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Objective: To assess the safety and acceptability of abortion through telemedicine at >9 +0  weeks of gestation., Design: Cohort study., Setting: Poland., Population: Six hundred and fifteen women who requested and underwent a abortion through telemedicine from 1 June to 31 December 2016., Methods: Risks of adverse outcomes were calculated as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) by unconditional logistic regression according to gestational age at abortion: ≤9 or >9 weeks of gestation., Main Outcome Measures: Self-reported clinical visits for complaints related to the abortion within 0-1 days of the treatment, heavy bleeding, pain or bleeding more than expected, and low satisfaction., Results: Among women undergoing a abortion at ≤9 or >9 weeks of gestation, 3.3 versus 11.7% went to hospital with concerns within 0-1 days of the termination (aOR 3.82, 95% CI 1.90-7.69). Among women undergoing a abortion from 11 +1 to 14 +2  weeks of gestation, the rate was 22.5% (aOR 9.20, 95% CI 3.58-23.60). Among women undergoing a abortion at ≤9 or >9 weeks of gestation, the rate of heavy bleeding was 6.8 versus 10.1% (aOR 1.65, 95% CI 0.90-3.04), the rate of low satisfaction was 2.4 versus 1.6% (aOR 0.69, 95% CI 0.14-3.36), the rate of bleeding more than expected was 45.6 versus 57.8% (aOR 1.26, 95% CI 0.78-2.02), and the rate of pain more than expected was 35.6 versus 38.8% (aOR 1.11, 95% CI 0.71-1.71)., Conclusions: Medical abortion through telemedicine at >9 weeks of gestation is associated with a higher risk of same-day or day-after clinical visits for concerns related to the procedure, and this risk increases with gestational age. Self-reported rates of heavy bleeding, low satisfaction, or unmet expectations with medical abortion do not increase with gestational age., Tweetable Abstract: A cohort study shows that abortion through telemedicine at >9 weeks of gestation is associated with more hospital visits but not with increased bleeding., (© 2018 Royal College of Obstetricians and Gynaecologists.)

Objective: To describe the efficacy, safety, and acceptability of medical abortion in the late first trimester., Study Design: We searched PubMed and Cochrane databases for articles in any language that examined the success of medical abortion at gestational ages (>63 to≤84 days gestation). We sought articles that compared: medical abortion with surgical abortion at this gestational age, combination mifepristone and misoprostol and/or misoprostol alone); different dosages of misoprostol; different routes of misoprostol administration; frequency of dosing; and location of medical abortion (in health care facility vs. outpatient management). Our primary outcome was complete abortion. Data was independently abstracted by two authors, graded for evidence quality, and assessed for risk of bias., Results: The search strategy returned 3384 articles, nine of which met inclusion criteria. Medical abortion, as compared with surgical abortion, was effective in the late first trimester (94.6% versus 97.9% complete abortion). A combined regimen of mifepristone and misoprostol was significantly more effective than misoprostol alone (90.4 versus 81.6% complete abortion). Complete abortion rates for all regimens investigated ranged from 78.6% to 94.6%. Success rates were higher with repeat dosing of misoprostol both in combination regimens and alone, and with vaginal compared with oral administration for repeat dosing., Conclusion: A limited body of evidence indicates a range of efficacy of medical abortion in the late first trimester and highlights the need for well-designed trials in this gestational age range., Implications: This review highlights the need for research focused on the late first trimester to strengthen the body of evidence. The available evidence is limited but offers reassurance that adverse events are rare for later first trimester abortion. Importantly, new research demonstrates that efficacy remains unchanged in the 10th gestational week regardless of whether the medication is taken in a facility or at a woman's home., (Copyright © 2018 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: For early miscarriage (pregnancy loss ≤ 12 weeks of gestation), two types of therapeutic treatment are offered (pharmacotherapy and curettage of the uterine cavity) depending on the presence and severity of clinical symptoms as well as patient choice. Our study aimed to assess the diagnostic value of the results of histopathological examinations of miscarriage products in relation to the administered treatments., Material and Methods: 850 medical records from patients diagnosed with missed miscarriage or empty gestational sac were analyzed retrospectively. Patients underwent surgical treatment or pharmacotherapy. Inefficacy of pharmacotherapy resulted in subsequent curettage. The results of histopathology were evaluated for their diagnostic value and classified: subgroup 1 - high value specimen (the studied specimen included fetal tissues, and villi), and subgroup 2 - no-diagnosis (the studied specimen included maternal tissues, autolyzed tissues, blood clots). Data were compared with chi-squared test. Differences was considered significant at p < 0.05., Results: 1128 histopathological test results were analyzed; 569 (50.4%) were obtained during pharmacotherapy and 559 (49.6%) after curettage; out of the latter 497 after the initial pharmacotherapy and 62 after surgery. In the pharmacotherapy group, high value specimens comprised 231 cases (40.59%) while no diagnosis was obtained in 338 cases (59.4%). Considering specimens obtained in the course curettage, high value specimens were found in 364 cases (65.1%) while results that did not allow a diagnosis to be made were found in 195 cases (34.9%)., Conclusions: Tissue specimens of high diagnostic value are obtained significantly more often during surgical treatment of miscarriage than during pharmacotherapy.

Objective: The decision to undergo a surgical or medical method of second-trimester termination for pregnancy complications should be preference-sensitive. Decision satisfaction has not been described in this population; understanding how women describe decision satisfaction in this setting could inform decision support efforts., Methods: We conducted qualitative interviews with women one to three weeks after termination who chose either a surgical or medical termination for fetal anomalies, pregnancy complications or fetal demise. We analyzed transcripts using modified grounded theory in an iterative manner with a generative thematic approach., Results: We interviewed 36 women (24 surgical and 12 medical). Subjects connected decision satisfaction with counseling experiences and their personal values, including (1) importance of adequate information, (2) autonomous decision making, and (3) choosing the method that facilitates coping., Conclusion: Offering women a choice between surgical and medical termination procedures in the setting of pregnancy complications is integral to decision satisfaction. Women in our study reported wanting this decision to be driven by their personal values., Practice Implications: Women should be able to choose between surgical and medical termination based on preference and not availability of services. Decision support from women's health providers should be based on values clarification and providing accurate information., (Copyright © 2018. Published by Elsevier B.V.)

Aim: The aim of the present study was to investigate the safety and efficacy of low-dose mifepristone combined with self-administered misoprostol for termination of early pregnancy., Methods: A total of 533 women seeking medical abortion in early pregnancy (≤49 days since the last menstrual period) were divided randomly into hospital- (H-Mis, 250) and self- (S-Mis, 283) administered misoprostol groups. Women in two groups took 100 mg of oral mifepristone in hospital followed by 200 μg of sublingual misoprostol 24 h later in hospital or home. The primary outcome parameter was complete abortion without surgical intervention. Secondary outcomes were uterine bleeding, return of regular menses, side effects and patient acceptability., Results: High rates of complete abortion were observed for both the H-Mis group (243/250; 94.8%) and the S-Mis group (266/283; 94.0%). No significant differences in outcomes (complete abortion/failure rates) or side effects were observed between the two groups. General satisfaction rates were similar for the two groups (H-Mis, 231/250, 92.4%; S-Mis, 263/283, 92.9%; P > 0.05). Higher convenience of administration (H-Mis, 211/250, 84.4%; S-Mis, 270/283, 95.4%; P < 0.05) and privacy protection (H-Mis, 214/250, 85.6%; S-Mis, 267/283, 94.3%; P < 0.05) satisfaction rates were obtained for the S-Mis group than for the H-Mis group., Conclusion: Self-administered sublingual misoprostol is as safe and effective as hospital-administered misoprostol following low-dose mifepristone to terminate early pregnancy (≤49 days of amenorrhoea) with fewer side effects., (© 2018 The Authors. Journal of Obstetrics and Gynaecology Research published by John Wiley & Sons Australia, Ltd on behalf of Japan Society of Obstetrics and Gynecology.)

