Misoprostol Protocol Research Articles

Retrospective cohort study comparing success of medical management of early pregnancy loss in pregnancies conceived with and without medical assistance

To compare the success rates of medical management using a combined mifepristone and misoprostol protocol in cases of early pregnancy loss (EPL) between women who conceived without medical assistance and those who conceived through invitro fertilization (IVF), after fresh or frozen embryo transfer, and evaluate for the predictive factors of success, time to first passage of tissue, and time to complete resolution of pregnancy. Retrospective cohort study. University hospital. Women who presented with EPL below 13 weeks of gestation between June 2013 and July 2021 who were managed medically with mifepristone 200 mg orally and misoprostol 800 mcg vaginally were included in the study. Medical management with mifepristone and misoprostol; conception without medical assistance vs. post-IVF, after fresh or frozen embryo transfer. We evaluated overall success and performed subgroup analysis according to the mode of conception and compared fresh vs. frozen-thawed embryo transfers for IVF pregnancies. In all groups, we also calculated success according to gestational age and compared the time to first passage of tissue. The potential predictive factors of treatment success were analyzed. The side effects and complications of treatment were recorded. A total of 930 women were included in the study, 99 (11%) of whom achieved pregnancy after IVF. The overall success of medical treatment was 89% with no statistically significant difference according to the mode of conception (89% vs. 89%) or type of transfer (fresh 89% vs. frozen 89%). Only lower gestational age by sonography was independently predictive of treatment success, showing a negative regression coefficient of β = -0.333 and an odds ratio of 0.717. The mean time to first passage of tissue was 5.0 ± 2.1 hours. Altogether, 666 women (72%) showed pregnancy resolution on the day of medication administration, an additional 110 women at 1-week follow-up, and a further 74 women after ≥4 weeks on ultrasound. Medical management of EPL with mifepristone and misoprostol is a highly successful treatment option that results in completed abortion in a timely fashion in both pregnancies conceived without medical assistance and those conceived after IVF.

Therapeutic Response of Mifepristone with Dinoprost and Misoprostol for Management of Canine Pyometra

Background: Canine pyometra (chronic purulent endometritis) is one of the most important uterine disorder of bitches seeks medical treatment. The hormonal therapies are not much popular among the veterinarians thus needs to exploit some hormonal protocols for this condition. Therefore, the experiment was carried out to study the therapeutic response of antiprogestin and prostaglandin in canine pyometra. Methods: The experiment was carried out in total 21 bitches affected with pyometra were selected and divided randomly into 3 groups. Animals of control group (TC) were treated with non-hormonal supportive treatment for 7 days. Animals of T1 were received non-hormonal supportive treatment for 7 days similar to TC along with mifepristone @ 3 mg/kg orally BID on day 1, 2 and 8 and Dinoprost in @ 50-200 mcg/kg S/C day 3 to 7. Animals of T2 were treated similar to TC plus mifepristone @ 3 mg/kg orally BID on day 1, 2 and 8 and Misoprostol @ 3 mcg/kg intravaginally twice daily on day 3 to 7. Result: Therapeutic responses was recorded better in T1 group (100%), followed by T2 (71.43%) and TC (42.86%). The mean TLC values after completion of treatment (day 8) were significantly decreased in T1 and T2. The neutrophil count in different groups T1, T2 and TC was reduced significantly. There was significant decrease in mean concentration of BUN and creatinine on day 8 after treatment in T1 and T2 groups. The mean ALT values decreased significantly in T1 group. However, ALP values decreased significantly in T1 and T2 groups. The mean serum progesterone declined significantly in both the hormone treated groups (T1 and T2). The study can be concluded that therapeutic response of mifepristone with dinoprost tromethamine was found most effective for the treatment of canine pyometra than mifepristone with misoprostol protocol.

Safety of medical second trimester abortions for women with prior cesarean sections.

