Medical abortion regimens: historical context and overview

Mifepristone (RU-486®) as a Schedule IV Controlled Drug—Implications for a Misleading Drug Policy on Women’s Health Care

Background: Mifepristone (RU-486) has been approved for abortion in Taiwan since 2000. Mifepristone was the first non-addictive medicine to be classified as a schedule IV controlled drug. As a case of the “misuse” of “misuse of drugs laws,” the policy and consequences of mifepristone-assisted abortion for pregnant women could be compared with those of illicit drug use for drug addicts. Methods: The rule-making process of mifepristone regulation was analyzed from various aspects of legitimacy, social stigma, women’s human rights, and access to health care. Results and Discussion: The restriction policy on mifepristone regulation in Taiwan has raised concerns over the legitimacy of listing a non-addictive substance as a controlled drug, which may produce stigma and negatively affect women’s reproductive and privacy rights. Such a restriction policy and social stigma may lead to the unwillingness of pregnant women to utilize safe abortion services. Under the threat of the COVID-19 pandemic, the US FDA’s action on mifepristone prescription and dispensing reminds us it is time to consider a change of policy. Conclusions: Listing mifepristone as a controlled drug could impede the acceptability and accessibility of safe mifepristone use and violates women’s right to health care.

Pharmacological Abortion in a Pandemic: An Italian Medico-Legal Perspective

The limitations caused by the spread of the SARS-CoV2 virus have had repercussions on the voluntary termination of pregnancy. During the pandemic, Italy issued updated guidelines regarding voluntary termination of pregnancy by means of mifepristone and prostaglandin. This included news concerning the time limit and location in which this procedure could be accessed: updates partially recognize women’s needs, and they are into line with the European parliament’s recent exhortations. However, these updates do not change the previously provided responsibilities that lie with doctors. This article aimed to compare regulations concerning medical abortion in Italy and other countries, with a focus on recent Italian updates in the context of pandemic.

Availability and prescription of misoprostol for medical abortion in community pharmacies and associated factors in Accra, Ghana

OBJECTIVE

To assess misoprostol availability at community pharmacies and determine factors affecting misoprostol prescription for medical abortion.

METHODS

A cross-sectional quantitative survey of randomly sampled community pharmacies and their corresponding pharmacists/pharmacy workers was conducted in the city of Accra, Ghana. Structured questionnaires were administered to collect data between May 1 and July 28, 2016. Descriptive statistics (frequencies and proportions) and bivariate and logistic regression analysis were used to analyze the data.

RESULTS

Of the 165 community pharmacies surveyed, approximately half (83 [50.3%]) stocked misoprostol. Availability of misoprostol however decreased when moving from first class to third class residential areas. 44 (26.7%) of the respondents had prescribed the drug at some time for medical abortion, but 140 (84.6%) indicated they would not prescribe the drug for medical abortion in future. Factors that significantly predicted misoprostol prescription for medical abortion included sex of the pharmacist/pharmacy worker, demand, and availability of misoprostol.

CONCLUSIONS

Demand for misoprostol for medical abortion was found to be high but only half of community pharmacies stocked it, and most pharmacy workers did not wish to prescribe the drug. If community pharmacies are to effectively contribute to expanding access to safe abortion services in Ghana, the disparity between misoprostol provision and demand needs to be addressed.

Systematic review to identify proxy indicators to quantify the impact of eHealth tools on maternal and neonatal health outcomes in low-income and middle-income countries including Delphi consensus

OBJECTIVE

To identify interventions that could serve as reliable proxy indicators to measure eHealth impact on maternal and neonatal outcomes.

DESIGN

Systematic review and Delphi study.

METHODS

We searched PubMed, Embase and Cochrane from January 1990 to May 2016 for studies and reviews that evaluated interventions aimed at improving maternal/neonatal health and reducing mortality. Interventions that are not low-income and middle-income context appropriate and that cannot currently be diagnosed, managed or impacted by eHealth (eg, via telemedicine distance diagnostic or e-learning) were excluded. We used the Cochrane risk of bias, Risk Of Bias In Non- randomised Studies - of Interventions and ROBIS tool to assess the risk of bias. A three-step modified Delphi method was added to identify additional proxy indicators and prioritise the results, involving a panel of 13 experts from different regions, representing obstetricians and neonatologists.

