The use of 16-16 dimethyl trans delta 2 PGE1 methyl ester (ONO 802) vaginal suppositories for the termination of early pregnancy. A comparative study

Menstrual induction: surgery versus prostaglandins

In most developed countries in which therapeutic abortions are legal, termination of pregnancy is performed at between 8 and 12 weeks of gestation. Because the complication rate after this procedure rises with increasing gestation, there would be many advantages in inducing abortion before the eighth week ('menstrual induction'). With the increasing availability of highly sensitive methods of detecting human chorionic gonadotropin, pregnancy can now be diagnosed as early as 10-14 days after conception. The uterus can be surgically evacuated safely and simply by suction aspiration under local anaesthesia. However, a safe and effective method of inducing abortion by medical means would be a useful and cheaper alternative. Of the potentially useful compounds, only derivatives of prostaglandins E and F administered by vaginal pessary have so far been shown to be effective. Although the rate of haemorrhage and infection is low, 10-30% of women experience moderate side-effects of pelvic pain, diarrhoea and/or vomiting. The possibilities are discussed of reducing the incidence of side-effects by different methods of release or using prostaglandins in combination with other compounds such as antigestogens which might lower the therapeutic threshold.

Mid-trimester induced abortion: a review

Mid-trimester abortion constitutes 10-15% of all induced abortion. The aim of this article is to provide a review of the current literature of mid-trimester methods of abortion with respect to efficacy, side effects and acceptability. There have been continuing efforts to improve the abortion technology in terms of effectiveness, technical ease of performance, acceptability and reduction of side effects and complications. During the last decade, medical methods for mid-trimester induced abortion have shown a considerable development and have become safe and more accessible. The combination of mifepristone and misoprostol is now an established and highly effective method for termination of pregnancy (TOP). Advantages and disadvantages of medical versus surgical methods are discussed. Randomized studies are lacking, and more studies on pain treatment and the safety of any method used in patients with a previous uterine scar are debated, and data are scarce. Pain management in abortion requires special attention. This review highlights the need for randomized studies to set guidelines for mid-trimester abortion methods in terms of safety and acceptability as well as for better analgesic regimens.

Frequently asked questions about medical abortion

The development of methods of inducing abortion medically (nonsurgically) has created alternative options to make abortion available to women in a variety of health-care settings. Medical abortion is induced with a regimen of mifepristone followed by a prostaglandin analogue. Since its first introduction in the late 1980s, the regimen has undergone some modifications based on research evidence, and, in many countries, clinicians are using regimens that may differ from the one that has been licensed. This causes confusion among providers, also because only a few countries have developed national guidelines for the provision of medical abortion. We approached health care personnel providing abortion services in various countries and asked them to send us questions that they, or their colleagues, might have concerning the clinical practice of medical abortion in the early first trimester (up to 63 days since the first day of the last menstrual period). These questions were sent to experts representing the fields of biomedical and clinical research, clinical practice and family planning, who conducted literature reviews so that, whenever possible, the answers could be based on existing evidence. A consensus meeting was held in Bellagio, Italy, between November 1 and 5, 2004, to review the questions and to discuss the answers. The aim of this article is to provide a brief overview of some of the questions asked and the answers discussed.

Medical abortion in the first trimester

Pregnancy can be terminated safely by inducing abortion medically at any stage of gestation. Antagonists such as mifepristone block the action of progesterone and hence result in uterine contractions and increase the sensitivity of the uterus to prostaglandins. In the last 15 years the combination of a single dose of mifepristone (600 mg) followed 48 hours later with a suitable prostaglandin (1 mg gemeprost vaginal pessary or 400 microg oral misoprostol) has been licensed in most countries in Europe and the USA for induction of abortion in the early weeks of pregnancy. The safety and efficacy of these methods is comparable to vacuum aspiration at the same gestation. The complete abortion rate is related to the type and dose of prostaglandin, the route of administration as well as the gestation and parity. Published data suggest that the dose of mifepristone can be reduced from 600 mg to 200 mg without loss of efficacy. Although misoprostol tablets are formulated for oral use, extensive clinical experience has demonstrated vaginal administration is more effective and is associated with fewer side-effects. Successful abortion using medical methods requires a well organized service which includes referral without delay and a robust system of follow up to identify failures. The failure rate as reflected by the number of women who require surgical intervention falls with increasing experience. In those countries where medical abortion has been freely available for about 10 years, such as France, Scotland and Sweden, about 60-70% of eligible women elect for this method.

