Congenital abnormalities in Brazilian children associated with misoprostol misuse in first trimester of pregnancy

BACKGROUND

Misoprostol is commonly used to induce abortion in Brazil, and in other countries in South and Central America where abortions are illegal. However, misoprostol is not very effective in inducing abortions, and exposure to the drug in utero can cause abnormalities in the fetus. We aimed to define the common phenotypical effects of exposure to the drug.

METHODS

We studied 42 infants from São Paulo, Brazil, who were exposed to misoprostol during the first 3 months of gestation, and then born with congenital abnormalities. We interviewed each of the infants' mothers to find out about misoprostol exposure and dosage. Each infant was physically examined by a geneticist or a neuropaediatrician.

FINDINGS

17 of the infants had equinovarus with cranial-nerve defects. Ten children had equinovarus as part of more extensive arthrogryposis. The most distinctive phenotypes were arthrogryposis confined to the legs (five cases) and terminal transverse-limb defects (nine cases) with or without Mobius sequence. The most common dose of misoprostol taken was 800 microg (range 200-16000 microg).

INTERPRETATION

Deformities attributed to vascular disruption were found in these children. We suggest that the uterine contractions induced by misoprostol cause vascular disruption in the fetus, including brain-stem ischaemia. Information on the effects of taking misoprostol during pregnancy should be made more widely available, to dissuade women from misusing the drug.

Methotrexate and misoprostol for early abortion

Methotrexate is cytotoxic to trophoblast and, in low doses, has minimal side effects. It is used to treat both gestational trophoblastic neoplasia and ectopic pregnancy. The cytotoxic effects of methotrexate on intrauterine trophoblast should be equivalent. To test this hypothesis, ten pregnant women, < 8 weeks' gestation were treated with methotrexate 50 mg/m2 intramuscularly followed 3 days later by misoprostol, a prostaglandin E1 analogue. The first 4 patients received misoprostol 600 micrograms orally; none aborted soon after the misoprostol. Two patients aborted 25 and 26 days after the methotrexate injection and two elected a suction abortion after 14 days (one by choice and one because the pregnancy was still viable). The last 6 patients received misoprostol 800 micrograms vaginally and aborted within 3-8 hours. One patient had an incomplete abortion requiring a suction curettage 34 days after the misoprostol. Vaginal bleeding for these 6 patients lasted an average of 29 +/- 11 days (range, 12-42 days). No methotrexate side effects were observed. Vaginal misoprostol (800 micrograms) was significantly more effective (p = 0.005) than oral misoprostol (600 micrograms) in effecting abortion after intramuscular methotrexate.

Pregnancy termination with a high and medium dosage regimen of RU 486

Sixty healthy pregnant women who wished to terminate their pregnancy and who were no more than 49 days pregnant were treated with one of three different dose regimens of a synthetic progesterone receptor blocker, RU 486. Serum cortisol was measured to determine the antiglucocorticoid effects of this compound. The high dose but shorter treatment regimen (400 mg/day RU 486 X 4 days or 200 mg/day X 4 days) was associated with a high (greater than 80%) rate of side effects, especially nausea, vomiting, weakness and heavy bleeding and a low rate of success (10%). A group of 50 subjects received the medium dose but longer treatment regimen (100 mg/day X 7 days). This group had less side effects (40-60%) and a 72.3% success rate of complete abortion. The AM cortisol values were significantly elevated in all treatment groups but higher in those receiving the high dose. These values returned to normal one week following cessation of treatment. Medium dose but longer duration (100 mg/day X 7 days) of RU 486 treatment is associated with a higher success rate and less side effects than higher dose therapy administered over a shorter period. There were no predictive indices to determine which subjects would respond successfully. The reason for the failure of the drug in 30% of the subjects on the medium dose is not known at this time.

