Expulsion at home for early medical abortion: A systematic review with meta-analyses.

INTRODUCTION: The safety and acceptability of medical abortion using mifepristone and misoprostol at home at ≤9+0  weeks' gestation is well established. However, the upper gestational limit at which the procedure remains safe and acceptable at home is not known. To inform a national guideline on abortion care we conducted a systematic review to determine what gestational limit for expulsion at home offers the best balance of benefits and harms for women who are having medical abortion. MATERIAL AND METHODS: We searched Embase, MEDLINE, Cochrane Library, Cinahl Plus and Web-of-Science on 2 January 2020 for prospective and retrospective cohort studies with ≥50 women per gestational age group, published in English from 1995 onwards, that included women undergoing medical abortion and compared home expulsion of pregnancies of ≤9+0  weeks' gestational age with pregnancies of 9+1 -10+0  weeks or >10+1  weeks' gestational age, or compared the latter two gestational age groups. We assessed risk-of-bias using the Newcastle-Ottowa scale. All outcomes were meta-analyzed as risk ratios (RR) using the Mantel-Haenszel method. The certainty of the evidence was assessed using GRADE. RESULTS: Six studies (n = 3381) were included. The "need for emergency care/admission to hospital" (RR = 0.79, 95% confidence interval [CI] 0.45-1.4), "hemorrhage requiring transfusion/≥500 mL blood loss" (RR = 0.62, 95% CI 0.11-3.55), patient satisfaction (RR = 0.99, 95% CI 0.95-1.03), pain (RR = 0.91, 95% CI 0.82-1.02), and "complete abortion without the need for surgical intervention" (RR = 1.03, 95% CI 1-1.05) did not differ statistically significantly between the ≤9+0 and >9+0  weeks' gestation groups. The rates of vomiting (RR = 0.8, 95% CI 0.69-0.93) and diarrhea (RR = 0.85, 95% CI 0.73-0.99) were statistically significantly lower in the ≤9+0  weeks group but these differences were not considered clinically important. We found no studies comparing pregnancies of 9+1 -10+0  weeks' gestation with pregnancies of >10+0  weeks' gestation. The certainty of this evidence was predominantly low and mainly compromised by low event rates and loss to follow up. CONCLUSIONS: Women who are having a medical abortion and will be taking mifepristone up to and including 10+0  weeks' gestation should be offered the option of expulsion at home after they have taken the misoprostol. Further research needs to determine whether the gestational limit for home expulsion can be extended beyond 10+0  weeks.

The role of day 0 and day 4 ß-human chorionic gonadotropin values and initial ultrasound findings in predicting the success of methotrexate treatment in ectopic pregnancy.

OBJECTIVES: To determine the role of baseline ultrasound findings and the changes between ß- human chorionic gonadotropin (hCG) values on day 0 to day 4 in patients receiving single-dose methotrexate (MTX) therapy for tubal ectopic pregnancy. MATERIAL AND METHODS: One hundred fourteen patients who were hospitalized with a diagnosis of ectopic pregnancy and treated with single-dose methotrexate were included in this retrospective study. The successful treatment group (n = 88) comprised patients in whom serum ß-hCG levels were resolved with single-dose methotrexate treatment, and the failed treatment group (n = 26) included patients who received second dose methotrexate and/or surgery. Ultrasound findings, laboratory findings, and serum ß-hCG values at the time of admission and D4 and D7 ß-hCG values were compared. RESULTS: The success rate of single-dose methotrexate treatment was 77.2%. In the successful treatment group, the initial ß-hCG values of the patients were lower than the unsuccessful treatment group (1479.14 ± 1253.49, 4442.88 ± 3392.58, respectively) (p = 0.0001). A decrease of more than 35% between D0-D4 increased the probability of successful treatment (p = 0.017). Although ectopic focus size and abdominal free fluid showed no significant difference between the two groups, endometrial stripe thickness was significantly higher in the unsuccessful treatment group (12.61 ± 5.79, 9.28 ± 3.53) (p = 0.002). CONCLUSIONS: In addition to the basal ß-hCG value, endometrial stripe thickness of ultrasound findings should also be considered in determining patients with a high chance of success in single-dose MTX treatment.ß-hCG changes between D0-D4 may be advantageous in the clinical management of ectopic pregnancy for earlier evaluation.