Medical abortion regimens: historical context and overview

Medical abortion offers an important alternative to surgical abortion for women with early pregnancies who wish to avoid a surgical procedure. More than 3 million women worldwide have had medical abortions in the past decade alone. The best-studied regimens include mifepristone orally followed 36 to 48 hours later by a prostaglandin analog administered either orally or intravaginally. Because of political and social restrictions related to mifepristone, however, researchers have investigated alternative regimens, most notably methotrexate and misoprostol. Mifepristone regimens are approximately 95% effective for abortion at </=49 days' gestation. Efficacy between 50 and 63 days' gestation varies according to the type and route of administration of the prostaglandin analog. Complete abortion rates among these later gestations are clinically acceptable when mifepristone is followed by intravaginally administered misoprostol or gemeprost. This report reviews the development, efficacy, and side effects of mifepristone regimens.

A pilot study of the effect of methotrexate or combined oral contraceptive on bleeding patterns after induction of abortion with mifepristone and a prostaglandin pessary

Although a combination of mifepristone and a prostaglandin is a safe, acceptable alternative to vacuum aspiration for inducing abortion in early pregnancy, the longer period of vaginal bleeding after medical abortion is a disadvantage. The present study investigated whether administration of the combined oral contraceptive pill (COC) or the injection of methotrexate at the time of abortion would shorten the period of vaginal bleeding after medical abortion. After having a medical abortion induced with mifepristone (200 mg) and 0.5 mg gemeprost pessary, 80 women were randomized to four groups of 20 women each; Group A, COC; Group B, control; Group C, 50 mg/m2 methotrexate; and Group D, placebo injection. There was no significant difference in the duration of bleeding between Groups A and B (median 14 and 17 days) or between Groups C and D (18 and 15 days), or in the amount of bleeding (4 days of heavy bleeding in each group). The first period occurred sooner in Group A who took the COC (median/range: 25/15-54 control group versus 32/16-46 days, p < 0.04). The administration of methotrexate was associated with a temporary elevation in liver enzyme concentration in one woman. It is concluded that women who wish to use COC can start immediately after medical abortion. Addition of methotrexate after abortion has no significant beneficial effect on patterns of bleeding and cannot be recommended.

Blood loss in termination of early pregnancy by vacuum aspiration and by combination of mifepristone and gemeprost

Blood loss was measured in 17 subjects undergoing surgical termination of pregnancy and in 96 subjects undergoing medical termination of pregnancy with sequential mifepristone (200 mg, 400 mg, 600 mg) and 1 mg prostaglandin analogue gemeprost. The median blood loss were 53.2, 84.1, 99.9 and 101.4 ml, respectively. There was a statistically significant difference between the surgical and each of the medical termination group of subjects but there was no difference among the subgroups in the medical termination group. The pattern of bleeding was also similar, being heaviest on the day and the days shortly after prostaglandin administration. Majority of them (> 90%) experienced blood loss of < 300 ml and there was no significant drop in hemoglobin level during the 6-week follow-up period. A few women experienced heavy bleeding and, hence, strict supervision on medical termination of pregnancy is recommended.

Medical abortion in women of less than or equal to 56 days amenorrhoea: a comparison between gemeprost (a PGE1 analogue) alone and mifepristone and gemeprost

OBJECTIVE

To determine the efficacy of a new dose regimen of vaginal gemeprost (1 mg every 6 h up to three doses) in induction of abortion in women less than or equal to 56 days gestation, and to compare this regimen with mifepristone (200-600 mg) followed 48 h later by a single dose of gemeprost (1 mg).

