Mon, 26 May 2003 02:28:59 -0400 (EDT)
From: "Cimf" <cimf@colfarma.org.ar>
Subject: [e-farmacos] Misoprostol (cont.)
E-farmacos: Misoprostol (cont.)
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Preocupacion: el Servicio de Adolescencia del Hospital Argerich inicio
un estudio. Usan un analgesico para producir abortos
http://www.lanacion.com.ar/03/05/19/sl_497187.asp

Su cobertura tiene una sustancia que causa contracciones uterinas; las jovenes llegan al hospital con hemorragia.

La droga debe venderse con receta, pero se consigue sin indicacion y a precios altisimos. Hay desconocimiento de los riesgos.

Falta adhesion a la salud reproductiva
Un estudio que conducen dos ginecologas del Servicio de Adolescencia del hospital Argerich busca desentranhar un tema controvertido: el uso indebido de un analgesico que genera contracciones uterinas y, en un 60% de los casos, logra producir un aborto.

El medicamento viene recubierto por una droga llamada misoprostol (que es la que causa las contracciones) y se vende bajo receta. Pero quienes pretenden darle ese uso inapropiado logran adquirirlo por unidad, aunque deben pagarlo mucho mas de lo que cuesta la caja.

El uso ginecologico de esta droga no se conocia en la Argentina hasta hace unos tres o cuatro anhos, explicaron las doctoras Nilda Gamarra y Sandra Vazquez, cuando, ante un numero creciente de jovenes que llegaba al Argerich con metrorragias (hemorragias uterinas) el interrogatorio comenzo a revelar que habian usado esta sustancia para producir un aborto.

"La complicacion mas habitual del aborto incompleto son las infecciones, - -explicaron las especialistas, que dirigen el primer estudio oficial sobre el problema gracias a la beca Arturo Onhativia-, y al usar este metodo esas complicaciones disminuyen. Pero no tenemos conocimiento sobre que pasa con las que no vemos. E ignoramos que consecuencias puede traer."

Las medicas explican que la bibliografia dice, por ejemplo, "que en casos en que la gestacion siguio su curso, nacieron algunos ninhos con malformaciones. Esto puede ocurrir porque quiza la hemorragia continua 15 dias o un mes y recien en ese momento la paciente viene a atenderse y resulta que sigue embarazada. O, cuando llegan, el aborto esta incompleto y debe concluirse en el hospital por medio de un legrado evacuador (comunmente llamado raspaje)."

Vazquez y Calandra agregan que el misoprostol es utilizado tambien por mujeres adultas. "Tiene indicaciones terapeuticas en obstetricia para generar contracciones en trabajo de parto -continuan las ginecologas-. Pero aquí no se le conocia un uso diferente. Asi que otro objetivo de nuestro trabajo es determinar como las jovenes recibieron informacion acerca de su efecto. Con esta droga ocurrio algo llamativo: se invirtio la circulacion del conocimiento, que habitualmente va desde el medico al paciente. Aqui, en cambio, se lo indico una amiga, una hermana o hasta la misma madre."

En franco aumento
Otra cuestion que preocupa es que el precio de la caja del analgesico (utilizado en reumatologia y traumatologia) ronda los 20 pesos. "Pero hubo pacientes que pagaron hasta 100 pesos por una pastilla", comentan.

Este farmaco puede usarse como ovulo vaginal o tomarse por boca, pero un error habitual es la dosis utilizada, por falta de control medico.

"Si, en los ultimos anhos un numero de pacientes internadas por complicaciones en el aborto refirieron haber utilizado un farmaco con misoprostol -explica la doctora Diana Galimberti, subdirectora medica del hospital Alvarez e integrante del comite cientifico del Centro Latinoamericano Salud y Mujer (Celsam)-. Esto no necesariamente redujo las complicaciones por abortos en los hospitales publicos, que aumentaron de 48.000 a 78.000 entre 1995 y 2000. De estos, el 40% corresponde a menores de 20 anhos. La explicacion es que probablemente las jovenes regulan la fecundidad a traves del aborto. Y esto preocupa mucho."

