Second trimester medical abortion with mifepristone followed by unlimited dosing of buccal misoprostol in Armenia

Sublingual sufentanil for patient-controlled analgesia during labor induction for pregnancy termination: an effective and well-tolerated approach

BACKGROUND

Effective pain management during labor induction for pregnancy termination is essential. However, to date, no effective treatment has been identified. The primary aim of this study was to measure the analgesic efficacy of a sufentanil sublingual tablet system during pregnancy termination and patient satisfaction by comparing nulliparous and multiparous women. The secondary aims were to characterize the safety profile by reporting any side effects or adverse events and to determine the need for rescue therapy.

METHODS

We conducted an observational, retrospective, single-center study involving 48 women. The data retrieved for analysis included the total and hourly doses of sublingual sufentanil, evaluations of pain management satisfaction using a 5-point rating scale (ranging from 1, indicating "not satisfied" to 5, denoting "completely satisfied"), occurrence of side effects and adverse events, and the rate of rescue analgesic use. Categorical and numerical variables were compared between the two groups, and a correlation analysis was performed.

RESULTS

The median total dose of sufentanil required was 60 mcg. Nulliparous women required a higher dose of sufentanil compared with multiparous women (105 mcg vs. 45 mcg; P = 0.01). Additionally, they underwent a longer labor, indirectly measured by the time of device usage (625 min vs. 165 min; P = 0.05). Regarding satisfaction, 40 patients (83.4%) were satisfied or completely satisfied, whereas only 8 patients (16.6%) reported dissatisfaction. Multiparous women exhibited higher satisfaction levels than did nulliparous women (P = 0.03). No adverse events were reported, and the most common side effects were nausea and vomiting (31.2%). Four patients (12%) required acetaminophen due to insufficient analgesia, with only one patient necessitating a switch to intravenous morphine.

CONCLUSIONS

Sublingual sufentanil was effective in both nulliparous and multiparous women with minimal side effects. Therefore, sublingual sufentanil can be considered a valid strategy for analgesia during labor induction for pregnancy termination.

Can mid-level providers manage medical abortion after 12 weeks' gestation as safely and effectively as physicians? A non-inferiority, randomized controlled trial in Addis Ababa, Ethiopia

OBJECTIVE

To determine whether clinical outcomes among clients undergoing medical abortion after 12 weeks' gestation differ by provider cadre.

METHODS

Randomized controlled trial conducted among eligible clients seeking abortion between 13 and 20 weeks' gestation. Participants seeking in-facility abortion were randomized to receive care from a mid-level provider (nurse/midwife) or physician. The primary outcome was median time to expulsion with non-inferiority margin of -1.5 h between provider groups. Quantile median regression models assessed non-inferiority. Secondary outcomes included retained placenta, complications, and patient acceptability.

RESULTS

After randomization and eligibility assessment by the provider, 171 women participated in the study: 81 in the physician group and 90 in the mid-level provider group. Their average age was 24 years, the mean gestational age was 16 weeks, and 65% were nulliparous in both groups. The median time to expulsion did not differ significantly, being 8.1 h for the mid-level group and 6.6 h for the physician group. The adjusted median difference was 0.8 h (95% confidence interval [CI] -1.15 to 2.66), within the non-inferiority margin. Retained placenta occurred similarly: 30.0% (n = 24) of the physician group and 20.5% (n = 18) of the mid-level provider group (adjusted risk difference [ARD] 7.6%, 95% CI -2.81 to 18.06). Complications occurred in 7% of cases, including 5.0% (n = 4) of patients in the physician group and 8.9% (n = 8) in the mid-level provider group (ARD -4.7%, 95% CI -12.43 to 3.12). Patient acceptability did not differ by group.

CONCLUSIONS

Training mid-level providers to provide abortion services after 12 weeks' gestation independently of physicians is feasible and may result in comparable clinical outcomes.