DESIGN

Two separate protocols, with 50% of the subjects randomized to one or other protocol.

SETTING

The Royal Infirmary of Edinburgh, Scotland, UK.

SUBJECTS

301 referred by their general practitioner or local family planning clinic, requesting termination of pregnancy at less than or equal to 56 days amenorrhoea.

INTERVENTIONS

Ongoing pregnancies and incomplete abortions were terminated surgically.

MAIN OUTCOME MEASURES

Number of complete abortions, analgesic requirements and bleeding pattern following treatment.

RESULTS

Complete abortion occurred in 87% of women treated with gemeprost alone and 98% of women treated with mifepristone and gemeprost (P = 0.0004). Analgesic requirements were greater in the group treated with gemeprost alone, compared with the group treated with mifepristone and gemeprost (P = 0.0001).

CONCLUSION

The new dose regimen of gemeprost can be used for early induced abortion, but the use of mifepristone and gemeprost has several advantages over the use of gemeprost alone.

Termination of early pregnancy through a combination of the antiprogestin and prostaglandin analogue

Termination of early pregnancy (less than 49 days of amenorrhea) was induced in 75 patients with the combination of the antigestagen mifepristone and a prostaglandin analogue, meteneprost. After 48 h a single oral dose of 600 mg of mifepristone was followed by a 10 mg meteneprost vaginal pessary. Pregnancy was confirmed by clinical and ultrasound examinations and plasma HCG assessment. Complete abortion occurred in 72 patients (96%) and the three others required a surgical uterine aspiration. Bleeding continued for 4 to 12 days (mean = 8). Uterine pain and side effects occurred during the 3 h following the use of prostaglandin. Only minor analgesic were required in 30 patients. The combination of mifepristone and meteneprost is a safe and effective method to terminate an early pregnancy.

Early termination of pregnancy: medical induction with prostaglandins versus surgical aspiration under local anesthetic

Termination of pregnancy at 4-8 weeks gestation in 1085 patients using either local prostaglandin instillation (n = 820) or uterine aspiration under local anesthetic (n = 265) have been analyzed. Morbidity for both methods was similar although the incidence of side-effects (0.4%) and the transfusion rate (0%) were lower after aspiration than the respective rates of 59% and 1.3% after prostaglandin treatment. However the rates of genital tract trauma (0.75%) and uterine sepsis (1.8%) after aspiration were higher than the respective rates of 0.3% and 0.9% after prostaglandin treatment. The major disadvantage of prostaglandin treatment was the rate of re-admission for evacuation (8.5%) compared with (0.9%) after aspiration, although patient acceptability for both techniques was similar. In view of the advantages, more widespread use of both methods of termination is indicated.

Late second trimester abortion with 16,16-dimethyl-trans-delta 2-PGE1 methyl ester (gemeprost)

The use of gemeprost (16,16-dimethyl-trans-delta 2-PGE1 methyl ester) vaginal pessaries for the termination of pregnancy in the late second trimester has been investigated in an open single-center study. Of 56 nulliparous women between 18 and 22 weeks amenorrhoea, 33 (58.9%) aborted after the administration of 1 mg gemeprost pessaries; 5 women did abort after 3 doses, 10 after 4 doses and 18 after 5 doses. There was no statistical correlation between gestational age and abortion. The mean induction-abortion interval was 15.2 hrs (range 8.5-20.3 hrs). There were no serious complications. The safe induction of therapeutic abortion in 58.9% of women using vaginal gemeprost pessaries alone offers an acceptable alternative to surgical evacuation in the late second trimester but should not be started without the possibility to terminate the procedure by dilatation and evacuation (D + E).

The efficacy and tolerance of mifepristone and prostaglandin in first trimester termination of pregnancy. UK Multicentre Trial

OBJECTIVE

To investigate the use of oral mifepristone (RU 486) and vaginal gemeprost for the induction of legal first trimester abortion.