"Los egresos por complicaciones del aborto aumentaron el 48% entre 1995 y 2000 -explica la licenciada Silvina Ramos, directora e investigadora titular del Centro de Estudios de Estado y Sociedad (Cedes)-. Este incremento puede deberse al aumento de la pobreza y de las dificultades para hacer frente a la crianza de un nuevo hijo, pero tambien al hecho de que estos abortos se estarian realizando en condiciones mas riesgosas." 

"Los egresos hospitalarios por complicaciones del aborto corresponden al 45% de las camas obstetricas del pais -agrega la licenciada Susana Checa, que junto a la doctora Martha Rosemberg y equipo estudian la calidad de atencion de los abortos hospitalizados por complicaciones en hospitales publicos de la ciudad de Buenos Aires-. La importante falta de informacion en las historias clinicas nos impide saber mas de estas mujeres para disenhar mejores politicas sobre el tema. Muchas pacientes
son mal miradas por el equipo de salud: para el medico no es facil enfrentarse con una mujer que pasa por esta situacion."

Checa, como Ramos, opina que la pobreza explica el aumento de los egresos hospitalarios por aborto, y agrega que estas cifras no reflejan la realidad, dado que el tema esta rodeado de un fuerte subregistro.

"El aumento es real, pero habla de que el tema esta mas visualizado y hay mayor conciencia -dice la doctora Eugenia Trumper, a cargo del Programa de Salud Reproductiva y Procreacion Responsable de la Ciudad de Buenos Aires-. Probablemente las mujeres acuden mas a los hospitales, cuando antes se usaban mas maniobras instrumentales o folkloricas ." 

Para Checa, sin embargo, el hecho de que este farmaco se comercialice a un alto precio (que, de todos modos, es mucho mas accesible que un aborto clandestino) causa que  muchas mujeres empobrecidas regresen a los metodos tradicionales (y mas riesgosos) para interrumpir los embarazos.

El doctor Enrique Berner, jefe del Servicio de Adolescencia del hospital Argerich, opina que el aumento de los egresos por aborto se explicaria por una mayor apertura y contencion del medico frente a estas pacientes.

Por Gabriela Navarra
De la Redaccion de LA NACION

Educacion para evitar el drama
Para Silvina Ramos, Monica Gogna, Monica Petracci, Mariana Romero y Dalia Szulik, autoras del estudio "Los medicos frente a la anticoncepcion y el aborto" (Ed. Cedes), que recopila informacion entre ginecologos de 25 hospitales de Buenos Aires y el conurbano, el personal de salud tiene conciencia acerca del impacto del aborto como problema de salud publica, pero hay diferencias importantes respecto de la forma de encarar la anticoncepcion y el juicio de valor que merecen las mujeres que abortan.

"Son muchas las cosas que se juegan en el vinculo medico-paciente en estas situaciones -dice Silvina Ramos-. Y no tenemos ninguna evidencia que nos permita conjeturar que este aumento se debe a un mejor registro de los egresos por esta causa."

Los profesionales coinciden en algo: las complicaciones del aborto se solucionan con salud reproductiva.

"A pesar de que hace muchos anhos venimos trabajando con el tema y de que hay 15 provincias con ley de salud reproductiva, todavia existen barreras culturales", afirma Eugenia Trumper.

Para Sandra Vazquez, la ley puesta en marcha en la ciudad de Buenos Aires dio un gran respaldo a su tarea: "Ahora los medicos podemos indicar un metodo anticonceptivo a los adolescentes -explica-. Aca sabemos que retar y enojarse con los pacientes no sirve, porque se van y no vuelven mas".

