Alternatives to mifepristone for early medical abortion.

OBJECTIVE: To review published reports of first-trimester medical abortion regimens that do not include mifepristone. METHODS: Reports listed in Pubmed and Medline on prospective and controlled trials of the efficacy of misoprostol, alone or associated with methotrexate, for first-trimester abortion were analyzed if they included more than 100 participants and were published since 1990. RESULTS: The efficacy of regimens using misoprostol alone ranged from 84% to 96%, and when misoprostol was used with methotrexate the efficacy ranged from 70% to 97%. Efficacy rates were influenced by follow-up interval. Treatment for infection, bleeding, and incomplete abortion were infrequent with both methods (0.3%-5%). CONCLUSION: Alone or in combination with methotrexate, misoprostol is an efficacious alternative to mifepristone for the medical termination of pregnancy.

Intra-cervical versus i.v. fentanyl for abortion.

BACKGROUND: The majority of abortions are performed using a para-cervical block (without general anaesthesia) and involve a significant amount of pain. If fentanyl was given with the lidocaine in the para-cervical block, it potentially could improve pain control while decreasing side effects and avoiding i.v. access for women having abortions. METHODS: This was a randomized double-blind placebo-controlled trial of two treatment arms: (i) para-cervical block with 100 microg of fentanyl i.v; or (ii) para-cervical block with 100 microg of fentanyl intra-cervically (i.c.) for first trimester abortion. The setting was a free-standing urban abortion clinic. The outcome measures were pain scores and side effects. RESULTS: A total of 104 women received the fentanyl i.v. and 98 received the fentanyl i.c. The two groups were similar with respect to age, gestational age, obstetric history, anxiety and depression. Pain scores (0-10) were 4.7 and 5.7 for dilation (P = 0.01) and 3.8 and 5.6 for suctioning (P < 0.001) in the i.v. and i.c. groups, respectively. Side effects were similar, but more women in the i.v. group received anti-emetics. More women in the i.c. group were dissatisfied with the pain control. CONCLUSION: I.v. fentanyl is more effective than i.c. fentanyl for pain control in abortion.

Anxieties and attitudes towards abortion in women presenting for medical and surgical abortions.

OBJECTIVE: To examine the differences in anxiety levels and attitudes towards abortion between women having an early medical abortion and women having a surgical (manual vacuum aspiration) abortion. METHODS: Women who presented for an early medical abortion or a surgical abortion at an urban, free-standing abortion clinic were invited to participate in this study. Fifty-nine women having a medical abortion and 43 women having a surgical abortion answered questionnaires before their scheduled abortion, and again 2 to 4 weeks after the abortion. Thirty women were interviewed about their answers. RESULTS: Anxiety levels were similar in both groups before the abortion procedure. Anti-choice views about abortion were seen in 60.5% of women having a medical abortion and in 37.3% of women having a surgical abortion (P = .027). Women who were pro-choice had a mean anxiety score of 5.0 (range, 0-10) before and 2.7 after the abortion, whereas women who were anti-choice had a mean anxiety score of 5.2 before and 4.4 after the abortion (P = .005). CONCLUSION: It is important for providers of abortion care to understand that women undergoing a medical abortion may be more ambivalent about abortion than women undergoing a surgical abortion, and women who are anti-choice but having an abortion may have unresolved anxiety after the procedure.

Universal screening for domestic violence in abortion.

The purpose of this study was to evaluate the policy of universal screening for domestic violence in an abortion clinic. Compliance with the policy was low, because only 254 of 499 women seen were asked the screening questions: 58% of Caucasians, 40% of East Asians, and 37% of South Asians were screened (P =.003). Of the 254 women asked about abuse, 38 said they had been abused in the past 12 months, giving a prevalence rate of domestic violence similar to that of the general population. Screening for domestic violence in women presenting for abortion is challenging, but feasible.

A randomized controlled trial of fentanyl for abortion pain.

