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Jayaweera RT, Moseson H, Gerdts C. Misoprostol in the era of COVID-19: a love letter to the original medical abortion pill. Sex Reprod Health Matters 2020; 28:1829406. [PMID: 33111643 PMCID: PMC7887983 DOI: 10.1080/26410397.2020.1829406] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Ruvani T Jayaweera
- Senior Project Manager, Ibis Reproductive Health, Oakland, CA, USA; Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, USA
| | - Heidi Moseson
- Epidemiologist, Ibis Reproductive Health, Oakland, CA, USA
| | - Caitlin Gerdts
- Vice-President for Research, Ibis Reproductive Health, Oakland, CA, USA
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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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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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Mukherjee AA. Comparison of Effectiveness of Sublingual and Vaginal Misoprostol for Second-Trimester Abortion. J Obstet Gynaecol India 2019; 69:246-251. [PMID: 31178640 DOI: 10.1007/s13224-018-1183-8] [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: 03/28/2018] [Accepted: 10/05/2018] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE The aim of this study was to compare the efficacy and safety of sublingual and vaginal misoprostol in second-trimester termination of pregnancy in 24 and 48 h. STUDY DESIGN This is a retrospective study of 240 pregnant women seeking termination in second trimester (13-18.5 weeks), in which the patients are subdivided into two groups-first group received 400 mcg of misoprostol sublingually (n = 120), and second group received 400 mcg of misoprostol vaginally (n = 120) every 4 h for a maximum of five doses. The course of misoprostol was repeated if the patient did not abort within 24 h. RESULTS The mean induction-to-abortion interval was shorter in sublingual group (10.28 ± 3.1 h) versus 14.68 ± 4.2 h in vaginal group in 24 h (p = 0.0001), and 36.9 ± 4.4 h in sublingual versus 29.7 ± 14 in vaginal group in 48 h (p = 0.0933). Mean dose requirement for misoprostol by sublingual route was low as compared to vaginal misoprostol (1048 ± 301 mg versus 1250 ± 375 mg; p = 0.0001 in 24 h and 1110 ± 833 mg versus 1325 ± 536 mg; p = 0.0231 in 48 h). No significant difference was found in the success rate (both at 24 and 48 h) and in side effects among the two comparison groups. CONCLUSION Misoprostol as such by any route has been proven as an effective abortifacient in second trimester. Both sublingual and vaginal routes are effective for medical abortion. But shorter induction-to-abortion interval in sublingual route, less dose requirement and higher acceptability makes sublingual route as a better choice.
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Affiliation(s)
- Alka A Mukherjee
- Mukherjee Multispeciality Hospital, Plot 179, Ayurvedic Lay Out, Bhande Plot Square, Umred Road, Nagpur, Maharashtra State India
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Tintara H, Voradithi P, Choobun T. Effectiveness of celecoxib for pain relief and antipyresis in second trimester medical abortions with misoprostol: a randomized controlled trial. Arch Gynecol Obstet 2018; 297:709-715. [PMID: 29327156 DOI: 10.1007/s00404-018-4653-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 01/04/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the effectiveness of celecoxib for pain relief and antipyresis during second trimester abortion using sublingual misoprostol. METHODS Fifty-six pregnant women of gestational age 14-24 weeks were randomly assigned in a double-blind randomized controlled trial to receive 400 mg of celecoxib or placebo just before sublingual administration of misoprostol 400 µg every 6 h. Pain and body temperature (BT) were assessed every 1 h until the abortion or 24 h after the first dose of misoprostol. Pain was assessed using a 10-cm Visual Analog Scale (VAS). BT was measured with an infrared thermometer. RESULTS From January 2016 through September 2016, 28 patients were randomized into each study group. The mean VAS pain score at the completion of the abortion in the celecoxib group was significantly lower than in the placebo group (4.6 ± 2.8 vs. 7.3 ± 2.2) (p = 0.012). But 42.9% of patients in both groups experienced severe pain and needed equivalent amounts of morphine rescue. The overall mean BT in the celecoxib group was significantly lower than in the placebo group [- 0.09 (SD = 0.04)] (p = 0.017). The mean BTs at 1, 2 and 6 h after each repeated dose of misoprostol in the celecoxib group were also significantly lower than in the placebo group. CONCLUSIONS Single-dose 400 mg celecoxib had an inadequate beneficial effect on pain relief but significant antipyretic effect during second trimester abortions using sublingual misoprostol.
