Medical termination of pregnancy at 63 to 83 days gestation

Development of medical termination of pregnancy: a review

The synthesis of mifepristone, an antiprogestin blocking the action of progesterone at the receptor level, started a new era of medical termination of pregnancy (MTOP). The initial results of MTOP with mifepristone alone were disappointing; however, mifepristone can sensitise the myometrium to the action of prostaglandins. Clinical trials have shown that the sequential administration of mifepristone followed 1-2 days later by a prostaglandin analogue is a safe, effective, and acceptable method for MTOP. This article will review the events and challenges leading to the development of the current evidence-based and yet off-label regimen for first-trimester MTOP.

TWEETABLE ABSTRACT

This article reviews the events and challenges in the development of medical termination of pregnancy.

Determination of medical abortion eligibility by women and community health volunteers in Nepal: A toolkit evaluation

Objective

To determine if pregnant, literate women and female community health volunteers (FCHVs) in Nepal can accurately determine a woman’s eligibility for medical abortion (MA) using a toolkit, compared to comprehensive abortion care (CAC) trained providers.

Study design

We conducted a prospective diagnostic accuracy study in which women presenting for first trimester abortion, and FCHVs, independently assessed each woman’s eligibility for MA using a modified gestational dating wheel to determine gestational age and a nine-point checklist of MA contraindications or cautions. Ability to determine MA eligibility was compared to experienced CAC-providers using Nepali standard of care.

Results

Both women (n = 3131) and FCHVs (n = 165) accurately interpreted the wheel 96% of the time, and the eligibility checklist 72% and 95% of the time, respectively. Of the 649 women who reported potential contraindications or cautions on the checklist, 88% misidentified as eligible. Positive predictive value (PPV) of women’s assessment of eligibility based on gestational age was 93% (95% CI 92, 94) compared to CAC-providers’ (n = 47); PPV of the medical contraindications checklist and overall (90% [95% CI 88, 91] and 93% [95% CI 92, 94] respectively) must be interpreted with caution given women’s difficulty using the checklist. PPV of FCHVs’ determinations were 93% (95% CI 92, 94), 90% (95% CI 89,91), and 93% (95% CI 91, 94) respectively.

Conclusion

Although a promising strategy to assist women and FCHVs to assess MA eligibility, further refinement of the eligibility tools, particularly the checklist, is needed before their widespread use.

Reaching women where they are: eliminating the initial in-person medical abortion visit

The requirement that every woman desiring medical abortion must come in person to a clinical facility to obtain the drugs is a substantial barrier for many women. To eliminate this requirement in the United States, two key components of the standard initial visit would need to be restructured. First, alternatives to ultrasound and pelvic exam would need to be identified for ensuring that gestational age is within the limit for safe and effective treatment. This is probably feasible: for example, data from a large study suggest that in selected patients menstrual history is highly sensitive for this purpose. Second, the Food and Drug Administration would need to remove the medically unwarranted restriction on distribution of mifepristone. These two changes could allow provision of the service by a broader range of providers in nontraditional venues or even by telemedicine. Such options could have profound benefits in reducing cost and expanding access to abortion.

Alternatives to routine ultrasound for eligibility assessment prior to early termination of pregnancy with mifepristone-misoprostol

OBJECTIVE

To test the feasibility and efficacy of an approach that foregoes the routine use of ultrasound for the determination of eligibility for medical termination of pregnancy.

DESIGN

Prospective trial.

SETTING

Ten termination of pregnancy clinics in the USA.

POPULATION

A total of 4484 women seeking termination of pregnancy with mifepristone-misoprostol.

METHODS

Women provided estimates of the date of their last menstrual period and underwent pelvic bimanual and ultrasound examinations. We compared estimates of gestational age using these three methods.

MAIN OUTCOME MEASURE

Proportion of women of ≤9 weeks' gestation by woman or provider estimate, but >9 weeks' gestation by ultrasound.

RESULTS

The reliance on women's report of their last menstrual period together with physical examination to determine their eligibility for termination of pregnancy with mifepristone-misoprostol would result in few women (63/4008 or 1.6%) accepted for treatment outside the current limits of standard mifepristone-misoprostol regimens used for early termination of pregnancy (i.e. ≤63 days' gestation on ultrasound).

CONCLUSIONS

Last menstrual period and physical examination alone, without the routine use of ultrasound, are highly effective for the determination of women's eligibility for early termination of pregnancy with mifepristone-misoprostol.

Mifepristone Followed in 24 Hours to 48 Hours by Misoprostol for Late First-Trimester Abortion

OBJECTIVE

To investigate the efficacy of mifepristone and misoprostol for the termination of pregnancies in the late first trimester.

