Elsevier

Contraception

Volume 69, Issue 1, January 2004, Pages 51-58
Contraception

Original research article
Midtrimester medical termination of pregnancy: a review of 1002 consecutive cases

https://doi.org/10.1016/j.contraception.2003.09.006Get rights and content

Abstract

We assessed the effectiveness, safety and factors that affected the outcome of midtrimester medical termination of pregnancy at 13–21 weeks gestation. Of the 1002 women, 3 took mifepristone and decided to continue with the pregnancy, with 999 women being compliant with the regimen. Of these, 2 women aborted prior to administration of misoprostol and 970 (97.1%) aborted successfully within five doses of misoprostol. Surgical intervention was necessary to complete the abortion process in 81 (8.1%) women. Women with no previous pregnancy (p = 0.02), no previous live birth (p = 0.0001) and gestations 17–21 weeks (p = 0.001) required more prostaglandin. Younger women (p = 0.0001) and women with a previous live birth (p = 0.001) were more likely to have a successful abortion. The induction abortion interval was significantly longer with increasing gestation [95% confidence interval (CI) difference in means: −2.52 to −0.89, p = 0.0001], increasing age (p = 0.0001) and no previous live birth (95% CI difference in means: −0.25 to −1.01, p = 0.0001). Surgical intervention was more likely to be required with increasing age (p = 0.008). Mifepristone in combination with misoprostol is a safe and effective regimen for midtrimester medical abortion with younger women and those with a previous live birth more likely to have a successful abortion.

Introduction

Dilatation and evacuation (D&E) of the uterus is the favored method for second-trimester termination of pregnancy in the United States and in the non-National Health Service (NHS) abortion sector in the United Kingdom, whereas within the NHS sector, medical methods are used predominantly [1]. D&E is safe and effective but can only be performed by gynecologists who are skilled in the technique [2], [3]. Between 1988 and 1996 there were nine maternal deaths in the United Kingdom related to legal abortion, of which five followed midtrimester abortion and three of these were following D&E of the uterus. A previous report on confidential inquiries into maternal deaths in the United Kingdom questioned the appropriateness of D&E as a method of terminating second-trimester pregnancy when safe and effective medical alternatives exist [4].

Medical induction of abortion using the prostaglandin (PG)E1 analogues, gemeprost or misoprostol alone, is efficient, although the mean induction-to-abortion interval can be as long as 12–16 h [5], [6]. Pretreatment with the antiprogesterone mifepristone, prior to prostaglandin administration, reduces the induction-to-abortion interval, as well as the analgesia requirements and the total dose of prostaglandin required [7], [8], [9]. In the UK, mifepristone in a 600-mg dose in combination with the prostaglandin E1 analogue, gemeprost, has been licensed for midtrimester medical abortion since 1995 and is increasingly used at all gestations [10], [11], [12]. However, randomized studies have indicated that a reduced dose of 200 mg of mifepristone is equally effective for termination of pregnancy in the second trimester [13], [14]. Similarly the prostaglandin E1 analogue, misoprostol, has been shown to be an effective alternative to gemeprost [15], [16], [17]. Moreover, it can be administered orally or vaginally and does not require special storage conditions [18].

This series of 1002 cases is a continuum to our previously reported experience [19], with the regimen comprising 200 mg mifepristone in combination with misoprostol. The aim of this study was to assess the factors affecting the outcome of midtrimester medical abortion in addition to assessing the effectiveness and safety of this regimen in clinical practice from one teaching hospital over an 8-year period.

Section snippets

Materials and methods

This report is based on a consecutive series of 1002 women with pregnancies between 13 and 21 weeks of amenorrhea undergoing induced abortion under the terms of the 1967 Abortion Act in one Scottish NHS hospital between May 1994 and November 2001. Women presenting beyond 13 weeks gestation were offered only medical termination of pregnancy (the regimen reported here). Women who presented with a previous cesarean section were offered the same regimen. Termination of pregnancy was not offered

Results

A total of 1002 women had medical midtrimester termination of pregnancy during the period May 1994 to November 2001. All data were prospectively collected.

Discussion

This study is the largest reported series evaluating the effectiveness of medical abortion in routine clinical practice in the second trimester using mifepristone and misoprostol. The effectiveness of the regimen is at least as, if not more, effective as the regimen using mifepristone and gemeprost. Tang et al. reviewed 956 women undergoing medical abortion in a single center using mifepristone and gemeprost and showed that 68.6% aborted within 10 h of prostaglandin administration and were

Acknowledgements

Study conducted at, and financial support provided by, the Department of Obstetrics and Gynecology, University of Aberdeen, Aberdeen, UK.

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