RESULTS

We included 44 studies and reviews, identifying 40 potential proxy indicators with a positive impact on maternal/neonatal outcomes. The Delphi experts completed and prioritised these, resulting in a list of 77 potential proxy indicators.

CONCLUSIONS

The proxy indicators propose relevant outcome measures to evaluate if eHealth tools directly affect maternal/neonatal outcomes. Some proxy indicators require mapping to the local context, practices and available resources. The local mapping facilitates the utilisation of the proxy indicators in various contexts while allowing the systematic collection of data from different projects and programmes. Based on the mapping, the same proxy indicator can be used for different contexts, allowing it to measure what is locally and temporally relevant, making the proxy indicator sustainable.

PROSPERO REGISTRATION NUMBER

CRD42015027351.

Medical abortion reversal: science and politics meet

Medical abortion is a safe, effective, and acceptable option for patients seeking an early nonsurgical abortion. In 2014, medical abortion accounted for nearly one third (31%) of all abortions performed in the United States. State-level attempts to restrict reproductive and sexual health have recently included bills that require physicians to inform women that a medical abortion is reversible. In this commentary, we will review the history, current evidence-based regimen, and regulation of medical abortion. We will then examine current proposed and existing abortion reversal legislation. The objective of this commentary is to ensure physicians are armed with rigorous evidence to inform patients, communities, and policy makers about the safety of medical abortion. Furthermore, given the current paucity of evidence for medical abortion reversal, physicians and policy makers can dispel bad science and misinformation and advocate against medical abortion reversal legislation.

Perinatal outcomes after induced termination of pregnancy by methods: A nationwide register-based study of first births in Finland 1996-2013

Background

Women with previous terminations of pregnancy (TOPs) before their first birth have been associated with poorer perinatal outcomes. However, previous studies on the perinatal outcomes by the method in previous TOPs are inconsistent.

Objective

To examine the perinatal outcomes of the first-time mothers with singleton births, by the method of previous TOP (medical and surgical vs no TOP, and surgical vs medical).

Method

This is a nationwide register-based study including 419,879 first-time Finnish mothers with singleton birth during the time period 1996–2013. Mothers having their first birth were identified from the Medical Birth Register and linked to the Abortion Register by their identification numbers. Multinomial logistic regression analysis was performed to examine the risk for preterm birth, low birth weight, small for gestational age and perinatal death by the method in previous TOPs.

Results

Among the first-time mothers, 87.0% had no history of TOPs, 3.2% had a history of medical TOP(s), 9.2% had a history of surgical TOP(s) and 0.6% had a history of both (medical and surgical) TOP(s). No significant differences in perinatal outcomes were found among the women with surgical TOPs, compared to the women with no TOPs. In unadjusted analysis, increased odds for preterm birth and low birth weight were found when comparing women having previous surgical TOPs with medical TOPs. Even after the adjustment of potential confounders, odds for preterm birth < 37 weeks (OR = 1.19, 95% CI = 1.04–1.36) and low birth weight < 2500 g (OR = 1.16, 95% CI = 1.00–1.35) remained significant. After restricting data to the single TOP, the results were similar; OR for both preterm birth and low birth weight was 1.18 (95% CIs = 1.02–1.36 and 1.01–1.38).

Conclusion

Perinatal outcomes did not differ among the mothers with surgical TOPs compared to the mothers with no TOPs, while the outcomes were poorer after surgical TOP(s) than after medical TOP(s).

Instability of misoprostol tablets stored outside the blister: a potential serious concern for clinical outcome in medical abortion

Introduction

Misoprostol (Cytotec) is recognised to be effective for many gynaecological indications including termination of pregnancy, management of miscarriage and postpartum haemorrhage. Although not licensed for such indications, it has been used for these purposes by millions of women throughout the world. Misoprostol tablets are most often packaged as multiple tablets within an aluminium strip, each within an individual alveolus. When an alveolus is opened, tablets will be exposed to atmospheric conditions.