METHODS

This was a prospective study of 321 women seeking termination of pregnancy with gestations from 64 days to 84 days (+/-3 days) by vaginal ultrasonography. Women were enrolled at three sites: University of Rochester Reproductive Health Program in Rochester, New York; Hung Vuong Hospital in Ho Chi Minh City, Vietnam; and K.E.M. Hospital in Pune, India. Eligible women received 800 mcg of misoprostol vaginally between 24 hours and 48 hours after administration of 200 mg mifepristone. Two additional doses of 400 mcg of misoprostol were administered either orally or vaginally as needed every 3 hours for a maximum of two additional doses (total 1,600 mcg). The primary study outcome measure was complete abortion without surgical intervention.

RESULTS

Eighty-nine percent of women who completed the study successfully terminated their pregnancies. Most women were either satisfied (64.8%) or very satisfied (28.6%) with their experience. Ninety-four percent of women reported that they would recommend the procedure to a friend. Most women (90.4%) also agreed they would request a medical abortion if they required another abortion at this gestational age.

CONCLUSION

Medical abortion is acceptable and effective in the late first trimester and offers women an acceptable alternative to surgical abortion.

LEVEL OF EVIDENCE

II.

Can mifepristone medical abortion be simplified? A review of the evidence and questions for future research

Mifepristone medical abortion has been a valuable addition to the reproductive health options of women. Aspects of its provision have however sometimes limited its accessibility and use. This article summarizes existing evidence for simplifying the provision of medical abortion and thus increasing its availability. We identify three ways through which medical abortion provision might be simplified based on existing evidence and suggest five additional simplifications that require further research to confirm their safety and efficacy.

Consistency of medical abortion efficacy from 5 through 14 weeks’ gestation

OBJECTIVE

To assess the efficacy of medical abortion performed according to a single protocol from 5 through 14 weeks.

STUDY DESIGN

Retrospective observational study of medical abortions through 14 weeks performed from January 2000 through August 2001. The protocol combined 400mg of mifepristone orally, followed 48 h later by 800 microg of misoprostol, administered vaginally, and repeated after 4 h if the patient did not begin to abort. Outcome measures were the abortion rate, the rates of immediate manual uterine revision and of secondary vacuum aspiration, the time to expulsion, the misoprostol dose, and analgesic use.

RESULTS

The study included 512 medical abortions. The abortion rate was 98.4% and the secondary vacuum aspiration rate 8.2%. The uterine exploration rate was 1.4%, but these occurred only at gestations above 13 weeks. The mean time to expulsion was 4.4+/-1.9 h (1-28), and the mean misoprostol dose 860+/-180 microg (0-2000). None of the characteristics studied differed significantly as a function of gestation. 1.6% of patients had complications.

CONCLUSION

Medical abortion was consistently effective through 14 weeks and can be offered as an alternative to the surgical technique.

Patient preference in a randomized study comparing medical and surgical abortion at 10-13 weeks gestation

The aim of this study was to assess women's preferences and acceptability of medical (MA) and surgical abortion (SA) at 10-13 weeks gestation. This was a partially randomized patient preference trial. Women were offered to enter the randomized arm of the trial. Those who expressed a strong preference for a method were entered into the preference arm. A total of 368 women were randomized (188 medical and 180 surgical) while 77 entered the preference arm (15 medical and 62 surgical). Prior to abortion, 253 women (72%) indicated a preference for MA while 98 (28%) showed a preference for surgery (p < .0001). Despite having a preference for a particular method, women were content with alternatives. Women were more likely to choose the same abortion method again if they had shown a preference for that method prior to abortion (p = .002 and .01 for MA and SA, respectively). The availability of MA is an important option for many women who wish to avoid surgery or anesthesia and should now be offered routinely in the late first trimester.

Comparison of gemeprost and vaginal misoprostol in first trimester mifepristone-induced abortion

BACKGROUND

The aim of this study was to compare efficacy and side effects of gemeprost and vaginal misoprostol in mifepristone-induced abortions in women up to 63 days of gestation.

METHODS

A retrospective study of 833 consecutive patients admitted for medical termination of first trimester pregnancy was conducted. Four-hundred ten patients received mifepristone 600 mg, followed 48 h later by gemeprost 1 mg (regimen I), and 423 patients received mifepristone 200 mg followed by vaginal misoprostol 800 microg (regimen II). Success rates were evaluated after 2 weeks and after 3 months. The severity of bleeding and side effects (pain, nausea, vomiting and diarrhea) was scored by the patients, and requests for supplementary analgesic treatment were recorded by the attending nurse.