Para Susana Checa, algo que los servicios deberian incluir a fin de disminuir las interrupciones de embarazos es la consejeria posaborto. Checa, que lleva muchos anhos investigando el tema, asegura que la mujer esta muy sola en su decision, pero que si al cabo de abortar no recibe suficiente informacion y contencion para aprender como evitarlo, el drama puede repetirse. Y el fantasma de la muerte, cada vez que eso ocurra, estara al acecho.
[NOTA: Mensaje sin acentos ni caracteres especiales.]

Mon, 26 May 2003 03:05:13 -0400 (EDT)
From: "Alves, Giane" <gaaoliveira@prefeitura.sp.gov.br>
Subject: [e-farmacos] Misoprostol (cont.)
E-farmacos: Misoprostol (cont.)
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Bom dia,
Obrigada pelas mensagens recebidas. Esta questao do misoprostol esta sendo discutida aqui no municipio de Sao Paulo pela Secretaria Municipal de Saude. Este medicamento nao constava em nossa lista padronizada de medicamentos para o Municipio, entretanto, houve a solicitacao de um hospital municipal para inclusao do mesmo para casos de aborto retido.
Nos fizemos uma pesquisa para saber se os outros hospitais municipais (que sao 15) tambem utilizavam misoprostol. Todos utilizam (exceto os que nao tem maternidade: 2 hospitais), principalmente para aborto retido e inducao do parto. Cada hospital utiliza de uma determinada forma e dosagem. Desta forma fizemos um levantamento bibliografico sobre esta
utilizacao. Existem muitos trabalhos sobre este assunto, e por isso enviei e-mail para a rede a fim de saber se alguem teria mais informacoes a respeito. A Helena Lutescia que trabalhou um tempo com misoprostol aqui no Brasil, nao esta mais se
dedicando a este assunto.

Aqui no Brasil ja existe registro de misoprostol 25 mcg comprimidos vaginais em que a industria  faz a divulgacao que e um "estimulador fisiologico do trabalho de parto". Existe tambem o comprimido 200 mcg via oral. Este medicamento esta sob controle de uma portaria da vigilancia sanitaria e so pode ser utilizado em hospitais.

Estamos organizando uma Oficina, em junho, com os hospitais municipais para discutir esta questao.

Obrigada,
Giane Sant Ana Alves Oliveira
Centro de Informacoes sobre Medicamentos - CIM
Secretaria Municipal da Saude de Sao Paulo
gaaoliveira@prefeitura.sp.gov.br
[NOTA: Mensaje sin acentos ni caracteres especiales.]

Mon, 26 May 2003 03:25:25 -0400 (EDT)
From: "Agusti, Antonia" <ag@icf.uab.es>
Subject: [e-farmacos] Misoprostol (cont.)

E-farmacos: Misoprostol (cont.)
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Estimada Giane, 

Te adjunto algunas referencias sobre el tema de misoprostol y aborto con su resumen en ingles, por si son de tu interes:

bstet Gynecol  2003 Apr;101(4):722-5
Gemeprost versus misoprostol for cervical priming before first-trimester
abortion: a randomized controlled trial.
Ekerhovd E, Radulovic N, Norstrom A.
Department of Obstetrics and Gynecology, Sahlgrenska University
Hospital, Goteborg University, Goteborg. erling.ekerhovd@obgyn.gu.se

OBJECTIVE: To compare the efficacy of 400 microg of misoprostol with
that of 1 mg of gemeprost as cervical priming agents when administered
vaginally 3 to 4 hours before first-trimester vacuum aspiration
abortion. METHODS: In a prospective controlled trial 90 nulliparous
women who requested termination of pregnancy before 12 weeks' gestation
were randomized to receive vaginally either misoprostol or gemeprost for
cervical priming. The force to dilate the cervix was measured by the use
of a cervical tonometer connected to Hegar dilators from 3 to 10 mm. The
main outcome measures were baseline cervical dilation; the peak force to
dilate the cervix at 8, 9, and 10 mm; and the cumulative force to dilate
the cervix to 10 mm. RESULTS: Baseline cervical dilation did not differ
significantly between the women who received misoprostol and those who
were treated with gemeprost. Neither the peak force required to dilate
the cervix at 8, 9, and 10 mm nor the cumulative force to dilate the
cervix to 10 mm showed any significant difference between the two
groups. CONCLUSION: Vaginally administered misoprostol (400 microg) is
as effective as gemeprost (1 mg) for cervical priming 3 to 4 hours
before surgical termination of first-trimester pregnancies.


