Are two doses of misoprostol after mifepristone for early abortion better than one?

OBJECTIVE: The objective of this study was to determine if a repeat dose of misoprostol following mifepristone or a single dose of misoprostol increases the efficacy of medical termination of pregnancy. DESIGN: Randomised, placebo controlled trial. SETTING: K.E.M. Hospital, Pune, India, and the Health Centre, Larsen and Toubro Limited, Mumbai, India. SAMPLE: A total of 300 women seeking an abortion with amenorrhoea of 8 weeks or less. Methods Women were randomised to receive one or two doses of 400 microgram oral misoprostol at the clinic 48 hours after administration of 200 mg mifepristone. Main outcome measure Complete abortion without surgical intervention. Results The repeat administration of misoprostol 400 microgram improved the complete abortion rate from 86 to 92% and significantly reduced the rate of continuing pregnancy from 7 to 1%. Almost all the women who were administered the additional dose of misoprostol were either very satisfied (58%) or satisfied (37%) with the method. Conclusion While an additional oral dose of 400 microgram misoprostol did not significantly increase the rate of complete abortion without surgical intervention, the additional dose did significantly reduce the rate of continuing pregnancies without compromising the acceptability and ease of use of the method.

Cervical dilatation in late first trimester termination by prostaglandin, hylase and isogel.

Pre-operative dilatation of the cervix was attempted in 223 cases prior to vacuum aspiration in patients seeking late first trimester termination beyond ten weeks. 15 Me PGF2a was used in the form of vaginal suppositories, intramuscular and intracervical injections. Dilatation of cervix of 10 mm or more was achieved within 4 hours in 86% cases with intra-cervical injections. Gastro-intestinal disturbances caused by intra-muscular injections could be avoided by intra-cervical injections, as the amount of prostaglandin required was only 100 ugm, but the success rate was significantly lower. The success with multiple dose suppositories was 80%. There was no significant difference in the success with 1.5 mgm or 1.0 mgm dosage, but the side effects were significantly higher with 1.5 mgm suppositories. Intra-cervical Hylase did not dilate the cervix but successfully softened it within 5 minutes to make metallic dilatation simple. The hygroscopic Isogel tents achieved dilatation of 10 mm or more in 73% of the patients in 12 hours. The tents as well as intra-cervical prostaglandin injection had the disadvantage of requiring an additional theatre procedure prior to suction curettage.

PIP: Preoperative dilatation of the cervix was attempted in 223 cases prior to vacuum aspiration in patients seeking late first trimester termination beyond 10 weeks. 15 Me PGF2alpha was used in the form of vaginal suppositiories, intramuscular and intracervical injections. Dilatation of cervix of 10 mm or more was achieved within 4 hours in 86% cases with intracervical injections. Gastrointestinal disturbances caused by intramuscular injections could be avoided by intracervical injections, as the amount of (PG) prostaglandin required was only 100 ugm, but the success rate was significantly lower. The success with multiple dose suppositories was 80%. There was no significant difference in the success with 1.5 mgm or 1.0 mgm dosage, but the side effects were significantly higher with 1.5 mgm suppositories. Intracervical Hylase did not dilate the cervix but successfully softened it within 5 minutes to make metallic dilatation simple. The hygroscopic Isogel tents achieved dilatation of 10 mm or more in 73% of the patients in 12 hours. The tents as well as intracervical PG injection had the disadvantage of requiring an additional theater procedure prior to suction curettage.

A study of interaction of low-dose combination oral contraceptive with Ampicillin and Metronidazole.

Plasma levels of norethisterone (NET), ethinyl estradiol (EE), Ampicillin or Metronidazole were estimated in 16 women, who were taking low-dose oral combination contraceptive pills (containing norethisterone acetate 1 mg and ethinyl estradiol 30 microgram) and in whom concurrently, either Ampicillin (6 women) or Metronidazole therapy (10 women) was given. Neither Ampicillin nor Metronidazole therapy altered the 'peak' or 24-hour plasma levels and area under the curve, for NET and EE. Furthermore, oral contraceptive treatment did not alter the 'peak' levels of Ampicillin or Metronidazole. Progesterone (P) levels were in the anovulatory range in all Ampicillin treated cycles. However, in Metronidazole treated group, two out of 10 women showed a P rise of more than 4 ng/ml. The study was expanded to include another group of 15 women treated with Metronidazole, where only one women showed a P rise of more than 4 ng/ml. The occurrence of 'escape ovulation' as suggested by P rise of more than 4 ng/ml in three out of 25 Metronidazole treated women is either a chance incidence due to a different pharmacological response in them, or most probably due to the default in the regular intake of pills in these women. This is supported by the observation that one out of three women showing a P rise (greater than 4 ng/ml( during concurrent Metronidazole therapy, also showed ovulatory P values in oral contraceptive-only treated cycles. Furthermore, in the control group also, one out of 10 women had ovulatory P levels (greater than 4 ng/ml) in oral contraceptive-only treated cycles.

