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Objective - There are many drugs regimens used in medical abortion between 7 and 9 weeks of amenorrhea (WA). The main objective of our study was to compare the efficacy of different routes of administration (oral, sublingual/buccal or vaginal) and doses of misoprostol. Methods - A prospective, randomized, single-center study comparing the efficacy of three routes of administration and two doses of misoprostol in drug-induced medical abortion between 7 and 9WA. Our primary criterion of outcome was defined as complete evacuation of pregnancy on ultrasound at three weeks. Results - 127 patients were included between June 1, 2017 and February 28, 2018. The overall success rate was of 72.6% for a failure rate of 27.4% with a rate of continuing pregnancy of 8.8%. We found no significant difference between the routes of administration (p=0,854) and the dose (p= 0,729). Discussion - Our success rate is low compared to other studies, however the evaluation of uterine vacuity was not always well specified in the literature. In addition, we included more women in the oral route, while a 2011 meta-analysis showed superiority of other routes of administration of misoprostol compared over the oral route. Conclusion - We failed to demonstrate significant difference between the routes of administration and doses of misoprostol, due to lack of potency. Since the withdrawal of Cytotec®, there is the question of health expenses related to abortion and the use of drugs made available.; Introduction - Il existe de nombreux schémas médicamenteux utilisés dans l’IVG entre 7 et 9 semaines d’aménorrhée (SA). L’objectif principal de notre étude était de comparer l’efficacité des différentes voies d’administration (per-os, sublinguale/intra-jugale ou vaginale) et doses du misoprostol. Matériel et méthodes - Étude prospective, randomisée, monocentrique, comparant l’efficacité de trois voies d’administration et de deux doses du misoprostol dans l’IVG médicamenteuse entre 7 et 9 SA. Notre critère de jugement principal était défini comme l’évacuation complète de la grossesse à l’échographie à trois semaines. Résultats - 127 patientes ont été incluses entre le 1er juin 2017 et le 28 février 2018. Le taux de succès global était de l’ordre de 72,6% pour un taux d’échec de 27,4% avec un taux de grossesses évolutives de 8,8%. Nous n’avons pas mis en évidence de différence significative entre les voies d’administration (p=0,854) et la dose (p=0,729). Discussion - Notre taux de succès est faible par rapport aux autres études, toutefois l’évaluation de la vacuité utérine n’était pas toujours bien précisée dans la littérature. De plus, nous avions inclus plus de femmes dans la voie per-os, alors qu’une méta-analyse de 2011 mettait en évidence une supériorité des autres voies d’administration du misoprostol par rapport à la voie orale. Conclusion - Nous n’avons pas réussi à mettre en évidence de différence significative entre les voies d’administration et les doses du misoprostol, en raison d’un manque de puissance. Depuis le retrait du Cytotec®, se pose la question du coût des dépenses de santé liées à l’IVG et de l’utilisation des médicaments mis à disposition.

Objectives : to assess the pain feeling during medical abortion at home or at hospital during 5 days. Materials and methods : monocentric descriptive study through 52 questionnaires given to women who chose to undergo medical abortion at the CHU of Caen from september 2017 to january 2018. Results : pain feelings during medical abortion are variable according to women. 25% of women describe a maximal pain level superior or equal to 8 to 10. A gestational age superior to 7 weeks of amenorrea and no delivery in medical history are associated to higher pain level. Younger women are more likely to use analgesic treatment longer. The study couldn t highlight links between psycho-social context and severe pain. 98% of women are satisfied with the pain management. Conclusion : it is necessary to bring efficient pain management to women during medical abortion. Grade 2 analgesics utilisation should be extend when ibuprofen is not enough efficient in pain management.; Objectifs : évaluer le ressenti de la douleur des femmes lors d'une IVG médicamenteuse à domicile ou en hospitalisation pendant 5 jours. Matériel et méthode : enquête descriptive unicentrique au travers de 52 questionnaires distribués aux femmes en demande d IVG médicamenteuse au CHU de Caen de septembre 2017 à janvier 2018. Résultats : le ressenti de la douleur lors d'une IVG médicamenteuse est variable selon les femmes. Un quart des femmes décrivent un score de la douleur maximale supérieur ou égal à 8 sur 10. Le terme de la grossesse supérieur à sept semaines d'aménorrhée et la nulliparité sont associés à des douleurs intenses. Le jeune âge de la femme est associé à une durée de traitement antalgique plus longue. L'étude n'a pas montré de lien entre le contexte psychosocial de la femme et le ressenti de douleurs intenses. 98% des femmes sont satisfaites de la prise en charge de la douleur. Conclusion : il est important d'apporter une prise en charge de la douleur efficace aux femmes lors d'une IVG médicamenteuse. L'utilisation d'un antalgique de palier II lors de l'insuffisance de l'ibuprofène dans la prise en charge de la douleur devrait être élargi.