RESULTS

Success rates were 99% in both groups after 2 weeks of follow-up. At 3 months of follow-up, success rates had declined to 94% for regimen I and 96% for regimen II. The frequency of severe pain was higher in regimen I compared to regimen II (72% vs. 60%, p < .001), but the severity of bleeding and gastrointestinal side effects was similar in the two regimens.

CONCLUSION

When combined with mifepristone, gemeprost and vaginal misoprostol are equally effective for termination of first trimester abortion, but may be associated with varying intensity of side effects.

Infection after medical abortion: A review of the literature

Medical abortion regimens have become widely used, but the frequency of infection after medical abortion is not well documented. This systematic review provides data on infectious complications after medical abortion. We searched Medline for articles written before July 2003 to determine the frequency of infection after medical abortion up to 26 weeks of gestation. We reviewed all articles and extracted data on the frequency of infection from 65 studies. The frequency of diagnosed and/or treated infection after medical abortion was very low (0.92%, N = 46,421) and varied among regimens. Results of this review confirm that, with respect to infectious complications, medical abortion is a safe and effective option for first- and second-trimester pregnancy termination. After accounting for regional variations in diagnosis, there is little difference in frequency of infection among the regimens reviewed. Future studies should report clear diagnosis and treatment standards for infection so that more precise information becomes available.

WHO multinational study of three misoprostol regimens after mifepristone for early medical abortion

OBJECTIVES

To compare the side effect profiles of regimens of oral and vaginal administration of misoprostol after a single oral dose of 200 mg of mifepristone and to investigate patients' perceptions of medical abortion.

DESIGN

Double-blind, randomised controlled trial.

SETTING

Fifteen gynaecological clinics in 11 countries.

POPULATION

A total of 2219 healthy pregnant women requesting medical abortion with < or =63 days of amenorrhoea. Two thousand women were asked about their perceptions of the method.

METHODS

Mifepristone 200 mg orally on day one, followed by 0.8 mg misoprostol either orally or vaginally on day three. The oral group (O/O group) and one of the vaginal groups (V/O group) continued with 0.4 mg of oral misoprostol, and the vaginal-only group (V-only group) with oral placebo, twice daily for seven days. Side effects were recorded daily by women and reported at each visit. After misoprostol administration at the clinic, side effects were recorded at 1-hour interval up to 3 hours. Patients' perceptions were asked at the second follow up visit, six weeks after treatment.

MAIN OUTCOME MEASURES

The outcome measures were the following: pregnancy-related symptoms (nausea, vomiting, breast tenderness, fatigue, dizziness, headache), drug-related side effects (diarrhoea, fever, rash and blood pressure change), side effects related to the abortion process (lower abdominal pain) and women's perceptions of the method.

RESULTS

The pregnancy-related symptoms decreased in all groups after misoprostol, and breast tenderness decreased already after mifepristone. Oral administration of misoprostol was associated with a higher frequency of nausea and vomiting than vaginal administration at 1 hour after administration. With oral misoprostol, diarrhoea was more frequent at 1, 2 and at 3 hours after administration than with vaginal administration. Misoprostol induced fever during at least 3 hours after administration in up to 6% of the women, this peak being slightly higher and taking place later with the vaginal route. Lower abdominal pain peaked at 1 and 2 hours after oral misoprostol, while it did so at 2 and 3 hours after vaginal misoprostol. In the two groups that continued misoprostol, 27% of women had diarrhoea between the misoprostol visit and the two-week follow up visit, compared with 9% in the placebo group. Among the women studied, 84% would choose medical abortion again, 9% would choose surgical abortion and 7% did not know. Twenty-three percent of the women would choose to have a possible future abortion at home, 70% at a health facility and 7% did not know.

CONCLUSIONS

The pregnancy-related symptoms decrease significantly with time during medical abortion. Nausea, vomiting and diarrhoea were more frequent after oral administration of misoprostol. Pain related to the abortion process occurs earlier after oral misoprostol. Should a need arise, a majority of women would choose medical abortion again and would prefer to have it at a health facility rather than at home.

Ectopic Pregnancy and Medical Abortion

OBJECTIVE

Medical abortion regimens have become more widely used to terminate early pregnancies. Medical abortion providers are concerned to diagnose and exclude women with ectopic pregnancy before initiating treatment, as with any early pregnancy termination. Yet, there is little information about whether the various pretreatment screening methods used are adequate. We reviewed published literature to determine the overall success of screening for ectopic pregnancy before medical abortion treatment.

DATA SOURCES

We searched MEDLINE for articles on medical abortion regimens published before July 2003.

