Search

Telehealth abortion has become critical to addressing surges in demand in states where abortion remains legal but evidence on its effectiveness and safety is limited. California Home Abortion by Telehealth (CHAT) is a prospective study that follows pregnant people who obtained medication abortion via telehealth from three virtual clinics operating in 20 states and Washington, DC between April 2021 and January 2022. Individuals were screened using a standardized no-test protocol, primarily relying on their medical history to assess medical eligibility. We assessed effectiveness, defined as complete abortion after 200 mg mifepristone and 1,600 μg misoprostol (or lower) without additional intervention; safety was measured by the absence of serious adverse events. We estimated rates using multivariable logistic regression and multiple imputation to account for missing data. Among 6,034 abortions, 97.7% (95% confidence interval (CI) = 97.2-98.1%) were complete without subsequent known intervention or ongoing pregnancy after the initial treatment. Overall, 99.8% (99.6-99.9%) of abortions were not followed by serious adverse events. In total, 0.25% of patients experienced a serious abortion-related adverse event, 0.16% were treated for an ectopic pregnancy and 1.3% abortions were followed by emergency department visits. There were no differences in effectiveness or safety between synchronous and asynchronous models of care. Telehealth medication abortion is effective, safe and comparable to published rates of in-person medication abortion care.

We tested five chemically and metabolically stable prostaglandin (PG) receptor agonists in a mouse model of dexamethasone-induced ocular hypertension (OHT). Whilst all compounds significantly (p < 0.05, ANOVA) lowered intraocular pressure (IOP) after twice-daily bilateral topical ocular dosing (5 µg/dose) over three weeks, the time course and magnitude of the responses varied. The onset of action of NS-304 (IP-PG receptor agonist) and rivenprost (EP4-PG receptor agonist) was slower than that of misoprostol (mixed EP2/EP3/EP4-PG receptor agonist), PF-04217329 (EP2-PG receptor agonist), and butaprost (EP2-PG receptor agonist). The rank order of IOP-lowering efficacies aligned with the onset of actions of these compounds. Peak IOP reductions relative to vehicle controls were as follows: misoprostol (74.52%) = PF-04217329 (74.32%) > butaprost (65.2%) > rivenprost (58.4%) > NS-304 (55.3%). A literature survey indicated that few previously evaluated compounds (e.g., latanoprost, timolol, pilocarpine, brimonidine, dorzolamide, cromakalim analog (CKLP1), losartan, tissue plasminogen activator, trans-resveratrol, sodium 4-phenyl acetic acid, etc.) in various animal models of steroid-induced OHT were able to match the effectiveness of misoprostol, PF-04217329 or butaprost. Since a common feature of the latter compounds is their relatively high affinity and potency at the EP2-PG receptor sub-type, which activates the production of intracellular cAMP in target cells, our studies suggest that drugs selective for the EP2-PG receptor may be suited to treat corticosteroid-induced OHT.

Objective: This study aims to compare the safety and efficacy of misoprostol administered orally and vaginally in obese pregnant women at term with either gestational hypertension or diabetes. Methods: A total of 264 pregnant women were enrolled and categorized into two groups based on their primary condition: hypertension (134 cases) or diabetes mellitus (130 cases) and were further divided into subgroups for misoprostol administration: orally (Oral group) or vaginally (Vaginal group). The primary outcomes measured were changes in the Bishop score following treatment, induction of labor (IOL) success rates, requirement for oxytocin augmentation, duration of labor, mode of delivery, and cesarean section rates. Results: Significant enhancements in Bishop scores, decreased cesarean section rates and increased success rates of IOL were noted in both administration groups. The incidence of vaginal delivery within 24 h was significantly higher in the Vaginal group compared to the Oral group. Adverse effects, including nausea, uterine overcontraction, hyperfrequency of uterine contraction and uterine hyperstimulation without fetal heart rate deceleration, were significantly more prevalent in the Vaginal group than in the Oral group. Conclusion: Misoprostol administration, both orally and vaginally, proves effective for labor induction in obese pregnant women with hypertension or diabetes. However, the oral route presents a lower risk of adverse maternal and neonatal outcomes, suggesting its preference for safer labor induction in this demographic. [ABSTRACT FROM AUTHOR]

Objective This study aimed to assess the impact of implementation of an induction of labor (IOL) guideline on IOL length and utilization of evidence-based practices. Study Design We conducted a quality improvement project to increase utilization of three evidence-based IOL practices: combined agent ripening, vaginal misoprostol, and early amniotomy. Singletons with intact membranes and cervical dilation ≤2 cm admitted for IOL were included. Primary outcome was IOL length. Secondary outcomes included cesarean delivery and practice utilization. We compared preimplementation (PRE; November 1, 2021 through January 31, 2022) to postimplementation (POST; March 1, 2022 through April 30, 2022) with sensitivity analyses by self-reported race and ethnicity. Cox proportional hazards models and logistic regression were used to test the association between period and outcomes. Results Among 495 birthing people (PRE, n = 293; POST, n = 202), IOL length was shorter POST (22.0 vs. 18.3 h, p = 0.003), with faster time to delivery (adjusted hazard ratio [aHR] = 1.38, 95% CI: 1.15–1.66), more birthing people delivered within 24 hours (57 vs. 68.8%, adjusted odds ratio [aOR] = 1.90 [95% CI: 1.25–2.89]), and no difference in cesarean. Utilization of combined agent ripening (31.1 vs. 42.6%, p = 0.009), vaginal misoprostol (34.5 vs. 68.3%, p < 0.001), and early amniotomy (19.1 vs. 31.7%, p = 0.001) increased POST. Conclusion Implementation of an evidence-based IOL guideline is associated with shorter induction time. Additional implementation efforts to increase adoption of practices are needed to optimize outcomes after IOL. Key Points Implementation of an IOL guideline is associated with faster time to delivery. Evidence-based induction practices were used more often after guideline implementation. Adoption of evidence-based induction practices is variable even with a guideline. [ABSTRACT FROM AUTHOR]