To describe the social characteristics of women seeking a medical abortion, and the conditions of that abortion, according to whether they had one or more previous induced abortions.An observational study was carried out in 11 French units in 2013-2014, among women 18 years or older. A self-administered questionnaire on the abortion context and social situation was given to them, as well as a diary to record the pain level for each of five days following the mifepristone intake. The sample included 453 women.Among the respondents, 22% had had one previous abortion and 8% had had two or more. Women having had a previous voluntary abortion were more often isolated and in a poorer social situation than women having their first abortion.Better support for contraception after abortion could reduce the number of repeated abortions.

Contexte : 229.000 IVG ont été réalisées en France en 2013. Ces dernières années, l’IVG par médicaments est devenue la méthode la plus utilisée. Bien qu’elle soit moins invasive, elle est considérée comme la méthode la plus douloureuse. Objectif : nous avons voulu évaluer l’intensité et la prise en charge de la douleur physique ressentie chez les femmes ayant recours à une IVG médicamenteuse au sein du CHU d’Amiens, et dans un second temps définir d’éventuels facteurs prédictifs de cette douleur afin d’en améliorer la prise en charge. Méthode : nous avons réalisé une étude observationnelle, descriptive à l’aide d’un questionnaire anonyme distribué aux patientes effectuant leur IVG dans le service d’orthogénie du CHU d’Amiens. Résultats : 67 questionnaires ont pu être analysés. L’END moyenne ressentie lors de l’IVG était de x sur 10, et 17 patientes (25,8 %) ont ressenti une douleur maximale supérieure ou égale à 6 sur 10. Nous avons pu définir de manière significative que les dysménorrhées étaient liées à une douleur intense.

Introduction : En France, l’IVG concerne 219000 grossesses et dans plus de la moitié des cas, la méthode est médicamenteuse. Méthodes : Cette étude rétrospective a été menée au CHU d’Amiens entre le 1er janvier 2014 et le 28 février 2015 chez 812 patientes ayant réalisé une IVG médicamenteuse jusqu’au terme de 9 SA, selon le protocole associant la prise de 200 mg de mifepristone à 400-800 μg de misoprostol par voie orale. Une échographie pelvienne était réalisée systématiquement au décours afin d’évaluer le résultat de l’IVG. L’objectif principal était de déterminer le succès de la procédure, sans recourir à un traitement chirurgical secondaire. Les objectifs secondaires étaient l’analyse de l’échographie comme moyen de surveillance, les facteurs de risque d’échec et la survenue de complications. Résultats : Le taux d’efficacité complète de la procédure était de 90,6% (n=734). Le principal facteur de risque d’échec était le terme de la grossesse au moment de l’IVG. 58 patientes ont bénéficié d’une aspiration en raison d’une rétention complète (21 patientes pour une grossesse évolutive, 37 pour une grossesse arrêtée), 16 pour une rétention partielle et 4 ont souhaité poursuivre la grossesse. Parmi ces échecs, 13 aspirations ont été réalisées dans un contexte d’urgence. L’interprétation de l’échographie (p=0,018) et la prise en charge des patientes (p=0,001) étaient différentes selon l’expérience de l’opérateur. Les complications étaient rares (1,6%) : douleurs pelviennes, métrorragies, anémie, infections génitales. Conclusion : La prise en charge de l’IVG médicamenteuse au CHU d’Amiens est satisfaisante avec un taux d’efficacité correct et des complications minimes. Une amélioration est envisageable par l’administration de 800μg de misoprostol par voie buccale, sublinguale ou vaginale ainsi qu’une harmonisation des pratiques concernant le suivi.

Interstitial pregnancy accounts for 3 to 11% of ectopic pregnancy; these pregnancies are the more frequently non-tubal ectopic pregnancy. Medical treatment can be used in case of unruptured interstitial pregnancy and is used more and more frequently to avoid hemorrhagic risk and risk of conversion to radical surgery when a surgical management is decided. However, a larger use of methotrexate in interstitial pregnancy and conditions of use are not clearly defined. The aim of this study is to report a series of unruptured interstitial pregnancy managed by in situ injection of methotrexate.This retrospective observational study included women treated for an interstitial pregnancy between 2010 and 2013 in a teaching hospital. Medical management used was an in situ injection of methotrexate (1mg/kg) guided by vaginal sonography plus an intramuscular injection of methotrexate (1mg/kg) in the 48hours following in situ injection and 600mg of mifepristone when progesterone blood rate was more than 9ng/mL. A great decrease of serum hCG without surgery was considered a success.Fourteen women had an interstitial pregnancy during the study period. Six were managed surgically in 5 cases for suspicion of uterine rupture and one for pregnancy of unknown location. Eight women had a medical management and the success rate was 100%. Mean time for decrease of serum hCG until 2 UI/L was 54.4 days [34.0-74.8]. No uterine rupture or immediate complication was reported. Five women out of 8 had a spontaneous pregnancy after management of interstitial pregnancy.Medical management by in situ injection of methotrexate under sonographic guidance with an intramuscular injection within the 48hours following the in situ injection and mifepristone when ectopic pregnancy was active can be proposed in first-line therapy in case of unruptured interstitial pregnancy. This treatment has a great efficiency and low rate of complications.

