Telemedicine for the provision of medication abortion to pregnant people at up to twelve weeks of pregnancy: a systematic literature review and meta-analysis.

BACKGROUND: Telemedicine represents an important strategy to facilitate access to medication abortion (MAB) procedures, reduces distance barriers and expands coverage to underserved communities. The aim is evaluating the self-managed MAB (provided through telemedicine as the sole intervention or in comparison to in-person care) in pregnant people at up to 12 weeks of pregnancy. METHODS: A literature search was conducted using electronic databases: MEDLINE, Embase, Cochrane (Central Register of Controlled Trials and Database of Systematic Reviews), LILACS, SciELO, and Google Scholar. The search was based on the Population, Intervention, Comparison, Outcome, and Study Design (PICOS) framework, and was not restricted to any years of publication, and studies could be published in English or Spanish. Study screening and selection, risk of bias assessment, and data extraction were performed by peer reviewers. Risk of bias was evaluated with RoB 2.0 and ROBIS-I. A narrative and descriptive synthesis of the results was conducted. Meta-analyses with random-effects models were performed using Review Manager version 5.4 to calculate pooled risk differences, along with their individual 95% confidence intervals. The rate of evidence certainty was based on GRADE recommendations. RESULTS: 21 articles published between 2011 and 2022 met the inclusion criteria. Among them, 20 were observational studies, and 1 was a randomized clinical trial. Regarding the risk of bias, 5 studies had a serious risk, 15 had a moderate risk, and 1 had an undetermined risk. In terms of the type of intervention, 7 compared telemedicine to standard care. The meta-analysis of effectiveness revealed no statistically significant differences between the two modalities of care (RD = 0.01; 95%CI 0.00, 0.02). Our meta-analyses show that there were no significant differences in the occurrence of adverse events or in patient satisfaction when comparing the two methods of healthcare delivery. CONCLUSION: Telemedicine is an effective and viable alternative for MAB, similar to standard care. The occurrence of complications was low in both forms of healthcare delivery. Telemedicine services are an opportunity to expand access to safe abortion services.

Effectiveness and safety of medication abortion via telemedicine versus in-person: A cohort of pregnant people in Colombia.

OBJECTIVE: To compare the effectiveness and safety of medication abortion (MAB) via telemedicine versus in-person in pregnant people with less than 12 gestational weeks in Colombia. STUDY DESIGN: A retrospective cohort study was conducted with 23,362 pregnant people who requested MAB service from Profamilia (a Colombian non-governmental organization) in 2021-2022. The outcomes were success and safety of MAB. We performed a descriptive and a multivariate statistical analysis using the binary regression model to obtain an adjusted Odds Ratio (aOR) to identify factors associated with abortion success. RESULTS: In comparison to in-person care (n = 20,289), individuals in telemedicine (n = 3073) were predominantly from urban areas, belonged to a lower socioeconomic stratum, single and did not identify with any ethnic group. In-person users tended to have higher levels of education and accessed the service through private insurance (p < 0,05). There were no differences in the odd of a successful abortion based on the modality of care (aOR 1.18; 95% CI=0.87-1.59). The results were also the same with sensitivity analysis stratified: pregnant people who were nine weeks gestation or less (aOR 0.86; 95% CI=0.63-1.17) or more (aOR 0.87; 95% CI=0.28-2.65). CONCLUSION: Telemedicine is an effective and safe option for MAB, as in-person care. Telemedicine has the potential to increase abortion access by extending the availability of providers and offering people a new option for obtaining care conveniently and privately, especially for women with disadvantaged socioeconomic and educational background. IMPLICATIONS: This study demonstrates that medication abortion (MAB) administered via telemedicine produces outcomes akin to those of in-person care, providing a compelling rationale for its adoption, particularly in underserved regions. This approach can be replicated in other countries in Latin America and the Caribbean.

Effectiveness of self-managed medication abortion with accompaniment support in Argentina and Nigeria (SAFE): a prospective, observational cohort study and non-inferiority analysis with historical controls.