Background: Abortion is partially legal in 48 of 54 countries in Sub-Saharan Africa (SSA); however, abortion laws are generally weakly implemented, and evidence suggests that extending abortion rights does not necessarily improve abortion access. Objective: Reflecting on the implementation challenges faced by the laws extending rights to abortion in SSA, and enriching this approach by considering complementary avenues to overcome barriers in access to abortion. Argument: Reproductive justice is a theory that emphasizes the importance of contexts and different levels of societal forces in shaping reproductive freedom. From a reproductive justice perspective, we suggest that the successful implementation of abortion laws is hampered by discrepancies between legal frameworks and socio-cultural contexts in many SSA countries. In many SSA contexts, the legalization of abortion has not been accompanied by a modification of socio-cultural contexts regarding abortion. Until these contexts are more receptive to abortion, implementation issues may persist and access to abortion may remain hindered. Since increasing social acceptability of abortion can be a lengthy process, exploring complementary strategies to improve abortion access can be beneficial. Nego-feminism, an African feminist theory rooted in African values of negotiation and relationships, may be an effective strategy to navigate societal forces to improve abortion access, in the meantime, until greater acceptability and enforcement of abortion laws. An illustration of this promising strategy can be found in abortion accompaniment models such as MAMA network which provide safe access to medication abortion in the informal sector. Conclusion: Nego-feminism could potentially improve access to abortion in legally and socially restricted settings. However, the continued fight for the legalization of abortion is essential, while using nego-feminism as a complement. [ABSTRACT FROM AUTHOR]

Objectives: To assess the value of misoprostol intake before hysteroscopy in nulliparous women. Search strategy: Databases screening was done from inception to July 2023 using "Misoprostol" AND "Hysteroscopy" AND "Nullipara" and their MeSH terms as keywords. Selection criteria: Thirteen studies were included in our analysis. Seven studies compared misoprostol to placebo, 3 studies compared it to dinoglandin, 1 study compared it to diclofenac and 4 studies compared different misoprostol doses and routes. These studies were conducted on 1528 participants,958 of them received misoprostol, 221 received dinoglandin, 51 received diclofenac and 308 received placebo. Data collection and analysis: Extracted data included study place, participants number, inclusion and exclusion criteria, intervention details as dose, route, timing and comparotor, and hysteroscopy details. Main Results: Ease of cervical dilatation was reported in 3 studies (309 participants) and revealed an effect estimate mean difference (MD) of -0.57 [-1.72, 0.58] and a P value of 0.33. The time needed for cervical dilatation was reported in 6 studies (512 participants) and revealed a MD of -22.96 [-43.29, -2.62] and a P value of 0.03. The preoperative cervical width was reported in 4 studies (263 participants) and revealed MD of 1.69 [-0.09, 3.46] and a P value of 0.06. The number of women with failure of cervical dilatation or who needed further dilatation was reported in 4 studies (372 participants) and revealed a MD of 0.40 with [0.13, 1.17] 95% CI and a P value of 0.09. The preoperative pain was reported in 3 studies (351 participants) and revealed a MD of -0.56 [-2.30, 1.18] and a P value of 0.53. Total number of cases who experienced side effects and procedure complications were reported in 2 and 3 studies (249 and 252 participants) respectively and revealed an effect estimate Odd Ratio of 1.99 and 0.42 with [0.27, 14.67] and [0.14,1.32] 95% CI and a P value of 0.50 and 0.14 respectively. In the 3 studies comparing misoprostol to dinoglandin, The ease of cervical dilatation, time needed for cervical dilatation and preoperative cervical width were evaluated in 1,3 and 2 studies with 60, 436 and 376 participants respectively. The estimated MD were not estimated, 0.17 and 0.01; 95% CI were not estimated, [-4.70, 5.05], and [-0.78, 0.79]; P values of 0.94, 0.98 and 0.99 and I2 of 96%,95% and 74% respectively. Conclusion: Misoprostol improved the time needed for cervical dilatation without affecting the rate of complications or drug side effects when compared to placebo but has similar outcomes to dinoglandin with higher side effects. Registration number: CRD42023438432. [ABSTRACT FROM AUTHOR]

Clinical experience shows an increased duration of labor in obese parturient women. It is unclear if this population should receive the same dose of vaginal misoprostol for induction of labor as non‐obese parturient women. We investigate the influence of obesity on the pharmacokinetics and placental transfer of the metabolite misoprostol acid in parturient women. Parturient women (n = 40) were enrolled and received misoprostol 25 µg/6 h vaginally and were allocated into two groups according to the pre‐pregnancy body mass index (BMI <30 kg/m2 non‐obese, n = 18 or BMI >30 kg/m2 obese, n = 22) or according to the labor induction outcome (failure [n = 10] or success [n = 30]). Blood collection for pharmacokinetic study occurred after the first misoprostol dose. The pharmacokinetic parameters obtained in non‐obese parturient women were not statistically different from those obtained in obese group (P Value >  .05). However, when the parturient women were grouped by the labor induction outcome, the failed labor induction group presented a higher (median [interquartile range]) BMI (44.4 [34.6‐47.9] vs 33.7 [28.9‐36.5] kg/m2) (P Value =  .0017), lower Cmax (11.5 [4.82‐22.2] vs 22.8 [14.2‐30.8] pg/mL) (P Value =  .0308) and not statistically different AUC0‐6 (31.8 [13.4‐61.5] vs 53.4 [35.4‐77.7]) pg·h/mL) (P Value =  .0580) and tmax (2.50 [1.19‐4.25] vs 3.00 (1.88‐5.00) h (P Value =  .3198) when compared with parturient women who presented successful labor induction. This data suggests a higher loading dose (higher volume of distribution) and unchanged maintenance dose (unchanged AUC0‐6) of misoprostol for this population. Further studies are required to investigate the efficacy and safety of higher misoprostol loading doses for this population. [ABSTRACT FROM AUTHOR]

