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Meyer R, Toussia-Cohen S, Shats M, Segal O, Mohr-Sasson A, Peretz-Bookstein S, Amitai-Komem D, Sindel O, Levin G, Mashiach R, Blumenthal PD. 24-Hour Compared With 12-Hour Mifepristone-Misoprostol Interval for Second-Trimester Abortion: A Randomized Controlled Trial. Obstet Gynecol 2024; 144:60-67. [PMID: 38781593 DOI: 10.1097/aog.0000000000005535] [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: 12/04/2023] [Accepted: 01/18/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To compare 24-hour and 12-hour mifepristone-to-misoprostol intervals for second-trimester medication abortion. METHODS We conducted a prospective randomized controlled trial. Participants were allocated to receive mifepristone either 24 hours or 12 hours before misoprostol administration. The primary outcome was the time from the first misoprostol administration to abortion (induction time). Secondary outcomes included the time from mifepristone to abortion (total abortion time); fetal expulsion percentages at 12, 24, and 48 hours after the first misoprostol dose; side effects proportion; and pain and satisfaction scores. A sample size of 40 per group (N=80) was planned to compare the 24- and 12-hour regimens. RESULTS Eighty patients were enrolled between July 2020 and June 2023, with 40 patients per group. Baseline characteristics were comparable between groups. Median induction time was 9.5 hours (95% CI, 10.3-17.8 hours) and 12.5 hours (95% CI, 13.5-20.2 hours) in the 24- and 12-hour interval arms, respectively ( P =.028). Median total abortion time was 33.0 hours (95% CI, 34.2-41.9 hours) and 24.5 hours (95% CI, 25.7-32.4 hours) in the 24- and 12-hour interval groups, respectively ( P <.001). At 12 hours from misoprostol administration, 25 patients (62.5%) in the 24-hour arm and 18 patients (45.0%) in the 12-hour arm completed abortion ( P =.178). At 24 hours from misoprostol administration, 36 patients (90.0%) in the 24-hour arm and 30 patients (75.0%) in the 12-hour arm had complete abortion ( P =.139). The need for additional medication or surgical treatment for uterine evacuation, pain scores, side effects, and satisfaction levels were not different between groups. CONCLUSION A 24-hour mifepristone-to-misoprostol regimen for medication abortion in the second trimester provides a median 3-hour shorter induction time compared with the 12-hour interval. However, the median total abortion time was 8.5-hours longer in the 24-hour interval regimen. These findings can aid in shared decision making before medication abortion in the second trimester. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT04160221.
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Affiliation(s)
- Raanan Meyer
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, and the Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Ramat-Gan, the School of Medicine, Tel-Aviv University, Tel-Aviv, and the Department of Obstetrics and Gynecology, Hadassah Medical Center, and the School of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; and the Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
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Kapp N, Dijkerman S, Getachew A, Eckersberger E, Pearson E, Abubeker FA, Birara M. 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. Int J Gynaecol Obstet 2024; 165:1268-1276. [PMID: 38282483 DOI: 10.1002/ijgo.15392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/22/2023] [Accepted: 01/09/2024] [Indexed: 01/30/2024]
Abstract
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.
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Affiliation(s)
| | | | - Abrham Getachew
- St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | | | - Ferid A Abubeker
- St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Malede Birara
- St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Pongsatha S, Suntornlimsiri N, Tongsong T. Comparing the outcomes of termination of second trimester pregnancy with a live fetus using intravaginal misoprostol between women with and without previous cesarean section. BMC Pregnancy Childbirth 2024; 24:274. [PMID: 38609883 PMCID: PMC11015687 DOI: 10.1186/s12884-024-06442-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVE To compare the outcomes of termination of pregnancy with live fetuses in the second trimester (14-28 weeks), using misoprostol 400 mcg intravaginal every 6 h, between women with previous cesarean section (PCS) and no previous cesarean section (no PCS). METHODS A comparative study was conducted on a prospective database of pregnancy termination in the second trimester, Chiang Mai university hospital. Inclusion criteria included: (1) singleton pregnancy; (2) gestational age between 14 and 28 weeks; and (3) pregnancy with a live fetus and medically indicated for termination. The participants were categorized into two groups; PCS and no PCS group. All were terminated using misoprostol 400 mcg intravaginal every 6 h. The main outcomes were induction to fetal delivery interval and success rate, defined as fetal delivery within 48 h. RESULTS A total of 238 women, including 80 PCS and 158 no PCS, were recruited. The success rate of fetal delivery within 48 h between both groups was not significantly different (91.3% vs. 93.0%; p-value 0.622). The induction to fetal delivery interval were not significantly different (1531 vs. 1279 min; p-value > 0.05). Gestational age was an independent factor for the success rate and required dosage of misoprostol. The rates of most adverse effects of misoprostol were similar. One case (1.3%) in the PCS group developed uterine rupture during termination, ending up with safe and successful surgical removal and uterine repair. CONCLUSION Intravaginal misoprostol is highly effective for second trimester termination of pregnancy with PCS and those with no PCS, with similar success rate and induction to fetal delivery interval. Gestational age was an independent factor for the success rate and required dosage of misoprostol. Uterine rupture could occur in 1.3% of PCS, implying that high precaution must be taken for early detection and proper management. SYNOPSIS Intravaginal misoprostol is highly effective for termination of second trimester pregnancy with a live fetus, with a comparable success rate between women with and without previous cesarean section, with a 1.3% risk of uterine rupture among women with previous cesarean section.
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Affiliation(s)
- Saipin Pongsatha
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Nuchanart Suntornlimsiri
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Theera Tongsong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.
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Sium AF, Teklu H, Reeves M, Tolu LB, Prager S. One-day versus two-day mifepristone-misoprostol interval prior to initiation of misoprostol during late second trimester medication abortion: A cohort study. Contraception 2024; 132:110356. [PMID: 38151223 DOI: 10.1016/j.contraception.2023.110356] [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: 09/07/2023] [Revised: 12/11/2023] [Accepted: 12/20/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVES To compare one-day versus two-day mifepristone-misoprostol interval in late second trimester medication abortion. STUDY DESIGN This retrospective cohort study was conducted at St. Paul's Hospital Millennium Medical College, in Ethiopia. Data were collected retrospectively and analysed with SPSS 23 using simple descriptive analysis, t-test, Chi-squared test, and regression analysis, as appropriate. P-value < 0.05 and adjusted odds ratio (AOR) with 95% CI were used to present results significance. RESULTS A total of 282 women who had medication abortion in the late second trimester (167 with one-day and 115 with two-day mifepristone-misoprostol intervals) at 20-28 weeks of gestation were analysed. Both median and mean induction to expulsion interval (I-E) were much higher in the one-day mifepristone-misoprostol (mife-miso) interval than in the two-day mife-miso interval group. The median (and mean) I-E in the one-day interval group was 24 hours (21.9+/-6.6 hours) compared to 12 hours (14.6+/-8.8 hours) in the two-day mife-miso interval group (p-value < 0.001). Expulsion rate within 12 hours of starting misoprostol was significantly higher in the two-day cohort than in the one-day cohort (73% vs 25.6%, p-value < 0.001, aOR = 19.08 95%, CI = 5.1-70.7). CONCLUSIONS For second trimester medication abortion at later gestation, a two-day mifepristone-to-misoprostol interval significantly reduces induction to expulsion time compared to a one-day interval. IMPLICATIONS Compared to one-day interval, administration of mifepristone two days prior to misoprostol initiation has a shorter interval of induction to expulsion and a higher rate of abortion completion within 12 hours of initiation of misoprostol during late second trimester medication abortion.
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Affiliation(s)
- Abraham Fessehaye Sium
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
| | - Hana Teklu
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | - Lemi Belay Tolu
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Sarah Prager
- Complex Family Planning Division, Department of Obstetrics and Gynecology, UW Medicine, Seattle, WA, USA
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Chandrasekaran S, Ruggiero S, Goodrick G. Outpatient medical management of later second trimester abortion (18-23.6 weeks) with procedural evacuation backup: A large case series. Contracept X 2024; 6:100104. [PMID: 38515629 PMCID: PMC10950721 DOI: 10.1016/j.conx.2024.100104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 03/23/2024] Open
Abstract
Objective Document the clinical outcomes of an outpatient medical management with procedural evacuation backup procedure for abortions between 18 weeks zero days to 23 weeks six days gestation. Study design We conducted a retrospective medical records review of adult patients who received mifepristone and repeated misoprostol for second trimester abortion with procedural evacuation backup at an Arizona clinic between October 2017 and November 2021. We extracted patient demographics; pregnancy and medical history; and preoperative, intraoperative, and postoperative data. We assessed abortion outcomes, including procedure timing, mode of completion (medication alone or medications and procedural evacuation), and safety. Results All 359 patients had a complete abortion with 63.5% of patients completing with medication alone and 36.5% with procedural evacuation backup. The median time from first dose of misoprostol to fetal expulsion was six hours, among those who completed the abortion with medications alone. Of those who received procedural evacuation as backup, the median time for procedural evacuation was 10 minutes. The vast majority of patients (99.4%) did not have any adverse events. Two safety incidents (0.6%) occurred, a broad right ligament tear and a uterine rupture. Conclusion Patients in one outpatient setting safely and effectively received medical management of second trimester abortion with procedural evacuation backup, and two thirds completed with medications alone. Implications Outpatient settings may consider medical management of abortion between 18 and 24 weeks with procedural evacuation back-up as a safe, effective, and manageable second trimester abortion option. Additional research is needed on patient experience and satisfaction.
