Premila W. Ashok

Nonsurgical mid‐trimester termination of pregnancy: a review of 500 consecutive cases

Objective To assess the effectiveness of a regimen comprising mifepristone followed by a combination of the vaginal and oral administration of misoprostol for mid‐trimester medical termination of pregnancy.

A randomized trial of mifepristone (10 mg) and levonorgestrel for emergency contraception.

OBJECTIVE: To compare the efficacy, patient acceptability and adverse effects of low-dose mifepristone (10 mg) with the levonorgestrel regimen (2 doses of 750 μg given 12 hours apart) for emergency contraception. METHODS: This randomized controlled trial compared mifepristone (10 mg) to levonorgestrel (2 doses of 750 μg given 12 hours apart) in the context of emergency contraception within 120 hours of unprotected intercourse. The primary outcome measure was unintended pregnancy. Secondary outcomes included adverse effects experienced by women, acceptability of the method of emergency contraception used, and the timing of the first menstrual cycle after treatment. RESULTS: The total number of women recruited was 2,065. The crude pregnancy rates were 1.3% and 2.0% for mifepristone and levonorgestrel (P = .46), with 77% and 64% of expected pregnancies prevented, respectively. Women receiving mifepristone were more likely to have a delayed onset of the subsequent menstrual cycle after treatment (P < .001), whereas those having levonorgestrel were more likely to have an early onset of the subsequent menstrual cycle (P < .001). Acceptability levels were high for both methods, with 94% of women receiving mifepristone and 91% receiving levonorgestrel expressing satisfaction. There was no difference in adverse effects (nausea, vomiting, breast tenderness, abdominal pain, lethargy, headache, hot flushes, and dizziness) experienced by women in the 2 groups. CONCLUSION: This study suggests that a small dose of mifepristone is not less effective than levonorgestrel for emergency contraception. Both regimens were highly acceptable to women. LEVEL OF EVIDENCE: II-1

Termination of pregnancy at 9–13 weeks' amenorrhoea with mifepristone and misoprostol

n The effectiveness of a combined regimen of mifepristone and vaginal misoprostol for termination of pregnancies of 9-13 weeks of gestation was investigated in 120 UK abortion patients (median age, 22.1 years; median duration of amenorrhea, 10.3 weeks). Each woman received a single oral dose of 200 mg of mifepristone 36-48 hours before admission, at which time 800 mcg of misoprostol was administered vaginally. Where indicated, a further two doses of 400 mcg of misoprostol (vaginal or oral) were provided every 3 hours. All 120 women aborted on the day of prostaglandin administration; however, 6 women (5%) required exploratory curettage after the procedure for retained placenta. The median prostaglandin dose was 1200 mcg (range, 800-1600 mcg). The median time from misoprostol administration to abortion was 4.33 hours (range, 1.3-16.0 hours). 60 women (50%) required oral analgesics and 26 (22%) received parenteral analgesia. Diarrhea occurred in 38 women (32%). The median duration of bleeding after abortion was 12.5 days (range, 3-43 days). In questionnaires administered to 73 women, only 3 (4%) expressed dissatisfaction with medical abortion, because of pain or prolonged bleeding. The relatively high dose of misoprostol used in this study and the vaginal route of administration are presumed to account for the 95% success rate. Extension of medical abortion to later gestation times would decrease the need for surgery and expand womens choice of methods of pregnancy termination.n

Medical management of late intrauterine death using a combination of mifepristone and misoprostol

Objective To assess the efficacy and safety of mifepristone in combination with misoprostol in the management of late fetal death.

The treatment of incomplete miscarriage with oral misoprostol

In a retrospective study of 112 women, the effectiveness of three sequential oral doses of misoprostol was evaluated for the treatment of incomplete miscarriage. We report our experience with this regimen, which achieved a complete miscarriage rate of 85%. Surgical intervention was required in 17 women (15%). The regimen appears to be effective in terms of a high rate of complete miscarriage, and it is safe.

Manual vacuum aspiration: a safe alternative for the surgical management of early pregnancy loss.

Manual vacuum aspiration (MVA) is an alternative to the standard surgical curettage, performed under local anaesthetic in the setting of a treatment room. The aim of our study was to assess the efficacy of MVA in the management of first trimester early fetal demise and first‐ and mid‐trimester incomplete miscarriage. This was a retrospective study of 246 patients who were scheduled to undergo MVA for first trimester early fetal demise and first‐ and mid‐trimester incomplete miscarriage. One woman was excluded in the analysis because of the procedure being abandoned prior to MVA. Efficacy of the procedure was 94.7% (232/245). Incomplete uterine evacuation was seen in 5.3% (13/245) patients. Although not widely used in the UK, MVA could be considered routinely, thus avoiding general anaesthesia and the need for access to theatre.

A rare case of postmenopausal bleeding due to Wegener's granulomatosis

Wegener’s granulomatosis (WG) is a disease of unknown etiology, characterized by immune-mediated necrotizing vasculitis and presence of granulomas, commonly affecting the upper respiratory tract, lungs and kidneys. Although commonly involves lungs and kidneys, it can potentially affect any organ in the body including the urogenital tract (1,2). However, involvement of the uterine cervix is very rare in WG (3).

Mifepristone versus the Yuzpe regimen (PC4) for emergency contraception

Objective: To compare side effects, womens acceptance and satisfaction with mifepristone (100 mg) versus the Yuzpe regimen for emergency contraception (EC). Methods: A total of 1000 women requesting EC within 72 h of unprotected intercourse were randomized to receive mifepristone 100 mg or the standard Yuzpe regimen. Outcome measures included patient acceptability and satisfaction. Results: A total of 620 (62%) questionnaires were returned, 64% in the mifepristone group and 60% in the Yuzpe group. Mifepristone was better tolerated than the Yuzpe regimen. The rates of nausea (P<0.0001), abdominal pain (P=0.001), tiredness (P<0.0001), lethargy (P=0.001), hot flushes (P<0.0001) and dizziness (P<0.0001) were all significantly higher in women given the Yuzpe regimen compared to those who received mifepristone. Of these 94% and 80% in the mifepristone and Yuzpe groups, respectively, were satisfied with treatment (P<0.0001). Of women in the mifepristone group, 56% (181/321) had used the Yuzpe regimen of EC in the past and of these, 93.6% (161/172) indicated they would use mifepristone in the future. A total of four women in the Yuzpe group had mifepristone in the past and all four said they would use mifepristone in the future. Conclusion: Mifepristone has high patient acceptability and few side effects compared to the standard Yuzpe regimen for EC.

An overview of medical abortion using low-dose mifepristone and misoprostol

It is now well established that pregnancy can be terminated safely medically at all gestations using the antiprogestogen mifepristone and a prostaglandin analog. This is an effective alternative to surgery, offering women additional choice. Although a regimen comprising 600 mg mifepristone and the prostaglandin analog gemeprost administered vaginally is licensed for use, evidence suggests that mifepristone in a 200-mg dose together with the prostaglandin E1 analog misoprostol is equally efficacious and cost effective. Additionally, unlike gemeprost, misoprostol does not require stringent storage conditions and can be administered orally, vaginally or sublingually. Efficacy of the medical regimen decreases with increasing gestation and also varies with the dose and route of the prostagladin analog administered. For the majority of women undergoing medical abortion, oral analgesia suffices. Initial studies have reported high efficacy and good acceptability of medical abortion in home settings. Developing an...