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Hsieh YP, Wang YJ, Feng LY, Wu LT, Li JH. Mifepristone (RU-486 ®) as a Schedule IV Controlled Drug-Implications for a Misleading Drug Policy on Women's Health Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:8363. [PMID: 35886217 PMCID: PMC9323789 DOI: 10.3390/ijerph19148363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Yi-Ping Hsieh
- Department of Social Work, University of North Dakota, Grand Forks, ND 58202, USA;
| | - Yun-Ju Wang
- College of Law, National Chung-Cheng University, Chia-Yi 62102, Taiwan;
| | - Ling-Yi Feng
- Doctoral/Master Degree Program in Toxicology, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences and Department of Medicine, School of Medicine, Duke University, Durham, NC 27710, USA;
| | - Jih-Heng Li
- Doctoral/Master Degree Program in Toxicology, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
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Razon N, Wulf S, Perez C, McNeil S, Maldonado L, Fields AB, Carvajal D, Logan R, Dehlendorf C. Exploring the impact of mifepristone's Risk Evaluation and Mitigation Strategy (REMS) on the integration of medication abortion into US family medicine primary care clinics. Contraception 2022; 109:19-24. [PMID: 35131289 PMCID: PMC9018589 DOI: 10.1016/j.contraception.2022.01.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 01/22/2023]
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Transcutaneous Electrical Nerve Stimulation to Reduce Pain With Medication Abortion: A Randomized Controlled Trial. Obstet Gynecol 2021; 137:100-107. [PMID: 33278292 DOI: 10.1097/aog.0000000000004208] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/09/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate whether high-frequency transcutaneous electrical nerve stimulation (hfTENS) reduces pain during medication abortion. METHODS We conducted a randomized, placebo-controlled trial. Participants who were undergoing medication abortion with mifepristone and misoprostol through 70 days of gestation either received active 80 Hz hfTENS or sham to use for a minimum of 60 minutes within 8 hours of misoprostol. Maximum pain on an 11-point numerical rating scale at 8 hours after misoprostol was the primary outcome. We estimated 20 per group for 80% power to detect a 2-point difference and up to 10% attrition. Secondary outcomes included a maximum pain score at 24 hours, additional analgesia use, the difference in score before and after treatment, the experience of side effects, abortion outcomes, and acceptability. We collected data at baseline, time of misoprostol (0-hour), 8-hour and 24 hours using real-time electronic surveys, and at follow-up. RESULTS Between June 2019 and March 2020, we screened 251 patients and randomized 40-20 each to hfTENS or sham-with one postrandomization exclusion and two patients lost to follow-up. Baseline characteristics were similar. Median maximum pain scores at 8 hours were 7.0 (interquartile range 3.0) and 10.0 (interquartile range 3.0) for hfTENS and sham, respectively. The distribution of these scores was lower among hfTENS users compared with sham (mean rank 15.17 vs 22.63, P=.036). High-frequency TENS users also experienced a significant reduction in posttreatment pain score (-2.0 [interquartile range 2.5] vs 0 [interquartile range 1.5], P=.008). We found no statistically significant differences in use of additional analgesia, distribution of maximum pain scores at 24 hours, side effects, or measures of acceptability. CONCLUSION High-frequency TENS reduced maximum pain scores within 8 hours of misoprostol and reduced pain scores immediately after treatment compared with placebo. High-frequency TENS offers an effective nonpharmacologic option for pain management during medication abortion. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT03925129.
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Appiah-Agyekum NN. Medical abortions among university students in Ghana: implications for reproductive health education and management. Int J Womens Health 2018; 10:515-522. [PMID: 30233253 PMCID: PMC6130263 DOI: 10.2147/ijwh.s160297] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose In Ghana, unsafe abortion is a major cause of maternal mortality. Even though pharmaceutical drugs seem to be a key means of unsafe abortion, a paucity of evidence exists on the issue among adolescents, students, and other groups at risk. This study therefore explores the abortion experiences of Ghanaian university students with particular reference to pharmaceutical drugs to fill the knowledge gap and enrich the evidence base for reproductive health education, policies, and interventions on abortions among students. Patients and methods Undergraduate students from the University of Ghana were randomly selected and interviewed. The interviews was recorded, transcribed, and analyzed thematically using the framework analysis. Results Students were aware of safe medical abortion services but were reluctant to use them because of cost, stigma, and proximity. Generally, medical abortions were more likely to be self-induced among students with misoprostol-based drugs administered orally or vaginally. However, students also used various over-the-counter drugs, contraceptives, and prescription drugs singly, in series, or in combinations to induce abortion. Yet students had relatively little knowledge on the inherent risks and long-term implications of unsafe medical abortions and were more likely to have repeat abortions through unsafe medical methods. Conclusion Students’ knowledge and awareness of safe medical abortion avenues have not influenced their propensity to use them because of stigma, cost, and other factors. Rather, several methods of unsafe medical abortions are used increasingly with dire long-term effects on students. Serious knowledge gaps exist among students on the methods and risks of medical abortion. Consequently, there is an urgent need to revise current abortion management approaches and redirect attention toward reducing stigma and financial and social costs of safe abortion services, and increasing the proactive engagement, counseling, and management of medical abortions among students.
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Affiliation(s)
- Nana Nimo Appiah-Agyekum
- Department of Public Administration and Health Services Management, University of Ghana, Legon, Accra Ghana, Ghana,
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Chae S, Kayembe PK, Philbin J, Mabika C, Bankole A. The incidence of induced abortion in Kinshasa, Democratic Republic of Congo, 2016. PLoS One 2017; 12:e0184389. [PMID: 28968414 PMCID: PMC5624571 DOI: 10.1371/journal.pone.0184389] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/18/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In the Democratic Republic of Congo, the penal code prohibits the provision of abortion. In practice, however, it is widely accepted that the procedure can be performed to save the life of a pregnant woman. Although abortion is highly restricted, anecdotal evidence indicates that women often resort to clandestine abortions, many of which are unsafe. However, to date, there are no official statistics or reliable data to support this assertion. OBJECTIVES Our study provides the first estimates of the incidence of abortion and unintended pregnancy in Kinshasa. METHODS We applied the Abortion Incidence Complications Method (AICM) to estimate the incidence of abortion and unintended pregnancy. We used data from a Health Facilities Survey and a Prospective Morbidity Survey to determine the annual number of women treated for abortion complications at health facilities. We also employed data from a Health Professionals Survey to calculate a multiplier representing the number of abortions for every induced abortion complication treated in a health facility. RESULTS In 2016, an estimated 37,865 women obtained treatment for induced abortion complications in health facilities in Kinshasa. For every woman treated in a facility, almost four times as many abortions occurred. In total, an estimated 146,713 abortions were performed, yielding an abortion rate of 56 per 1,000 women aged 15-49. Furthermore, more than 343,000 unintended pregnancies occurred, resulting in an unintended pregnancy rate of 147 per 1,000 women aged 15-49. CONCLUSIONS Increasing contraceptive uptake can reduce the number of women who experience unintended pregnancies, and as a consequence, result in fewer women obtaining unsafe abortions, suffering abortion complications, and dying needlessly from unsafe abortion. Increasing access to safe abortion and improving post-abortion care are other measures that can be implemented to reduce unsafe abortion and/or its negative consequences, including maternal mortality.