BACKGROUND: Clinical trials have established the high effectiveness and safety of medication abortion in clinical settings. However, barriers to clinical abortion care have shifted most medication abortion use to out-of-clinic settings, especially in the context of the COVID-19 pandemic. Given this shift, we aimed to estimate the effectiveness of self-managed medication abortion (medication abortion without clinical support), and to compare it to effectiveness of clinician-managed medication abortion. METHODS: For this prospective, observational cohort study, we recruited callers from two safe abortion accompaniment groups in Argentina and Nigeria who requested information on self-managed medication abortion. Before using one of two medication regimens (misoprostol alone or in combination with mifepristone), participants completed a baseline survey, and then two follow-up phone surveys at 1 week and 3 weeks after taking pills. The primary outcome was the proportion of participants reporting a complete abortion without surgical intervention. Legal restrictions precluded enrolment of a concurrent clinical control group; thus, a non-inferiority analysis compared abortion completion among those in our self-managed medication abortion cohort with abortion completion reported in historical clinical trials using the same medication regimens, restricted to participants with pregnancies of less than 9 weeks' gestation. This study was registered with ISCRTN, ISRCTN95769543. FINDINGS: Between July 31, 2019, and April 27, 2020, we enrolled 1051 participants. We analysed abortion outcomes for 961 participants, with an additional 47 participants reached after the study period. Most pregnancies were less than 12 weeks' duration. Participants in follow-up self-managed their abortions using misoprostol alone (593 participants) or the combined regimen of misoprostol plus mifepristone (356 participants). At last follow-up, 586 (99%) misoprostol alone users and 334 (94%) combined regimen users had a complete abortion without surgical intervention. For those with pregnancies of less than 9 weeks' gestation, both regimens were non-inferior to medication abortion effectiveness in clinical settings. INTERPRETATION: Findings from this prospective cohort study show that self-managed medication abortion with accompaniment group support is highly effective and, for those with pregnancies of less than 9 weeks' gestation, non-inferior to the effectiveness of clinician-managed medication abortion administered in a clinical setting. These findings support the use of remote self-managed models of early abortion care, as well as telemedicine, as is being considered in several countries because of the COVID-19 pandemic. FUNDING: David and Lucile Packard Foundation. TRANSLATIONS: For the Arabic, French, Bahasa Indonesian, Spanish and Yoruba translations of the Article see Supplementary Materials section.

The "Abortion Pill" Misoprostol in Brazil: Women's Empowerment in a Conservative and Repressive Political Environment.

In the aftermath of the introduction of severe restrictions on abortion in several US states, some activists have argued that providing widespread access to an abortive drug, misoprostol, will transform an induced abortion into a fully private act and therefore will empower women. In Brazil, where abortion is criminalized, the majority of women who wish to terminate an unwanted pregnancy already use the illegal, but easily accessible, misoprostol. We examine the history of misoprostol as an abortifacient in Brazil from the late 1980s until today and the professional debates on the teratogenicity of this drug. The effects of a given pharmaceutical compound, we argue, are always articulated, elicited, and informed within dense networks of sociocultural, economic, legal, and political settings. In a conservative and repressive environment, the use of misoprostol for self-induced abortions, even when supported by formal or informal solidarity networks, is far from being a satisfactory solution to the curbing of women's reproductive rights.

Uterine artery embolization with methotrexate infusion as treatment for cesarean scar pregnancy. Case report.

Cesarean scar pregnancy is a rare form of ectopic pregnancy. It is associated with many complications, including a high risk of massive bleeding and hysterectomy under unfavorable conditions. Conservative treatment with systemic methotrexate (MTX) has been used preferentially with the aim of allowing the patient to have a reproductive future. However, cases of complex ectopic masses in a cesarean scar with guarded prognosis demand techniques that are more effective, such as uterine artery embolization (UAE) in association with intra-arterial MTX infusion. We describe the case of a 35-year-old patient in the 8th week of pregnancy who was referred to us because of genital bleeding and suspected ectopic pregnancy in the cesarean scar. After confirmation of the diagnosis, an initial attempt at systemic treatment with MTX was made. This was abandoned due to the elevation of the hepatic transaminase level. In addition, because of the complexity of the mass and the patient's desire to preserve her reproductive capacity, it was decided to perform UAE with local MTX infusion. The procedure was performed successfully and the patient's fertility was preserved.

Obstetrician-gynecologists' knowledge of and attitudes toward medical abortion in Guatemala.