DESIGN

An uncontrolled multicentre observational study.

SETTING

13 Hospital gynaecological units in Scotland and England.

SUBJECTS

588 Pregnant women with up to nine weeks amenorrhoea having legal abortions.

INTERVENTIONS

Oral mifepristone 600 mg followed 48 h later by vaginal gemeprost 1 mg. Women stayed in the hospital for a minimum of 4 h on each occasion.

MAIN OUTCOME MEASURES

Frequency of complete abortion and the need for subsequent surgical evacuation, analgesia and blood transfusion.

RESULTS

There was complete abortion in 94% (95% CI 92-96%). None of the 46 women at less than 43 days gestation needed surgical evacuation. This was performed in 6.5% of the remainder but among these the rate did not increase with gestation. Five women (four from one centre) required both curettage and blood transfusion. A fall in haemoglobin concentration of 2-4 g/dl occurred in only 1%. Narcotic analgesia was required after gemeprost by 37% of nullipara and 13% of multipara. Overall 26% had vomiting and 13% diarrhoea.

CONCLUSION

The sequential use of oral mifepristone and vaginal gemeprost is effective in inducing abortion up to the 63rd day of pregnancy. Efficient management of pain and bleeding is easier if women are in a hospital for some hours after the gemeprost.

Voluntary interruption of pregnancy with mifepristone (RU 486) and a prostaglandin analogue. A large-scale French experience

In 2115 women seeking voluntary termination of pregnancy after 49 days of amenorrhea or less, we studied the effect of a single 600-mg dose of mifepristone (RU 486), followed 36 to 48 hours later by the administration of one of two prostaglandin analogues, either gemeprost (1 mg by vaginal suppository) or sulprostone (0.25, 0.375, or 0.5 mg by intramuscular injection). The women were monitored for four hours after prostaglandin administration. Efficacy was indicated by the complete expulsion of the conceptus without the need of an additional procedure. All other results were considered failures, and the pregnancy was then terminated by a surgical method. The overall efficacy rate was 96.0 percent (95 percent confidence interval, 95.0 to 96.8). The failures included persisting pregnancies (1.0 percent), incomplete expulsions (2.1 percent), and the need for hemostatic procedure (0.9 percent). The mean time to expulsion was significantly shorter when sulprostone was given in the high dose (4.5 hours) than when it was given in the two lower doses (13.1 and 19.3 hours) or when gemeprost was given (22.7 hours). The mean duration of uterine bleeding was 8.9 days (range, 1 to 35); one woman received a blood transfusion. Most women had transient abdominal pain after receiving prostaglandin, but there were few other side effects. We conclude that the administration of mifepristone followed by a small dose of a prostaglandin analogue is an effective and safe method for the early termination of pregnancy.

Clinical effects and cervical tissue changes after treatment with 16,16 dimethyl-trans delta 2 PGE1 methylester in the first trimester

Cervagem pessaries, containing 1 mg of 16,16-dimethyl-trans delta 2-PGE1 methylester, was administered in the posterior vaginal fornix 4 h before vacuum aspiration in the 1st trimester. The effects of cervical dilatation, cervical collagen metabolism and cervical smooth muscle activity were investigated. In treated women the mean cervical dilatation was 7.9 mm as compared with 3.9 mm in controls. The in vitro incorporation of 14C proline in cervical tissue as well as the hydrolytic activity against a synthetic "collagen-like" polypeptide was increased after treatment with cervagem. The cervical smooth muscle sensitivity to prostaglandins, as revealed by inhibition of muscle activity, was higher in treated women than in controls. It is concluded that cervical dilatation, as induced by cervagem, involves an adaptation of both connective tissue and smooth muscle components.