Am J Obstet Gynecol  2003 Mar;188(3):664-9
Mifepristone and misoprostol and methotrexate/misoprostol in clinical
practice for abortion.
Creinin MD, Potter C, Holovanisin M, Janczukiewicz L, Pymar HC, Schwartz
JL,Meyn L.
Department of Obstetrics, Gynecology, and Women's Health, University of
Pittsburgh Physicians, Pa, USA.

OBJECTIVE: The purpose of this study was to evaluate the efficacy,
side-effect profile, and follow-up rates in women who obtain a medical
abortion in a nonresearch setting. STUDY DESIGN: From December 1, 2000,
to June 30, 2001, we prospectively followed 218 women who had been
evaluated in our private office for medical abortion. Women received
either mifepristone 200 mg orally followed 1 to 2 days later by
self-administered misoprostol 800 microg vaginally or methotrexate 50
mg/m(2) intramuscularly followed 3 to 7 days later by self-administered
misoprostol 800 microg vaginally. RESULTS: Of the 174 women who had a
medical abortion, 148 women (85%) chose mifepristone/misoprostol, and 26
women (15%) chose methotrexate/misoprostol. In women up to 49 days of
gestation, complete abortion occurred by the first follow-up visit in 82
of 86 women (95%; 95% CI, 89-99) and in 21 of 25 women (84%; 95% CI,
64-95) women, respectively. In women who used mifepristone/misoprostol
from 50 to 63 days of gestation, complete abortions occurred in 56 of 59
women (95%; 95% CI, 86-99) women. Four women (2%; 95% CI, 1-6) were lost
to follow-up. CONCLUSION: Medical abortion with mifepristone/misoprostol
and with methotrexate/misoprostol can be provided in a nonresearch
setting with efficacy similar to that reported in the medical literature
for research protocols.


Gynecol Obstet Invest  2002;54(3):176-9
High-dose oral misoprostol for mid-trimester pregnancy interruption.
Ramin KD, Ogburn PL, Danilenko DR, Ramsey PS.
Division of Maternal-Fetal Medicine, Department of Obstetrics and
Gynecology, Mayo Medical Center, Rochester, MN 55905, USA.
ramin.kirk@mayo.edu

OBJECTIVE: To evaluate the efficacy of high-dose oral misoprostol for
mid-trimester pregnancy interruption. METHODS: We reviewed our
experience with high-dose oral misoprostol for mid-trimester pregnancy
interruption from November 1995 to May 1999. Patients undergoing labor
induction for intrauterine fetal demise or medically indicated pregnancy
termination at 13-32 weeks of gestation with a non-dilated cervix were
evaluated. Patients received 400 microg misoprostol orally every 4 h.
Women undelivered within 24 h were considered failures and were treated
with high-dose oxytocin as previously described. For comparison, a group
of women treated with high-dose oxytocin were evaluated.
RESULTS: Forty-seven pregnancies were managed with misoprostol (n = 23)
or high-dose oxytocin regimen (n = 24). Both groups were similar with
respect to induction indication, gestational age, maternal age/parity,
laminaria use, and initial cervical dilation. Induction-to-delivery
interval (mean  SD) was significantly shorter in the misoprostol cohort
(15.2  6.7 h) compared with those treated with oxytocin (21.7  11.0 h; p
= 0.02). Additionally, a significantly greater percentage of women
treated with misoprostol delivered within 24 h (91.0%) compared with the
oxytocin group (62.0%; p = 0.04). Adverse outcomes and side effects were
not significantly different between the study groups. CONCLUSION:
High-dose oral misoprostol is more effective than concentrated oxytocin
infusion for mid-trimester pregnancy interruption.


