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Raymond EG, Weaver MA, Shochet T. Effectiveness and safety of misoprostol-only for first-trimester medication abortion: An updated systematic review and meta-analysis. Contraception 2023; 127:110132. [PMID: 37517447 DOI: 10.1016/j.contraception.2023.110132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/20/2023] [Accepted: 07/26/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES This study aimed to update our 2019 systematic review of data on the effectiveness and safety of misoprostol-only for first-trimester abortion. STUDY DESIGN We searched PubMed on December 18, 2022, to find published articles describing the outcomes of treatment with misoprostol-only for abortion of viable intrauterine pregnancy at ≤91 days of gestation. From each article identified, two authors independently abstracted relevant data about each group of patients treated with a distinct regimen. We assessed the risk of bias using four defined indicators. We estimated the proportion of patients with treatment failure using meta-analytic methods as well as the proportion hospitalized or transfused after treatment. We examined associations between treatment failure and selected characteristics of the groups. RESULTS We identified 49 papers with 66 groups that collectively included 16,354 evaluable patients, of whom 2960 (meta-analytic estimate 15%, 95% CI 12%, 19%) had treatment failures. Of 9228 patients assessed for ongoing pregnancy after treatment, 521 (meta-analytic estimate 6%, 95% CI 5%, 8%) had that condition. Failure risk was significantly associated with misoprostol dose, the total allowed number of doses, the maximum duration of dosing, and certain indicators of risk of bias. Among 11,007 patients allowed to take at least three misoprostol doses, the first consisting of misoprostol 800 mcg administered vaginally, sublingually, or buccally, the meta-analytic estimate of the failure risk was 11% (95% CI 8%, 14%). At most, 0.2% of 15,679 evaluable patients were hospitalized or received transfusions. CONCLUSIONS Although some studies in this updated review were adjudicated to have a high risk of bias, the results continue to support the key conclusion of our 2019 analysis: misoprostol-only is effective and safe for the termination of first-trimester intrauterine pregnancy. IMPLICATIONS Misoprostol-only is a safe and effective option for medication abortion in the first trimester if mifepristone is unavailable or inaccessible.
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Affiliation(s)
| | - Mark A Weaver
- Elon University, Department of Mathematics and Statistics, Elon, NC, United States
| | - Tara Shochet
- Gynuity Health Projects, New York, NY, United States
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Dickinson JE, Doherty DA. Mifepristone priming and subsequent misoprostol for second trimester medical abortion in women with previous caesarean delivery. Aust N Z J Obstet Gynaecol 2023. [PMID: 36789734 DOI: 10.1111/ajo.13653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/22/2023] [Indexed: 02/16/2023]
Abstract
AIMS To assess clinical outcomes and complications in women with ≥1 prior caesarean delivery (CS) during mid-pregnancy medical abortion with misoprostol following mifepristone priming. MATERIALS AND METHODS Retrospective analysis of abortions at 13-28 weeks gestation using sequential mifepristone and misoprostol at a single centre from 1/2008-12/2018. Procedural outcomes were compared between cases with no prior CS, one prior and ≥2 prior CS. RESULTS There were 1399 consecutive women who underwent a medical abortion, with 304 (21.7%) having ≥1 prior lower segment CS (241 one, 49 two, 12 three, one four) and one a prior classical CS. Median gestation was 19 weeks (interquartile range (IQR) 17-21) among nulliparas, multiparas with no prior CS and multiparas with prior CS, P = 0.505. Compared with nulliparas (median procedural duration 10.8 h, IQR 7.5-16.5; adjusted hazards ratio (aHR) = 1.20 95%CI 1.04-1.40, P = 0.015), multiparas with prior CS had a shorter procedural duration (9.5 h, IQR 6.5-13.5) while multiparas with no CS had the shortest duration (7.0 h, IQR 5.0-9.8; aHR = 2.28 95%CI 2.01-2.58, P < 0.001). Complications were more frequent with prior CS: estimated blood loss (medians: 100 cc no CS vs 150 cc ≥1 CS, P = 0.002), blood loss >1000 cc (3.6% no CS vs 7.2% ≥1 CS; odds ratio (OR) = 2.11 95%CI 1.23-3.62, P = 0.007) and placental retention (17.3% no CS vs 25.3% ≥1 CS; adjusted OR = 1.44 95%CI 1.05-1.99, P = 0.024). Uterine rupture occurred in 4/304 women with ≥1 prior CS (1.3%). CONCLUSIONS Mifepristone-misoprostol abortion in women with prior CS is generally safe but associated with an increased risk of procedural complications. Lowering of the misoprostol dosage with prior CS may reduce uterine rupture, although this hypothesis requires ongoing research.