The efficacy of oral Mifepristone (RU 38,486) with a prostaglandin E1 analog vaginal pessary for the termination of early pregnancy: complications and patient acceptability

Outpatient terminations were performed on 100 ultrasonographically confirmed pregnancies of less than or equal to 63 days with a single oral dose of RU 38,486 (600 mg) and a single vaginal pessary of 16,16-dimethyl-trans-delta 2-prostaglandin E1 (1 mg) 48 hours later. Abortion occurred in all patients; in 95 it was complete, in four it was incomplete, and one resulted in a missed abortion. In 88% the abortion occurred within 4 hours of prostaglandin treatment. A total of 25% of patients had nausea and 15% vomited after RU 38,486 treatment. After prostaglandin-treatment, 13% vomited, 10% had diarrhea, and 23% required administration of an opiate analgesic agent. No patient was transfused and there was no genital tract trauma; one case of suspected pelvic infection occurred. If the need for termination arose again, 88% would elect to use the method again, 9% would not. The combination of the antiprogestin RU 38,486 and a vaginal prostaglandin pessary appears to offer a safe, efficient, acceptable nonsurgical outpatient method of termination. Further studies on dosage and treatment protocols would be justified.

Blood loss following induction of early abortion using mifepristone (RU 486) and a prostaglandin analogue (gemeprost)

The pattern and amount of blood loss following induction of therapeutic abortion using mifepristone (RU 486) and a prostaglandin E analogue (gemeprost) was studied in 222 women of less than 63 days amenorrhoea. A single oral dose of mifepristone (400, 500 or 600 mg) was followed 48 hours later by a half or 1 mg gemeprost vaginal pessary. Complete abortion occurred in 218 (98%) women without necessity for surgical evacuation of the uterus. Bleeding commonly occurred following administration of mifepristone and prior to prostaglandin administration. The median duration of bleeding following abortion was 13 days with a range of from 1 to 44 days. There was a wide individual variation in measured blood loss between women, from 14 to 512 ml, with a median loss of 74 ml. The amount of blood loss was independent of the dose of mifepristone or prostaglandin but was significantly correlated with gestation. These results confirm that the combination of mifepristone and gemeprost is a highly effective and safe method of inducing therapeutic abortion medically. As the amount of blood loss increases with increasing gestation, it is suggested that its use should be restricted to women with amenorrhoea less than or equal to 56 days.

The use of prostaglandins and antiprogestins for pregnancy termination

Although vacuum aspiration could be regarded as a simple procedure, complications do occur and attempts have been made to develop non-surgical procedures for termination of pregnancy during the first 3-4 weeks following the first missed menstrual period. A variety of prostaglandin (PG) analogs have been developed which are equally effective as vacuum aspiration to induce abortion during early pregnancy. However, the widespread acceptance of PG treatment is limited by a relatively high incidence of gastrointestinal side effects and uterine pain. Treatment with presently available antiprogestins alone is not sufficiently effective to compete with vacuum aspiration. However, administration of these compounds induces uterine contractions and increases the sensitivity of the myometrium to prostaglandin. These effects allow the development of sequential treatment with RU 486 and a low dose of PG analogs administered intramuscularly or vaginally which is highly effective and is seemingly associated with a lower frequency of side effects than if PG analogs are used alone. It can be concluded that this medical abortion method has the capacity to compete with vacuum aspiration for termination of early pregnancy. Randomized studies comparing the two procedures are, however, needed to confirm this statement.

Induction of early abortion with mifepristone (RU486) and two different doses of prostaglandin pessary (gemeprost)

One-hundred-and-twenty women of less than 56 days amenorrhoea were treated with a single dose of 600 mg of mifepristone in combination with half or a whole 1 mg gemeprost vaginal pessary. Complete abortion was induced in 119 (99%) women and there were no continuing pregnancies. There were few gastro-intestinal side effects following prostaglandin. The smaller dose of prostaglandin caused significantly less severe pain. This study confirmed the effectiveness of mifepristone and prostaglandin for the induction of early abortion but suggests that more research should be carried out to determine the lowest effective doses of both drugs.