Aglepristone and cloprostenol combination in the termination of late-term pregnancy in queens.

OBJECTIVES: Termination rates for the highly recommended aglepristone (AGL) treatment are low in late-term pregnancy in queens. We studied the effects of an AGL and cloprostenol (CLO) combination in the termination of late-term pregnancy. METHODS: Pregnant queens were assigned to two groups. Queens in the AGL group (n = 10) received AGL 10 mg/kg, twice, 24 h apart. Queens in the AGL-CLO group (n = 9) were additionally injected with a single dose of CLO (5 µg/kg) 24 h after the second dose of AGL. Progesterone, 17beta(ß)-oestradiol, cortisol, oxytocin and prostaglandin F2alpha (PGF2α) metabolite were measured in sera obtained at days 0, 1 and 2, and on the day of abortion. RESULTS: Average gestational age in both groups was similar (AGL 38.61 ± 0.91 days vs AGL-CLO 39.39 ± 1.35 days; P >0.05). Termination rates were 80% and 100% in the AGL and AGL-CLO groups, respectively (P <0.05). Fetal expulsion time was significantly longer (P <0.001) in the AGL group (96.9 ± 6 h) compared with the AGL-CLO group (69.8 ± 3.3 h). Duration of abortion was 19.8 ± 2.6 h and 12.6 ± 1.4 h in the AGL and AGL-CLO groups, respectively (P <0.05). Both treatments were well tolerated. Significantly (P <0.05) lower serum progesterone concentrations were observed in both groups at the day of abortion and concentrations in the AGL-CLO group (4.19 ± 0.80 ng/ml) were lower than in the AGL group (9.89 ± 2.21 ng/ml; P <0.05). CONCLUSIONS AND RELEVANCE: AGL and CLO combination increases pregnancy termination rate in late-term pregnant queens. In addition, CLO contributes to a decrease in luteal function in AGL-treated late-term pregnant queens.

Comparison of the diagnostic value of histopathological examinations of miscarriage products after pharmacological induction of miscarriage and curettage.

OBJECTIVES: For early miscarriage (pregnancy loss ≤ 12 weeks of gestation), two types of therapeutic treatment are offered (pharmacotherapy and curettage of the uterine cavity) depending on the presence and severity of clinical symptoms as well as patient choice. Our study aimed to assess the diagnostic value of the results of histopathological examinations of miscarriage products in relation to the administered treatments. MATERIAL AND METHODS: 850 medical records from patients diagnosed with missed miscarriage or empty gestational sac were analyzed retrospectively. Patients underwent surgical treatment or pharmacotherapy. Inefficacy of pharmacotherapy resulted in subsequent curettage. The results of histopathology were evaluated for their diagnostic value and classified: subgroup 1 - high value specimen (the studied specimen included fetal tissues, and villi), and subgroup 2 - no-diagnosis (the studied specimen included maternal tissues, autolyzed tissues, blood clots). Data were compared with chi-squared test. Differences was considered significant at p < 0.05. RESULTS: 1128 histopathological test results were analyzed; 569 (50.4%) were obtained during pharmacotherapy and 559 (49.6%) after curettage; out of the latter 497 after the initial pharmacotherapy and 62 after surgery. In the pharmacotherapy group, high value specimens comprised 231 cases (40.59%) while no diagnosis was obtained in 338 cases (59.4%). Considering specimens obtained in the course curettage, high value specimens were found in 364 cases (65.1%) while results that did not allow a diagnosis to be made were found in 195 cases (34.9%). CONCLUSIONS: Tissue specimens of high diagnostic value are obtained significantly more often during surgical treatment of miscarriage than during pharmacotherapy.

Medical management of first trimester missed miscarriage: the efficacy and complication rate.