To propose a protocol for induction of labor to terminate pregnancy after 22weeks of amenorrhea allowing to decrease the duration of labor and of hospitalization but also, allowing to reduce the number of emergency pretreatment-induced fetal death, to improve the experience of the patients and to limit the cost.We realized a retrospective single-center study including 269patients and comparing three protocols, with and without laminaria and with various intervals mifepristone-misoprostol (14 and 38hours). The outcome measures were the misoprostol-delivery interval, the delivery time and the number of emergency pretreatment-induced fetal death.We showed that the misoprostol-delivery interval and the delivery time were comparable for the three periods of our study, even after decrease of 24hours of the mifepristone-misoprostol interval and in the absence of laminaria. The misoprostol-delivery interval was between 7h30 and 8h35 between protocols (P=0.055). The delivery time was between 5:18pm and 6:48pm between protocols (P=0.252). The early administration of misoprostol allowed the patients to give birth earlier (P=0.001). Finally, we showed that the increase of the size and the number of laminarias were risk factors of emergency pretreatment-induced fetal death (respectively P=0.013 and P=0.002).The absence of laminaria and the reduction of the interval mifepristone-misoprostol of 24hours do not change the time to delivery and allow to reduce the duration of hospitalization, the number of emergency pretreatment-induced fetal death and the cost of the TOP.

To offer a therapeutic management of cesarean scar pregnancies (GSC) in the first trimester of pregnancy with a first approach by uterine artery embolization (UAE) PATIENTS AND METHODS: This study describes seven cases of GSC diagnosed between 2009 and 2013 in the clinic of the University Hospital of the Hospital of Croix-Rousse. We present the symptoms and how imagery has led to the diagnosis and the therapeutic management conducted.The mean gestational age at diagnosis was 9 weeks gestation. There were ongoing pregnancies with cardiac activity present for each patient. An additional MRI was performed in five patients. Five patients were treated with methotrexate injection, two patients received the Mifegyne. All patients then received a selective uterine artery embolization. Finally within 48hours, suction curettage was performed in 6 patients. A patient at 13 WA+1 required a subtotal hysterectomy for placenta accreta. Intra-operative complications were represented by a bladder injury, two bleeding of 1000mL in patients at 13 WA+1 and 12 WA. For the 6 cases of GSC with a gestational age less than 10 WA, average blood loss was less than 500mL. Three patients underwent resection of scar isthmocele confirmed by EVAC. An intrauterine pregnancy was carried to term after care.Cesarean scar pregnancies is a diagnostic and therapeutic challenge, which should be diagnosed as early as soon as possible with care in a medical facility with a uterine artery embolization technical platform. Our protocol combining Mifegyne and methotrexate for termination of pregnancy and uterine artery embolization (UAE) followed by curettage for evacuation of pregnancy allows conservative treatment while minimizing the risk of bleeding (for GSC diagnosed before 10 WA).

A retrospective monocentric clinical trial was performed to evaluate the efficacy of the association of mifepristone and misoprostol for the management of early pregnancy failure.Ninety-two women with early pregnancy failure or anembryonic pregnancy were first treated with 600 mg of mifepristone and 48 hours later with 400 μg of misoprostol by oral administration. Successful treatment, defined as an empty uterus, was searched at day 3, with the association of misoprostol-mifepristone alone or with complementary medical treatment, prostaglandins or ocytocine.The overall treatment success was 82% (75 of 92 women) with 69 successful cases at day 3 (75%). Six of 92 women (7%) needed a second-line medical treatment. For the last 17 women (18%), the failure of the associated tested medical treatment lead to a secondary surgery. No prognostic factor for the successful medical treatment has been highlighted.A high efficacy for the management of early pregnancy failure is demonstrated for the mifepristone and misoprostol medical treatment. The specific contribution of mifepristone, although proven in the cases of termination of evolutive pregnancies, should be further evaluated in the future for the specific management of early pregnancy failure. Nevertheless, no prognostic factor for the success of the propose treatment can be determined, as the amount of patients enrolled in this study was not sufficient.