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Affiliation(s)
- Hatern Tintara
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand.
| | - Peangpailin Voradithi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Thanapan Choobun
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
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Rahimi-Sharbaf F, Adabi K, Valadan M, Shirazi M, Nekuie S, Ghaffari P, Khansari N. The combination route versus sublingual and vaginal misoprostol for the termination of 13 to 24 week pregnancies: A randomized clinical trial. Taiwan J Obstet Gynecol 2016; 54:660-5. [PMID: 26700981 DOI: 10.1016/j.tjog.2014.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2014] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The goal of this study was to compare the effectiveness of misoprostol via sublingual and vaginal administration versus the combination route in the termination of 13 to 24 week pregnancies. MATERIALS AND METHODS One hundred and ninety-five patients, divided into three groups, were enrolled in this study. In the vaginal group, two 200-μg misoprostol tablets were inserted into the posterior fornix every 4 hours for 48 hours. In the sublingual group, patients took two 200-μg misoprostol tablets every 4 hours for up to 48 hours. In the combination group, two 200-μg misoprostol tablets were inserted within the posterior fornix followed by the administration of 400 μg misoprostol sublingually every 4 hours for a period of 48 hours. Efficacy was defined as a successful termination without the need for any interventions. RESULTS The success rate, after 24-48 hours, was not significantly different among the three groups. It was significantly higher within the first 12 hours of misoprostol administration within the sublingual group (p = 0.031). Nonetheless, the overall failure rate was not significantly different between three groups. The mean duration of abortion was shortest among the sublingual group (655 ± 46 minutes), p = 0.005, and the number of misoprostol tablets administered was lower when compared to the other groups (5.9 ± 0.3), p = 0.001. The duration of abortion and the number of misoprostol tablets used significantly varied in the cases in which the patient had a history of a previous normal vaginal delivery (NVD; p = 0.007). The average number of tablets administered was the lowest in the sublingual group. The prevalence of fever among the NVD cases were significantly higher in the combination group (p = 0.008). Overall, of all the methods, patients preferred the sublingual route (p = 0.001). CONCLUSION Sublingual misoprostol has a higher efficacy when compared to the vaginal and combination methods.
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Affiliation(s)
- Fatemeh Rahimi-Sharbaf
- Department of Obstetrics and Gynecology, Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Khadijeh Adabi
- Department of Obstetrics and Gynecology, Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrnaz Valadan
- Department of Obstetrics and Gynecology, Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Shirazi
- Department of Obstetrics and Gynecology, Maternal-Fetal and Neonatal Research Center, Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sepideh Nekuie
- Department of Obstetrics and Gynecology, Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Parisa Ghaffari
- Department of Obstetrics and Gynecology, Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Narges Khansari
- Department of Obstetrics and Gynecology, Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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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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A double-blind randomized controlled trial of mifepristone or placebo before buccal misoprostol for abortion at 14-21 weeks of pregnancy. Int J Gynaecol Obstet 2015; 130:40-4. [PMID: 25896965 DOI: 10.1016/j.ijgo.2015.02.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 01/27/2015] [Accepted: 03/27/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess differences in outcomes of misoprostol with or without mifepristone for second-trimester abortion. METHODS A randomized, double-blind, placebo-controlled trial of buccal misoprostol following placebo or 200mg mifepristone was done in Tunisia among women presenting for abortions at 14-21 weeks of pregnancy between August 2009 and December 2011. Women with a live fetus, a closed cervical os, no cervical bleeding, and no contraindications to study drugs were eligible and underwent randomization (block size 10). Participants returned 24 hours later to receive 400 μg buccal misoprostol every 3 hours until complete fetal and placental expulsion (maximum 10 doses, five per 24-hour period). The primary outcomes were rates of complete uterine evacuation at 48 hours and time to expulsion. RESULTS A total of 120 women were evenly randomized to treatment. Complete uterine evacuation at 48 hours was recorded in 55 (91.7%) women in the combined group versus 43 (71.7%) in the misoprostol alone group (relative risk 1.28; 95% confidence interval 1.07-1.53). Mean time to complete abortion was 10.4±6.6 hours in the group who received mifepristone versus 20.6±9.7 hours in the misoprostol alone group (P<0.001). Side effects were similar in both groups. CONCLUSION Adding mifepristone before misoprostol can improve the quality of second-trimester abortion care by making the process faster.
