Misoprostol Regimen Research Articles

Role of Combined Mifepristone and Misoprostol Verses Misoprostol Alone in Induction of Labour in Patients with Intrauterine Foetal Death - a Randomized Comparison Between their Outcome

Background: Intrauterine fetal death is means- intrapartum death after the fetus has reached the age of viability8. As in IUFD journey, labor pain will be fruitless. So, it is of utmost importance to search for the method which can reduce hours of pain in labor of IUFD cases.Metarials Methods: In this research work patients divided in two groups. Induction of labour in one group was given by combination of mifepristone and misoprostol other group by misoprostol only and we try to find out the best method. To compare the effectiveness, induction to delivery interval, safety and side effects of combination of mifepristone and misoprostol versus conventional use of misoprostol alone in induction of labour in patients with intrauterine fetal death. It is a Prospective randomized comparative study in Anwer Khan Modern Medical College Hospital and Dhaka Medical College Hospital among 70 patients with IUFD after 28 weeks of gestation during January 2014- January 2016.Result: We allowed the patients up to third gravid and after 28 weeks of gestation. Patients were grouped as Group A(35) & Group B (35). In Group A Induction was given by single oral dose of 200 mg mifepristone, and after 48 hours, tab. Misoprostol in post. fornix started if <34 weeks-100 ?gm dose and >34 weeks-50 ?gm dose. Doses were repeated every 6 hourly intervals if required. In Group B Induction was given by 100 ?gm misoprostol at 6 hourly interval in post. Fornix. In both groups we allowed misoprostol maximum 600 ?gm. Oxytocin was given for augmentation if needed. The two study groups did not differ demographically. Induction to delivery time was shorter with combined regimen group (P<0.001). Induction to delivery interval ranges from 10-12 hours in mifepristone plus misoprostole group.In only misoprostol group it was about 24-26 hours. Doses of misoprostol was lower in combined group (P<0.001). 4 patients need Oxytocin for augmentation in only misoprostol group. In combined group oxytocin was not needed. The two groups did not differ as regards complications experienced during labour and delivery significantly. In overall out come 2 failed induction in misoprostol only group but not in combinedgroup.Conclusion: In Induction of IUFD mifepriston plus misoprostol is an effective combined group. It is safe, non invasive, easily tolerable, highly cost effective, had less induction to delivery interval, required less dose of misoprostol and no need of augmentation with oxytocin. So,the combined group is more effective than conventional regimen of misoprostol alone.Anwer Khan Modern Medical College Journal Vol. 8, No. 1: Jan 2017, P 50-54

Titrated oral misoprostol as a safe route for induction of labour at term (a clinical trial)

Objective:To assess safety and efficacy of induction of labour at term by low doses of oral misoprostol in the form of titration versus the standard regimen of vaginal misoprostol in the term of induction delivery interval, operative interventions and fetal outcome. Methods:Clinical comparative study was carried out for a period of one year from November 2008 to October 2009 at Zagazig university hospital. The study protocol was approved by the ethics committee of our hospital. One hundred women at term with indication of labour and Bishop score less than or equal 5, no either Obstetric or maternal contraindications for induction of labour were randomly assigned to receive oral (titrated) or vaginal misoprostol for induction of labour. The oral group received a basal of 20ml misoprostol solution (1mcg/ml) every hour for four doses and then were titrated according uterine response individually, the vaginal group received 25 mcg every 4 hours(maximum number of doses limited to six) until cervix became more favorable. The induction delivery interval, oxytocin need, mode of delivery, frequency of side effects and neonatal and maternal outcome were assessed. Chi-square or Fisher exact test, Student's T-test and Wilcoxon rank sum test were used for analysis the data statistically. Results:The oral misoprostol group had 50 women (50%) and was given it in the form of titrated oral solution and vaginal misoprostol group had 50 women (50%). Vaginal delivery occurred within 12 hours in 38 women (76%) in oral group and in 12 women (24%) in vaginal group. The median interval from starting induction by misoprostol to vaginal delivery was significantly shorter in oral titrated misoprostol group (7.5 h) compared with vaginal misoprostol group (16.1h) with P value <0.01.The incidence of hyper-stimulation in oral group was 0.0% compared with 12% in vaginal group with P value <0.01 which is significantly different. More women had nausea 8% in oral group but fewer infants had Apgar score less than 7 at 1 minute in oral group than in vaginal group. Conclusion:Oral misoprostol in the form of titration is associated with lower incidence of uterine hyper-stimulation and lower cesarean delivery rate, better fetal outcome than vaginal misoprostol for labour induction at term in patients with unripe cervix.

