II-trimester abortion with II-trimester abortion with MifepristoneMifepristone
Kristina Gemzell Danielsson,
Dept of Obst. & Gyn
Karolinska University Hospital / Institute,
Stockholm, Sweden
FIAPAC, Moscow, October 2005
II-timester abortion, K Gemzell Danielsson
Legal abortion in Sweden
• Since 1975 ”free abortion” until 18 weeks
• Thereafter only with permission from the
National Board of Health and Welfare on
special indications until 22 weeks
• About 30 000 abortions, 90 000 births/ year
II-timester abortion, K Gemzell Danielsson
The Swedish abortion act
• Has a limited influence on the number of abortions
• Has a profound influence on the conditions under
which the abortion is performed
• Has a significant effect on women’s health
• A liberal abortion law is a prerequisite for the
development of safe abortion methods
II-timester abortion, K Gemzell Danielsson
Year Pregnancy length (weeks)
-12 13 -16 17-20 21- 24
1964 10% 27,9% 54,9%
7.4%
17.0 weeks
Källa: Rätten till abort SOU 1971:58 och EPC Socialstyrelsen
-11 12-17 18+
2002 93,3% 6.0% 0,7%
8,1 weeks
Mean
Percentages of abortionsin relation to pregnancy week
II-timester abortion, K Gemzell Danielsson
Mifepristone abortion in Sweden
• 1992: up to 63 days
• 1994: II-trimester abortion
– 600 mg mifepristone followed by gemeprost
1mg/ 3h
– 2003: 600 mg mifepristone followed by a
suitable prostaglandin analogue
II-timester abortion, K Gemzell Danielsson
II-trimester abortion 1996 to 1998
• 197 consecutive abortions in 192 women
• Regimen:
– 600 mg mifepristone
– 24 to 48 h later gemeprost 1mg every 6 hours x 4
– If no abortion within 24 h, I mg gemeprost / 3 h
• Curettage routinely performed up to 18 weeks,
thereafter when neededGemzell Danielsson K & Östlund 2000
II-timester abortion, K Gemzell Danielsson
Demography
• Median age: 30 (15 to 44) years
• Median pregnancy length: 17 (14 to 26) weeks
• Primigravidae: 42 (21.3) %
• Multigravidae: 155 (78.7) % (Nulliparous (n=45))
• Indications:
– Social (n=113) 57.4 %
– Chromosomal aberration (n=30) 15.2 %, Foetal malformation (n=34) 17.2%, Missed abortion (n=20)
10.2 %
II-timester abortion, K Gemzell Danielsson
Results
• Median numbers of gemeprost (Cervagem): 2
• Induction-to-abortion interval:
– Primigravidae: 9.0 (1.4-40.5) h vs.
– Multigravidae: 7.2 (0-152.5) h (ns)
• Nulliparous (n=45) 10.6 (2.8-30.6) h vs.
• Parous (n= 104) 6.0 (0-152.5) h (p<0.001)
II-timester abortion, K Gemzell Danielsson
Results
• 96.3 % aborted within 24 h (all women with missed abortion)
• Significant correlation between pregnancy length and
abortion time
• Narcotic analgesia required by 93 %
• PCB (n=8)
• EDA (n=1)
• One woman required a blood transfusion
II-timester abortion, K Gemzell Danielsson
II-trimester abortion200mg mifepristone and gemeprost
• Case series report
• 200mg mifepristone followed 36h later by 1 mg
gemeprost/6h x4, /3h
• Median gestational length 16 weeks (12-24 w)
• Median induction-to-abortion interval 7.8h
• Surgical evacuation 11.5%Tang OS, Thong KJ, Baird DT, Contraception 2001
II-timester abortion, K Gemzell Danielsson
II-trimester abortiongemeprost vs.misoprostol orally
• 50 women
• 200 mg mifepristone followed by
• 400 g misoprostol p.o/ 3h or 1 mg gemeprost/ 6h
• Induction – abortion interval 8.7 vs. 10.8 h (ns)
• No difference in incidence of side effectsHo et al., 1996
• Similar efficacy: El Refaey et al., 1993, Dickinson et al., 1998,
Nuutila et al., 1997
• Higher efficacy: Wong et al., 1996
II-timester abortion, K Gemzell Danielsson
II-trimester abortion misoprostol 3h vs. 6h intervals
• 148 women
• Misoprostol 400 g vaginally
• Repeated every 3h vs. 6h
• Induction-ab interval 15.2 vs.19.0 h (P< 0.01)
• Abortion within 48 h 90.5 vs. 75.7% (P< 0.02)
• Fever more common in the 3h group (P = 0.01).
