. Int J Gynaecol Obstet 2003; 84:264-5. [PMID: 15001379 DOI: 10.1016/s0020-7292(03)00327-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2003] [Revised: 07/08/2003] [Accepted: 07/15/2003] [Indexed: 11/26/2022]
Affiliation(s)
- E Abdel-Aziz
- Department of Obstetrics and Gynaecology, The Queen Elizabeth Hospital, King's Lynn, Norfolk, UK.
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Medina Sanpedro M. [Voluntary termination of pregnancy and illegal abortion. Reflections of a family doctor]. Aten Primaria 2003; 32:548. [PMID: 14651840 PMCID: PMC7668941 DOI: 10.1016/s0212-6567(03)70791-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Numerous medical, surgical, psychiatric, gynecologic, and obstetric disorders can cause abdominal pain during pregnancy. The patient history, physical examination, laboratory data, and radiologic findings usually provide the diagnosis. The pregnant woman has physiologic alterations that affect the clinical presentation, including atypical normative laboratory values. Abdominal ultrasound is generally the recommended radiologic imaging modality; roentgenograms are generally contraindicated during pregnancy because of radiation teratogenicity. Concerns about the fetus limit the pharmacotherapy. Maternal and fetal survival have recently increased in many life-threatening conditions, such as ectopic pregnancy, appendicitis, and eclampsia, because of improved diagnostic technology, better maternal and fetal monitoring, improved laparoscopic technology, and earlier therapy.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, Woodhull Medical Center, 760 Broadway Avenue, Brooklyn, NY 11206, USA
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Beal MW, Simmonds K. Clinical uses of mifepristone: an update for women's health practitioners. J Midwifery Womens Health 2002; 47:451-60. [PMID: 12484667 DOI: 10.1016/s1526-9523(02)00331-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In September 2000, the U.S. Food and Drug Administration (FDA) approved the use of mifepristone for the provision of medical abortion. Although mifepristone was developed and marketed because of its potential to effect early first-trimester medical abortion, it has additional applications to health care, including the treatment of gynecologic conditions, cancer, and Cushing's disease. The controversial nature of abortion has dominated the publicity about mifepristone. The evidence for the safety and efficacy of mifepristone in medical abortion has been overshadowed, and many clinicians are unaware of the other potential uses of the drug. This article provides a discussion of background information on the pharmacology, development of, and research on mifepristone and an update on current and potential uses in health care today. Information on the FDA-approved regimen and alternative protocols for management of mifepristone in its use in abortion care are presented.
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Affiliation(s)
- Margaret W Beal
- Yale University School of Nursing, New Haven, CT 06536-0740, USA
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Paul ME, Mitchell CM, Rogers AJ, Fox MC, Lackie EG. Early surgical abortion: efficacy and safety. Am J Obstet Gynecol 2002; 187:407-11. [PMID: 12193934 DOI: 10.1067/mob.2002.123898] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Because of concern over the higher rates of failed abortion, many clinicians defer surgical abortion until 7 menstrual weeks or later. We conducted this study to evaluate the efficacy and safety of early surgical abortions that are performed by numerous physicians in a community-based setting. STUDY DESIGN We prospectively gathered data on all eligible patients who had surgical abortions at <6 weeks of gestation at 3 Planned Parenthood clinics from January 1, 1998, to August 31, 2000. Outcomes were evaluated with the use of proportions with 95% CI and chi(2) analysis. RESULTS A total of 1132 women had early surgical abortions during the study interval, and follow-up was available for 750 of those women (66%). Seventeen women (2.3%; 95% CI, 1.4%, 3.7%) had failed attempted abortions. Other complications occurred in 13 women. CONCLUSION Early surgical abortion is safe and effective. In this series, the frequency of complications that required curettage was similar to that reported with mifepristone and vaginal misoprostol.
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Affiliation(s)
- Maureen E Paul
- Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Boston, MA, USA
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Abstract
Primary care clinicians who provide comprehensive reproductive heath care can now offer patients mifepristone (Mifeprex) as an abortifacient option. Clinicians, however, must first determine if the state in which they practice has regulations specifying who can perform abortions and dispense drugs, and they must consider clinical office zoning ordinances, staffing, public relations issues, and reimbursement. This article discusses the pharmacology of mifepristone and misoprostol, professional considerations, and how to prevent and manage adverse effects and complications of medical abortion.