Introduction: The concomitant use of non‐steroidal anti‐inflammatory drugs (NSAIDs) and proton pump inhibitors (PPIs) potentially increases the risk of acute kidney injury (AKI). However, the risk of AKI has not been comprehensively assessed for the concomitant use of NSAIDs with gastroprotective agents such as misoprostol and PPIs. The objective of this study was to evaluate whether the use of various gastroprotective agents affects the risk of AKI in patients receiving NSAIDs. Methods: The data analyzed were obtained from the JMDC hospital‐based administrative claims database between April 2014 and August 2022. Histamine‐2 receptor antagonists (H2RAs) were compared with PPIs or misoprostol in patients receiving NSAIDs. The primary outcome was the incidence of AKI. The covariates considered were age and sex, admission to intensive care unit, presence of comorbidities based on the modified Charlson Comorbidity Index, and use of renin‐angiotensin system inhibitors, loop diuretics, other diuretics, and lithium. AKI was identified by changes in serum creatinine. The distribution of AKI was analyzed using the log‐rank test, and estimates of the incidence of AKI were compared among the groups using a Cox proportional hazards model with time‐varying variables. Models were adjusted using a doubly robust method that accounts for the inverse probability of treatment weighting at baseline while adjusting for covariates. Results: After screening, 11,688 patients were eligible for inclusion (1729 for H2RAs, 368 for misoprostol, and 9591 for PPIs). AKI occurred in 0.5% of H2RA recipients and 1.1% of PPI recipients; no AKI was observed in the misoprostol group. Compared with H2RAs, the risk of AKI tended to be higher with PPIs (adjusted hazard ratio 1.83, 95% confidence interval 0.92–3.63, p = 0.08). Conclusion: Compared with H2RAs, PPIs may increase the risk of AKI in patients receiving NSAIDs, although no statistically significant difference was observed. Further research is required to assess the risk trade‐off with consideration of both peptic ulcer prevention and the increased risk of AKI in patients concurrently treated with NSAIDs and H2RAs, misoprostol, or PPIs. [ABSTRACT FROM AUTHOR]

Objective: Our objective was to evaluate the feasibility of a new protocol for telemedicine follow-up after medication management of early pregnancy loss. Study Design: The study was designed to assess the feasibility of planned telemedicine follow-up after medication management of early pregnancy loss. We compared these follow-up rates with those after planned in-person follow-up of medication management of early pregnancy loss and planned telemedicine follow-up after medication abortion. We conducted a retrospective cohort study, including patients initiating medication management of early pregnancy loss <13w0d gestation and medication abortion ≤10w0d with a combination of mifepristone and misoprostol between April 1, 2020, and March 28, 2021. As part of a new clinical protocol, patients could opt for telemedicine follow-up one week after treatment and a home urine pregnancy test 4 weeks after treatment. Our primary outcome was completed follow-up as per clinical protocol. We also examined outcomes related to complications across telemedicine and in-person follow-up groups. Results: Of patients reviewed, 181 were eligible for inclusion; 75 had medication management of early pregnancy loss, and 106 had medication abortion. Thirty-six out of 75 patients elected for telemedicine follow-up after early pregnancy loss. Of patients scheduled for telemedicine follow-up, 29/36 (81%, 95% CI: 64–92) with early pregnancy loss and 64/69 (93%, 95% CI: 84–98) undergoing medication abortion completed follow-up as per protocol (p = 0.06). Completed follow-up was also similar among patients undergoing medication management of early pregnancy loss who planned for in-person follow-up (p = 0.135). Complications were rare and did not differ across early pregnancy loss and medication abortion groups. Conclusions: Telemedicine follow-up is a feasible alternative to in-person assessment after medication management of early pregnancy loss. [ABSTRACT FROM AUTHOR]

Objective: This study offered an updated meta-analysis of randomized controlled trials (RCTs) that assessed preoperative misoprostol compared to control (matched placebos or no treatment) during abdominal myomectomies. Methods: Six databases underwent screening until 7 April 2024. The risk of bias was assessed using the Cochrane Collaboration tool. The results were presented as mean differences (MDs) or risk ratios (RRs) along with 95% confidence intervals (CIs) using the random-effects model. Results: Sixteen RCTs were analyzed, involving 975 women. The overall quality of the studies was rated as "low" or had "some concerns" of bias in seven and eight RCTs, respectively; one RCT had an overall "high" risk of bias. For primary endpoints, the misoprostol intervention had significantly lower mean intraoperative blood loss (n = 15, MD = −180.2 mL, 95% CI [−224.04, −136.35], p < 0.001), mean hemoglobin drop (n = 13, MD = −0.58 g/dl, 95% CI [−0.82, −0.35], p < 0.001), and rate of perioperative blood transfusion (n = 13, RR = 0.43, 95% CI [0.29, 0.63], p < 0.001) compared to the control intervention. For secondary endpoints, the misoprostol intervention had significantly lower mean hematocrit drop (MD = 2.15, 95% CI −3.34, −0.96], p < 0.001), mean operative time (MD = −12.95 min, 95% CI [−19.89, −6.01], p < 0.001), and mean hospital stay (MD = −0.14 days, 95% CI [−0.25, −0.02], p = 0.02) compared to the control intervention. Nonetheless, no significant change was indicated between both interventions regarding the rate of postoperative fever. Conclusions: During abdominal myomectomy, the administration of preoperative misoprostol was generally safe and yielded statistically significant reductions in intraoperative blood loss, hemoglobin drop, and perioperative blood transfusion. [ABSTRACT FROM AUTHOR]

Introduction: Labor induction exhibits considerable variations in protocols and medication regimens. Limited studies compare vaginal dinoprostone inserts with different oral misoprostol dosages, considering parity influence. This study explores the distinctions among 10 mg vaginal dinoprostone inserts and oral misoprostol 25 μg every 2 and every 4 h for labor induction, stratified by parity. Material and Methods: This retrospective cohort study involved 607 participants across two hospitals. The primary outcome, time from induction to delivery, and secondary outcomes, including mode of delivery and maternal and fetal safety, were assessed. Results: Patient characteristics revealed differences in indication for labor induction, with the dinoprostone cohort having fewer post‐term and premature rupture of membranes cases but more intrauterine growth restriction/small‐for‐gestational age. Both oral misoprostol regimens showed a shorter time to delivery interval compared to the dinoprostone cohort (median: 1380 min [IQR 1381.0] and 1127.0 min [IQR 1214.0] vs 1631.5 [IQR 1736.2], p < 0.001 and p = 0.014). Only the difference between oral misoprostol q2h and vaginal dinoprostone remained significant for nulliparous but not multiparous women, losing significance over all the population after adjusting for confounding factors. The proportion of women giving birth within 24 h did not significantly differ between misoprostol q2h and dinoprostone after adjusting for confounders. When comparing misoprostol q4h with dinoprostone after confounder adjustment, an increased time to delivery interval for misoprostol q4h was found (p = 0.001). Both oral misoprostol regimens exhibited fewer meconium‐stained liquor (miso q4h: OR 0.44, miso q2h: OR 0.34) and cesarean sections (miso q4h: OR 0.48, miso q2h: OR 0.53) compared to dinoprostone, even after adjustment for confounders. Conclusions: Our study suggests that oral misoprostol 25 μg q4h is less effective than 10 mg vaginal dinoprostone for labor induction if parity and indication for induction are adjusted for, particularly in multiparous women. In terms of side effects, oral misoprostol regimens seem superior to vaginal dinoprostone. Our data support the individualized use of different agents for labor induction according to parity, indication for induction, bishop score, and women's preference. [ABSTRACT FROM AUTHOR]