Safety and Efficacy of Different Doses of Misoprostol in Termination of Intrauterine Fetal Death (IUFD) Cases

Introduction: Misoprostol regimens for the induction of labor in second and third trimester IUFDs, in different doses range from 50 to 400mcg are all clinically effective. Larger doses of misoprostol potentially have an increased risk of adverse effects. If low dose of vaginal misoprostol have similar effectiveness than a higher dose used on its own, lower dose will impose dual benefit on patient in terms of less cost/risk of adverse effects.Objective: To evaluate safety and efficacy of different doses of misoprostol in termination of IUD cases during the period from January to December, 2011 in the dept. of obs and gynae, BSMMU and Khulna Medical College Hospital.Materials &amp; Methods: A randomized control trial was conducted with sixty IUD primi or multigravida cases having 28 to 42 weeks or more gestation, singletone pregnancy and Bishop’s score 5 or less were included. Grand multiparas, women having history of previous caesarean section or myomectomy, transverse lie, placenta praevia were excluded from the study. The selected patients were randomly divided into two groups for termination using two different doses of misoprostol. Among 60 patients 30 (group -1) received 50mcg of misoprostol 6 hourly and 30 patients received (group -2) 100mcg of misoprostol 8 hourly per vaginally.Outcome variables: Induction delivery time, number of delivery within 24 hours, mode of delivery, side-effects and complications of misoprostol were recorded. Pulse, BP, Temperature were noted every 4 hourly.Result: Induction delivery time, mean+SD was 21.7±9.47 and 26.17±11.17 hours respectively in group-1 and group-2, (P=0.10). Number of doses required was, mean±SD 2.67±0.9 in group-1 and 2.08±0.81 in group-2, the difference was statistically significant (P&lt;0.006). Delivery within 24 hours occurred in 20(66.67%) cases in group-1 and in 16(53.33%) in group-2. Nausea, vomiting were present 16.67% and 10% in group-1 and 33.33% and 16.67% in group- 2 respectively. In both groups most of the cases had no side effect. In group-1 there was hyperstimulation in 2(6.67%) cases and tachysystole in 1(3.33%) case. In group-2 hyperstimulation and tachysystole developed in 4(13.33%) and 2(6.67%) cases respectively.Conclusion: Both50mcg and100mcg intravaginal misoprostol are safe and effective in termination of intrauterine foetal deathBangladesh J Obstet Gynaecol, 2013; Vol. 28(1) : 15-20

Induction of Labor Using a Foley Catheter or Misoprostol: A Systematic Review and Meta-analysis.