METHODS OF STUDY SELECTION

We selected English language articles of studies of medical abortion with sample sizes greater than 100, which reported on ectopic pregnancy diagnosed after medical abortion treatment. Fifty-seven of 85 prospective studies and randomized trials (69%) met these inclusion criteria. We also included data from 2 unpublished studies because they were large and well-controlled and because they included serious adverse events known to us, which we did not deem fair to exclude from our analysis.

TABULATION, INTEGRATION, AND RESULTS

Each article was reviewed by one author. Data from selected studies were compiled, and the frequency of ectopic pregnancy diagnosed after medical abortion treatment was calculated. Ectopic pregnancy was diagnosed very infrequently following medical abortion procedures, occurring in only 10 of 44,789 (0.02%) women.

CONCLUSION

The very low frequency of ectopic pregnancies diagnosed after medical abortion treatment demonstrates that the various pretreatment screening methods that providers use to exclude patients with ectopic pregnancies are successful. Further, there is no evidence to suggest that medical abortion treatment leads to unusual complications for women with ectopic pregnancies.

Progesterone antagonists and progesterone receptor modulators: an overview

Since the original description of the structure of the antiprogestin, mifepristone, was published, numerous related compounds have been synthesized which may function as progesterone antagonists (PAs) or progesterone receptor modulators (PRMs). The latter are mixed agonists-antagonists. Both PAs and PRMs have therapeutic applications in female health care. Mifepristone is predominantly a PA and displays only minimum agonist activity in certain systems. Together with a prostaglandin, mifepristone can terminate pregnancies of less than 9 weeks duration, and it may also be used at later gestational ages. Mifepristone causes expulsion of the uterine contents following intrauterine fetal death. A mifepristone-prostaglandin combination has been shown to be very effective treatment in women with menses delay of 11 days or less. Many PAs and PRMs display antiproliferative effects in the endometrium. Serum estradiol levels however remain in the early to mid-follicular phase range. For this reason, they have application in the treatment of endometriosis and myoma without being associated with bone loss and hypoestrogenism. PRMs may also find application in the treatment of dysfunctional bleeding as well as an adjunct to estrogens in hormone replacement therapy in postmenopausal women. Many PAs have contraceptive potential by suppressing follicular development and blocking the LH surge. Low doses may also be potential contraceptives by retarding endometrial maturation without affecting ovulation or inducing bleeding. Mifepristone is an excellent agent for use as an emergency "postcoital" contraceptive. PAs may also be useful in IVF programs to prevent a premature LH surge and to delay the emergence of the implantation window. In addition to their use in women's health care, mifepristone and several other PAs are potent antiglucocorticoid agents and may be used to treat ACTH-independent Cushing's syndrome. They may also be used in the treatment of tumors containing steroid receptors and in other situations which require suppression of the ACTH-cortisol axis.

WHO multinational study of three misoprostol regimens after mifepristone for early medical abortion. I: Efficacy

OBJECTIVES

To compare the efficacy of oral and vaginal administration of misoprostol after a single oral dose of 200 mg of mifepristone and to investigate whether the efficacy can be improved and the duration of bleeding shortened by continuing oral misoprostol for one week.

DESIGN

Double blind, randomised controlled trial.

SETTING

Fifteen gynaecological clinics in 11 countries.

POPULATION

A total of 2219 healthy pregnant women requesting medical abortion with < or =63 days of amenorrhoea.

METHODS

Mifepristone 200 mg administered orally on day one, followed by 0.8 mg misoprostol either orally or vaginally on day three. The oral group and one of the vaginal groups continued with 0.4 mg of oral misoprostol twice daily for seven days.

MAIN OUTCOME MEASURES

Complete abortion was the main outcome. Secondary outcomes were side effects, timing of expulsion and duration of bleeding.

RESULTS

The crude complete abortion rate was 92.3% in the oral plus continued oral misoprostol group, in the vaginal-only group it was 93.5%, and it was 94.7% in the vaginal group that continued with oral misoprostol, when considering undetermined cases as failures. Among women with amenorrhoea length > or =57 days, the risk of failure of complete abortion was almost three times higher in the oral plus continued oral misoprostol group (RR = 2.8, 95% CI 1.3 to 5.8), and over two times higher in the vaginal-only group (RR = 2.2, 95% CI 1.0 to 4.7), when compared with the vaginal plus continued oral misoprostol group. Among women with amenorrhoea length < 57 days, the differences were not significant. Timing of expulsions and duration of bleeding were similar in the three groups.