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Affiliation(s)
- Sophia Chae
- Guttmacher Institute, New York, New York, United States of America
| | - Patrick K. Kayembe
- Department of Epidemiology & Biostatistics, University of Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
- * E-mail:
| | - Jesse Philbin
- Guttmacher Institute, New York, New York, United States of America
| | - Crispin Mabika
- Department of Population Sciences and Development, University of Kinshasa, Kinshasa, Democratic Republic of Congo
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Upadhyay UD, Johns NE, Combellick SL, Kohn JE, Keder LM, Roberts SCM. Comparison of Outcomes before and after Ohio's Law Mandating Use of the FDA-Approved Protocol for Medication Abortion: A Retrospective Cohort Study. PLoS Med 2016; 13:e1002110. [PMID: 27575488 PMCID: PMC5004901 DOI: 10.1371/journal.pmed.1002110] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 07/11/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In February 2011, an Ohio law took effect mandating use of the United States Food and Drug Administration (FDA)-approved protocol for mifepristone, which is used with misoprostol for medication abortion. Other state legislatures have passed or enacted similar laws requiring use of the FDA-approved protocol for medication abortion. The objective of this study is to examine the association of this legal change with medication abortion outcomes and utilization. METHODS AND FINDINGS We used a retrospective cohort design, comparing outcomes of medication abortion patients in the prelaw period to those in the postlaw period. Sociodemographic and clinical chart data were abstracted from all medication abortion patients from 1 y prior to the law's implementation (January 2010-January 2011) to 3 y post implementation (February 2011-October 2014) at four abortion-providing health care facilities in Ohio. Outcome data were analyzed for all women undergoing abortion at ≤49 d gestation during the study period. The main outcomes were as follows: need for additional intervention following medication abortion (such as aspiration, repeat misoprostol, and blood transfusion), frequency of continuing pregnancy, reports of side effects, and the proportion of abortions that were medication abortions (versus other abortion procedures). Among the 2,783 medication abortions ≤49 d gestation, 4.9% (95% CI: 3.7%-6.2%) in the prelaw and 14.3% (95% CI: 12.6%-16.0%) in the postlaw period required one or more additional interventions. Women obtaining a medication abortion in the postlaw period had three times the odds of requiring an additional intervention as women in the prelaw period (adjusted odds ratio [AOR] = 3.11, 95% CI: 2.27-4.27). In a mixed effects multivariable model that uses facility-months as the unit of analysis to account for lack of independence by site, we found that the law change was associated with a 9.4% (95% CI: 4.0%-18.4%) absolute increase in the rate of requiring an additional intervention. The most common subsequent intervention in both periods was an additional misoprostol dose and was most commonly administered to treat incomplete abortion. The percentage of women requiring two or more follow-up visits increased from 4.2% (95% CI: 3.0%-5.3%) in the prelaw period to 6.2% (95% CI: 5.5%-8.0%) in the postlaw period (p = 0.003). Continuing pregnancy was rare (0.3%). Overall, 12.6% of women reported at least one side effect during their medication abortion: 8.4% (95% CI: 6.8%-10.0%) in the prelaw period and 15.6% (95% CI: 13.8%-17.3%) in the postlaw period (p < 0.001). Medication abortions fell from 22% (95% CI: 20.8%-22.3%) of all abortions the year before the law went into effect (2010) to 5% (95% CI: 4.8%-5.6%) 3 y after (2014) (p < 0.001). The average patient charge increased from US$426 in 2010 to US$551 in 2014, representing a 16% increase after adjusting for inflation in medical prices. The primary limitation to the study is that it was a pre/post-observational study with no control group that was not exposed to the law. CONCLUSIONS Ohio law required use of a medication abortion protocol that is associated with a greater need for additional intervention, more visits, more side effects, and higher costs for women relative to the evidence-based protocol. There is no evidence that the change in law led to improved abortion outcomes. Indeed, our findings suggest the opposite. In March 2016, the FDA-protocol was updated, so Ohio providers may now legally provide current evidence-based protocols. However, this law is still in place and bans physicians from using mifepristone based on any new developments in clinical research as best practices continue to be updated.
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Affiliation(s)
- Ushma D. Upadhyay
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California, United States of America
- * E-mail:
| | - Nicole E. Johns
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California, United States of America
| | - Sarah L. Combellick
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California, United States of America
| | - Julia E. Kohn
- Planned Parenthood Federation of America, New York, New York, United States of America
| | - Lisa M. Keder
- Obstetrics and Gynecology, Ohio State University Wexner Medical Center, Ohio State University, Columbus, Ohio, United States of America
| | - Sarah C. M. Roberts
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California, United States of America
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Zhang L, Hapon MB, Goyeneche AA, Srinivasan R, Gamarra-Luques CD, Callegari EA, Drappeau DD, Terpstra EJ, Pan B, Knapp JR, Chien J, Wang X, Eyster KM, Telleria CM. Mifepristone increases mRNA translation rate, triggers the unfolded protein response, increases autophagic flux, and kills ovarian cancer cells in combination with proteasome or lysosome inhibitors. Mol Oncol 2016; 10:1099-117. [PMID: 27233943 DOI: 10.1016/j.molonc.2016.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/25/2016] [Accepted: 05/11/2016] [Indexed: 12/12/2022] Open
Abstract
The synthetic steroid mifepristone blocks the growth of ovarian cancer cells, yet the mechanism driving such effect is not entirely understood. Unbiased genomic and proteomic screenings using ovarian cancer cell lines of different genetic backgrounds and sensitivities to platinum led to the identification of two key genes upregulated by mifepristone and involved in the unfolded protein response (UPR): the master chaperone of the endoplasmic reticulum (ER), glucose regulated protein (GRP) of 78 kDa, and the CCAAT/enhancer binding protein homologous transcription factor (CHOP). GRP78 and CHOP were upregulated by mifepristone in ovarian cancer cells regardless of p53 status and platinum sensitivity. Further studies revealed that the three UPR-associated pathways, PERK, IRE1α, and ATF6, were activated by mifepristone. Also, the synthetic steroid acutely increased mRNA translation rate, which, if prevented, abrogated the splicing of XBP1 mRNA, a non-translatable readout of IRE1α activation. Moreover, mifepristone increased LC3-II levels due to increased autophagic flux. When the autophagic-lysosomal pathway was inhibited with chloroquine, mifepristone was lethal to the cells. Lastly, doses of proteasome inhibitors that are inadequate to block the activity of the proteasomes, caused cell death when combined with mifepristone; this phenotype was accompanied by accumulation of poly-ubiquitinated proteins denoting proteasome inhibition. The stimulation by mifepristone of ER stress and autophagic flux offers a therapeutic opportunity for utilizing this compound to sensitize ovarian cancer cells to proteasome or lysosome inhibitors.