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Henkel A, Miller HE, Zhang J, Lyell DJ, Shaw KA. Prior Cesarean Birth and Risk of Uterine Rupture in Second-Trimester Medication Abortions Using Mifepristone and Misoprostol: A Systematic Review and Meta-analysis. Obstet Gynecol 2023; 142:1357-1364. [PMID: 37884011 DOI: 10.1097/aog.0000000000005259] [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: 02/28/2023] [Accepted: 05/11/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVE To assess the risk difference of uterine rupture when using current mifepristone and misoprostol regimens for second-trimester abortion among individuals with prior cesarean birth compared with those without prior cesarean birth. DATA SOURCES We searched the terms second trimester, induction, mifepristone, and abortion in PubMed, EMBASE, POPLINE, ClinicalTrials.gov , and Cochrane Library from inception until December 2022. METHODS OF STUDY SELECTION We included randomized trials and observational studies including a mixed cohort, with and without uterine scar, of individuals at 14-28 weeks of gestation who used mifepristone and misoprostol to end a pregnancy or to manage a fetal death. We excluded case reports, narrative reviews, and studies not published in English. Two reviewers independently screened studies. TABULATION, INTEGRATION, AND RESULTS Absolute risks with binomial CIs were calculated from pooled data. Using R software, we estimated total risk difference by the Mantel-Haenszel random-effects method without continuity correction. For studies with zero events, a continuity correction of 0.5 was applied for individual risk differences and plotted graphically with forest plots. Statistical heterogeneity was assessed with Higgins I2 statistics. Funnel plot assessed for publication bias. Of 198 articles identified, 22 met the inclusion criteria: seven randomized trials (n=923) and 15 observational studies (n=6,195). Uterine rupture risk with prior cesarean birth was 1.1% (10/874) (95% CI 0.6-2.1) and without prior cesarean birth was 0.01% (2/6,244) (95% CI 0.0-0.12). The risk difference was 1.23% (95% CI 0.46-2.00, I2 =0%). Of the 12 reported uterine ruptures, three resulted in hysterectomy. CONCLUSION Uterine rupture with mifepristone and misoprostol use during second-trimester induction abortion is rare, with the risk increased to 1% in individuals with prior cesarean birth. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022302626.
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Affiliation(s)
- Andrea Henkel
- Division of Family Planning Services and Research and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
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Zwerling B, Edelman A, Jackson A, Burke A, Prabhu M. 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. Am J Obstet Gynecol 2023:S0002-9378(23)00726-3. [PMID: 37821258 DOI: 10.1016/j.ajog.2023.09.097] [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: 04/21/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 10/13/2023]
Abstract
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.
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Affiliation(s)
- Blake Zwerling
- Department of Gynecology & Obstetrics, Division of Family Planning, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States.
| | - Alison Edelman
- Department of Obstetrics & Gynecology, Division of Complex Family Planning, Oregon Health & Science University, Portland, OR, United States
| | - Anwar Jackson
- Department of Obstetrics & Gynecology, Aurora Health Care, Milwaukee, WI, United States
| | - Anne Burke
- Department of Gynecology & Obstetrics, Division of Family Planning, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States
| | - Malavika Prabhu
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Massachusetts General Hospital, Obstetrics and Gynecology, Yawkey Center for Outpatient Care, Boston, MA, United States
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Zwerling B, Edelman A, Jackson A, Burke A, Prabhu WTAOM. 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. Contraception 2023:110143. [PMID: 37821241 DOI: 10.1016/j.contraception.2023.110143] [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: 04/21/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 10/13/2023]
Abstract
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.
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Affiliation(s)
- Blake Zwerling
- Department of Gynecology & Obstetrics, Division of Family Planning, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States.
| | - Alison Edelman
- Department of Obstetrics & Gynecology, Division of Complex Family Planning, Oregon Health & Science University, Portland, OR, United States
| | - Anwar Jackson
- Department of Obstetrics & Gynecology, Aurora Health Care, Milwaukee, WI, United States
| | - Anne Burke
- Department of Gynecology & Obstetrics, Division of Family Planning, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States
| | - With The Assistance Of Malavika Prabhu
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Massachusetts General Hospital, Obstetrics and Gynecology, Yawkey Center for Outpatient Care, Boston, MA, United States
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Dickinson JE, Doherty DA. Maternal complications associated with second trimester medical abortion using mifepristone priming and subsequent misoprostol. Contraception 2023; 125:110080. [PMID: 37245784 DOI: 10.1016/j.contraception.2023.110080] [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: 03/09/2023] [Revised: 05/17/2023] [Accepted: 05/19/2023] [Indexed: 05/30/2023]
Abstract
OBJECTIVES To assess the frequency of maternal adverse events associated with second trimester medical abortion using sequential mifepristone and misoprostol. STUDY DESIGN Retrospective analysis of medical abortions 13 to 28 weeks gestation using sequential mifepristone and misoprostol in a single center from January 2008 to December 2018. The main outcomes evaluated were the nature and incidence of adverse procedural events and the impact of gestation upon these outcomes. RESULTS During the study period, 1393 people underwent a medical abortion with sequential mifepristone and misoprostol. The median maternal age was 31 years (IQR 27-36 years) and 21.8% had at least one prior cesarean delivery. The median gestational age at abortion commencement was 19 weeks (IQR 17-21). The main adverse maternal events were complete or partial placental retention greater than 60 minutes triggering removal in the operating room (19%), maternal hemorrhage>1000 cc (4.3%), blood transfusion (1.7%), hospital readmission (1.4%), uterine rupture (0.29%) and hysterectomy (0.07%). There were significant reductions in placental retention rates with increasing gestational age (23.3% at 13-16 weeks gestation declining to 10.1% at>23 weeks gestation, p < 0.001). CONCLUSIONS Serious adverse maternal events associated with second trimester medical abortion with sequential mifepristone-misoprostol are uncommon. IMPLICATIONS Second trimester medical abortion with mifepristone and misoprostol is generally safe, however, on occasions serious complications may occur. All health care units providing a medical abortion service require the facilities and expertise to deal with these adverse events in a timely manner.
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Affiliation(s)
- Jan E Dickinson
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia.
| | - Dorota A Doherty
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia; Biostatistics and Study Design, Women and Infants Research Foundation, King Edward Memorial Hospital, Perth, Western Australia, Australia
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Direct Effects of Mifepristone on Mice Embryogenesis: An In Vitro Evaluation by Single-Embryo RNA Sequencing Analysis. Biomedicines 2023; 11:biomedicines11030907. [PMID: 36979886 PMCID: PMC10046204 DOI: 10.3390/biomedicines11030907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 03/17/2023] Open
Abstract
The clinical use of mifepristone for medical abortions has been established in 1987 in France and since 2000 in the United States. Mifepristone has a limited medical period that lasts <9 weeks of gestation, and the incidence of mifepristone treatment failure increases with gestation time. Mifepristone functions as an antagonist for progesterone and glucocorticoid receptors. Studies have confirmed that mifepristone treatments can directly contribute to endometrium disability by interfering with the endometrial receptivity of the embryo, thus causing decidual endometrial degeneration. However, whether mifepristone efficacy directly affects embryo survival and growth is still an open question. Some women choose to continue their pregnancy after mifepristone treatment fails, and some women express regret and seek medically unapproved mifepristone antagonization with high doses of progesterone. These unapproved treatments raise the potential risk of embryonic fatality and developmental anomalies. Accordingly, in the present study, we collected mouse blastocysts ex vivo and treated implanted blastocysts with mifepristone for 24 h. The embryos were further cultured to day 8 in vitro to finish their growth in the early somite stage, and the embryos were then collected for RNA sequencing (control n = 3, mifepristone n = 3). When we performed a gene set enrichment analysis, our data indicated that mifepristone treatment considerably altered the cellular pathways of embryos in terms of viability, proliferation, and development. The data indicated that mifepristone was involved in hallmark gene sets of protein secretion, mTORC1, fatty acid metabolism, IL-2-STAT5 signaling, adipogenesis, peroxisome, glycolysis, E2F targets, and heme metabolism. The data further revealed that mifepristone interfered with normal embryonic development. In sum, our data suggest that continuing a pregnancy after mifepristone treatment fails is inappropriate and infeasible. The results of our study reveal a high risk of fetus fatality and developmental problems when pregnancies are continued after mifepristone treatment fails.