Objective

To compare the pharmaco technical characteristics (weight, friability), water content, misoprostol content and decomposition product content (type A misoprostol, type B misoprostol and 8-epi misoprostol) of misoprostol tablets Cytotec (Pfizer) exposed to air for periods of 1 hour to 720 hours (30 days), to those of identical non exposed tablets.

Methods

Four hundred and twenty (420) tablets of Cytotec (Pfizer) were removed from their alveoli blister and stored at 25°C/60% relative humidity. Water content, and misoprostol degradation products were assayed in tablets exposed from 1 to 720 hours (30 days). Comparison was made with control tablets (N = 60) from the same batch stored in non-damaged blisters. Statistical analyses were carried out using Fisher’s exact test for small sample sizes.

Results

By 48 hours, exposed tablets demonstrated increased weight (+4.5%), friability (+1 300%), and water content (+80%) compared to controls. Exposed tablets also exhibited a decrease in Cytotec active ingredient dosage (−5.1% after 48 hours) and an increase in the inactive degradation products (+25% for type B, +50% for type A and +11% for 8-epi misoprostol after 48 hours) compared to controls.

Conclusion

Exposure of Cytotec tablets to ‘typical’ European levels of air and humidity results in significant time-dependent changes in physical and biological composition that could impact adversely upon clinical efficacy. Health professionals should be made aware of the degradation of misoprostol with inappropriate storage of misoprostol tablets.

Medical abortion practices among private providers in Vietnam

Objective

To describe medical abortion (MA) practices among private providers in Vietnam.

Methods

The study subjects were women (n = 258) undergoing early MA through 12 private providers in Hanoi during February–June 2012. The women were interviewed on the day of their procedure and were followed up by telephone 14 days after mifepristone administration.

Results

Of the 258 women in the study, 97% used a regimen of mifepristone plus misoprostol; 80% were instructed to administer misoprostol at home. MA resulted in a complete termination in 90.8% of cases. All women were provided with information on potential complications and were instructed to return for a follow-up visit. We successfully followed up 77.5% (n = 200) of participants by telephone, while nearly two-thirds of women returned to the clinic for a follow-up visit. At follow-up, 39.5% of women reported having used a Help line service, while 7% had sought help from a health provider. A high unmet need for postabortion family planning was identified.

Conclusion

Follow-up of women, postabortion care, and the provision of family planning have been identified as important areas to address for strengthening MA services in the private sector in Vietnam.

Repeated abortion affects subsequent pregnancy outcomes in BALB/c mice

AIM

In this study, we aimed to establish a mouse model of repeated medical termination of pregnancy in order to determine subsequent outcomes.

METHODS

A model of mifepristone (RU 486)-induced medical abortion was established in BALB/c mice to facilitate the investigation of the impact of medical abortion on subsequent pregnancies, including litter sizes and newborn birth weights. Pregnant mice were sacrificed to examine midterm pregnancy status, investigate the frequency of fetal resorption, and measure placental function gene expression by real-time PCR and immunohistochemistry. Offspring liver mRNA was harvested for real-time PCR to determine gene expression and assess the effects of abortion on offspring development.

RESULTS

Mice subjected to 2 previous medical abortions experienced spontaneous abortions in subsequent pregnancies. Medical abortion caused reduced reproductive capacity and affected placental dysfunction, with reduced expression of tissue factor (TF) and genes encoding proteins involved in metabolic functions relevant to pregnancy, such as 11β-hydroxysteroid dehydrogenase 1/2 (11β-HSD1/2) and glucocorticoid receptor (GR). Reduced expression was also observed for platelet endothelial cell adhesion molecule-1 (CD31) and vascular endothelial growth factor (VEGF). In offspring from subsequent pregnancies, genes involved in lipid metabolism, which may enhance key lipid transcription factors, such as PPARA and PPARG, as well as GR/11β-HSD1, were downregulated in the liver. In addition, the sperm motility of the F1 males reduced.