Early abortion with a single dose of the antiprogestin RU-486

RU-486 is a synthetic progesterone antagonist that is abortifacient in early pregnancy. This trial evaluated the effectiveness and safety of a single 600 mg oral dose given to 50 healthy women less than or equal to 49 days from their last menstrual period. Efficacy was inversely related to the initial beta-subunit of human chorionic gonadotropin level, ranging from 100% at less than 5000 mIU/ml to 81% at greater than 20,000 mIU/ml (p less than 0.05). Uterine bleeding was the most serious side effect. However, the mean change in the hemoglobin value 14 days after treatment was -0.4 gm/dl, and no patient required blood transfusion. This regimen appears to be simple, effective, and safe.

Abortion induced with methotrexate and misoprostol: a comparison of various protocols

Seven hundred fifty-six women had abortions induced with methotrexate and misoprostol. Various protocols were compared. In Group 1, phase 1, after receiving 50 mg/m2 methotrexate IM, 289 women were randomized to receive either 750 or 500 micrograms of vaginal misoprostol. In Group 1, phase 2, 84 women who had failed to abort after one dose of misoprostol were randomized to receive either vaginal or oral routes for the second dose of misoprostol given on Day 8. In Group 2, a cohort of 226 women who received 60 mg/m2 methotrexate were compared to the 289 women who received 50 mg/m2 in Group 1. There were no differences in rates of effectiveness in the various trial groups. Side effects were greater with 60 mg/m2 of methotrexate. In Group 3, a cohort of 241 women received the misoprostol in three vaginal doses 8 hr apart starting on Day 5, and were compared to the 289 women in Group 1 receiving one vaginal dose. In women whose medical abortion failed, fetuses were found to have limb abnormalities In the total group of 756 women, 88.8% aborted successfully without surgical aspiration, with only minor side effects, and the acceptance rate was high. This study indicates that medical abortions induced with methotrexate and misoprostol are safe and effective, but more research is needed to find a more effective protocol.

Oral methotrexate and vaginal misoprostol for early abortion

Intramuscular methotrexate followed by vaginal misoprostol has been shown to be effective for abortion at < or = 49 days gestation. Oral dosing of the methotrexate may offer advantages over parenteral dosing. This pilot study was performed to evaluate if oral methotrexate would be effective when combined with vaginal misoprostol to effect abortion at < or = 49 days gestation. Twenty pregnant women were randomized to receive methotrexate 25 mg or 50 mg followed 7 days later by misoprostol 800 micrograms vaginally. The misoprostol dose was repeated the next day if the abortion did not occur. Complete abortion occurred in all subjects in both groups within 20 days after the methotrexate. However, women in the 50 mg group passed the pregnancy within 24 hours of the first or second dose of methotrexate more often than women in the 25 mg group (80% vs. 50%, p = 0.35). Vaginal bleeding lasted 12.1 +/- 3.1 days and 9.4 +/- 4.5 days in immediate success and delayed success patients, respectively. Oral methotrexate may be an effective alternative to intramuscular methotrexate in treatment regimens for nonsurgical abortion.

The antiprogestational agent RU 486 as an abortifacient in early human pregnancy: a comparison of three dose regimens

Three different regimens of RU 486, a progesterone receptor blocking agent, were compared for their ability to terminate early human pregnancy. One-hundred-fifty-three healthy women with a gestational length less than 49 days from the last menstrual period were recruited to the study and randomly allocated to one of three treatment regimens: 1) RU 486 10 mg x 2 for seven days; 2) RU 486 25 mg x 2 for seven days; or 3) RU 486 50 mg x 2 for seven days. No significant difference in efficacy was seen between the three dose regimens. Treatment with 10 mg x 2 x VII resulted in 73 per cent complete abortions, 25 mg x 2 x VII in 66 per cent and 50 mg x 2 x VII in 64 per cent complete abortions. Response to treatment, measured as reported onset of bleeding and passage of products of conception, however, occurred significantly later on the 10 mg x 2 regimen than on the other two dose regimens. In each treatment group, women who subsequently aborted completely had significantly lower pretreatment levels of hCG than women with incomplete abortion or continuing pregnancy. The treatment was well tolerated by the women and except for one woman who experienced a profound bleeding necessitating a blood transfusion, no serious side effects were seen.