Catalyst for change: Lessons learned from overcoming barriers to providing safe abortion care in Médecins Sans Frontières projects

CONTEXT

Despite instituting a policy in 2004, Médecins Sans Frontières (MSF) continuously struggled to routinely provide safe abortion care (SAC). In 2016, the organization launched an initiative aimed at increasing availability of SAC in MSF projects and increasing understanding of abortion-related dynamics in humanitarian settings.

METHODOLOGY

From March 2017 to April 2018, MSF staff conducted support visits to 10 projects in a country in sub-Saharan Africa. Each visit followed a systematic approach with six key components and related tools that were later shared with teams worldwide. Data regarding women seeking abortion services and related outcomes were collected and analyzed retrospectively.

RESULTS

From Q1 2017 through Q4 2019, SAC provision increased significantly in all 10 projects, rising from three to 759 safe abortions per quarter. Teams received 3831 patients seeking SAC and provided 3640 first and second trimester abortions, over 99% via medication methods. The overall complication rate was 4.29% and 0.3% for severe, life-threatening complications. No major security incidents were reported. MSF provision of SAC worldwide increased from 781 in 2016 (the year before this initiative began) to 21,546 in 2019.

CONCLUSION

Implementation of SAC in humanitarian settings-even those with significant legal restrictions-is possible and necessary. Both first and second trimester medication abortion can be safely and effectively provided through both home- and facility-based models of care. Programmatic data provide valuable insights into abortion-related dynamics which must shape operational decision-making. Addressing internal barriers and providing direct field support were key to stimulating organizational cultural change.

Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine

The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.

Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine

The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.

[Medical strategy for abortions between 14 and 16 weeks of gestation]

OBJECTIVE

To adapt the protocols for the management of voluntary termination of pregnancy following the new law extending the practice to 16 weeks of gestation.

MATERIAL AND METHOD

A systematic review of the literature in French and English concerning the management of patients requesting medically induced abortion was performed on PubMed, Cochrane Library and on the recommendations of international learned societies.

RESULTS

The efficacy of the medical method is greater than 95% when the protocols are adapted to the gestational age. The combination of mifepristone and misoprostol currently represents the "gold standard" of drug-based management. Mifepristone 200mg is sufficient, followed 24 to 48hours later by misoprostol 800μg administered sublingually or buccally. After the first dose, 400μg should be administered every 3hours buccally or sublingually until expulsion. Adverse effects (digestive and thermoregulatory disorders) during medical abortion are usually mild and short-lived. An anti-emetic treatment should be proposed as a prophylactic measure. For pain, ibuprofen is the analgesic treatment of choice, with the addition of level 2 analgesics if necessary.

CONCLUSION

Medical abortion is a safe and effective method up to 16 weeks of gestation, provided that the protocols, which differ according to gestational age, are respected. Women must be informed of the advantages and disadvantages of the methods according to the term and the side effects, which will allow them to choose the method that fits them best.

Termination of pregnancy in the second trimester - the course of different therapy regimens

OBJECTIVES

To compare two prostaglandin analogs and two application intervals between mifepristone and the prostaglandin analog administration on the time to abortion in second trimester termination of pregnancy. Other endpoints were live birth rate and fetal lifetime after expulsion.

METHODS

Retrospective data of 373 abortions performed were evaluated. Four medical induction subgroups and two feticide subgroups were considered. The definition criteria of the subgroups were the choice of administered prostaglandin analog (misoprostol vs. sulprostone) and the time interval between mifepristone and prostaglandin analog administration (48 vs. 24 h). The outcome parameters were the time to complete uterine evacuation (TCUE), the live birth rate and duration of fetal life.

RESULTS

In the misoprostol subgroups, the median TCUE was 1.6 h longer in the 24-h group than in the 48-h group (p=0.950). In the sulprostone subgroups, the median TCUE was 1.9 h shorter in the 24-h group than in the 48-h group (p=0.950). The median TCUE was shorter for sulprostone than for misoprostol in all six subgroups (p<0.001). The rate of fetal live births ranged between 13.6 and 15.9% within the medical induction subgroups (p=0.969). The median fetal lifetime was slightly shorter in the sulprostone groups than in the misoprostol groups (p=0.563).