CONCLUSION

Repeated medical abortion impaired the reproductive function of female mice, significantly affecting the outcomes of subsequent pregnancies. The impact of repeated abortions on the offspring of subsequent pregnancies was also noteworthy and deserves further exploration. Thus, this model provides a useful means to study the mechanisms underlying the above phenomena, which will ultimately benefit the health of women and their children.

Aborto e misoprostol: usos médicos, práticas de saúde e controvérsia científica

Este artigo coloca em perspectiva a controvérsia entre a associação do uso de misoprostol para aborto e teratogenicidade, encontrada em estudos do tipo relato de caso, e a consagração do uso de medicamentos à base do fármaco na área médico-obstétrica e em documentos normativos nacionais e internacionais que regulam o registro e a circulação de produtos farmacêuticos. Através do método monográfico, foram revisados, sistematizados e analisados documentos oficiais da Anvisa, Ministério da Saúde e Organização Mundial da Saúde sobre o uso do misoprostol, bem como 68 artigos do tipo relato de casos clínicos, publicados em periódicos científicos nacionais, que associam aborto, misoprostol e teratogenicidade. A interdição legal do aborto impede a prescrição e o uso adequados de uma droga que produz efeitos eficazes e seguros como o misoprostol. Assim, o grande malefício à saúde de mulheres está ligado não a características intrínsecas ao fármaco, mas a argumentos morais que representam descaso e desrespeito aos direitos fundamentais de mulheres.

Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: a systematic review

OBJECTIVE

To compare medical abortion practised at home and in clinics in terms of effectiveness, safety and acceptability.

METHODS

A systematic search for randomized controlled trials and prospective cohort studies comparing home-based and clinic-based medical abortion was conducted. The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE and Popline were searched. Failure to abort completely, side-effects and acceptability were the main outcomes of interest. Odds ratios and their 95% confidence intervals (CIs) were calculated. Estimates were pooled using a random-effects model.

FINDINGS

Nine studies met the inclusion criteria (n = 4522 participants). All were prospective cohort studies that used mifepristone and misoprostol to induce abortion. Complete abortion was achieved by 86-97% of the women who underwent home-based abortion (n = 3478) and by 80-99% of those who underwent clinic-based abortion (n = 1044). Pooled analyses from all studies revealed no difference in complete abortion rates between groups (odds ratio = 0.8; 95% CI: 0.5-1.5). Serious complications from abortion were rare. Pain and vomiting lasted 0.3 days longer among women who took misoprostol at home rather than in clinic. Women who chose home-based medical abortion were more likely to be satisfied, to choose the method again and to recommend it to a friend than women who opted for medical abortion in a clinic.

CONCLUSION

Home-based abortion is safe under the conditions in place in the included studies. Prospective cohort studies have shown no differences in effectiveness or acceptability between home-based and clinic-based medical abortion across countries.

The potential of medical abortion to reduce maternal mortality in Africa: what benefits for Tanzania and Ethiopia?

Background

Unsafe abortion is estimated to account for 13% of maternal mortality globally. Medical abortion is a safe alternative.

Methods

By estimating mortality risks for unsafe and medical abortion and childbirth for Tanzania and Ethiopia, we modelled changes in maternal mortality that are achievable if unsafe abortion were replaced by medical abortion. We selected Ethiopia and Tanzania because of their high maternal mortality ratios (MMRatios) and contrasting situations regarding health care provision and abortion legislation. We focused on misoprostol-only regimens due to the drug's low cost and accessibility. We included the impact of medical abortion on women who would otherwise choose unsafe abortion and on women with unwanted/mistimed pregnancies who would otherwise carry to term.

Results

Thousands of lives could be saved each year in each country by implementing medical abortion using misoprostol (2122 in Tanzania and 2551 in Ethiopia assuming coverage equals family planning services levels: 56% for Tanzania, 31% for Ethiopia). Changes in MMRatios would be less pronounced because the intervention would also affect national birth rates.

Conclusions

This is the first analysis of impact of medical abortion provision which takes into account additional potential users other than those currently using unsafe abortion. Thousands of women's lives could be saved, but this may not be reflected in as substantial changes in MMRatios because of medical abortion's demographic impact. Therefore policy makers must be aware of the inability of some traditional measures of maternal mortality to detect the real benefits offered by such an intervention.