Induction of labor is a widely used obstetric intervention, occurring in one in four pregnancies. When the cervix is unfavorable, still many different induction methods are used. We compared Foley catheter alone to different misoprostol dosages and administration routes, and the combination of Foley catheter with misoprostol. We reviewed the literature on the best induction method regarding their safety and effectiveness, using the outcome measures hyperstimulation, fetal distress, neonatal morbidity and mortality as well as cesarean delivery, vaginal instrumental delivery, and maternal morbidity. We searched Pubmed, Cochrane, and Web of Science from January 1, 1980 to February 12, 2016. Twenty-two randomized controlled trials (RCTs) were included, comparing Foley catheter with or without misoprostol to misoprostol alone (both vaginal and oral) for induction of labor (5,015 women). Most included studies were underpowered to detect differences in safety outcomes, as the majority are powered for time to delivery or cesarean delivery. Meta-analysis of these studies does not allow assessment of the safety profile of Foley catheter compared to misoprostol (any dose, any administration route) with sufficient power. For the safety outcomes of the total group of Foley catheter versus misoprostol (any dose, any administration route) (17 studies, 4,234 women) we found that Foley catheter results in less hyperstimulation compared to misoprostol (2% versus 4%; risk ratio [RR], 0.54; 95% confidence interval [CI], 0.37-0.79) and fewer cesarean deliveries for nonreassuring fetal heart rate, 5% vs 7%; RR, 0.72; 95% CI, 0.55-0.95; while there were no statistically significant differences in neonatal outcomes. The total number of cesarean deliveries was 26% versus 22% (RR, 1.16; 95% CI, 1.00-1.34). There were fewer vaginal instrumental deliveries with a Foley catheter compared to misoprostol (10% vs 14%; RR, 0.74; 95% CI, 0.60-0.91). Foley catheter with misoprostol compared to misoprostol alone (any dose, any administration route) (7 studies, 1,073 women) resulted in less hyperstimulation than misoprostol alone (17% vs 23%; RR, 0.71; 95% CI, 0.52-0.97). Cesarean deliveries for nonreassuring fetal heart rate were comparable (7% vs 9%; RR, 0.79; 95% CI, 0.51-1.22). Neonatal outcomes were infrequently reported. The total number of cesarean deliveries was 34% versus 34% (RR, 1.01; 95% CI, 0.86-1.19). In women with an unripe cervix at term, Foley catheter seems to have a better safety profile than misoprostol (any dose, any administration route) for induction of labor. Larger studies are needed to investigate the safety profile of a Foley catheter compared to separate dosing and administration regimens of misoprostol.

Single Dose Misoprostol Regimen for Early Pregnancy Loss at an Academic Community Hospital [3D

INTRODUCTION: A new ACOG Practice Bulletin was published for management of early pregnancy loss recommending single dose misoprostol 800 mcg per vagina. As patients in the emergent setting are often stable with no need for urgent management they are typically offered expectant, medical, or surgical management. Many patients require time to process and grieve their loss. However, for those desiring medical management a research question was proposed evaluating if immediate initiation of single dose misoprostol for early pregnancy loss results in fewer follow up visits when compared to outpatient management. METHODS: A retrospective chart review was performed evaluating patients seen by a provider in the Emergency Department diagnosed with early pregnancy loss at 9 weeks gestation or less, and received treatment with misoprostol from 1/1/11 to 3/1/15. RESULTS: A two-sample proportion test analysis was performed showing no statistically significant results. Of the twenty-three patients seen by a provider and eligible for immediate initiation of single dose misoprostol regimen, eighteen opted for immediate management. Twelve of these patients had one follow up visit with single dose regimen success. Of the five patients evaluated who opted for delayed initiation of misoprostol, two patients had one follow up visit with single dose regimen success. Three patients required two additional follow up visits. CONCLUSION: No statistically significant difference in the total number of clinic visits was noted. However given the small sample size of this population, a larger difference may be detected with a larger sample size.

Misoprostol versus misoprostol and foley catheter combination in 2nd trimester pregnancy terminations

Objective: The efficacy and safety were assessed of a misoprostol regimen used alone or in combination with foley catheter for second trimester pregnancy termination. Methods: A retrospective examination was made of the records of patients who underwent pregnancy termination at 14–24 weeks of gestation in our university hospital between January 2011 and June 2014. Records were available for patients 378 who underwent terminations. Group 1 comprised patients with no history of cesarean section. An initial dose of 200 μg misoprostol was administered intravaginally and then until the termination was completed an additional 200 μgr dose was administered sublingually every 4 hours (Group 1: 234 patients). Group 2 comprised patients with a history of cesarean section. An initial dose of 200 μg misoprostol was administered intravaginally and 2 hours later an intracervical foley catheter was inserted (Group 2: 144 patients). Results: The total misoprostol dosage used was 1160 μg and 560 μg (p< 0.001), intervals from the administration of the first misoprostol tablet until termination were 854.8 and 704.2 minutes (p= 0.03) in Groups 1 and 2, respectively. Conclusions: The misoprostol + foley catheter combination reduces the total dosage of misoprostol required for termination and shortens the termination interval, thereby increasing patient’s comfort. Based on these results, the usage of the misoprostol + foley catheter combination can be recommended especially for patients with a history of caesarian section.