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Affiliation(s)
- Lei Zhang
- Division of Basic Biomedical Sciences, Sanford School of Medicine of The University of South Dakota, Vermillion, SD 57069, USA
| | - Maria B Hapon
- Division of Basic Biomedical Sciences, Sanford School of Medicine of The University of South Dakota, Vermillion, SD 57069, USA
| | - Alicia A Goyeneche
- Division of Basic Biomedical Sciences, Sanford School of Medicine of The University of South Dakota, Vermillion, SD 57069, USA; Department of Pathology, Faculty of Medicine, McGill University, Montreal, QC H3A 2B4, Canada
| | - Rekha Srinivasan
- Division of Basic Biomedical Sciences, Sanford School of Medicine of The University of South Dakota, Vermillion, SD 57069, USA
| | - Carlos D Gamarra-Luques
- Division of Basic Biomedical Sciences, Sanford School of Medicine of The University of South Dakota, Vermillion, SD 57069, USA
| | - Eduardo A Callegari
- Division of Basic Biomedical Sciences, Sanford School of Medicine of The University of South Dakota, Vermillion, SD 57069, USA
| | - Donis D Drappeau
- Division of Basic Biomedical Sciences, Sanford School of Medicine of The University of South Dakota, Vermillion, SD 57069, USA
| | - Erin J Terpstra
- Division of Basic Biomedical Sciences, Sanford School of Medicine of The University of South Dakota, Vermillion, SD 57069, USA
| | - Bo Pan
- Division of Basic Biomedical Sciences, Sanford School of Medicine of The University of South Dakota, Vermillion, SD 57069, USA
| | - Jennifer R Knapp
- Kansas Intellectual and Development Disabilities Research Center, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Jeremy Chien
- Department of Cancer Biology, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Xuejun Wang
- Division of Basic Biomedical Sciences, Sanford School of Medicine of The University of South Dakota, Vermillion, SD 57069, USA
| | - Kathleen M Eyster
- Division of Basic Biomedical Sciences, Sanford School of Medicine of The University of South Dakota, Vermillion, SD 57069, USA
| | - Carlos M Telleria
- Division of Basic Biomedical Sciences, Sanford School of Medicine of The University of South Dakota, Vermillion, SD 57069, USA; Department of Pathology, Faculty of Medicine, McGill University, Montreal, QC H3A 2B4, Canada.
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Abstract
Medical abortion is a safe, convenient, and effective method for terminating an early unintended pregnancy. Medical abortion can be performed up to 63 days from the last menstrual period and may even be used up to 70 days for women who prefer medical abortion over surgical abortion. Counseling on the adverse effects and expectations for medical abortion is critical to success. Medical abortion can be performed in a clinic without special equipment, and it is perceived as more "natural" than a surgical abortion by many women. Follow-up for medical abortion can be simplified to include only serum human chorionic gonadotropin measurements when necessary, although obtaining an ultrasound remains the criterion standard. Pain associated with medical abortion is best treated with nonsteroidal anti-inflammatory medications, possibly in combination with opioid analgesics. Medical abortion can contribute to continuity of care for women who wish to remain with their primary care providers for management of their abortion.
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Berard V, Fiala C, Cameron S, Bombas T, Parachini M, Gemzell-Danielsson K. Instability of misoprostol tablets stored outside the blister: a potential serious concern for clinical outcome in medical abortion. PLoS One 2014; 9:e112401. [PMID: 25502819 PMCID: PMC4266501 DOI: 10.1371/journal.pone.0112401] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 10/15/2014] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Veronique Berard
- ICB - CNRS, Division MaNaPI, Département Nanosciences, Université de Bourgogne, Dijon, France
- * E-mail:
| | - Christian Fiala
- Gynmed Clinic, Vienna, Austria
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | | | - Teresa Bombas
- Obstetric Service, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | | | - Kristina Gemzell-Danielsson
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
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Swica Y, Raghavan S, Bracken H, Dabash R, Winikoff B. Review of the literature on patient satisfaction with early medical abortion using mifepristone and misoprostol. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.11.37] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Medical abortion follow-up with serum human chorionic gonadotropin compared with ultrasonography: a randomized controlled trial. Obstet Gynecol 2013; 121:607-613. [PMID: 23635625 DOI: 10.1097/aog.0b013e3182839fda] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To estimate whether follow-up with serum human chorionic gonadotropin (hCG) results in fewer unplanned visits and interventions than follow-up with ultrasonography. METHODS Women were randomized to either in-clinic serum hCG or ultrasound follow-up after medical abortion. The primary outcome, unplanned interventions and visits, was measured as a composite binary outcome including: additional clinic or emergency room visits, repeat dosing of misoprostol, and surgical evacuation of the uterus. Surveys were administered at initial follow-up and again 1 month after abortion to inquire about unscheduled visits, interventions, and patient satisfaction. Medical records were reviewed for evidence of additional interventions and visits. RESULTS A total of 376 patients was randomized. Most participants were white (56%), single (83%), nulliparous (63%), and had completed high school (96%). Average participant age was 26±6 years and average gestational age was 46±6 days. Within 2 weeks of abortion, there was no significant difference in the rate of unplanned interventions and visits between arms, 8.2% (13/159) in the serum hCG arm compared with 6.6% (10/151) in the ultrasound arm (relative risk 1.23, 95% confidence interval [CI] 0.56-2.73, P=.60). By 4 weeks postabortion, 4.4% (6/135) in the ultrasound arm and 1.4% (2/142) in the hCG arm had undergone surgical evacuation (relative risk 0.32, 95% CI 0.07-1.54, P=.16). The majority in both the serum hCG (88%) and ultrasound (95%) arms was satisfied with their assigned follow-up method. CONCLUSION Medical abortion follow-up with serum hCG does not reduce the rate of unplanned interventions and visits compared with ultrasonography. Overall, the number of unplanned interventions is low and both methods of follow-up are acceptable to women.
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Huo XX, Gao ES, Cheng YM, Luo L, Liang H, Huang GY, Miao MH, Yuan W. Effect of interpregnancy interval after a mifepristone-induced abortion on neonatal outcomes in subsequent pregnancy. Contraception 2013; 87:38-44. [DOI: 10.1016/j.contraception.2012.08.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Revised: 08/30/2012] [Accepted: 08/30/2012] [Indexed: 11/25/2022]
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Comparison of medical abortion follow-up with serum human chorionic gonadotropin testing and in-office assessment. Contraception 2012; 85:402-7. [DOI: 10.1016/j.contraception.2011.09.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 09/15/2011] [Accepted: 09/16/2011] [Indexed: 11/30/2022]
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Rodriguez MI, Seuc A, Kapp N, von Hertzen H, Huong NTM, Wojdyla D, Mittal S, Arustamyan K, Shah R. Acceptability of misoprostol-only medical termination of pregnancy compared with vacuum aspiration: an international, multicentre trial. BJOG 2012; 119:817-23. [DOI: 10.1111/j.1471-0528.2012.03310.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lavoué V, Vandenbroucke L, Grouin A, Briand E, Bauville E, Boyer L, Lemeut P, Bernard O, Poulain P, Morcel K. [Medical abortion from 12 through 14 weeks' gestation: a retrospective study with 126 patients]. J Gynecol Obstet Hum Reprod 2011; 40:626-632. [PMID: 21741780 DOI: 10.1016/j.jgyn.2011.06.003] [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: 01/31/2011] [Revised: 05/23/2011] [Accepted: 06/03/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To assess the efficacy of medical abortion performed according to a single protocol from 12 through 14 weeks. STUDY DESIGN Retrospective observational study of medical abortions from 12 through 14 weeks performed from January 2007 through March 2009. The protocol combined 600 mg de mifepristone orally, followed 48 h later by 400 μg of misoprostol, administered orally, and repeated after 3h, four times a day (during two days), if patient did not begin to abort. Outcome measures were the abortion rate, the rate of complication, the rate of manual uterine revision or vacuum aspiration, the time of expulsion and the misoprostol dose. RESULTS The study included 126 medical abortions. The abortion rate was 98% and the secondary manual revision or vacuum aspiration rate was 41%. The mean time to expulsion was 10.4 (±8.8)h, and the mean misoprostol dose 1040 (±420) μg. Higher parity was significantly correlated with shorter time to expulsion (P=0.02). CONCLUSION Medical abortion was consistently effective from 12 through 14 weeks but with high rate of secondary manual revision or vacuum aspiration.