OBJECTIVE: To characterize the legal and clinical knowledge of Guatemalan obstetrician-gynecologists (OB/GYNs) regarding medical abortion and to determine factors associated with approval of its use for specific indications. METHODS: A trained interviewer administered a multiple-choice survey to 172 private-practice OB/GYNs across Guatemala. Univariate, bivariate, and multivariate analyses characterized medical abortion opinion and knowledge, and logistic regression identified influential factors. RESULTS: 73% of OB/GYNs knew that abortion is legally permitted when the woman's life is at risk. Although 92% knew that misoprostol can be used to induce abortion, only 35% knew the WHO-recommended dosage. Only 25% knew of mifepristone. Compared with older OB/GYNs, those under 40 years of age were 7 times more likely, and 40-49 year olds were twice as likely to approve of medical abortion for fetal death and severe eclampsia with fetal death, respectively. CONCLUSION: Current indications for abortion under Guatemalan law, as well as OB/GYN practices and beliefs regarding medical abortion, are hindering women's access to safe medical abortion and, therefore, potential reductions in maternal morbidity and mortality. Future research should aim to identify whether and why Guatemalan OB/GYNs are unfamiliar with these drugs, prefer to use other methods, or are completely against abortion.

[Acute toxicity by methotrexate used for abortion purpose. Case report]. / Intoxicación aguda por metotrexato utilizado con fines abortivos. Reporte de caso.

We report the case of a 16 years old female patient, with a pregnancy history of 11.4 weeks by ultrasound and intrauterine fetal death. In a private clinic were prescribed methotrexate 500 mg intramuscular single dose, and vaginal misoprostol. She had a clinical feature of five days of evolution characterized by fever of 39 degrees C, nausea, general attack and vomiting. The initial diagnosis was severe sepsis secondary to septic abortion, oral candidiasis and acute poisoning by methotrexate. After that, she was referred to the Instituto Nacional de Perinatologia, where stayed with fever for four days, and was managed with hydration, antibiotics, folinic acid and alkalizing. Her recovery was gradual. She was discharged after 12 days with significant clinical improvement. The literature review describes that the use of methotrexate for abortion purpose with therapeutic-dose presents a similar adverse effects to those found in our patient, however there are no case reports that describe the use of this drug in macrodosis for the same purpose, and their cytotoxic effects. We present this case because the patient used a macrodosis of this antimetabolite and due to the premature and empirical management with folinic acid, joined with alkalinization of urine, is the ideal treatment and as it is illustrated in our case.

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.

An experimental model to study resistance index and systolic/diastolic ratio of uterine arteries in adverse canine pregnancy outcome.

The aim of this study was to describe the changes in the resistance index (RI) and systolic/diastolic ratio (S/D) of the uterine arteries during mid-pregnancy abortion induction in the dog. Sixteen 30-35 day pregnant bitches were randomly assigned to either a pharmacological protocol to interrupt gestation (n = 8) or were used as untreated control group (n = 8). Doppler assessments of uterine arteries blood flow were carried out before the initiation of the protocol and then every other day up to abortion (treated group) or parturition (control group). All treated bitches aborted 6 +/- 1.2 days after initiation of the treatment (while none of the non-treated bitches aborted). Pre-treatment RI and S/D did not differ between groups (p > 0.2) while average post-treatment indexes were (mean +/- SD): 0.62 +/- 0.1 vs 0.53 +/- 0.1 (p < 0.01) and 2.96 +/- 0.9 vs 2.23 +/- 0.3 (p = 0.01), for the treated and non-treated group respectively. Correlations between days to abortion and RI or S/D were 0.75 (p < 0.01) and 0.79 (p < 0.01) and, -0.78 (p < 0.01) and -0.73 (p < 0.01) for the treated and non-treated groups respectively. In the treated group, correlations between serum progesterone (P(4)) concentrations and RI and S/D were -0.76 (p < 0.01) and -0.59 (p < 0.01) respectively. It is concluded that, during induction of abortion, RI and S/D of uterine arteries progressively increased while P(4) decreased.

Medical abortion in primary care: pitfalls and benefits.

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.

A combination of oral cabergoline and double cloprostenol injections to produce third-quarter gestation termination in the bitch.

To assess the efficacy and safety of a combined cabergoline and cloprostenol protocol to terminate third-quarter pregnancy, 22 pregnant bitches that ranged from 35 to 45 days after mating were randomly assigned to a treatment group (n=13) or to an untreated control group (n=9). The animals were monitored for 12 days, and pregnancy termination was confirmed by ultrasound examination. Twelve of the 13 treated bitches aborted within 9 days of the initiation of treatment (mean 4.6 days). Only mild side effects were observed. The control animals had normal gestational courses, as did the bitch that did not respond to the therapy. This combination of drugs appeared to be a practical, safe, and efficient abortifacient when used in third-quarter pregnancies.