Background & Objective: In situations where misoprostol is not available or its use is contraindicated, hyoscine can be an alternative option. The present study was conducted with aim to compare the effect of vaginal hyoscine butyl bromide and versus vaginal misoprostol on cervical ripening before hysteroscopy. Materials & Methods: This double-blind randomized clinical trial study was conducted on 150 patients who were candidates for diagnostic or therapeutic hysteroscopy and were divided into two groups. In group one, 75 patients received 20 mg of Hyosin vaginally 4 hours before surgery, and in group 2, 200 micrograms of misoprostol was administered vaginally 4 hours before surgery. The two groups were compared in terms of passage of Hegar dilator number 5, amount of cervical dilatation, operation length, postoperative pain and drug side effects. Results: The passage rate of Hegar dilator number 5 in the misoprostol group was 51 (68%) and in the hyoscine group was 44 (58.7%). Also, the mean pain in the misoprostol group was 5.32±2.16 and in the hyosin group was 5.68±1.61. The mean operation length in the misoprostol group was 38.36±6.14 minutes and the in the hyosin group was 40.23±6.41 minutes. The mean amount of cervical dilatation in the misoprostol group was 5.43±1.53 cm and in the hyosin group was 4.97±1.44 cm. Conclusion: Hyoscine for cervical ripening for diagnostic and therapeutic hysteroscopy had no significant difference with misoprostol. Also, there was no significant difference between the two groups in surgical complications, duration of surgery, postoperative pain, and the amount of cervical dilatation. Therefore, considering the low cost and availability of hyoscine, its use for ripening the cervix before hysteroscopy seems logical. [ABSTRACT FROM AUTHOR]

Simple Summary: Different strategies for the termination of pregnancy in humans have proven to be efficient and safe. However, few studies have investigated the utility of these regimens in non-human primates. Therefore, this review discusses the most relevant research reporting the termination of viable and non-viable pregnancies in primates. An overview of the clinically applicable drugs is presented, including dosage, administration route, safety, and efficacy. Limited information is available concerning the termination of pregnancy in non-human primates. Thus, a comprehensive review of this topic will be beneficial for veterinary staff in laboratories, zoos, and wildlife rehabilitation centers. The most relevant studies concerning the termination of viable and non-viable pregnancy in non-human primates were analyzed, and dosages, administration routes, adverse effects, and the efficacy of the drugs used are reported. The literature revealed that termination of pregnancy is most commonly performed in marmosets and macaques. The combination of mifepristone and misoprostol was reported to be effective and fast-acting in terminating first-trimester pregnancy in macaques, while cloprostenol was identified as the best agent for use in marmosets. This review also provides insights about the limitations of previously described methods of pregnancy termination and discusses potential alternatives and areas for future investigation. [ABSTRACT FROM AUTHOR]

Background: The prostaglandin E1 analog "misoprostol" is a drug that has powerful ecbolic effects and can be beneficial in the prevention and treatment of postpartum hemorrhage, which is the leading cause of maternal mortality worldwide. Objectives: To assess the value of adding intrauterine misoprostol together with intravenous oxytocin injection compared with sublingual misoprostol together with intravenous oxytocin injection during elective cesarean section to reduce blood loss intraoperatively and prevent postpartum hemorrhage. Methods: A total of 192 pregnant women were counseled and recruited from the labor and delivery unit at Kasr Al Aini Hospital, Cairo University, and equally randomized into two groups. Group (A) included 96 women who received intrauterine misoprostol (400 mg) + oxytocin. Group (B) included 96 women who received sublingual misoprostol (400 mg) + oxytocin. The primary outcome of our study was estimation of the amount of blood loss during and after cesarean delivery. The secondary outcomes were the incidence of PPH within the first 6 h after labor, the need for blood transfusion, the need for any supplementary ecbolic drugs, the need for additional surgical intervention for PPH, changes in hematocrit and hemoglobin in both groups after delivery, and the incidence of side effects of the study medications. Results: We observed a significant discrepancy between the two groups in terms of postoperative Hb and Hct, postoperative differences (pre- and post-Hb and post-Hct) and EBL favoring the intrauterine group. However, no significant difference was observed between the groups with respect to excessive blood loss > 1000 ml in the 1st six hours, the need for supplementary ecbolics, the necessity for blood or blood prod, the need for additional surgical intervention (for PPH) or side effects. Conclusion: Intrauterine misoprostol combined with oxytocin intravenous infusion is more effective than sublingual misoprostol combined with oxytocin intravenous infusion in lowering intraoperative blood loss and preventing postpartum hemorrhage in elective cesarean section. Trial registration: This trial was retrospectively registered with the ClinicalTrials.gov Registry on 12-April-2024 (registration number: NCT06364098). [ABSTRACT FROM AUTHOR]