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Affiliation(s)
- V Lavoué
- Service d'obstétrique, CHU Anne-de-Bretagne, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex 2, France.
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“Comparative study of medical abortion by mifepristone with vaginal misoprostol in women < 49 days versus 50–63 days of amenorrhoea”. J Obstet Gynaecol India 2010. [DOI: 10.1007/s13224-010-0066-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
OBJECTIVE To evaluate the ability of women and their providers to assess abortion outcome without the routine use of ultrasonography. METHODS This multicenter trial enrolled 4,484 women seeking medical abortion at 10 clinics in the United States. Women received the standard medical abortion care with mifepristone-misoprostol in those clinics and blinded clinical assessments before follow-up ultrasonography. Data were collected prospectively on abortion outcomes, receipt of additional treatment, and clinical, laboratory, and ultrasound assessments associated with the procedure. We constructed five model algorithms for evaluating women's postabortion status, each using a different assortment of data. Four of the algorithms (algorithms 1-4) rely on data collected by the woman and on the results of the low-sensitivity pregnancy test. Algorithm 5 relies on the woman's assessment, the results of the pregnancy test, and follow-up physician assessment (sometimes including bimanual or speculum examination). RESULTS A total of 3,054 women received medical abortion and had adequate data for evaluation. Twenty women (0.7%) had an ongoing pregnancy; 26 (0.9%) received curettage for retained tissue, empiric treatment for possible infection, or both; and 55 (1.8%) received additional uterotonics or other medical abortion-related care. Screening algorithms including patient-observed outcomes, a low-sensitivity pregnancy test, and nonsonographic clinical evaluation were as effective as sonography in identifying women who received interventions at or after the follow-up visit. CONCLUSION Relying on women's observations, a low-sensitivity pregnancy test, and clinical examination, women and their providers can accurately assess whether follow-up care is required after medical abortion without routine ultrasonography. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT00120224. LEVEL OF EVIDENCE II.
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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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Provansal M, Mimari R, Grégoire B, Agostini A, Thirion X, Gamerre M. [Medical abortion at home and at hospital: a trial of efficacy and acceptability]. ACTA ACUST UNITED AC 2009; 37:850-6. [PMID: 19766038 DOI: 10.1016/j.gyobfe.2009.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2008] [Accepted: 07/17/2009] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To evaluate the efficacy and the acceptability of medical abortion at home and at hospital. PATIENTS AND METHODS From 11 February 2008 to 16 July 2008, 399 patients were included in the study: 173 at home and 226 at hospital. RESULTS Efficacy was evaluated for 305 patients because 94 were lost of follow-up (23.6%). Efficacy of medical abortion was 86.7% (124/143) at home and 95.8% (155/162) at hospital. There were one ongoing pregnancy and 25 surgical aspirations (8.6%). The family planning nurse received a phone call from five patients after mifepristone at home (2.9%) and seven patients after mifepristone at hospital (3.1%). Only one patient "at home" had an emergency consultation (0.6%) and nine patients "at hospital" (4%). Ten patients went back to their gynecologist before their appointment for follow-up (2.5%): five "at home" (2.9%) and five "at hospital" (2.2%). Thirteen patients were referred by the private provider to the hospital medical specialist. Acceptability is known for 70.2% of patients: 98% thought that medical abortion at home was acceptable and 92.9% at hospital. DISCUSSION AND CONCLUSION The failure rate of medical abortion is higher at home and is due to aspirations for incomplete abortion. The procedure at home seems to be more acceptable than at hospital. It will be interesting to realize a prospective randomized study to compare the procedures at home and at hospital.
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Affiliation(s)
- M Provansal
- Centre de gynécologie sociale, hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France.
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Teal SB, Harken T, Sheeder J, Westhoff C. Efficacy, acceptability and safety of medication abortion in low-income, urban Latina women. Contraception 2009; 80:479-83. [PMID: 19835724 DOI: 10.1016/j.contraception.2009.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 04/14/2009] [Accepted: 04/27/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Health care providers may be reluctant to offer medication abortion to low-income, non-English-speaking populations. Concerns include lack of patient interest, incorrect use of misoprostol at home, missing mandatory follow-up visits and inappropriate use of emergency services. We describe the appeal, acceptability, safety and follow-up rates of medication abortion in a low-income Latina population in New York City. STUDY DESIGN Nested analysis of 270 subjects up to 63 days' gestation enrolled in a multicenter trial of medication abortion comparing different mifepristone-misoprostol intervals. After receiving mifepristone, subjects were instructed on home use of misoprostol, what to do in an emergency and when to return. RESULTS This population was predominantly Spanish-speaking, unmarried, poor and publicly insured. Ninety-six percent took the misoprostol at home correctly, 90% returned as scheduled without reminders and 2% were lost to follow-up. Ninety-six percent described the experience as positive or neutral and 94% would recommend medication abortion to a friend. Three serious adverse events occurred and women accessed emergency services appropriately. CONCLUSION Medication abortion can be a very appealing, safe and effective option in low-income, non-English-speaking populations.
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Affiliation(s)
- Stephanie B Teal
- University of Colorado, Denver School of Medicine, Denver, CO, USA.
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Wiegerinck MM, Jones HE, O'Connell K, Lichtenberg ES, Paul M, Westhoff CL. Medical abortion practices: a survey of National Abortion Federation members in the United States. Contraception 2008; 78:486-91. [DOI: 10.1016/j.contraception.2008.07.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Revised: 07/28/2008] [Accepted: 07/28/2008] [Indexed: 10/21/2022]
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Crane S. Remember 1967? We do... JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2007; 33:290. [PMID: 17925128 DOI: 10.1783/147118907782101814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Esen UI. Review of abortion laws. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2007; 33:289-90; author reply 290. [PMID: 17925125 DOI: 10.1783/147118907782101977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Furedi A. Reply. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2007. [DOI: 10.1783/147118907782101823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lohr PA, Reeves MF, Hayes JL, Harwood B, Creinin MD. Oral mifepristone and buccal misoprostol administered simultaneously for abortion: a pilot study. Contraception 2007; 76:215-20. [PMID: 17707719 DOI: 10.1016/j.contraception.2007.05.088] [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] [Received: 03/14/2007] [Revised: 05/14/2007] [Accepted: 05/24/2007] [Indexed: 12/01/2022]
Abstract
BACKGROUND Simultaneous oral mifepristone and vaginal misoprostol has a 24-h expulsion rate of approximately 90% when used for abortion through 63 days' gestation. This pilot study sought to determine if a simultaneous regimen using buccal misoprostol would be similarly effective and merit further investigation. STUDY DESIGN One hundred twenty women were enrolled into three equal groups by gestational age: < or =49 days (Group 1), 50-56 days (Group 2) and 57-63 days (Group 3). After swallowing 200 mg of mifepristone, subjects received 800 mcg buccal misoprostol. Participants returned in 24+/-1 h for evaluation of expulsion by ultrasonography. Women with a persistent gestational sac received 800 mcg vaginal misoprostol. Further follow-up occurred at 1, 2 and 5 weeks by telephone or in person, as appropriate. Sample sizes for each group were estimated with the aim of establishing a 24-h expulsion rate of 90% (95% CI=76-95). RESULTS The 24-h expulsion rates for Groups 1, 2 and 3 were 73% (95% CI=56-85), 69% (95% CI=52-83) and 73% (95% CI=56-85), respectively. Common side effects were nausea (62%), vomiting (33%) and diarrhea (48%), which did not differ by gestational age. Forty-three percent of subjects found the taste of buccal misoprostol objectionable; 30% found buccal retention uncomfortable or inconvenient, and 10% reported oral irritation, sensitivity, numbness or oral ulcers. CONCLUSIONS Simultaneous oral mifepristone and buccal misoprostol had a lower-than-hypothesized expulsion rate at 24 h. Although overall success rates at 7 or 15 days could have been higher than those observed at 24 h, we believe that this regimen does not warrant further study.