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Affiliation(s)
- S L Fielding
- Reproductive Health Program, University of Rochester, Rochester, N.Y., USA
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Bartley J, Brown A, Elton R, Baird DT. Double-blind randomized trial of mifepristone in combination with vaginal gemeprost or misoprostol for induction of abortion up to 63 days gestation. Hum Reprod 2001; 16:2098-102. [PMID: 11574498 DOI: 10.1093/humrep/16.10.2098] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Gemeprost and misoprostol are two of the most widely used prostaglandins in combination with mifepristone for medical abortion in early pregnancy. However, the efficacy and side-effects of those two drugs given vaginally have not been assessed in a randomized trial. METHODS Randomized double-blind controlled trial involving 999 women undergoing an abortion at gestational age < or =63 days who received either 0.5 mg gemeprost (group I, n = 499) or 800 microg misoprostol (group II, n = 500) vaginally approximately 48 h after taking 200 mg mifepristone by mouth. The rate of complete abortion and the side-effects were compared between the groups. RESULTS A total of 89 cases was excluded from full analysis of outcome because either they aborted after mifepristone alone (n = 2), had an ectopic pregnancy (n = 1), or because the outcome was uncertain as they failed to attend their follow-up appointment (n = 86). The rate of complete abortion was very high (>95%) in both groups but significantly higher after treatment with misoprostol than with gemeprost [436/453 (98.7%) versus 451/457 (96.2%), P = 0.019, difference 2.5%, confidence interval 0.4-4.7%] and there were fewer ongoing pregnancies (n = 1 versus n = 8, P < 0.018). Surgical intervention rose significantly with gestation in women who received gemeprost (P < 0.03) but not with misoprostol. The incidence of side-effects such as diarrhoea (13.7 versus 16.4%) and vomiting (27.8 versus 29.7%) was similar in women who received misoprostol or gemeprost respectively, as was the duration and amount of bleeding. CONCLUSIONS (i) Both regimens using a reduced dose of mifepristone are highly effective methods of inducing abortion in early pregnancy; (ii) vaginal misoprostol is the preferred prostaglandin because it is it is associated with fewer failures than low-dose gemeprost, particularly at gestation > or =49 days.
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Affiliation(s)
- J Bartley
- Centre for Reproductive Biology, University of Edinburgh, 37 Chalmers Street, Edinburgh EH3 9ET, UK
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Abstract
OBJECTIVE To review the efficacy and safety of mifepristone (with misoprostol) for the termination of early pregnancy. DATA SOURCES A MEDLINE search (1966-October 2000) was conducted, and additional references listed in articles were included; unpublished data obtained from the manufacturer were used to identify data from the scientific literature. Studies evaluating mifepristone were considered for inclusion. STUDY SELECTION Human clinical studies in the English language were reviewed and evaluated. Clinical trials selected for detailed review were limited to those including the regimens of mifepristone and misoprostol, recently approved by the Food and Drug Administration for early pregnancy termination. DATA SYNTHESIS Mifepristone is an antiprogestin available for pregnancy termination in combination with a prostaglandin such as misoprostol. Mifepristone offers efficacy similar to, if not better than, other drugs used for pregnancy termination, but appears less efficacious overall than surgical termination of pregnancy. Mifepristone in combination with misoprostol commonly causes adverse effects such as abdominal pain and, less commonly, can cause serious adverse effects such as incomplete abortion; endometritis; and bleeding warranting transfusion, hospitalization, or surgery. Mifepristone is metabolized by the cytochrome P450 system. Thus, the potential for drug interactions with this agent exists, although this has not been well studied. Data are included from clinical trials evaluating the safety, tolerability, efficacy, and pharmacoeconomics of mifepristone combined with misoprostol for early pregnancy termination. Data comparing the use of these agents with surgical abortion and other drugs used for pregnancy termination are included where available. CONCLUSIONS Mifepristone in combination with misoprostol for the termination of early pregnancy (amenorrhea of < or = 49 d) is effective in 92-95% of women. Incomplete abortion requiring surgical abortion after the fact occurs in 3-5% of women, and pregnancy continues 1-2% of the time. Mifepristone with misoprostol treatment is not without significant risks, including hemorrhage, infection, and potential for long-term emotional consequences.
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Affiliation(s)
- R M DeHart
- McWhorter School of Pharmacy, Samford University, USA.
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