Mifepristone-induced abortion and duration of third stage labour in a subsequent pregnancy

To evaluate the impact of mifepristone-induced abortion (MA) on the duration of third stage labour in a subsequent pregnancy, an observational cohort study was conducted from 1998 to 2001 at antenatal clinics in Shanghai, Beijing and Chengdu, China. A total of 4925 pregnant women with no history of induced abortion (NA) and 4931 pregnant women with one previous MA were enrolled and followed until delivery. Of these, 5139 women who delivered singletons vaginally were used in the present analyses, including 2614 with NA and 2525 with a history of MA. Maternal characteristics, labour duration and other obstetric and gynaecological information were obtained. The incidence rates of prolonged third stage of labour were 1.55% and 1.49% in NA and MA, respectively. After adjusting for age at delivery, maternal education, maternal occupation, area of residence, duration of gestational, type of delivery and pregnancy-induced hypertension, MA was not associated with the risk of prolonged third stage of labour (odds ratios = 0.92, 95% confidence interval 0.58, 1.44). Subgroup analysis of women with MA showed similar results regardless of gestational age at abortion, woman's age at abortion, subsequent curettage/complications and the interpregnancy interval. In conclusion, the data did not provide evidence that one MA was associated with the risk of prolonged third stage of labour in a subsequent pregnancy in primiparae.

Assessment of women's satisfaction with medical termination of pregnancy

This was a prospective study involving 205 women seeking medical abortion with gestational age<or=63 days. Questionnaires regarding expectations, experience and satisfaction with medical abortion were self-completed at the end of the procedure. Women's satisfaction was assessed using the visual analogue scale from 0 to 10. Satisfaction and acceptability parameters were correlated with socio-demographic and obstetric data. The mean degree of overall satisfaction was 8.3 (range 1-10). Around 90% of women would select the method again and would recommend it to a friend or relative. The degree of satisfaction showed a positive correlation with women's age (P<0.001) and number of children (P<0.05) and a significant negative correlation with gestational age (P<0.005). Marital status, type of financial support and acceptable pain and bleeding experience also showed a correlation with the satisfaction score. On the other hand, acceptability was correlated with husband/partner agreement and support during the procedure and adequate counselling regarding pain and bleeding.

Medical abortion and the risk of subsequent adverse pregnancy outcomes

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.

Can mifepristone medication abortion be successfully integrated into medical practices that do not offer surgical abortion?

BACKGROUND

The introduction of medication abortion with mifepristone has expanded women's abortion options. Medication abortion may be easier than aspiration abortion to incorporate into medical practices. The purpose of this study was to determine the proportion of women who select medication abortion in a clinic setting where surgical abortion is not available.

METHODS

This retrospective cohort study examines patients presenting for pregnancy options counseling to Family Medicine and Obstetrics/Gynecology clinics at the University of New Mexico from 2002 to 2005. All women presenting for options counseling received a dating ultrasound. All patients with an estimated gestational age of 63 days or less who chose to terminate were offered on-site medication abortion or referral to affiliated sites for uterine aspiration. Medical charts were abstracted for surgical and medical abortions, follow-up visits and complications.

RESULTS

Two hundred twenty women presented for options counseling and 204 (92.7%) were eligible for medication abortion. One hundred seventy-three (85%) of the 204 eligible women chose medication abortion. One hundred thirty-six (88.3%) of 154 women under 7 completed weeks (49 days) chose medication abortion compared to 37 (74%) of 50 eligible women over 7 completed weeks (p<.03). Ninety-six percent of women undergoing medication abortion had at least one follow-up visit where 98% had a documented complete abortion.

CONCLUSIONS

Medication abortion can be successfully integrated into a practice that does not offer surgical abortion. Family medicine and obstetrician/gynecologist physicians may consider incorporating medication abortion into their practices even if they are unable to offer aspiration abortion.