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Affiliation(s)
- Patricia A Lohr
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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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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Blanchard K, Schaffer K, McLeod S, Winikoff B. Medication abortion in the private sector in South Africa. EUR J CONTRACEP REPR 2007; 11:285-90. [PMID: 17484194 DOI: 10.1080/13625180600834343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To collect information about how private physicians in South Africa provide medication abortion services to their patients. METHODS In April 2003 we asked physicians in private practice in South Africa who had purchased mifepristone (Mifegyne) from the South African distributor about the medication abortion regimen they offered, satisfaction with the method, and how services have been incorporated into their practices. RESULTS Forty-four providers participated in the survey. They report using a range of doses and regimens. Most respondents offer mifepristone-misoprostol to their patients, although a significant minority also offer misoprostol-alone for pregnancy termination. While the majority of medication abortion providers also offer surgical abortions, a significant number of non-surgical providers were only offering medication abortion. CONCLUSION South African medication abortion providers find the method acceptable, indicate that their staff are largely supportive of offering it to their patients, and report that clients like the method. Those surveyed believe that most of their patients are eligible for the regimen, although uptake has been limited.
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Clark WH, Gold M, Grossman D, Winikoff B. Can mifepristone medical abortion be simplified? A review of the evidence and questions for future research. Contraception 2007; 75:245-50. [PMID: 17362700 DOI: 10.1016/j.contraception.2006.11.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2005] [Revised: 10/31/2006] [Accepted: 11/15/2006] [Indexed: 11/22/2022]
Abstract
Mifepristone medical abortion has been a valuable addition to the reproductive health options of women. Aspects of its provision have however sometimes limited its accessibility and use. This article summarizes existing evidence for simplifying the provision of medical abortion and thus increasing its availability. We identify three ways through which medical abortion provision might be simplified based on existing evidence and suggest five additional simplifications that require further research to confirm their safety and efficacy.
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Clark W, Panton T, Hann L, Gold M. Medication abortion employing routine sequential measurements of serum hCG and sonography only when indicated. Contraception 2006; 75:131-5. [PMID: 17241843 DOI: 10.1016/j.contraception.2006.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2005] [Revised: 07/27/2006] [Accepted: 08/02/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study was designed to demonstrate the safety and efficacy of providing medication abortion in a primary care site without routine use of pre- and postprocedure transvaginal sonography. METHODS We performed a retrospective record review of 172 consecutive patients choosing medication abortion at our clinic. Our protocol used sonography only as needed for specific indications. All patients were intended to be followed up with serum human chorionic gonadotropin (hCG) testing pre- and posttreatment. RESULTS Of the 151 patients not lost to follow-up, 96 (63%) had pretreatment sonography according to protocol or physician preference and 55 did not. Ninety-nine percent (95/96) of those receiving initial sonography had a successful, and uneventful, medication abortion treatment, while 98.2% (54/55) of those not receiving an initial sonography did so. This difference was not statistically significant (.597 by one-sided Fisher's Exact Test). All 119 of the women who did not receive postabortion sonography aborted completely. Only 4 of the 91 women who had both pre- and postprocedure hCG measurements, all of whom aborted successfully, had follow-up-to-initial hCG ratios of greater than 0.2 (20%). CONCLUSION Using a clinical protocol that involves obtaining pre- and posttreatment serum hCG measurements, with sonograms only when indicated, has similar outcomes to a protocol that uses mandatory pre- and posttreatment sonograms.
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Affiliation(s)
- Wesley Clark
- Gynuity Health Projects, New York, NY 10010, USA
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Afable-Munsuz A, Gould H, Stewart F, Phillips KA, Van Bebber SL, Moore C. Provider practice models for and costs of delivering medication abortion -- evidence from 11 US abortion care settings. Contraception 2006; 75:45-51. [PMID: 17161124 DOI: 10.1016/j.contraception.2006.09.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2006] [Revised: 09/08/2006] [Accepted: 09/12/2006] [Indexed: 11/30/2022]
Abstract
PURPOSE Understanding practice models and provider costs for medication abortion (MAB) provision may elucidate ways to facilitate MAB integration into a larger arena of health care services. This study provides descriptive data on the diverse MAB practice models currently being utilized by US health care providers and the costs associated with the components of those models. METHOD Data were gathered from a sample of 11 abortion care settings, using clinic administrative records and patient satisfaction surveys. RESULTS Practice models varied dramatically, with a wide range in the type of staff employed to provide MAB. The total episode cost for providing MAB ranged from 252 to 460 US Dollars, and patient satisfaction was high across all practices. CONCLUSION Information from this study can be used to guide decisions regarding MAB integration into practices not currently providing abortion or which provide only aspiration abortions. The information may also be useful for providers wishing to refine their MAB services.
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Affiliation(s)
- Aimee Afable-Munsuz
- University of California, San Francisco and Advancing New Standards in Reproductive Health (ANSIRH) program, Bixby Center for Reproductive Health Research & Policy, San Francisco, CA 94143, USA.
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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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Seelig MD, Gelberg L, Tavrow P, Lee M, Rubenstein LV. Determinants of physician unwillingness to offer medical abortion using mifepristone. Womens Health Issues 2006; 16:14-21. [PMID: 16487920 DOI: 10.1016/j.whi.2005.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2004] [Revised: 05/04/2005] [Accepted: 10/03/2005] [Indexed: 11/23/2022]
Abstract
PURPOSE We sought to identify factors associated with contemplating versus not contemplating offering medical abortion with mifepristone among physicians not opposed to it. METHODS We analyzed data from a Kaiser Family Foundation survey of a nationally representative sample of 790 American obstetrician/gynecologists and primary care physicians. Our study sample consisted of 419 physicians who were not personally opposed to medical abortion and could be classified as not actively considering (precontemplation) or actively considering (contemplation) offering mifepristone. We conducted multivariate logistic regression to predict being unlikely to offer mifepristone (i.e., in the precontemplation stage of change). PRINCIPAL FINDINGS In 2001, 1 year after U.S. Food and Drug Administration (FDA) approval, 5% of physicians surveyed were offering mifepristone. Among the 750 physicians not offering mifepristone, 57% were not opposed. Of those not opposed, 74% reported that they were unlikely to offer mifepristone in the next year (precontemplation) as compared to 23% who might offer it (contemplation). Independent predictors of being in the precontemplation stage were being a primary care versus OB/GYN physician (odds ratio [OR] 3.29, p = .02), being in private versus hospital-based practice (OR 2.40, p = .03), and lacking concerns about FDA regulations (OR 2.06, p = .01) or violence and protests (OR 1.93, p = .03) as barriers to offering mifepristone. CONCLUSIONS For precontemplation-stage physicians, the most efficient strategy for increasing the availability of medical abortion may be to design programs that emphasize clinical benefits and feasibility to stimulate interest in the procedure. For contemplation-stage physicians, the optimum approach may be one that helps to overcome barriers associated with FDA regulations and concerns about violence and protests.