Background: In South Africa, access to second-trimester abortion services, which are generally performed using medical induction with misoprostol alone, is challenging for many women. We aimed to estimate the costs and cost effectiveness of providing three safe second-trimester abortion services (dilation and evacuation (D&E)), medical induction with mifepristone and misoprostol (MI-combined), or medical induction with misoprostol alone (MI-misoprostol)) in Western Cape Province, South Africa to aid policymakers with planning for service provision in South Africa and similar settings., Methods: We derived clinical outcomes data for this economic evaluation from two previously conducted clinical studies. In 2013-2014, we collected cost data from three public hospitals where the studies took place. We collected cost data from the health service perspective through micro-costing activities, including discussions with site staff. We used decision tree analysis to estimate average costs per patient interaction (e.g. first visit, procedure visit, etc.), the total average cost per procedure, and cost-effectiveness in terms of the cost per complete abortion. We discounted equipment costs at 3%, and present the results in 2015 US dollars., Results: D&E services were the least costly and the most cost-effective at $91.17 per complete abortion. MI-combined was also less costly and more cost-effective (at $298.03 per complete abortion) than MI-misoprostol (at $375.31 per complete abortion), in part due to a shortened inpatient stay. However, an overlap in the plausible cost ranges for the two medical procedures suggests that the two may have equivalent costs in some circumstances., Conclusion: D&E was most cost-effective in this analysis. However, due to resistance from health care providers and other barriers, these services are not widely available and scale-up is challenging. Given South Africa's reliance on medical induction, switching to the combined regimen could result in greater access to second-trimester services due to shorter inpatient stays without increasing costs., Competing Interests: The authors have declared that no competing interests exist.

Importance: Multiple states have laws requiring abortion facilities to meet ambulatory surgery center (ASC) standards. There is limited evidence regarding abortion-related morbidities and adverse events following abortions performed at ASCs vs office-based settings., Objective: To compare abortion-related morbidities and adverse events at ASCs vs office-based settings., Design, Setting, and Participants: Retrospective cohort study of women with US private health insurance who underwent induced abortions in an ASC or office-based setting (January 1, 2011-December 31, 2014). Outcomes were abstracted from a large national private insurance claims database during the 6 weeks following the abortion (date of final follow-up, February 11, 2015)., Exposures: Facility type for abortion (ASCs vs office-based settings, including facilities such as abortion clinics, nonspecialized clinics, and physician offices)., Main Outcomes and Measures: The primary outcome was any abortion-related morbidity or adverse event (such as retained products of conception, abortion-related infection, hemorrhage, and uterine perforation) within 6 weeks after an abortion. Two secondary outcomes, both subsets of the primary outcome, were major abortion-related morbidities and adverse events (such as hemorrhages treated with a transfusion, missed ectopic pregnancies treated with surgery, and abortion-related infections that resulted in an overnight hospital admission) and abortion-related infections., Results: Among 49 287 women (mean age, 28 years [SD, 7.3]) who had 50 311 induced abortions, (23 891 [47%] first-trimester aspiration, 13 480 [27%] first-trimester medication, and 12 940 [26%] second trimester or later), 5660 abortions (11%) were performed in ASCs and 44 651 (89%) in office-based settings. Overall, 3.33% had an abortion-related morbidity or adverse event; 0.32% had a major abortion-related morbidity or adverse event; and 0.74% had an abortion-related infection. In adjusted analyses, there was no statistically significant difference between ASCs vs office-based settings, respectively, in the rates of abortion-related morbidities or adverse events (3.25% vs 3.33%, difference, -0.08%; [corrected] 95% CI, -0.58% to 0.43%; adjusted OR, 0.97; 95% CI, 0.81-1.17), major morbidities or adverse events (0.26% vs 0.33%; difference, -0.06%; 95% CI, -0.18% to 0.06%; adjusted OR, 0.78; 95% CI, 0.45-1.37), or infections (0.58% vs 0.77%; difference, -0.16%; 95% CI, -0.35% to 0.03%; adjusted OR, 0.75; 95% CI, 0.52-1.09)., Conclusions and Relevance: Among women with private health insurance who had an induced abortion, performance of the abortion in an ambulatory surgical center compared with an office-based setting was not associated with a significant difference in abortion-related morbidities and adverse events. These findings, in addition to individual patient and individual facility factors, may inform decisions about the type of facility in which induced abortions are performed.

Objective: There is insufficient evidence on the continuation, safety and acceptability of immediate insertion of the intrauterine device (IUD) after medical abortion. The objective of the present study was to evaluate clinical outcomes of early IUD insertion, compared with those of delayed IUD insertion, following medical abortion., Methods: Women undergoing medical abortion with mifepristone and misoprostol up to 49 days' gestation and opting for Copper T 380A IUD contraception underwent early (5-14 days after mifepristone) or delayed insertion (3-4 weeks after mifepristone). The primary outcome measure was 6 month IUD continuation rate after medical abortion. Secondary outcome measures included user acceptability and safety., Results: Between October 2015 and October 2016, post-medical abortion IUD insertion was performed in 120 eligible women fulfilling the inclusion and exclusion criteria. There was no statistically significant difference in the continuation rates of the early and delayed IUD insertion groups at 6 months (76.7 versus 83.3%, p = .75). The 6 month IUD expulsion rates were 6.7 and 3.3% in the early and delayed insertion groups, respectively (p = .56). There were 10 (16.7%) removals in the early and eight (13.3%) in the delayed insertion groups (p = .77). Level of satisfaction with postabortal IUD use was comparable in both groups. Adverse events were rare and did not differ significantly between the two groups., Conclusion: We demonstrated high continuation rates, safety and acceptability of early IUD insertion after medical abortion.