CONCLUSIONS

Both application intervals and prostaglandin analogs are similarly effective. The therapy regime should be adapted to the personal preferences of the woman, the situational and clinical conditions.

Abortion Care Beyond 13 Weeks' Gestation: A Global Perspective

The majority of abortions are performed early in pregnancy, but later abortion accounts for a large proportion of abortion-related morbidity and mortality. People who need this care are often the most vulnerable-the poor, the young, those who experience violence, and those with significant health issues. In settings with access to safe care, studies demonstrate significant declines in abortion-related morbidity and mortality. This review focuses on evidence-based practices for induced abortion beyond 13 weeks' gestation and post-abortion care in both high- and low-resource settings. We also highlight key programmatic issues to consider when expanding the gestational age for abortion services.

Medical abortion at 13 or more weeks gestation provided through telemedicine: A retrospective review of services

Objectives

To evaluate medical abortion effectiveness and safety in women at 13 or more weeks gestation provided care through Women on Web's telemedicine service.

Study Design

We conducted a retrospective case study of abortions at 13 or more weeks gestation provided by Women on Web between 2016 and 2019. Women received mifepristone and misoprostol or misoprostol alone for abortion. We extracted demographic characteristics and outcome data for cases with pregnancy continuation outcomes.

Results

We identified 144 women who used medical abortion at 13 or more weeks; 131 (91%) provided abortion outcome data. Almost all, 118 (90%) received mifepristone and misoprostol. The population had an average age of 26 ± 5.8 years, 102 (78%) reported a gestational age of 13 to 15 weeks, 114 (87%) had experienced prior pregnancy, and represented all world regions. Overall, 13 (10%) women reported a continuing pregnancy, with 5 (5%) among women 13 to 15 weeks and 8 (28%) among those ≥16 weeks (p = 0.001); 38 (29%) reported adverse events (heavy bleeding, fever), 53 (43%) sought additional care from a health provider, and 18% of all cases received treatment with D&C/aspiration.

Conclusions

Efficacy of self-administered medical abortion decreases as gestational age increases, risking continuation of pregnancy. Provision through telemedicine at 13 to 15 weeks appears safe and effective.

Implications

Limited data suggest that medical abortion through telemedicine services may be a safe option through 15 weeks gestation in settings where there is ready access to the formal health system. More research with adequate sample sizes and high rates of follow-up is needed to inform on the safety of telemedicine for pregnancies 13 weeks and greater.

Medical regimens for abortion at 12 weeks and above: a systematic review and meta-analysis

BACKGROUND

Mifepristone and misoprostol are recommended for second-trimester medical abortion, but consensus is unclear on the ideal regimen.

OBJECTIVES

The objectives were to systematically review randomized controlled trials (RCTs) investigating efficacy, safety and satisfaction of medical abortion at ≥ 12 weeks' gestation.

DATA SOURCES

We searched PubMed, Popline, Embase, Global Index Medicus, Cochrane Controlled Register of Trials and International Clinical Trials Registry Platform from January 2008 to May 2017.

STUDY ELIGIBILITY PARTICIPANTS AND INTERVENTIONS

We included RCTs on medical abortion at ≥ 12 weeks' gestation using mifepristone and/or misoprostol. We excluded studies with spontaneous abortion, fetal demise and mechanical cervical ripening and those not reporting ongoing pregnancy (OP).

STUDY APPRAISAL AND SYNTHESIS METHODS

After extracting prespecified data and assessing risk of bias in accordance with the Cochrane handbook, we used Revman5 software to combine data and GRADE to assess certainty of evidence.

RESULTS

We included 43 of the 1894 references identified. Combination mifepristone-misoprostol had lower rates of OP [risk ratio (RR) 0.12, 95% confidence interval (CI) 0.04-0.35] vs. misoprostol only. A 24-h interval between mifepristone and misoprostol had lower OP rate at 24 h than simultaneous dosing (RR 3.13, 95% CI 1.23-7.94). Every 3-h dosing had lower OP rate at 48 h (RR 0.39, 95% CI 0.17-0.88).