AbstractPurposeMethodsResultsConclusions\nSHORT CONDENSATIONTo evaluate the feasibility and acceptability of outpatient medical induction at 13-18 weeks’ gestation to limit overnight hospital stays.In this prospective cohort study, participants with 13-18-week pregnancies seeking abortions at two government hospitals swallowed mifepristone 200 mg and self-administered misoprostol 400 mcg buccally 24-48 h later, 1-2 h before returning to the outpatient clinic (OPD). Repeat misoprostol was dosed every 3 h until expulsion. Participants requiring care beyond OPD hours were admitted as inpatients. Acceptability was evaluated by exit interview before discharge. Participants were contacted two weeks later to assess any subsequent issues.Ninety-eight (82%) of 120 participants had successful outpatient abortions using a median two (IQR 2, 3) misoprostol doses. The median induction-to-abortion time was five hours (IQR 4, 7.5). Eleven (9%) participants expelled before clinic arrival. Twenty-two (18%) participants were transferred as inpatients at OPD closing. Transferred participants remained inpatient for a median 18 h (IQR 18, 21.25). There were no serious adverse events and satisfaction with the abortion process was high.Although the outpatient model did not meet statistical expectations, it is clinically feasible, acceptable, and improves efficiency, expands access, and reduces burdens for women and providers. Operational adjustments may facilitate higher outpatient success.Outpatient medical induction at 13-18 weeks’ gestation is feasible, improves efficiency, expands access, reduces staff and patient burdens, and aligns guidelines and practice with evidence. [ABSTRACT FROM AUTHOR]

Background Objectives Search Strategy Selection Criteria Data Collection and Analysis Main Results Conclusion Misoprostol is largely used in labor induction in cases of intrauterine fetal death. However, recent randomized clinical trials (RCTs) showed that the combination of mifepristone and misoprostol might have better effects than the use of misoprostol alone.To compare mifepristone and misoprostol lines of treatment.Pubmed, Embase, Cochrane and Web of Science databases were systematically searched until April 9, 2024.The eligibility criteria were (1) RCT, (2) comparing misoprostol alone versus the combined treatment, (3) patients undergoing labor induction due to intrauterine fetal death and (4) reporting at least one relevant outcome.Data were examined using the Mantel–Haenszel method and 95% CIs. Heterogeneity was assessed using I2 statics. R, version 4.2.3 was used for statistical analysis. The analyzed outcomes were delivery time interval, adverse effects (fever, vomiting, diarrhea and nausea) and the preinduction Bishop score. Other important outcomes, such as uterus rupture, could not be included due to lack of data from the included studies.A total of seven RCTs comprising 599 patients with intrauterine fetal death were randomized to misoprostol or combined treatment to induce labor. Compared to the misoprostol only group, combined treatment presented lower delivery time interval (MD –6.86 h; 95% CI: −10.32 to −3.4; P = 0.0001; I2 = 87%). However, in terms of adverse effects, the combined treatment group presented lower occurrence of fever (2.25% vs 12.12%; RR 0.26; 95% CI: 0.09–0.74; P = 0.01; I2 = 0%) and vomiting (7.64% vs 14.45%; RR 0.54; 95% CI: 0.29–1.01; P = 0.05; I2 = 0%). No statistically significant differences were observed when comparing the preinduction Bishop score of the two groups (MD –0.09; 95% CI: −0.28–0.10; P = 0.35; I2 = 0%). Additionally, the mean of the preinduction Bishop score of the combined treatment was 2 versus 2.1 of the control group.In this updated meta‐analysis, consistent results suggest that the combined treatment is associated with more beneficial outcomes than the misoprostol alone treatment in patients undergoing labor induction in intrauterine fetal death. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective Design Setting Population Methods Main Outcome Measures Results Conclusions Trial Registration To assess if off‐label oral solution of misoprostol compared with licensed oral tablet of misoprostol approved for induction of labour (IOL) is as efficient in resulting in vaginal delivery within 24 h, using a non‐inferiority design.Prospective, randomised, non‐inferiority, open‐label, blinded endpoint trial.Two tertiary level hospitals, Stockholm, Sweden, January 2022 to May 2023.In all, 874 women, without previous caesarean section, with an unripe cervix and a singleton, cephalic foetus at 37 + 0 to 42 + 0 gestational weeks, with a normal cardiotocography, planned for IOL were included.Women were randomised 1:1 to intervention (25 μg oral solution of misoprostol) or control (25 μg oral tablet of misoprostol) two‐hourly for a maximum of eight doses. Subsequent methods of induction followed clinical practice.The primary outcome was vaginal delivery within 24 h tested using non‐inferiority testing procedures at a non‐inferiority margin of 5 percentage points. Secondary efficacy outcomes were tested for superiority of either treatment. Analyses were by intention‐to‐treat.There were 207 (47.4%) vaginal deliveries within 24 h for women receiving oral solution and 192 (43.9%) vaginal deliveries within 24 h for women receiving oral tablet, establishing non‐inferiority with an absolute risk difference of 3.4% (95% CI −3.2% to 10.0%). Women receiving oral solution required fewer doses to reach active labour than women receiving oral tablet (5.7 vs. 6.1, p = 0.007). There were no significant differences for other secondary or safety outcomes.Off‐label oral solution of misoprostol was non‐inferior to the licensed oral tablet regarding efficacy of IOL defined as vaginal delivery within 24 h.Clinicaltrials.gov identifier: NCT05424445 [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion To compare perinatal outcomes in subsequent pregnancies following second‐trimester abortions, stratified by the method of abortion.A historic cohort study was conducted in a single tertiary hospital, including women who had second‐trimester abortions between 12+0 and 24+0 weeks and subsequent documented pregnancies within 3–60 months. Data were collected from hospitalization and perinatal databases. Composite outcome variables were constructed, and multivariable logistic regression was used to analyze associations, adjusting for confounders.Among 771 women meeting the inclusion criteria, 83% had surgical abortions and 17% had medical abortions. Medical abortion was associated with a higher incidence of placenta‐associated pregnancy complications compared with surgical abortion. No significant differences were found in other perinatal outcomes.The study highlights the potential influence of the abortion method on subsequent pregnancy outcomes, particularly regarding placenta‐associated complications. This underscores the importance of considering the method of second‐trimester abortion in counseling women regarding potential risks to subsequent pregnancies. Adverse outcomes in subsequent pregnancies following second‐trimester abortion were associated with the medical method of abortion, warranting further research and careful counseling in clinical practice. [ABSTRACT FROM AUTHOR]

