Clinical Scenario A 34-year-old p...

Clinical Scenario

A 34-year-old patient, gravida 3 para 2 has an unplanned pregnancy and prayers referral for abortion. Her last menstrual period began 39 days ago. She asks what you know about "the abortion pill."

<AA> Cochrane Abstract

Background. Surgical abortion from vacuum aspiration or dilatation and curettage up to 63 days' gestation has been the system of choice since the 1960 Medical abortion became an alternative manner of first-trimester pregnancy termination with the availability of prostaglandins in the early 1970 and anti-progesterones in the 1980 The greatest in number widely researched drugs are prostaglandins alone, mifepristone alone, methotrex-ate alone, mifepristone with prostaglandins, and methotrexate with prostaglandins.

Objectives. To compare different medical systems for first-trimester abortion.

Search Strategy. The authors (1) searched the Cochrane Controll Trials Register, MEDLINE, and Popline. intimation lists of retrieved papers also were searched. master-hands in the World Health Organization Human Reproduction Programme were contacted.

Selection Criteria. Randomized controll trials comparing different regularitys (e.g., single-drug and combination regimens), manners of application, or dosage regimens for medical abortion were considered. After assessment, trials were included if they had adequate randomization measure concealment of allocation, and follow-up Women in the first trimester of pregnancy who were undergoing medical abortion were the participants. Different medical rules used for first-trimester abortion, compared with each other or placebo, were included. issues included mortality, failure to achieve consummated abortion, surgical evacuation (as extremity procedure, non-emergency procedure, or undefined), ongoing pregnancy at follow-up time until passing of conceptus (more than three to six hours), kindred transfusion, blood loss (measured or clinically relevant globule in hemoglobin), days of bleeding, pain resulting from the action (reported by the women or measured from use of analgesics), additional uterotonics used, women's dissatisfaction with the action nausea, vomiting, and diarrhea.

Data Collection and Analysis. couple reviewers independently selected trials for inclusion from the accrues of the search strategy described previously. Trials in a less degree than consideration were evaluated for appropriateness for inclusion and methodologic quality without consideration of their flows A form was designed to facilitate the data extraction. Data were procedureed using Revman software.

Primary springs Thirty-nine trials were included in the review. Unles otherwise stated, the effectiveness issues refer to failure to achieve undivided abortion with the intended method

Mifepristone in a dosage of 600 mg compared with a dosage of 200 mg has similar effectiveness in achieving perfect abortion (four trials; relative risk [RR] 107; 95 percent confidence interval [CI], 087 to 132) Misoprostol administered orally is les effective (more failures) than misoprostol administered vaginally (RR 300; 95 percent CI, 144 to 624) and may be associated with more of common occurrence side effects, such as nausea and diarrhea.

Mifepristone alone is les effective than a combination of mifepristone and prostaglandin (RR 376; 95 percent CI, 230 to 615) Similarly, all unless one of the five trials comparing prostaglandin with the combined regimen reported higher effectiveness with the combined regimen. The flows of these studies were not loched but the RR of failure with prostaglandin alone is between 14 and 375 and the 95 percent CI indicates statistical significance.

In the same trial comparing gemeprost in a dosage of 05 mg with misoprostol in a dosage of 800 mcg misoprostol was more effective (failure with gemeprost: RR 286; 95 percent CI, 114 to 718) [Editor's note: Gemeprost is a prostaglandin available in the United Kingdom still not in the United States.] There was no difference between using a split dose or a single dose of prostaglandin.

There was no statistically significant difference in failure to achieve undiminished abortion when intramuscular methotrexate was compared with oral methotrexate (RR 204; 95 percent CI, 051 to 807) Similarly, early (day 3) versus late (day 5) administration of prostaglandin showed no significant difference (RR 072; 95 percent CI, 036 to 143) individual trial compared the effects of tamoxifen versus methotrexate, and no statistically significant differences were observ between the groups

Reviewers' Conclusions. Safe and effective medical abortion modes are available. Combined regimens are more effective than use of single agents. In the combined regimen, the dosage of mifepristone can be lowered to 200 mg without significantly decreasing effectiveness. Vaginal misoprostol is more effective than oral misoprostol. an results are based on small studies solitary and therefore carry some uncertainty. Almost all trials were leadershiped in hospital settings with fit access to support and urgency services. It is therefore not clear if the rises are readily applicable to under-resourced settings where of that kind services are lacking, even if the agents used are available.