Medical second-trimester abortion in women with prior cesarean section (CS) is becoming an increasingly common phenomenon. However, data about the safety of the procedure are limited. This study addresses this issue. Retrospective cohort single-center study, done in Hadassah Medical Center in Jerusalem, a tertiary-care university hospital. This study included 779 women who needed pregnancy termination between 13 and 26 gestational weeks. 128 women had at least one previous CS (study group), whereas 651 had no CS (reference group). Protocols used were: (1) misoprostol tablets, 800 mcg vaginally followed by 400 mcg orally every 3h up to four oral doses, (2) Oxytocin drip. Nearly one-fourth of the women received mifepristone as a preliminary treatment for cervical ripening. The outcomes assessed included the following complications: retained placenta, bleeding with or without requiring blood transfusion, infection, cervical lacerations, uterine adhesions and uterine ruptures. Previous CS does not appear to increase the incidence of complications, excluding clinical bleeding without requiring blood transfusions (p value 0.05), which has a minimal clinical significance. Oxytocin protocol had 3.44 OR for complications, compared to misoprostol (p value 0.03, CI; 1.12- 10.52). No significant correlation was found between Misoprostol dosage and complications (Mann-Whitney U test, p value 0.057). Medical second-trimester abortions for women with prior CS should be considered a safe and effective procedure, with a low complication rate. The most serious complication is uterine rupture, which is uncommon; we recorded one case only. Misoprostol protocol should be preferred. IRB 0177-17-HMO, 5/2014.

Labor Induction Outcomes With Outpatient Misoprostol for Cervical Ripening Among Low-Risk Patients [OP03-6C

INTRODUCTION: Labor induction is becoming increasingly common. The objective of this study is to evaluate the effect of outpatient misoprostol for cervical ripening on inpatient time-to-delivery and maternal and neonatal outcomes. METHODS: We conducted an IRB approved retrospective cohort study of 10,467 patients (559 outpatient, 9,908 inpatient) who received misoprostol for cervical ripening at Kaiser Permanente Northern California hospitals between 2012 and 2017. Time-to-delivery and maternal and neonatal outcomes after misoprostol administration were analyzed with standard statistical tests. RESULTS: Patients induced with misoprostol in the outpatient and inpatient settings were comparable in demographics and predominantly nulliparous (70.3% and 64.3%, respectively). Patients who received outpatient misoprostol were more likely to have a cervical dilation of 3cm on admission (39.5% vs 9.7%, P < .0001). The outpatient misoprostol cohort had a shorter time between admission and delivery (20.6 [interquartile range (IQR) 12.4-31.7] vs 27.5 [IQR 19.2-37.4] hours, P < .0001), with no difference in mode of delivery or neonatal outcomes. Patients who received outpatient misoprostol were more likely to have a C-section for failure to progress in labor (14.0% vs 11.2%, P=.04), however the overall C-section rate was not significantly different between groups. Patients who received outpatient misoprostol had a higher rate of chorioamnionitis and a trend towards a lower maternal blood transfusion (14.3% vs 10.6%, P=.01; 0.7% vs 1.8%, P=.06, respectively). CONCLUSION: Outpatient misoprostol reduced inpatient time-to-delivery by a median of 7 hours with no significant differences in maternal or neonatal outcomes. An outpatient misoprostol protocol has the potential to decrease inpatient burden on Labor and Delivery.

Home-Based Extended Low-Dose Oral Misoprostol in Management of First-Trimester Pregnancy Loss in Low-Resource Communities: A Randomized Trial.

To investigate the efficacy, safety and tolerability of a home-based extended low-dose oral misoprostol for management of first-trimester pregnancy loss. A randomized trial that was conducted in the Woman's Health University Hospital and El-eman Maternity Hospital, Assiut, Egypt. One hundred and sixty patients were included. They were randomly assigned to receive four tablets of 200μg misoprostol vaginally (max. 800μg-hospital group) or 12 tablets orally, one every 3h, over 2 consecutive days (max. 2400μg-extended low-dose home group). For failed first dose, another similar second dose was given. Primary outcome measure was the percentage of patients with 'medically completed miscarriages' in each group (including complete miscarriages + incomplete miscarriages with successful post-miscarriage misoprostol). The total number of patients with 'medically completed miscarriages' in home group was 65/79 (82.3%), which was comparable to the hospital group (52/71 or 73.2%) (P = 0.182). However, the majority of patients in home group had significantly successful miscarriages after a single course of low-dose oral misoprostol, experienced much less heavy bleeding attacks and had less systemic side effects. In low-resource communities, the home-based extended low-dose oral misoprostol protocol proved high efficacy, safety and tolerability in management of first-trimester pregnancy loss.

Does feticide shorten termination duration in second trimester pregnancy terminations?

