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Misoprostol is a prostaglandin analog commonly used to induce termination of pregnancy. Clandestine home terminations complicate forensic fetal autopsy when a history of misoprostol use is withheld and the gross and histologic findings are sparse, as is often the case. One hundred thirty-two placentas with no vaginal misoprostol use, low-dose misoprostol use, and high-dose misoprostol use were reviewed for the presence, volume, and locations of microcrystalline cellulose and crospovidone, common tablet fillers in misoprostol tablets. Microcrystalline cellulose and/or crospovidone was identified in 0 (0%) of 88 cases with no vaginal administration or low-dose vaginal administration and 29 (66%) of 44 placentas with high-dose vaginal administration. When identified, microcrystalline cellulose and/or crospovidone is most commonly present on the maternal surfaces of the extraplacental membranes. The presence of microcrystalline cellulose and/or crospovidone was associated with smaller placental weight (Mann-Whitney U, P = 0.019). These fillers have a reasonable sensitivity for high-dose vaginal tablet use and are very specific. Although they are not diagnostic for misoprostol administration, they provide a finding that may prompt additional investigation into the nature of the vaginal tablet administered and the circumstances surrounding birth.

Background: Methotrexate (MTX) is widely used as an immunosuppressant, chemotherapeutic, and abortifacient agent. It is also a potent teratogen, and intentional or unintentional exposure during pregnancy is associated with heterogeneous birth anomalies. Methods: We retrospectively reviewed a cohort of patients who presented to our clinic with limb anomalies in the setting of MTX embryopathy. Results: In our case series, we describe 7 cases of patients who had limb anomalies with heterogeneous functionality, from severely debilitating to completely asymptomatic. Most of the upper extremity anomalies in our group were managed conservatively. Conclusions: Methotrexate embryopathy is a rare but clinically important entity with phenotypic and functional variability. This series underscores the need for proper counseling of patients and raises concern regarding using this medication for the purpose of abortion.

Cesarean scar ectopic pregnancy (CSEP) has a high rate of morbidity with nonspecific signs and symptoms making identification difficult. The criterion-standard treatment of CSEP has been subject to debate.This review defines CSEP, discusses pathogenesis and diagnosis, and compares treatment options and outcomes.A literature review was performed utilizing the termFive basic pathways have been identified in treatment of CSEP: expectant management, medical therapy, surgical intervention, uterine artery embolization, or a combination approach. Expectant management has the highest probability of morbid outcomes, including hemorrhage, uterine rupture, and preterm delivery. Medical management often requires further treatment with additional medication or surgery. Different surgical methods have been explored including uterine artery embolization; dilation and curettage; surgical removal via vaginal, laparoscopic, or laparotomic approach; and hysterectomy. Each method has various levels of success and depends on surgeon skill and patient presentation.Recent research supports any method that removes the pregnancy and scar to reduce morbidity and promote future fertility. Laparoscopic and transvaginal approaches are options for CSEP treatment, although continued research is required to identify the optimal approach.As cesarean delivery numbers rise, a subsequent increase in CSEPs can be anticipated. The ability to accurately diagnose and treat this morbid condition is vital to the practice of any specialist in general obstetrics and gynecology.

Chronic ectopic pregnancy (CEP) is a rare form of tubal pregnancy. It is characterised by chronic degeneration of an early trophoblastic tissue causing tubal destruction. CEP remains a diagnostical...

Medical abortion offers a well tolerated and effective method to terminate early pregnancy, but remains underutilized in the United States. Over the last decade, 'telemedicine' has been studied as an option for medical abortion to improve access when patients and providers are not together. A number of studies have explored various practice models and their feasibility as an alternative to in-person service provision.A direct-to-clinic model of telemedicine medical abortion has similar efficacy with no increased risk of significant adverse events when compared with in-person abortion. A direct-to-consumer model is currently being studied in the United States. International models of direct-to-consumer medical abortion have shown promising results.The introduction of telemedicine into abortion care has been met with early success. Currently, there are limitations to the reach of telemedicine because of specific restrictions on mifepristone in the United States as well as laws that specifically prohibit telemedicine for abortion. If these barriers are removed, telemedicine can potentially increase abortion access.

