Abortion mifepristone

Coyaji K, Elul B, Krishna U, Otiv S, Ambardekar S, Bopardikar A, Raote V, Ellertson C, Winikoff B. Mifepristone abortion outside the urban research hospital setting in India. Lancet 2001 357(9250) 120-2. 

Pregnancy term/naf/on- Misoprostol has been used in combination with mifepristone for pregnancy termination. Patients taking mifepristone must take 400 meg misoprostol orally 2 days after taking mifepristone unless a complete abortion has already been confirmed before that time. 

Antiprogestins (eg, mifepristone) have been combined with an oral oxytocic synthetic analog of PGE1 (misoprostol) to produce early abortion. This regimen is available in the USA and Europe (see Chapter 39). The ease of use and the effectiveness of the combination have aroused considerable opposition in some quarters. The major toxicities are cramping pain and diarrhea. The oral and vaginal routes of administration are equally effective, but the vaginal route has been associated with an increased incidence of sepsis, so the oral route is now recommended. 

In a double-blind, randomized, controlled trial, 896 healthy women requesting a medical abortion (57-63 days gestation, mean age 25 years) were randomized to a single oral dose of mifepristone 200 or 600 mg, both followed in 48 hours by gemeprost 1 mg vaginally (2). The complete abortion rates were similar with the lower and higher doses of mifepristone (92 versus 92%). The incidences of adverse effects were similar, with the exception of nausea at 1 week, which was less frequent in the low-dose group (3.6 versus 7.6%). 

Vaginal misoprostol is more effective and better tolerated than oral misoprostol for induction of first and second trimester abortions after the administration of mifepristone (1,2). It is more effective than either gemeprost or sulprostone combined with mifepristone for induction of first trimester abortion, although uterine rupture has been reported (3). 

There were four deaths in previously healthy women due to endometritis and toxic shock syndrome within 1 week after medically induced abortions with oral mifepristone 200 mg and vaginal misoprostol 800 micrograms in two cases Clostridium sordellii was found (19). Another similar case was reported in Canada in 2001. Endometritis and toxic shock syndrome associated with C. sordellii are rare. Of 10 cases identified by authors in the previous literature, eight occurred after the delivery of live-born infants, one after a medical abortion, and one was not associated with pregnancy. The cases produced an FDA alert with a Dear Health Care Provider letter from the manufacturer and publication of a Dispatch in the Morbidity and Mortality Weekly Report (20). 

Schaff EA, Fielding SL, Westhoff C, EUertson C, Eisinger SH, Stadalius LS, Fuller L. Vaginal misoprostol administered 1, 2, or 3 days after mifepristone for early medical abortion A randomized trial. JAMA 2000 284(15) 1948-53. 

Centers for Disease Control and Prevention. Clostridium sordellii toxic shock syndrome after medical abortion with mifepristone and intravaginal misoprostol—United States and Canada, 2001-2005. MMWR Morb Mortal Wkl Rep 2005 54 724. 

Whatever the adverse effects of mifepristone, the risks have to be looked at realistically and compared with those of the alternatives available to a particular woman in particular circumstances. Particularly in rural areas in developing countries, the risks of surgical and non-professional abortion are high, whereas, as has been shown in a study in rural India, a regimen of mifepristone plus misoprostol can be used as effectively and safely, through family planning clinics and country hospitals, as in a European environment (2). 

The effective oral doses of mifepristone are 100-600 mg, and at any dose the bulk of recipients abort. Of 150 healthy women who received the higher dose, 131 attained a complete abortion. Three women reported bleeding for more than 2 weeks after abortion 16 women had a reduced hemoglobin concentration of under 11 g/dl, justifying iron therapy. Other adverse effects were uterine contractions and pelvic pain (n = 4), transient asthenia (n = 3), and nausea (n = 2) (5). These findings seem to be typical, even though dosage schemes have varied as little as 100 mg orally has been used successfully with similar adverse effects (SED-12,1037 6). 

No doubt in part because of ethical controversies it has sometimes been difficult to mount adequate controlled studies, especially in the USA. Many women and practitioners have retained a preference for dilatation and evacuation as a means of performing abortion rather than using a medicinal technique. In a pilot study at Chapel Hill, North Carolina oral mifepristone 200 mg followed 2 days later by vaginal and oral misoprostol was compared with the surgical method (11). Of 47 women eligible for the trial, 29 declined to participate, primarily because of a preference for dilatation and evacuation. Of the 18 participants enrolled, nine were randomized to treatment with mifepristone + misoprostol and 9 to dilatation and evacuation. Mifepristone + misoprostol caused more pain and adverse events, although none was serious.)... 

A rare case of a non-metastatic gestational trophoblastic tumor after induction of early abortion with mifepristone and misoprostol has been reported (20). 

There has sometimes been reluctance to use higher doses of mifepristone, because of a supposedly greater risk of severe adverse effects. However, in a randomized comparison of a single oral dose of mifepristone (either 200 mg or 600 mg) followed 48 hours later by oral misoprostol 400 pg the two regimens produced identical results as regards the induction of abortion and the incidence of adverse effects (22). 

Hausknecht R. Mifepristone and misoprostol for early medical abortion 18 months experience in the United States. Contraception 2003 67 463-5. 

Shannon CS, Winikoff B, Hausknecht R, Schaff E, Blumenthal PD, Oyer D, Sankey H, Wolff J, Goldberg R. Multicenter trial of a simplified mifepristone medical abortion regimen. Obstet Gynecol 2005 105 345-51. 

Liao AH, Han XJ, Wu SY, Xiao DZ, Xiong CL, Wu XR. Randomized, double-blind, controlled trial of mifepristone in capsule versus tablet form followed by misoprostol for early medical abortion. Eur J Obstet Gynecol Reprod Biol 2004 116 211-6. 

Grimes DA, Smith MS, Witham AD. Mifepristone and misoprostol versus dilation and evacuation for midtrimester abortion a pilot randomised controlled trial. Int J Obstet Gynaecol 2004 111 148-53. 

Creinin MD, Pymar HC, Schwartz JL. Mifepristone 100 mg in abortion regimens Obstet Gynecol 2001 98(3) 434—9. 

Knudsen UB. First trimester abortion with mifepristone and vaginal misoprostol. Contraception 2001 63(5) 247-50. 

Schreiber C, Creinin M. Mifepristone in abortion care. Semin Reprod Med. 2005 23 82-91. 

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