Menstrual regulation by intramuscular injections of 16-phenoxy-tetranor PGE2 methyl sulfonylamide (sulprostone). A multicentre study. World Health Organization

In a previous study we have shown that three intramuscular injections of 0.5 mg of the prostaglandin analogue, sulprostone (16-phenoxy-W-17,18,19,20-tetranor PGE2 methyl sulfonylamide), were equally effective as vacuum aspiration for menstrual regulation in women with a delay of up to 21 days in the onset of expected menses. To assess whether lower doses of the prostaglandin could be effective if treatment were restricted to women with a delay of menses of up to 14 days, a multicentre trial investigated the effect of two injections of 0.25 mg sulprostone given with a 4-h interval. After an interim analysis showed a clinically unacceptable low rate of complete abortion (41%) amongst the 64 pregnant women thus treated, the dose was doubled to two injections of 0.5 mg. In the group of 51 pregnant women treated with the increased dose, the frequency of complete abortion (67%) was significantly higher although still well below the 91% success rate achieved in our previous study. Both the duration and the subjective vaginal blood loss were greater in women with complete abortion than in those with incomplete abortion or continuing pregnancy. It is concluded that the sulprostone dose used in our previous study (3 x 0.5 mg) represents the minimal, required dose for menstrual regulation.

Early pregnancy termination: a comparison between vacuum aspiration and medical abortion using prostaglandin (16,16 dimethyl-trans-delta 2-PGE1 methyl ester) or the antiprogestogen RU 486

Three different regimens for termination of early pregnancy by medical means were compared to vacuum aspiration. Women seeking therapeutic abortion of pregnancy (less than or equal to 56 days amenorrhoea) were allocated to one of four treatment groups: (1) vacuum aspiration (n = 28); (2) 1 mg vaginal pessary of a prostaglandin analogue (gemeprost) every 3 h for up to 5 pessaries (n = 30); (3) the antigestogen (RU 486--mefipristone) 150 mg per day for 4 days by mouth (n = 20); (4) RU 486 in the same dose as group 3 together with 1 mg gemeprost on day 3 (n = 19). Complete abortion occurred more often in women treated with vacuum aspiration (96%), gemeprost alone (97%) and RU 486 plus gemeprost (95%) than in those treated with RU 486 alone (60%). In women receiving up to five gemeprost pessaries alone vomiting occurred in 7 (23%) and diarrhoea in 10 (33%); 16 (53%) required parenteral opiates for relief of pain. Side-effects and analgesic requirements were much reduced in the women who received RU 486 alone or in combination with a single gemeprost pessary. There was no difference in the number of days of vaginal bleeding after abortion between the four groups although there was wide individual variation (mean 10 days, range 1-34). These results confirm that medical induction of abortion in early pregnancy with prostaglandin vaginal pessaries is as effective as vacuum aspiration and that the dose can be reduced five-fold without loss of efficacy when used in combination with RU 486.

Induction of therapeutic abortion in early pregnancy with mifepristone in combination with prostaglandin pessary

Therapeutic abortion was induced in 100 women in early pregnancy (less than 56 days' amenorrhoea) with a combination of the antigestagen mifepristone (RU 486) and a synthetic prostaglandin analogue, gemeprost. Mifepristone in oral doses of 400-600 mg was followed 48 h later by a gemeprost vaginal pessary (0.5-1.0 mg). Bleeding was induced in all women 22-70 h after the mifepristone dose and although bleeding continued for 4-43 days (median 12) the total measured blood-loss was only a median of 72.5 ml (range 15-398). Complete abortion occurred in 95 women. Surgical evacuation of the uterus for minimum debris was required in the remaining 5. Only 10 women had diarrhoea or pain that required opioid analgesia. The combination of mifepristone and gemeprost provides a safe and effective alternative to surgical evacuation of the uterus for therapeutic abortion in early pregnancy.