Objective: To evaluate outcomes with simultaneous administration of mifepristone and misoprostol for medical abortion at 63 days of gestation or less in the year after its implementation in a British clinic system., Methods: We conducted a retrospective cohort study using deidentified data from the electronic booking and complications databases and medical records of women who underwent medical abortion at British Pregnancy Advisory Service. Our primary outcome was treatment success with simultaneous dosing compared with a regimen with a 24- to 48-hour interval between medications. We defined success as complete abortion without surgical evacuation and without continuing pregnancy. To assess relative regimen effectiveness while accounting for self-assignment to simultaneous or interval dosing, we modeled the probability of treatment success using logistic regression with propensity score adjustment for demographic and clinical characteristics. Secondary outcomes were reasons for abortion failure and clinically significant adverse events (hospital admission, blood transfusion, intravenous antibiotic administration)., Results: Of 28,901 women treated between May 2015 and April 2016, 85% chose simultaneous dosing. Overall success rates were high with both regimens but lower with simultaneous than with interval dosing (94.5% vs 97.1%, respectively, adjusted relative risk 0.973, 95% CI 0.967-0.979). For both regimens, success rates were lower at higher gestational ages, but the relative effectiveness of simultaneous dosing did not vary significantly with gestational age (P=.268). Surgical intervention rates for continuing pregnancy were lowest at 49 days of gestation or less (1.4% simultaneous vs 0.2% interval, P<.001) and highest at 57-63 days of gestation (5.0% and 2.2%, P<.001). The rate of clinically significant adverse events was 0.2% and did not differ by regimen (P=.972)., Conclusion: Simultaneous administration of mifepristone and misoprostol is 97% as effective as a 24- to 48-hour interval at all gestational ages 63 days or less with no increase in the risk of clinically significant adverse events. Pragmatic use of simultaneous dosing is reasonable given the small difference in effectiveness.

Introduction: The consequences of unsafe abortion are devastating to women, their families, and their communities. Medication abortion presents an important alternative to harmful self-induction practices and surgical intervention under questionable circumstances. In settings where mifepristone is unavailable, the use of misoprostol alone is a safe and effective option for terminating an unwanted pregnancy. Studies have demonstrated the safety and efficacy of administration of misoprostol by community health workers (CHW) for indications such as postpartum hemorrhage and treatment of incomplete abortion., Objectives: The current study assesses the safety and efficacy of CHW managing misoprostol-only abortion in the first trimester., Methods: A retrospective review of clinical files of women who received abortion services in three countries in Latin America between April 2009 and December 2015 included analysis of 173 cases., Results: In 94% of cases, the pregnancy was terminated without any further intervention. In the remaining cases, clients were referred for manual vacuum aspiration. In four cases, a complication was reported by the provider. In one, the complication was promptly resolved through referral to a higher level of care; in the remaining three, the complication was resolved directly by the provider. In 98% of cases, women reported being satisfied with the treatment they received., Conclusion: This study demonstrates that CHW are able to provide misoprostol-only abortion services to women effectively and safely. The benefits of this model of care also extend beyond the abortion service: CHW are able to offer women a comprehensive range of quality health services, including contraceptive services, increasing access to vital healthcare in areas with few other options.

We undertook a systematic review to assess 1) the level and quality of pharmacy and drug shop provision of medical abortion (MA) in low- and middle-income countries (LMICs) and 2) interventions to improve quality of provision. We used standardized terms to search six databases for peer-reviewed and grey literature. We double-extracted data using a standardized template, and double-graded studies for methodological quality. We identified 22 studies from 16 countries reporting on level and quality of MA provision through pharmacies and drug sellers, and three intervention studies. Despite widespread awareness and provision of MA drugs, even in legally restricted contexts, most studies found that pharmacy workers and drug sellers had poor knowledge of effective regimens. Evidence on interventions to improve pharmacy and drug shop provision of MA was limited and generally low quality, but indicated that training could be effective in improving knowledge. Programmatic attention should focus on the development and rigorous evaluation of innovative interventions to improve women's access to information about MA self-management in low-and middle-income countries., (© 2018 The Population Council, Inc.)

Ectopic pregnancies account for 1.5% to 2% of all pregnancy in the United States. Of these, approximately 10% implant in nontubal locations, including the abdominal cavity, cervix, ovary, interstitial portion of the fallopian tube, broad ligament, the uterine cornua, or within a cesarean section scar. Because these pregnancies tend to present later than typical tubal pregnancies, they have been associated with greater maternal morbidity and mortality. Advances in ultrasound technology have allowed for earlier diagnosis of nontubal ectopic pregnancies, which in turn has led to the development of novel minimally invasive techniques to manage them. One of these methods involves the local injection of 1 of several agents directly into the ectopic pregnancy. In this article we provide a guide to this technique of local injection, including an overview of the potential agents that can be used, and review the diagnostic and specific ultrasound criteria, other possible treatment options, and overall outcomes for nontubal ectopic pregnancies., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Objective: To measure the prevalence of believing that abortion should be illegal in all or most cases among women obtaining an abortion in the United States and to identify correlates of holding this belief., Methods: Study population was drawn from the nationally-representative 2008 Abortion Patient Survey. The primary outcome was having an anti-legal abortion attitude, defined as agreeing that abortion should be illegal in all or most cases. We assessed potential correlates in bivariable and multivariable analyses using weights to account for the complex sampling., Results: A total of 4769 abortion patients completed the survey module containing the question on abortion legality, of which 4492 (94.2%) had non-missing data for the outcome. Overall, 4.1% of patients (N=183) reported an anti-legal abortion attitude. Correlates of having anti-legal attitude included being married, at <200% federal poverty level, fundamentalist, contraception non-use, no abortion history, perceiving the pregnancy with ambivalence or as unintended, and using misoprostol or another product on their own to bring back their period or end the pregnancy., Conclusions: Abortion patients who do not believe abortion should be legal appear to differ substantially from women who are more supportive of legality. Findings raise important questions about this subset of patients, including whether possible discordance between patient beliefs and behavior could influence their use of medical abortion or other products., Implications: Some abortion patients do not agree with abortion legality, and this subset could experience a degree of cognitive dissonance, which could influence the method by which they seek to abort., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The aim of this study was to investigate the efficacy, safety, and acceptability of low-dose mifepristone combined with self-administered misoprostol for ultra-early medical abortion. A total of 744 women with ultra-early pregnancy (amenorrhea ≤35 days) who fulfilled the inclusion criteria were enrolled in the study. Equal numbers of participants were allocated randomly to the hospital administration and self-administration groups. All participants took 75 mg mifepristone at the initial visit and 400 µg oral misoprostol 24 hours later in the hospital or by self-administration. The primary end point was complete abortion. Secondary end points were rates of unscheduled reattendance, time required for and cost of hospital observation and follow-up, vaginal bleeding, adverse effects, menstrual disturbance in the posttreatment period, and satisfaction rating. No differences in the rates of complete abortion, unscheduled reattendance, vaginal bleeding, adverse effects, or return of posttreatment menstruation were observed. The time required for (and costs of) hospital observation and follow-up per participant was 557.82 minutes (and US$40.12) in the hospital administration group and 18.46 minutes (and US$1.96) in the self-administration group (both P < .001). Satisfaction rates were similar in both groups, but the rates of "very satisfied" responses (87.60% vs 25.41%) and follow-up compliance (loss to follow-up, 0.45% vs 7.70%) were higher in the self-administration group (both P < .001). Low-dose mifepristone combined with self-administered misoprostol for ultra-early pregnancy termination was as effective and safe as hospital administration, with greater acceptability and lower cost to the women.