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The use of misoprostol in termination of second-trimester pregnancy. Taiwan J Obstet Gynecol 2012; 50:275-82. [PMID: 22030039 DOI: 10.1016/j.tjog.2011.07.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2008] [Indexed: 11/23/2022] Open
Abstract
Misoprostol, a synthetic prostaglandin E1 analog, is initially used to prevent peptic ulcer. The initial US Food and Drug Administration-approved indication in the product labeling is the treatment and prevention of intestinal ulcer disease resulting from nonsteroidal anti-inflammatory drugs use. In recent two decades, misoprostol has approved to be an effective agent for termination of pregnancy in various gestation, cervical ripening, labor induction in term pregnancy, and possible management of postpartum hemorrhage. For the termination of second-trimester pregnancy using the combination of mifepristone and misoprostol seems to have the highest efficacy and the shortest time interval of abortion. When mifepristone is not available, misoprostol alone is a good alternative. Misoprostol, 400 μg given vaginally every 3-6 hours, is probably the optimal regimen for second-trimester abortion. More than 800 μg of misoprostol is likely to have more side effects, especially diarrhea. Although misoprostol can be used in women with scarred uterus for termination of second-trimester pregnancy, it is recommended that women with a scarred uterus should receive lower doses and do not double the dose if there is no initial response. It is also important for us to recognize the associated teratogenic effects of misoprostol and thorough consultation before prescribing this medication to patients regarding these risks, especially when failure of abortion occurs, is needed.
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A randomized comparative study on vaginal administration of acetic acid-moistened versus dry misoprostol for mid-trimester pregnancy termination. Arch Gynecol Obstet 2011; 285:311-6. [PMID: 21735193 DOI: 10.1007/s00404-011-1949-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2010] [Accepted: 06/08/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Absorption and effectiveness of vaginally administered misoprostol tablets may vary according to the medium in which it is placed. This study was directed to compare the outcomes of vaginal administrations of acetic acid-moistened misoprostol tablets with those of dry tablets for induction of second-trimester abortion. METHODS A randomized comparative trial where 322 women at 13-20 weeks gestation, requiring medical abortion, were randomly assigned to vaginal administration of either acetic acid-moistened or dry misoprostol tablets with a dose schedule of 400 μg three-hourly, up to a maximum five doses over 24 h. The same doses were repeated for another 24 h in nonresponders. Primary outcome measure was complete abortion rate at 24 and 48 h, and the secondary outcome measures were induction-abortion interval, failure rate and side effects. A difference of 15% in success rates at 24 h was used to calculate the sample size required with a power of 0.8 at the 5% significance level. RESULTS No statistically significant differences in the complete abortion rates were observed at 24 h (70.95 vs. 68.71%, P = 0.675) and at 48 h (86.49 vs. 84.35%, P = 0.604) when both groups were compared. The difference in mean induction-abortion interval was also statistically insignificant between the groups (12.5 ± 1.6 vs. 12.8 ± 1.5 h, P = 0.97). Other outcome measures were also comparable in both groups. CONCLUSION Moistening misoprostol tablets with 5% acetic acid before vaginal application creates no difference in outcomes when compared with those after the vaginal application of dry tablets for the termination of second-trimester pregnancy.
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Association between gestational age and induction-to-abortion interval in mid-trimester pregnancy termination using misoprostol. Eur J Obstet Gynecol Reprod Biol 2011; 156:140-3. [PMID: 21507550 DOI: 10.1016/j.ejogrb.2010.12.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 12/05/2010] [Accepted: 12/23/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The study was aimed to evaluate the effectiveness, outcome, and pain intensity of the vaginal administration of misoprostol for the induction of abortion between 13 and 24 gestational weeks. STUDY DESIGN A retrospective study was conducted at our tertiary medical center from January 2006 to December 2009 on 122 consecutive women who underwent termination of pregnancy (TOP) in the mid-trimester. They were given 400 mcg of vaginal misoprostol every 6h, up to four doses. The induction-to-abortion interval and the level of pain experienced during the process were assessed. Success was defined by the fetus being expelled within 48 h. RESULTS Vaginal misoprostol was effective in 84% (98/122) of patients. The median duration of the induction-to-abortion interval was 16 (5-48)h. The induction-to-abortion interval was correlated with gestational age, while inversely correlated with parity. A correlation was also found between gestational age and pain intensity at 12h from induction. CONCLUSION Misoprostol is safe and effective in mid-trimester abortion induction. The induction-to-abortion interval is shorter and abortion less painful with lower gestational age. Higher parity is also associated with shorter induction to abortion interval.