Our aim of the study was to evaluate the efficacy and complication rate of our inpatient medical management protocol for missed miscarriages. Three-hundred and ninety women hospitalised at our tertiary centre because of a missed miscarriage/anembryonic pregnancy in 2012-2013 were included in this retrospective study. The women underwent either a low (until 9 + 0 weeks of gestation) or high gestational age (from 9 + 1 until 15 + 6 weeks of gestation) management protocol. The success rate, curettage in the first 48 hours after the procedure, the complication rate and the factors that might influence these outcomes were evaluated. The overall success rate was 83.3%. The curettage in the first 48 hours after the procedure was performed in 7.4% of the patients and was more often in the high gestational age protocol. Complications that required another outpatient visit or hospitalisation occurred in 9% of the patients. Higher beta-hCG values 14 days after the procedure and the absence of evacuation of products of conception during hospitalisation were associated with a higher complication rate. IMPACT STATEMENT What is already known on this subject? As much as 10-20% of clinically recognised pregnancies end in a spontaneous abortion. A missed miscarriage and a blighted ovum represent a form of spontaneous abortion, which has long been treated with surgical evacuation. However, nowadays, medical management represents a well-established alternative with very high success rates and is considered as an equivalent and safe method that is also very well accepted by patients. What do the results of this study add? According to our results, a medical management of a first trimester missed miscarriage and a blighted ovum is very effective with an overall success rate of 83.3% and a very low percentage of curettage in the first 48 hours after the procedure (7.4%). Our study was also able to identify higher beta-hCG values 14 days after procedure and absence of evacuation of products of conception during hospitalisation as risk factors for complication occurrence. What are the implications of these findings for clinical practice and/or further research? Our study helps to identify patients who are at greater risk for developing complications after the medical management of a first trimester missed miscarriage.

Effect of oral misoprostol, alone or in combination with aglepristone, on mid-term pregnancy termination in cats.

OBJECTIVES: This study aimed to determine the efficacy and safety of oral misoprostol (MIS) administration in the induction of mid-term pregnancy termination in cats. METHODS: Twenty-eight cats that were pregnant for 30-40 days were allocated to four groups. The aglepristone (AGL) group (n = 7) received 10 mg/kg SC aglepristone q24h for two consecutive days. In the AGL+MIS group (n = 7), AGL (as administered in the AGL group) and MIS (200 µg/cat PO q12h until the start of abortion) were administered. The MIS200 (n = 7) and MIS400 groups (n = 7) received MIS (200 or 400 µg/cat misoprostol, respectively) alone PO q12h until the start of abortion. Blood samples were collected at the start of treatment (d0), 4 days after the start of treatment (d4) and on the day of complete abortion/end of administration (dA/d7). RESULTS: The efficacy of the treatment was 71.4% in the AGL group, 100% in the AGL+MIS group, 0% in MIS200 group and 57.4% in MIS400 group (P = 0.004). No significance was found in relation to the interval from treatment to the start/end of abortion and the duration of abortion in all groups. The most observed side effect was vomiting in both groups administered MIS, particularly in the MIS400 group (56.7%). Progesterone (P4) concentrations were reduced during the abortion, but not to basal levels, in all groups. P4 concentrations were significantly lower at dA/d7 in the MIS400 group compared with the AGL and AGL+MIS groups (P = 0.002). CONCLUSIONS AND RELEVANCE: The results obtained from this study showed that low doses of MIS do not induce abortions in cats but increase the effect of AGL. Although higher doses could terminate pregnancies, this also causes intense unwanted side effects. Therefore, the use of MIS alone as an abortifacient in cats is not recommended. For mid-term pregnancy termination in cats, the combination of misoprostol and aglepristone provides a more effective abortifacient than using either of them alone.

Association of Facility Type With Procedural-Related Morbidities and Adverse Events Among Patients Undergoing Induced Abortions.