PIP: Plasma levels of (NET) norethisterone, (EE) ethinyl estradiol, Ampicillin, or Metronidazole were estimated in 16 women who were taking low-dose (OC) oral contraceptives (containing norethisterone acetate, 1 mg, and ethinyl estradiol, 30 mcg) and in whom concurrently, either Ampicillin (6 women) or Metronidazole therapy (10 women) was given. Neither drug altered the peak or 24-hour plasma levels and area under the curve for NET and EE. Furthermore, OC treatment did not alter the peak levels of either Ampicillin or Metronidazole. (P) Progresterone levels were in the anovulatory range in all Ampicillin-treated cycles. However, in Metronidazole-treated group, 2 of 10 women showed a P rise of more than 4 ng/ml. The study was expanded to include another group of 15 women treated with Metronidazole and only 1 woman showed a P rise of more than 4 ng/ml. The occurrence of 'escape ovulation' as suggested by a P rise of more than 4 ng/ml in 3 of 25 Metronidazole-treated women is either a chance incidence due to a different pharmacological response in them, or most probably due to the default in the regular intake of pills in these women. This is supported by the observation that 1 out of 3 women showing a P rise ( 4 ng/ml) during concurrent Metronidazole therapy also showed ovulatory P values in OC-only treated cycles. Furthermore, in the control group, 1 out of 10 women had ovulatory P levels ( 4 ng/ml) in OC-only treated cycles.

Flurbiprofen in the treatment of primary dysmenorrhoea.

1 In a double-blind crossover study, flurbiprofen produced marked relief of pain which was significantly more than with aspirin and placebo in patients suffering from primary dysmenorrhoea. In contrast, there was no significant difference between the relief of pain obtained with aspirin and placebo. 2 The clinician's overall assessment of efficacy also indicated that flurbiprofen produced better response as compared to aspirin and placebo in these patients with dysmenorrhoea. 3 Both flurbiprofen and aspirin did not produce any apparent adverse effects on blood loss during the menstrual period. 4 In conclusion, the analgesic effect of flurbiprofen seen in this trial establishes the therapeutic usefulness of the drug in the treatment of primary dysmenorrhoea.

Coagulation studies in women on combination type of oral contraceptives.

PIP: In view of the controversy stemming from reports indicating young women who take combined types of oral contraceptives are at greater risk of venous thrombosis and cerebral or coronary thrombosis, a clinical investigation of blood coagulation changes among 41 oral contraceptive users and 25 controls was undertaken at the K.E.M. Hospital in Bombay, India. The 25 controls (Group A) were women who planned to begin using oral contraceptives but had not yet begun use. 16 of the 41 oral contraceptive users had been taking combined pills for 1 l/2 - 5 years (Group B) and the other 35 for more than 5 years (Group C). Coagulation parameters investigated were 1) prothrombin time; 2) partial thromboplastin time; 3) serum fibrinogen; 4) euglobulin clot lysis time; 5) platelet count; 6) platelet adhesiveness; and 7) platelet aggregation. Significant changes occurred in partial thromboplastin time, platelet count, platlet aggregation, and prothrombin time. Group B had a higher rise in prothrombin time than Group A and a rise in platelet aggregation and in partial thromboplastin time compared to Group A. Platelet counts were higher for both groups of oral contraceptive users than for the controls.^ieng

Administration of prostaglandins by various routes for induction of abortion. Merits and demerits.

Prostaglandin F2alpha and its methyl analogues were used for induction of abortion in 598 patients with gestational age from 9 to 20 weeks. Different routes of administration were studied and various dosages given. The incidence of gastrointestinal side effects were within acceptable range for all methods. Both intra-amniotic injections of 50 mg PGF2alpha and 2.5 mg 15-methyl PGF2alpha as well as intramuscular and vaginal administration of 15-methyl PGF2alpha or its methyl ester, respectively, were highly effective in termination of pregnancy. The intramuscular route was, however, associated with the highest frequency of gastrointestinal side effects. If both efficacy and side effects were taken into consideration, the intra-amniotic and vaginal routes were superior. The ease of administration as well as the applicability over a wider range of gestation in termination of pregnancy may, however, in many situations speak in favour of the repeated vaginal administration of 15-methyl PGF2alpha methyl ester.

A comparison of metal and plastic cannulae for vacuum aspiration.

A comparative study of the safety and effectiveness of metal (Purandare) versus plastic (Karman) cannulae for first trimester abortion was conducted on 400 women. Two hundred vacuum aspiration procedures were performed using each type of cannula. All aspirations were performed by a single physician, and patient follow-up was performed by a second physician. The complication rates, amount of retained tissue, rates of cannula obstruction and procedure times of the two cannulae were compared. Our findings showed no significant difference in any of these evaluation criteria for the metal and plastic cannulae.