Cervical ectopic pregnancy can lead to catastrophic hemorrhage, and may be managed conservatively with intra-amniotic methotrexate (MTX), systemic MTX, or both; surgical evacuation with or without balloon tamponade; and uterine artery embolization. However, some patients require hysterectomy, which has traditionally been performed abdominally.A 39-year-old parous woman was diagnosed with cervical ectopic pregnancy at an estimated 7 1/7 weeks of gestation. Her β-hCG level remained at 29,433 milli-international units/mL, and the gestational sac persisted on ultrasonography after first intra-amniotic then multidose systemic MTX treatment. After a review of other fertility-sparing procedures, she chose definitive treatment with hysterectomy because she did not desire future childbearing. She underwent a successful vaginal hysterectomy, a novel approach for this condition.Vaginal hysterectomy can be performed successfully for treatment of cervical ectopic pregnancy in patients who have completed childbearing and for whom conservative treatment has failed.

Abortion “Reversal” Four states require abortion providers to tell their patients about treatment that may reverse the effect of mifepristone if they change their mind after starting a medication abortion. But abortion reversal treatment remains experimental and unproven.

Sera from 378 female Mijaheem camels of different age groups were collected from different parts of the country. All of them were simultaneously tested serologically for specific antibodies against brucellosis, chlamydiosis and coxiellosis while 368 of the same serum samples were also tested for toxoplasmosis and neosporosis, using indirect enzyme-linked immunosorbent assays. The results were statistically analyzed to determine the prevalence rate of each of these abortifacient agents and the association of the geographical location and age of the animal with the prevalence. The overall serological prevalence was 16.67% for brucellosis, 49.18% for toxoplasmosis, 13.32% for neosporosis, 10.05% for chlamydiosis and 42.36% for coxiellosis. Statistical analysis revealed significant associations between the serological prevalence of each of the studied abortifacient agents with the location of the animal, and there was also a significant association with age in the case of toxoplasmosis and chlamydiosis. The results indicate that the causative agents of brucellosis, toxoplasmosis, neosporosis, chlamydiosis and coxiellosis are widespread among indigenous Mijaheem camels in Saudi Arabia, and that their prevalence varied with region and age group. These different agents should therefore be considered in the differential diagnosis of infectious abortion in Saudi Arabian camels.

Access to abortion in the United States has eroded significantly. Accordingly, there is a growing movement to empower women to self-induce abortion. To date, physicians' roles and responsibilities in this changing environment have not been defined. Here, we consider a harm reduction approach to first-trimester abortion as a way for physicians to honor clinical and moral obligations to care for women, negotiate ever-increasing abortion restrictions, and support women who consider abortion self-induction. Harm reduction approaches to abortion have been successfully implemented in a range of countries around the world and typically take the form of teaching women how to use misoprostol. When women self-administer misoprostol, rather than resort to other means such as self-instrumentation or abdominal trauma, to end a pregnancy, maternal mortality falls. There are clinical and ethical benefits as well as limitations to a harm reduction approach to abortion in U.S. Settings Its legal implications for patients and physicians are unclear. Ultimately, we suggest that despite its limitations, a harm reduction approach may help both physicians and patients.