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Wildschut H, Both MI, Medema S, Thomee E, Wildhagen MF, Kapp N. Medical methods for mid-trimester termination of pregnancy. Cochrane Database Syst Rev 2011; 2011:CD005216. [PMID: 21249669 PMCID: PMC8557267 DOI: 10.1002/14651858.cd005216.pub2] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND With the improvement of ultrasound technology, the likelihood of detection of major fetal structural anomalies in mid-pregnancy has increased considerably. Upon the detection of serious anomalies, women typically are offered the option of pregnancy termination. Additionally, there are still many reasons other than fetal anomalies why women seek abortion in the mid-trimester. OBJECTIVES To compare different methods of second trimester medical termination of pregnancy for their efficacy and side-effects. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, Popline and reference lists of retrieved papers and other sources. SELECTION CRITERIA All randomised controlled trials (RCTs) examining medical regimens for termination of pregnancy of a singleton living fetus between 12-28 weeks' gestation were analysed. The outcome measures were the induction to abortion interval, abortion rate within 24 hours, need for surgical evacuation, blood loss, uterine rupture, pain, and side-effects.Trials including >20% fetal death, multiple pregnancies, previous uterine scars and regimens which involved cervical preparation were excluded. DATA COLLECTION AND ANALYSIS Two authors selected the trials and three authors extracted data. MAIN RESULTS Fourty RCTs were included, addressing various agents for pregnancy termination and methods of administration. When used alone, misoprostol was an effective inductive agent, though it appeared to be more effective in combination with mifepristone. However, the evidence from RCTs is limited.Misoprostol was preferably administered vaginally, although among multiparous women sublingual administration appeared equally effective. A range of doses of vaginally administered misoprostol has been used. No randomised trials comparing doses of misoprostol were identified; however low doses of misoprostol appear to be associated with fewer side-effects while moderate doses appear to be more efficient in completing abortion. Four RCTs showed that the induction to abortion interval with 3-hourly vaginal administration of prostaglandins is shorter than 6-hourly administration without an increase in side-effects.Many studies reported the need for surgical evacuation. Indications for surgical evacuation include retained products of the placenta and heavy vaginal bleeding. Fewer women required surgical evacuation when misoprostol was administrated vaginally compared with women receiving intra-amniotical PGF(2a) . Mild, self-limiting diarrhoea was more common among women who received misoprostol compared to other agents. AUTHORS' CONCLUSIONS Medical abortion in the second trimester using the combination of mifepristone and misoprostol appeared to have the highest efficacy and shortest abortion time interval. Where mifepristone is not available, misoprostol alone is a reasonable alternative. The optimal route for administering misoprostol is vaginally, preferably using tablets at 3-hourly intervals. Apart from pain, the side-effects of vaginal misoprostol are usually mild and self limiting. Conclusions from this review are limited by the gestational age ranges and variable medical regimens, including dosing, administrative routes and intervals of medication, of the included trials.
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Affiliation(s)
- Hajo Wildschut
- Erasmus Medical CenterDepartment of Obstetrics and GynaecologyPO Box 2040RotterdamNetherlands3000 CA
| | - Marieke I Both
- Erasmus Medical CenterDepartment of Obstetrics and GynaecologyPO Box 2040RotterdamNetherlands3000 CA
| | - Suzanne Medema
- Bouman GGZPieter de Hoogh Weg 14RotterdamNetherlands3024 BH
| | - Eeke Thomee
- The Royal Marsden HospitalFulham RoadLondonUKSW 3
| | - Mark F Wildhagen
- Erasmus Medical CenterDepartment of Urology and Obstetrics and GynecologyPO Box 2040RotterdamNetherlands3000 CA
| | - Nathalie Kapp
- World Health OrganizationDepartment of Reproductive Health and Research20 Rue AppiaGeneva 27SwitzerlandCH‐1211
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CABRERA Y, FERNÁNDEZ-GUISASOLA J, LOBO P, GÁMIR S, ÁLVAREZ J. Comparison of sublingual versus vaginal misoprostol for second-trimester pregnancy termination: A meta-analysis. Aust N Z J Obstet Gynaecol 2011; 51:158-65. [DOI: 10.1111/j.1479-828x.2010.01264.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Baggaley RF, Burgin J, Campbell OMR. The potential of medical abortion to reduce maternal mortality in Africa: what benefits for Tanzania and Ethiopia? PLoS One 2010; 5:e13260. [PMID: 20948995 PMCID: PMC2952582 DOI: 10.1371/journal.pone.0013260] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 09/15/2010] [Indexed: 01/23/2023] Open