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Affiliation(s)
- Michelle D Seelig
- David Geffen School of Medicine at UCLA, Department of Family Medicine, Los Angeles, California 90024-4142, USA.
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Stojnić J, Ljubić A, Jeremić K, Radunović N, Tulić I, Bosković V, Dukanac J. Medicamentous abortion with mifepristone and misoprostol in Serbia and Montenegro. VOJNOSANIT PREGL 2006; 63:558-63. [PMID: 16796021 DOI: 10.2298/vsp0606558s] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background/Aim. Medicamentous abortion was first introduced in Serbia and Montenegro in September 2001. The aim of this study was to assess the efficiency, side effects, and acceptability of medicamentous abortion using mifeprostone orally (600 mg), and 48 hours later, misoprostol both orally and vaginally in different regiments in our population (400 mcg, 600 mcg, 800 mcg). Methods. A total of 235 consecutive women with pregnancies up to 49 days of gestational age were assigned to 4 groups according to the different misoprostol regiment (group I 400 mcg, group II 600 mcg, group III 800 mcg orally, and group IV 800 mcg both orally and vaginally). The principal outcome measure was a successful abortion defined as a complete expulsion of intrauterine contents without a need for surgical intervention 14 days after the procedure. Other outcome measures were the following: drug related effects, and adverse effects related to the abortion process. Results. In general, the success rate was 50%, 89.48%, 75% and 92.11% in the groups I, II, III, and IV, respectively, as judged by the complete expulsion of the intrauterine contents without surgical intervention (t1:4 = 7.005; t2:4 = 0.3872, t3:4 = 2.9784, p < 0.01). The incidence of adverse effects (vomiting, abdominal pain, bleeding, and fever) was low in general, but among our groups it occurred mostly with the higher doses of orally applied misoprostol (800 and 600 mcg). Only one case required urgent curettage for heavy vaginal bleeding, and two blood transfusions, as well. No cases of intact pregnancies were recorded in the study. Conclusion. Our study showed that a mifepristone dose of 600 mg orally, and misoprostol 400 mcg orally and 400 mcg vaginally were most effective. Thus, a combination of mifepristone and misoprostol for medicamentous abortion should take a higher proportion in the termination of early pregnancy in our population.
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Affiliation(s)
- Jelena Stojnić
- Klinicki centar Srbije, Institut za ginekologiju i akuserstvo, Beograd, Srbija i Crna Gora.
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Ravn P, Rasmussen A, Knudsen UB, Kristiansen FV. An outpatient regimen of combined oral mifepristone 400 mg and misoprostol 400 microg for first-trimester legal medical abortion. Acta Obstet Gynecol Scand 2005; 84:1098-102. [PMID: 16232179 DOI: 10.1111/j.0001-6349.2005.00868.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM To evaluate the success rate of medical abortion using an outpatient regimen of oral mifepristone 400 mg and oral misoprostol 400 microg for legal abortion in women < 56 days pregnant. METHODS Successful abortion was defined as an endometrial thickness < 20 mm evaluated by transvaginal ultrasound and minimal vaginal bleeding at a control examination performed 14 days after administration of misoprostol. Over a 6-month period in 2003, a questionnaire (completion rate 70%) was used for a spot check of the patients' evaluation of the method. RESULTS Six hundred and sixty women underwent the procedure over a 3-year period and 606 (92%) experienced successful medical abortion. The remaining 8% had vacuum aspiration performed mainly due to uterine retention (70%). Other reasons were vaginal bleeding (25%), vomiting (2%), or pelvic infection (4%). Most women reported no days with severe pain (67%), 0--1 days with moderate pain (82%), and 0--1 days with light pain (62%). In terms of gastrointestinal side effects, 68% reported nausea, 33% vomiting, and 27% diarrhea. Most women (90%) felt that the information given at the hospital prior to the abortion was sufficient, 74% would prefer medical abortion again in case of a future unwanted pregnancy, and 85% would prefer to abort at home again. CONCLUSION A high acceptance and success rate was seen using this outpatient oral regimen of mifepristone and misoprostol.
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Affiliation(s)
- Pernille Ravn
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense C, Denmark.
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Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C, Frederick MM. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med 2005; 353:761-9. [PMID: 16120856 DOI: 10.1056/nejmoa044064] [Citation(s) in RCA: 212] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Misoprostol is increasingly used to treat women who have a failed pregnancy in the first trimester. We assessed the efficacy, safety, and acceptability of this treatment in a large, randomized trial. METHODS A total of 652 women with a first-trimester pregnancy failure (anembryonic gestation, embryonic or fetal death, or incomplete or inevitable spontaneous abortion) were randomly assigned to receive 800 microg of misoprostol vaginally or to undergo vacuum aspiration (standard of care) in a 3:1 ratio. The misoprostol group received treatment on day 1, a second dose on day 3 if expulsion was incomplete, and vacuum aspiration on day 8 if expulsion was still incomplete. Surgical treatment (for the misoprostol group) or repeated aspiration (for the vacuum-aspiration group) within 30 days after the initial treatment constituted treatment failure. RESULTS Of the 491 women assigned to receive misoprostol, 71 percent had complete expulsion by day 3 and 84 percent by day 8 (95 percent confidence interval, 81 to 87 percent). Treatment failed in 16 percent of the misoprostol group and 3 percent of the surgical group (absolute difference, 12 percent; 95 percent confidence interval, 9 to 16 percent) by day 30. Hemorrhage or endometritis requiring hospitalization was rare (1 percent or less in each group), with no significant differences between the groups. In the misoprostol group, 78 percent of the women stated that they would use misoprostol again if the need arose and 83 percent stated that they would recommend it to others. CONCLUSIONS Treatment of early pregnancy failure with 800 microg of misoprostol vaginally is a safe and acceptable approach, with a success rate of approximately 84 percent.
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Affiliation(s)
- Jun Zhang
- Epidemiology Branch, National Institute of Child Health and Human Development, Bethesda, Md 20892, USA.
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Hollander I. Viagra's rise above women's health issues: an analysis of the social and political influences on drug approvals in the United States and Japan. Soc Sci Med 2005; 62:683-93. [PMID: 16040176 DOI: 10.1016/j.socscimed.2005.03.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2004] [Accepted: 03/11/2005] [Indexed: 11/23/2022]
Abstract
In the United States, Viagra was approved in less than 6 months of its application to the Food and Drug Administration, while the medical abortion pill was approved 4 years after its application, and 17 years after research was first permitted. Congruently, the Ministry of Health in Japan legalized Viagra in 6 months, while oral contraceptives were approved 35 years after the ministry received initial applications. The pharmaceutical review agencies in each country are founded on safety and efficacy standards, in which objective decisions arise from science and clinical investigations. Analyses of these recent drug approvals demonstrate that conclusions may not have been based simply on science and health concerns. Instead, agency actions and application of pharmaceutical law appear to have been influenced by social and political pressures surrounding the products under scrutiny. Pharmaceutical regulations were effectively ignored or manipulated in the United States during the review process for medical abortion, and were applied inconsistently in Japan--ultimately yielding results that happened to conform to contemporary sociopolitical beliefs. Such disregard of legislation holds serious ramifications for public health, national consumer trust and the pharmaceutical industry. It is imperative that external pressures remain outside the scope of drug approval processes.