Cochrane Database Syst Rev  2003;(1):CD000941
Update of:      Cochrane Database Syst Rev. 2001;(3):CD000941.
Vaginal misoprostol for cervical ripening and induction of labour.
Hofmeyr GJ, Gulmezoglu AM.
(Director, Effective Care Research Unit, University of the
Witwatersrand),
Frere/Cecilia Makiwane Hospitals, Private Bag 9047, East London 5200,
Eastern Cape, South Africa. gjh@global.co.za

BACKGROUND: Misoprostol (Cytotec, Searle) is a prostaglandin E1 analogue
marketed for use in the prevention and treatment of peptic ulcer
disease. It is inexpensive, easily stored at room temperature and has
few systemic side effects. It is rapidly absorbed orally and vaginally.
Although not registered for such use, misoprostol has been widely used
for obstetric and gynaecological indications, such as induction of
abortion and of labour. This is one of a series of reviews of methods of
cervical ripening and labour induction using standardised methodology.
OBJECTIVES: To determine the effects of vaginal misoprostol for third
trimester cervical ripening or induction of labour. SEARCH STRATEGY: The
Cochrane Pregnancy and Childbirth Group trials register (October 2002),
the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3,
2002) and bibliographies of relevant papers. SELECTION CRITERIA: The
criteria for inclusion included the following: (1) clinical trials
comparing vaginal misoprostol used for third trimester cervical ripening
or labour induction with placebo/no treatment or other methods listed
above it on a predefined list of labour induction methods; (2) random
allocation to the treatment or control group; (3) adequate allocation
concealment; (4) violations of allocated management not sufficient to
materially affect conclusions; (5) clinically meaningful outcome
measures reported; (6) data available for analysis according to the
random allocation; (7) missing data insufficient to materially affect
the conclusions. DATA COLLECTION AND ANALYSIS: A strategy was developed
to deal with the large volume and complexity of trial data relating to
labour induction. This involved a two-stage method of data extraction.
The initial data extraction was done centrally, and incorporated into a
series of primary reviews arranged by methods of induction of labour,
following a standardised methodology. The data will be extracted from
the primary reviews into a series of secondary reviews, arranged by
category of woman. To avoid duplication of data in the primary reviews,
the labour induction methods have been listed in a specific order, from
one to 25. Each primary review includes comparisons between one of the
methods (from two to 25) with only those methods above it on the list.
MAIN RESULTS: Sixty-two trials have been included. Compared to placebo,
misoprostol was associated with increased cervical ripening (relative
risk of unfavourable or unchanged cervix after 12 to 24 hours with
misoprostol 0.09, 95% confidence interval (CI) 0.03 to 0.24). It was
also associated with reduced failure to achieve vaginal delivery within
24 hours (relative risk (RR) 0.36, 95% CI 0.19 to 0.68). Uterine
hyperstimulation, without fetal heart rate changes, was increased (RR
11.7 95% CI 2.78 to 49). Compared with vaginal prostaglandin E2,
intracervical prostaglandin E2 and oxytocin, vaginal misoprostol labour
induction was associated with less epidural analgesia use, fewer
failures to achieve vaginal delivery within 24 hours and more uterine
hyperstimulation. Compared with vaginal or intracervical prostaglandin
E2, oxytocin augmentation was less common, with misoprostol and
meconium-stained liquor more common. Compared with intracervical
prostaglandin E2, unchanged or unfavourable cervix after 12 to 24 hours
was less common with misoprostol. Lower doses of misoprostol compared to
higher doses were associated with more need for oxytocin augmentation,
less uterine hyperstimulation, with and without fetal heart rate
changes, and a non-significant trend to fewer admissions to neonatal
intensive care unit. Use of a gel preparation of misoprostol versus
tablet was associated with less hyperstimulation and more use of
oxytocin and epidural analgesia. Information on women's views is
conspicuously lacking. REVIEWER'S CONCLUSIONS: Vaginal misoprostol
appears to be more effective than conventional methods of cervical
ripening and labour induction. The apparent increase in uterine
hyperstimulation is of concern. Doses not exceeding 25 mcg four-hourly
of concern. Doses not exceeding 25 mcg four-hourly appeared to have
similar effectiveness and risk of uterine hyperstimulation to
conventional labour inducing methods. The studies reviewed were not
large enough to exclude the possibility of rare but serious adverse
events, particularly uterine rupture, which has been reported
anecdotally following misoprostol use in women with and without previous
caesarean section. The authors request information on cases of uterine
rupture known to readers. Further research is needed to establish the
ideal route of administration and dosage, and safety. Professional and
governmental bodies should agree guidelines for the use of misoprostol,
based on the best available evidence and local circumstances.