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Shimels T, Getnet M, Shafie M, Belay L. Comparison of mifepristone plus misoprostol with misoprostol alone for first trimester medical abortion: A systematic review and meta-analysis. Front Glob Womens Health 2023; 4:1112392. [PMID: 36970118 PMCID: PMC10038101 DOI: 10.3389/fgwh.2023.1112392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/07/2023] [Indexed: 03/08/2023] Open
Abstract
ObjectiveTo compare mifepristone plus a misoprostol-combined regimen with misoprostol alone in the medical abortion of first trimester pregnancy.MethodsAn internet-based search of available literature was performed using text words contained in titles and abstracts. PubMed/Medline, Cochrane CENTRAL, EMBASE, and Google scholar were used to locate English-based articles published until December 2021. Studies fulfilling the inclusion criteria were selected, appraised, and assessed for methodological quality. The included studies were pooled for meta-analysis, and the results were presented in risk ratio at a 95% confidence interval.FindingsNine studies comprising 2,052 participants (1,035 intervention and 1,017 controls) were considered. Primary endpoints were complete expulsion, incomplete expulsion, missed abortion, and ongoing pregnancy. The intervention was found to more likely induce complete expulsion irrespective of gestational age (RR: 1.19; 95% CI: 1.14–1.25). The administration of misoprostol 800 mcg after 24 h of mifepristone pre-treatment in the intervention group more likely induced complete expulsion (RR: 1.23; 95% CI: 1.17–1.30) than after 48 h. The intervention group was also more likely to experience complete expulsion when misoprostol was used either vaginally (RR: 1.16; 95% CI: 1.09–1.17) or buccally (RR: 1.23; 95% CI: 1.16–1.30). The intervention was more effective in the subgroup with a negative foetal heartbeat at reducing incomplete abortion (RR: 0.45; 95% CI: 0.26–0.78) compared with the control group. The intervention more likely reduced both missed abortion (RR: 0.21; 95% CI: 0.08–0.91) and ongoing pregnancy (RR: 0.12; 95% CI: 0.05–0.26). Fever was less likely to be reported (RR: 0.78; 95% CI: 0.12–0.89), whereas the subjective experience of bleeding was more likely to be encountered (RR: 1.31; 95% CI: 1.13–1.53) by the intervention group.ConclusionThe review strengthened the theory that a combined mifepristone and misoprostol regimen can be an effective medical management for inducing abortions during first trimester pregnancy in all contexts. Specifically, there is a high-level certainty of evidence on complete expulsion during the early stage and its ability to reduce both missed and ongoing pregnancies.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019134213, identifier CRD42019134213.
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Affiliation(s)
- Tariku Shimels
- Research Directorate,St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
- Correspondence: Tariku Shimels
| | - Melsew Getnet
- Research Directorate,St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mensur Shafie
- Department of Pharmacology, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Lemi Belay
- Department of Obstetrics and Gynaecology, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
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12
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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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13
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Latta K, Barker E, Kendall P, Testani E, Laursen L, McClosky L, York S. Complications of second trimester induction for abortion or fetal demise for patients with and without prior cesarean delivery. Contraception 2023; 117:55-60. [PMID: 35760083 DOI: 10.1016/j.contraception.2022.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/13/2022] [Accepted: 06/17/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Compare complication rates of second trimester induction for abortion or fetal demise for patients with and without prior cesarean delivery. STUDY DESIGN Retrospective cohort study examining induction for abortion or fetal demise for pregnancies from 14w0d to 23w6d gestation at 2 urban academic medical centers from 2009 to 2019. Exclusion criteria included preterm labor or cervical insufficiency, neonatal interventions, or if misoprostol was not the primary induction method. Complication rates were compared between those with no prior, 1 prior, and 2 or more (2+) prior cesarean deliveries. Complications analyzed were retained placenta, failed induction, infection, hemorrhage, blood transfusion, uterine rupture, intensive care unit admission, death, and readmission. Secondary analysis included cumulative misoprostol dosages and complete abortion rate within 24 hours. RESULTS Of 520 patients, 411 patients had no prior cesarean delivery, 77 had 1 prior cesarean delivery, and 32 had 2+ prior cesarean deliveries. Eleven patients had a prior vertical uterine incision. About 26.5% of all patients received mifepristone. The 2+ prior cesarean delivery group was significantly older (35 vs 32 vs 32, p < 0.001) and more likely to be induced for fetal demise (62.5 vs 41.56 vs 39.17%, p = 0.04). Both cesarean groups were more likely to be obese (58.62 vs 49.35 vs 34.26%, p = 0.003). Patients with 2+ prior cesarean deliveries were more likely to experience uterine rupture (6.25 vs 0 vs 0%, p = 0.004), and require ICU admission (6.45 vs 1.3 vs 0.49%, p = 0.02). Secondary analysis outcomes were similar. Logistic regression showed patients with 2+ prior cesarean deliveries were more likely to experience a complication than those with 1 prior (adjusted odds ratio [aOR] 2.71, confidence interval [CI] 1.09-6.86, p = 0.03) or 0 prior cesarean deliveries (aOR 3.00, CI 1.30-7.02, p = 0.01). Patients with 1 prior or no prior cesarean deliveries had a similar risk of experiencing a complication (aOR 1.11, CI 0.64-1.89, p = 0.7). CONCLUSIONS Most patients with prior cesarean deliveries can safely undergo induction in the second trimester for abortion or fetal demise. Patients with 2+ prior cesarean deliveries had a higher rate of at least 1 complication when compared to those with one or no prior cesarean delivery, despite similar misoprostol dosages and rates of complete abortion. IMPLICATIONS This large 10-year retrospective study examines the impact of prior cesarean delivery on the safety of second trimester induction. While second trimester labor induction abortion remains an option for all patients, specialized counseling for patients with 2 or more prior cesarean deliveries may be warranted.
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Affiliation(s)
- Kristen Latta
- Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, IL, United States.
| | - Emily Barker
- Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, IL, United States
| | - Paige Kendall
- Department of Obstetrics and Gynecology, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Erica Testani
- Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, IL, United States
| | - Laura Laursen
- Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, IL, United States
| | - Leanne McClosky
- Department of Obstetrics and Gynecology, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Sloane York
- Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, IL, United States
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14
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Accounting for Misclassification and Selection Bias in Estimating Effectiveness of Self-managed Medication Abortion. Epidemiology 2023; 34:140-149. [PMID: 36455250 DOI: 10.1097/ede.0000000000001546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Studies on the effectiveness of self-managed medication abortion may suffer from misclassification and selection bias due to self-reported outcomes and loss of follow-up. Monte Carlo sensitivity analysis can estimate self-managed abortion effectiveness accounting for these potential biases. METHODS We conducted a Monte Carlo sensitivity analysis based on data from the Studying Accompaniment model Feasibility and Effectiveness Study (the SAFE Study), to generate bias-adjusted estimates of the effectiveness of self-managed abortion with accompaniment group support. Between July 2019 and April 2020, we enrolled a total of 1051 callers who contacted accompaniment groups in Argentina and Nigeria for self-managed abortion information; 961 took abortion medications and completed at least one follow-up. Using these data, we calculated measures of effectiveness adjusted for ineligibility, misclassification, and selection bias across 50,000 simulations with bias parameters drawn from pre-specified Beta distributions in R. RESULTS After accounting for the potential influence of various sources of bias, bias-adjusted estimates of effectiveness were similar to observed estimates, conditional on chosen bias parameters: 92.68% (95% simulation interval: 87.80%, 95.74%) for mifepristone in combination with misoprostol (versus 93.7% in the observed data) and 98.47% (95% simulation interval: 96.79%, 99.39%) for misoprostol alone (versus 99.3% in the observed data). CONCLUSIONS After adjustment for multiple potential sources of bias, estimates of self-managed medication abortion effectiveness remain high. Monte Carlo sensitivity analysis may be useful in studies measuring an epidemiologic proportion (i.e., effectiveness, prevalence, cumulative incidence) while accounting for possible selection or misclassification bias.
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15
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Testani E, Latta K, Barker E, York SL, Laursen L. Complications of second-trimester medical termination of pregnancy for fetal anomalies compared with intrauterine fetal demise. Int J Gynaecol Obstet 2023; 160:145-149. [PMID: 35695042 DOI: 10.1002/ijgo.14302] [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: 04/22/2021] [Revised: 05/23/2022] [Accepted: 06/08/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess complication rates of patients undergoing a second-trimester medical termination for intrauterine fetal demise compared with fetal anomalies. METHODS We performed a retrospective cohort study comparing patients undergoing medical termination for a fetal anomaly versus medical termination for intrauterine fetal demise (IUFD) before 24 weeks of gestation. Data were collected from two urban academic medical centers from 2009 to 2019. Institutional review board approval was obtained from both institutions and patient consent was not required. We included singleton gestations between 14.0 weeks and 23.6 weeks undergoing induction with mifepristone and misoprostol or misoprostol alone. Groups were matched based on gestational age with a 1:1 ratio. The primary outcome was composite complication rate (retained placenta requiring dilation and curettage, suspected infection, hemorrhage, failed induction requiring dilation and evacuation, intensive care unit admission, and readmission). RESULTS Ninety-five patients were in each group. The groups differed in patient mean age (fetal anomaly 34 years versus 31 years for IUFD, P = 0.005) and mifepristone pretreatment (fetal anomaly 55% versus IUFD 5%, P < 0.001). Composite complication rate was similar (fetal anomaly 14% versus IUFD 17%), and specific complications did not differ. CONCLUSION Second-trimester medical termination for IUFDs have similar complication rates as those undergoing induction terminations for fetal anomalies.