OBJECTIVE: To compare the treatment success and failure rates, as well as side effects and surgery rates between methotrexate protocols. DATA SOURCES: PubMed, Embase and the Cochrane library searched up till July 2018. STUDY ELIGIBILITY CRITERIA: RCTs that compared women with ectopic pregnancies receiving the single dose, two dose or multi-dose methotrexate protocols. STUDY APPRAISAL AND SYNTHESIS METHODS: Odds of treatment success, treatment failure, side effects and surgery for tubal rupture as well as length of follow-up until treatment success compared using random and fixed effects meta-analysis. Sensitivity analyses compared treatment success in high hCG and large adnexal mass groups, as defined by individual studies. Cochrane’s collaboration tool used to assess risk of bias. RESULTS: The two dose protocol was associated with higher treatment success compared to single dose protocol (OR: 1.84, 95% CI: 1.13, 3.00). The two dose protocol was more successful in women with high hCG (OR: 3.23, 95% CI: 1.53, 6.84) and in women with a large adnexal mass (OR: 2.93 95% CI: 1.23, 6.9). The odds of surgery for tubal rupture were lower in the two dose protocol (OR: 0.65, 95%CI: 0.26, 1.63), but not statistically significant. The length of follow up was 7.9 days shorter for the two dose protocol (95% CI: −12.2, −3.5). Odds of side effects were higher in the two dose protocol (OR: 1.53, 95% CI: 1.01, 2.30). Compared to the single dose protocol the multi-dose protocol is associated with a nonsignificant reduction in treatment failure (OR: 0.56, 95% CI: 0.28, 1.13) and a higher chance of side effects (OR: 2.10, 95% CI: 1.24, 3.54). Odds of surgery for tubal rupture (OR: 1.62, 95% CI: 0.41, 6.49) and time to follow-up (−1.3, 95% CI: −5.4, 2.7) were similar. CONCLUSION: The two dose methotrexate protocol is superior to the single dose protocol for the treatment of ectopic pregnancy in terms of treatment success and time to success. Importantly, these findings hold true in patients thought to be at a lower likelihood of responding to medical management, such as those with higher hCGs and large adnexal mass.

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To describe the human chorionic gonadotropin (hCG) elimination rate in patients with intentionally retained placenta percreta.Medical records for cases of placenta percreta with intentional retention of the placenta were reviewed. The natural log of the hCG levels were plotted versus time and then the elimination rate equations were derived.The hCG elimination rate equations were log-linear in three cases individually (R (2) = 0.96-0.99) and in aggregate R (2) = 0.92). The mean half-life of hCG elimination was 146.3 h (6.1 days).The elimination of hCG in patients with intentionally retained placenta percreta is consistent with a two-compartment elimination model. The hCG elimination in retained placenta percreta is predictable in a log-linear manner that is similar to other reports of retained abnormally adherent placentae treated with or without methotrexate.

Pregnancy of unknown location (PUL) is a common diagnostic challenge. The primary diagnostic goal is to ensure that the PUL is nonviable prior to proceeding with any invasive procedures. In nonviable PUL, there are several diagnostic and treatment strategies, which are generally quite safe. However, the management option that provides the most definite diagnosis is uterine curettage. We advocate use of uterine curettage in all cases of nonviable PUL because it limits exposure to a chemotherapeutic agent to only those who need it and it allows for the most accurate information for counseling the patient on prognosis of future pregnancies.

To compare outcomes with simultaneous administration of mifepristone and misoprostol with a regimen in which the drugs are administered at a 24-hour interval for second-trimester abortion.In this placebo-controlled, double-blind trial, participants were randomized to receive mifepristone either 24 hours before or at the same time as misoprostol. Participants were hospitalized to receive 400 micrograms buccal misoprostol at 3-hour intervals up to 48 hours or until uterine expulsion. The primary outcome was the proportion of women who experienced uterine expulsion within 24 hours after the first misoprostol dose and this required 504 women to examine our hypothesis that this rate would be 85% in the 24-hour interval arm compared with 70% in the simultaneous arm. Secondary outcomes included total abortion time from mifepristone and misoprostol.From February 2013 to April 2014, 509 women were enrolled. Women in the 24-hour interval arm were more likely to abort within 24 hours (94.4% compared with 85.0%, relative risk 1.11, 95% confidence interval [CI] 1.05-1.18). At 48 hours, the rate was similar in the two arms (96.8% [24-hour interval] and 95.7% [simultaneous], relative risk 1.01, 95% CI 0.97-1.04). Median misoprostol dosing time was shorter in the 24-hour interval arm (7.7 compared with 13 hours; P.001) and consistent with the median misoprostol doses required (three compared with five; P.001). Median time from mifepristone to uterine expulsion was longer in the 24-hour interval arm (32.3 compared with 13 hours; P.001). Both regimens had high acceptability rates and reported similar side effects and pain scores.Administering mifepristone and misoprostol simultaneously results in lower expulsion rates within 24 hours of taking misoprostol, longer median misoprostol treatment times, and requires more misoprostol doses. At 48 hours, both regimens work equally well. Simultaneous dosing results in less total time from the first clinical contact to complete abortion.ClinicalTrials.gov, https://clinicaltrials.gov, NCT01768299.