Cochrane Database Syst Rev  2002;(4):CD003037
Medical versus surgical methods for first trimester termination of
pregnancy.
Say L, Kulier R, Gulmezoglu M, Campana A.
Moda, Atifet s N.18/2 D.3, Kadikoy, Istanbul, Turkey, 81310.
lalesay@superonline.com

BACKGROUND: Induced abortions are very commonly practiced interventions
worldwide. A variety of medical abortion methods have been introduced
during the last decade in addition to existing surgical methods. In this
review we systematically searched for and combined all evidence from
randomised controlled trials comparing surgical with medical abortion.
OBJECTIVES: To evaluate medical methods in comparison to surgical
methods for first-trimester abortion with respect to efficacy, side
effects and acceptability. SEARCH STRATEGY: The Cochrane Controlled
Trials Register, MEDLINE (with the Cochrane 3-stage search
strategy)(1966-2000) and Popline (1970-2000) were systematically
searched. There were no language preferences in searching. Reference
lists of retrieved papers were searched. Experts in WHO/HRP were
contacted. SELECTION CRITERIA: Randomised trials of any surgical
abortion method compared with any medical abortion method in the first
trimester. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and
data extraction was made independently by two reviewers. MAIN RESULTS:
Five studies mostly with small sample sizes, comparing 4 different
interventions (prostaglandins alone, mifepristone alone, and
mifepristone/misoprostol and methotrexate/misoprostol versus vacuum
aspiration) were included. Results are sometimes based on one trial
only. Prostaglandins vs vacuum aspiration: the rate of abortions not
completed with the intended method was statistically significant higher
in the prostaglandin group (2.7, 95% CI 1.1 to 6.8) compared to surgery.
There are no data on the most commonly medical
(mifepristone/misoprostol) and surgical abortion available to be
included in the review. Duration of bleeding was longer in the medical
abortion groups compared to vacuum aspiration. There was only one major
complication (uterine perforation) in one trial in the surgical group.
There was no difference between the groups for ongoing pregnancies at
the time of follow-up or pelvic infections. No data on acceptability,
side effects or women's satisfaction with the procedure were available
for inclusion in the review. REVIEWER'S CONCLUSIONS: The results are
derived from small trials. Prostaglandins used alone seems to be less
effective and more painful compared to surgical first-trimester
abortion. However, there is inadequate evidence to comment on the
acceptability and side effects of medical compared to surgical
first-trimester abortions. There is a need for trials to address the
efficacy of currently used methods and women's preferences more
reliably.

BJOG  2002 Nov;109(11):1290-4
A randomised study of misoprostol and gemeprost in combination with
mifepristone for induction of abortion in the second trimester of
pregnancy.
Bartley J, Baird DT.
Centre for Reproductive Biology, University of Edinburgh, Edinburgh, UK.