OBJECTIVE: Our aim was to find out whether intravenous fentanyl was effective in reducing the pain of first-trimester abortion. STUDY DESIGN: This randomized controlled trial included 825 women attending a nonhospital abortion facility. Some women chose standard care. Women who did not choose standard care were randomly assigned to receive either 50 to 100 microg of fentanyl, a placebo, or no intervention. With SAS software and a mixed effects analysis of variance model with covariates, we compared mean pain scores of the fentanyl and placebo groups to detect a difference of at least 1 point on an 11-point pain scale. RESULTS: The mean pain score of the fentanyl group was 1.0 point less than that of the placebo group (95% confidence interval, 3.7-4.3) and 0.9 point less than that of the observational group (95% confidence interval, 4.7-5.1). This pain reduction was statistically significant, but the women who were studied wanted a 2-point reduction from fentanyl. CONCLUSION: Fentanyl, when compared with the placebo, reduced abortion pain by 1.0 point on an 11-point scale. This reduction was of questionable clinical significance and was less than desired by the women included in the study.

Misoprostol administration in medical abortion. A comparison of three regimens.

OBJECTIVE: To determine the best regimen for using misoprostol after methotrexate in medical abortion with respect to outcome and side effects. STUDY DESIGN: In a cohort study, we compared vaginal misoprostol in one cohort of 134 women who used 800 micrograms dry tablets with 99 women who used 600 micrograms wet and 197 women who used 800 micrograms wet. These cohorts were compared with respect to outcome and side effects. RESULTS: The "dry" group had fewer completed abortions by day 8 (55.2% as compared to 69.7% and 71.1%, P = .008) but similar surgery rates. The dry group also had fewer side effects, especially fever and chills (4.5% as compared to 25.3% and 40.6%, P = .0001) and vomiting (8.2% as compared to 16.2% and 20.3%, P = .01). CONCLUSION: Of the three methods, the one consisting of 600 micrograms of wet misoprostol is the most effective for early completion of abortion and has the fewest side effects.

Arteriovenous malformations of the uterus associated with medical abortion.

Seven cases of uterine arteriovenous malformations associated with pregnancy were initially suspected by the history of prolonged bleeding after a medical abortion and then confirmed by color Doppler scanning. All cases were managed expectantly and resolved spontaneously. When AVMs required diagnosis by pathology or angiography, only the most severe cases would have been reported. Now that they can be recognized on ultrasound, it is possible that mild cases such as these will be found to be much more common.

Time lost from work among women choosing medical or surgical abortions.

This was a prospective cohort questionnaire study to compare the loss of ability to work in 62 women having medical and 69 having surgical abortions. Outcomes included the number of days lost from work outside the home and inside the home before and after the abortion appointment. The mean total loss from work inside the home was 10.1 days for the surgical group and 5.3 days for the medical group (P <.05). The mean total loss from work outside the home was not significant at 4.0 days for the surgical group and 2.5 days for the medical group.

Offering HIV prophylaxis to people who have been sexually assaulted: 16 months' experience in a sexual assault service.

The sexual assault service, operated by the Children's & Women's Health Centre of British Columbia in partnership with the Vancouver General Hospital Emergency Department, started offering HIV prophylaxis in November 1996 to patients presenting to the emergency department after a sexual assault. In the first 16 months of the program a total of 258 people were seen by the service, of whom 71 accepted the offer of HIV prophylaxis. Only 29 continued with the drug treatment after receiving the initial 5-day starter pack, and only 8 completed the full 4-week treatment regmen and returned for their final follow-up visit. Patients at highest risk for HIV infection (those who had penetration by an assailant known to be HIV positive or at high risk for HIV infection [men who have sex with men, injection drug users]) were more likely to accept prophylaxis and more likely to complete the treatment than those at lower risk. Compliance and follow-up were the main problems with implementing this service. Service providers found it difficult to give the information about HIV prophylaxis to traumatized patients. After this program evaluation, the service changed its policy to offer HIV prophylaxis only to people at high risk of HIV infection. This targeting of services is expected to make the service providers' jobs easier and to make the program more cost-effective while still protecting sexual assault victims against HIV infection.

Tamoxifen compared to methotrexate when used with misoprostol for abortion.

The purpose of this study was to compare tamoxifen to methotrexate, with respect to effectiveness, when followed by misoprostol to induce abortion. In the first phase, 198 women presenting for medical abortion at < 7 weeks gestation were randomized to receive either 40 mg of tamoxifen, followed 2 to 3 days later by 800 micrograms of misoprostol self-administered vaginally or 50 mg/m2 of methotrexate, followed 5 to 7 days later by the same dose of misoprostol. In the second phase, 200 women were randomized to receive 20 mg tamoxifen twice daily for 4 days, followed by 800 micrograms misoprostol or the same regimen of methotrexate and misoprostol as in phase 1. The main outcome measure was success rate determined by the number of women who aborted without surgery. In phase 1, the success rate was higher in the methotrexate group (93.0%) compared to the tamoxifen group (85.7%) (p = 0.045). In the tamoxifen group, nine of 98 women had incomplete abortions with symptoms requiring a surgical aspiration, compared to one of 100 women in the methotrexate group. In phase 2, the success rates were 90.9% in the methotrexate group compared to 84.7% in the tamoxifen group (p = 0.20). The side effects were less in the tamoxifen group in phase 1 but not in phase 2. When tamoxifen is given as a single dose, it is less effective than methotrexate but when it is given 20 mg twice daily for 4 days, there is no significant difference. Tamoxifen does not appear to have any benefits over methotrexate.