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Affiliation(s)
- Erica Testani
- From the Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois, USA
| | - Kristen Latta
- From the Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois, USA
| | - Emily Barker
- From the Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois, USA
| | - Sloane L York
- From the Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois, USA
| | - Laura Laursen
- From the Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois, USA
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16
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Pongsatha S, Suntornlimsiri N, Tongsong T. Outcomes of Pregnancy Termination of Dead Fetus in Utero in Second Trimester by Misoprostol with Various Regimens. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12655. [PMID: 36231955 PMCID: PMC9565128 DOI: 10.3390/ijerph191912655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/22/2022] [Accepted: 08/22/2022] [Indexed: 06/16/2023]
Abstract
Objective: To determine the efficacy and adverse outcomes of misoprostol with various regimens for the second-trimester-pregnancy termination of a dead fetus in utero (DFIU). Patients and Methods: A retrospective descriptive study, based on the prospective database, was conducted on pregnancies with dead fetuses in utero in the second trimester. All patients underwent pregnancy termination with various regimens of misoprostol. Results: A total of 199 pregnancies meeting the inclusion criteria were included. The mean age of the participants and the mean gestational age were 30.2 years and 21.1 weeks, respectively. The two most common regimens were 400 mcg injected intravaginally every six hours and 400 mcg taken orally every four hours. In the analysis of the overall efficacy, including all regimens, the mean fetal delivery time was 18.9 h. When considering only the cases involving a delivery within 48 h (success cases), the mean fetal delivery time was 13.6 h. The rates of fetal delivery for all cases at 12, 24, 36, and 48 h were 50.3%, 83.8%, 89.3%, and 93.9%. In the comparison between the various regimens, there were no significant differences in the rate of fetal delivery at 12, 24, 36, and 48 h and adverse effects such as chill, diarrhea, nausea, vomiting, and other parameters such as the requirement for intravenous analgesia, the requirement for curettage for incomplete abortions, the mean total dose of misoprostol, and the rate of postpartum hemorrhage (PPH). Nevertheless, the rate of fever was significantly higher in the regimen of intravaginal insertion of 400 mcg every six hours and that of the requirement for oxytocin was significantly higher in the regimen of oral supplementation of 400 mcg every four hours. Conclusions: The overall success rate within 48 h was 93.6%, which was not different among the various misoprostol regimens. In addition, there were no significant differences in the mean fetal delivery times and the rates of fetal delivery at 12, 24, 36, and 48 h. However, some parameters such as fever, oxytocin requirement, and mean total dose of misoprostol were statistically significant between regimens. In the aspect of global health, misoprostol can be a good option in clinical practice, especially in geographical areas with low-resource levels.
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17
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Vlad S, Boucoiran I, St-Pierre ÉR, Ferreira E. Mifepristone-Misoprostol Use for Second and Third Trimester Medical Termination of Pregnancy in a Canadian Tertiary Care Centre. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:683-689. [PMID: 35114381 DOI: 10.1016/j.jogc.2021.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/22/2021] [Accepted: 12/24/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aims to evaluate the impact of the implementation a mifepristone-misoprostol protocol (MIFE/MISO) on the induction-to-expulsion interval in the context of second- and third-trimester pregnancy termination or intrauterine fetal death (IUFD) compared with misoprostol alone (MISO), and to share the experience of a Canadian tertiary hospital concerning the feasibility and safety of such a protocol. METHODS This is a single-centre retrospective pre-post cohort study carried out at the Centre Hospitalier Universitaire (CHU) Sainte-Justine between 2017 and 2019. Women in the MIFE/MISO group were instructed to take mifepristone 24-48 hours before induction. Induction in the MIFE/MISO group was performed with misoprostol dosages adjusted to gestational age and the presence of previous uterine scars, while, in the MISO group, all patients received 400 μg of misoprostol vaginally every 4 hours. RESULTS Ninety-four patients were included in the MIFE/MISO group and 103 patients, in the MISO group. Median time to expulsion was significantly lower in the MIFE/MISO group than the MISO group (13.5 and 19.5 h respectively; P < 0.001). The total dose of misoprostol administered was significantly lower in the MIFE/MISO group than the MISO group, and adverse effects were reported in 60% and 82% of patient records, respectively (P < 0.001). Complication rates were similar between the two groups. CONCLUSION The MIFE/MISO protocol is highly effective for second- and third-trimester induction for pregnancy termination or IUFD, without increasing complication rates and with fewer reported adverse effects. Its implementation is safe and feasible in a tertiary medical centre.
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Affiliation(s)
- Sergiu Vlad
- Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, QC; Faculty of Medicine, University of Montréal, Montréal, QC
| | - Isabelle Boucoiran
- Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, QC; Faculty of Medicine, University of Montréal, Montréal, QC
| | | | - Ema Ferreira
- Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, QC; Faculty of Pharmacy, University of Montréal, Montréal, QC
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18
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Costescu D, Mui C. When there is only one patient: Induction of labour for termination of pregnancy. Best Pract Res Clin Obstet Gynaecol 2021; 79:81-94. [PMID: 35000810 DOI: 10.1016/j.bpobgyn.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 11/01/2021] [Indexed: 12/21/2022]
Abstract
Induction of labour when no live birth is anticipated presents a number of unique considerations for members of the healthcare team. The main indication for Induction of Labour for Termination of Pregnancy (iTOP) is intrauterine fetal death (IUFD) beyond a gestational age where surgical management is available, but may also be indicated in the setting of induction abortion (with or without feticide), and termination of pregnancy (with or without infant palliation) for pregnancies where a lethal fetal anomaly is diagnosed. In tertiary care centres, iTOP may represent a significant proportion of labouring patients. Despite this, there are few guidelines dedicated specifically to iTOP in either obstetrical or family planning specialties. In this article, we will consider four main themes from an evidence-informed perspective: method selection; pre-induction preparation; clinical considerations during and after iTOP; and complications management.
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Affiliation(s)
- Dustin Costescu
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, L8N 3Z5, Canada.
| | - Carween Mui
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, L8N 3Z5, Canada
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Caruso G, Paladini V, D'ambrosio V, Giancotti A, Piccioni MG, Palaia I, Di Donato V, Perniola G, Brunelli R, Pecorini F, Muzii L, Scudo M. Combined vesicouterine rupture during second-trimester medical abortion for fetal abnormality after prior cesarean delivery: A case report. Case Rep Womens Health 2021; 32:e00364. [PMID: 34765461 PMCID: PMC8570940 DOI: 10.1016/j.crwh.2021.e00364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction The use of mifepristone and misoprostol for the induction of a second-trimester abortion is common and effective. However, its safety in women with previous cesarean delivery is still controversial, given the potentially higher risk of uterine rupture. Case presentation We present the case of a 30-year-old woman (G2P1) who experienced vesicouterine rupture with escape of the dead fetus into the bladder during second-trimester induced abortion after prior cesarean delivery. She was successfully managed with conservative surgery. Conclusion This case highlights the challenges of early diagnosis of vesicouterine rupture during second-trimester medical abortion. We argue that a close monitoring of patients with prior cesarean section is mandatory, particularly if uterine contractions suddenly stop or the fetal head fails to descend. A prompt conservative surgical approach allows preservation of fertility. The use of mifepristone/misoprostol for the induction of abortion is common and effective. For women who have previously had a cesarean delivery, there is a higher risk of uterine rupture. Diagnosis of vesicouterine rupture is challenging and close monitoring is mandatory.
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Affiliation(s)
- Giuseppe Caruso
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Vanessa Paladini
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Valentina D'ambrosio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Antonella Giancotti
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Maria Grazia Piccioni
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Innocenza Palaia
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Violante Di Donato
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Giorgia Perniola
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Roberto Brunelli
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Francesco Pecorini
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Maria Scudo
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
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20
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Shay RL, Benson LS, Lokken EM, Micks EA. Same-day mifepristone prior to second-trimester induction termination with misoprostol: A retrospective cohort study. Contraception 2021; 107:29-35. [PMID: 34529952 DOI: 10.1016/j.contraception.2021.09.006] [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: 04/20/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate whether same-day administration of mifepristone and misoprostol, compared with misoprostol alone, reduces the duration of second-trimester induction of labor for termination of pregnancy or increases the rate of fetal expulsion within 24 hours. STUDY DESIGN We conducted a retrospective analysis of patients undergoing induction of labor for pregnancy termination in the second trimester between 2009 and 2018. We compared patients who received mifepristone on the same day as the first dose of misoprostol to those who received misoprostol alone. The primary outcome was expulsion within 24 hours after the first dose of misoprostol. RESULTS Two hundred ninety-eight patients met criteria for inclusion, of whom 94 (31.5%) received same-day mifepristone. Expulsion within 24 hours occurred in 93.6% of the mifepristone-plus-misoprostol group and 79.9% of the misoprostol-only group (RR 1.17, 95%CI 1.07-1.28). Expulsion within 12 hours occurred in 56.4% of the mifepristone-plus-misoprostol group and 34.0% of the misoprostol-only group (RR 1.66, 95%CI 1.28-2.16). After adjusting for demographic and clinical characteristics, the rate of expulsion within 24 hours was similar between groups (RR 1.07, 95%CI 0.92-1.26), while the rate of expulsion within 12 hours remained different (RR 1.69, 95%CI 1.01-2.83). Median time to expulsion was shorter in the mifepristone-plus-misoprostol group than the misoprostol-only group (689 minutes vs 901 minutes, p < 0.001). CONCLUSION(S) Patients who received mifepristone on the same day as misoprostol had a shorter duration of induction termination and higher rate of success within 12 hours.