Objectives: The aim of the study was to assess the efficacy and acceptability of a regimen using mifepristone and buccal misoprostol with unlimited dosing for second trimester abortion in Armenia., Methods: Women seeking to terminate 13-22 week pregnancies were enrolled in the study. Participants swallowed 200 mg mifepristone in the clinic and were instructed to return to the hospital for induction 24-48 h later. During induction, women were given 400 μg buccal misoprostol every 3 h until the fetus and placenta were expelled. The abortion was considered a success if complete uterine evacuation was achieved without oxytocin or surgery., Results: A total of 120 women with a median gestational age of 18 weeks participated in the study. All women began misoprostol induction around 24 h after taking mifepristone. Complete uterine evacuation was achieved in 119 (99.2%) women. The median induction-to-abortion interval was 10.3 h (range 4-17.4) with a mean of 9.5 ± 2.5 h. A median of four misoprostol doses (range 2-6) with a mean of 4 ± 1 misoprostol doses were administered. The induction-to-abortion interval, number of misoprostol doses, pain score and analgesia use increased as gestational age advanced. Acceptability of the method was high among both patients and providers., Conclusion: The medical abortion regimen of 200 mg mifepristone followed 24 h later by induction with 400 μg buccal misoprostol administered every 3 h, with no limit on the number of doses used for the termination of pregnancies of 13-22 weeks' gestation is an effective and acceptable option for women.

Objective: To compare the physical and emotional effects of two medical protocols for induced abortion during the second trimester., Methods: The present study was part of a prospective randomized controlled trial comparing mifepristone followed by oxytocin or misoprostol that was conducted at the Hadassah Hebrew University Medical Center, Jerusalem, Israel, from January 10, 2009, to February 22, 2012. Inclusion criteria were pregnancy (14-24weeks), epidural analgesia, and medical induction of abortion (either elective or following missed abortion). A structured questionnaire was used to assess the participants' physical symptoms and emotional responses. The primary outcome for the present analysis was the degree of physical symptoms reported., Results: Overall, 68 women in the oxytocin group and 67 in the misoprostol group received epidural analgesia and completed the questionnaire. As assessed using a five-point Likert scale, women in the misoprostol group were more likely than those in the oxytocin group to experience diarrhea (1.34±0.84 vs 1.10±0.55; P=0.05) and shivers (3.03±1.75 vs 1.75±1.21; P<0.001). No other between-group differences were detected for the physical or emotional variables evaluated., Conclusion: Differences in physical symptoms experienced by the two treatment groups did not influence the participants' subsequent emotional response. ClinicalTrials.gov: NCT00784797., (Copyright © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Objective: 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., Methods: 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., Results: 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., Conclusion: 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., Clinical Trial Registration: ClinicalTrials.gov, https://clinicaltrials.gov, NCT01768299.

Women with fibroid uteri seeking surgical abortion often represent a unique challenge. When the uterine cavity is significantly enlarged or distorted making surgical evacuation difficult or impossible, we offer medical abortion using mifepristone followed by misoprostol beyond the standard 63- to 70-day gestational age cutoff that is typically recommended. This case series describes our regimen and outcomes for 6 patients from 10 to 13 weeks gestation underdoing outpatient medical abortion and 6 patients from 14 to 20 weeks gestation undergoing inpatient medical abortion. Three patients required evacuation for retained products and all others had successful medical abortions without complications., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To analyze the success rate, time to passage of tissue and subjective patient experience of a newly implemented protocol for medical management of early pregnancy failure (EPF) over a 2-year period., Methods: A retrospective chart review of all patients with early pregnancy failure primarily opting for medical management was performed. 200 mg mifepristone were administered orally, followed by a single vaginal dose of 800 mcg misoprostol after 36-48 h. We followed-up with our patients using a written questionnaire., Results: 167 women were included in the present study. We observed an overall success rate of 92 %, defined as no need for surgical management after medication administration. We could not identify predictive values for success in a multivariate regression analysis. Most patients (84 %) passed tissue within 6 h after misoprostol administration. The protocol was well tolerated with a low incidence of side effects. Pain was managed well with sufficient analgesics. Responders to the questionnaire felt adequately informed prior to treatment and rated their overall experience as positive., Conclusion: The adaption of the institutional medical protocol resulted in a marked improvement of success rate when compared to the previously used protocol (92 vs. 61 %). We credit this increase to the adjusted medication schema as well as to targeted physician education on the expected course and interpretation of outcome measures. Our results underscore that the medical management of EPF is a safe and effective alternative to surgical evacuation in the clinical setting., Competing Interests: The authors declare that they have no conflicts of interest. Funding The study did not have external funding. Ethics/informed consent The study was approved by the Ethics Committee of the Medical University of Innsbruck. All individual participants included in the study gave their informed consent for the prospective portion of the study. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Objective: To document clinical outcomes and women's experiences following the introduction of mifepristone into South African public sector second-trimester medical abortion services, and compare with historic cohorts receiving misoprostol-only., Methods: Repeated cross-sectional observational studies documented service delivery and experiences of women undergoing second-trimester medical abortion in public sector hospitals in the Western Cape, South Africa. Women recruited to the study in 2008 (n = 84) and 2010 (n = 58) received misoprostol only. Those recruited in 2014 (n = 208) received mifepristone and misoprostol. Consenting women were interviewed during hospitalization by study fieldworkers with respect to socio-demographic information, reproductive history, and their experiences with the abortion. Clinical details were extracted from medical charts following discharge. Telephone follow-up interviews to record delayed complications were conducted 2-4 weeks after discharge for the 2014 cohort., Results: The 2014 cohort received 200 mg mifepristone, which was self-administered 24-48 hours prior to admission. For all cohorts, following hospital admission, initial misoprostol doses were generally administered vaginally: 800 mcg in the 2014 cohort and 600 mcg in the earlier cohorts. Women received subsequent doses of misoprostol 400 mcg orally every 3-4 hours until fetal expulsion. Thereafter, uterine evacuation of placental tissue was performed as needed. With one exception, all women in all cohorts expelled the fetus. Median time-to-fetal expulsion was reduced to 8.0 hours from 14.5 hours (p<0.001) in the mifepristone compared to the 2010 misoprostol-only cohort (time of fetal expulsion was not recorded in 2008). Uterine evacuation of placental tissue using curettage or vacuum aspiration was more often performed (76% vs. 58%, p<0.001) for those receiving mifepristone; major complication rates were unchanged. Hospitalization duration and extreme pain levels were reduced (p<0.001), but side effects of medication were similar or more common for the mifepristone cohort. Overall satisfaction remained unchanged (95% vs. 91%), while other acceptability measures were higher (p<0.001) for the mifepristone compared to the misoprostol-only cohorts., Conclusion: The introduction of a combined mifepristone-misoprostol regimen into public sector second-trimester medical abortion services in South Africa has been successful with shorter time-to-abortion events, less extreme pain and greater acceptability for women. High rates of uterine evacuation for placental tissue need to be addressed., Competing Interests: The authors have declared that no competing interests exist.