Importance: Multiple states have laws requiring abortion facilities to meet ambulatory surgery center (ASC) standards. There is limited evidence regarding abortion-related morbidities and adverse events following abortions performed at ASCs vs office-based settings. Objective: To compare abortion-related morbidities and adverse events at ASCs vs office-based settings. Design, Setting, and Participants: Retrospective cohort study of women with US private health insurance who underwent induced abortions in an ASC or office-based setting (January 1, 2011-December 31, 2014). Outcomes were abstracted from a large national private insurance claims database during the 6 weeks following the abortion (date of final follow-up, February 11, 2015). Exposures: Facility type for abortion (ASCs vs office-based settings, including facilities such as abortion clinics, nonspecialized clinics, and physician offices). Main Outcomes and Measures: The primary outcome was any abortion-related morbidity or adverse event (such as retained products of conception, abortion-related infection, hemorrhage, and uterine perforation) within 6 weeks after an abortion. Two secondary outcomes, both subsets of the primary outcome, were major abortion-related morbidities and adverse events (such as hemorrhages treated with a transfusion, missed ectopic pregnancies treated with surgery, and abortion-related infections that resulted in an overnight hospital admission) and abortion-related infections. Results: Among 49 287 women (mean age, 28 years [SD, 7.3]) who had 50 311 induced abortions, (23 891 [47%] first-trimester aspiration, 13 480 [27%] first-trimester medication, and 12 940 [26%] second trimester or later), 5660 abortions (11%) were performed in ASCs and 44 651 (89%) in office-based settings. Overall, 3.33% had an abortion-related morbidity or adverse event; 0.32% had a major abortion-related morbidity or adverse event; and 0.74% had an abortion-related infection. In adjusted analyses, there was no statistically significant difference between ASCs vs office-based settings, respectively, in the rates of abortion-related morbidities or adverse events (3.25% vs 3.33%, difference, -0.08%; [corrected] 95% CI, -0.58% to 0.43%; adjusted OR, 0.97; 95% CI, 0.81-1.17), major morbidities or adverse events (0.26% vs 0.33%; difference, -0.06%; 95% CI, -0.18% to 0.06%; adjusted OR, 0.78; 95% CI, 0.45-1.37), or infections (0.58% vs 0.77%; difference, -0.16%; 95% CI, -0.35% to 0.03%; adjusted OR, 0.75; 95% CI, 0.52-1.09). Conclusions and Relevance: Among women with private health insurance who had an induced abortion, performance of the abortion in an ambulatory surgical center compared with an office-based setting was not associated with a significant difference in abortion-related morbidities and adverse events. These findings, in addition to individual patient and individual facility factors, may inform decisions about the type of facility in which induced abortions are performed.

Second trimester medical abortion with mifepristone followed by unlimited dosing of buccal misoprostol in Armenia.

OBJECTIVES: The aim of the study was to assess the efficacy and acceptability of a regimen using mifepristone and buccal misoprostol with unlimited dosing for second trimester abortion in Armenia. METHODS: Women seeking to terminate 13-22 week pregnancies were enrolled in the study. Participants swallowed 200 mg mifepristone in the clinic and were instructed to return to the hospital for induction 24-48 h later. During induction, women were given 400 µg buccal misoprostol every 3 h until the fetus and placenta were expelled. The abortion was considered a success if complete uterine evacuation was achieved without oxytocin or surgery. RESULTS: A total of 120 women with a median gestational age of 18 weeks participated in the study. All women began misoprostol induction around 24 h after taking mifepristone. Complete uterine evacuation was achieved in 119 (99.2%) women. The median induction-to-abortion interval was 10.3 h (range 4-17.4) with a mean of 9.5 ± 2.5 h. A median of four misoprostol doses (range 2-6) with a mean of 4 ± 1 misoprostol doses were administered. The induction-to-abortion interval, number of misoprostol doses, pain score and analgesia use increased as gestational age advanced. Acceptability of the method was high among both patients and providers. CONCLUSION: The medical abortion regimen of 200 mg mifepristone followed 24 h later by induction with 400 µg buccal misoprostol administered every 3 h, with no limit on the number of doses used for the termination of pregnancies of 13-22 weeks' gestation is an effective and acceptable option for women.

Medical abortion in women with large uterine fibroids: a case series.

