Vaginal misoprostol administered at home after mifepristone for abortion - RU486

Journal of Family Practice, April, 1997 by Eric A. Schaff, Lisa S. Stadalius, Steven H. Eisinger, Peter Franks

Table 3 demonstrates the time intervals (1) from mifepristone to bleeding, (2) from vaginal misoprostol to cramping and bleeding, and (3) from beginning to cessation of bleeding. The average onset of bleeding after mifepristone was 3.0 days, and the average onset of bleeding after using misoprostol was 3.5 hours. Bleeding lasted an average of 16.3 days (SD, 11.7). Thirteen percent of the subjects received depo medroxy-progesterone acetate, and 49% were to start oral contraceptives on the following Sunday.

No subjects required a transfusion. One subject was hospitalized for heavy bleeding under unusual circumstances. She was a 27-year-old woman (gravida 5, para 1, therapeutic abortion 2, spontaneous abortion 1) with a 7.0-week gestation who presented with heavy bleeding on study day 2 before using misoprostol. Since the subject was unable to tell either her partner or primary physician about her medical abortion, she was hospitalized to prevent a spontaneous miscarriage. She was treated with intravenous fluids, and the bleeding slowed without surgical intervention. The gestational sac was not present at study day 5.

Eight subjects had moderate bleeding from 4 to 8 weeks after taking mifepristone; the bleeding required treatment with methylergonovine or misoprostol orally for presumed retained products or doubling of oral contraceptive pills for presumed breakthrough bleeding. Five of these subjects responded to conservative treatment. Three subjects required surgical intervention as noted earlier. Three additional subjects with study gestations of 47, 51, and 52 days presented with pelvic pain and uterine tenderness 2, 10, and 5 days after a negative TVS. Their condition was diagnosed clinically as endometritis, and they were treated with oral antibiotics and responded well.

Table 4 provides the symptoms noted by subjects from each medication. One third of the subjects reported nausea to both medications. One hundred thirteen (68%) of the subjects used an oral narcotic analgesic. Table 5 shows the results of the acceptability questionnaire. Ninety-six percent of the subjects agreed that the procedure "went well." Nine (5%) subjects found the side effects of the medications unacceptable and had comments that included a request for more pain medicine and medication for nausea and diarrhea. Although 22 (13%) subjects found the pain unacceptable, only 2 of these 22 subjects found the overall procedure unacceptable. Of the 9 (5%) subjects who found that taking misoprostol at home was unacceptable, their responses to open-ended questions included that being alone, the "crampy" pain, and the 48-hour wait were problematic. Only one of these 9 subjects found the overall procedure unacceptable. There was no significant difference between the acceptability ratings of the women when controlled for prior surgical abortion, so the data are reported as combined results.

DISCUSSION

Vaginal misoprostol after mifepristone was highly effective at inducing abortion in women up to 8 weeks' gestation. All the subjects had vaginal bleeding within 5 days of using mifepristone. Of note the majority of women with bleeding before taking misoprostol still used misoprostol The consistent bleeding response in this study is in marked contrast to abortion induced by methotrexate where only two thirds of the women begin to bleed in the first week.