Objective: To compare patients' satisfaction with medical and surgical abortion, implementing the Italian guidelines on medical abortion entailing an "in patient" procedure., Methods: A total of 1832 pregnant chose between surgical (vacuum aspiration) or medical abortion (mifepristone p.o. followed after 3 days by sublingual misoprostol) and expressed their expected satisfaction on a visual analog scale (VAS). A total of 885 women chose surgical and 947 medical abortion. The primary end-point was satisfaction VAS score 20 days after the procedure. Secondary end-points were: difference between pre- and post-abortion VAS score; difference in satisfaction VAS scores according to parity and previous abortion; incidence of side effects., Results: VAS score was high in each group but significantly higher for the 1-day surgical than for the 3-day medical abortion procedure (7.9 ± 1.0 versus 7.2 ± 1.2; p < 0.0001). In the surgical group the VAS score increased after the treatment (6.9 ± 1.6 versus 7.9 ± 1.0, p < 0.0001), while it decreased in the medical group (7.5 ± 1.0 versus 7.2 ± 1.2; p < 0.0001). Multiparous women reported higher satisfaction with medical abortion; women with a previous abortion preferred surgical abortion., Conclusions: Both procedures are considered satisfactory by the patients. Performing medical abortion as a 3-day "in patient" procedure, decreased women's satisfaction scores from their baseline expectations.

Objectives: To propose a protocol for induction of labor to terminate pregnancy after 22weeks of amenorrhea allowing to decrease the duration of labor and of hospitalization but also, allowing to reduce the number of emergency pretreatment-induced fetal death, to improve the experience of the patients and to limit the cost., Methods: We realized a retrospective single-center study including 269patients and comparing three protocols, with and without laminaria and with various intervals mifepristone-misoprostol (14 and 38hours). The outcome measures were the misoprostol-delivery interval, the delivery time and the number of emergency pretreatment-induced fetal death., Results: We showed that the misoprostol-delivery interval and the delivery time were comparable for the three periods of our study, even after decrease of 24hours of the mifepristone-misoprostol interval and in the absence of laminaria. The misoprostol-delivery interval was between 7h30 and 8h35 between protocols (P=0.055). The delivery time was between 5:18pm and 6:48pm between protocols (P=0.252). The early administration of misoprostol allowed the patients to give birth earlier (P=0.001). Finally, we showed that the increase of the size and the number of laminarias were risk factors of emergency pretreatment-induced fetal death (respectively P=0.013 and P=0.002)., Conclusion: The absence of laminaria and the reduction of the interval mifepristone-misoprostol of 24hours do not change the time to delivery and allow to reduce the duration of hospitalization, the number of emergency pretreatment-induced fetal death and the cost of the TOP., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

In summer 2015, the Iowa Supreme Court unanimously struck down a restriction that would have prevented physicians from administering a medication abortion remotely through video teleconferencing. In its ruling, the Iowa Supreme Court stated that the restriction would have placed an undue burden on a woman's right to access abortion services. It is crucially important for clinicians--especially primary care clinicians, obstetrician-gynecologists (ob-gyns), and all health care providers of telemedicine services--to understand the implications of this recent ruling, especially in rural settings. The Court's decision has potential ramifications across the country, for both women's access to abortion and the field of telemedicine. Today telemedicine abortion is available only in Iowa and Minnesota; 18 states have adopted bans on it. If telemedicine abortions are indeed being unconstitutionally restricted as the Iowa Supreme Court determined, court decisions reversing these bans could improve access to abortion services for the 21 million reproductive-age women living in these 18 states, which have a limited supply of ob-gyns, mostly concentrated in urban, metropolitan areas. Beyond the potential effects on abortion access, we argue that the Court's decision also has broader implications for telemedicine, by limiting the role of state boards of medicine regarding the restriction of politically controversial medical services when provided through telemedicine. The interplay between telemedicine policy, abortion politics, and the science of medicine is at the heart of the Court's decision and has meaning beyond Iowa's borders for reproductive-age women across the United States.

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., (© 2015 S. Karger AG, Basel.)

Background: Primary ovarian ectopic pregnancy is a rare type of ectopic pregnancy which has an estimated prevalence ranging from 1:7000 to 1:70,000 accounting for almost 3 % of all ectopic cases. Here we report the case of a 25-year-old woman who presented to our clinic with abdominal pain, 6 weeks' delay of menstruation and 3 days of vaginal bleeding, whose transvaginal ultrasonography showed an ectopic gestational sac with yolk sac inside, in her right ovary. This case shows that early diagnosis is very important particularly in places like the Sub-Saharan region of Africa., Case Presentation: A 25-year-old African woman was referred to our clinic with 6 weeks' delay of menstruation, frequent increasing abdominal pain and 3 days of vaginal bleeding. Her general condition was good and her vital signs were normal. She felt tenderness in an abdominal examination and had a small amount of vaginal bleeding. Transvaginal ultrasonography showed an ectopic gestational sac with yolk sac inside, in her right ovary. Our final diagnosis was ectopic ovarian pregnancy and we successfully treated her with methotrexate. After 3 weeks of methotrexate administration her beta human chorionic gonadotropin was negative and a sonographic examination was completely normal., Conclusions: Ectopic ovarian pregnancy is a very important medical situation. It should be diagnosed in its early stages otherwise it could be life-threatening and surgical treatment may be inevitable. Because of the importance of fertility, medical treatment is an acceptable option and can be feasible with early diagnosis.