Le taux de recours à l'IVG à La Réunion est de 22 pour 10000 femmes, et la part des IVG par méthode médicamenteuse ne cesse de progresser. Le taux d'efficacité de cette méthode est globalement satisfaisant (environ 92%), néanmoins il persiste un certain nombre d'échec. En étudiant les caractéristiques épidémiologiques des femmes réunionnaises ayant eu recours à l'IVG médicamenteuse, nous avons cherché à identifier des facteurs de risque d'échec de cette méthode. Méthodes : Étude rétrospective dans un centre d'orthogénie de l'ouest de La Réunion. Entre le 1er mai et le 31 décembre 2012, toutes les femmes ayant eu recours à l'IVG médicamenteuse jusqu'au 63e jour d'aménorrhée ont été inclues (226 patientes). Le protocole médicamenteux associait 600mg de Mifepristone à 400ug de Misoprostol. Nous avons comparé les caractéristiques épidémiologiques de ces femmes en fonction de l'"échec" ou du "succès". Résultats : L'efficacité globale de la méthode était de 63%. Les échecs étaient représentés par des rétentions intra utérines (31%), des grossesses évolutives (4,5%) et des curetages hémostatiques (1,5%). L'antécédent d'IVG chirurgicales était un facteur de risque d'échec, avec un risque multiplié par plus de 10 (OR : 11,5 ; IC95% 2,4-54,8) pour les femmes y ayant eu recours au moins 2 fois. Nous avons retrouvé une diminution de l'efficacité de la méthode pour les femmes d'âge avancé (27,5 +/- 7,0 vs 26,3 +/- 7,6) et les multipares (67% vs 59,5%). Les caractéristiques épidémiologiques étaient marquées par un nombre élevé de grossesses (3,0) et d'enfants (1,4) avant l'IVG, un taux de recours important aux IVG itératives (40%), et une grande part de mineures (9,5%). Conclusion : Il convient d'informer les patientes aux antécédents d'IVG chirurgicale qu'une aspiration assurerait un succès supérieur. De nouveaux travaux doivent être mis en œuvre pour évaluer et améliorer le succès de la méthode.

Better management of patients with cystic fibrosis has resulted in an increased rate of pregnancy, especially in mild forms. In case of severe respiratory impairment, physiological changes occurring during pregnancy can be life threatening. Medical termination of pregnancy may be necessary. We report a case of severe cystic fibrosis requiring a termination of pregnancy due to significant maternal risk at 17 weeks of gestation. Mifepristone used for induction of labor has a well-known antiglucocorticoid action. We discuss here its potential effect on the onset of an acute pulmonary failure in this patient with long-term corticosteroid therapy.

International audience; OBJECTIVE: To assess the efficacy of medical abortion performed according to a single protocol from 12 through 14 weeks. STUDY DESIGN: Retrospective observational study of medical abortions from 12 through 14 weeks performed from January 2007 through March 2009. The protocol combined 600 mg de mifepristone orally, followed 48 h later by 400 μg of misoprostol, administered orally, and repeated after 3h, four times a day (during two days), if patient did not begin to abort. Outcome measures were the abortion rate, the rate of complication, the rate of manual uterine revision or vacuum aspiration, the time of expulsion and the misoprostol dose. RESULTS: The study included 126 medical abortions. The abortion rate was 98% and the secondary manual revision or vacuum aspiration rate was 41%. The mean time to expulsion was 10.4 (±8.8)h, and the mean misoprostol dose 1040 (±420) μg. Higher parity was significantly correlated with shorter time to expulsion (P=0.02). CONCLUSION: Medical abortion was consistently effective from 12 through 14 weeks but with high rate of secondary manual revision or vacuum aspiration.

Objectifs. - Les objectifs de notre étude ont été de décrire la prise en charge des IVG chez des patientes avec un antécédent de césarienne, d'identifier la méthode utilisée en fonction du nombre de cicatrice et du terme, de décrire les modalités de prise en charge et d'évaluer le taux de complications survenues suite à l'IVG. Méthode. - Nous avons utilisé les dossiers des patientes avec un utérus cicatriciel qui ont eu recours à une IVG au cours de l'année 2009 à l'Hôpital Couple-Enfant de Grenoble. Résultats. - Cent trente dossiers ont pu être exploités. 82.3% des IVG ont été réalisées par la méthode chirurgicale et aucune IVG n'a été effectuée par la méthode médicale après 9 SA. Les patientes qui ont pu bénéficier d'une IVG par la méthode médicale avaient, pour 95.6%, une seule cicatrice de césarienne. Le taux global de complications est de 10%. Les complications qui ont été retrouvées sont les lésions du col avec un taux de 2.3%, 7.7% de saignement modéré et 2.3% d'échec de l'IVG. Conclusion. - L'IVG par la méthode chirurgicale est la plus employée chez les patientes porteuses d'une cicatrice utérine. Elle est pratiquement toujours utilisée sur les utérus multi-cicatriciels et est la seule méthode réalisée après 9 SA. Les complications n'ont pas été plus importantes sur les utérus multi-cicatriciels, ni en fonction d'un âge gestationnel avancé.