Short versus Standard Mifepristone and Misoprostol Regimen for Second- and Third-Trimester Termination of Pregnancy for Fetal Anomaly

Background: Termination of pregnancy requires a 48-hour ‘window' between mifepristone and misoprostol. Shorter durations have been used in first-trimester termination, but there are few data available in later termination for fetal anomaly. Material and Methods: We reviewed all terminations for fetal anomaly at ≥13 weeks from May 2013 to May 2014. Cases were managed using a short (≤12 h) or standard (≥36 h) mifepristone-to-misoprostol interval. Results: Two hundred and twenty women underwent a termination of pregnancy for fetal anomaly during the study period, of which 119 were included for analysis. Sixty-six (55%) women were managed according to the short regimen and 53 (45%) women with the standard regimen. The short regimen resulted in a shorter mifepristone-to-delivery interval but was less likely to result in delivery within 12 h of misoprostol. Delivery rates at 24 h were equivocal. There was no difference in blood loss, vaginal delivery rates, complications or bed nights. The short regimen did require more doses of misoprostol. Feticide or previous uterine scar had no effect on outcomes. Discussion: There was no significant difference in clinical outcome for women managed with a short (≤12 h) or a standard (≥36 h) regimen for medical termination of pregnancy for fetal anomaly, suggesting that either regimen could be offered.

Comparison of two misoprostol regimens for mid-trimester pregnancy terminations after FIGO’s misoprostol dosage recommendation in 2012

Objective: To compare the safety and efficacy of two misoprostol regimens for mid-trimester pregnancy terminations.Methods: Retrospective analysis of 263 cases of pregnancy terminations with misoprostol between 12 and 24 weeks was performed. Group 1 (total 129 patients) consisted of patients who were given 200 mcg vaginal misoprostol every 4 h until the abortion, whereas Group 2 patients (total 134 patients) were given misoprostol as in International Federation of Gynecology and Obstetrics’s (FIGO) 2012 recommendation. In case of a previous cesarean section doses were halved in both groups. Primary outcomes of the study were the time to abortion and the total drug dose used. Secondary outcome was the rate of complications.Results: Total dose and time to abortion did not differ between the groups. As for complications, one patient (%0.8) in group 1 developed HELLP syndrome and had hysterotomy. One patient (%0.8) in group 2 had uterine rupture and had total hysterectomy. Two patients in both groups considered failure of induction and terminated with surgery (hysterotomy). Groups did not show difference in induction failure rates.Conclusions: We respect the presence of dose recommendation stated by the FIGO and found similar results with our recent protocol. Other misoprostol regimens used worldwide should also be compared with this guideline in order to improve its efficacy.

Efficacy and acceptability of a mifepristone–misoprostol combined regimen for early induced abortion among women in Mexico City

ObjectiveTo evaluate the experience of women receiving mifepristone–misoprostol for early induced abortion in public sector facilities in the Federal District of Mexico City. MethodsAn open-label prospective study was conducted with 1000 pregnant women who sought induced abortion with a pregnancy of up to 63days of gestation, as measured from the date of their last menstrual period. The study was conducted in three public sector healthcare facilities: two secondary level hospitals and one primary care clinic. Women ingested 200mg mifepristone on day 1, followed by 800μg buccal misoprostol 24hours later, and they returned for follow-up on day 8. The primary outcome was complete abortion without recourse to surgical intervention. ResultsA total of 971 women received mifepristone–misoprostol and were included in the analysis for efficacy of treatment. The overall efficacy of the combined medical abortion regimen studied was 97.3% (n=945); the success rate did not vary significantly by gestational age (95.9%–100%; P=0.449). Most women (n=922, 95.0%) had a successful induced abortion with only one dose of misoprostol. ConclusionThe combined mifepristone and buccal misoprostol regimen was found to be highly effective and acceptable among Mexican women. www.ClinicalTrials.gov: NCT00386282.