Medical management has become increasingly popular in the treatment of ectopic pregnancy. Given its convenience, for many it is used as a first-line treatment, however, this is not always the optimal choice for the patient. It is important to understand the options for medical treatment and when it is appropriate to treat a particular patient with medical management, or when one should opt for surgical management. This review outlines the different regimens for methotrexate administration and the associated risks and benefits to medical management.

This study evaluated the clinical efficacy, safety, and side effects of intramuscular administration of 15(S) methyl F2 alpha for midtrimester pregnancy termination. 25 healthy women, generally in the 14-6th weeks of pregnancy, were given repeated doses of 250 mcg of 15(S) followed by 300-600 mcg at 2-3 hour intervals, depending upon the uterine contractions and side effects. In addition, 15 women were given Lomotil tablets before prostaglandin administration to counteract gastrointestinal side effects. The mean required dosage of prostaglandin was 2.3 mg. The induction-abortion interval was 5-10 hours in 32%, 11-15 hours in 52%, 16-20 hours in 8%, and 21-25 hours in 8%, with a mean abortion time of 13.04 hours. 23 women (92%) has complete and spontaneous abortion. Women treated with Lomotil experienced fewer episodes of vomiting and diarrhea. Other side effects included nausea in 40% of cases, cough in 12%, and fever in 16%. These side effects were mild and well tolerated by the patients, however. It is concluded that serial intramuscular injection of prostaglandin 15(S) methyl F2 alpha is an effective method for midtrimester abortion. In view of the minimal blood loss and asepsis associated with this method, it is particularly suitable for centers where blood transfusion facilities are inadequate.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 39 - N° 3S - p. F17-F24

Please cite this paper as: Moores K, Keriakos R, Anumba D, Connor M, Lashenb H. Management challenges of a live 12-week sub-hepatic intra-abdominal pregnancy.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 39 - N° 3S - p. F3-F10

Resume Objectif Comparer l'impact d'une politique de prise en charge conservatrice ou radicale du placenta accreta sur la morbidite maternelle. Methodes Il s'agit d'une revue retrospective des donnees medicales de toutes les patientes ayant accouche a la maternite Port-Royal avec un diagnostic de placenta accreta, increta ou percreta de janvier 1993 a octobre 2005. Nous avons compare deux periodes consecutives. Durant la periode A (janvier 1993 a juin 1997), le protocole de service comportait une tentative de delivrance complete du placenta pour toutes les patientes. Durant la periode B (Juillet 1997 a octobre 2005), une politique conservatrice a ete appliquee. Les criteres suivants ont ete etudies pour les deux periodes : taux d'hysterectomie et de transfusion, admission en reanimation, duree de sejour en reanimation, septicemie et coagulation intravasculaire disseminee, infection du post-partum. Resultats Cinquante et un cas de placenta accreta ont ete observes pour 40 281 accouchements (1,3/1000). L'incidence des hysterectomies (11/13 versus 10/38 ; p p p p = 0,22). Conclusion Une prise en charge conservatrice du placenta accreta pourrait permettre de reduire la morbidite maternelle et de preserver la fertilite.