Plasma levels of progesterone during the luteal phase in normal women treated with synthetic oestrogens (RS 2874, F 6103 and ethinyloestradiol)

Three synthetic oestrogens (RS 2874, F 6103 and ethinyloestradiol)1) were given orally during the luteal phase to healthy young women. The compounds were administered for various periods of time starting on the third day following ovulation. The changes of the daily plasma levels of progesterone and the length of the luteal phase were studied. The highest dose of RS 2874 was 60 mg daily for 8 days, that for F 6103, 300 mg daily for 6 days and that for ethinyloestradiol, 200 μg daily for 8 days. The doses were selected to give approximately the same oestrogenic effects in women, using the proliferative activity of the endometrium as an end point. In the cycles treated with RS 2874 and ethinyloestradiol the length of the luteal phase was shortened by one to two days and the sum of the daily plasma levels of progesterone was decreased accordingly. No differences were seen between the control cycles and the cycles treated with F 6103. The doses of the three compounds used did not seem to delay the onset of menstrual bleeding. The lack of antifertility effect of F 6103 and of ethinyloestradiol when given after ovulation as reported by other investigators, agree well with the minor changes in the corpus luteum function found in this study.

Termination of early pregnancy by the 3 beta-hydroxysteroid dehydrogenase inhibitor epostane

Progesterone is essential to sustain pregnancy in the first eight weeks. Its synthesis requires the enzyme 3 beta-hydroxysteroid dehydrogenase (3-HSD). We tested the efficacy of an orally administered 3-HSD inhibitor, epostane, in terminating unwanted early pregnancy. Fifty women in the fifth through eight weeks of pregnancy took epostane (200 mg orally every six hours) for seven days. By day 14, pregnancy had been terminated in 42 of the 50 patients (84 percent). Eight women (16 percent) did not abort and underwent dilation and curettage. Vaginal blood loss occurred on average on the third day of epostane treatment, and abortion on the fifth day. Two patients had incomplete abortions; one required a transfusion because of blood loss. Nausea was frequent (in 86 percent), but 76 percent of the participants concluded that epostane was preferable to dilation and curettage. The mean (+/- SD) pretreatment progesterone level (76 +/- 16 nmol per liter) decreased by day 7 (to 16 +/- 11 nmol per liter) and day 14 (to 10 +/- 9 nmol per liter) in those who aborted; levels of human chorionic gonadotropin also decreased from the mean at base line (73 +/- 72 kIU per liter) to 18 +/- 7 kIU per liter on day 7 and 9 +/- 5 kIU per liter on day 14. In those who did not abort after epostane treatment, progesterone levels decreased only slightly by day 7 (to 52 +/- 21 nmol per liter) and rose again (to 81 +/- 18 nmol per liter) by day 14. Among women who responded to epostane, normal menstrual periods had resumed by day 42 after the beginning of treatment in 72 percent. We conclude that epostane taken orally is an effective and safe method for the noninvasive termination of undesired early pregnancy.

Termination of second trimester pregnancy with gemeprost and misoprostol: a randomized double-blind placebo-controlled trial

A prospective randomized double-blind placebo-controlled trial was conducted in 70 subjects to determine whether pre-treatment with misoprostol could facilitate termination of second trimester pregnancy by gemeprost. The women received either 400 micrograms oral misoprostol or placebo tablets 12 hours before the administration of vaginal pessary of gemeprost 1 mg every 3 hours. There were no significant differences in induction-abortion interval and the amount of gemeprost required between the misoprostol and the placebo group. There was no significant difference in the incidence of side effects or analgesic requirement between the two groups. We conclude that oral misoprostol is not useful in facilitating termination of second trimester pregnancy by gemeprost.

