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

Although subjects in this study were offered the option to use misoprostol in the office and be observed for 4 hours, all but three used misoprostol at home. The counselors in the study were experienced with methotrexate and home self-administered misoprostol and were biased toward reassuring women about home use of misoprostol unless the woman was to be alone during insertion. Almost 90% of the subjects found home use of misoprostol acceptable. The concern about excessive bleeding requiring intervention occurring in the first 4 hours of observation was not confirmed in this study. Providers may find home-administered misoprostol more acceptable because there is one fewer visit and therefore associated decreased costs, less staff is needed to monitor misoprostol use, and there is less demand on office facilities such as bathrooms. On the other hand, some providers may find the 24-hour telephone availability and need for surgical backup for excessive bleeding problematic.

Six subjects required additional misoprostol. (One subject was given one-third dose of misoprostol, which was not part of the protocol.) This is in marked contrast to methotrexate- induced abortion, where multiple doses of misoprostol ate common. Repeat doses of misoprostol after mifepristone have not been shown to effect complete abortion rates but can decrease the integral to expulsion. (7)

Complications experienced by study participants included endometritis (n=3); excessive bleeding requiring hospitalization (n=1); and persistent bleeding and incomplete abortion (n=3). Endometritis following a medical abortion is unusual in our experience with methotrexate; although it occurred in three of our study subjects, it has not been reported in the methotrexate-induced abortion literature. A larger sample size is needed to determine if this frequency continues. The three subjects who eventually required an aspiration (surgical) procedure had normal TVS at their first follow-up visits. We have also seen this with methotrexate subjects, le, subjects with a negative TVS can still have retained products of conception. Therefore, persistent vaginal bleeding unresponsive to conservative treatment should be evaluated with [beta]-hCG and TVS and treated with an aspiration dilation and curettage procedure, if indicated.

The medications were highly acceptable to our subjects; no difference was noted by subjects who had had a prior surgical abortion. In response to open-ended questions, the subjects commented that the privacy and the 24-hour availability of a clinician were appreciated. While almost all women experienced "crampy" pain, two thirds of the women used acetaminophen with codeine for this pain, and only 12 found the pain unacceptable. The availability of pain medications probably made the pain acceptable for many subjects.

The results of the acceptability questionnaire may be skewed owing to the lack of randomization of the study and the likely selection of subjects who may have had negative experiences or feelings about surgical abortion. The duration of bleeding may be less than in previous reports from medical abortion because of the use of hormonal contraception after the abortion that may have affected bleeding patterns.