Study Question: What is the efficacy of maintaining or restoring non-pregnant status with low-dose mifepristone combined with misoprostol administered before expected menstruation?, Summary Answer: Low-dose mifepristone and misoprostol administered at the time of expected menstruation was effective and safe in maintaining or restoring non-pregnant status, with no obvious menstrual disturbance., What Is Known Already: Menstrual regulation involves the medical or mechanical stimulation of uterine sloughing in women with up to 2-3 weeks of menstrual delay. Low-dose mifepristone plus misoprostol is efficacious for termination of ultra-early pregnancy (≤ 35 days of amenorrhoea) with no obvious menstrual disturbance., Study Design, Size, Duration: A total of 678 women fulfilled all criteria and were recruited. Seventeen women dropped out after deciding to remain pregnant and 11 others were lost to follow-up. Thus, data from 650 women who completed the procedure were included in analyses. Participants were enrolled at any time during their menstrual cycle and administered medication 1 day before expected menstruation. The end of the study was defined on a per-patient basis as the date of completion of the post-treatment menstrual cycle. The primary outcome was the efficacy of abortion induction (for pregnant women) or menstrual regulation (for non-pregnant women)., Participants, Setting, Methods: Women with regular menstrual cycles (25-35 days) were voluntarily recruited for this study between February 2012 and December 2014. Serum β-hCG was measured before mifepristone intake. Mifepristone (50 mg) was administered orally 1 day before expected menstruation and 200 µg misoprostol was administered orally on the day of expected menstruation. Efficacy, disturbance in bleeding patterns in the treatment and post-treatment cycles, satisfaction with the treatment, and subsequent contraception preference were analysed., Main Results and the Role of Chance: Retrospective analysis of serum β-hCG levels at admission indicated that 23.3% (158/678) of the women were pregnant. The success rate for pregnancy termination was 98.6% (136/138). Two women (1.5%, 2/138) had ongoing pregnancy that was subsequently terminated surgically. The overall bleeding induction rate within 7 days was 98.3% (639/650), with 100% (138/138) in pregnant participants and 97.9% (501/512) in non-pregnant participants. Most pregnant and non-pregnant participants experienced no significant menstrual disturbance during the treatment [96.3% (131/136) versus 97.6% (489/501)] or post-treatment [97.8% (133/136) versus 98.4% (493/501)] menstrual cycle. The general rate of satisfaction with the treatment was 96.7% (618/639). Generally, 36.0% (230/639) of participants preferred to use the regimen as a routine contraception method versus the 64.0% (409/639) who preferred to use it as a remedy for pregnancy prevention after unprotected sex (P < 0.001)., Limitations, Reasons for Caution: Study participants were recruited from a single region; further studies should include participants from multiple centres in different cities and nations. Given the uncertain efficacy of regimen reuse, the assessment of efficacy was based solely on the first treatment administration. Studies with larger samples and long-term follow-up may provide more data on whether repeated use of this regimen hampers its efficacy., Wider Implications of the Findings: Menstrual regulation with low-dose mifepristone and misoprostol at expected menstruation can be efficacious and highly acceptable to maintain or restore non-pregnant status, which may have potential for routine contraception., (© The Author 2015. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: To determine the acceptability of taking mifepristone at home for early medical abortion in the United States., Study Design: This prospective, non-randomized, open-label study at six Planned Parenthood centers gave women with pregnancies up to 63 days' gestation seeking medical abortion the choice of taking mifepristone in the center or at home. Participants were interviewed at a follow-up visit 1-2 weeks after mifepristone administration to assess their experience with the option they selected., Results: Four-hundred women were enrolled between April 2013 and June 2014 of which 32% (n=128) chose to take mifepristone at home. Abortion success rates did not differ between home and center users (96% and 97%). Among home users, 82% reported taking the mifepristone at the time they planned with their provider and no participant took it after 63 days' gestation. The most common reason cited for selecting home use was scheduling flexibility and significantly more home users took misoprostol on the weekend (50% vs. 36%, p=.02). Home users were more likely than center users to report missing no days of work due to the abortion (47% vs. 28%, p=.08). Ninety-nine percent of home users reported that they would take mifepristone at home again and 96% would recommend home use to a friend. Offering this option did not increase the service delivery burden on study providers, who would recommend home use in the future for most participants., Conclusions: Home use of mifepristone is a highly acceptable practice for which there is current demand, and it should be offered as part of routine medical abortion services., Implications: Offering the option of home use of mifepristone to medical abortion patients can provide women and clinics with more flexibility while maintaining a safe, effective and acceptable service. These results provide support for telemedicine or pharmacy distribution., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The requirement that every woman desiring medical abortion must come in person to a clinical facility to obtain the drugs is a substantial barrier for many women. To eliminate this requirement in the United States, two key components of the standard initial visit would need to be restructured. First, alternatives to ultrasound and pelvic exam would need to be identified for ensuring that gestational age is within the limit for safe and effective treatment. This is probably feasible: for example, data from a large study suggest that in selected patients menstrual history is highly sensitive for this purpose. Second, the Food and Drug Administration would need to remove the medically unwarranted restriction on distribution of mifepristone. These two changes could allow provision of the service by a broader range of providers in nontraditional venues or even by telemedicine. Such options could have profound benefits in reducing cost and expanding access to abortion., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Data show that an outpatient regimen of 200-mg mifepristone followed by a single dose of misoprostol is safe and effective for medical abortion for up to 70 days from last menstrual period (LMP). Yet, many clinics only provide services up to 63 days LMP, and some practice guidelines do not recommend the higher gestational age limit. We review the studies published to date that include women 64 to 70 days LMP and conclude that outpatient medical abortion is safe and effective in this interval and that there are no clinically meaningful differences between outcomes at 57 to 63 days LMP and 64 to 70 days LMP. Updating clinical protocols and revising the Food and Drug administration label for Mifeprex® to change the indication for termination of pregnancies through 70 days LMP will give women more choices and expand access to safe abortion services., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Given the highly political nature of abortion in the United States, the provision of medical abortion with mifepristone (Mifeprex®) and misoprostol has always occurred under a unique set of circumstances. The Food and Drug Administration-approved regimen requires clinicians to administer the mifepristone in the office and also requires women to return to the office for the misoprostol. In the US, where off-label drug use is an accepted practice when supportive evidence exists, most clinicians give women the misoprostol at the initial visit for her to take at home, eliminating an unnecessary visit to the office. This commentary suggests that, based on current studies, there is also enough evidence to offer women the option to self-administer mifepristone out of the office and that this is just another feature of off-label use. Six studies, enrolling over 1800 women, found that the option of taking mifepristone out of the office was popular and acceptable among women and providers. Given that it is safe, highly acceptable and not burdensome on providers, outside-office-use of mifepristone should be offered to all women as part of routine medical abortion services., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The requirement that mifepristone be dispensed only by physicians in offices, clinics or hospitals - and not by prescription in pharmacies - has likely limited uptake by providers in the United States. However, in several other countries, provision by prescription in pharmacies is allowed, including in Australia. Mifepristone was first registered in Australia in 2012, and in 2015, a composite package including 200 mg mifepristone and four tablets of misoprostol 200 mcg was registered. Both were approved as Schedule 4 medications, which require prescribing by a physician and may be dispensed at pharmacies. As part of the registration for both products, a risk management plan was instituted that has several components. First, physicians must be certified to prescribe mifepristone. General practitioners wishing to become certified must complete online training that includes prescribing requirements and managing the medical abortion process; obstetrician-gynecologists are exempt from the online learning module. Pharmacists must also be certified in order to dispense the medication, although this does not require additional training. When a pharmacist receives a prescription for mifepristone, she or he must confirm through a secure website that the prescriber is certified. In every region of the country, there are more certified prescribers and dispensers of mifepristone than the number of facilities providing abortion care. The experience in Australia demonstrates the feasibility of mifepristone by prescription and should be a model for expanding access to early medical abortion in the United States., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To summarize clinical outcomes and adverse effects of medical abortion regimens consisting of mifepristone followed by buccal misoprostol in pregnancies through 70 days of gestation., Data Sources: We used PubMed, ClinicalTrials.gov, and reference lists from published reports to identify relevant studies published between November 2005 and January 2015 using the search terms "mifepristone and medical abortion" and "buccal and misoprostol.", Methods of Study Selection: Studies were included if they presented clinical outcomes of medical abortion using mifepristone and buccal misoprostol through 70 days of gestation. Studies with duplicate data were excluded., Tabulation, Integration, and Results: We included 20 studies with a total of 33,846 women through 70 days of gestation. We abstracted efficacy and ongoing pregnancy rates as an overall rate and by gestational age in days in reference to completed weeks (eg, 49 days or less, 50-56 days, 57-63 days, 64-70 days) and adverse effects when reported. The overall efficacy of mifepristone followed by buccal misoprostol is 96.7% (95% confidence interval [CI] 96.5-96.8%) and the continuing pregnancy rate is 0.8% (95% CI 0.7-0.9%) in approximately 33,000 pregnancies through 63 days of gestation. Only 332 women with pregnancies between 64 and 70 days of gestation are reported in the literature with an overall efficacy of 93.1% (95% CI 89.6-95.5%) and a continuing pregnancy rate of 2.9% (95% CI 1.4-5.7%). Currently available data suggest that regimens with a 24-hour time interval between mifepristone and buccal misoprostol administration are slightly less effective than those with a 24- to 48-hour interval. Rates of surgical evacuation for reasons other than ongoing pregnancy range from 1.8% to 4.2%. Severe adverse events like blood transfusion (0.03-0.6%) and hospitalization (0.04-0.9%) are uncommon., Conclusion: Outpatient medical abortion regimens with mifepristone followed in 24-48 hours by buccal misoprostol are highly effective for pregnancy termination through 63 days of gestation. More data are needed to evaluate clinical outcomes with regimens containing mifepristone followed in 24 hours by buccal misoprostol and in pregnancies beyond 63 days of gestation.