To assess the efficacy of medical abortion performed according to a single protocol from 12 through 14 weeks.Retrospective observational study of medical abortions from 12 through 14 weeks performed from January 2007 through March 2009. The protocol combined 600 mg de mifepristone orally, followed 48 h later by 400 μg of misoprostol, administered orally, and repeated after 3h, four times a day (during two days), if patient did not begin to abort. Outcome measures were the abortion rate, the rate of complication, the rate of manual uterine revision or vacuum aspiration, the time of expulsion and the misoprostol dose.The study included 126 medical abortions. The abortion rate was 98% and the secondary manual revision or vacuum aspiration rate was 41%. The mean time to expulsion was 10.4 (±8.8)h, and the mean misoprostol dose 1040 (±420) μg. Higher parity was significantly correlated with shorter time to expulsion (P=0.02).Medical abortion was consistently effective from 12 through 14 weeks but with high rate of secondary manual revision or vacuum aspiration.

To propose a new home safe abortion protocol and effective immediate contraception.Four hundred women undergoing home safe abortion with RU 486. Hundred accepted to start contraception with Evra® patch.Concerning home abortion, the failure rate of the protocol was only 3% (12 cases). Concerning contraception, the continuation rate was 50% (50 cases).Early home abortion is a promising method to propose an immediate contraception. The Evra® patch is well accepted and appears to be a first line contraceptive choice.

Mifepristone, a progesterone receptor antagonist steroid, can reduce uterine fibroid tumours' growth by several pathways. Its efficiency has been widely evaluated in symptomatic patients for more than 10 years. A significant decrease in fibroid tumours and uterine volume concomitant with better quality of life scores can be obtained with a daily administration of Mifepristone 5mg. Mifepristone can be compared with GnRH agonists in terms of efficiency. Observed adverse outcomes are hot flushes (38%), elevated hepatic enzymes (4%) and benign endometrial hyperplasia (28%). Hot flushes and endometrial hyperplasia are not observed with 5mg daily doses. Data suggest that many invasive procedures could be avoided with the routine use of Mifepristone for fibroid tumours care. However, published study periods are only three to 12 months: long lasting evaluation in larger groups of patients seems necessary before this treatment could be proposed as routine care.

In France, since 2001, medical abortion can be performed in ambulatory conditions, provided an agreement is signed with a hospital serving as referral for complications or failures of the method. This study, reports on the experience of a family planning center (NGO MFPF, Mouvement français de planning familial) in partnership with Delafontaine Hospital in Saint-Denis. In 2004, the MFPF has managed 161 cases of ambulatory medical abortion using a protocol of 200mg of mifepristone on day 1 and 400 to 800 microg of misoprostol on day 3, with possibility for the women to stay at home or go to the hospital for the expulsion. The average age of the women was 24 years and the proportion of young and vulnerable women quite high. The rate of success, defined as the absence or surgical intervention, approached 94.5% and only one case of severe complication was reported, massive hemorrhage 40 days after the initial intake of misoprostol. 75% of women chose to stay home. Acceptance of the method was very good with minimal request for more consultations than the three visits proposed in the protocol. The quality of the follow-up was high with 82% of women attending the medical check, with no difference being observed with regard to age, obstetrical history or socio-economic groups. Ambulatory medical abortion was successful and safe even among vulnerable women. NGOs with multidisciplinary staff involving counsellors, nurses and doctors can offer high quality preparation and follow-up.

To assess the clinical efficacy of mifepristone 100 mg followed two days later by misoprostol 400 microg orally in women undergoing medical termination of pregnancy up to 56 days gestational age.Retrospective study over 8.5 months of 762 cases early medical abortion. 100 mg mifepristone was used on day 1 after clinic visit and vaginal ultrasonography. Misoprostol 400 microg was administered orally on day 3. Following administration of prostaglandin, women were observed in the ward for 4 hours. A control visit on day 15 was systematic. Success was defined as a complete uterine evacuation without the need for surgical intervention.Medical terminations accounted for 42% of all abortions. 16% of women were pregnant for42 days, 76% for 43 to 49 days and 8% for 50 to 56 days. Termination occurred within 4 hours after administration of misoprostol in 80.2% of the women. Only one woman aborted within 48 hours of mifepristone administration only. The success rate in this study was 94.4% and the failure rate increased with the gestational age. Pain was the predominant side effect. Six cases of bleeding required a surgical intervention. No patient required transfusion. 96% of patients attended a control visit on day 15. The acceptability rate of the method has been 94%.Mifepristone 100 mg followed two days later by misoprostol 400 microg orally is safe and effective for early termination of pregnancy.

