Vaginal misoprostol for early second-trimester abortion

An analysis of misoprostol effectiveness in second trimester pregnancy terminations

Background/Aim: Misoprostol is frequently used as a single agent in pregnancy terminations. However, it increases the risk of uterine rupture in patients who have had previous uterine surgery and terminations due to stillbirths. Therefore, it is used with concern by clinicians. The aim of this study was to evaluate the clinical features of the groups that responded and did not respond to termination treatment with misoprostol in a tertiary center and to investigate its efficacy and safety. Methods: The study design was comprised of a retrospective cohort study. A total of 114 second trimester pregnancies (between 13-24 weeks gestational age) were included in the study. These pregnancies were indicated for termination based on the prenatal diagnosis unit for fetal or maternal causes. According to the International Federation of Gynecology and Obstetrics (FIGO) directions, misoprostol was applied in the following dosages: for 13-17 weeks gestational ages, one tablet per 6 hours; for 18-26 gestational ages, ½ tablet per 6 hours; and for other indications 2 tablets per 3 hours were administered. If the patient had had a previous cesarean operation, all doses were halved. After the first 24 hours, the percentage and demographics results, such as age, body mass index (BMI), gravida, number of cesareans, number of curettages, cervical lengths, BISHOP scores, gestational age, amniotic fluid index, and fetal cardiac beat of the patients with miscarriage, were recorded. Results: The number of cases resulting in miscarriage within 24 hours were 84 (73.7%) and within 48 hours were 14 (12.2%). The total of misoprostol doses used were 8 tablets of 200 mg, mean time until the complete abortion was 17 hours. Sixteen patients required additional treatment, of whom four required Foley catheterization, five required D&E, seven required resting, and no one required a hysterectomy. Uterine rupture occurred in two patients who needed laparotomic surgery. The maternal age (P=0.340), BMI (P=0.790), gravida (P=0.270), previous cesarean history (P=0.390), previous curettage number (P=0.520), cervical length (P=0.380), Bishop score (P=0.190), gestational age (P=0.072), amniotic fluid index (P=0.470) and presence of fetal cardiac beat (P=0.350) were similar between groups Conclusion: Our results indicated that misoprostol is a safe, useful, and effective treatment option for second trimester medical terminations. Caution should be exercised in its use in patients with a history of uterine surgery.

Thalidomide and misoprostol: Ophthalmologic manifestations and associations both expected and unexpected

Thalidomide is a very potent teratogen capable of causing severe systemic malformations if the fetus is exposed during the sensitive period. Although structural anomalies of the eye can occur from thalidomide exposure, the most frequent eye complication is secondary to damage to the cranial nuclei in the brain stem, resulting in aberrant neurologic connections causing a condition of abnormal ocular movement, Duane syndrome. A less frequent anomalous neurologic complication is tearing when eating (paradoxical gustolacrimal tearing or "crocodile tears") or lack of emotional tearing. The involvement of the 6th and 7th cranial nerves, often seen together in the thalidomide-affected individual, is also characteristic of Möbius syndrome/sequence. This syndrome usually occurs sporadically, but characteristic findings of this condition have also been observed in South American children who were born after an unsuccessful attempt to induce abortion with the prostaglandin drug misoprostol (Cytotec). Aberrant tearing also occurs in some individuals with Möbius syndrome. Autism spectrum disorder (ASD), an unexpected associated finding in a Swedish thalidomide study, is now also noted in Möbius studies, in patients both with and without exposure to misoprostol.

Vaginal misoprostol 800 μg every 12 h for second-trimester abortion

The objective of the study was to evaluate the efficacy and safety of 800 microg misoprostol every 12 h, up to three doses, for pharmacological second-trimester abortion. The misoprostol doses were always administered by doctors into the vagina. Two-hundred and sixty-nine women with gestations within 12 and 20 weeks were recruited into the study. The main outcomes measured were successful abortion (passage of fetus and placenta without surgery), side effects and mean drop in hemoglobin, vaginal bleeding and mean time of return of menstruation. Complete abortion occurred in 245/269 (91.1%, 95% confidence interval 87-94%) patients. Vaginal bleeding lasted 15.7 +/- 4.1 days. The mean drop in hemoglobin, calculated 24 h after abortion, were statistically significant (p = 0.0001), as also was the mean hemoglobin measured 14 days after abortion, but without clinical relevance. According to the results obtained, 800 microg of misoprostol administered every 12 h, up to a maximum of three doses, could be a valid method for abortion within 12 and 20 weeks of gestation.

[Medical termination of pregnancy at 9-14 weeks gestation. Prospective study of 105 cases in Saint-Laurent-du-Maroni (French Guyana)]

OBJECTIVES

To demonstrate the effectiveness and safety of mifepristone 600mg with misoprostol 800 mg, for termination of pregnancy at 9-14 weeks gestation.

