a viable alternative to surgical vacuum aspiration: repeated doses of intravaginal misoprostol over...
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A viable alternative to surgical vacuum aspiration: repeateddoses of intravaginal misoprostol over 9 hours for medical
termination of pregnancies up to eight weeks
Kuldip Singha,*, Y.F. Fonga, F. Dongb
Objective To study the efficacy of repeated doses of vaginal misoprostol over 9 hours in a day care setting forterminating pregnancies up to eight weeks of gestation.
Design An open, single arm prospective study conducted between January 2000 and December 2001.
Setting Fertility Control Clinic, National University Hospital, Singapore.
Population One hundred and fifty pregnant women with an unwanted pregnancy up to eight weeks ofgestation requesting medical abortion.
Methods The women were given an initial dose of 800 Ag of vaginal misoprostol. A further dose of 400 Agwas repeated every 3 hours for a maximum of three doses.
Main outcome measures The complete abortion rate defined as successful cases that did not require vacuumaspiration.
Results The complete abortion rate was 84.7% and 96.0% at 15 days and 43 days after initial administration ofvaginal misoprostol. The mean interval between first dose of misoprostol and the onset of expulsion ofproducts of conception (SD) was 8.1 hours (6.3). The mean and the median percentage changes in the serumh-hCG levels at day 15 as compared with pre-abortion levels were statistically significant ( P < 0.001) andwere a good predictor of the likely outcome of the medical abortion. The mean duration of bleeding (SD)was 11.7 days (4.7) and the mean duration between the onset of procedure and the return of normalmenstruation (SD) was 35.5 days (5.7). There was no significant change in haemoglobin concentration.Lower abdominal pain, fever (> 38.0jC) and diarrhoea were the most common side effects.
Conclusions This regimen of repeated doses of vaginal misoprostol every 3 hours over a period of 9 hours, inkeeping with the plasma level and pharmacokinetic of misoprostol administered vaginally, is an effectivemethod of medical abortion that approaches the efficacy of surgical vacuum aspiration. The regimen wouldoffer a suitable option for women requesting termination of pregnancy up to eight weeks of gestation incountries where mifespristone is and will never be made available.
INTRODUCTION
Surgical vacuum aspiration has traditionally been the
method of choice of successfully terminating unwanted
first trimester pregnancies and it should ideally be carried
out beyond seven weeks of gestation1. It has a success rate
of more than 95%2. Major morbidity is up to 1% and minor
morbidity is seen in 10% of women3. However, with the
advent of more sophisticated and sensitive pregnancy
diagnostic kits, women may seek induced abortion much
earlier (four to eight weeks of gestation) and may be not
willing to wait up to seven weeks of gestation for a surgical
vacuum aspiration.
Medical abortion using mifespristone and misoprostol
has been shown to be an effective method of abortion up to
63 days of gestation4. In fact, misoprostol, although not
licensed for medical abortion, is the prostaglandin of choice
and it is cheap, easily available and stable at room temper-
ature. Mifespristone, however, is expensive and is only
available in a limited number of developing countries,
including China, France, Sweden, the UK and the USA.
Thus, there is the pressing and important need to develop a
regimen of medical abortion without mifepristone. Com-
plete abortion rates varying from 20.0% to 93.9% have
been reported with the use of misoprostol alone5 – 9. How-
ever, in most of these studies, the dosing interval of
misoprostol has ranged from every 4 hours to every 48
hours. It would thus take several days to complete the
treatment, which is thus inconvenient and expensive.
Pharmacokinetics show that peak plasma levels of miso-
prostol are sustained for up to 4 hours after vaginal admin-
istration10. It would thus be logical to administer misoprostol
BJOG: an International Journal of Obstetrics and GynaecologyFebruary 2003, Vol. 110, pp. 175–180
D RCOG 2003 BJOG: an International Journal of Obstetrics and Gynaecology
PII: S 1 47 0 - 0 3 2 8 ( 0 2 ) 0 2 2 25 - 5 www.bjog-elsevier.com
aDepartment of Obstetrics and Gynaecology, National
University Hospital, SingaporebBiostatistics Consultancy Unit, National University of
Singapore Medical Institute, Singapore
* Correspondence: Professor K. Singh, Department of Obstetrics and
Gynaecology, National University Hospital, Lower Kent Ridge Road,
119074, Singapore.
repeatedly 3 hours. Thus, based on this pharmacokinetics,
we initiated this study of administering misoprostol every 3
hours for a maximum of four doses over 9 hours to present a
convenient and acceptable day care regimen for medical
abortion that did not require overnight stay nor need to return
for repeated administration.