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Affiliation(s)
- Ilyssa Hollander
- Social Sectors Development Strategies, Inc., 1411 Washington St., Suite 6, Boston, MA 02118, USA.
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Abstract
Abortion is an extremely safe and common medical procedure. In the United States, over one million women had an abortion in the year 2000. Advances in early abortion techniques have helped to increase the proportion of early procedures, the safest type. Abortion rates have been declining since the early nineties among adults and adolescents, but rates among poor, minority women remain high. State restrictions to abortion have a larger impact on poor women and young women. Restrictions and regulations have also resulted in the concentration of abortion services in specialized clinics. These clinics are subject to harassment. The expansion of abortion services to more types of providers could increase access, as well as integrate abortion into women's health care.
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Affiliation(s)
- Cynthia C Harper
- Center for Reproductive Health Research and Policy, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, 94143, USA.
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Murthy AS, Creinin MD, Harwood B, Schreiber C. A pilot study of mifepristone and misoprostol administered at the same time for abortion up to 49 days gestation. Contraception 2005; 71:333-6. [PMID: 15854632 DOI: 10.1016/j.contraception.2004.10.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2004] [Revised: 10/14/2004] [Accepted: 10/25/2004] [Indexed: 11/18/2022]
Abstract
HYPOTHESIS Simultaneous administration of mifepristone and misoprostol for medical abortion in women up to 49 days gestation will result in complete abortion in 90% of women within 24 h of treatment. MATERIALS AND METHODS Forty women with pregnancies up to 49 days gestation inserted 800 mug vaginal misoprostol in our office immediately after taking mifepristone 200 mg orally. Follow-up visits, which included vaginal ultrasonography, occurred 24+/-1 h and 2 weeks after treatment. If a gestational sac was still present at the first follow-up visit, the misoprostol dose was repeated. Suction abortion was performed for a viable gestation at the second follow-up visit, presence of a nonviable gestation within 5 weeks of treatment and when clinically indicated. RESULTS Expulsion occurred in 36/40 (90%, 95% CI 80-99) and 39/40 (98%, 95% CI 93-100) women by the first and second follow-up visits, respectively. One woman who had initially expelled the gestational sac after a single dose of misoprostol later required a suction curettage for an incomplete abortion. CONCLUSION Simultaneous administration of mifepristone and vaginal misoprostol is a promising regimen for medical abortion up to 49 days gestation.
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Affiliation(s)
- Amitasrigowri S Murthy
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine and Magee Womens Research Institute, Pittsburgh, PA 15213, USA
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Ashima T, Vinita A, Shalini R. Early medical abortion: A new regimen up to 49 days' gestation. Aust N Z J Obstet Gynaecol 2005; 45:137-9. [PMID: 15760315 DOI: 10.1111/j.1479-828x.2005.00380.x] [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] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Taneja Ashima
- Department of Obstetrics & Gynaecology, Dayanand Medical College & Hospital, Ludhiana, India.
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Faucher P, Baunot N, Madelenat P. [The efficacy and acceptability of mifepristone medical abortion with home administration misoprostol provided by private providers linked with the hospital: a prospective study of 433 patients]. ACTA ACUST UNITED AC 2005; 33:220-7. [PMID: 15894206 DOI: 10.1016/j.gyobfe.2005.02.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2004] [Accepted: 02/23/2005] [Indexed: 11/22/2022]
Abstract
BACKGROUND Until July 2001 medical abortion was only authorized in France in public hospitals or private clinics. A new law effective in July 2001 allows private practitioners (gynaecologists or general practitioners) to provide medical abortion in their offices as long as they are linked to a hospital official agreement. Unfortunately mifepristone was not available outside hospitals before September 2004, so the study was conducted still providing the drugs in the hospital family planning clinic. OBJECTIVE To evaluate the efficacy and the acceptability of mifepristone medical abortion with home administration of misoprostol provided by private practitioners linked with the hospital. PATIENTS AND METHODS Four hundred thirty-three women seeking medical abortion before 7 weeks LMP were included between 2 January 2003 and 7 July 2004. All consultations before abortion and 2 weeks after abortion took place in a private provider's office. Drugs were administrated in the hospital family planning clinic: patients were given 3 tablets of mifepristone (600 mg) orally by the midwife and received 2 tablets of misoprostol (400 microg) that they would take at home 48 hours later. In case of any problems or complications, patients could phone or meet their private providers, phone the hospital midwife or go to the hospital emergency service. Private providers received training in medical abortion training and could at any time reach a medical specialist in the hospital family planning clinic for information or to refer a patient. RESULTS - Efficacy was evaluated for 339 women, because 94 patients were lost to follow-up (21.7%). Efficacy of medical abortion was 93.8% (318/339). There were 21 surgical aspirations (6.2%): for women's decision in 1.5% of cases, for medical decision without complications in 3.5% of cases, and for failure of the method in 1.2% of cases (2 ongoing pregnancies and 2 heavy haemorrhages with transfusion). The family planning midwife received a phone call from 21 patients after mifepristone (4.8%), Twenty-five patients had an emergency consultation (5.7%), and 22 patients went back to their private providers before their appointment for follow-up (5%). Twenty-two patients (5%) were referred by the private provider to the hospital medical specialist. Acceptability is known for 26% of patients; 96.2% thought that the abortion procedure was acceptable. DISCUSSION AND CONCLUSIONS The failure rate of medical abortion in this study is largely due to aspirations for incomplete abortion. To improve the efficacy of medical abortion offered by private providers linked with the hospital, all the relevant professionals (private providers, residents in the emergency service, family planning providers) must be well trained in medical abortion, especially in how to interpret and react to ultrasound images obtained in the follow up visit. The procedure is very acceptable to women. Medical abortion offered via a network should be well accepted by practitioners, since only 5% of women will need more than two consultations and only 6.2% will need surgical aspiration in the hospital. This study allows us to be optimistic about the expansion of medical abortion in France outside the hospital via a provider-hospital network based on the fact that since September 2004 private providers can get mifepristone directly in the pharmacies of the city.
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Affiliation(s)
- P Faucher
- Service de gynécologie-obstétrique, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France.
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Hamoda H, Flett GMM. Medical termination of pregnancy in the early first trimester. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2005; 31:10-4. [PMID: 15720840 DOI: 10.1783/0000000052972906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Surgical abortion using vacuum aspiration or dilatation and curettage has been the method of choice for termination of pregnancy up to 63 days' gestation since the 1960s. Over the last three decades many studies have explored the use of medical methods for inducing abortion at these gestations. Earlier regimens assessed the systemic and intrauterine injection of prostaglandins. This was followed in the 1980s by the introduction of the antiprogesterone, mifepristone. Since its introduction, the uptake of medical abortion has been steadily increasing in countries where it has been available for routine use. Most current clinical protocols require the use of prostaglandins in combination with anti-progesterones or antimetabolites. The safety, efficacy and acceptability of the medical regimen are now well established at all gestations of pregnancy. Provision of medical abortion increases the choice available to women, in particular those wishing to avoid surgery.