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Affiliation(s)
- Rosemary L Shay
- University of Washington Medical Center, Department of Obstetrics & Gynecology, Seattle, WA 98195, United States.
| | - Lyndsey S Benson
- University of Washington Medical Center, Department of Obstetrics & Gynecology, Seattle, WA 98195, United States
| | - Erica M Lokken
- University of Washington Medical Center, Department of Obstetrics & Gynecology, Seattle, WA 98195, United States
| | - Elizabeth A Micks
- University of Washington Medical Center, Department of Obstetrics & Gynecology, Seattle, WA 98195, United States
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21
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Pretreatment With Mifepristone Compared With Misoprostol Alone for Delivery After Fetal Death Between 14 and 28 Weeks of Gestation: A Randomized Controlled Trial. Obstet Gynecol 2021; 137:801-809. [PMID: 33831935 DOI: 10.1097/aog.0000000000004344] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 12/22/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the efficacy of pretreatment with mifepristone before misoprostol, compared with misoprostol alone, for termination of pregnancy after a fetal death in the second trimester. METHODS This prospective, double blind, placebo-controlled trial randomized women requiring a termination of pregnancy after fetal death between 14 and 28 weeks of gestation to placebo or 200 mg mifepristone orally 24-48 hours before the termination of pregnancy with misoprostol (400 micrograms every 6 hours vaginally for women at 24 weeks of gestation or less, and 200 micrograms every 4 hours vaginally for women at 24 weeks of gestation or more). Based on a median labor with misoprostol alone in the second trimester of 13 hours, a sample size of 116 women per group was planned to compare the primary outcome of time from administration of misoprostol to delivery. The trial was ceased after 66 women were enrolled secondary to prolonged time to achieve recruitment. RESULTS From April 2013 to November 2016, 66 women were randomized (34 to placebo and 32 to mifepristone). There were no differences in the characteristics between the two groups. The median time for the primary outcome of administration of misoprostol to delivery in the placebo group was 10.5 hours, compared with 6.8 hours in the treatment group (hazard ratio 2.41 95% CI 1.39-4.17, P=.002). Women in the placebo group required more doses of misoprostol (3.4 vs 2.1, P=.002) and more misoprostol overall (1,181.8 micrograms, vs 767.7 micrograms, P=.003). There was no difference in maternal complications between the two groups. Women in the mifepristone group reported improved perception of the procedure. CONCLUSION The sequential use of mifepristone and misoprostol for the termination of pregnancy after fetal deaths between 14 and 28 weeks of gestation reduces the time to delivery, compared with the use of misoprostol alone, with no worsening of maternal complications. CLINICAL TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12612000884808.
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22
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Kapp N, Andersen K, Griffin R, Handayani AP, Schellekens M, Gomperts R. Medical abortion at 13 or more weeks gestation provided through telemedicine: A retrospective review of services. Contracept X 2021; 3:100057. [PMID: 33615210 PMCID: PMC7881210 DOI: 10.1016/j.conx.2021.100057] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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Kalogiannidis I, Tsakiridis I, Dagklis T, Kapetanios G, Mamopoulos A, Athanasiadis A. Comparison of the efficacy and safety of two combined misoprostol regimens for second trimester medical abortion. EUR J CONTRACEP REPR 2020; 26:42-47. [PMID: 33044101 DOI: 10.1080/13625187.2020.1830966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of the study was to compare the efficacy and safety of two combined misoprostol regimens for second trimester medical abortion. METHODS This was a retrospective cohort study examining data on singleton pregnancies that underwent second trimester medical abortion between November 2011 and November 2019 in a tertiary care centre in northern Greece. In the first study period (November 2011 to August 2015), the management protocol (protocol 1) consisted of 800 μg vaginal misoprostol followed by 400 μg oral misoprostol, every 3 h, for up to five doses. In the second study period (September 2015 to November 2019), a new protocol (protocol 2) was introduced, where the oral route was changed to sublingual, using the same dosage. The two routes were compared in terms of efficacy and safety. RESULTS The study comprised 85 women: 43 (50.6%) received the protocol 1 regimen (vaginal-oral), while 42 (49.4%) received the protocol 2 regimen (vaginal-sublingual). The groups did not differ in terms of maternal age, gestational age and parity. Sublingual misoprostol was more effective than oral misoprostol, both in terms of dose needed (median 1600 μg vs 2000 μg; p = 0.031) and induction-to-abortion interval (8 h vs 11 h; p = 0.001). Surgical evacuation due to incomplete abortion was necessary in 11.9% of women in the sublingual group vs 18.6% in the oral group (p = 0.394). Women in the sublingual group reported a higher rate of severe pain (odds ratio [OR] 6.061; 95% confidence interval [95% CI] 1.240, 29.619) and shivering (OR 4.632; 95% CI 1.788, 11.995). CONCLUSION The administration of vaginal-sublingual misoprostol, when compared with the vaginal-oral regimen, was associated with a shorter induction-to-abortion interval but a higher incidence of severe pain and shivering.
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Affiliation(s)
- Ioannis Kalogiannidis
- Third Department of Obstetrics and Gynaecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Tsakiridis
- Third Department of Obstetrics and Gynaecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Themistoklis Dagklis
- Third Department of Obstetrics and Gynaecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Kapetanios
- Third Department of Obstetrics and Gynaecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Mamopoulos
- Third Department of Obstetrics and Gynaecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Athanasiadis
- Third Department of Obstetrics and Gynaecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Whitehouse K, Brant A, Fonhus MS, Lavelanet A, Ganatra B. Medical regimens for abortion at 12 weeks and above: a systematic review and meta-analysis. Contracept X 2020; 2:100037. [PMID: 32954250 PMCID: PMC7484538 DOI: 10.1016/j.conx.2020.100037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 01/14/2023] Open
Abstract
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.
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Affiliation(s)
- Katherine Whitehouse
- The UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Department of Reproductive Health and Research, Avenue Appia 20, 1211 Geneva, Switzerland
| | - Ashley Brant
- MedStar Washington Hospital Center, 110 Irving St., Washington, DC, 20010, USA
| | | | - Antonella Lavelanet
- The UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Department of Reproductive Health and Research, Avenue Appia 20, 1211 Geneva, Switzerland
| | - Bela Ganatra
- The UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Department of Reproductive Health and Research, Avenue Appia 20, 1211 Geneva, Switzerland
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Moseson H, Bullard KA, Cisternas C, Grosso B, Vera V, Gerdts C. Effectiveness of self-managed medication abortion between 13 and 24 weeks gestation: A retrospective review of case records from accompaniment groups in Argentina, Chile, and Ecuador. Contraception 2020; 102:91-98. [DOI: 10.1016/j.contraception.2020.04.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
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Henkel A, Lerma K, Blumenthal PD, Shaw KA. Evaluation of shorter mifepristone to misoprostol intervals for second trimester medical abortion: a retrospective cohort study. Contraception 2020; 102:327-331. [PMID: 32592800 DOI: 10.1016/j.contraception.2020.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess shorter mifepristone-misoprostol intervals compared to current guidelines for second trimester medical abortion on total abortion time (mifepristone to fetal expulsion) and induction time (first misoprostol to fetal expulsion). METHODS This retrospective cohort study included women who elected for a second trimester medical abortion with mifepristone and misoprostol at an academic tertiary medical center in the United States from January 2008 to June 2018. We abstracted times of mifepristone administration, first dose of misoprostol, and fetal expulsion from the medical record. We assessed outcomes based on the shorter intervals <12 h and 12 to 24 h compared to the guideline mifepristone-misoprostol interval (24-48 h). RESULTS The study population included eighty-nine women, 47, 28, and 14 women in the <12 h, 12 24 h, guideline (24-48 h) groups, respectively. The cohort had a median gestational age of 220/7 weeks (range: 150/7-270/7) and parity of 1 (range: 0-5) with no differences observed between groups. Total abortion times were 20.7 h (range: 3.7-46.9), 30.6 h (16.7-48.0), and 42.8 h (32.7-62.6), respectively (p < 0.001). Induction times were 12.9 h (range: 1.2-36.6), 11.7 h (2.0-35.2), and 9.3 h (5.3-16.5), respectively. Fetal expulsion within 12 h of first misoprostol dose occurred in 22 (47%), 14 (50%), and 9 (64%), respectively (p = 0.52). CONCLUSIONS Shorter mifepristone-misoprostol intervals (less than 24 h) significantly decrease the total abortion time while maintaining a clinically similar induction time. IMPLICATIONS Shortening the mifepristone-misoprostol interval in second trimester medical abortion significantly decreases the total abortion time which may be preferable to some women or health systems.