Women with fibroid uteri seeking surgical abortion often represent a unique challenge. When the uterine cavity is significantly enlarged or distorted making surgical evacuation difficult or impossible, we offer medical abortion using mifepristone followed by misoprostol beyond the standard 63- to 70-day gestational age cutoff that is typically recommended. This case series describes our regimen and outcomes for 6 patients from 10 to 13 weeks gestation underdoing outpatient medical abortion and 6 patients from 14 to 20 weeks gestation undergoing inpatient medical abortion. Three patients required evacuation for retained products and all others had successful medical abortions without complications.

Medical management of an ovarian ectopic pregnancy: a case report.

BACKGROUND: Primary ovarian ectopic pregnancy is a rare type of ectopic pregnancy which has an estimated prevalence ranging from 1:7000 to 1:70,000 accounting for almost 3 % of all ectopic cases. Here we report the case of a 25-year-old woman who presented to our clinic with abdominal pain, 6 weeks' delay of menstruation and 3 days of vaginal bleeding, whose transvaginal ultrasonography showed an ectopic gestational sac with yolk sac inside, in her right ovary. This case shows that early diagnosis is very important particularly in places like the Sub-Saharan region of Africa. CASE PRESENTATION: A 25-year-old African woman was referred to our clinic with 6 weeks' delay of menstruation, frequent increasing abdominal pain and 3 days of vaginal bleeding. Her general condition was good and her vital signs were normal. She felt tenderness in an abdominal examination and had a small amount of vaginal bleeding. Transvaginal ultrasonography showed an ectopic gestational sac with yolk sac inside, in her right ovary. Our final diagnosis was ectopic ovarian pregnancy and we successfully treated her with methotrexate. After 3 weeks of methotrexate administration her beta human chorionic gonadotropin was negative and a sonographic examination was completely normal. CONCLUSIONS: Ectopic ovarian pregnancy is a very important medical situation. It should be diagnosed in its early stages otherwise it could be life-threatening and surgical treatment may be inevitable. Because of the importance of fertility, medical treatment is an acceptable option and can be feasible with early diagnosis.

The effects of aglepristone alone and in combination with cloprostenol on hormonal values during termination of mid-term pregnancy in bitches.

This study was designed to assess endocrine changes associated with termination of mid-term pregnancy after use of two different protocols. For this purpose we compared the effects of aglepristone (AGL) alone and in combination with cloprostenol (CLO) on serum concentrations of progesterone (P4), estradiol (E2) and relaxin (RLN) measured at short-term intervals during the abortion period in bitches. Fourteen pregnant bitches between day 25 and 32 of gestation were used in the study. In the AGL group (n=7), aglepristone was administered solely (10mg/kg body weight (BW), subcutaneously, once daily on two consecutive days) whereas in the AGL-CLO group (n=7), aglepristone (dosage as in AGL group) and cloprostenol (1µg/kg BW, subcutaneously, same with aglepristone) were combined. All pregnancies were successfully terminated 5.2±1.6 days after initiation of treatments, which was significant in both groups (P>0.05). At the time of the start of abortion (SA) and the end of abortion (EA), the mean P4 concentrations were 26.6±7.3 and 12.0±6.4ng/ml in AGL group, and 2.7±0.7 and 0.9±0.1ng/ml, in AGL-CLO group, respectively (P<0.01). Serum E2 concentrations were significantly higher (P<0.05) in AGL group at 42, 48, 54h and SA after initiation of treatment. In the AGL-CLO group, serum RLN concentrations did not significantly change from the initiation of treatment to EA (P>0.05). However, markedly higher RLN concentrations (P<0.05) were observed in the AGL group at 48h (1.5±0.7ng/ml) and at SA (1.6±0.5ng/ml). The results of the present study indicate that changes in the hormonal concentrations affect the mechanism of abortion in different ways. Further in depth studies investigating changes in the expression of hormone receptors inside the ovary, endometrium and placenta might be helpful to our understanding of the endocrinological differences observed in this study.

Abortifacient effect of metoclopramide in female albino rats.