LIMITATIONS

Direct comparisons of buccal misoprostol to sublingual or vaginal routes after mifepristone were limited. Evidence from clinical trials on how to best manage women with prior uterine incisions was lacking.

CONCLUSION

Our analysis supports the use of mifepristone 200 mg 1 to 2 days before misoprostol 400 mcg vaginally every 3 h at ≥ 12 weeks' gestation.

IMPLICATIONS

Where available, providers should use mifepristone plus misoprostol for second-trimester medical abortion. Vaginal misoprostol appears to be most efficacious with fewest side effects, but sublingual and buccal routes are also acceptable.

Feasibility of a hospital outpatient day procedure for medication abortion at 13-18 weeks gestation: Findings from Nepal

OBJECTIVES

To evaluate the safety, acceptability and feasibility of a one-day outpatient medication abortion service at gestations 13-18 weeks.

STUDY DESIGN

Open-label prospective study in which participants received mifepristone 200 mg orally to swallow at home or at the clinic followed 24 h later by misoprostol 400 mcg buccally. They presented to the outpatient clinic 24-48 h after mifepristone for misoprostol 400 mcg buccally every three hours (no maximum dose). The primary outcome was successful abortion without transfer to overnight inpatient care. Secondary outcomes included time to abortion from initial misoprostol dose, safety, additional interventions and side effects.

RESULTS

We enrolled 230 women from December 2017 to November 2018. Approximately nine of ten (n = 206, 89.6%) achieved a successful abortion without transfer to overnight care. Twenty-four were transferred to overnight inpatient care; of these 18 were to manage a complication, five for incomplete abortion and two by choice. Among these 24, three women experienced an SAE. The median time to successful abortion from time of the first misoprostol dose was 7.2 h (range: 0.75-92.3), with an average of three misoprostol doses. Most participants expelled the fetus and the placenta at or around the same time; median time between fetal and placental expulsion was 15 minutes (range: 0-4.5 h). Fifteen participants (6.6%) received more than five misoprostol doses and were transferred to inpatient care. Administration of more than five doses of misoprostol was associated with nulliparity. Provision of antibiotics (27.9%, n = 64), manual removal of placenta (15.3%, n = 35), uterotonics (4.4%, n = 10) and surgical interventions (4.4%, n = 10) were also reported. About one in four participants experienced nausea, vomiting and chills; fever was infrequent (2.5%, n = 5).

CONCLUSIONS

For gestations 13-18 weeks, an outpatient day process for medication abortion is safe, effective and feasible.

IMPLICATIONS

Medication abortion in 13 - 18 weeks need not be limited to inpatient care; nine of ten cases can be managed as an outpatient day service.

A prospective study of mifepristone and unlimited dosing of sublingual misoprostol for termination of second-trimester pregnancy in Uzbekistan and Ukraine

INTRODUCTION

We aimed to assess the feasibility and acceptability of a second-trimester medical abortion regimen using mifepristone and sublingual misoprostol with no maximum number of misoprostol doses in Uzbekistan and Ukraine.

METHODS

This prospective open-label study enrolled 306 women with pregnancies of 13-22 weeks in Uzbekistan (n=134) and Ukraine (n=172). Women took 200 mg mifepristone at a place of their choosing, and 24-48 hours later received 400 μg sublingual misoprostol every 3 hours until the expulsion of both fetus and placenta. Study staff interviewed women about the intensity of pain, side effects, and satisfaction with the procedure. The primary outcome was the rate of complete uterine evacuation without surgical intervention or oxytocin at 15 hours after the first dose of misoprostol.

RESULTS

The median gestational age was 18.1 weeks, and half of the women (n=149, 48.9%) chose to take mifepristone at home. The majority of women (n=266, 86.9%, 95% CI 82.6% to 90.5%) expelled by 15 hours after the start of misoprostol treatment, and by 48 hours complete uterine evacuation was achieved in 296 (96.7%) women. Most women found pain (76.1%) and side effects (89.0%) to be acceptable or very acceptable, and reported high satisfaction (89.8%) with the procedure.