Wong et al., 2001
II-timester abortion, K Gemzell Danielsson
II - trimester abortion oral vs. vaginal misoprostol
• 142 women: 200 mg mifepristone +
misoprostol 400 g oral vs. 200 g vaginal/ 3 h up to x 5
• Complete abortion rate: 81.4% vs.75.4% (ns.)
• Diarrhoea 40 vs. 23.2 % (p= 0.03)
• Total dose 1734 vs. 812 g (p< 0.0001)
• Median induction-to-abortion interval: 10.4 vs. 10 h
• 82% preferred the oral routeNgai et al. 2000
II-timester abortion, K Gemzell Danielsson
II-trimester abortion
• 200 mg mifepristone followed 48h later by
– Misoprostol 400 g vaginally every 3h vs.
– Misoprostol 600 g vaginally + 400 g po/ 3h
• No significant difference between the
groupsEl-Refaey & Templeton 1995
II-timester abortion, K Gemzell Danielsson
II-trimester abortion 1000 women, 13-21 weeks
Mifepristone 200 mg, after 36-48 h followed by
– vaginal misoprostol 800 g (4 tabl Cytotec) followed by
– 400 g po.(2 tabl Cytotec) every 3h to max 4 doses
• 97% aborted successfully
• median dose of misoprostol: 1200 g
• median induction-to-abortion interval: 6.5 h.
• 9.4% curettage, > 75 % day casesAshok & Templeton 1999, 2004
II-timester abortion, K Gemzell Danielsson
II-trimester abortionsublingual misoprostol
• Significantly higher acceptance for sublingual
administration
400 microg misoprostol/ 3h x 5 vaginal. vs. SublingualTang et al., 2004
• Higher acceptance for sublingual but more pain,
more opiates needed
600 microg sublingual vs. 800 microg vaginal followed by 400
microg /3h sublingual or vaginalHamoda et al., 2005
II-timester abortion, K Gemzell Danielsson
Effect of the time interval between mifepristone and the prostaglandin
• No difference in induction to abortion time with
mifepristone administered 24, 36 or 48 h prior to the
prostaglandinUrquhart and Templeton 1990
• Effect on uterine contractility maximal at 36 to 48hBygdeman & Swahn 1985
• Ripening effect of mifepristone on cervix, more
pronounced at 36 to 48 hRådestad et al 1988
II-timester abortion, K Gemzell Danielsson
The contraindication is unfounded
NSAIDs are prostaglandin synthetase inhibitors
Effect of mifepristone on uterine contractility: , regardless of
NSAID administration (Norman et al.,)
No effect on cervical ripening when coadministered with
misoprostol (Ho et al)
Efficacy of medical abortion is the same, when NSAIDs
prophylaxis is used
Shortened induction-to abortion interval and less misoprostol in
nulliparaousFiala et al Human Reprod 2005
Arguments for the use of NSAIDs
II-timester abortion, K Gemzell Danielsson
Conclusion Mifepristone in II-trimester abortion
• Our data confirm the efficacy and safety of
mifepristone and gemeprost for II-trimester abortion.
• Oral misoprostol has been shown to be as effective
and safe as gemeprost
• Vaginal misoprostol is more effective but less
accepted than the oral route
• The combined vaginal-oral regimen is as effective as
repeated vaginal misoprostol
II-timester abortion, K Gemzell Danielsson
II-trimester abortion
Mifepristone followed 24-48h later by
Misoprostol 800 g (CytotecR 4 tabl ) vaginally followed
by 400 g (CytotecR 2 tabl) orally
every 3h
Curettage only in case of incomplete abortion
II-timester abortion, K Gemzell Danielsson
Pain prophylaxis
• T Diclofenac 100 mg T Panocod.® together with the first
dose of Cytotec
• Contraceptive councelling
• Screening and treatment/ prophylactic antibiotics for STI
II-trimester abortion with II-trimester abortion with MifepristoneMifepristone
Kristina Gemzell Danielsson,
Dept of Obst. & Gyn
Karolinska University Hospital / Institute,
Stockholm, Sweden
FIAPAC, Moscow, October 2005