Therapeutic abortion in early pregnancy with antiprogestogen RU486 alone or in combination with prostaglandin analogue (gemeprost)

Abortion was attempted in 39 women in early pregnancy (less than 56 days amenorrhea) with the progesterone antagonist RU486 alone (150 mg per day for 4 days) or in combination with a PG analogue, 16,16-dimethyl-trans-delta 2-PGE1 (Gemeprost) in the form of a 1 mg vaginal pessary. Complete abortion was also attempted in 5 women who received RU486 together with 2 X 1 mg PG pessaries. Vaginal bleeding followed by complete abortion occurred in 18 of 19 women who received RU486 + 1 mg PG pessary as compared to only 12 of 20 women who received RU486 alone (P less than 0.01). All women who received RU486 + 2 mg Gemeprost had a complete abortion. The onset of crampy abdominal pain (median: 3 vs 4 days) and vaginal bleeding (3 vs 3 days) was similar in the RU486 and RU486 + PG groups, respectively. Slightly less than half the patients in both groups had nausea and/or vomiting, but the incidence did not differ from that occurring prior to treatment. The mean duration (range) of vaginal bleeding [RU486 alone: 10 (0,29) days and RU486 + PG: (5,34) days], and the measured blood loss [RU486: 53 (2,227) ml and RU486 + PG: 81 (32,222) ml] did not differ significantly between the two treatments. It is concluded that the combination of RU486 and a single PG vaginal pessary is a highly effective means of inducing therapeutic abortion in early pregnancy and offers an alternative to surgery.

A controlled release form of 16,16-dimethyl-trans-delta 2-PGE, methyl ester for early abortion

The termination of early pregnancy (less than 56 days amenorrhoea) has been investigated using 16,16-dimethyl-trans-delta 2-PGE, methyl ester in a controlled release preparation. The onset of crampy abdominal pain was seen after 270 +/- 39 minutes and bleeding occurred after 603 +/- 95 minutes. Two (15%) patients required no pain relief during treatment, however 5 (38%) requested oral analgesia, and in 6 (46%) individuals the pain was severe enough to warrant parenteral opiates. The overall success rate for complete abortion was 85%. No serious adverse effects were seen, but vomiting occurred in 2 (15%) women, and diarrhoea in 3 (23%). Although the use of this prostaglandin analogue in slow release form provides an effective treatment method for early abortion using a reduced total dose of prostaglandin, the acceptability of the drug as an agent for menstrual induction continues to be limited by the occurrence of troublesome gastro-intestinal side effects.

Preoperative cervical dilatation for first trimester induced abortion: comparison of two prostaglandin analogues

The present study compares two methods of local application of prostaglandins prior to surgical abortion in the first trimester. Fifty patients were treated with a vaginal tablet of Gemeprost (E1 analogue); 50 others by the intra-cervical application of PGF2 alpha gel. Gemeprost was found to be superior to the PGF2 alpha gel. Several hypotheses are formulated to explain this observation. The side effects of the two methods are compared and discussed.

Ectopic pregnancy among early abortion patients: does prostaglandin reduce the incidence?

The availability and efficacy of prostaglandin (PG) F2 alpha and E series analogues has prompted their frequent use for pregnancy interruption. In the course of evaluating our experience with PGs for interrupting early first trimester gestations, we became increasingly impressed by the absence of any with extrauterine pregnancy. A review of 63 reports encompassing 2,965 patients whose pregnancies were less than 8 weeks' gestational age dating from the last menstrual period and who were similarly treated yielded only 2 cases of ectopic pregnancy. When compared with the generally accepted ectopic gestation rates of the order of 1 in 200 pregnancies, this frequency of 1 in 1,483 is unexpectedly low. Preselection does not appear to explain this impressive discrepancy. If the observation proves correct, it implies that PGs have some form of therapeutic effect in eradicating extrauterine pregnancy by nonoperative means. The implications are obvious in terms of its potential therapeutic benefits.