The evolution of progesterone receptor ligands

Progesterone is one of the first nuclear receptor hormones to be described functionally and subsequently approached as a drug target. Because progesterone (1) affects both menstruation and gestation via the progesterone receptor (PR), research aimed at modulating its activity is usually surrounded by controversy. However, ligands for PR were developed into drugs, and their evolution can be crudely divided into three periods: (1) drug-like steroids that mimic the gestational properties of progesterone; (2) drug-like steroids with different properties from progesterone and expanded therapeutic applications; and (3) non-steroidal PR ligands with improved selectivity and modulator properties and further expanded therapeutic applications. Although the latter have yet to see widespread clinical applications, their development is founded on a half century of research, and they represent the future for this drug target.

The use of vaginal misoprostol for second-trimester pregnancy termination in women with previous single cesarean section

INTRODUCTION

This retrospective study reports of 85 women in the second trimester with one prior cesarean section undergoing medical abortion of a viable unwanted pregnancy using vaginal misoprostol. Two regimens that were selected in a nonrandomized manner were used.

MATERIALS AND METHODS

Eighty-five women treated with vaginal misoprostol in a 3-year period were retrospectively analyzed. All received 400 mug of misoprostol initially and 22 (25.8%) aborted. Then Group A (n=43) received subsequent administration of 200 microg every 6 h, whereas Group B (n=20) received 400 microg/6 h.

RESULTS

All patients aborted. The groups had no statistical difference in mean age, gravidity, parity, gestational age, and time from previous cesarean section, and there was no difference in occurrence of side effects and mean induction to abortion time interval. The lower dosage group received a median of 600 microg of vaginal misoprostol (min 600 microg to max 1000 microg). There were no uterine ruptures, need for hysterotomy, or excess bleeding in any patient.

CONCLUSIONS

This is the largest series reported to date of second-trimester pregnancy termination in cases with one previous cesarean section using only vaginal misoprostol. The study shows that both used regimens are safe and equally effective. All 85 women aborted.

Providing medication abortion information to diverse communities: use patterns of a multilingual web site

OBJECTIVE

This study analyzes the use patterns of , an English-, Spanish-, Arabic- and French-language web site dedicated to three methods of early pregnancy termination: mifepristone/misoprostol, methotrexate/misoprostol and misoprostol alone.

METHODS

This study examines both the overall and language-specific use patterns of the web site from October 1, 2004, through September 30, 2005. Data were recorded using Wusage 8.0, a web site statistics program.

RESULTS

Over the 12-month study period, received more than 78,000 visits and nearly 240,000 page requests. The English version is the most popular version of the web site (accessed in 46.1% of all visits), followed by the Spanish (35.0%), Arabic (10.4%) and French (8.8%) versions. Spanish-language visits are nearly three times as likely to access the misoprostol-only section of the web site when compared with the other language versions (p<.001).

CONCLUSION

This study confirms that multilingual, medically accurate online resources have the potential to expand information about medication abortion to both providers and women considering the option of abortion in diverse communities. Analysis of the language-specific use patterns highlights the different priorities of various types of web site visitors and suggests future priorities for educational outreach, collaboration and research.

First trimester medical termination of pregnancy: An alternative for New Zealand women

BACKGROUND

First trimester medical terminations of pregnancy (TOP) have been carried out in a private abortion clinic in Auckland from 1 July 2003 to 30 June 2005.

AIMS

To audit first trimester medical TOP outcomes over the first 2 years and to compare the demographics and complication rates of women opting for medical TOP with those choosing surgical TOP during this period.

METHODS

Retrospective, consecutive case audit of women presenting for a first trimester TOP. Anonymous audit included ethnicity, gestation at first appointment, pain relief requirements, blood loss, timing from the taking of misoprostol to expulsion of products of conception, complications and comparison of outcomes and characteristics between medical termination of pregnancy (MTOP) and surgical termination of pregnancy (STOP).

RESULTS

A total of 3311 TOPs were performed over the 2-year study period, including 390 MTOPs (12%). No significant differences were found in age, ethnicity or history of previous TOP between women choosing MTOP or STOP. Gravida 1 and nulliparous women were significantly more likely to choose MTOP. Five per cent (21/390) of women taking mifepristone progressed to STOP. Complications involving hospitalisation occurred in six MTOPs (1.5%) and 18 STOPs (0.6%).