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Affiliation(s)
- Andrea Henkel
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA.
| | - Klaira Lerma
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA
| | - Paul D Blumenthal
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA
| | - Kate A Shaw
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA
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Wingo E, Raifman S, Landau C, Sella S, Grossman D. Mifepristone-misoprostol versus misoprostol-alone regimen for medication abortion at ≥24 weeks' gestation. Contraception 2020; 102:99-103. [PMID: 32407810 DOI: 10.1016/j.contraception.2020.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To compare time from misoprostol initiation to fetal expulsion for mifepristone-misoprostol versus misoprostol-alone regimens of medication abortion performed at ≥24 weeks' gestation. STUDY DESIGN We conducted a retrospective study of medication abortion performed at ≥24 weeks' gestation between May 2016 and January 2018 at one site, comparing outcomes of patients receiving mifepristone-misoprostol versus misoprostol alone during two periods. All patients received feticidal injection and laminaria; the mifepristone-misoprostol group also received mifepristone 200 mg orally around the time of initial laminaria. Beginning 24-72 h later (depending on cervical assessment), both groups received misoprostol buccally every two hours. RESULTS Analyses included 257 patients in the mifepristone-misoprostol group and 152 patients in the misoprostol-alone group. Median time from misoprostol initiation to fetal expulsion was similar between groups (4.8 h vs. 4.9 h; p = 0.43). Patients in the mifepristone-misoprostol group received less misoprostol overall (median [IQR]: 800 mcg [800-1200 mcg] vs. 1200 mcg [800-1600 mcg]; p < 0.01) and fewer patients received a second round of laminaria (n = 56, 22% vs. n = 58, 33%; p < 0.01) than the misoprostol-alone group. Seven patients (2%) were transferred to a hospital for complications; this proportion did not vary by regimen. CONCLUSIONS Addition of mifepristone was not associated with a reduction in induction interval at ≥24 weeks. However, patients in the mifepristone-misoprostol group received a lower total dose of misoprostol and were less likely to require two days of laminaria. The clinical significance of these differences is unclear, but may have implications for patient experience. Both regimens had low rates of complications. IMPLICATIONS A randomized controlled trial comparing the mifepristone-misoprostol and misoprostol-alone regimens at ≥24 weeks is needed, as is evidence on patient perspectives on these regimens. Given the existing evidence, either regimen is reasonable.
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Affiliation(s)
- Erin Wingo
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA 94612, USA.
| | - Sarah Raifman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA 94612, USA
| | - Carmen Landau
- Southwestern Women's Options, 522 Lomas Blvd NE, Albuquerque, NM 87102, USA
| | - Shelley Sella
- Southwestern Women's Options, 522 Lomas Blvd NE, Albuquerque, NM 87102, USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA 94612, USA
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Mifepristone pretreatment followed by misoprostol 200 mcg buccal for the medical management of intrauterine fetal death at 14-28 weeks: A randomized, placebo-controlled, double blind trial. Contraception 2020; 102:7-12. [PMID: 32135126 DOI: 10.1016/j.contraception.2020.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 02/12/2020] [Accepted: 02/15/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate whether fetal and placental expulsion is more likely within 48 h if women receive mifepristone pre-treatment vs placebo pre-treatment followed by misoprostol 200 mcg buccally for treatment of fetal death at 14 weeks 0 days to 28 weeks and 6 days gestation. STUDY DESIGN We randomized 176 women with a confirmed fetal death between 14 weeks and 0 days to 28 weeks and 6 days to mifepristone 200 mg or placebo; 24 h later all participants received misoprostol 200 mcg buccally every 3 h for up to 16 doses or 48 h. The trial took place in Hanoi, Vietnam and Mexico City in 2015-2018. RESULTS Complete expulsion of the fetus and placenta within 48 h of misoprostol administration occurred in 74 of 90 women (82.2%, 95% confidence interval (CI), 72.7%-89.5%) in the mifepristone-misoprostol group and in 70 of 86 women (81.4%, 95% CI, 71.6%-89.0%) in the placebo-misoprostol group (Relative Risk (RR) 1.01, 95%CI 0.87-1.16, p = 0.887). The median time from the start of the misoprostol induction to fetal expulsion was shorter among women who received mifepristone-misoprostol compared to women assigned to placebo-misoprostol (7 h vs ±5 vs 12 ± 13 h; p < 0.001). Women in the mifepristone-misoprostol group were more likely to expel the fetus within 24 h of the start of misoprostol administration (96% vs 78%; RR 1.22 (1.09-1.39) p = 0.009). CONCLUSION(S) Mifepristone-misoprostol did not result in a higher rate of complete expulsion of the fetus and the placenta within 48 h of the start of misoprostol administration without any additional surgical intervention or medication (e.g. additional misoprostol doses or oxytocin) than placebo-misoprostol. However, treatment with mifepristone-misoprostol did result in a shorter time to expulsion than placebo misoprostol. IMPLICATIONS Pretreatment with mifepristone followed by misoprostol bucally resulted in a shorter treatment time for medical management of fetal death than treatment with misoprostol alone. Pre-treatment with mifepristone may be more acceptable to women and providers by both reducing the length of hospital stay and the amount of misoprostol required.
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Kapp N, Lohr PA. Modern methods to induce abortion: Safety, efficacy and choice. Best Pract Res Clin Obstet Gynaecol 2020; 63:37-44. [DOI: 10.1016/j.bpobgyn.2019.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 10/22/2019] [Accepted: 11/25/2019] [Indexed: 12/01/2022]
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Dadhwal V, Garimella S, Khoiwal K, Sharma KA, Perumal V, Deka D. Mifepristone Followed by Misoprostol or Ethacridine Lactate and Oxytocin for Second Trimester Abortion: A Randomized Trial. Eurasian J Med 2019; 51:262-266. [PMID: 31692613 DOI: 10.5152/eurasianjmed.2019.18341] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/22/2019] [Indexed: 11/22/2022] Open
Abstract
Objective To compare two medical methods for second-trimester abortion, mifepristone followed by misoprostol versus mifepristone followed by ethacridine lactate and oxytocin for success rate, induction to abortion time and acceptability. Materials and Methods This is a randomized trial conducted from July 2014 to May 2016 and enrolled 120 women undergoing second trimester abortion (13-20 weeks). All patients received 200mg mifepristone orally and were randomized to receive further treatment after 36 hrs. Patients in Group M (n=60) received 400 microgram of misoprostol vaginally every 3 hours (maximum - 5 doses) and Group E (n=60) had extra-amniotic ethacridine lactate instillation followed by oxytocin infusion (max-100miu). Results Baseline demographic characteristics were comparable in both the groups. Success rate was 100% in group M and 98.3% in group E (p=0.31). Mean induction to abortion time was significantly shorter in group M than group E (8.2+2.3hours & 10.9+2.6 hours respectively; p=0.001). Majority of women reported side effects, 96.7% women in group M and 75% women in group E (p=0.001). Fall in hemoglobin after procedure was significantly higher in group M (0.70+0.33gram %) than group E (0.52+0.23 gram %) (p=0.001). Perception of intensity of pain was significantly more in group M but patient satisfaction in both groups was similar. Conclusion Both methods are comparable for success rate, induction interval was more for ethacridine lactate compared to misoprostol.
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Affiliation(s)
- Vatsla Dadhwal
- All India Institute of Medical Sciences, New Delhi, India
| | - Sita Garimella
- All India Institute of Medical Sciences, New Delhi, India
| | - Kavita Khoiwal
- All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Dipika Deka
- All India Institute of Medical Sciences, New Delhi, India
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Costescu D, Guilbert É. No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 40:750-783. [PMID: 29861084 DOI: 10.1016/j.jogc.2017.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care. INTENDED USERS Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs. TARGET POPULATION Women with an unintended or abnormal first or second trimester pregnancy. EVIDENCE PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched. VALUES The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request. BENEFITS, HARMS, AND/OR COSTS IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.
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Feasibility of a hospital outpatient day procedure for medication abortion at 13-18 weeks gestation: Findings from Nepal .. Contraception 2019; 100:451-456. [PMID: 31491379 DOI: 10.1016/j.contraception.2019.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/21/2019] [Accepted: 08/26/2019] [Indexed: 11/24/2022]
Abstract
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.
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Lerma K, Blumenthal PD. Current and potential methods for second trimester abortion. Best Pract Res Clin Obstet Gynaecol 2019; 63:24-36. [PMID: 31281014 DOI: 10.1016/j.bpobgyn.2019.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Klaira Lerma
- Stanford University, Department of Obstetrics & Gynecology, Division of Family Planning Services & Research, Stanford, CA 94503, USA.
| | - Paul D Blumenthal
- Stanford University, Department of Obstetrics & Gynecology, Division of Family Planning Services & Research, Stanford, CA 94503, USA
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Shochet T, Dragoman M, Blum J, Abbas D, Louie K, Platais I, Tsereteli T, Winikoff B. Could second-trimester medical abortion be offered as a day service? Assessing the feasibility of a 1-day outpatient procedure using pooled data from six clinical studies. Contraception 2019; 99:288-292. [DOI: 10.1016/j.contraception.2018.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 12/28/2018] [Accepted: 12/31/2018] [Indexed: 10/27/2022]
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Abstract
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.