Cornual ectopic pregnancies are a rare, but very challenging form of ectopic pregnancy to manage. They account for 2–4% of all ectopic pregnancies and the mortality rate remains 6–7 times higher th...

Body temperature responses and the timing of abortions were evaluated in pregnant bitches with the anti-progestin aglepristone. Fifteen purebred and crossbred, 25-45 days pregnant, were included in this study and seven untreated bitches at the same stage of pregnancy served as controls. Treated bitches were administered two applications of aglepristone (10 mg/kg SC) 24 h apart for pregnancy termination. Pregnancy termination was confirmed by ultrasonographic assessment. Body temperature was rectally measured three times a day for 6 days beginning 24 h before treatment or pregnancy diagnosis in the treated and control bitches, respectively. Additionally, serum progesterone concentrations were assessed at time points during the study in the treated bitches. Pregnancy was terminated in 14 treated bitches in a mean+/-S.E.M. of 4.3+/-0.7 days after treatment. Control bitches remained pregnant. In the treated bitches, but not in the controls, body temperature significantly decreased 24 h after the beginning of the treatments (P0.01) and then gradually returned to pre-treatment values. Correlation between the day of mean minimum body temperature and the day of pregnancy termination was low (0.07;0.05). Progesterone did not show significant change throughout the study. Body temperature does not seem to be a suitable variable to clinically monitor the aborting effect of aglepristone. Decrease of body temperature after aglepristone treatment could represent further evidence of its hypothalamic effects.

The objective of the study was to evaluate the efficacy and safety of 800 microg of misoprostol every 12 h, for a period of 36 h for pharmacological abortion. A group of 162 volunteer women with gestations between 50 and 63 days received misoprostol every 12 h up to a maximum of three doses for abortion. Outcome measures assessed included: successful abortion (complete abortion without requiring surgery), side effects, and a decrease in hemoglobin, mean time of vaginal bleeding, mean expulsion time and mean time of returning of menses. Complete abortion occurred in 148 of 162 (91%, 95% confidence interval 87.95) patients. The mean decrease in hemoglobin was statistically significant (p = 0.001). Vaginal bleeding lasted 8.0 +/- 3.2 days, spotting 8.0 +/- 3.5 days, and total bleeding 16 +/- 4.0 days. The mean expulsion time was 8.5 +/- 4.0 h. According to the observed outcomes, 800 microg of misoprostol vaginally could be a valid method to terminate pregnancies up to 9 weeks of gestation.

The subject of misoprostol in the field of reproductive health care has courted much controversy. The aim of this review is to survey the literature published in this field over the past year, and to evaluate developments in this area. This article will cover termination of pregnancy, induction of labor and the issue of postpartum hemorrhage.The use of misoprostol as a single agent remains of clinical value when mifepristone is unavailable. The sublingual and rectal routes are alternative modes of administration. For induction of labor, the optimum dose and route of misoprostol is still undetermined. Lower doses of between 20 microg to 40 microg may increase the safety profile for labor induction. Misoprostol may be a useful adjunct to the therapeutic options available for the prevention and treatment of postpartum hemorrhage.There are many potential uses for misoprostol in pregnancy. However clinicians must judge the evidence and the emotive debate surrounding this field and decide how it will influence their clinical practice depending on the priorities of their own clinical circumstances.

We describe two cases with persistent ascites after ovarian hyperstimulation syndrome (OHSS). Mifepristone (RU 486), an anti-progestin was administered to terminate pregnancy in both cases. To our knowledge, this is the first such report and we discuss the implications.

