Abortion, Second Trimester Clinical Trial
Official title:
A Randomized Double-blinded Comparison of 24-hour Interval-Mifepristone and Buccal Misoprostol Versus Mifepristone and Vaginal Misoprostol for Cervical Preparation in Second-Trimester Surgical Abortion
This study aims to compare mifepristone and buccal misoprostol to mifepristone and vaginal misoprostol for cervical preparation for second trimester dilation and evacuation (D&E).
Standard of care for cervical preparation prior to second trimester surgical abortion has
traditionally been a pelvic exam with speculum, a paracervical block with lidocaine, and
placement of a number of osmotic dilators through the cervical canal. Dilators obtain maximal
expansion within 4-6 hours and patients experience cramping with this process. This cervical
preparation allows for a faster procedure for the patient (limiting time for anesthesia) and
an easier procedure for the provider (decreasing necessity for further dilation, decreasing
risk of cervical laceration, and decreasing blood loss). Following cervical preparation,
trained providers use instruments to remove the pregnancy per standard of care. Several
studies have examined the use of medication (mifepristone and/or misoprostol) to dilate the
cervix as an alternative to osmotic dilators . Patients prefer medication to dilators as
medication is associated with less discomfort. Medications alone can achieve adequate
cervical preparation but the optimal timing and routes of these medications has not been
sufficiently evaluated.
The addition of mifepristone, a progesterone antagonist, to a misoprostol regimen has been
shown to significantly decrease the medication-to-abortion interval in second-trimester
induction terminations. Vaginal administration has demonstrated improved dilation as compared
to buccal administration but it is known that patients prefer buccal administration. A
comparison of mifepristone and vaginal versus mifepristone and buccal misoprostol has not
been studied prior to second-trimester surgical abortion.
A review of cervical preparation for second-trimester D&E did not recommend mifepristone and
misoprostol for cervical priming due to high rates of pre-procedural expulsions. However, the
primary basis for this conclusion is a trial in which the 48-hour interval between the
medications accounts for the high out-of-facility expulsion risk. A retrospective cohort of
over 200 women between 14 and 19 6/7 weeks gestation showed no difference in difficulty of
cervical dilation for patients receiving mifepristone 24-48 hours misoprostol as compared to
osmotic dilators prior to surgical abortion. Two out of facility expulsions occurred in the
mifepristone-misoprostol arms but the timing of medication to expulsion interval is not
reported.
More recent studies have limited the timing of mifepristone to 24 hours or less prior to
procedure. Mifepristone only has been shown to provide adequate cervical dilation as compared
to osmotic dilators to 16 weeks gestation with noninferiority design to detect a 3-minute
difference in procedure time. A 24-hour interval between 200mg mifepristone and 400mcg buccal
misoprostol has been shown as non-inferior to osmotic dilators for total procedure time for
15-18 week surgical abortions. Mifepristone and one-set of osmotic dilators was found to be
non-inferior for total procedure time as compared to two sets of osmotic dilators for
surgical abortion 19-23 6/7 weeks gestation.
The addition of mifepristone has benefit as a cervical priming agent as an adjunct or
alternative to osmotic dilators for surgical abortion, but it is not known whether the
addition of vaginal versus buccal misoprostol changes cervical dilation and thus procedure
time outcomes.
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