CONCLUSIONS

For amenorrhoea length > or =57 days, vaginal misoprostol is more effective than oral when continued with 0.4 mg oral misoprostol twice daily for seven days. Misoprostol continuation improved the efficacy in this amenorrhoea group compared with a single dose of vaginal misoprostol on day three, but it did not shorten the duration of bleeding. No differences in efficacy were observed when amenorrhoea length was < 57 days.

Mifepristone and misoprostol for medical termination of pregnancy: the effectiveness of a flexible regimen

BACKGROUND

Mifepristone, followed 48 hours later by administration of misoprostol, is a well-established regimen for medical termination of pregnancy (TOP). Although this regimen is effective, its inflexibility may limit its provision in an outpatient service.

OBJECTIVE

To confirm that misoprostol administration is effective whether administered 24, 48 or 72 hours after oral mifepristone.

DESIGN

Observational study of 234 consecutive women with pregnancies up to 83 days' gestational age in whom medical TOP was performed during the period December 2000-July 2001.

SETTING

Women's Health Care Department, Royal Bolton Hospital, Bolton, UK.

RESULTS

There was a high success rate for complete abortion in all groups whether mifepristone was administered 24, 48 or 72 hours prior to misoprostol.

CONCLUSION

This study suggests that a more flexible regimen of mifepristone/misoprostol administration for medical TOP is effective in routine clinical practice.

Medical termination of pregnancy at 9-12 weeks of gestation

Current RCOG guidelines advise that surgical termination should be offered to those within the 9-12 weeks gestation band. While auditing the quality of services offered for termination of pregnancy in our unit, it became apparent that many women presenting at this gestation were requesting a medical method. There has been little clinical research into medical method of abortion at this gestation. The aim of the study was to assess the efficacy of medical methods of termination at 9-12 weeks gestation. A retrospective analysis of 25 cases who underwent medical termination using a regime of mifepristone followed 48 hours later by a course of vaginal gemeprost was undertaken. Complete abortion was achieved in 96% of cases; 92% of women required no more than two pessaries to achieve complete abortion. All but one patient was suitable for discharge on the same day. One woman underwent surgical evacuation in view of heavy bleeding. We conclude that medical TOP is a safe alternative to surgical method at 9-12 weeks' gestation.

Mifepristone: contraceptive and non-contraceptive uses

Mifepristone is an orally active progesterone antagonist. It can be used for both contraceptive and non-contraceptive clinical indications. It is a very effective drug for emergency contraception with a low incidence of side effects. There is a potential for mifepristone to be used as a once-a-month pill. There is a need, however, for a simple, inexpensive and accurate method to identify the luteinizing hormone surge before this method can be used in clinical practice. The daily administration of mifepristone offers promise as an effective method of contraception but more studies need to be done. The combination of mifepristone with a prostaglandin analogue is a well-established method for termination of pregnancy of up to 9 weeks. Recent data suggest that this combination may also be used up to 9-13 weeks of pregnancy. Although mifepristone is effective in dilating the cervix before vacuum aspiration, misoprostol is probably the drug of choice in most situations. In the second trimester, mifepristone is effective in shortening the abortion process induced by prostaglandin analogues. The combination of mifepristone and prostaglandin also offers a medical method for management of miscarriages. Mifepristone has been used for a number of other indications, but further studies are needed before such treatment can be recommended.

First trimester abortion with mifepristone and vaginal misoprostol

This study assessed the efficacy and side effects of first trimester medical abortion using mifepristone and vaginally administered misoprostol. Medical abortion was first introduced in Denmark in December 1997, and the acceptability of this new approach in a Danish population was evaluated. The study included the first 100 women seeking medical abortion. The gestational age was from 33 to 56 days. All received 600 mg mifepristone (RU 486) orally followed 2 days later by vaginally administered misoprostol 400 microg. Success was defined as achieving complete abortion without the need for surgical evacuation. Ninety-three percent achieved a successful medical termination of pregnancy. Side effects were few, and the acceptability was high. Ninety percent of the women would prefer medical abortion in case of a new unwanted pregnancy. The combination of mifepristone and vaginally administrated misoprostol is effective, safe, has few side effects and is well accepted by Danish women.

Care of women having termination of first-trimester pregnancy

The care of women having termination of pregnancy has always presented social, ethical and legal concerns to nurses and other healthcare professionals. Women having first-trimester termination of pregnancy may have the choice between medical and surgical methods. The process and procedure of these two approaches are discussed and the implications for nursing practice identified. There is now research evidence that explores women's experiences of these various methods and gives some insight into what the woman may experience. Nurses must have knowledge of these methods of termination to enable women to make the correct choices. The challenge for nurses then is to provide and evaluate information that is as effective as possible in meeting the needs of the individual woman.