Misoprostol abortion

The administration of this product by any route is contraindicated in pregnant women because its misoprostol component can cause abortion. 

Uterine rupture has been reported when misoprostol was administered intravaginally in pregnant women to induce labor or to induce abortion beyond the first trimester of pregnancy. 

Uterine perforation has been reported following administration of combined vaginal and oral misoprostol in pregnant women to induce abortion. In each of these reported cases, the gestational age of the pregnancies was unknown. 

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. 

Seven Brazilian infants were born with limb deficiencies both with and without Mobius sequence after exposure to misoprostol in the first trimester during unsuccessful abortion attempts (118). 

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). 

Intramuscular methotrexate 50 mg/m2 followed by intravaginal misoprostol was effective in the induction of first trimester abortion. Adverse events following the administration of misoprostol included nausea (12%), vomiting (8.1%), diarrhea (7.4%), and fevers/chills (3.4%) (4). 

Misoprostol has been used to induce abortions in 150 adolescents (age range 12-17 years) at gestations of 63-84 days (7). They received vaginal misoprostol 800 micro-grams/day to a maximum of three doses. Complete abortion occurred in 84%. Adverse effects were more frequent in these adolescents than in adult women, and included nausea (31%), vomiting (41%), diarrhea (48%), dizziness (19%), headache (17%), a subjective feeling of fever (26%), flushing (16%), and chills (49%). 

Several cases of uterine rupture due to misoprostol after second trimester have been reported. However, unexpectedly, administration of misoprostol for cervical ripening before surgical evacuation of a missed abortion reportedly produced uterine rupture in the first trimester... 

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). 

Jain JK, Mishell DR Jr. A comparison of misoprostol with and without laminaria tents for induction of second-trimester abortion. Am J Obstet Gynecol 1996 175(1) 173—7. 

Creinin MD, Vittinghoff E, Keder L, Darney PD, Tiller G. Methotrexate and misoprostol for early abortion a multicenter trial. I. Safety and efficacy. Contraception 1996 53(6) 321-7. 

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. 

Al-Hussaini TK. Uterine rupture in second trimester abortion in a grand multiparous woman. A complication of misoprostol and oxytocin. Eur J Obstet Gynecol Reprod Biol 2001 96(2) 218-9. 

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. 

Searle GD. Important drug warning concerning unapproved use of intravaginal or oral misoprostol in pregnant women for induction of labor or abortion. Media Release 23 August 2000. 

Hamoda H, Ashok PW, Flett GM, Templeton A. A randomized controlled comparison of sublingual and vaginal administration of misoprostol for cervical priming before first-trimester surgical abortion. Am J Obstet Gynecol 2004 190 55-9. 

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). 

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. 

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. 

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

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