This study aimed to investigate the effectiveness and safety of lower doses of mifepristone combined with misoprostol for the termination of ultra-early pregnancy. A total of 2500 women with ultra-early pregnancy (amenorrhea ≤ 35 days) were randomly divided into 5 groups with gradually decreased dose of oral mifepristone from 150 to 50 mg followed by 200 µg of oral misoprostol 24 hours later. The primary end point was complete abortion without surgical intervention. Secondary end points were vaginal bleeding, return of menses, and side effects. Rates of complete abortion were high in all groups. Moreover, the lower doses of mifepristone led to shorter vaginal bleeding period, the return of menses on the expected date, and fewer side effects. Lower doses of mifepristone combined with 200 µg of misoprostol are as effective and safe as higher doses of this combination for the termination of ultra-early pregnancy with lower possibility of vaginal bleeding and side effects., (© The Author(s) 2014.)

Objective: To examine the acceptability and feasibility of early medical abortion using mifepristone and misoprostol in Azerbaijan., Methods: A total of 863 women in Baku and two regions of Azerbaijan who sought termination of gestations up to 63 days were enrolled in the study. In the capital, women swallowed 200 mg mifepristone in the clinic and were given the option of taking 800 μg misoprostol buccally either at the clinic or at home 24-48 hours later. In the regions, women were given the option of taking both drugs at home. Follow-up visits were to take place two weeks after mifepristone administration to determine abortion status., Results: Seventy-four percent of women in the regions chose home administration of mifepristone, and 92% of women from all locations selected misoprostol home administration. Ninety-seven percent of women had complete abortions, and 97% were satisfied or very satisfied with the method. The vast majority of participants preferred medical abortion for a future procedure (96%). Nearly all women (98%) would recommend medical abortion for pregnancy termination to a friend., Conclusion: Mifepristone-misoprostol medical abortion with the option of home administration of both drugs is an acceptable and feasible option for women in Azerbaijan.

Objective: To evaluate if the 72 hours interval between mifepristone and gemeprost has a similar efficacy compared to the 48 hours interval for second trimester termination of pregnancy, Study Design: Two-hundred and fifteen consecutive pregnant women, admitted to our hospital, for second trimester TOP, were included in this retrospective analysis. Standard protocol was followed for all patients. On the first day of the procedure oral mifepristone 200 mg was administered. After 72 (group A, n = 78) or 48 hours (group B, n = 113) women were admitted for administration of gemeprost 1 mg pessary as per protocol. The induction to abortion time was defined as the interval between the insertion of the first gemeprost pessary and the expulsion of the fetus., Results: There are no significant differences in the number of pessaries in the two groups. The induction to abortion interval was longer in group A than in group B. Twenty-one women required surgical evacuation of the uterus for retained placenta or incomplete abortion without difference between groups., Conclusion: A 48-hours interval between mifepristone and gemeprost leads to better results than a 72-hours interval, with a shorter abortion length and represents the elective method for second trimester TOP.

Background: No systematic empirical research exists addressing the question of optimal pregnancy termination method in second trimester pregnancies., Objectives: The purpose of this study was to determine the efficacy and safety of intravaginal misoprostol and extraamniotic Foley catheter combination for second trimester pregnancy termination., Methods: A single center observational study was conducted in a total of 91 pregnancies. Women who met the termination of pregnancy criteria due to feto-maternal indications between 13 to 26 gestational weeks were included into the study. Study participants received intravaginal misoprostol in combination with Foley catheter (n = 46) or intravaginal misoprostol alone (n = 45)., Results: The efficacy of intravaginal misoprostol and Foley catheter insertion combination was comparable to that of intravaginal misoprostol alone in terms of time to abortion/birth [median (95% Confidential Interval [95% CI]): 14.33 (11.33-17.25) hours and 12.08 (9.50-15.33) hours, respectively Hazard Ratio: 0.73, 95% CI: 0.47 to 1.12, p = 0.14 (log-rank)]. The only serious maternal event was uterine rupture observed in one woman in Foley combination group., Conclusion: The combination of intravaginal misoprostol and extraamniotic Foley catheter for second trimester pregnancy termination does not provide additional efficacy.

Objective: To compare the efficacy of mifepristone and ethacridine lactate with ethacridine lactate alone for second trimester pregnancy termination., Study Design: Two hundred and seventy-six healthy women between 16 and 27 weeks of gestation, desiring a termination, were assigned at random into two groups. The study group consisted of 140 women who received an intra-amniotic injection of 100mg ethacridine lactate, followed by oral administration of 50mg mifepristone at 0, 12 and 24h (total dose of mifepristone 150mg). The control group consisted of 136 women who received an intra-amniotic injection of 100mg ethacridine lactate alone. The primary outcome measure was the induction-to-abortion interval. Secondary outcomes included blood loss in 24h, successful abortion rate, retained placental tissue rate, rate of uterine evacuation and cervical laceration., Results: Induction-to-abortion interval, blood loss in 24h, rate of retained placental tissue and uterine evacuation were significantly less in the study group compared with the control group (p<0.001). Termination was successful in 140 of 140 women (100%) in the study group and 133 of 136 women (97.8%) in the control group. All women in the study group delivered within 72h, and three nulliparous women in the control group did not deliver within 72h. The cervical laceration rate was 0 and 1.47% (2/136) in the study group and the control group, respectively. No significant difference in the successful abortion rate (p=0.235) or the cervical laceration rate (p=0.242) was found between the two groups., Conclusion: Mifepristone in combination with ethacridine lactate may significantly improve the outcomes of second trimester pregnancy termination compared with ethacridine lactate alone, without increasing complications and side effects apart from nausea., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: To investigate the attributes of service users associated with uptake of medical abortion (MA) versus manual vacuum aspiration (MVA) at public health facilities in Vietnam., Methods: Structured exit interviews were conducted among women who underwent termination at 62 public health facilities in Hanoi, Khanh Hoa, and Ho Chi Minh City (HCMC) between August and December 2011. Data on sociodemographic, abortion-related, and service-related factors were compared between women who underwent MVA versus MA., Results: Overall, 1233 women completed the study survey: 541 (43.9%) from Hanoi; 163 (13.2%) from Khanh Hoa; and 529 (42.9%) from HCMC. Almost one-quarter of women (23.1%) had chosen MA. After controlling for sociodemographic factors, women living in Khanh Hoa (odds ratio [OR], 13.4; 95% confidence interval [CI], 5.3-33.8) and HCMC (OR, 5.8; 95% CI, 2.1-15.9) were more likely to have undergone MA than women in Hanoi. Older women were less likely to have undergone MA (P < 0.05), and those who had previously heard of MA were twice as likely to have undergone MA (P = 0.020)., Conclusion: Uptake of MA was lower than that of MVA and varied by province. Women in Vietnam will make their own judgment about which method to choose if they have prior knowledge of both., (Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