A retrospective (case-controlled) study was conducted with the aim of identifying the effect of the use of misoprostol on termination time in patients who did and did not undergo feticide procedures in second trimester pregnancy terminations. The sampling of the study consisted of 144 pregnant women who were diagnosed as having major fetal anomalies incompatible with life, and were recommended for termination of pregnancy. The investigation showed that feticide procedures were performed for 99 women, and feticide procedures were not performed for 45 women. Misoprostol protocol was administered for 48 hours in the termination period; whether the feticide procedure directly affected the termination duration in patients who did and did not undergo feticide was evaluated. Abortion/birth was achieved in 103 (71.5%) women during the first 48 hours. There was no significant difference between the termination duration of the misoprostol protocol among the women who did and did not undergo feticide. There was no significant difference between the termination durations and fetal biometric measurements (BPD, HC) except head diameters (p=0.020 and p=0.015). The misoprostol protocol is shown to be effective and safe for the termination of pregnancies during the second trimester. Feticide has no affect on the duration of termination.

Hysteroscopic removal of retained products of conception following first trimester medical abortion.

Study Objective:To investigate the use of operative hysteroscopy instead of traditional curettage in women with retained products of conception (RPOC) following first trimester medical abortion, with the aim of reducing post-operative intrauterine adhesions.Design:Retrospective study.Setting:Gynecology department in a University affiliated hospital.Patients:All women treated by hysteroscopy for RPOC following first trimester medical abortion using the mifepristone-misoprostol protocol for pregnancy termination or the misoprostol protocol for early missed abortion from January 2013 to August 2016.Intervention:Operative hysteroscopy for removal of RPOC. Post-operative intrauterine adhesions were assessed by diagnostic office hysteroscopy after 6–8 weeks.Measurements and Main Results:50 cases were identified. The mean time from medication administration to the operative hysteroscopy was 1.7 ± 0.7 months. Operative hysteroscopy with blunt use of the resectoscopic loop was used to remove all specimens, and all procedures were completed without intra-operative complications. Two patients (4.0%) were readmitted for fever. Pathology confirmed the presence of RPOC in 45 (90.0%) cases. On follow-up office hysteroscopy, a normal uterine cavity without evidence of intrauterine adhesions was seen in 29/29 (100%) women.Conclusion:Hysteroscopy for removal of RPOC following medical abortion is associated with low rates of complications and post-operative intrauterine adhesions.

Efficacy of mifepristone and misoprostol in termination of pregnancy in second and third trimester versus intraamniotic application of prostaglandins

Introduction: According to the published data, a combination of mifepristone and misoprostol is recommended in literature for labour induction in the second and third pregnancy trimester after a foeticide due to a fetal malformation or intrauterine fetal death and for abortion induction in the first pregnancy weeks. At our department we perform foeticide by applying Fentanyl and Xylocaine into the fetal heart. Since the intraamnial input is applied in this procedure, we also perform labour induction by intraamnial prostaglandin application. During the first weeks of pregnancy we performs abortion induction with mifepristone and misoprostol. Through the analysis of our own data, we aimed at establishing in what time fetal expulsion occurs after abortion induction with mifepristone and misoprostol compared to labour induction through intraamnial prostaglandin application. Methods: The retrospective study included all women on whom abortion or labour induction was performed between 2010 and 2015 due to fetal malformations established by means of ultrasound. The first group included all participants in the 16th–24th week of pregnancy or with the fetus weight under 500 g determined through ultrasound where the abortion induction was performed with mifepristone and misoprostol according to the following protocol: mifepristone 200 mg orally, followed 36–48 h later by misoprostol 800 μg vaginally, then misoprostol 400 μm orally, 3-hourly, to a maximum of four further doses. The second group included women after the 24th week of pregnancy or with the fetus weight above 500 g determined through ultrasound. Labour induction were performed through intraamnial 1000 μg prostaglandin application. We compared the time at which the fetal expulsion occurred after the beginning of induction in the first group with the same time in the second group. Results and conclusions: Based on the data from literature, the best abortion or labour induction method is the application of mifepristone and misoprostol regardless of the duration of pregnancy. The aim of our research was to establish whether the cases when a foeticide needs to be performed and therefore intraamnial input is already being used it also makes sense to apply prostaglandins in order to commence induction at the same time. Compared to the protocol with mifepristone and misoprostol we benefit from extra time since it is recommended to wait 36–48 h after mifepristone application before misoprostol application is continued. Based on the data from literature, the time to fetal expulsion in case of induced abortions or labours is proportional to the duration of pregnancy. With our research, we aimed to prove that in the group with the labour induction by means of intraamnial prostaglandin application despite being further into the pregnancy, the time to fetal expulsion is shorter due to the 36–48-h-long break in the mifepristone and misoprostol protocol.