Study of 16,16'-dimethyl-trans-delta 2 prostaglandin E1 methyl ester vaginal suppository for cervical dilatation in premenopausal and postmenopausal women

In a double-blind placebo-controlled comparative study, 180 female patients were randomly assigned to groups and treated approximately 3 h before dilatation and curettage with either a single 1 mg vaginal suppository of Gemeprost or a matching placebo. The patient population included premenopausal non-pregnant or postmenopausal patients presenting at four participating centers in West Germany. Patients were monitored from the time of drug administration to approximately 24 h after the operation. A marked response to treatment with Gemeprost was noted at the general cervical assessment performed immediately prior to dilatation. A significant increase in diameter of the cervical canal was observed and subsequent mechanical dilatation was found to be significantly easier as a result of Gemeprost treatment. No differences between the response to treatment in premenopausal and postmenopausal patients were found in our interim analysis of 113 patients. The incidence of preoperative uterine pain increased with time as a result of Gemeprost treatment but it was predominantly mild and no analgesics were required. Gastrointestinal side-effects were rare and well tolerated in both treatment groups. This study indicates that Gemeprost is an effective, well tolerated preoperative cervical dilator/softener in non-pregnant patients.

The use of 16,16-dimethyl-trans delta 2 prostaglandin E1 methyl ester (gemeprost) vaginal pessaries for the termination of pregnancy in the early second trimester. A comparison with extra-amniotic prostaglandin E2

The use of gemeprost pessaries has been compared in an open randomized trial with the extra-amniotic infusion of prostaglandin E2 (PGE2) for the termination of pregnancy between 12 and 16 weeks gestation. The success rates were 77% and 79% for the pessary and infusion group respectively, and these rates were unaffected by parity. There was no significant difference in the cumulative abortion rate between the two groups, nor were there differences in the induction-abortion interval, nor in the time taken to the onset of pain or bleeding. However, women in the pessary group required significantly less analgesia than those in the infusion group. Side-effects, experienced both during treatment and during the 6 weeks after abortion, were similar in both groups. Gemeprost vaginal pessaries are an effective alternative to the extra-amniotic infusion of PGE2 for the termination of pregnancy in the early second trimester.

Pre-operative cervical dilatation in termination of first trimester pregnancies using 16, 16-dimethyl-trans-delta 2 PGE1 methyl ester vaginal pessaries

The effect of a prostaglandin E1 analogue on the cervix prior to termination of first trimester pregnancy was studied in a double-blind placebo-controlled trial with 70 primigravid and 125 multigravid patients in the Hong Kong University Gynaecological Unit. One mg of 16, 16-dimethyl-trans-delta 2-prostaglandin E1 methyl ester (ONO 802) in the form of vaginal pessary was inserted 3 hours before vacuum aspiration. The cervical dilatation in patients receiving ONO 802 pessaries was significantly greater than that in patients who received no treatment or placebo pessaries but the difference in dilatation between patients who received no treatment or placebo was not significant. The blood loss during operation in patients receiving ONO 802 pessaries was also significantly less than that in patients receiving placebo pessaries. The side effects due to ONO 802 pessaries were mild and infrequent.

Termination of early first trimester pregnancy with 16,16-dimethyl trans delta 2 prostaglandin E1 methyl ester

Thirty healthy women with early first trimester pregnancy applying for legal abortion were given five vagitories containing 1 mg 16,16-dimethyl-trans delta 2 prostaglandin E1 (16,16-dimethyl PGE1). They were instructed to take one vagitory every third hour. The treatment was evaluated at follow-up visits after one, two and four weeks. Complete abortion was recorded in 27 cases. The pregnancy test was still positive after two weeks in three women, who underwent surgical termination, and were recorded as failures. The most common side-effects were bleeding, pain and gastrointestinal symptoms. No serious side-effects were recorded. Repeated administration of vagitories containing 1 mg 16,16-dimethyl PGE1 seems to be a safe and effective method of "menstrual extraction". The efficacy should be increased and the rate and intensity of side effects decreased if "menstrual extraction" is to compete with conventional dilatation and curettage.