BACKGROUND: Metoclopramide a dopamine receptor antagonist is commonly used to treat nausea and vomiting. Long term use can cause parkinsonism, galactorrhoea and gynaecomastia. As it is lipid soluble, it enters the brain, easily crosses the placental barrier and can affect the fetus. Hence, the present study is designed to assess the risk of metoclopramide in pregnant albino rats. OBJECTIVES: To study the abortifacient effect of metoclopramide in pregnant albino rats. METHODS: Eighteen pregnant rats were divided into three groups of six rats each. The abortifacient activities of metoclopramide were studied in the doses of 1 mg/kg and 3 mg/kg intramuscularly. The treatments were started on the 6th day of pregnancy and continued till the 15th day. Rats were laparotomised on 19th day of pregnancy for evaluation of abortifacient action. In both the horns of the uterus, number of implantation sites, resorption sites, dead and live fetuses were observed. RESULTS: The mean percentage of aborted fetus was 17.22 +/= 21.13 33.88 +/= 37.73 after 1mg/kg and 85.21 +/=18.93 after 3mg/kg of metoclopramide. The abortifacient effect of higher dose was significantly larger compared to both control group and low dose group, but there was no significant difference between the mean percentage of abortion in control group and the low dose group of metoclopramide. CONCLUSION: Metoclopramide at 3mg/kg intra muscular has abortifacient effects in female albino rats.

Medical methods for cervical ripening before the removal of intrauterine devices in postmenopausal women: a systematic review.

In China, most women with intrauterine devices (IUDs) ask to have them removed following the menopause. As the cervix is stenotic after the menopause and most IUDs do not have a thread attached, various medical methods are used for cervical ripening prior to IUD removal. A systematic review of the relevant literature was conducted to compare different medical methods for cervical priming with no treatment, or with other methods, prior to IUD removal in postmenopausal women. Multiple electronic databases including the Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, the WHO Reproductive Health Library (2011) and the Chinese Biomedical Literature Database were searched systematically. Reference lists of articles published in English or Chinese between 1980 and 2011 were searched. All randomized controlled trials (RCTs) on IUD removal following the menopause using medical agents compared with no treatment, or with other treatments, were included. Outcomes were the ease of IUD removal, need for forced cervical dilatation, cervical width, procedure time, severe pain and any side-effects. Data were processed using RevMan 5 software. Thirty original RCTs were eligible for inclusion. Most medical agents such as oestrogens, mifepristone, misoprostol and methyl carboprost were highly effective for facilitating IUD removal, and reduced the need for further dilatation during the procedure. In particular, treatment with mifepristone or misoprostol prior to IUD removal was found to increase the width of the cervical canal and reduce the procedure time. Mifepristone was more effective than vaginal misoprostol for cervical dilatation, but it showed similar effectiveness to misoprostol and nilestriol in terms of the ease of IUD removal. Sublingual misoprostol was superior to oral misoprostol for facilitating IUD removal. A dose of misoprostol as low as 200µg was effective for cervical priming. For vaginal and oral misoprostol, the optimum times of application were 2-3h and 1 day prior to the procedure, respectively. All the prophylactic medical methods were able to alleviate pain during IUD removal, and vaginal misoprostol was more effective than nilestriol. Uterine injury was more common with no treatment and with nilestriol. Gastrointestinal side-effects such as nausea and diarrhoea were common with oral misoprostol and vaginal misoprostol, respectively. Therefore, mifepristone or sublingual misoprostol should be the medical treatments of choice. Oestrogen regimens might be alternatives when mifepristone or misoprostol are contraindicated, and there is a need for further study on combined regimens for cervical priming.

Early ovarian pregnancy diagnosed by ultrasound and successfully treated with multidose methotrexate. A case report.