Misoprostol for induction of second trimester abortion in pregnancies resulting from sexual violence: effectiveness analysis of a protocol applied in the Brazilian public health service

ObjectiveTo evaluate the effectiveness of misoprostol protocol on abortion of pregnancies resulting from sexual violence. MethodRetrospective study with a convenience sample of 253 patients with pregnancy between 13 and 22 weeks of pregnancy who underwent legal abortion in the Hospital Pérola Byington, São Paulo, Brazil, between January 2008 and December 2014. Doses of misoprostol 400μg (13–17 weeks of gestation) and 200μg (18–22 weeks of gestation) were administered vaginally every 12h. The dose was doubled after two doses of no response and maintained for up to four days. In the absence of fetal expulsion, a second cycle of misoprostol was conducted after a 72-h pause. The failure of misoprostol was considered complete after two cycles without fetal elimination. The outcome was complete or incomplete fetal expulsion, evaluated in number of days and misoprostol dose required for abortion. Data were entered in Microsoft Excel 2010 program. ResultsThe age ranged from 11 to 44 years of age, average 22.6±8.2 years of age, with the mean gestational age of 16.8±2.6 weeks. Abortion occurred in 248 cases (98.0%) with an average of 1468.8μg of misoprostol. The analysis of the dispersion of the total dose of misoprostol indicates no significant change with increasing gestational age (y=0.9475x+1453) (R2=0.0001). The average induction time was 2.3 days and in 81.8% of the cases abortion occurred in the first 72h. Excessive and immediate uterine bleeding after fetal elimination was observed in 2.6% of the cases. ConclusionMisoprostol protocol used was effective and safe for second trimester abortion in pregnancy resulting from sexual violence.

Efficacy and safety of intravaginal misoprostol versus intracervical dinoprostone for labor induction at term: A systematic review and meta‐analysis

Recent studies suggest that misoprostol may be more effective than dinoprostone in pregnant women with unfavorable cervix. The objective here is to investigate and compare the efficacy and safety of intravaginal misoprostol and intracervical dinoprostone for labor induction, including incidence of cesarean section, vaginal delivery rate within 24 h, uterine hyperstimulation, tachysystole, oxytocin augmentation, neonatal intensive care unit (NICU) admissions, and Apgar score of less than 7 at 1 and 5 min. Databases searched were MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials, up to July 2013. Randomized controlled trials comparing intravaginal misoprostol with intracervical dinoprostone in women with singleton pregnancy, intact membranes and unfavorable cervix (Bishop's <6) were included. Pooled relative risk, mean difference and 95% confidence intervals were calculated. The use of misoprostol was significantly effective in increasing the rate of vaginal delivery within 24 h and less oxytocin augmentation when compared with dinoprostone. However, the incidents of uterine hyperstimulation and tachysystole were significantly higher under the misoprostol protocol than dinoprostone protocol. Furthermore, we found similar efficiency in the rate of cesarean delivery, NICU admission and Apgar score at 1 and 5 min among the study groups. Intravaginal misoprostol appears to be more efficient for labor induction than intracervical dinoprostone; however, dinoprostone has been demonstrated to be safer because of the lower incidence of uterine hyperstimulation and tachysystole. Further high-quality studies assessing the possible effectiveness of misoprostol and dinoprostone in selected groups of patients are warranted.

İkinci Trimester Gebelik Sonlandırmalarında Misoprostolün Etkinliğinin, Güvenilirliğinin ve Maliyetinin Değerlendirilmesi

Objective: The aim of the study was to evaluate the efficacy, safety, cost analysis and complications of the misoprostol protocol of our clinic (using intravaginal misoprostol after using oral misoprostol) in the second trimester termination of pregnancy. Methods: The study was designed in Gynecology & Obstetrics Clinic of Suleymaniye Maternity Training and Research Hospital, Istanbul between January 2010 and July 2011. Eighty patients, of whose pregnancies were terminated at 14-28 weeks of gestation, were retrospectively analyzed. The patients were separated into two groups as with and without a history of previous cesarean section. 200 mcg misoprostol was applied vaginally to the group without a history of previous cesarean section, and then 4 doses of 400 mcg misoprostol was applied orally every 4 hours. Patients with a prior cesarean delivery were administered 200 mcg misoprostol vaginally, and 200 mcg misoprostol was applied every 4 hours orally. Findings of the cases at 24th and 48th hours were recorded. The method was considered to fail in cases that birth does not happen after 48 hours. Results: Delivery/abortion was carried out in 85%of patients (68 cases) during the first 48 hours. The number of patients, who gave birth in the first 24 hours, was 43. The success rate in the first 24 hours was 53.75%. Ten out of 13 patients with a history of previous cesarean section had abortion in the first 48 hours. The success rate in the first 48 hours was 76.9%. Only 3 cases (3.75%) had fever and one case (1.25%) had cervical laceration. Conclusion: Our study shows that our misoprostol protocol which we used in the second trimester termination of pregnancy is safe, effective and acceptable in terms of cost. However, there is no consensus yet about the dose and the most effective application method of misoprostol.