Mifepristone, a derivative of norethindrone, a first generation synthetic progestative, has a very potent antiprogestative activity and to a lesser degree antiandrogenic and antiglucocorticoid activities. This action makes it potentially useful in the treatment of multiple hormone dependent diseases in obstetrics-gynecology as well as in a variety of medical specialties such as neurology, ophthalmology, and oncology. Nevertheless, the label of abortive pill has incited numerous ethical and political debates concerning the permission to market this drug, and this has contributed to the delay in the assessment of the potential indications of mifepristone. Largely under-utilized in practice despite its increasing theoretical benefit, clinical studies should now de conducted. Thus, based on an international review of literature during the last ten years, we have shed light on the present and potential indications of mifepristone in medical practice.

Medical treatment of ectopic pregnancy is widespread. To increase the efficacy of methotrexate, combination with mifepristone has been proposed.We performed a large prospective multicentre double-blind sequential randomized trial in order to compare the efficacy of methotrexate and mifepristone (600 mg given orally) versus methotrexate and placebo.Two hundred twelve ectopic pregnancies were randomized. There was no significant difference in the initial characteristics between the 2 groups. There was no significant difference in the success rate of medical treatment between the methotrexate-mifepristone (n=113) and the methotrexate-placebo group (n=99): 79.6% (90/113) vs 74.2% (72/97) respectively, RR [95% CI]: 1.07 [0.92-1.25], p=0.41. However, there was a quantitative interaction between progesterone level and effect of treatment: when progesterone level was 10 ng/l, the efficacy of the combination of mifepristone and methotrexate was significantly higher than the combination of methotrexate and placebo, with a 83.3% success rate (15/18) vs 38.5% (5/13) respectively.Our study failed to demonstrate any benefit of the addition of mifepristone to methotrexate. By contrast, the quantitative interaction between treatment effect and base line serum progesterone suggested that this combination could be reserved to ectopic pregnancies associated with high serum progesterone concentrations.

Until July 2001 medical abortion was only authorized in France in public hospitals or private clinics. A new law effective in July 2001 allows private practitioners (gynaecologists or general practitioners) to provide medical abortion in their offices as long as they are linked to a hospital official agreement. Unfortunately mifepristone was not available outside hospitals before September 2004, so the study was conducted still providing the drugs in the hospital family planning clinic.To evaluate the efficacy and the acceptability of mifepristone medical abortion with home administration of misoprostol provided by private practitioners linked with the hospital.Four hundred thirty-three women seeking medical abortion before 7 weeks LMP were included between 2 January 2003 and 7 July 2004. All consultations before abortion and 2 weeks after abortion took place in a private provider's office. Drugs were administrated in the hospital family planning clinic: patients were given 3 tablets of mifepristone (600 mg) orally by the midwife and received 2 tablets of misoprostol (400 microg) that they would take at home 48 hours later. In case of any problems or complications, patients could phone or meet their private providers, phone the hospital midwife or go to the hospital emergency service. Private providers received training in medical abortion training and could at any time reach a medical specialist in the hospital family planning clinic for information or to refer a patient.- Efficacy was evaluated for 339 women, because 94 patients were lost to follow-up (21.7%). Efficacy of medical abortion was 93.8% (318/339). There were 21 surgical aspirations (6.2%): for women's decision in 1.5% of cases, for medical decision without complications in 3.5% of cases, and for failure of the method in 1.2% of cases (2 ongoing pregnancies and 2 heavy haemorrhages with transfusion). The family planning midwife received a phone call from 21 patients after mifepristone (4.8%), Twenty-five patients had an emergency consultation (5.7%), and 22 patients went back to their private providers before their appointment for follow-up (5%). Twenty-two patients (5%) were referred by the private provider to the hospital medical specialist. Acceptability is known for 26% of patients; 96.2% thought that the abortion procedure was acceptable.The failure rate of medical abortion in this study is largely due to aspirations for incomplete abortion. To improve the efficacy of medical abortion offered by private providers linked with the hospital, all the relevant professionals (private providers, residents in the emergency service, family planning providers) must be well trained in medical abortion, especially in how to interpret and react to ultrasound images obtained in the follow up visit. The procedure is very acceptable to women. Medical abortion offered via a network should be well accepted by practitioners, since only 5% of women will need more than two consultations and only 6.2% will need surgical aspiration in the hospital. This study allows us to be optimistic about the expansion of medical abortion in France outside the hospital via a provider-hospital network based on the fact that since September 2004 private providers can get mifepristone directly in the pharmacies of the city.