CONCLUSION

Medical abortion in pregnancies of 13-22 weeks with 200 mg mifepristone followed 24-48 hours later by 400 μg sublingual misoprostol administered every 3 hours until complete expulsion is effective, safe and acceptable to women. Women can be given the option to take mifepristone at home and return to the hospital.

CLINICAL TRIALS REGISTRATION NUMBER

ClinicalTrials.gov, www.clinicaltrials.gov, NCT02415894, NCT02235155.

Current and potential methods for second trimester abortion

Medical and surgical methods can both be recommended for second trimester abortion (after 12-weeks of gestational age). Induced abortion with a mifepristone and misoprostol regimen is the preferred approach; where mifepristone is not available, misoprostol alone for medical abortion is also effective. Dilation and evacuation (D&E) is the procedure of choice for surgical abortions, and adequate cervical preparation contributes significantly to safety. Availability of drugs and instruments, ability to provide pain control, provider skill and comfort, client preference, cultural considerations, and local legislation all influence the method of abortion likely to be performed in a given setting. Both surgical and modern medical methods are safe and effective when provided by a trained, experienced provider.

Update on second trimester medical abortion

PURPOSE OF REVIEW

To review recent literature on second trimester abortion with medical methods.

RECENT FINDINGS

Across studies published in the recent past, it is apparent that women prefer shorter procedures and procedure times. Several randomized controlled trials have confirmed adding mifepristone to the second trimester medication abortion regimen results in shorter abortion intervals from first misoprostol administration to complete fetal expulsion. A study of simultaneous administration of mifepristone and misoprostol yielded shorter mean 'total' abortion times, presenting several logistical advantages. Recent studies on the continuous dosing of misoprostol have produced critical evidence to support continued dosing until expulsion. These studies had a more practical design compared with previous protocols that capped the number of misoprostol doses.

SUMMARY

Second trimester surgical abortion is well tolerated and increasingly expeditious. Further research is needed to refine second trimester medical abortion methods, specific to the mifepristone, misoprostol dosing interval. A 12-hour mifepristone to misoprostol interval may be the optimal interval balancing patient preferences and logistical considerations. Pragmatic dosing, including continuous dosing of misoprostol, could yield results that better inform clinical guidelines and reduce burden on patient, provider, and health facility.

The immunological effect of Galectin-9/TIM-3 pathway after low dose Mifepristone treatment in mice at 14.5 day of pregnancy

The abortifacient Mifepristone (RU486) has proven to be a safe, effective, acceptable option for millions of women seeking abortion during the first and second trimester of pregnancy although its precise mechanism of action is not well understood. The main objective of this study was to investigate the impact of low dose Mifepristone administration on placental Galectin-9 (Gal-9) expression, as well as its effect on the cell surface expression of Gal-9, TIM-3 and CD107a molecules by different T and NK cell subsets. A model of Mifepristone-induced immunological changes was established in syngeneic pregnant BALB/c mice. RU486-induced alteration in placental Gal-9 expression was determined by immunohistochemistry. For immunophenotypic analysis, mid-pregnancy decidual lymphocytes and peripheral mononuclear cells were obtained from Mifepristone treated and control mice at the 14.5 day of gestation. TIM-3 and Gal-9 expression by peripheral and decidual immune cells were examined by flow cytometry. Our results revealed a dramatically decreased intracellular Gal-9 expression in the spongiotrophoblast layer of the haemochorial placenta in Mifepristone treated pregnant mice. Although low dose RU486 treatment did not cause considerable change in the phenotypic distribution of decidual and peripheral immune cells, it altered the Gal-9 and TIM-3 expression by different NK and T cell subsets. In addition, the treatment significantly decreased the CD107a expression by decidual TIM-3+ NK cells, but increased its expression by decidual NKT cell compared to the peripheral counterparts. These findings suggest that low dose Mifepristone administration might induce immune alterations in both progesterone dependent and independent way.