OBJECTIVE: To compare the effectiveness of gemeprost and misoprostol as
prostaglandins used in combination with mifepristone for induction of
mid-trimester termination. DESIGN: Randomised trial. SETTING: Scottish
teaching hospital. SAMPLE: One hundred women undergoing abortion between
12 and 20 weeks. METHODS: Each woman received 200 mg mifepristone and
36-48 hours later either 1 mg gemeprost vaginal pessary every 6 hours
for 18 hours or 4 x 200 microg misoprostol tablets vaginally followed by
2 x 200 microg misoprostol tablets orally every 3 hours for 12 hours.
Success was defined as the percentage of women aborted within 24 hours
of the first administration of prostaglandin. MAIN OUTCOME MEASURES:
Prostaglandin-abortion interval and side effects. RESULTS: There were no
significant differences in median prostaglandin-abortion interval
between gemeprost (6.6 hours 95% CI 6.0-10.7) and misoprostol (6.1 hours
95% CI 5.5-7.5) (P = 0.22). The cumulative abortion rates at 24 hours
(96% vs 94%, respectively), the surgical evacuation rates (12% and 10%)
and the incidence of vomiting, diarrhoea and pain were similar.
CONCLUSION: Two hundred milligrammes of mifepristone followed 36-48
hours later by either vaginal gemeprost or misoprostol is a highly
effective way of inducing abortion in the second trimester of pregnancy.

Drugs  2002;62(17):2459-70
Options for early therapeutic abortion: a comparative review.
Bygdeman M, Danielsson KG.
Department of Obstetrics and Gynecology, Karolinska Hospital, Stockholm,
Sweden.
bygdeman@privat.utfors.se

Vacuum aspiration, either manual or electric, has for many years been
the most commonly used method for termination of an early pregnancy.
More recently, new medical methods have been developed which for many
women are attractive alternatives to the surgical procedure. The
compounds mainly used are prostaglandin analogues, methotrexate, and
mifepristone in combination with a suitable prostaglandin analogue.
However, only the last method has been registered for routine clinical
use. The treatment schedule mainly used is mifepristone 200 to 600 mg
followed 36 to 48 hours later by oral misoprostol 0.4 to 0.6 mg in
pregnancies up to 49 days and vaginal gemeprost 1.0mg or misoprostol 0.8
mg if the treatment period is extended to 63 days of amenorrhoea. The
ability to compare medical and surgical methods is limited by the fact
that there are few randomised studies and the definitions of successful
outcome (complete abortion), adverse effects and complications vary from
one study to the other. Experience with the method used is also
important for the outcome. However, it seems adequate to state that the
medical method is equally, or almost equally, as effective as vacuum
aspiration. Duration of bleeding and amount of blood loss is greater
following medical abortion. Also the frequency of uterine pain, vomiting
and diarrhoea is higher following medical abortion than following vacuum
aspiration. On the other hand, the frequency of major complications such
as excessive bleeding, blood transfusion and pelvic infection does not
seem to differ between the two procedures. Surgical complications, for
example, uterine perforation and cervical tears, are obviously not a
risk associated with medical abortion. Both methods are equally well
accepted provided the woman is allowed to choose. It is not possible to
state which method is best. Medical termination of early pregnancy will
not replace, but is an alternative to, vacuum aspiration and ideally
both methods should be available to give the woman a choice.