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Affiliation(s)
- Haitham Hamoda
- Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen Maternity Hospital, Foresterhill, UK.
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Hedley A, Ellertson C, Trussell J, Turner AN, Aubény E, Coyaji K, Ngoc NTN, Winikoff B. Accounting for time: insights from a life-table analysis of the efficacy of medical abortion. Am J Obstet Gynecol 2004; 191:1928-33. [PMID: 15592274 DOI: 10.1016/j.ajog.2004.06.108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Previously published analyses have ignored the temporal nature of medical abortion and calculated effectiveness as the proportion of abortions that succeed. By using life tables, we incorporate the important element of time to produce unbiased efficacy rates as well as afford insight into the medical abortion process. STUDY DESIGN Using data on 6568 women from 6 previously published mifepristone-misoprostol medical abortion studies, we generated multidecrement life table efficacy curves and evaluated the cumulative probability of successful medical abortion. RESULTS Efficacy rates calculated using proportions are biased because of loss to follow-up. Compliance with the medical abortion regimen was high. More than 80% of abortions were complete within a week of receiving mifepristone. Success continued to improve thereafter. Most surgical interventions were unnecessary. CONCLUSION Follow-up visits can be scheduled within a week of receiving mifepristone; however, aspirations should not be performed routinely if the abortion is not complete.
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Affiliation(s)
- Allison Hedley
- Office of Population Research, Princeton University, Princeton, NJ, USA
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Borgatta L, Mullally B, Vragovic O, Gittinger E, Chen A. Misoprostol as the primary agent for medical abortion in a low-income urban setting. Contraception 2004; 70:121-6. [PMID: 15288216 DOI: 10.1016/j.contraception.2004.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2003] [Revised: 01/10/2004] [Accepted: 03/04/2004] [Indexed: 11/20/2022]
Abstract
The purpose of this study was to assess the outcomes of early medical abortion in an inner-city hospital abortion service, using misoprostol as the primary agent. This was a retrospective chart review from July 2001 through December 2002. Women were eligible if they had a viable pregnancy with gestational age 8 weeks or less by transvaginal ultrasound and no medical contraindications. Two doses of 800 microg misoprostol were administered vaginally, 24 h apart. Initial follow-up was scheduled 2-3 days later. Of the 440 women who underwent medical abortion, 373 (90.8%, 95% confidence interval (CI) 88-94%) completed abortion medically, 38 (9.2%) had uterine aspiration and the remainder had incomplete or no follow-up. Of uterine aspirations, 11 were medically indicated, giving a rate of indicated aspiration of 2.7%. Gestational age, age, gravidity, parity, past abortion history, ethnic group and payer did not significantly correlate with overall rate of aspiration or rate of follow-up, but gestational age was correlated with medically indicated aspiration. Among 57 women who reported a time of tissue passage, the mean time from initial misoprostol dose was 8.5 h (95% CI 6.5-13 h).
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Affiliation(s)
- Lynn Borgatta
- Department of Obstetrics and Gynecology, Boston University School of Medicine and Boston Medical Center, 85 East Concord Street, 6th Floor, Boston, MA 02118, USA.
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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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Hedley A, Trussell J, Turner AN, Coyaji K, Ngoc NTN, Winikoff B, Ellertson C. Differences in efficacy, differences in providers: results from a hazard analysis of medical abortion. Contraception 2004; 69:157-63. [PMID: 14759622 DOI: 10.1016/j.contraception.2003.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2003] [Revised: 11/06/2003] [Accepted: 11/17/2003] [Indexed: 11/25/2022]
Abstract
Sample sizes of even the largest medical abortion trials are generally not adequate to provide an understanding of how well the regimen works for subgroups of women, particularly when controlling for factors known to influence efficacy, such as gestational age. By pooling data from four previously published studies of medical abortion and using hazard analyses, we can undertake such an investigation. We find that women with lower gestational ages, women younger than 23 years of age, women with more than 12 years of education and women with no previous induced abortion experience were more likely to experience a successful medical abortion. After taking into account demographic factors, we find that significant differences in efficacy persist across study sites, indicating that differences in providers' tendency to intervene by performing vacuum aspiration vary across medical abortion providers.
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Affiliation(s)
- Allison Hedley
- Office of Population Research, Princeton University, Wallace Hall, Princeton, NJ 08544, USA
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Abstract
Surgical abortion in the first trimester comprises the majority of voluntary pregnancy interruptions performed in the United States. The majority of these procedures are done in outpatient settings with the patient under local anesthesia. Appropriate volume of and deep injection of local anesthetic can reduce pain associated with the procedure. Waiting between administration of the paracervical block and initiating the procedure does not affect pain. Intravenous administration of sedation and analgesia improves patient satisfaction but does not significantly affect pain ratings. Antibiotic prophylaxis is warranted. Vasopressin is useful for prevention of hematometra and hemorrhage. Less evidence supports the routine use of ergots. Preoperative cervical priming reduces the risk of cervical injury and uterine perforation. Attention to operative technique can reduce the risk of incomplete abortion. Routine postoperative care at 2 or 3 weeks is timed to identify complications and to reinforce pregnancy and sexually transmitted disease prevention.
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Affiliation(s)
- Lisa M Keder
- Department of Obstetrics and Gynecology, Ohio State University, Columbus, USA
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Fox MC, Creinin MD, Harwood B. Mifepristone and vaginal misoprostol on the same day for abortion from 50 to 63 days' gestation. Contraception 2002; 66:225-9. [PMID: 12413616 DOI: 10.1016/s0010-7824(02)00358-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In a previous study of 40 women up to 49 days' gestation, our research center demonstrated that mifepristone 200 mg followed on the same day by misoprostol 800 microg vaginally produced abortion at rates similar to standard regimens which administer the two drugs 24 or 48 h apart. We performed this study to evaluate the same regimen in women with pregnancies at 50 to 63 days' gestation. Forty women from 50 to 56 days' gestation (Group 1) and 40 women from 57 to 63 days' gestation (Group 2) inserted misoprostol vaginally 6 to 8 h after taking mifepristone. Participants were instructed to return 24 +/- 1 h after using misoprostol for an evaluation that included transvaginal ultrasonography. Subjects who had not aborted received a second dose of misoprostol to administer 48 h after the mifepristone. All participants were to return 2 weeks later. Ultrasound examinations were performed in those who required a second dose of misoprostol to confirm the abortion was successful. At 24 h after receiving misoprostol, 37/40 (93%, 95% CI 80, 98%) and 36/40 (90%, 95% CI 76, 97%) women from Groups 1 and 2, respectively, had expelled the pregnancy. By follow-up 2 weeks after taking mifepristone, all 40 women in Group 1 (100%, 95% CI 91,100%) and 39/40 women in Group 2 (98%, 95% CI 87,100%) had complete abortions. One woman in the latter group who aborted within the first 24 h had an incomplete abortion treated by suction curettage. This pilot study suggests that mifepristone 200 mg, followed on the same day by misoprostol 800 microg vaginally, effects abortion in women 50 to 63 days' gestation at rates comparable to regimens using longer dosing intervals between medications. Though this regimen is promising, larger randomized trials comparing it to standard regimens are needed before widespread use.
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Affiliation(s)
- Michelle C Fox
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine and Magee-Womens Research Institute, Pittsburgh, PA, USA.
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