METHODS
This is an open, single arm prospective study. A total of
150 pregnant women with a period of amenorrhoea of up to
and including 56 days were recruited in the gynaecological
outpatient clinic among women requesting termination of
pregnancy at the National University Hospital, Singapore
between January 2000 and December 2001. All gave
informed consent after the study had been explained,
including their right to withdraw from the trial at any time
without prejudice to their future medical care. The study
was approved by the local hospital ethics committee.
The women were between 15 and 45 years of age and
they satisfied the following criteria: (i) normal general and
gynaecological examination; (ii) intrauterine pregnancy
with gestational age of �8 weeks as established by reliable
menstrual history, pelvic examination and confirmed by
ultrasound assessment on day one of study; (iii) haemo-
globin higher than 10 gm/dL. Exclusion criteria included:
(i) history or evidence of illnesses that represent a contra-
indication to the use of misoprostol—heart disease, hyper-
tension, bronchial asthma; (ii) history or evidence of
thromboembolism; (iii) severe or recurrent liver disease
or pruritus of pregnancy; (iv) presence of intrauterine
contraceptive device in uterus; (v) use of hormonal contra-
ception during the cycle before conception or during the
conception cycle itself; (vi) breastfeeding; (vii) heavy
smoking (smoking >10 cigarettes daily in the past two
years); or (viii) known allergy to misoprostol.
All the women were admitted to the day care ward of the
hospital at 0700 hours on day one of the treatment. Blood
was taken for serum h-hCG. Blood pressure and pulse rate
were recorded and the presence of any possible side effects
was noted. During vaginal examination, 800 Ag of miso-
prostol (Cytotec, Searle Pharmaceutical, USA) wet in water
was placed into the posterior vaginal fornix by one of the
two designated clinicians (KS or YFF). The decision by the
researchers to use this loading dose of 800 Ag was arrived
after a small pilot unpublished study comparing 400 and
800 Ag of misoprostol among 40 patients revealed a high
successful complete abortion rate with this higher dose.
Thereafter, blood pressure, pulse rate and temperature and
the occurrence of side effects such as abdominal pain,
vaginal bleeding, nausea, vomiting and diarrhoea were
monitored hourly.
Three hours later, vaginal assessment was done and
400 Ag of misoprostol wet in water was placed into the
posterior vaginal fornix. This 400 Ag misoprostol dose was
repeated every 3 hours for another two doses. All vaginal
assessment and insertion of the drug was done by one of the
two designated clinicians (KK or YFF) to reduce individual
variation in assessment. Throughout the period in the day
care ward, the women were monitored hourly for side
effects mentioned above and the passage of products of
conception. They were ambulatory and were allowed anal-
gesics for their abdominal pain if required.
At the end of 10 hours, an hour after the fourth and last
dose, the women were allowed home. A diary card was given
to them to record the duration of bleeding, passage of pro-
ducts of conception and side effects. They were reminded to
return to the hospital at any time if there was heavy bleeding,
severe abdominal pain or any evidence of infection.
All the women were followed up on days 15 and 43. On
both these follow up visits, pelvic examination, blood
serum h-hCG and haemoglobin estimation were conducted.
In addition, an ultrasound examination of the pelvis was
performed in all the women on day 15.
The outcome of treatment was classified as (i) complete
abortion, (ii) incomplete abortion, (iii) missed abortion and
(iv) live pregnancy. The initial assessment about the
outcome of therapy was made at the follow up visit on
day 15. If the ultrasound findings showed a live pregnancy
(i.e. fetal heart activity present on day 15), vacuum aspira-
tion would be performed and the aspirated would be sent
for histological examination. If the ultrasound findings on
day 15 were compatible with missed abortion (i.e. identifi-
able gestational sac without fetal heart activity), the women
had the option of either terminating the pregnancy by
vacuum aspiration or having a repeat of two dose of 400
Ag misoprostol at 3 hours interval on the same day in the
clinic and they were monitored for expulsion of products of
conception. If the ultrasound findings were compatible with
complete or incomplete abortion, no further action would
be taken unless there was heavy bleeding or pelvic infec-
tion. In these women, the final assessment would be made
on day 43. If no emergency or elective vacuum aspiration
was necessary during the period up to day 43 or the first
menstruation, the outcome was classified as complete
abortion. Bleeding patterns were recorded on both follow
up visits.