Comparison of intravaginal misoprostol and intracervical Foley catheter alone or in combination for termination of second trimester pregnancy

Objectives: To examine the effectiveness, safety and acceptability of intravaginal misoprostol and intracervical Foley catheter alone or in combination for termination of second trimester pregnancy.Methods: This clinical study was conducted on 90 pregnant patients intended for termination of pregnancy between 13 and 24 gestational weeks for any indication. Enrolled women are equally allocated into three groups:• Group I (Misoprostol group): a standard regimen of moistened misoprostol (400 μg) 4 hourly inserted vaginally.• Group II (Catheter group): intracervical Foley catheter inserted, inflated and placed on traction.• Group III (Combined group): intracervical Foley catheter inserted with a standard regimen of moistened misoprostol (400 μg) 4 hourly intravaginally was used.Procedure efficacy (defined as complete abortion performed on site), safety and acceptability were assessed.Results: The induction to abortion interval was 7.5 ± 1.25 h in the combined group, compared to 11.76 ± 1.63 h in the misoprostol group and 19.76 ± 1.52 h in the catheter group (p value < 0.001) with a success rate of 100% and no major complications reported.Conclusions: The present results confirmed the high success rate with the shortest induction to abortion interval with a combined use of intracervical Foley catheter and misoprostol for termination of second trimester pregnancy.

Maternal and neonatal outcome of labour induction at term comparing two regimens of misoprostol

To compare the efficacy and safety of two misoprostol dosing regimens for induction of labour in primiparous (1P) and multiparous (>1P) women. Retrospective study of induction of labour using vaginal misoprostol 25 μg vs. 50 μg every 6 h in 942 women at a tertiary centre. The main outcome variables are induction-to-delivery interval, latency period duration, vaginal delivery within 24 h, and maternal and foetal safety outcome. With the 50 μg regimen, induction-to-delivery intervals were significantly shorter: 18.4 h vs. 24.6 h (1P) and 14 h vs. 17.9 h (>1P), as was latency period duration (by 5.4 and 4 h, respectively). Vaginal delivery within 24 h was significantly more frequent, as were non-reassuring foetal heart rate (1P: 20% vs. 14%) and tachysystole (1P: 31% vs. 11%; >1P: 21% vs. 7%). No uterine rupture was reported. Neonatal outcomes were similar except for significantly more frequent infant referral to neonatal intensive care in the >1P group receiving the 50 μg regimen (11% vs. 4%). Vaginal misoprostol 25 μg seems to maintain efficacy with more acceptable maternal and neonatal safety. As induction of labour is an off-label use for misoprostol, safety should be prioritised with the lower dosage regimen despite the longer induction-to-delivery interval.

Practice variation in the management of first trimester miscarriage in the Netherlands: a nationwide survey.

Objectives. To survey practice variation in the management of first trimester miscarriage in The Netherlands. Methods. We sent an online questionnaire to gynecologists in eight academic, 37 nonacademic teaching, and 47 nonteaching hospitals. Main outcome measures were availability of a local protocol; estimated number of patients treated with curettage, misoprostol, or expectant management; misoprostol regimen; and estimated number of curettages performed after initial misoprostol treatment. Outcomes were compared to the results of a previous nationwide survey. Results. The response rate was 100%. A miscarriage protocol was present in all academic hospitals, 68% of nonacademic teaching hospitals, and 38% of nonteaching hospitals (P = 0.008). Misoprostol was first-choice treatment for 41% of patients in academic hospitals versus 34% and 27% in teaching-and nonteaching hospitals (P = 0.045). There were 23 different misoprostol regimens. Curettage was first-choice treatment in 29% of patients in academic hospitals versus 46% and 50% in nonacademic teaching or nonteaching hospitals (P = 0.007). In 30% of patients, initial misoprostol treatment was followed by curettage. Conclusions. Although the percentage of gynaecologists who are aware of the availability of misoprostol for miscarriage treatment has doubled to almost 100% since 2005, practice variation is still large. This practice variation underlines the need for a national guideline.