Abstract
Background Unsafe abortion is estimated to account for 13% of maternal mortality globally. Medical abortion is a safe alternative. Methods By estimating mortality risks for unsafe and medical abortion and childbirth for Tanzania and Ethiopia, we modelled changes in maternal mortality that are achievable if unsafe abortion were replaced by medical abortion. We selected Ethiopia and Tanzania because of their high maternal mortality ratios (MMRatios) and contrasting situations regarding health care provision and abortion legislation. We focused on misoprostol-only regimens due to the drug's low cost and accessibility. We included the impact of medical abortion on women who would otherwise choose unsafe abortion and on women with unwanted/mistimed pregnancies who would otherwise carry to term. Results Thousands of lives could be saved each year in each country by implementing medical abortion using misoprostol (2122 in Tanzania and 2551 in Ethiopia assuming coverage equals family planning services levels: 56% for Tanzania, 31% for Ethiopia). Changes in MMRatios would be less pronounced because the intervention would also affect national birth rates. Conclusions This is the first analysis of impact of medical abortion provision which takes into account additional potential users other than those currently using unsafe abortion. Thousands of women's lives could be saved, but this may not be reflected in as substantial changes in MMRatios because of medical abortion's demographic impact. Therefore policy makers must be aware of the inability of some traditional measures of maternal mortality to detect the real benefits offered by such an intervention.
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Affiliation(s)
- Rebecca F Baggaley
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom.
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Napolitano R, Thilaganathan B. Late termination of pregnancy and foetal reduction for foetal anomaly. Best Pract Res Clin Obstet Gynaecol 2010; 24:529-37. [PMID: 20350838 DOI: 10.1016/j.bpobgyn.2010.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Accepted: 02/04/2010] [Indexed: 11/25/2022]
Abstract
Late termination of pregnancy is a relatively rare procedure accounting for approximately 1% of all registered terminations in England and Wales; however, with improving detection rates for foetal anomalies, this number is increasing. Surgical dilation and evacuation (D&E) appears to be a safe and cost-effective procedure as long as the clinical expertise exists to provide this service. Medical termination appears equally safe and is best undertaken with the combined use of mifepristone and misoprostol. Foeticide, when required, should be performed from 22 weeks' gestation using strong KCl administered either by cardiocentesis or by cordocentesis. All women should be offered a post-mortem and any other appropriate investigation to allow accurate counselling regarding future pregnancies. The issue of late selective foetal reduction for foetal abnormality is complicated by the need to balance the risks to the healthy co-twin of expectant management versus selective termination.
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Geels YP, de Gouberville MCG, Visser L, van Asten HA. Comparing vaginal and sublingual administration of misoprostol for labour induction in women with intra-uterine fetal death. Trop Doct 2010; 40:77-80. [PMID: 20305098 DOI: 10.1258/td.2009.090339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The objective of this study was to compare complications and effectiveness of induction after vaginal and sublingual administration of misoprostol for labor induction in women with intra-uterine fetal death (IUFD). In a district hospital in Ghana, 23 women with IUFD who underwent labor induction with sublingual misoprostol were compared with a control group of 21 women who received vaginal misoprostol. In the vaginal group 28.6% had one or more complications compared to 21.7% in the sublingual group. In the sublingual group three inductions did not lead to delivery within 48 hours (13%), compared to four in the other group (19%). The mean induction-to-delivery time in the sublingual group was 13 hours and 17 hours in the vaginal group. In this study, both sublingual and vaginal misoprostol were safe and efficient for labor induction in women with IUFD. However, more research on larger numbers of patients is needed, in order to compare complications.
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Affiliation(s)
- Yvette Pernella Geels
- Radboud University Nijmegen Medical Centre, Nijmegen Institute for International Health, Nijmegen, The Netherlands.