PATIENTS AND METHODS

This prospective study included 105 women at 9 to 14 weeks gestation given 800 mg of vaginal misoprostol, 2 or 3 days after a single dose of 600 mg of mifepristone for pregnancy termination. Outcomes measures included mean expulsion time, the interval between fotal and placental expulsion, adverse effects, vaginal bleeding, requirement for analgesia, and hospital stay, analyzed by parity and gestational age.

RESULTS

Pregnancy termination was successful in 92.4% of the patients without requirement for surgery. The mean time to expulsion was 6 hours. The fetus and placenta were expelled together in 79% of the cases. In 15% the conception products were retained in the cervical canal, and removed with a ring forceps. Additional misoprostol doses were necessary in 33% and analgesia (nalbuphine sublingually, mean dose was 10mg) in 56%. Significant bleeding was observed in 7.5%, leading to curettage in 2 patients. No statistically significant differences were found between the rate of success and term (9-12 versus 12-14) or parity.

CONCLUSION

Combining oral mifepristone and vaginal misoprostol is a successful alternative to surgical termination of pregnancy, even after 9 weeks' gestation. The use of nalbuphine for analgesia improves acceptability; sublingual administration helps avoid invasive procedures. Before 14 weeks gestation, the legal limit for termination of pregnancy in France, the choice between the surgical and medical alternatives should be left to the patient.

Prostaglandins for first-trimester termination

Since the 1980s, when mifepristone combined with a prostaglandin was found to be safe and effective for early abortion, many studies have refined the regimens and investigated alternatives such as methotrexate plus misoprostol, and misoprostol alone. Evidence now demonstrates that more than 200 mg of mifepristone provides no additional benefit, that vaginal misoprostol is superior to oral, especially between 7 and 9 weeks' gestation, and that misoprostol may be safely self-administered at home. Buccal and sublingual routes of administration of misoprostol also are promising. Absolute contraindications to medical abortion arise infrequently. Gastrointestinal and other side-effects occur in about one-third of women, primarily after administration of the prostaglandin. Careful assessment before and after medical abortion is essential and can be accomplished in various ways, depending on the skills of the clinician.

A randomized comparison of two regimens of misoprostol for second-trimester pregnancy termination

OBJECTIVE

The purpose of this study was to compare the efficacy and side effects of two different misoprostol regimens for second-trimester pregnancy termination.

STUDY DESIGN

We performed a randomized clinical trial in patients who were at 14 to 23 weeks of gestation and who were admitted for medical termination of pregnancy. All patients received 800 microg of vaginal misoprostol and were assigned randomly to 400 microg of oral misoprostol or 400 microg of vaginal misoprostol every 8 hours. Efficacy and side effects were compared. The mean induction time of the study group was compared with that of an historic control group that had received 400 microg vaginally every 12 hours.

RESULTS

Forty-three women were assigned randomly, 22 women to vaginal misoprostol and 21 women to oral misoprostol. Induction time and hospital stay were slightly shorter for the oral group; however, the differences were not significant. Side effects were similar for both groups.

CONCLUSION

After an initial 800 microg dose of vaginal misoprostol, a regimen of 400 microg of oral misoprostol every 8 hours is as effective as the same dose of vaginal misoprostol with no additional side effects, which provides a convenient alternative for midtrimester pregnancy termination.

Vaginal misoprostol 1000 μg for early abortion

The objective of this study was to evaluate the safety and efficacy of 1000 microg misoprostol vaginally (Cytotec) self-administered into the vagina for medical abortion. Three-hundred women with gestations between 42 and 63 days, with previous written consent, received vaginal misoprostol every 24 h up to a maximum of three doses for abortion. Outcome measures assessed included: successful abortion (complete abortion without surgery), side effects, decrease in hemoglobin, mean time of vaginal bleeding, mean expulsion time and mean time of returning of menses. Complete abortion occurred in 279/300 (93.0%, 95% CI 90, 96) patients. Medication to relieve symptoms was administered to all subjects after every misoprostol dose. Vaginal bleeding lasted 14.7 +/- 5.4 days. Mean expulsion time was 8.1 +/- 3.0 h for those who aborted after the first misoprostol dose. The mean drop in hemoglobin was statistically significant (p = 0.0001) but without clinical relevance. The frequencies of nausea and diarrhea were high. According to the observed outcomes, 1000-microg misoprostol vaginally could be a valid method to terminate pregnancies up to nine weeks gestation.

Use of misoprostol in obstetrics and gynecology

Misoprostol is prostaglandin E1 analogous and marketed for prevention and treatment of peptic ulcer disease. However, it has been used widely in obstetrics and gynecology practice because of its effectiveness, low cost, stability in light and hot climate conditions, and ease of administration compared with its licensed counterparts--dinoprostone and gemeprost. A large number of studies have shown that misoprostol is effective in first and second trimester abortion, late pregnancy labor induction, and third stage of labor management (misoprostol has not been approved by the U.S. Food and Drug Administration for these indications). Because misoprostol is not registered for such use, it has not undergone the extensive testing for appropriate dosage and safety required for registration. Serious complications such as teratogenesis after failed abortions and uterine rupture during second trimester abortions and third trimester labor induction have been reported as the result of increasingly wide use of misoprostol in obstetric and gynecology practice. There is an urgent need to evaluate all the available data and organize a large randomized trial to determine the safety of its use in obstetric and gynecology practice.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to identify the various uses of misoprostol, to describe the potential complications of misoprostol use and its teratogenic effects, to compare the various routes of administration, and to define the appropriate dose.