A pilot study of acceptability of RU486 and ONO 802 in a Chinese population

RU486 and ONO 802 in combination have been shown to be effective in early termination of pregnancy. Anecdotal information suggests that Chinese women have been using herbs to induce abortion, believing that such medication and means of abortion is less harmful to the body than surgery. Hence, a medical means of abortion using RU486 and ONO 802 may be the method of choice for some Chinese women. A pilot study involving 42 Chinese women in Hong Kong was conducted to explore the reasons for acceptance or refusal of RU486 and ONO 802 as abortifacient agents. It was found that more single women chose the medical method for abortion, the main reasons being fear of trauma to the body due to surgery and the feeling of having undergone menstrual regulation rather than having had an abortion with the medical method. Those who refused the treatment were worried about the efficacy and side effects of the new drugs and the long induction-abortion interval. There were 3 failures in the medical group of 23 women. All these 23 women were gland they had chosen the medical abortion method. Twenty-one out of the 23 women said they would choose the same abortion method again. The practice of the use of Chinese herbs was not more common in this group of women as compared to women who did not choose this method of abortion.

Termination of second trimester pregnancy with gemeprost vaginal pessaries and intra-amniotic PGF2 alpha. A comparative study

152 women admitted for legal abortion in the second trimester of pregnancy were included in an open, randomized, controlled six-centre study. 75 patients received gemeprost 1 mg vaginal pessaries at 3 hours intervals up to a maximum of 5 mg and 66 patients were treated with a single 40 mg intra-amniotic dose of PGF2 alpha. The 24-hour success rate was 81% (n = 61/75) in the gemeprost and 64% (n = 42/66) in the PGF2 alpha group (p less than 0.02). The mean abortion times were 14.3 and 14.8 hours in the gemeprost and the PGF2 alpha groups, respectively. The mean time to onset of pain was shorter and more patients experienced blood loss over 100 ml during the induction in the PGF2 alpha group than in the gemeprost group (p less than 0.02). Apart from that, the nature and severity of side effects were comparable between the two groups. Besides significantly better efficacy, the non-invasive gemeprost treatment was found to be easier and safer as compared to the PGF2 alpha treatment.

Effects of Epostane on progesterone synthesis in early human pregnancy

Healthy women requiring abortion in early normal pregnancy were recruited to study the abortifacient effects of different doses of Epostane, an inhibitor of 3 beta-hydroxy steroid dehydrogenase, that previously has been shown to interfere with progesterone production in the luteal phase of humans and to have abortifacient effects in animals. A single dose of 100 mg resulted in decreasing progesterone and estradiol, which rapidly recovered, and none of the women started to bleed. Repeated doses of 50 or 100 mg during one day resulted in a more pronounced decrease in both progesterone and estradiol, but no bleeding. When treatment was prolonged over several days with 100 mg X 4 for five days and 400 mg X 2 for four days, respectively, a suppression of progesterone and estradiol was found and two out of four and eight out of ten women started to bleed and subsequently aborted. The treatment was well tolerated by most of the women. Routine laboratory parameters remained unaltered throughout treatment. Cortisol levels remained within the normal range.

Potassium permanganate induced oesophageal stricture

A case of oesophageal stenosis following ingestion of potassium permanganate as an abortifacient is described.

Abortifacient effects of Vibrio cholerae exo-enterotoxin and endotoxin in mice

To study antifertility properties of microbial toxins, exoenterotoxin and endotoxin from Vibrio cholerae were injected intravenously into mice at different times during pregnancy. The two substances induced termination of pregnancy, but the patterns of abortifacient activity were different. Exotoxin terminated pregnancy in mice when administered between Days 4 and 10 of gestation, but abortifacient activity was reduced in animals more than 10 days pregnant; exogenous progesterone did not protect the pregnancies. Endotoxin was most effective in terminating pregnancy when injected after mid-gestation and the active principle was heat-stable; exogenous progesterone was not able to prevent the effects of endotoxin. Animals treated with endotoxin on Day 17 often gave birth to live young prematurely; indomethacin reduced the incidence of premature littering. The results demonstrate that exo- and endotoxins have antifertility properties and both appear to act on intrauterine targets rather than inducing progestin deficiency.