A case report of a primary interstitial ovarian pregnancy is presented. A 37-year-old married woman with two children after two Cesarean sections and a spontaneous abortion, with a contraceptive intrauterine device (IUD) inserted three years before, presented at five weeks plus five days amenorrhea with a positive pregnancy test and lower abdominal pain but with no vaginal bleeding. Her previous menstrual cycles had been regular. She was hemodynamically stable. On bimanual examination, the uterus was of normal size, and there was an approximate four-cm tender right adnexal mass. Serum beta-human chorionic gonadotropin (b-hCG) was confirmed positive. Ultrasound revealed a well-positioned IUD in the uterus and a right adnexal mass with normal vascular flow on Doppler, that contained a well-defined gestational sac, well-distinct from the quiescent hemorrhagic corpus luteum. There was no fetal node or cardiac activity or free fluid. The patient received four injections of methotrexate intramuscularly using the multidose regimen that involves the administration of methotrexate calculated according to body weight, alternated with 0.1 mg/kg of leucovorin calcium per os after 30 hours until the values of 3-hCG had decreased by 15%. The patient's post-treatment period was uneventful with a full restoration of ovarian morphology and the complete absorption of the gestational sac. This case is the first where diagnosis was made by endovaginal sonography and treatment was made by multidose methotrexate. Spiegelberg criteria for the diagnosis of ovarian pregnancy are obsolete; new ultrasound and laboratory criteria are needed for a diagnosis as early as possible without the need of surgery.

The intravaginal application of misoprostol improves induction of abortion with aglepristone.

The aim of the present study was to compare the clinical and endocrinological effects of four different treatments for the induction of abortion in bitches. For this purpose, 28 pregnant bitches between days 25 and 35 of gestation, were randomly assigned to four groups. In group I (n = 7), only aglepristone (AGL, 10mg/kg bw, two injections 24 h apart, s.c.) was administered. In group II (n = 7), AGL (as in group I), cabergolin (CAB, 5 µg/kg, daily p.o., until completion of abortion) and misoprostol (MIS, 200 µg for bitches with ≤ 20 kg bw, 400 µg for bitches with > 20 kg bw, daily intravaginally, until completion of abortion) were administered. In group III (n = 7), AGL (as in group I) and MIS (as in group II) were administered. In group IV (n = 7) AGL, (as in group I) and cloprostenol (CLO, 1µg/kg bw, s.c., two injections 24 h apart with the AGL injections) were combined. In all groups, bitches were examined daily, clinically and ultrasonographically to monitor resorptions/abortions. To measure serum progesterone (P4) and total estrogen (TE) concentrations, blood samples were collected in all groups immediately after the first AGL administration and every other day until completion of abortion. No statistical differences were found between groups concerning the duration until completion of abortion following treatment (n.s.); however, in Group III, 6 d after the start of treatment all pregnancies were terminated whereas in Group I, II and IV, only 57.1% (4/7), 85.7 % (6/7) and 42.8 % (3/7) of pregnancies were terminated. In the latter groups, all pregnancies were terminated between days 8 and 10 after the start of treatment. In Group IV, P4 concentrations on days two and one before the beginning of abortion and the day the abortion started was significantly lower than in the other groups (P < 0.01). No statistical differences were found between groups for TE concentrations (P > 0.05). In Groups I, II and III, no severe side effects occurred. Severe vomiting after each treatment and until the end of abortion was observed in Group IV only. In conclusion, only when a combination of AGL and MIS was used abortion was completed within 6 d in all bitches whereas the additional use of CAB did not improve the treatment.

A pilot study on the use of letrozole with either misoprostol or mifepristone for termination of pregnancy up to 63 days.

BACKGROUND: Letrozole is a third-generation selective aromatase inhibitor. Animal data suggested that it might be useful in medical abortion. We performed two pilot studies to assess the feasibility of using letrozole in combination with either mifepristone or misoprostol for termination of pregnancy up to 63 days. STUDY DESIGN: We recruited 40 subjects who requested legal termination of pregnancies up to 63 days. Medical abortion was performed with letrozole 7.5 mg daily for 2 days followed by 800 mcg vaginal misoprostol in 20 subjects and letrozole 7.5 mg combined with 200 mg mifepristone in another 20 subjects. RESULTS: The mean induction-to-abortion interval of the regimen of letrozole and misoprostol was 9.1 h (median 7.9 h, range 2.7-23.6 h). The complete abortion rate was 80% (95% CI: 56.3-94.3%). For those with gestation of ≤ 49 days, the complete abortion rate was 87.5% (14/16; 95% CI: 61.7-98.5%). The mean induction-to-abortion interval of letrozole combined with mifepristone was 90.1 h (median 93.4 h, range 66.0-121.2 h). The complete abortion rate was 71.4% (95% CI: 47.8-88.7%). CONCLUSION: These preliminary results suggest that a regimen of letrozole and misoprostol may be useful in medical abortion, but the combination with mifepristone is less effective and takes longer. Randomized studies comparing letrozole and misoprostol to misoprostol alone are warranted.