Objective Postpartum hemorrhage (PPH) protocols improve patient safety and reduce utilization of blood products; however, few data exist on sustainability of PPH checklist use, how use affects care delivery, and variation of use among patient subgroups. This study aimed to (1) examine compliance with PPH checklist use during vaginal deliveries, (2) evaluate whether checklist use varied by patient and/or care team characteristics, and (3) evaluate whether checklist use was associated with increased use of recommended medications/interventions. Study Design This was a quality improvement study performed from April 2021 through June 2023. A multidisciplinary team developed a revised PPH checklist and used quality improvement methodology to increase checklist use following vaginal birth. Data were collected from medical records and clinician survey. Control charts were generated to track checklist use and evaluate special cause variation. Chi-square tests and logistic regression were used to evaluate variation in medications/interventions and across subgroups. Results During the study period, there were 342 cases of PPH at the time of vaginal birth. The checklist was used in 67% of PPH cases during the 20-month period after implementation in a setting where no checklist was previously being used. We found no statistically significant differences in checklist use by patient or health care team characteristics. Use of tranexamic acid, carboprost, and misoprostol were significantly associated with checklist use. Conclusion This study demonstrated successful implementation of a checklist protocol where no checklist was previously being used, with sustained use in an average of 67% of PPH cases over 20 months. Checklist use was consistent across subgroups and was associated with higher use of interventions shown to lower blood loss. Key Points Our study showed sustainability of PPH checklist use over a 20-month period. PPH checklist use was associated with increased use of interventions known to reduce blood loss. Checklist was used consistently across patient subgroups; may help address inequities in obstetric outcomes. [ABSTRACT FROM AUTHOR]

Background: There has been a debate concerning the use of misoprostol for mid-trimester (13-26 weeks) pregnancy termination in women with prior cesarean scars due to concerns regarding a potential higher risk of uterine rupture. Objectives: To evaluate the efficacy and safety of two misoprostol regimens (400 mcg misoprostol versus 200 mcg misoprostol) for 2nd -trimester pregnancy termination in individuals with a prior cesarean section scar. Patients and methods: A prospective randomized study included one hundred and seventy-six patients at 13-26 weeks gestation with previous one cesarean section who were scheduled for pregnancy termination using misoprostol. Participants were randomly divided into two equal groups. Group A (standard misoprostol regimen, 88 patients) received 400 mcg of misoprostol vaginally every 4 hours until the fetus was expelled, and Group B (reduced misoprostol regimen, 88 patients) received 200 mcg of misoprostol vaginally every 4 hours until the fetus was expelled. Primary outcomes were time to abortion and complete abortion rates, secondary outcomes were side effect and complications. Results: There was no significant difference between the two groups regarding demographic data. The only documented advantage of standard misoprostol regimen in the current study was significantly shorter inductionabortion interval (28.26 ±2.52 hours) versus 36.6±2.16 hours in reduced misoprostol group. However, reduced misoprostol regimen has comparable complete abortion rates to standard misoprostol regimen with no significant difference (75% and 84.1% respectively, p=0.13). Additionally, there were no significant differences between groups regarding the need of curettage for incomplete abortion. Conclusion: Low-dose vaginal misoprostol administration seems to be beneficial for terminating a 2 nd -trimester pregnancy in women with a prior cesarean scar without causing side effects or complications. [ABSTRACT FROM AUTHOR]

Background: Postpartum hemorrhage (PPH) is a significant cause of maternal morbidity and mortality, especially in resource-constrained settings. The study compares the effectiveness of two doses of oral misoprostol (400µg and 600µg) with intramuscular oxytocin (10 IU) in managing the third stage of labor. The objective is to determine the efficacy, safety, and side effects of each intervention, aiming to identify a suitable alternative in environments where oxytocin's storage requirements pose challenges. Material and Methods: A prospective, randomized case-control study was conducted on 300 pregnant women in labor, divided into three groups. Group A1 received 400µg of misoprostol, Group A2 received 600µg, and Group B received 10 IU of intramuscular oxytocin. Blood loss was measured using a calibrated drape, and maternal and fetal parameters were closely monitored. Primary outcomes included PPH incidence and drug side effects, while secondary outcomes covered total blood loss, hemoglobin drop, and thirdstage labor duration. Results: The average blood loss was lowest in the oxytocin group (208.25 ml), with slightly higher values in the misoprostol groups (218.25 ml for 600µg and 235.75 ml for 400µg). PPH incidence did not significantly differ among groups. Notably, adverse effects, particularly pyrexia and shivering, were more common in the misoprostol groups, with higher frequencies observed in the 600µg group. Conclusion: Oral misoprostol presents a viable option for managing the third stage of labor, particularly where oxytocin storage is problematic. However, its increased side effects, especially at higher doses, suggest a careful balance in dose selection. Oxytocin remains preferable where available and feasible for storage. [ABSTRACT FROM AUTHOR]

Objective: To assess whether, in those requiring continuing uterine stimulation after cervical ripening with oral misoprostol and membrane rupture, augmentation with low‐dose oral misoprostol is superior to intravenous oxytocin. Design: Open‐label, superiority randomised trial. Setting: Government hospitals in India. Population: Women who were induced for hypertensive disease in pregnancy and had undergone cervical ripening with oral misoprostol, but required continuing stimulation after artificial membrane rupture. Methods: Participants received misoprostol (25 micrograms, orally, 2‐hourly) or titrated oxytocin through an infusion pump. All women had one‐to‐one care; fetal monitoring was conducted using a mixture of intermittent and continuous electronic fetal monitoring. Main outcome measures: Caesarean birth. Results: A total of 520 women were randomised and the baseline characteristics were comparable between the groups. The caesarean section rate was not reduced with the use of misoprostol (misoprostol, 84/260, 32.3%, vs oxytocin, 71/260, 27.3%; aOR 1.23; 95% CI 0.81–1.85; P = 0.33). The interval from randomisation to birth was somewhat longer with misoprostol (225 min, 207–244 min, vs 194 min, 179–210 min; aOR 1.137; 95% CI 1.023–1.264; P = 0.017). There were no cases of hyperstimulation in either arm. The rates of fetal heart rate abnormalities and maternal side effects were similar. Fewer babies in the misoprostol arm were admitted to the special care unit (10 vs 21 in the oxytocin group; aOR 0.463; 95% CI 0.203–1.058; P = 0.068) and there were no neonatal deaths in the misoprostol group, compared with three neonatal deaths in the oxytocin arm. Women's acceptability ratings were high in both study groups. Conclusions: Following cervical preparation with oral misoprostol and membrane rupture, the use of continuing oral misoprostol for augmentation did not significantly reduce caesarean rates, compared with the use of oxytocin. There were no hyperstimulation or significant adverse events in either arm of the trial. [ABSTRACT FROM AUTHOR]