CONCLUSIONS

First trimester MTOP is safe and effective and is a realistic alternative for women wanting choice of method in New Zealand.

Ultrasonographic appearance of the conceptus, fetal heart rate and profiles of pregnancy-associated glycoproteins (PAG) and prostaglandin F2α-metabolite (PGF2α-metabolite) after induction of fetal death with aglepristone during early gestation in cattle

A higher incidence of fetal losses, especially after the use of artificial reproduction techniques, asks for more intensive monitoring of bovine pregnancies. In this study, a model for fetal death (FD) was created by administering the antiprogesterone aglepristone twice, at Day 47 and 48 of gestation (n=5). Control heifers received the solvent (n=5). The temporal relationships between changes in ultrasonographic appearance of fetal fluids and membranes, fetal heart rate (FHR) and peripheral plasma levels of pregnancy-associated glycoprotein (PAG) and PGF2alpha-metabolite as determined by radioimmunoassay associated with FD were monitored at eight hour intervals around treatment. For the analysis of plasma levels the period under study was divided into five epochs (T1: before injection of aglepristone/solvent; T2: from first to second injection; T3: from second injection to FD; T4: from diagnosis of FD to 56 h later; T5: from 56 h to 104 h after diagnosis of FD). Control heifers produced healthy calves at term, but in treated heifers, FD occurred on average at 58 (range 48-80) h after first injection of aglepristone. Fetal death was always preceded by a visible reduction of the amount of allantoic fluid and by segregation of the allantochorionic membrane from the endometrium. FHR remained rather constant in both groups, but a (non-significant) drop in FHR around 8h before FD was diagnosed in four of five treated animals. All fetuses were expulsed after FD. Levels of PAG remained constant or even slightly increased in controls, but decreased in treated animals from T2 onward: levels during T4 and T5 significantly differed from those during T1 and from values in controls during T4 and T5 (P<0.01). PGF2alpha-metabolite levels did not change in the controls, but in the treated group they were significantly higher during T3 when compared to T1 (P<0.05). After this increase, a sharp decrease in PGF2alpha-metabolite level occurred, reaching a significantly lower level at T5 when compared to control animals (P=0.01). It is concluded, that FD induced by aglepristone is preceded by ultrasonographic visible changes in fetal membranes and fluids and a rise in PGF2alpha-metabolite and is followed by a drop in PAG and PGF2alpha-metabolite.

Early medical abortion: A new regimen up to 49 days' gestation

AIM

To evaluate a new regimen of mifepristone and misoprostol in early medical abortion up to 49 days of amenorrhoea.

METHODS

One hundred healthy women requesting pregnancy termination up to 49 days gestation received 200 mg mifepristone followed by 800 microg misoprostol orally 24 h later. Statistical analysis was carried out by unpaired t-test.

RESULTS

Ninety-six percent of patients aborted completely 4.3 h after they were given misoprostol. No significant side-effects were noted. The duration of bleeding correlated with gestational age (P-value 0.009).

CONCLUSION

This new regimen of mifepristone-misoprostol is effective in terminating early pregnancy, with shorter induction to abortion interval and greater acceptability.

Emergency contraception: the politics of post-coital contraception

The literature and events related to the politicization of emergency contraceptive pills (ECPs) in the United States is reviewed. The basis of opposition to the regimen, rooted in the mode of action of ECPs, the confusion with mifepristone, and the challenges this presents for ECP advocates is also discussed. Legislative actions that impact availability of ECPs are described, as well as efforts to increase access and availability through innovate programs, legislation, and changes in medical practice. Recommendations for future research, service delivery, and public policy are also presented.

Willing and able? Provision of medication for abortion by future internists

INTRODUCTION AND BACKGROUND

The development of medications such as mifepristone (RU486) has created the opportunity to introduce medication abortion as a component of office practice.