Contraception  2002 Oct;66(4):247-50
Erratum in: Contraception. 2002 Dec;66(6):481.
Randomized trial of oral versus vaginal misoprostol 2 days after
mifepristone 200 mg for abortion up to 63 days of pregnancy.
Schaff EA, Fielding SL, Westhoff C.
Department of Family Medicine, University of Rochester School of
Medicine, Rochester, NY 14620, USA. eschaff@aol.com

This prospective, open-label, randomized trial of healthy adult women up
to 9 weeks pregnant compared mifepristone 200 mg followed 2 days later
with misoprostol 400 microg orally versus misoprostol 800 microg
vaginally. The study was interrupted after the oral misoprostol group
experienced a higher than expected failure rate. This treatment was
discontinued and another substituted consisting of oral misoprostol 800
microg divided into two doses two hours apart. Women returned for a
follow-up visit from Day 4 to 8. All women with a continuing pregnancy
received a repeat dose of misoprostol vaginally and returned before Day
15. The primary outcome measure was a complete medical abortion without
surgical intervention at the first visit. Of the 1045 women enrolled,
1011 had complete data: Group 1 (220) used oral misoprostol 400 microg,
Group 2 (269) used oral misoprostol 800 microg, and Group 3 (522) used
vaginal misoprostol 800 microg. At first follow-up visit, the primary
outcome, that is, a complete abortion, was 84% for Group 1, 92% for
Group 2, and 96% for Group 3, p &lt; 0.001. After a second dose of
vaginal misoprostol in women with on-going pregnancies at their first
follow-up visit, the complete abortion rates were 91%, 95%, and 98%,
respectively, p &lt; 0.001. There were minimal differences in side
effects, onset of bleeding and overall acceptability in the three
groups. Mifepristone 200 mg followed by vaginal misoprostol 2 days later
was more effective at inducing an abortion up to 9 weeks of pregnancy
than the same dose of mifepristone followed by oral misoprostol.

Am J Obstet Gynecol  2002 Oct;187(4):853-7
A randomized controlled trial comparing two protocols for the use of
misoprostol in midtrimester pregnancy termination.
Bebbington MW, Kent N, Lim K, Gagnon A, Delisle MF, Tessier F, Wilson
RD.
Division of Maternal Fetal Medicine, Department of Obstetrics and
Gynecology, British Women's Hospital, University of British Columbia,
Vancouver, BC, Canada.

OBJECTIVE: Our purpose was to compare the efficacy of oral misoprostol
with that of vaginal misoprostol for midtrimester termination of
pregnancy. STUDY DESIGN: Women seen for midtrimester pregnancy
termination were randomly assigned to receive either misoprostol orally
in a dose of 200 microg every hour for 3 hours followed by 400 microg
every 4 hours or vaginally in a dose of 400 microg every 4 hours. The
protocol was followed for 24 hours, after which time further management
was at the discretion of the attending physician. The primary outcome
measure was the induction-to-delivery interval. Sample size was
calculated a priori. Statistical analysis was performed with the t test
for continuous variables and the chi(2) test for categorical variables.
P &lt;.05 was considered significant. RESULTS: One hundred fourteen
women were randomized, with 49 receiving vaginal misoprostol and 65
receiving oral misoprostol. The two groups were comparable with respect
to maternal age, parity, indication for pregnancy  termination,
gestational age, and maternal weight. The mean induction-to-delivery
interval was significantly shorter for the vaginal group (19.6  17.5
hours vs 34.5  28.2 hours, P &lt;.01). Length of stay was also shorter
in the vaginal group (32.3  17.3 hours vs 50.9  27.9 hours, P &lt;.01).
Significantly more patients in the vaginal group were delivered within
24 hours (85.1% vs 39.5%, P &lt;.01), and more patients in the oral
group required changes in the method of induction when they were
undelivered after 24 hours (38.2% vs 7%, P &lt;.01). The only
complication was an increase in febrile morbidity in the vaginal group
(25% vs 6.7%, P =.046). This did not result in an increased use of
antibiotics, and all the fevers resolved post partum without further
complications. CONCLUSIONS: Vaginal administration of misoprostol
resulted in a shorter induction-to-delivery interval. The shorter length
of stay should result in improved patient care.

Antonia Agusti
Fundacio ICF
Barcelona
ag@icf.uab.es
[NOTA: Mensaje sin acentos ni caracteres especiales.]