Vaginal misoprostol 600 microg for early abortion

The objective of this study was to evaluate the efficacy and safety of the vaginal self-administration of 600 microg misoprostol up to a maximum administration of three doses in a 24-h period, one every 8 h, for abortion up to 9 weeks' gestation. A group of 90 voluntary women with gestations from 35 to 63 days participated in the study. All women who aborted received a single additional dose of 600 microg misoprostol. Outcome measures included successful abortion (complete abortion without requiring surgical procedure) and side-effects. Complete abortion occurred in 57/89 (64%, 95% confidence interval 53-74%) subjects. The mean expulsion time was 7.4 +/- 3.8 h (median 7.2 h, range 3-20 h) for all women who aborted within the first 24 h of the administration of misoprostol. Thirty-two cases failed to abort, 28 cases due to failure of the method, of which 24 had a negative cardiac rhythm after the third dose, and four cases due to the doctor's decision. The results obtained in this study led us to the conclusion that the 600-microg misoprostol dose regimen was not adequate to produce a high or an acceptable abortive efficacy.

Genetic abortion: considerations for patient care

Women who receive abnormal prenatal diagnosis results potentially face two emotionally difficult decisions. In this article, the first decision--whether or not to terminate the pregnancy--is presented with a discussion of the factors that may influence a women's choice. Women who choose to terminate the pregnancy face a second decision when more than one type of abortion procedure is available. Two second trimester abortion procedures--dilation and evacuation and labor induction--are compared and contrasted to delineate potential advantages and disadvantages of each. The decision-making process is examined, emphasizing the individual ways in which women may weigh this information to make a fully informed decision. In addition, a number of recommendations are offered to health care providers in the role of discussing options and supporting women in their choices.

Early abortion with 800 micrograms of misoprostol by the vaginal route

The objective of this study was to confirm the effectiveness and safety of self-administration of misoprostol every 24 h, for abortion up to 9 weeks of gestation. A group of 720 volunteer subjects with gestations from 35 to 63 days received 800 micrograms of vaginal misoprostol every 24 h up to a maximum of three main doses for abortion. Outcome measures assessed included successful abortion (complete abortion without requiring surgery), side effects, decrease in hemoglobin, mean time of vaginal bleeding, and mean time of return of menses. Complete abortion occurred in 644 of 720 (89.4%, 95% CI 87, 92) subjects. The mean decrease in hemoglobin was statistically significant (p = 0.0001). There were 14 subjects with clinically significant decreases in hemoglobin, but only two required transfusions. Vaginal bleeding lasted 6.7 +/- 3.9 days, spotting 8.1 +/- 4 days, and total bleeding 14 +/- 5.3 days. Mean expulsion time was 8.0 +/- 3.4 h. Although mifepristone remains unavailable, given the low price and availability of misoprostol in > 72 countries of the world, this latter drug constitutes an abortion alternative, provided that a minimum clinical network is nearby or accessible.

Vaginal misoprostol for abortion at 10-13 weeks' gestation

OBJECTIVE

The effectiveness and safety of misoprostol have been reported for abortion up to 22 weeks' gestation. The objective of this study was to demonstrate the effectiveness and safety of self-administration of misoprostol every 12 h, without the need of postexpulsion systematic curettage, in late first-trimester abortions (10-13 weeks' gestation).

METHODS

A group of 180 women with gestations from 64 to 91 days, self-administered 800 micrograms of vaginal misoprostol every 12 h for a maximum of three doses without performing postexpulsion systematic preventive curettage. Outcome measures included successful abortion (complete and incomplete abortion without requiring a surgical procedure), side-effects, mean expulsion time and vaginal bleeding.

RESULTS

Successful abortion occurred in 153/180 (85%) subjects (95% confidence interval (CI) 79-90). The decrease of hemoglobin was statistically significant (p = 0.0001) but clinically unimportant: 12.1 mg/dl (SD 1.1) before treatment and 11.7 mg/dl (SD 1.1) afterwards. The mean expulsion time for patients who aborted after the first dose was 8.3 +/- 3.6 h (median 8 h, range 2-12 h). Vaginal bleeding lasted 6 +/- 3 days, spotting 7 +/- 3 days and total bleeding 13 +/- 4 days. The median dose of misoprostol administered was 1780 micrograms (range 1400-3000 micrograms).

CONCLUSIONS

The high degree of acceptability, its efficacy and the fact that postabortion systematic curettage was not needed make misoprostol a suitable alternative to the currently available methods for termination of pregnancy at 10-13 weeks' gestation.