Randomization of two dosing regimens of vaginal misoprostol for cervical ripening and labor induction in a low resource setting

To compare the effectiveness of two dosing regimens of vaginal misoprostol for cervical ripening and induction of labour. Pregnant women with singleton low risk pregnancy at term scheduled for elective induction of labour were randomized to receive either 25 μg or 50 μg of vaginal misoprostol for pre-labour cervical ripening. All the patients received antenatal care and delivered at the University College Hospital (UCH) from January 1 st to May 31 st 2006. A total of 128 patients were randomized; 65 patients received 25 μg and 63 patients received 50 μg of vaginal misoprostol. Significantly higher number of patients in the 50 μg group progressed to active labour as compared with the 25 μg group (95.2% versus 84.6%, P < 0.05). The need for oxytocin augmentation of labour was higher among the 25 μg as compared with 50 μg (39.7% versus 16.4%, P = 0.007). There was higher proportion of patients in the 50 μg group delivering vaginally within 24 hours as compared with the 25 μg group (98.2% versus 90.0%, P = 0.063). However, the mean interval between the first dose of misoprostol and vaginal delivery was not statistically different in the two groups (754 ± 362 minutes and 885 ± 582 minutes, P = 0.152). The incidence of caesarean section was similar in the two groups (7.7% versus 11%, P = 0.580). Labour complications, such as precipitate labour, tachysystole and abnormal fetal heart rate patterns were greater in the 50 μg group. Twenty-five microgram of misoprostol appears to be as effective as 50 μg for pre-induction cervical ripening and labour induction. Though 50 μg of vaginal misoprostol resulted in relatively faster delivery and less need for oxytocin augmentation, it was associated with more labour complications as compared with 25 μg of misoprostol.

Practice of self-medication of mifepristone-misoprostol drug combination for medical abortion

Most medical abortion protocols require women to take mifepristone in the hospital setting. The rate of complete abortion up to 63 days’ gestation with mifepristone and misoprostol was reported to be 92-95% using the Food and Drug Administration-approved regimen.1,2 In a recent study, the completion rates of 96-97% was reported in early pregnancy, including pregnancies up to 63 days’ gestation.3 Women choosing medical abortion must consent to undergo vacuum aspiration or dilatation and curettage in cases of incomplete abortion.Medical methods for first trimester abortion have been demonstrated to be both safe and effective. Regimens that combine mifepristone with a prostaglandin analogue such as misoprostol are more efficacious than a prostaglandin alone. Mifepristone, (RU 486, a substitute 19- norethisterone derivative)by blocking the progesterone receptors causes estrogen dominance and results in intrauterine fetal death. Simultaneously, it sensitizes the uterus to the activity of the prostaglandin. Thus, a combination of these two drugs is significantly more efficacious for termination of early pregnancy when compared to mifepristone given alone. A regimen that includes mifepristone in a dosage of 200 mg administered orally, followed by misoprostol in a dosage of 800 µg vaginally administered 48 hrs after mifepristone, and is highly effective for medical abortion up to 63 days gestation. This regimen is reported to be the best in most of the studies and moreover mifepristone serum levels do not increase proportionally with increasing oral doses.4In a study conducted by Schaff et al., it was observed that the success rate was seen in 96-97% of women who were prescribed a combination of mifepristone and misoprostol by authorized personnel at the hospital.3 Women are commonly advised to return for one or more follow-up visits, after 10-14 days because in cases of incomplete abortion she can be managed either expectantly, with an additional dose of misoprostol, or with an aspiration procedure. Women may be given the option of home administration of misoprostol after the initial clinic visit.5However, the use of mifepristone – misoprostol combination for medical abortion used as self-medication, is rising due to changing socio-cultural practices and increased awareness among women for the termination of early pregnancy up to 63 days. It is observed that many women indulge in the practice of self-medication for termination of pregnancy. They take medicines either from local pharmacists, nurses, on advice of relatives, friends, husband, neighbors, newspaper articles, radio, television, magazines or any other such unauthorized sources for termination of pregnancy which mostly leads to incomplete abortion or many complications. It is observed that only few number of women have complete abortion with self-medication from an unauthorized source and moreover they suffer from pain and heavy bleeding when compared to normal menstrual flow. It is noticed that now-a-days, these drugs are used irrationally and nonjudiciously. Women are thus advised to take proper regimen of mifepristone and misoprostol under the guidance of an authorized practitioner and if they still fail to abort, then they have to undergo surgical evacuation that is, vaccum aspiration for termination of pregnancy.