A comparison of the psychologic impact and client satisfaction of surgical treatment with medical treatment of spontaneous abortion: A randomized controlled trial

Objective: The purpose of this study was to compare the psychologic impact and client satisfaction of routine surgical evacuation of the uterus with medical evacuation in cases of spontaneous abortion. Study Design: This was a prospective, randomized controlled trial. Two hundred eighteen women who were admitted to a university teaching hospital after spontaneous abortion and who consented to the study were randomized to routine surgical evacuation or medical evacuation of the uterus with the use of misoprostol. General psychologic well-being, level of depression, fatigue symptoms, psychiatric morbidity, social functioning, client satisfaction, and acceptance were measured in the 2 groups. Results: The 2 groups did not differ in any of the measured psychological outcomes. Significantly more participants who experienced successful evacuation of the uterus with the misoprostol protocol would choose the same mode of treatment if they were able to choose again. However, participants for whom the medical treatment failed to evacuate the uterus and subsequent surgical evacuation was required are significantly less satisfied with the treatment. Conclusion: Medical treatment of spontaneous abortion with misoprostol is psychologically safe and more compatible with the ethnomedical beliefs of our Chinese participants. Client satisfaction and acceptance should be taken into consideration in the evaluation of treatment outcomes. (Am J Obstet Gynecol 2001;185: 953-8.)

Setting up a one-stop mifepristonemisoprostol medical termination of pregnancy service for all gestations from 5 to 23 weeksa review of 482 cases

Mifepristone - misoprostol combination is increasingly being utilised for medical termination of pregnancy on account of its reported efficacy, safety and lower cost. Experience with this modality of effecting termination of pregnancy from 9 to 13 weeks' gestation is scanty. At the Scunthorpe General Hospital in the United Kingdom, we established a nurse-led, one-stop medical termination of pregnancy service using mifepristone and misoprostol for all gestations from 5 to 23 weeks. A review of the case records of 482 women who had medical termination of pregnancy at all gestations from 5 to 23 weeks from December 1997 to May 1999 was undertaken in order to assess the effectiveness and complications associated with the mifepristone - misoprostol protocol. Complete abortion was achieved in 406 (84%) women. Surgical evacuation was required to complete the abortion in 74 (16%) women. The complete abortion rate was similar across the spectrum, i.e. 87% in the 5- 8-weeks group; 79% in the 9-13 weeks group; and 87% in those of S 14 weeks. Two failures occurred: one of them proceeded to surgical evacuation after three courses of misoprostol, while the other continued with her pregnancy after one course. Three women (0·6%) required blood transfusion for haemorrhage, while two others were treated for infection. Oral mifepristone with or without vaginal misoprostol in an effective and safe regimen for termination of all pregnancies from 5 to 23 weeks' gestation.

Can misoprostol be interchanged with oxytocin for augmentation of labor?

Objective: To evaluate if misoprostol used as an augmentation agent reduces the duration of labor.Methods: Fifty-nine patients presenting for labor induction/augmentation who met inclusion criteria were recruited for study. All were randomized to one of two groups for augmentation medication. Group A (n = 31) received oxytocin at standard infusion rate. Group B (n = 28) received 25 μg of misoprostol per vagina every 4 hours. An additional 25 μg at 2 hours was given if active labor was inadequate. Patients failed the misoprostol protocol if labor arrested for more than 4 hours despite a 50-μg dose. Misoprostol was stopped if nonreassuring fetal heart rate developed. Data were analyzed by intent to treat to a significance level of P <0.05.Results: The groups were similar in outcome and Apgar score. Duration of labor in groups A and B was 11.43 ± 7.02 hours and 9.36 ± 10.00 hours (P = NS). The cesarean delivery rate was similar, 10.9% versus 12.9%. Two patients failed the misoprostol protocol; one developed nonreassuring fetal heart rate and the other failed to progress. No patient developed hyperstimulation or uterine rupture. Five patients receiving misoprostol and one receiving oxytocin developed chorioamnionitis (P = 0.0007).Conclusions: Misoprostol seems to be an effective alternative to oxytocin augmentation of labor. Further investigation is required to assess associated infectious morbidity.