Background: Misoprostol is a synthetic version of prostaglandin E1, unlike its naturally occurring counterpart. Prostaglandins enhance the contractions of the myometrium, resulting in a decrease in bleeding from the myometrium. Objective: To assess the effect of preoperative sublingual misoprostol versus a placebo on intraoperative blood loss during abdominal myomectomy. Patients and methods: This case control study conducted on 100 patients at Damanhour Medical National Institute from October 2023 until March 2024. Results: There was no discernible disparity in the use of Vasopressin among laparoscopic & open myomectomy (p-value = 0.15) or Tranexamic Acid (pvalue = 0.39). In terms of postoperative complications, in the misoprostol group, 8% of patients had nausea, 4% had vomiting, and 8% had shivering, while in the control group, 4% of patients had nausea, 6% of patients had vomiting, and 4% of patients had shivering. There was no discernible disparity in complications between the groups. Conclusions: Our study concluded that there was a significant disparity in blood loss during surgery amongst the two groups. Our findings also indicate that administering sublingual misoprostol before surgery is an easy, easily implemented, and comfortable approach to decreasing intraoperative blood loss throughout abdominal myomectomy. [ABSTRACT FROM AUTHOR]

Objective: The present study aimed to evaluate low‐dose oral misoprostol induction, and compare different methods used in second‐line induction in patients with a Bishop score less than 6. Methods: This retrospective study analyzed the medical history and courses of pregnancy of all patients induced with first‐line of low‐dose oral misoprostol (50 μg every 4 h with a total of 200 μg/24 h) from April 2021 to June 2022 in a university hospital center, and reported outcomes according to the second‐line method of induction. Results: Among 437 labor inductions with low‐dose oral misoprostol, 120 patients required a second‐line induction. Predictive factors of first‐line failure were higher body mass index (P = 0.011), absence of premature rupture of membranes (P = 0.021) and earlier term of pregnancy (P < 0.001). Regarding second methods of induction of labor, time from induction to delivery was shorter in the oxytocin group than the dinoprostone and misoprostol groups (24.0 vs. 41 and 51.0 h, respectively; P < 0.001), and was also significantly shorter in the dinoprostone than the misoprostol group (P = 0.048). Cesarean section rates did not differ between the three groups (P = 0.651). There were no clinically significant differences in adverse events between the groups. Conclusion: Normal body mass index, previous rupture of membranes and later term of induction of labor were the three favoring success factors during first‐line oral misoprostol. In cases of a Bishop score <6, oxytocin may be the best option to reduce duration to delivery, with the same maternal‐fetal outcomes, including a similar rate of vaginal delivery. Synopsis: If a Bishop score was <6 after 24 h oral misoprostol, oxytocin could be the best method to reduce duration to delivery. [ABSTRACT FROM AUTHOR]

Purpose: The treatment of early miscarriage with medication is effective and low in side effects. Nevertheless, no uniform dosage regimen has yet been established, nor has it been possible to determine whether previous pregnancies and births with their respective modes of delivery play a role in the effectiveness of Misoprostol. This study aimed to find predictive parameters for successful treatment with Misoprostol in early miscarriage. Methods: In a retrospective study at the Otto von Guericke University Women's Hospital, records of patients with early miscarriage and medical treatment using Misoprostol from 2018 to 2021 were reviewed for this purpose. The need for a curettage subsequent to treatment was scored as a parameter of failure. The data were analyzed using Statistical Package for the Social Science Version 28.0. The significance level was set to 0.050. Results: We found that successful therapy with misoprostol was seen in 86% (n = 114). 14% (n = 20) of the patients had curettage after taking Misoprostol as advised. Out of 134 women, 16% (n = 21) reported mild side effects, with nausea as the leading one (9.2% (n = 12)). Significance was found comparing the measurement of double endometrial stripe thickness after the second cycle of Misoprostol in women with and without curettage after medical treatment (exact value two-sided 0.035 at p < 0.05). A cutoff value at 8.8 mm was calculated using ROC Analysis. Conclusions: Our results indicate that the treatment of early miscarriage in the first trimester with Misoprostol is effective and has few side effects. The measurement of the endometrial stripe thickness after the second cycle of Misoprostol via transvaginal ultrasound could present a predictive marker during therapy. [ABSTRACT FROM AUTHOR]

Objective Combining pharmacologic agents with mechanical ripening achieves the shortest labor duration, yet there is no clear evidence on route of drug administration in obese individuals. The use of buccal misoprostol has shown greater patient acceptance but remains understudied. Our objective was to evaluate the difference in time to delivery of buccal compared with vaginal misoprostol in combination with a Foley catheter (FC) for induction of labor (IOL) in the obese population. Study Design This was a secondary analysis of a randomized controlled trial comparing identical dosages (25 μg) of buccal and vaginal misoprostol in combination with a FC. The parent trial was an institutional review board-approved, randomized clinical trial conducted from June 2019 through January 2020. Labor management was standardized among participants. Women undergoing IOL at ≥37 weeks with a singleton gestation and cervical dilation ≤2 cm were included. Body mass index (BMI, kg/m 2) was stratified. The primary outcome was time to delivery. Results A total of 215 participants were included. Demographic characteristics were similar between the three groups. Vaginal drug administration achieved a faster median time to delivery than the buccal route among patients with a body mass index greater than or equal to 30 kg/m 2 (vaginal misoprostol–FC: 21.3 hours vs. buccal misoprostol–FC: 25.2 hours, p = 0.006). There was no difference in the cesarean delivery rate between the two groups. Furthermore, patients with a BMI greater than or equal to 30 kg/m 2 receiving vaginal misoprostol delivered 1.2 times faster than women who received buccal misoprostol after censoring for cesarean delivery and adjusting for parity (hazard ratio: 1.2, 95% confidence interval: 1.1–1.7). There were no significant differences in maternal and neonatal outcomes. Conclusion We found that vaginal misoprostol was superior to buccal misoprostol when combined with a FC among individuals with a BMI greater than or equal to 30 kg/m 2. Vaginal misoprostol should be the preferred route of drug administration for term IOL in this population. Key Points Vaginal misoprostol was superior to buccal route among patients with obesity. There was no difference in the cesarean delivery rate between the two groups. Vaginal misoprostol should be the preferred route of administration among patients with obesity. [ABSTRACT FROM AUTHOR]