To demonstrate the effectiveness and safety of mifepristone 600mg with misoprostol 800 mg, for termination of pregnancy at 9-14 weeks gestation.This prospective study included 105 women at 9 to 14 weeks gestation given 800 mg of vaginal misoprostol, 2 or 3 days after a single dose of 600 mg of mifepristone for pregnancy termination. Outcomes measures included mean expulsion time, the interval between fotal and placental expulsion, adverse effects, vaginal bleeding, requirement for analgesia, and hospital stay, analyzed by parity and gestational age.Pregnancy termination was successful in 92.4% of the patients without requirement for surgery. The mean time to expulsion was 6 hours. The fetus and placenta were expelled together in 79% of the cases. In 15% the conception products were retained in the cervical canal, and removed with a ring forceps. Additional misoprostol doses were necessary in 33% and analgesia (nalbuphine sublingually, mean dose was 10mg) in 56%. Significant bleeding was observed in 7.5%, leading to curettage in 2 patients. No statistically significant differences were found between the rate of success and term (9-12 versus 12-14) or parity.Combining oral mifepristone and vaginal misoprostol is a successful alternative to surgical termination of pregnancy, even after 9 weeks' gestation. The use of nalbuphine for analgesia improves acceptability; sublingual administration helps avoid invasive procedures. Before 14 weeks gestation, the legal limit for termination of pregnancy in France, the choice between the surgical and medical alternatives should be left to the patient.

To compare the mode of delivery in two groups of patients selected by their response after induction of labour with mifepristone.We studied retrospectively 89 cases of labour induction with viable children after 41 weeks of gestation. Bishop scores were less than 6. Patients were given 200 mg of mifepristone per day for 48 h. They were retrospectively divided into group 1 (spontaneous onset of labour or premature rupture of membranes before the third day) and group 2 (not in labour by that date).The mean Bishop score at inclusion was 3.1 +/- 1.3. Among the 51 patients (53.9%) in group 1, one required prostaglandins and we performed 10 cesarean sections. In group 2, the mean Bishop score at the 3rd day was 4.4 +/- 1.3 (P0.0001). Twenty-four patients required prostaglandins (P0.0001) and we performed 17 cesarean sections (P = 0.01). The number of cesarean sections increased with the dose of prostaglandins (P = 0.025). We observed no maternal or fetal complications.Mifepristone was successful in inducing labour spontaneously in over 50% of pregnancies after 41 weeks of gestation. In the other group, the probability of vaginal delivery was reduced especially when high doses of prostaglandins were required. After the use of mifepristone, we suggest to shorten the duration of prostaglandin administration (two applications of 2 mg dinoprostone) before performing cesarean section.

The object of this trial was to appreciate the acceptability of Misoprostol home use in medical abortion.From 1 January 2001 to 28 February 2002, 120 voluntary patients were included in the study of medical voluntary pregnancy interruption with Misoprostol at home, and 289 patients were using the protocol "Misoprostol at hospital".The method was well tolerated by all patients.The protocol "Misoprostol at home" is accepted under certain conditions: strict criteria selection, strict rules of security, good counseling of patients, and finally the availability at the telephone of the gynecologist to respond to any eventuality.

Antiprogestins are a promising class of therapeutic agents in the field of reproductive health. Mifepristone (exRU486) remains the leading compound of this class and is the only one presently used in clinical practice. Beyond the main action of antiprogestins on human pregnancy, these compounds may prove useful in the treatment of uterine leiomyomas and endometriosis, and for contraception. IN CANCEROLOGY: Rare tumors such as meningiomas or leiomyoarcomas expressing progesterone receptors may be successfully treated with these antihormones. MAIN INDICATIONS: The main characteristics of the different antiprogestins discovered so far are addressed and the key results from the large clinical studies conducted with mifepristone are described here for indications where the product is approved for clinical use: medical termination of pregnancy during the first trimester, cervical dilatation prior to surgical termination of pregnancy, preparation for prostaglandin action in the therapeutic termination of pregnancy beyond the first trimester, labor induction in case of foetal death in utero.

To evaluate a new protocol for mid and third trimester medical termination of pregnancy using RU 486-misoprostol-epidural analgesia.Monocentric, prospective and descriptive study in a teaching hospital.Eighty-three women undergoing legal induced abortion during the second and third trimester. Administration of 600 mg mifepristone 36 hours prior to laminaria tents. 48 hours after RU 486, misoprostol was orally given on a 3 hours basis. Epidural analgesia was systematically performed.Induction-abortion interval, median dose of misoprostol, maternal complications, number of fetal autopsies obtained within 24 hours.The mean induction abortion interval was 3 h for multiparas and 4.45 h for nulliparas. The median dose of misoprostol was 800 micrograms. A uterine rupture on a scarred uterus occurred. The rate of fetal autopsies in cases of malformations within 24 hours reached 96%.This protocol allows a safe, rapid, cheap and painless late termination of pregnancy, when compared to other protocols.

New perspectives have been envisioned for the TOP instrumental technique, through the utilization of pharmacologic products, whose property is to dilatate the cervix. Misoprostol or mifepristone, when administrated to a patient a few hours before a TOP by uterine suction curettage, enables a dilatation of the cervix in such a way that it allows the surgically induced abortion to be carried out with local anesthesia, under optimal comfort conditions for the patients as well as for the operator.