Medical and surgical options for induced abortion in first trimester.

Medical abortion has been shown to be an effective alternative to surgery for termination of pregnancy in the late as well as the early first trimester of pregnancy. This review discusses the development, application and the current issues with medical and surgical abortion in the first trimester. Studies comparing the two approaches are also assessed as well as potential research directions in this area.

Medical abortion in primary care: pitfalls and benefits / Aborto medico en la atención primaria: riesgos y beneficios

We describe five pitfalls of medical abortion: ectopic pregnancy not terminated after misoprostol, but without negative side-effects; long-term vaginal blood loss with suspicious retained products which disappeared spontaneously; a patient with uterus myomatatosus with severe pain and retained products in the uterus; repetition of misoprostol because of retained products in the uterus after two weeks and an allergic reaction to methotrexate. Despite these pitfalls, there are enough benefits to consider medical abortion with methotrexate and misoprostol as a safe method with a high success rate of more than 91% and a good alternative for surgical abortion. An invasive procedure is not necessary, there are no long-term complications and it can be performed at an earlier stage, which makes it more acceptable in society. In Curaçao, where abortion is legally restricted, medical abortion is performed with methotrexate and misoprostol. In countries where abortion is legal, mifepristone and misoprostol are the first choice.

Describimos cinco riesgos del aborto medico: el embrazo ectópico no terminado después de misoprostol, pero sin efectos secundarios negativos; la pérdida de sangre vaginal a largo plazo sin productos retenidos sospechosos que desaparecieron espontáneamente; una paciente con útero miomatoso con dolor severo y productos retenidos en el útero; repetición del misoprostol debido a productos retenidos en el útero después de dos semanas y una reacción alérgica al metotrexato. A pesar de estas dificultades, hay suficientes beneficios para considerar el aborto médico con metotrexato y misoprostol como un método seguro con una alta tasa de éxito superior al 91%, y como una buena alternativa al aborto quirúrgico. No se requiere un procedimiento invasivo, no hay complicaciones a largo plazo, y puede realizarse en una etapa más temprana, lo que resulta más aceptable para la sociedad. En Curazao, donde el aborto está legalmente restringido, el aborto médico se realiza con metotrexato y misoprostol. En países donde el aborto es legal, la mefepristona y el misoprostol son la primera elección.

Successful treatment of cesarean scar pregnancy using laparoscopically assisted local injection of etoposide with transvaginal ultrasound guidance.

OBJECTIVE: To present a case of cesarean scar ectopic pregnancy (CSEP) successfully diagnosed and treated with a laparoscopic local injection of 100 mg etoposide under transvaginal ultrasound assistance. DESIGN: Case report. SETTING: University-affiliated teaching hospital. PATIENT(S): A 37-year-old woman with CSEP. INTERVENTION(S): Local injection of 100 mg etoposide. MAIN OUTCOME MEASURE(S): Serial serum levels of beta-hCG and return of normal menstruation. RESULT(S): Serial serum beta-hCG levels were 572.2 mIU/mL before operation, 340.7 mIU/mL on the first postoperative day, 28.1 mIU/mL on postoperative day 9, and 5 mIU/mL on postoperative day 17. Menstruation was initiated on postoperative day 45. CONCLUSION(S): Use of laparoscopic local injection of 100 mg etoposide with transvaginal ultrasound guidance might be an effective method for the management of CSEP.