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Affiliation(s)
- Jan E Dickinson
- Maternal Fetal Medicine, Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Dorota A Doherty
- Biostatistics and Research Design Unit, Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
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Efficacy of Misoprostol Alone for First-Trimester Medical Abortion: A Systematic Review. Obstet Gynecol 2019; 133:137-147. [PMID: 30531568 DOI: 10.1097/aog.0000000000003017] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To summarize available data on the effectiveness and safety of single-agent misoprostol for medical abortion in the first trimester. DATA SOURCES We searched MEDLINE, CABI, Cochrane, EMBASE, LILACS, the Web of Science, and ClinicalTrials.gov for English-language studies that evaluated misoprostol alone for abortion of a viable pregnancy in the first trimester. METHODS OF STUDY SELECTION Our search yielded 1,562 citations, of which 38 included data from 53 trial groups that met our inclusion and exclusion criteria. TABULATION, INTEGRATION, AND RESULTS We abstracted data about each trial group, including study characteristics, treatment regimen, clinical protocol, number of women treated and followed, and numbers with outcomes of interest. We used meta-analytic methods and logistic regression to examine factors associated with surgical intervention after treatment. Among all 12,829 evaluable women, 2,536 (meta-analytic estimate 22.0%, 95% CI 18.8-25.5%) had surgical uterine evacuation. Multiple factors were significantly associated with this proportion, including misoprostol amount per dose and route of administration, loss to follow-up rate, publication date, geographic region, number of misoprostol doses, duration of dosing, and time between dosing and evaluation. Of 6,359 evaluable women, 384 (meta-analytic estimate 6.8%, 95% CI 5.3-8.5%) had ongoing pregnancies. At most 26 of 12,184 evaluable women (meta-analytic estimate 0.7%, 95% CI 0.4-1.0%) were transfused or hospitalized for abortion-related reasons. In trials that provided satisfaction data, most women were satisfied or very satisfied with the treatment (meta-analytic estimate 78%, 95% CI 71-85%). CONCLUSIONS Misoprostol alone is effective and safe and is a reasonable option for women seeking abortion in the first trimester. Research is indicated to further refine the regimen and to establish efficacy in the late first trimester. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42018083589.
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Cuellar Torriente M, Steinberg WJ, Joubert G. Misoprostol use for second-trimester termination of pregnancy among women with one or more previous cesarean deliveries. Int J Gynaecol Obstet 2017; 138:23-27. [PMID: 28378361 DOI: 10.1002/ijgo.12168] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/14/2017] [Accepted: 03/31/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To establish the safety and efficacy of misoprostol for second-trimester termination of pregnancy among women with one or more previous cesarean deliveries. METHODS In a retrospective study, data were reviewed from women attending a reproductive health clinic in Bloemfontein, South Africa, for second-trimester termination between 2010 and 2013. The study group, comprising women with one or more previous cesareans, was compared with a control group, comprising women with no previous cesarean or uterine scarring. Procedure-specific information was compared, including misoprostol use, termination duration, need for other methods (e.g. oxytocin), placenta delivery, termination outcome, and bleeding. RESULTS The study group comprised 268 women: 231 (86.2%) with one and 37 (13.8%) with two previous cesareans. The control group comprised 266 women. Incomplete abortion was recorded in 223 (85.4%) of 261 women in the study group and 213 (80.4%) of 265 in the control group. The number of women with retained placenta was higher in the study than in the control group (158/261 [60.5%] vs 146/265 [55.1%]; P<0.001). Severe bleeding was observed only in the control group (7/266 [2.6%]). No uterine rupture was observed. CONCLUSION Misoprostol was safe for second-trimester termination among women with previous cesareans; however, the efficacy of the local regimen was reduced owing to high placental retention.