PIP: This study aims to compare the effectiveness of tamoxifen with that of methotrexate when each is used in combination with misoprostol for abortion. In the 1st phase of the study, 198 medical abortion cases at 7 weeks gestation were randomized to receive either 40 mg of tamoxifen followed by 800 mcg of misoprostol after 2-3 days or 50 mg/sq. m of methotrexate followed by the same dose of misoprostol after 5-7 days. In the 2nd phase, 20 mg tamoxifen twice daily for 4 days was administered to 200 women, followed by 800 mcg misoprostol or the same methotrexate and misoprostol regimen as in phase 1. The number of women who experienced abortion without surgery was determined to measure the success rate. The success rate in phase 1 was higher in the methotrexate group (93.0%) than in the tamoxifen group (85.7%) (p = 0.045). About 9 in 98 women in the tamoxifen group and 1 in 100 women in the methotrexate group had incomplete abortions, indicating surgical aspirations. In the 2nd phase, the success rates were 90.9% in the methotrexate group and 84.7% in the tamoxifen group (p = 0.20). There were fewer side effects in the tamoxifen group during the 1st phase but not in the 2nd phase. Tamoxifen was seen to be less effective than methotrexate if given in a single dose. There was no significant difference when tamoxifen was given in 20 mg doses twice daily for 4 days. There were no advantages observed in tamoxifen over methotrexate.

Oral methotrexate compared with injected methotrexate when used with misoprostol for abortion.

OBJECTIVE: This study was undertaken to compare oral to injected methotrexate with respect to effectiveness, side effects, and acceptability. STUDY DESIGN: One hundred women in an urban primary care practice were randomly assigned in phase 1 to receive 50 mg/m(2) methotrexate by either the oral or the injected route. In phase 2 another 87 women were allowed to choose between the oral and injected routes. In both phases and in all groups the methotrexate was followed 5 to 7 days later by misoprostol administered vaginally by the patient. The main outcome was the success rate (the number whose pregnancies aborted without surgery); other outcomes included side effects and acceptability. RESULTS: There were no differences in rates of success, side effects, or acceptability between groups receiving oral and injected methotrexate. Among the women in phase 2 the oral form was chosen by 57.5%. CONCLUSION: This study indicates that for medical abortions induced with methotrexate and misoprostol it is possible to offer both the oral and injected routes of methotrexate without sacrificing efficacy and that about half of the women offered a choice will choose the oral route.

Comparing abortion induced with methotrexate and misoprostol to methotrexate alone.

This was a dual-cohort study performed to determine if, by using methotrexate alone, abortions could be induced with fewer side effects, without sacrificing effectiveness and patient satisfaction. The subjects were 358 consecutive patients who requested elective medical termination of pregnancy at < 7 weeks gestation. Women were given information and allowed to choose between methotrexate alone (50 mg/m2 intramuscularly) or methotrexate followed 4 days later by 800 micrograms misoprostol vaginally. The two groups were compared with respect to the number of surgical aspirations required, the number of days until the abortion was completed, side effects, and the number of women who would choose the same method again. The surgery rate for methotrexate was 17.2%, whereas for the combination it was 10.9%. The mean numbers of days until the abortion were complete was 23 and 12, respectively. Side effects, mean pain scores, total days of bleeding, and satisfaction rates were not significantly different in the two groups. The high failure rate with methotreaxate alone suggests that it should not be offered despite the high level of satisfaction.