Fragestellung: Diese prospektive Studie erfasst die Wirksamkeit und somatische Verträglichkeit der medikamentösen Abruptio mit Mifepriston und Misoprostol sowie das Erleben der verschiedenen Phasen des Abbruchs. Des weiteren wurde der subjektive Einfluss der Beratung und Begleitung auf das Erleben und die psychischen Auswirkungen des Abbruchs geprüft. Methode: Alle somatischen Daten der Patientinnen, die vom 1. Dezember 1999 bis 31. Oktober 2000 eine medikamentöse Abruptio erhielten, wurden durch Krankenakten erfasst. Das Erleben der Abruptio wurde mittels eines Fragebogens unmittelbar danach und eines strukturierten telefonischen Interviews 6 Monate später erfragt. Ergebnisse: Die medikamentöse Abruptio mit Mifepriston und Misoprostol was bei 95,2% der Patientinnen erfolgreich. Die Beratung bewerteten 90,4% als sehr gut bzw. gut, die Begleitung 73,7% der betroffenen Frauen als gut. Psychisches Wohlbefinden wurde von 95,5% der Frauen 6 Monate danach angegeben. Schlussfolgerungen: Eine medikamentöse Abruptio mit Mifepriston und Misoprostol war bei 95,2% der Patientinnen erfolgreich. Das von uns entwickelte Betreuungskonzept wurde von den betroffenen Frauen insgesamt sehr positiv bewertet.

Placenta percreta is a rare obstetric condition associated with life-threatening hemorrhage. MR imaging has a role in prenatal diagnosis of these cases. However, its role in the postnatal diagnosis and in the follow up yet to be established.A 33-year-old patient has adherent placenta following spontaneous delivery at 37 weeks gestation. MR imaging diagnosed placenta percreta. Intramuscular methotrexate treatment was initiated with follow up with serial beta-human chorionic gonadotrophin (beta-hCG). In spite of dropping of the level of beta-hCG, the trophoblastic tissue was still present 6 weeks postnatally where the patient complained of vaginal bleeding where she opted to abdominal hysterectomy.Patients who are suitable for non-surgical therapy, T2-weighted MR imaging may, in conjunction with serial beta-hCG assays, provide an alternative treatment modality for cases of placenta percreta.

Mifepristone (RU-486) has recently been granted approval from the Food and Drug Administration for the early termination of pregnancy. Availability is anticipated during 1997. This article describes the pharmacologic function of mifepristone and discusses its potential clinical use in the United States, including its safety, efficacy, and possible complications.The US Food and Drug Administration's recent approval of medical abortion involving use of RU-486, in combination with misoprostol, will provide US women with a new option that offers more privacy and greater accessibility than surgical abortion. When introduced before 8 weeks of gestation, RU-486 acts as a progesterone antagonist, competitively binding with the progesterone receptor and blocking the effect of natural progesterone. Although RU-486 alone is only 64-85% successful in expelling a pregnancy, addition of a prostaglandin analogue increases this rate to 95-99%. Potential complications of medical abortion include incomplete abortion and vaginal bleeding. The cost of an RU-486-induced abortion is expected to be comparable to that of surgical abortion (US $300). The choice of surgical versus medical abortion should be based on consideration of factors such as gestational age, the greater time and clinic visits required for RU-486 abortion, whether women prefer an active or passive role in the termination, and women's comfort level with exposure to the products of conception. Medical abortion should be denied to those with ongoing miscarriage, ectopic pregnancy, allergy to prostaglandins, cardiac conditions, heavy smoking, and age over 35 years. In 1992, the American College of Nurse-Midwives rescinded its ban on nurse-midwives performing pregnancy terminations, an important step given the shortage of abortion providers in the US. Surveys conducted among both nurse-midwives and physicians have revealed a greater willingness to provide medical than surgical abortions.

Medical abortion with mifepristone and misoprostol is a two-step process where some women will change their minds about going through the abortion process after taking mifepristone. Of these, some pregnancies will continue. A woman with a twin pregnancy who changed her mind is presented. Twin pregnancies may need higher dosages of mifepristone than single pregnancies due to the presence of two corpora lutea and increased amount of trophoblast tissue. There is little, if any, documentation regarding congenital abnormalities after taking mifepristone. Therefore, there is little evidence to support persuasion of the patient to continue the abortion process with the prostaglandin analouge.