Knowledge and provision practices regarding medical abortion among public providers in Hanoi, Khanh Hoa, and Ho Chi Minh City, Vietnam

ObjectiveTo assess public service providers’ knowledge of medical abortion (MA) and practices, and perspectives on expanding the use of MA to primary and secondary health facilities in Vietnam. MethodsA cross-sectional study was conducted via an interviewer-administered questionnaire among abortion providers (n=905) from public health facilities between August 2011 and January 2012. ResultsOverall, 31.1% of providers performed both surgical and medical abortions; 68.9% offered only surgical abortion. Providers were knowledgeable about the regimen/dosage of mifepristone plus misoprostol regimen; however, knowledge scores were low for gestational age limits for MA, adverse effects of the combined drug regimen, and safety and effectiveness of MA compared with surgical abortion. Knowledge scores were significantly lower among providers in rural areas than among those in urban settings. A large proportion of providers (82.9%) thought that MA should be expanded to primary and secondary health facilities. Perceived barriers to MA expansion included lack of knowledge and training, qualified staff, adequate drug supplies, equipment, or facilities, guidelines and protocols on MA, and patient awareness. ConclusionProvision of MA in Vietnam was found to be disproportionate to surgical abortion provision and to vary by region. Knowledge of MA was moderate, but poorer among providers in rural settings.

A two-pill sublingual misoprostol outpatient regimen following mifepristone for medical abortion through 70 days' LMP: a prospective comparative open-label trial

ObjectiveTo test the effectiveness and acceptability of an outpatient medical abortion protocol with 200 mg mifepristone and 400 mcg sublingual misoprostol at 64–70 days' last menstrual period (LMP) and compare it to the already known efficacy of the 57–63 days' LMP gestational age range. Study DesignWe conducted a prospective, comparative open-label trial in six hospitals and clinics in Ukraine, Georgia, India and Tunisia. We enrolled 714 reproductive age women with pregnancies 57 to 70 days who presented requesting abortion. Medical abortions were managed with the current service delivery protocol (200 mg oral mifepristone followed in 24–48 h by 400 mcg sublingual misoprostol). Data on safety, efficacy and acceptability were collected. The main outcome measure was complete abortion without surgical intervention at any point. ResultsA total of 703 cases were analyzable for efficacy. Success rates did not differ significantly in the two groups [57–63-day group: 94·8%; 64–70-day group: 91.9%; Relative Risk (RR): 0.79 (0.61–1.04)]. Ongoing pregnancy rates also did not differ significantly (57–63 days: 1.8%; 64–70 days: 2.2%; RR: 1.10 (0.65–1.87)]. ConclusionA medical abortion regimen of 200 mg mifepristone followed in 24–48 h by 400 mcg sublingual misoprostol is effective through 70 days' gestation and may be offered within existing outpatient abortion services. ImplicationsA regimen of 200 mg mifepristone followed in 24–48 h by 400 mcg sublingual misoprostol is effective up to 70 days' LMP. The findings have important implications for expanding access to outpatient medical abortion services in settings where the cost of misoprostol is of concern or a two-pill misoprostol regimen is the standard of care.

Misoprostol versus High Dose Oxytocin and Laminaria in Termination of Pregnancy in Second Trimester Pregnancies.

Background:In 2 recent decades, found drug regimen to induce abortion that are more effective than surgery. Prostaglandins especially misoprostol, oxytocin and osmotic dilators such as laminaria use for termination but the best method is unknown. Therefore we aimed to assess the comparison between the Misoprostol regimen and the highly concentrated oxytocin with laminaria regimen in second trimester of pregnancy termination.Methods:In this randomized clinical trial, 100 women with gestational age 14 to 24 week coming to hospital due to termination of pregnancy in the absence of uterine contractions and items of exclusion criteria enrolled to study and randomly assign to 2 groups and received misoprostol (group 1) or oxytocin (group 2). Data collected with use of observation, examination and demographic checklist. In group 1, in admission time and then every 6 hour patients received 200 µgr misoprostol until start the pain or vaginal bleeding or abortion in 48 hr. in group 2, patients first received laminaria in cervix with duration of 6 hr and then oxytocin 50 unit in 500 cc normal saline in 3 hr. after 1 hr rest, oxytocin dosage elevated as multiple into 2 and continue until termination or maximum dose of 300 u in 500 cc normal saline. Data entered to SPSS software version 16 and analyzed with use of descriptive methods and also Chi-square and T-test.Results:In each group enrolled 50 women that approximately no different in baseline characteristic. Number of abortion in misoprostol group was more than oxytocin group (P<0.001) and duration of abortion also was shorter than oxytocin in misoprostol group (P<0.001). Side effects in 23 (46%) women in misoprostol group were seen but no side effect seen in oxytocin group. Complementally interventions was seen in 31 women (60%) in misoprostol group versus 32 women (62%) in oxytocin group but this difference was not significant (P>0.05).Conclusion:This study demonstrated that misoprostol is effective than oxytocin in termination of pregnancy but with attention to limitation of this study include of limited abortion causes due to legal laws, additional studies on different doses of misoprostol and oxytocin due to achieve to suitable regimen with lower side effects recommended.