Abstract Objectives To assess the value of misoprostol administration before IUD insertion. Search strategy Screening of PubMed, Scopus, Web Of Science, ScienceDirect, and clinical trials registry till April 2024 using the keywords misoprostol, prostaglandin E1 analogue, IUD, IUCD, intrauterine device, IUD insertion, and their MeSH terms. Selection criteria All RCTs that included misoprostol administration before IUD insertion. All doses, routes, and times of administration of misoprostol compared to placebo, analgesics, or other prostaglandins were included. This review included 19 RCTs including 2743 women (1333 had misoprostol administration and 1410 comparators (1281 received placebo, 16 received diclofenac, 43 received dinoglandin, and 70 received lignocaine). Data collection and analysis The extracted data included location setting, number of participants randomized and analyzed, participants selection criteria, the exact intervention details (including misoprostol dose, route and timing of administration, the comparator group details, and type of IUD inserted), primary and secondary outcomes of the trial ( including pain score, easiness of insertion score, the need for analgesics, the need for additional measures as cervical dilatation, failure of insertion, complications of the insertions process, and drug side effects), risk of bias of the included studies, and trial registration number and site. Main results Failure of IUD insertion was evaluated in 9 studies with 1350 participants and revealed an odd ratio (OR) of 0.87 with 0.39–1.98 95% CI, P value = 0.75, and I 2 score = 45%. The easiness score of insertion was evaluated in 7 studies with 780 participants and revealed an OR of − 1.12 with − 1.73 to 0.52 95% CI, P value

Abstract Background Abortion is partially legal in 48 of 54 countries in Sub-Saharan Africa (SSA); however, abortion laws are generally weakly implemented, and evidence suggests that extending abortion rights does not necessarily improve abortion access. Objective Reflecting on the implementation challenges faced by the laws extending rights to abortion in SSA, and enriching this approach by considering complementary avenues to overcome barriers in access to abortion. Argument Reproductive justice is a theory that emphasizes the importance of contexts and different levels of societal forces in shaping reproductive freedom. From a reproductive justice perspective, we suggest that the successful implementation of abortion laws is hampered by discrepancies between legal frameworks and socio-cultural contexts in many SSA countries. In many SSA contexts, the legalization of abortion has not been accompanied by a modification of socio-cultural contexts regarding abortion. Until these contexts are more receptive to abortion, implementation issues may persist and access to abortion may remain hindered. Since increasing social acceptability of abortion can be a lengthy process, exploring complementary strategies to improve abortion access can be beneficial. Nego-feminism, an African feminist theory rooted in African values of negotiation and relationships, may be an effective strategy to navigate societal forces to improve abortion access, in the meantime, until greater acceptability and enforcement of abortion laws. An illustration of this promising strategy can be found in abortion accompaniment models such as MAMA network which provide safe access to medication abortion in the informal sector. Conclusion Nego-feminism could potentially improve access to abortion in legally and socially restricted settings. However, the continued fight for the legalization of abortion is essential, while using nego-feminism as a complement.

Abstract Objectives To assess the value of misoprostol intake before hysteroscopy in nulliparous women. Search strategy Databases screening was done from inception to July 2023 using “Misoprostol” AND “Hysteroscopy” AND “Nullipara” and their MeSH terms as keywords. Selection criteria Thirteen studies were included in our analysis. Seven studies compared misoprostol to placebo, 3 studies compared it to dinoglandin, 1 study compared it to diclofenac and 4 studies compared different misoprostol doses and routes. These studies were conducted on 1528 participants,958 of them received misoprostol, 221 received dinoglandin, 51 received diclofenac and 308 received placebo. Data collection and analysis Extracted data included study place, participants number, inclusion and exclusion criteria, intervention details as dose, route, timing and comparotor, and hysteroscopy details. Main Results Ease of cervical dilatation was reported in 3 studies (309 participants) and revealed an effect estimate mean difference (MD) of -0.57 [-1.72, 0.58] and a P value of 0.33. The time needed for cervical dilatation was reported in 6 studies (512 participants) and revealed a MD of -22.96 [-43.29, -2.62] and a P value of 0.03. The preoperative cervical width was reported in 4 studies (263 participants) and revealed MD of 1.69 [-0.09, 3.46] and a P value of 0.06. The number of women with failure of cervical dilatation or who needed further dilatation was reported in 4 studies (372 participants) and revealed a MD of 0.40 with [0.13, 1.17] 95% CI and a P value of 0.09. The preoperative pain was reported in 3 studies (351 participants) and revealed a MD of -0.56 [-2.30, 1.18] and a P value of 0.53. Total number of cases who experienced side effects and procedure complications were reported in 2 and 3 studies (249 and 252 participants) respectively and revealed an effect estimate Odd Ratio of 1.99 and 0.42 with [0.27, 14.67] and [0.14,1.32] 95% CI and a P value of 0.50 and 0.14 respectively. In the 3 studies comparing misoprostol to dinoglandin, The ease of cervical dilatation, time needed for cervical dilatation and preoperative cervical width were evaluated in 1,3 and 2 studies with 60, 436 and 376 participants respectively. The estimated MD were not estimated, 0.17 and 0.01; 95% CI were not estimated, [-4.70, 5.05], and [-0.78, 0.79]; P values of 0.94, 0.98 and 0.99 and I2 of 96%,95% and 74% respectively. Conclusion Misoprostol improved the time needed for cervical dilatation without affecting the rate of complications or drug side effects when compared to placebo but has similar outcomes to dinoglandin with higher side effects. Registration number CRD42023438432.