PIP: A dual-cohort study was conducted to determine whether abortion induced by methotrexate alone produces fewer side effects than a misoprostol-methotrexate regimen without sacrificing efficacy. 358 consecutive Canadian abortion seekers with pregnancies of 7 weeks' gestation or less were given the choice of a regimen of 50 mg/sq. m of intramuscular methotrexate or methotrexate followed 4 days later by 800 mcg of vaginal misoprostol. 101 women chose the former and 257 opted for the latter regimen. Women tended to choose the methotrexate-only regimen to avoid misoprostol-related side effects; selection of the combination was motivated by a desire for a rapid pregnancy termination. 82 women (82.8%) in the methotrexate-only group and 228 (89.1%) in the combination group aborted successfully. The failure rate in both groups was significantly higher when the procedure was performed at 6 or more weeks of gestation. It took a mean of 23.1 days from injection to complete abortion in the methotrexate-only group compared with 11.7 days in the methotrexate-misoprostol group. More than half the women had medication-related side effects, primarily nausea, vomiting, and diarrhea, with no significant differences between groups. The mean number of days of bleeding was 9.0 in the methotrexate-only group and 10.1 in the combination group. The mean worst pain score (on an 11-point scale) was 6.4 in the former and 6.1 in the latter group. 91.8% of women in the methotrexate-only group and 90.7% of those in the misoprostol-methotrexate group who successfully aborted stated they would chose the same method again. Given the high failure rate, methotrexate alone should not be offered routinely to abortion seekers. Its use should be reserved for women with very early pregnancies who have relative contraindications for misoprostol.

Abortion induced with methotrexate and misoprostol: a comparison of various protocols.

Seven hundred fifty-six women had abortions induced with methotrexate and misoprostol. Various protocols were compared. In Group 1, phase 1, after receiving 50 mg/m2 methotrexate IM, 289 women were randomized to receive either 750 or 500 micrograms of vaginal misoprostol. In Group 1, phase 2, 84 women who had failed to abort after one dose of misoprostol were randomized to receive either vaginal or oral routes for the second dose of misoprostol given on Day 8. In Group 2, a cohort of 226 women who received 60 mg/m2 methotrexate were compared to the 289 women who received 50 mg/m2 in Group 1. There were no differences in rates of effectiveness in the various trial groups. Side effects were greater with 60 mg/m2 of methotrexate. In Group 3, a cohort of 241 women received the misoprostol in three vaginal doses 8 hr apart starting on Day 5, and were compared to the 289 women in Group 1 receiving one vaginal dose. In women whose medical abortion failed, fetuses were found to have limb abnormalities In the total group of 756 women, 88.8% aborted successfully without surgical aspiration, with only minor side effects, and the acceptance rate was high. This study indicates that medical abortions induced with methotrexate and misoprostol are safe and effective, but more research is needed to find a more effective protocol.

Choosing between surgical abortions and medical abortions induced with methotrexate and misoprostol.

Women phoning to request an abortion at a free-standing abortion clinic who were less than 46 days from the last menstrual period were given a choice between a surgical abortion and a medical abortion induced with methotrexate and misoprostol. Twenty-six percent (116 of 405 women) chose a medical abortion. Younger women were more likely to choose a surgical abortion. There were no other significant differences in the two groups in terms of gestational age, race, or prior pregnancies. The reasons most women listed as "very important" when making the decision to have a medical abortion were the timing (being able to have the abortion before 7 weeks), the privacy of aborting at home, and fear of surgery. The women who chose surgery gave the reasons of fear of experimental medications, the lack of emotional support at home, and wanting to avoid the extra visits and blood tests.

Abortion induced with methotrexate and misoprostol.

OBJECTIVE: To determine the outcome and side effects of a new drug protocol to induce abortion. DESIGN: Case series. SETTING: An urban primary care practice. PATIENTS: One hundred consecutive patients who requested elective termination of pregnancies of less than 8 weeks' gestation. INTERVENTION: Subjects received methotrexate (50 mg/m2 body surface area, administered intramuscularly) and, 3 days afterward, misoprostol (800 micrograms, given vaginally). OUTCOME MEASURES: Number of abortions induced within 24 hours and within 10 days of misoprostol administration, number of surgical aspirations conducted because of incomplete abortion, mean amount of bleeding and pain and the number of women who, if faced with the same situation, said they would again choose a drug-induced abortion over a surgical one. RESULTS: Abortion occurred within 24 hours of misoprostol administration among 48 women and within 10 days among 69 women. In total, 89 women had an abortion without surgical aspiration. Of these women, 71 said they would choose a drug-induced abortion if faced with the choice again. CONCLUSION: Abortion induced with methotrexate and misoprostol appears to be a feasible alternative to surgical abortion and deserves further study.