In 1989 the French Ministry of Health gave its agreement to the utilisation of the combination mifepristone + a prostaglandin analogue for abortion up to 49 DA. Since then, research activities have been carried out to improve this method. Research to define the best prostaglandin analogue: sulprostone and gemeprost were dropped out; misoprostol was authorized in 1992 following very convincing trials, it is now commonly used and has never generated any major problem. Research to extend the application time limit to 63 DA: it showed a significant drop in efficiency (86.8% instead of 95.4%) as well as an increase of the rate of haemorrhages (2.25% instead of 0.3%). Therefore the method currently used reads as follows. Day 1: mifepristone 600 mg, day 3: misoprostol 400 micrograms, day 10-15: control visit. The efficiency rate is 95.4%; an additional dose of 400 micrograms of misoprostol 3 hours after the first dose if no expulsion has occurred, increases the rate up to 98.5%. This method is well accepted by women as it enables an early abortion and avoids surgery and anesthies. The arrangements required to implement the method are not easy to make as they call for a change of habits by the institutions as well as by medical teams.Since the use of misoprostol, the abortion by mifepristone using. 400 micrograms + 400 micrograms of misoprostol has become a method which is safe, efficient and much appreciated by women, but it implies a change in the usual practice of abortion.

To report our experience with the mifepristone and misoprostol combination in second and third trimester medically induced abortion.Prospective study without control group between January 1993 and december 1994.Saint-Antoine Hospital, Paris.Fifty-three patients admitted for a medically induced abortion.Induction-to-abortion mean time was 12.9 +/- 7.5 hours (time distinctly decreased in fetal death: 8.3 +/- 4.4 hours).The combination of misoprostol with mifepristone has equivalent with the other protocol used for therapeutic pregnancy termination, is less expensive (25 to 100 times) and finally is simple and non-invasive.

The word contragestion is used to name voluntary interruption of very early pregnancy. The RU associated with an analogue of prostaglandine E1 is used in this indication until 49 days of amenorrhea. Based on a study carried out by Roussel in 1993 on 488 patients, the rate of efficacy is 96.9%. Failures are: ongoing pregnancy 1.8%, hemostatic surgical procedure 0.4%, stopped but non expelled pregnancy 1.8%. Side effects are mainly pelvic pains but pain killers were necessary only for 20% of patients. The contraception with RU 486 has just started. The RU seems to be a very efficient post-coital contraceptive when taken within 72 hours after an unprotected intercourse. Two trials have had a rate of success of 100%. The RU in ordinary contraception could be used either just after ovulation or during all the cycle with very low doses. Trials have just started.

RU 486 is the code name for mifepristone, a 19-norsteroid first synthesized in 1980. Its chemical structure is similar to progesterone and progesterone derivatives. The difference lies in an 11 beta ring substitution which results in high affinity for progesterone and cortisol receptors. Once linked to the receptor, RU 486 temporarily blocks the action of the corresponding hormone. In vitro and in vivo, RU 486 has a powerful anti-progesterone and anti-glucocorticoid effect and a less powerful but nevertheless important anti-androgen effect. The essential clinical application for RU 486 involves its anti-progesterone effect, currently used in several indications including voluntary pregnancy termination and preparation for the prostaglandin action used to induce labour in interrupted pregnancies. Potential indications have been suggested for preparing the cervix for endo-uterine manoeuvres, induction of labour in term pregnancy and contraception. Other potential indications in gynaecology include breast cancer, endometriosis and uterine fibroma. Meningioma and Cushing's syndrome would be further indications. How far will we go with RU 486? All will depend on the social and economic resistance to the drug and to an even greater extent on ethical considerations. The strength of the anti-RU 486 lobby may well dampen the development of non-contraception indications for this effective anti-progesterone agent.

Mifepristone (RU 486) has many therapeutic possibilities, which largely exceed simple interruption of pregnancy. They are due to its unique properties of progesterone--and glucocorticosteroid--receptor blockage. In early interruption of pregnancy, the association with a prostaglandin analogue represents an efficient and well-tolerated method. The safety and comfort of the method have been improved by the association with misoprostol, an oral prostaglandin analogue. Mifepristone can also be used in late pregnancy interruptions for medical reasons, as well as for expulsion of an in utero dead fetus. In these indications, its use allows to decrease or even to avoid the use of prostaglandins, thus diminishing the side-effects due to these products. Several other gynaecological and obstetrical indications seem promising in the future: dilatation and ripening of uterine cervix, induction of labour for medical reasons, contraception. Trials are ongoing to evaluate the antitumoral activity of mifepristone in meningiomas and breast cancer. Finally, its anti-glucocorticosteroid effect is used in the treatment of Cushing's syndromes due to ectopic secretion of ACTH and other indications may be foreseen.