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No 360 - Avortement provoqué : avortement chirurgical et méthodes médicales au deuxième trimestre. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:784-821. [DOI: 10.1016/j.jogc.2018.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Niinimäki M, Mentula M, Jahangiri R, Männistö J, Haverinen A, Heikinheimo O. Medical treatment of second-trimester fetal miscarriage; A retrospective analysis. PLoS One 2017; 12:e0182198. [PMID: 28753654 PMCID: PMC5533459 DOI: 10.1371/journal.pone.0182198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 07/16/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Research on the treatment of second-trimester miscarriages is scarce. We studied the outcomes, and the factors associated with adverse events and need for hospital resources in the medical treatment of second-trimester miscarriage. MATERIALS AND METHODS In these retrospective analyses we studied women treated for spontaneous fetal miscarriage with misoprostol-only (n = 24) or mifepristone and misoprostol (n = 177) in duration of gestation 12+1-21+6. Primary outcomes were the risk factors for surgical evacuation and excessive bleeding. Secondary outcomes were total misoprostol dose, time to expulsion and the length of hospital stay. RESULTS History of surgical evacuation of the uterus increased the risk of surgical evacuation (p = 0.027). Excessive bleeding was not associated with any of the studied variables. More misoprostol was needed when the duration of gestation exceeded 17+0 weeks (p = 0.036). In multivariate analysis the time to fetal expulsion was shorter in women with history of 1-2 deliveries (hazard ratio [HR] 1.49, 95% confidence interval [CI]; 1.07-2.07), ≥3 deliveries (HR 1.63, 95% CI; 1.11-2.38) and with a two-day interval between mifepristone-misoprostol administration (HR 1.71, 95% CI; 1.05-2.81). Patients with symptoms (i.e. uterine bleeding or pain) at baseline had longer hospital stay (HR 0.66, 95% CI; 0.47-0.92). CONCLUSIONS The factors affecting the outcomes of medical treatment of second-trimester fetal miscarriage are similar to those of second-trimester induced abortion. Two-day interval between mifepristone-misoprostol administration might decrease the time to fetal expulsion and the need of hospital resources.
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Affiliation(s)
- Maarit Niinimäki
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Center Oulu, University Hospital of Oulu and University of Oulu, Oulu, Finland
| | - Maarit Mentula
- Department of Obstetrics and Gynecology, University of Helsinki, and Helsinki University Hospital/Kätilöopisto Hospital, Helsinki, Finland
| | - Reetta Jahangiri
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Center Oulu, University Hospital of Oulu and University of Oulu, Oulu, Finland
| | - Jaana Männistö
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Center Oulu, University Hospital of Oulu and University of Oulu, Oulu, Finland
| | - Annina Haverinen
- Department of Obstetrics and Gynecology, University of Helsinki, and Helsinki University Hospital/Kätilöopisto Hospital, Helsinki, Finland
| | - Oskari Heikinheimo
- Department of Obstetrics and Gynecology, University of Helsinki, and Helsinki University Hospital/Kätilöopisto Hospital, Helsinki, Finland
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Sonalkar S, Ogden SN, Tran LK, Chen AY. Comparison of complications associated with induction by misoprostol versus dilation and evacuation for second-trimester abortion. Int J Gynaecol Obstet 2017; 138:272-275. [DOI: 10.1002/ijgo.12229] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/16/2017] [Accepted: 06/02/2017] [Indexed: 11/12/2022]
Affiliation(s)
- Sarita Sonalkar
- Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
| | - Shannon N. Ogden
- Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
| | | | - Angela Y. Chen
- University of California - Los Angeles; Los Angeles CA USA
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Fyfe R, Murray H. Comparison of induction of labour regimes for termination of pregnancy, with and without mifepristone, from 20 to 41 weeks gestation. Aust N Z J Obstet Gynaecol 2017; 57:604-608. [DOI: 10.1111/ajo.12648] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 04/25/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Rina Fyfe
- John Hunter Hospital; Newcastle New South Wales Australia
| | - Henry Murray
- John Hunter Hospital; Newcastle New South Wales Australia
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40
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Koh DSC, Ang EPJ, Coyuco JC, Teo HZ, Huang X, Wei X, Ng MJ, Lim SL, Tan KH. Comparing two regimens of intravaginal misoprostol with intravaginal gemeprost for second-trimester pregnancy termination: a randomised controlled trial. ACTA ACUST UNITED AC 2017; 43:252-259. [PMID: 28432086 DOI: 10.1136/jfprhc-2016-101652] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/21/2017] [Accepted: 03/20/2017] [Indexed: 11/03/2022]
Abstract
AIM To compare the efficacy and safety of intravaginal misoprostol 200 µg, 400 µg and gemeprost regimens for second-trimester termination of pregnancy (TOP). METHODS A three- armed randomi sed controlled trial (Clinical Trial Certificate 1100015) where 116 women undergoing second-trimester TOP were given intravaginal misoprostol 200 µ g (n=37), misoprostol 400 µg (n=40) or gemeprost 1 mg (n=39) at 4- hour intervals until abortion occurred with a maximum of five doses. RESULTS The misoprostol 400 µg group had the highest incidence of successful abortions (92.5%) compared to the misoprostol 200 µg (70.3%; p=0.017) and gemeprost 1 mg (74.4%; p=0.037) within 48 hours. There was no significant difference in abortion rate between misoprostol 200 µg and gemeprost. The misoprostol 400 µg group had the highest incidence of fever (70.0%) compared to misoprostol 200 µg (24.3%; p<0.001) and gemeprost 1 mg (46.2%; p=0.041). The gemeprost group had the highest incidence of diarrhoea (38.5%) compared to misoprostol 400 µg (10.0%; p=0.004) and misoprostol 200 µg (8.1%; p=0.003) groups. CONCLUSIONS Intravaginal misoprostol 400 µ g at 4- hour intervals was the most effective regimen but was associated with a high incidence of fever. Misoprostol 200 µg demonstrated similar effectiveness as gemeprost and had lower incidence of diarrhoea. Gemeprost should not be first line for medical therapy given the cost, storage requirements and lower efficacy.
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Affiliation(s)
- Daniel Seow Choon Koh
- Associate Consultant, Division of Obstetrics & Gynecology, KK Women's and Children's Hospital, Singapore, Singapore
| | - Esther Pei Jing Ang
- Pharmacist, Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jurja Chua Coyuco
- Pharmacist, Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Hua Zhen Teo
- Clinical Pharmacist, Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Xiaoling Huang
- Clinical Pharmacist, Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Xing Wei
- Executive, Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Mor Jack Ng
- Manager, Division of Obstetrics & Gynecology, OBGYN Academic Clinical Program, KK Women's and Children's Hospital, Singapore, Singapore
| | - Serene Liqing Lim
- Associate Consultant, Division of Surgery, Singapore General Hospital, Singapore, Singapore
| | - Kok Hian Tan
- Senior Consultant, Division of Obstetrics & Gynecology, KK Women's and Children's Hospital, Singapore, Singapore
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41
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Goldstone P, Walker C, Hawtin K. Efficacy and safety of mifepristone-buccal misoprostol for early medical abortion in an Australian clinical setting. Aust N Z J Obstet Gynaecol 2017; 57:366-371. [DOI: 10.1111/ajo.12608] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 12/15/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Philip Goldstone
- Marie Stopes International in Australia; Melbourne Victoria Australia
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Louie KS, Chong E, Tsereteli T, Avagyan G, Abrahamyan R, Winikoff B. Second trimester medical abortion with mifepristone followed by unlimited dosing of buccal misoprostol in Armenia. EUR J CONTRACEP REPR 2016; 22:76-80. [DOI: 10.1080/13625187.2016.1258461] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | | | | | - Gayane Avagyan
- Department of Obstetrics and Gynaecology No2, Yerevan State Medical University, Yerevan, Armenia
| | - Ruzanna Abrahamyan
- Republican Institute of Reproductive Health, Perinatology, Obstetrics and Gynaecology, Yerevan, Armenia
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Simultaneous Administration Compared With a 24-Hour Mifepristone–Misoprostol Interval in Second-Trimester Abortion. Obstet Gynecol 2016; 128:1077-1083. [DOI: 10.1097/aog.0000000000001688] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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44
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Mitwaly ABA, Abbas AM, Abdellah MS. Intra uterine extra-amniotic versus vaginal misoprostol for termination of second trimester miscarriage: A randomized controlled trial. Int J Reprod Biomed 2016. [DOI: 10.29252/ijrm.14.10.643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Constant D, Harries J, Malaba T, Myer L, Patel M, Petro G, Grossman D. Clinical Outcomes and Women's Experiences before and after the Introduction of Mifepristone into Second-Trimester Medical Abortion Services in South Africa. PLoS One 2016; 11:e0161843. [PMID: 27583448 PMCID: PMC5008795 DOI: 10.1371/journal.pone.0161843] [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] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 08/12/2016] [Indexed: 11/18/2022] Open
Abstract
Objective To document clinical outcomes and women’s experiences following the introduction of mifepristone into South African public sector second-trimester medical abortion services, and compare with historic cohorts receiving misoprostol-only. Methods Repeated cross-sectional observational studies documented service delivery and experiences of women undergoing second-trimester medical abortion in public sector hospitals in the Western Cape, South Africa. Women recruited to the study in 2008 (n = 84) and 2010 (n = 58) received misoprostol only. Those recruited in 2014 (n = 208) received mifepristone and misoprostol. Consenting women were interviewed during hospitalization by study fieldworkers with respect to socio-demographic information, reproductive history, and their experiences with the abortion. Clinical details were extracted from medical charts following discharge. Telephone follow-up interviews to record delayed complications were conducted 2–4 weeks after discharge for the 2014 cohort. Results The 2014 cohort received 200 mg mifepristone, which was self-administered 24–48 hours prior to admission. For all cohorts, following hospital admission, initial misoprostol doses were generally administered vaginally: 800 mcg in the 2014 cohort and 600 mcg in the earlier cohorts. Women received subsequent doses of misoprostol 400 mcg orally every 3–4 hours until fetal expulsion. Thereafter, uterine evacuation of placental tissue was performed as needed. With one exception, all women in all cohorts expelled the fetus. Median time-to-fetal expulsion was reduced to 8.0 hours from 14.5 hours (p<0.001) in the mifepristone compared to the 2010 misoprostol-only cohort (time of fetal expulsion was not recorded in 2008). Uterine evacuation of placental tissue using curettage or vacuum aspiration was more often performed (76% vs. 58%, p<0.001) for those receiving mifepristone; major complication rates were unchanged. Hospitalization duration and extreme pain levels were reduced (p<0.001), but side effects of medication were similar or more common for the mifepristone cohort. Overall satisfaction remained unchanged (95% vs. 91%), while other acceptability measures were higher (p<0.001) for the mifepristone compared to the misoprostol-only cohorts. Conclusion The introduction of a combined mifepristone-misoprostol regimen into public sector second-trimester medical abortion services in South Africa has been successful with shorter time-to-abortion events, less extreme pain and greater acceptability for women. High rates of uterine evacuation for placental tissue need to be addressed.