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Affiliation(s)
- Martin Cuellar Torriente
- Department of Family Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Wilhelm J Steinberg
- Department of Family Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Gina Joubert
- Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
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Andrikopoulou M, Lavery JA, Ananth CV, Vintzileos AM. Cervical ripening agents in the second trimester of pregnancy in women with a scarred uterus: a systematic review and metaanalysis of observational studies. Am J Obstet Gynecol 2016; 215:177-94. [PMID: 27018469 DOI: 10.1016/j.ajog.2016.03.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 03/16/2016] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The aim of this systematic review and metaanalysis was to determine the efficacy and safety of cervical ripening agents in the second trimester of pregnancy in patients with previous cesarean delivery. STUDY DESIGN Data sources were PubMed, EMBASE, CINAHL, LILACS, Google Scholar, and clinicaltrials.gov (1983 through 2015). Eligibility criteria were cohort or cross-sectional studies that reported on efficacy and safety of cervical ripening agents in patients with previous cesarean delivery. Efficacy was determined based on the proportion of patients achieving vaginal delivery and vaginal delivery within 24 hours following administration of a cervical ripening agent. Safety was assessed by the risk of uterine rupture and complications such as retained placental products, blood transfusion requirement, and endometritis, when available, as secondary outcomes. Of the 176 studies identified, 38 met the inclusion criteria. Of these, 17 studies were descriptive and 21 studies compared the efficacy and safety of cervical ripening agents between patients with previous cesarean and those with no previous cesarean. From included studies, we abstracted data on cervical ripening agents and estimated the pooled risk differences and risk ratios with 95% confidence intervals. To account for between-study heterogeneity, we estimated risk ratios based on underlying random effects analyses. Publication bias was assessed via funnel plots and across-study heterogeneity was assessed based on the I(2) measure. RESULTS The most commonly used agent was PGE1. In descriptive studies, PGE1 was associated with a vaginal delivery rate of 96.8%, of which 76.3% occurred within 24 hours, uterine rupture in 0.8%, retained placenta in 10.8%, and endometritis in 3.9% in patients with ≥1 cesarean. In comparative studies, the use of PGE1, PGE2, and mechanical methods (laminaria and dilation and curettage) were equally efficacious in achieving vaginal delivery between patients with and without prior cesarean (risk ratio, 0.99, and 95% confidence interval, 0.98-1.00; risk ratio, 1.00, and 95% confidence interval, 0.98-1.02; and risk ratio, 1.00, and 95% confidence interval, 0.98-1.01; respectively). In patients with history of ≥1 cesarean the use of PGE1 was associated with higher risk of uterine rupture (risk ratio, 6.57; 95% confidence interval, 2.21-19.52) and retained placenta (risk ratio, 1.21; 95% confidence interval, 1.03-1.43) compared to women without a prior cesarean. However, the risk of uterine rupture among women with history of only 1 cesarean (0.47%) was not statistically significant (risk ratio, 2.36; 95% confidence interval, 0.39-14.32), whereas among those with history of ≥2 cesareans (2.5%) was increased as compared to those with no previous cesarean (0.08%) (risk ratio, 17.55; 95% confidence interval, 3.00-102.8). Funnel plots did not demonstrate any clear evidence of publication bias. Across-study heterogeneity ranged from 0-81%. CONCLUSION This systematic review and metaanalysis provides evidence that PGE1, PGE2, and mechanical methods are efficacious for achieving vaginal delivery in women with previous cesarean delivery. The use of prostaglandin PGE1 in the second trimester was not associated with significantly increased risk for uterine rupture among women with only 1 cesarean; however, this risk was substantially increased among women with ≥2 cesareans although the absolute risk appeared to be relatively small.
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Affiliation(s)
- Maria Andrikopoulou
- Department of Obstetrics and Gynecology, Winthrop-University Hospital, Mineola, NY.
| | - Jessica A Lavery
- Biostatistics Coordinating Center, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Cande V Ananth
- Biostatistics Coordinating Center, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY
| | - Anthony M Vintzileos
- Department of Obstetrics and Gynecology, Winthrop-University Hospital, Mineola, NY
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Datta S, Minocha S. How much misoprostol is safe? - First reported case of second-trimester uterine rupture after a single low dose. J OBSTET GYNAECOL 2015; 36:549-51. [PMID: 26467469 DOI: 10.3109/01443615.2015.1072808] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
With the rising rate of caesarean births, the scenario of fetal demise occurring in a woman with previous caesarean births is becoming more prevalent. The optimal mode of management of intrauterine fetal demise in women with multiple caesarean births presents a challenge for the obstetricians due to absence of a definite protocol with good efficacy, safety and acceptability in these women. The risks of hysterotomy have to be balanced against the risk of uterine rupture with induction. Misoprostol is one of the most common drugs being used in mid-trimester miscarriage but with variable doses. The reports of uterine rupture with previous caesarean scar are rare and have occurred with different doses, making it difficult to counsel women regarding maternal risks. It is difficult to conduct a randomised control trial to address this issue due to limited number of patients and therefore no drug or dosage can be recommended with certainty. We present a unique and first case of second-trimester uterine rupture in a woman with three previous caesarean births and intrauterine fetal demise, after a single low dose of 25 μg vaginal misoprostol. This highlights the need for further research in context of misoprostol dosage in women with more than two previous caesarean births having second-trimester induction of labour.