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Yilmaz B, Ertas IE, Kelekci S, Sut N, Mollamahmutoglu L, Danisman N. Moistening of misoprostol tablets with acetic acid prior to vaginal administration for mid-trimester termination of anomalous pregnancy: A randomised comparison of three regimens. EUR J CONTRACEP REPR 2010; 15:54-9. [DOI: 10.3109/13625180903417486] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Dickinson JE, Doherty DA. Optimization of third-stage management after second-trimester medical pregnancy termination. Am J Obstet Gynecol 2009; 201:303.e1-7. [PMID: 19632665 DOI: 10.1016/j.ajog.2009.05.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Revised: 04/26/2009] [Accepted: 05/22/2009] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Comparison of 3 regimens for third-stage management after second-trimester intravaginal misoprostol termination. STUDY DESIGN Prospective randomized trial. Three third-stage management strategies were compared: 10 units of intramuscular oxytocin (group 1), 600 microg oral misoprostol (group 2), or no additional medication (group 3) after fetal expulsion. Primary study outcome was the incidence of placental retention. RESULTS Two hundred fifty-one women were randomly assigned to the groups. There was a significant difference in placental retention rates: group 1, 8 of 83 (10%) vs group 2, 24 of 83 (29%) vs group 3, 26 of 85 (31%); P = .002. Blood loss was significantly lower in group 1, 100 mL (interquartile ranges, 50-200) vs group 2, 200 mL (interquartile ranges, 100-370) vs group 3, 200 mL (interquartile ranges, 100-375); P < .001. Requirement for blood transfusion: group 1, 1 of 83 (1%) vs group 2, 1 of 83 (1%) vs group 3, 5 of 85 (6%); P = .103. CONCLUSION Intramuscular oxytocin administered after fetal delivery after second-trimester medical termination significantly increases placental expulsion rates and decreases short-term postpartum blood loss.
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Affiliation(s)
- Jan E Dickinson
- School of Women's and Infants' Health, The University of Western Australia, and The Women and Infants' Research Foundation, Perth, Western Australia
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Diop A, Raghavan S, Rakotovao JP, Comendant R, Blumenthal PD, Winikoff B. Two routes of administration for misoprostol in the treatment of incomplete abortion: a randomized clinical trial. Contraception 2009; 79:456-62. [PMID: 19442782 DOI: 10.1016/j.contraception.2008.11.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Revised: 11/26/2008] [Accepted: 11/27/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND This study was conducted to compare the safety, effectiveness and acceptability of 400 mcg sublingual misoprostol and 600 mcg oral misoprostol for treatment of incomplete abortion. STUDY DESIGN We used an open-label randomized controlled trial conducted from July 2005 to August 2006 in a large tertiary level maternity hospital in Antananarivo, Madagascar, and a large tertiary level hospital in Chisinau, Moldova. Three hundred consenting women seeking treatment for clinically diagnosed incomplete abortion with uterine size <or=12 weeks since last menstrual period were randomized to misoprostol either 600 mcg orally or 400 mcg sublingually. The primary outcome measure was the complete resolution of clinical signs and symptoms of incomplete abortion without need for surgical intervention. Women were seen for follow-up on Day 7 and, if necessary, on Day 14 to assess abortion status. The study was powered to detect a 7% difference in efficacy with a total of 142 women required in each arm. RESULTS Efficacy rates were 94.6% and 94.5%, for the oral and sublingual routes, respectively (RR: 1.00, 95% CI=0.95-1.06, p=.98). At 1 week follow-up, more than 80% of women had completed abortions (77.8% oral and 84.8% sublingual, p=.12). Mean pain scores were 2.95 and 3.04, respectively, for the oral and sublingual groups. Side effects included abdominal pain, bleeding, headaches and dizziness/weakness with no differences reported between the two groups. Acceptability and satisfaction were high for both routes and women indicated a preference for medical versus surgical treatment if ever needed in the future. CONCLUSIONS Both treatment regimens were very effective. Four hundred micrograms of sublingual misoprostol and 600 mcg oral misoprostol appear to have similar safety and effectiveness profiles when used for the treatment of incomplete abortion. A lower 400-mcg misoprostol dose may provide an alternative treatment option as well as have potential benefits in terms of cost.
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Affiliation(s)
- Ayisha Diop
- Gynuity Health Projects, New York, NY 10010, USA.
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Caliskan E, Doger E, Cakiroglu Y, Corakci A, Yucesoy I. Sublingual misoprostol 100 microgram versus 200 microgram for second trimester abortion: a randomised trial. EUR J CONTRACEP REPR 2009; 14:55-60. [DOI: 10.1080/13625180802360865] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Karsidag AYK, Buyukbayrak EE, Kars B, Dansuk R, Unal O, Turan MC. Vaginal versus sublingual misoprostol for second-trimester pregnancy termination and effect on Doppler measurements. Int J Gynaecol Obstet 2009; 106:250-3. [DOI: 10.1016/j.ijgo.2009.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 03/17/2009] [Accepted: 04/01/2009] [Indexed: 11/29/2022]
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