METHODS

Two hundred twelve residents training in internal medicine, family practice, and gynecology at 11 residency programs completed anonymous surveys assessing willingness to provide medication for abortion and perceived barriers to future provision of mifepristone.

RESULTS

Residents training in internal medicine knew less about mifepristone and preabortion screening than other primary care trainees. Forty-two percent of internists, 84% of family practitioners, and 83% of gynecologists were willing to prescribe mifepristone (p < .001). Many internists were concerned about lacking adequate "backup" access to vacuum aspiration services (84% of internists, 74% of family practitioners, 35% of gynecologists; p < .001). In multivariable analysis, the training-related factors most predictive of whether an internist was willing to provide medication for abortion were feeling that mifepristone is very safe, abortion services are needed by the patients served, knowing to check an ultrasound before inducing abortion, and having no concern of how to manage bleeding or of lacking adequate backup should vacuum aspiration be needed.

CONCLUSIONS AND DISCUSSION

Many (42%) future internists are willing to provide mifepristone, but most lack adequate knowledge of mifepristone and preabortion screening. As access to abortion services is limited in many U.S. counties, internists who are willing to provide mifepristone should be offered the necessary training to do so safely.

Early medical termination pregnancy with methotrexate and misoprostol in lower segment cesarean section cases

AIM

The aim of the study was to investigate the efficacy of methotrexate and misoprostol for the medical termination of early pregnancy with previous cesarean section.

METHODS

Sixty-six pregnant women of 60 days or less in duration with previous one or two cesarean sections were selected. Each woman received intramuscularly a dose of methotrexate (50mg). Two to 3 days later, 800 microg of misoprostol was administered intravaginally. Repeat doses were used if there was no significant bleeding. An ultrasonography was done in each case after seven days. Subjects with continuing pregnancies or excessive bleeding had a surgical abortion. A successful medical abortion was defined by vaginal bleeding without surgical intervention and a negative transvaginal ultrasound. Side-effects were noted.

RESULTS

Complete abortion occurred in 87.9% cases after first dose of misoprostol, and 6.1% cases had complete abortion after second dose, so out of 66 cases 62 (94%) had a successful medical abortion. Four (6%) subjects required surgical intervention; one for continued pregnancies, one for missed abortion, and two for excessive bleeding. The complete abortion rate was higher for early gestations: 30/30 (100%) at < or = 45 days gestation, 28/30 (93.3%) at 46-50 days gestation, and 2/6 (33.3%) from 50 to 63 days gestation. Vaginal bleeding lasted 15 +/- 7 days. Gastrointestinal side-effects were uncommon, mild, and brief. There was no case of uterine rupture.

CONCLUSION

Medical abortion using methotrexate with misoprostol is safe, cheap, and effective for early pregnancy termination through 8 weeks' gestation even with previous cesarean section.

Clinical uses of mifepristone: an update for women's health practitioners

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.

Intravaginal 400 microg misoprostol for pregnancy termination in cases of blighted ovum: a randomised controlled trial

OBJECTIVE

To investigate the effectiveness and side effects of intravaginal misoprostol 400 micrograms compared with a placebo for facilitating complete abortion in cases of blighted ovum.

DESIGN

A prospective randomised placebo-controlled trial.

SETTING

Rajavithi Hospital, Thailand between 1 July 1998 and 31 January 1999.

SAMPLE

Fifty-four pregnant women with gestations of up to 12 weeks whose diagnosis of blighted ovum had been made by transvaginal ultrasound.

METHODS

The patients were assigned randomly into two equal groups; the study group received two tablets of vaginal misoprostol (200 micrograms/tablet), and the control group received two tablets of a vaginal placebo.

RESULTS

The complete abortion rate was significantly higher in the women receiving misoprostol (63%) compared with those receiving the placebo (18.5%) (p < 0.05). Lower abdominal pain (74.1%) and fever (14.8%) were significantly higher in the study group than in the placebo group (22.2%) and (0%) respectively, (p < 0.05).

CONCLUSION

Intravaginal 400 microg misoprostol is significantly more effective for termination of blighted ovum than placebo, but lower abdominal pain and fever are signifcantly higher in the misoprostol group.