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Affiliation(s)
- S Datta
- a Department of Obstetrics and Gynaecology , Royal Hospital , Muscat , Oman
| | - S Minocha
- a Department of Obstetrics and Gynaecology , Royal Hospital , Muscat , Oman
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Patil E, Edelman A. Medical Abortion: Use of Mifepristone and Misoprostol in First and Second Trimesters of Pregnancy. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015. [DOI: 10.1007/s13669-014-0109-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Küçükgöz Güleç Ü, Urunsak IF, Eser E, Guzel AB, Ozgunen FT, Evruke IC, Buyukkurt S. Misoprostol for midtrimester termination of pregnancy in women with 1 or more prior cesarean deliveries. Int J Gynaecol Obstet 2012. [DOI: 10.1016/j.ijgo.2012.08.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Pongsatha S, Tongsong T. How to manage unresponsiveness to misoprostol in failed second trimester pregnancy termination. J Obstet Gynaecol Res 2012; 39:154-9. [PMID: 22691227 DOI: 10.1111/j.1447-0756.2012.01911.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To present the experience of management of second trimester pregnancy termination by misoprostol after failure to abort within 48 h of its use. MATERIAL AND METHODS A retrospective, cohort descriptive study was carried out in the Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University Thailand between 1998 and 2010. All women at 14-28 weeks of gestation who failed to abort using misoprostol within 48 h were included. Management of failed pregnancy termination among these women is described here. RESULTS Of a total of 680 women undergoing termination of pregnancy, 68 (10%) failed to abort. Mean maternal age was 28.71 years and mean gestational age was 19.91 weeks. Further management after failure included additional administration of misoprostol only (19.1%), modified condom balloon technique only (17.7%), modified condom balloon technique plus other methods (16.1%), while 47.1% needed only oxytocin as necessary. The mean interval between initiation of termination and delivery was 96.97 h. CONCLUSION Failure of pregnancy termination using misoprostol can be successfully managed by introducing additional misoprostol, modified condom balloon technique and oxytocin infusion. These methods should be considered before proceeding to hysterotomy.
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Affiliation(s)
- Saipin Pongsatha
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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Choudhary N, Bagga R, Raveendran A, Saha SC, Dhaliwal LK. Second trimester abortion in women with and without previous uterine scar: Eleven years experience from a developing country. EUR J CONTRACEP REPR 2011; 16:378-86. [DOI: 10.3109/13625187.2011.599453] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Silent uterine rupture with the use of misoprostol for second trimester termination of pregnancy : a case report. Obstet Gynecol Int 2011; 2011:584652. [PMID: 21765835 PMCID: PMC3135046 DOI: 10.1155/2011/584652] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Revised: 11/10/2010] [Accepted: 02/22/2011] [Indexed: 11/18/2022] Open
Abstract
Uterine rupture is an uncommon, but a life-threatening, complication following second trimester medical termination of pregnancy (TOP). The reported cases have been in both the scarred and unscarred uterus (Rajesh et al. 2002, Drey et al. 2006, and Dickinson). A 27-year-old with two previous deliveries, no previous caesarean section, no history of induced abortions, and no gynaecological operations. She presented with amenorrhoea, and according to her last normal menstruation, she was 10 weeks and 5 days. Ultrasound was done, and it reported 16 weeks and 5 days. She asked for TOP. According to the clinic's protocol, misoprostol 800 mcg (4 tabs) were given to be used vaginally as a loading dose and another three to be taken orally after that. In the following day when she attended the clinic for follow up, a manual vacuum aspiration (MVA). A manual vacuum aspiration was indicated as an incomplete abortion. During the procedure, a uterine rupture was found in the uterine lower segment. A laparotomy was done and a lineal uterine rupture was found and sutured. The patient had a good postoperative recovery and was discharged from hospital after four days. The clinician dealing with second trimester terminations should be aware of the possibility of having a uterine rupture, especially in patients with a uterine scar in order to make an early diagnosis.
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Basu JK, Basu D. The management of failed second-trimester termination of pregnancy. Contraception 2009; 80:170-3. [DOI: 10.1016/j.contraception.2009.01.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Revised: 01/27/2009] [Accepted: 01/27/2009] [Indexed: 11/26/2022]
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Uterine Rupture in Second-Trimester Misoprostol-Induced Abortion After Cesarean Delivery. Obstet Gynecol 2009; 113:1117-1123. [DOI: 10.1097/aog.0b013e31819dbfe2] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Effect of Previous Live Birth and Prior Route of Delivery on the Outcome of Early Medical Abortion. Obstet Gynecol 2009; 113:669-674. [DOI: 10.1097/aog.0b013e31819638e6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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