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Affiliation(s)
- Deborah Constant
- Women’s Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Jane Harries
- Women’s Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Thokozile Malaba
- Women’s Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Malika Patel
- Department of Obstetrics & Gynaecology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Gregory Petro
- Department of Obstetrics & Gynaecology, University of Cape Town and New Somerset Hospital, Cape Town, South Africa
| | - Daniel Grossman
- Ibis Reproductive Health, Oakland, California, United States of America
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Colleselli V, Nell T, Bartosik T, Brunner C, Ciresa-Koenig A, Wildt L, Marth C, Seeber B. Marked improvement in the success rate of medical management of early pregnancy failure following the implementation of a novel institutional protocol and treatment guidelines: a follow-up study. Arch Gynecol Obstet 2016; 294:1265-1272. [PMID: 27554492 PMCID: PMC5071363 DOI: 10.1007/s00404-016-4179-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 08/09/2016] [Indexed: 11/30/2022]
Abstract
Purpose To analyze the success rate, time to passage of tissue and subjective patient experience of a newly implemented protocol for medical management of early pregnancy failure (EPF) over a 2-year period. Methods A retrospective chart review of all patients with early pregnancy failure primarily opting for medical management was performed. 200 mg mifepristone were administered orally, followed by a single vaginal dose of 800 mcg misoprostol after 36–48 h. We followed-up with our patients using a written questionnaire. Results 167 women were included in the present study. We observed an overall success rate of 92 %, defined as no need for surgical management after medication administration. We could not identify predictive values for success in a multivariate regression analysis. Most patients (84 %) passed tissue within 6 h after misoprostol administration. The protocol was well tolerated with a low incidence of side effects. Pain was managed well with sufficient analgesics. Responders to the questionnaire felt adequately informed prior to treatment and rated their overall experience as positive. Conclusion The adaption of the institutional medical protocol resulted in a marked improvement of success rate when compared to the previously used protocol (92 vs. 61 %). We credit this increase to the adjusted medication schema as well as to targeted physician education on the expected course and interpretation of outcome measures. Our results underscore that the medical management of EPF is a safe and effective alternative to surgical evacuation in the clinical setting.
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Affiliation(s)
- V Colleselli
- Department of Gynecology and Obstetrics, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - T Nell
- Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - T Bartosik
- Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - C Brunner
- Department of Gynecology and Obstetrics, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - A Ciresa-Koenig
- Department of Gynecology and Obstetrics, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - L Wildt
- Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - C Marth
- Department of Gynecology and Obstetrics, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - B Seeber
- Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Mifepristone and misoprostol is safe and effective method in the second-trimester pregnancy termination. Arch Gynecol Obstet 2016; 294:1243-1247. [PMID: 27522599 DOI: 10.1007/s00404-016-4169-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 08/03/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The second-trimester medical abortions constitute 10-15 % of all induced abortions worldwide, but are responsible for two-thirds of major abortion related complications. During the last decade, medical methods for the second-trimester-induced abortion have been become safer and more accessible. The aim of this study is to evaluate factors affecting clinical effectiveness of the second-trimester medical terminations using mifepristone and misoprostol combination. METHODS In this retrospective observational study, 142 consecutive women underwent medical abortion on 12-24 weeks of gestation. Clinical data were collected from Oulu University Hospital patients' records for the period between January 2008 and June 2011. The associations between patient characteristics and different outcomes were evaluated using the standard statistical test for correlation. RESULTS The majority (92 %) of women aborted successfully within 24 h and were considered as day cases with small complication rate, as compared to hospitalized patients. In nulliparous patients, the time for complete abortion was longer than in other groups (P < 0.0019). Nulliparous women and women with gestation more than 16 weeks required opiate analgesia more often (P = 0.003 and <0.001, respectively). CONCLUSION Women with previous live births aborted more often within 8 h than women with no previous births. Mifepristone and misoprostol is safe and effective method for the second-trimester pregnancy termination. The second-trimester medical abortion can be provided by a nurse-midwife with the back-up of a gynecologist.
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Randomized trial assessing home use of two pregnancy tests for determining early medical abortion outcomes at 3, 7 and 14days after mifepristone. Contraception 2016; 94:115-21. [DOI: 10.1016/j.contraception.2016.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 04/01/2016] [Accepted: 04/04/2016] [Indexed: 11/16/2022]
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Akkenapally PL. A Comparative Study of Misoprostol Only and Mifepristone Plus Misoprostol in Second Trimester Termination of Pregnancy. J Obstet Gynaecol India 2016; 66:251-7. [PMID: 27651613 DOI: 10.1007/s13224-016-0869-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 03/19/2016] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To compare the effectiveness, success rate and induction to abortion interval between administration of misoprostol only and mifepristone with misoprostol in second trimester abortions (14-20 weeks) . MATERIALS AND METHODS The study was conducted by dividing women approaching for second trimester termination, into two groups each consisting of 100 women. Group-I received only misoprostol; 600 mcg initial vaginal insertion followed by 400 mcg sublingually every 3 h until termination. Women in Group-II received mifepristone 200 mg and after 24 h started with 600 mcg misoprostol, per vaginal followed by 400 mcg sublingually till abortion was completed, up to a maximum of five doses in both groups. RESULTS The success rate in Group-I was 89 %, whereas in Group-II it was 96 %. The mean induction abortion interval in Group-I was 10.67 ± 3.96 h compared to Group-II which was significantly less 6.19 ± 2.70 h (p value < 0.01). The mean dose of misoprostol in Group-I was 1610 ± 511.18 mcg and in Group-II, it was lesser 1046 ± 392.71 mcg (p value < 0.01). There was significant difference in the mean blood loss also, 97.20 ± 36.35 ml in Group-I and 52.55 ± 27.96 ml in Group-II. Also among the individual groups multigravidae and lower gestational age (<17 weeks), women had lesser IAI as well as lesser misoprostol dose was required. CONCLUSION Pretreatment with mifepristone significantly reduces the induction abortion interval and the misoprostol dose along with minimal blood loss.
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Vaginal Misoprostol Compared With Buccal Misoprostol for Termination of Second-Trimester Pregnancy: A Randomized Controlled Trial. Obstet Gynecol 2015; 126:593-598. [PMID: 26181087 DOI: 10.1097/aog.0000000000000946] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the efficacy of vaginal misoprostol with buccal misoprostol for second-trimester termination of pregnancies. METHODS In a randomized trial, we compared 400 micrograms vaginal and buccal misoprostol every 3 hours for up to six doses for induction of labor at 13-24 weeks of gestation with a live fetus and intact membranes. Women who had a uterine scar were excluded from the study. The primary outcome of the study was induction-to-abortion interval. Based on a two-tailed α of 0.05, we planned to include 65 patients per group to detect a 50% difference in the primary outcome with a power of 80%. RESULTS From January 2014 to December 2014, 172 women were screened and 130 were randomized: 65 vaginal and 65 buccal misoprostol. Characteristics of patients were similar between groups. Patients administered vaginal misoprostol compared with buccal misoprostol had a shorter induction-to-abortion interval (25±17 hours compared with 40±29 hours, P=.001) and a higher abortion rate within both 24 hours (41 [63%] compared with 27 [42%] P=.014) and 48 hours (59 [91%] compared with 44 [68%], P=.001). Complete abortion rates were similar in both groups (vaginal 51 [78%] compared with buccal 54 [83%]). The incidence of side effects was similar for both groups. The perceived pain was higher in the buccal group, but the small difference did not appear to be clinically meaningful. CONCLUSION Vaginal compared with buccal misoprostol administration has a shorter induction-to-abortion interval for second-trimester termination of viable pregnancies. However, both administration routes are equally effective for induction of termination. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT02048098. LEVEL OF EVIDENCE I.
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