Review articleFirst-trimester medical abortion with mifepristone 200 mg and misoprostol: a systematic review☆
Introduction
Since mifepristone was introduced in France and China more than two decades ago, medical abortion with this antiprogestin has expanded rapidly throughout the world. Mifepristone is now registered in 50 countries (www.gynuity.org, accessed 14 December 2011). In the United States, about one fifth of all outpatient abortions are performed medically [1], and in several countries in Europe, the proportion exceeds 60% [2], [3].
Although medical abortion regimens approved by most government regulatory agencies specify 600 mg mifepristone, in practice, a dose of 200 mg is standard worldwide [4], [5], [6], [7]. A prostaglandin, misoprostol, is administered after the mifepristone to enhance success. The dose, route, and timing of administration of misoprostol are not standardized. In the United States, affiliates of Planned Parenthood Federation of America provide 800 mcg buccally 24–48 h after the mifepristone [4]. The International Federation of Obstetricians and Gynaecologists recommends either vaginal, buccal, or sublingual administration [5] as do the World Health Organization [6] and the United Kingdom Royal College of Obstetricians and Gynaecologists [7], which also recommend oral dosing at gestational ages up to 49 days. Lower doses, divided doses, oral administration, and a shorter or longer interval between the two drugs also have been used clinically or evaluated in research studies.
The purpose of this review is to summarize published data on the effectiveness and safety of regimens including 200 mg mifepristone followed by misoprostol for early medical abortion. We also explore whether variation among studies in the frequency of medical abortion failure could be explained by characteristics of the study designs, treatment protocols, or study populations.
Section snippets
Materials and methods
We searched Medline using PubMed on 7 July 2011 for studies of medical abortion using mifepristone and misoprostol. Our search strategy was as follows: (abortion OR pregnancy termination OR termination of pregnancy) AND (mifepristone OR RU 486 OR RU-486 OR RU486 OR Mifegyne OR Mifeprex OR Medabon) AND (misoprostol OR prostaglandin). In addition, we reviewed the reference lists of relevant articles, and we contacted experts in the field for information about any published or unpublished trials
Results
The Medline search yielded 860 citations. Of these, 81 included at least one group of women who were treated with an abortion regimen that used 200 mg mifepristone followed by misoprostol in viable first trimester pregnancy [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53],
Discussion
Medical abortion using mifepristone 200 mg followed by misoprostol in the first 63 days of gestation is remarkably effective and safe. In trials that together included more than 45,000 women conducted in disparate settings over nearly two decades using a variety of regimens and treatment protocols, fewer than 5% of subjects required surgery to complete termination of the pregnancy. The proportion who had ongoing pregnancy at follow-up — the outcome of greatest concern to clinicians — was 1.1%.
Acknowledgments
Financial support for this review was provided by an anonymous charitable foundation.
Reprints will not be available.
References (91)
- et al.
Unexpected heaping in reported gestational age for women undergoing medical abortion
Contraception
(2009) The combination of mifepristone and misoprostol for the termination of pregnancy
Int J Gynaecol Obstet
(2011)- et al.
Uterine contractility and induction of abortion in early pregnancy by misoprostol and mifepristone
Lancet
(1991) - et al.
Use of mifepristone and sublingual misoprostol for early medical abortion
Taiwan J Obstet Gynecol
(2006) - et al.
A pilot study of mifepristone in combination with sublingual or vaginal misoprostol for medical termination of pregnancy up to 63 days gestation
Contraception
(2003) - et al.
Termination of early pregnancy using flexible, low-dose mifepristone-misoprostol regimens
Contraception
(2007) - et al.
Results and lessons learned from a small medical abortion clinical study in Turkey
Contraception
(2004) - et al.
Factors affecting the outcome of early medical abortion: a review of 4132 consecutive cases
Br J Obstet Gynaecol
(2002) - et al.