Induction of abortion in early first trimester human pregnancy using epostane

The role of epostane (Sterling Winthrop, Guildford, UK), a competitive inhibitor of the 3 beta hydroxysteroid dehydrogenase enzyme system (3 beta-HSD), as an abortifacient agent in early human pregnancy has been studied in 54 women. All were less than 49 days from their last menstrual period. Thirty were treated with 200 mg of epostane every 8 h for 7 days and 24 were given 200 mg every 6 h for 7 days. This caused a sustained reduction in circulating progesterone concentrations, a smaller fall in 17 beta-oestradiol and no effect on serum cortisol. Abortion occurred in 21 women (70%) in the lower dosage group and in 20 women (87%) in the higher dosage group. Abortion was incomplete in 6 of these 41 women. A worsening of pregnancy nausea and vomiting was noted by 66% of women in the first group and 84% in the second. There was no delay in the resumption of normal menstruation following abortion. This study confirms the potential of epostane as an effective inhibitor of ovarian and placental steroidogenesis and as a potent abortifacient agent in early human pregnancy.

[Transcervical extraamniotic Rivanol instillation as a method of avoiding complications in pregnancy interruption]

The number of abortions performed is steadily increasing. According to information available to date from the Federal Statistics Office in the Federal Republic of Germany, pregnancies are still largely terminated by means of cervical dilatation with Hegar dilatators and subsequent curettage. Almost half of all abortions are performed in young women who have not yet given birth. In a great number of cases these patients have a gracile, rigid cervical os which has to be opened abruptly in a few minutes with Hegar's dilatators, often under asserting quite some force. This can result in lacerations of the cervix, cervical insufficiency, inflammation and cicatrization. The transcervical extraamnial Rivanol instillation seems to be a method for avoiding these early and the serious late complications ensuing. Using this method--an alternative to the Prostaglandine application, with its even more serious secondary effects and contraindications--the highest possible degree of success can be achieved in avoiding cervical injuries and in reducing inflammation in the pelvis minor to a minimum, which could later on lead to sterility.

Placental histopathology of midtrimester termination

Placentas spontaneously passed after second-trimester terminations of pregnancy using either hypertonic sodium chloride or hyperosmolar urea plus prostaglandin F2alpha (PGF2alpha) were examined to determine histologic characteristics. The placentas of hypertonic sodium chloride terminations demonstrated a type of "coagulation necrosis" that has been described previously, while placentas of pregnancies terminated by hyperosmolar urea plus PGF2alpha showed a similar pattern in about one half the cases but a histologic pattern of less severe damage in the remaining cases. The 2 groups showed no significant differences when characteristics such as injection-abortion interval or estimated hypertonicity of the fluid were examined.

[Intra-amniotic injection of crystal trichosanthin for induction of labour in second trimester pregnancy]

Labor was induced in a group of 200 women in 2nd trimester of pregnancy by crystal trichosanthia injected into the amniotic cavity. It was effective and the success rate was 99.5%. The average abortion inducing interval was 4.69 days porm 1.15 days. Blood loss was scanty during labor in 90.5% cases, being less than 100 ml. There was only 1 case suffering laceration of cervix. The side effects of crystal trichosanthin were dramatically reduced with the simultaneous use of betamethason intramuscularly for 3 successive days. Side effects were reduced because the drug was concentrated in the cavity and only a little was present in the blood stream and, what's more, the anti-allergic action of betamethason was effective. Trichosanthin is a kind of plant protein so it will possibly cause allergic reaction, which can induce the production of antibodies that will influence the effect of its reinjection.