This study was designed to assess endocrine changes associated with termination of mid-term pregnancy after use of two different protocols. For this purpose we compared the effects of aglepristone (AGL) alone and in combination with cloprostenol (CLO) on serum concentrations of progesterone (P4), estradiol (E2) and relaxin (RLN) measured at short-term intervals during the abortion period in bitches. Fourteen pregnant bitches between day 25 and 32 of gestation were used in the study. In the AGL group (n=7), aglepristone was administered solely (10mg/kg body weight (BW), subcutaneously, once daily on two consecutive days) whereas in the AGL-CLO group (n=7), aglepristone (dosage as in AGL group) and cloprostenol (1μg/kg BW, subcutaneously, same with aglepristone) were combined. All pregnancies were successfully terminated 5.2±1.6 days after initiation of treatments, which was significant in both groups (P>0.05). At the time of the start of abortion (SA) and the end of abortion (EA), the mean P4 concentrations were 26.6±7.3 and 12.0±6.4ng/ml in AGL group, and 2.7±0.7 and 0.9±0.1ng/ml, in AGL-CLO group, respectively (P<0.01). Serum E2 concentrations were significantly higher (P<0.05) in AGL group at 42, 48, 54h and SA after initiation of treatment. In the AGL-CLO group, serum RLN concentrations did not significantly change from the initiation of treatment to EA (P>0.05). However, markedly higher RLN concentrations (P<0.05) were observed in the AGL group at 48h (1.5±0.7ng/ml) and at SA (1.6±0.5ng/ml). The results of the present study indicate that changes in the hormonal concentrations affect the mechanism of abortion in different ways. Further in depth studies investigating changes in the expression of hormone receptors inside the ovary, endometrium and placenta might be helpful to our understanding of the endocrinological differences observed in this study., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Objective: Demand for second-trimester induced abortions (STIAs) increases in Italy. For these procedures, prostaglandins alone were used until 2010, when mifepristone became available. The present study compares the two modalities, and investigates the reasons for STIAs., Methods: The records of all such procedures performed at the Department of Gynaecology, Obstetrics and Urology of the 'Sapienza' University (Rome), between January 2004 and December 2012, and of all those done at the 'San Filippo' Hospital (Rome), between January 2010 and December 2012, were analysed. Data gathered included women's age, obstetric history, reasons for requesting the STIA, gestational age, mode of intervention, and complications if any., Results: During the study period, 353 women requested a STIA. Karyotype or genetic anomalies were the reason for the request in 187 cases (53%), while structural anomalies, both single and multiple, were given as the reason in 158 (45%). In most cases, these anomalies were assessed by ultrasound scan., Conclusion: Few studies have investigated reasons for requesting STIAs. Of all chromosome abnormalities diagnosed in this study, trisomy 21 was the most common (59%) and it was the most frequent reason for requesting pregnancy termination.

Objective: To 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., Methods: A 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., Results: Overall, 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., Conclusion: Provision 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., (Copyright © 2013 International Federation of Gynecology and Obstetrics. All rights reserved.)

Objectives: Induction of fetal demise before second-trimester termination is performed for a number of reasons. One method for inducing fetal demise is via sonographically guided intracardiac potassium chloride (KCl) injection. We performed a retrospective cohort study to determine the efficacy and safety of intracardiac KCl injection as a method of second-trimester induced fetal demise., Methods: We reviewed records from patients who were referred for induced fetal demise from October 2002 to October 2011. We excluded patients undergoing selective fetal reduction in multiple gestations. Procedural complications, the dose of KCl, and the number of failed procedures were determined., Results: Of the 192 completed procedures, 191 were successful (99.5%). The median gestational age at termination was 22 weeks (range, 15.4-24.9 weeks), and most terminations were surgical (68.0%). Major indications for termination were fetal anomalies (41.6%), unwanted pregnancy (20.8%), and aneuploidy (15.7%). The median dose of KCl was 10 mL (range, 3-40 mL). We found a significant correlation between the dose of KCl and estimated fetal weight. There was no significant correlation between the dose of KCl and body mass index or gestational age. We had 1 maternal complication of a seizure after needle placement but before KCl injection., Conclusions: Intracardiac KCl injection is an effective and safe method for induced fetal demise.

Objective: To compare the efficacy of a shorter interval (24hours) between misoprostol and mifepristone administration with that of the conventional dosing interval (48hours) for second-trimester termination of pregnancy (TOP)., Methods: This was a prospective randomized, controlled, open-label study of 98 healthy women opting for mid-trimester TOP. The women were randomized to receive 200mg mifepristone orally, followed 24hours (Group 1) or 48hours (Group 2) later by misoprostol (800μg, then 400μg every 3hours). The primary outcome measure was the percentage of successful abortions within 24hours. Secondary outcome measures were the induction-to-abortion interval (measured from misoprostol administration) and the frequencies of complications and adverse effects., Results: The rate of successful abortions was similar with the 24-hour and 48-hour dosing intervals (95.8% and 93.6%, respectively; P=0.38). The mean induction-to-abortion interval was also comparable between the 2 groups (8.6±4.1hours versus 8.7±3.9hours; P=0.37). Nulliparous women and women with a pregnancy duration of 16weeks or more had a longer induction-to-abortion interval in both groups., Conclusion: The 24-hour dosing interval between misoprostol and mifepristone administration seems to be as effective as the 48-hour dosing interval for second trimester TOP. Clinical Trial Registry India: CTRI/2011/05/001770., (© 2013.)

The aim of this study is to compare the effectiveness of 100 mg versus 200 mg mifepristone along with misoprostol for medical abortion in gestation upto 56 days. This is a prospective controlled study. Eighty women seeking medical abortion with a gestation up to 56 days were included in the study. The women were randomly allotted into two groups. They received 100 mg/200 mg mifepristone on day 1 followed by 800 mcg misoprostol two days later. Women who had not aborted completely by day 14, received a repeat dose of 400 mcg misoprostol and were evaluated on day 21 for completeness of the procedure. Five women in both the groups had incomplete abortion by day 14 (12.5%), while one woman in the test group had to undergo dilatation and evacuation on day 3 due to excessive bleeding. By repeating a second dose of misoprostol, all of them aborted completely and the complete abortion rates were markedly improved from 85% and 87.5% in the test and the control group, respectively to 97.5% and 100%, respectively. It may be concluded that 100 mg mifepristone is as effective as 200 mg and appears to be the lowest effective dose for medical abortion.