The medical abortion experiences of married and unmarried women in Tunis, Tunisia
Contraception
(2004) Home administration of misoprostol for early medical abortion in India
Int J Gynaecol Obstet
(2010)
Mifepristone and misoprostol and methotrexate/misoprostol in clinical practice for abortion
Am J Obstet Gynecol
Can women in less-developed countries use a simplified medical abortion regimen?
Lancet
Sublingual misoprostol for first trimester termination of pregnancy
Int J Gynaecol Obstet
Mifepristone and vaginal misoprostol on the same day for abortion from 50 to 63 days' gestation
Contraception
Expanding medical abortion in Tunisia: women's experiences from a multi-site expansion study
Contraception
Acceptability and feasibility of medical abortion in Nepal
Int J Gynaecol Obstet
Concurrent use of mifepristone and misoprostol for early medical abortion
Taiwan J Obstet Gynecol
Simultaneous use of mifepristone and misoprostol for early pregnancy termination
Taiwan J Obstet Gynecol
Oral mifepristone and buccal misoprostol administered simultaneously for abortion: a pilot study
Contraception
Randomized trial of mifepristone and buccal or vaginal misoprostol for abortion through 56 days of last menstrual period
Contraception
Increasing access to safe abortion services in rural India: experiences with medical abortion in a primary health center
Contraception
A pilot study of mifepristone and misoprostol administered at the same time for abortion up to 49 days gestation
Contraception
Comparing two early medical abortion regimens: mifepristone+misoprostol vs. misoprostol alone
Contraception
Feasibility of telephone follow-up after medical abortion
Contraception
Mifepristone abortion in minors
Contraception
Mifepristone followed on the same day by vaginal misoprostol for early abortion
Contraception
Comparison of 400 mcg buccal and 400 mcg sublingual misoprostol after mifepristone medical abortion through 63 days' LMP: a randomized controlled trial
Contraception
Two-pill regimens of misoprostol after mifepristone medical abortion through 63 days' gestational age: a randomized controlled trial of sublingual and oral misoprostol
Contraception
Termination of early pregnancy by two regimens of mifepristone with misoprostol and mifepristone with PG05 — a multicentre randomized clinical trial in China
Contraception
Low-dose mifepristone 200 mg and vaginal misoprostol for abortion
Contraception
Mifepristone and misoprostol for early abortion when no gestational sac is present
Contraception
Low-dose mifepristone followed by vaginal misoprostol at 48 hours for abortion up to 63 days
Contraception
Randomized trial of oral versus vaginal misoprostol 2 days after mifepristone 200 mg for abortion up to 63 days of pregnancy
Contraception
Randomized trial of oral versus vaginal misoprostol at one day after mifepristone for early medical abortion
Contraception
A pilot study of mifepristone and misoprostol administered at the same time for abortion in women with gestation from 50 to 63 days
Contraception
Pilot study on the use of a two-week course of oral misoprostol in patients after termination of pregnancy with mifepristone and misoprostol
Contraception
Feasibility, efficacy, safety, and acceptability of mifepristone-misoprostol for medical abortion in the Democratic People's Republic of Korea
Int J Gynaecol Obstet
WHO multinational study of three misoprostol regimens after mifepristone for early medical abortion. I: Efficacy
Br J Obstet Gynaecol
Can midlevel health-care providers administer early medical abortion as safely and effectively as doctors? A randomised controlled equivalence trial in Nepal
Lancet
Abortion incidence and access to services in the United States, 2008
Perspect Sex Reprod Health
Immediate complications after medical compared with surgical termination of pregnancy
Obstet Gynecol
Mifepristone for early medical abortion: experiences in France, Great Britain and Sweden
Perspect Sex Reprod Health
The care of women requesting induced abortion: evidence-based clinical guideline number 7
Randomized trial of oral versus sublingual misoprostol 24 h after mifepristone for medical abortion
Arch Gynecol Obstet
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E.G.R. and C.S. conducted literature searches and abstracted data. M.A.W. performed statistical analyses. All authors contributed equally to interpretation and manuscript preparation. No authors have any conflicts of interest.