Availability and provision of misoprostol and other medicines for menstrual regulation among pharmacies in Bangladesh via mystery client survey

ObjectiveTo explore the availability and provision of misoprostol and other medicines for menstrual regulation (MR) among pharmacies in Bangladesh. MethodsBetween March and November 2011, a cross-sectional study using mystery client visits was conducted among pharmacy workers in Dhaka and Gazipur Districts, Bangladesh. Mystery clients were trained to present 1 of 4 pre-developed situations to pharmacy workers to elicit information on the regimen, adverse effects, and complications of misoprostol use. ResultsMystery clients visited 331 pharmacies. Among the 331 pharmacy workers, 45.8% offered the mystery clients misoprostol and/or other medicines for MR; 25.7% referred them to private clinics or hospitals. Only 7% recommended an effective regimen of misoprostol for MR; 65% suggested administering vaginal and oral misoprostol together. Overall, 72.4% did not provide any advice on complications; the remainder suggested visiting trained providers for complications. Counseling on excessive bleeding as a danger sign was provided by 46% of pharmacy workers. Most (94%) did not provide or refer for post-MR family planning. ConclusionPharmacy workers in urban Bangladesh are providing ineffective drugs and regimens for MR. A training package is needed to strengthen service delivery by providing accurate information, high-quality products, and referral mechanisms for women seeking MR through pharmacies.

A pilot study on the combined use of letrozole, mifepristone and misoprostol in termination of first trimester pregnancy up to 9 weeks’ gestation

ObjectiveTo assess the feasibility of adding letrozole to the standard regimen of mifepristone and misoprostol for termination of pregnancy up to 63 days. Study designWe recruited 50 subjects who had requested legal termination of pregnancy up to 63 days. Medical abortion was performed with a singe dose of 200mg mifepristone and 10mg of letrozole daily for 3 days followed by 800mcg vaginal misoprostol. ResultsThe complete abortion rate was 98% (95% CI: 94–100%). The median induction-to-abortion interval of the regimen was 5.1h (range 1.2–56h). No serious adverse effects were reported. ConclusionsThe results of this pilot study suggest that a regimen of mifepristone, letrozole and misoprostol is associated with a high complete abortion rate without major adverse events.

Labor induction outcomes in third-trimester stillbirths

ObjectiveTo describe the management of third-trimester stillbirth at a single institution, stratifying induction intervals and adverse outcomes by method. MethodsWomen diagnosed with fetal demise at 28weeks or later and admitted to an academic hospital between January 2007 and September 2010 were identified. A chart review extracted demographics, history, induction method, delivery interval, and adverse outcomes. ResultsSeventy-four women were included, with a median gestational age of 35.5weeks (range, 28–40weeks). Ten women had undergone at least 1 prior cesarean. Induction methods included misoprostol alone or for cervical ripening; oxytocin and amniotomy; transcervical Foley catheter; and mifepristone. Overall, 88% of patients delivered within 24hours; median time to fetal delivery was 11hours 20minutes (range, 7minutes to 57hours 12minutes). Adverse outcomes included intrapartum fever and postpartum hemorrhage. In total, 98% of patients, including those with prior cesarean, had a successful vaginal delivery. ConclusionRegardless of third-trimester induction method for management of stillbirth, the majority of women experience safe delivery within 24hours. The descriptive data imply that misoprostol-only inductions might confer the shortest induction intervals; however, further prospective trials are needed to identify the optimal misoprostol regimen for women with third-trimester stillbirth.