Effect of Ruta graveolens L. on pregnant mice.

Ruta graveolens L. is used in many countries, including Brazil, as an abortifacient. To determine its effect on pregnancy, the lyophilized hydroalcoholic extract of its aerial parts was administered orally at a dose of 1000 mg/kg per day to mice between the first and third day of pregnancy (DOP), between the fourth and sixth DOP or between the seventh and ninth DOP. The extract did not cause preimplantation embryonic loss or reabsorptions. Fetal death was found. Estrogenic activity was not exhibited by the extract.

Management of cervical pregnancy: risk factors for failed systemic methotrexate.

Cervical pregnancy is a rare obstetrical complication. Conservative management with systemic methotrexate has been reported to be successful, obviating the need for surgical treatment which entails a risk for hysterectomy. We report the case of a nulliparous patient with a cervical pregnancy diagnosed at 9 weeks' gestation who after systemic methotrexate treatment necessitated conservative surgical management. This patient highlights the utility of identified risk factors for failure of methotrexate treatment.

Effect of Maytenus ilicifolia Mart. on pregnant mice.

Maytenus ilicifolia Mart. is used in Brazilian herbal medicine particularly for stomach disorders, but it is also used, as in other parts of South America, for fertility control. To verify its potential as an abortifacient, the lyophilized hydroalcoholic extract of its leaves was administered orally at a dose of 1000 mg/kg/day to mice between the first and third day of pregnancy (DOP), between the forth and sixth DOP, or between the seventh and ninth DOP. The extract caused a pre-implantation embryonic loss, but it did not have an effect on implantation or organogenesis. Morphological alterations of the reproductive system, not an embryotoxic effect, were not found. Estrogenic activity of the extract, exhibited by an uterotrophic effect, suggests that it may be interfering with the uterine receptivity to the embryo.

Blood loss with mifepristone--misoprostol abortion: measures from a trial in China, Cuba and India.

OBJECTIVE: We compared bleeding patterns following early mifepristone-misoprostol abortion with those following early surgical abortions ( < or = 56 days gestation LMP). We analyzed women's reports of their bleeding and clinical measures of blood loss, and modeled the relationships between different bleeding measures and indicators of success and satisfaction. METHOD: Using data from a multicenter trial held in China, Cuba and India, we fit bivariate and multivariate models to analyze bleeding patterns, controlling for a range of demographic, experiential and medical factors (n = 1373). RESULT: Medical abortion patients perceived their bleeding to be heavier than did the surgical patients; however, there were few statistically significant differences in clinical measures of blood loss between the two groups, and blood loss rarely represented a medical problem. Nationality, far more than actual levels of bleeding, influenced women's impressions about blood loss. Although medical abortion patients saw their bleeding as heavier than did the surgical patients, their perceptions of heavier bleeding did not prevent them from having higher satisfaction levels. One exception was that if bleeding exceeded prior expectations, women with the medical method were more likely to be dissatisfied. Pain and cramps, which often accompanied bleeding, were an independently significant factor in predicting satisfaction with the method. CONCLUSION: In order for women to know what to expect with medical abortion, they must be informed beforehand about the level of bleeding that generally accompanies the procedure vs. excessive bleeding that would signal a clinical problem.

Ausência de efeito abortivo do extrato benzênico de Hibiscus rosa sinensis em ratas / Absence of abortifacient effect of the benzene extract of Hibiscus rosa sinensis in rats

O extrato benzênico de flores de Hibiscus rosa sinensis foi administrado a ratas grávidas, desde o dia 1§ ao 10§ de gestaçäo (dose: 200 mg/kg peso corporal), com o objetivo de confirmar seu efeito abortivo. Os resultados obtidos näo confirmam os dados da literatura, uma vez que näo ocorreram efetios embriotóxicos ou zigotóxicos do extato. É possível que os resultados conflitantes se devam, ao fato de planta ser cultivada em solo e climas diferentes e, talvez, muitos os resultados dicrepantes em estudos de plantas possam ser devido ao local onde a planta foi obtida