The number of women in the study has been calculated
using the Minitab Statistical Software on the basis of the
following considerations: (i) published evidence indicates
the success of surgical vacuum aspiration is about 97%
( P ¼ 0.97); (ii) type 1 error of 0.05; and (iii) power of 0.8.
The medical abortion regimen will be considered accept-
able if it can be demonstrated with a 95% confidence limit
that the regimen is at worst 10% inferior to surgical
vacuum aspiration. From the above considerations, the
number of woman needed is 140. Assuming 10% default
at follow up, the sample size chosen was 150.
The primary outcome measure was the complete abor-
tion rate defined as successful cases that did not require
vacuum aspiration. Failure was defined as the recourse to
176 K. SINGH ET AL.
D RCOG 2003 Br J Obstet Gynaecol 110, pp. 175–180
surgical abortion either as a result of method failure or
change of the woman’s decision. The change in hae-
moglobin concentration, the intervals between initial dose
of misoprostol and bleeding, and passage of production of
conception, duration of vaginal bleeding after abortion and
side effects were also noted.
Statistical analyses were performed using Student’s
t test, paired t test and Fisher’s exact test. Variables that
were normally distributed are presented by mean and
standard deviation of the mean. The percentage change of
the serum h-hCG levels were compared using the paired t
test. The frequency of side effects associated with use of
vaginal misoprostol was compared with using the Fisher’s
exact test (two-tailed).
RESULTS
Table 1 summarises the demographic characteristic of
the 150 women who underwent medical abortion with
vaginal misoprostol. The mean gestational age was 7.1
weeks. At the first follow up visit on day 15, 127 (84.7%)
had a complete abortion as determined by ultrasound
scanning. There was however no significant difference in
efficacy in relation to gestation (Table 2). Six women
(4.0%) had an ongoing pregnancy on this visit and had
surgical vacuum aspiration performed. Products of concep-
tion were confirmed on histology. Five women (3.3%) on
day 15 follow up showed a missed abortion in ultrasound.
All five of them opted for a repeat of two doses of 400 Ag
misoprostol at 3 hours interval on the same day in the
clinic. All five aborted or passed out products of conception
ranging from 2 to 6 hours after administration of the first
repeat dose of misoprostol. Complete abortion a week later
was confirmed by noting an empty uterine cavity on
ultrasound scanning and rapidly falling serum h-hCG
levels.
On the follow up on day 15, 12 women (8.0%) were on
ultrasound examination noted to have either retained pro-
ducts of conception and/or blood clots. They were diag-
nosed to have an incomplete abortion. No intact gestational
sac was seen in any of them. Because their bleeding was
not excessive, they had no signs of infection and their
h-hCG level had shown a more than 90% fall, they were
managed conservatively and told to return should they have
any excessive bleeding or signs of infection. All 12 women
remained well and were next seen on day 43. Thus, at
the end of the study with a 100.0% follow up, on day 43
(Table 2), 144 or 96.0% of the women had a complete
abortion as diagnosed by a return of their menses clinically
and a fall of their serum h-hCG to less than 2.5 mIU/mL.
Excluding the six women with a continuing pregnancy
and five women with a missed abortion on the day 15 follow
up, there were 139 women (i.e. 127 with a complete abortion
and 12 with an incomplete abortion) diagnosed by ultra-
sound scan on day 15. For these 139 women, the mean
interval between the first dose of misoprostol and the first
onset of bleeding (SD) was 4.9 hours (1.8) with a median
interval of 6.0 hours. Similarly, from Table 3, it can be seen
that the interval between the first dose of misoprostol and
the first expulsion of products of conception (SD) was
8.1 hours (6.3) with a median interval of 6.5 hours. In fact,
by the time the last and final dose of misoprostol was
inserted, 135 (97.1%) had passed out products of conception
Table 1. Demographic characteristic of woman in study.
Characteristic Mean (SD) [Range] n (%)
Age (years) 28.5 (6.7) [15– 45]
Weight (kg) 53.0 (8.9) [36– 94]
Height (cm) 159.8 (6.1) [144– 177]
Gestational age (weeks) 7.1 (0.6) [5.9– 8.0]
No. of women <6 weeks 8 (5.3)
No. of women 6– 7 weeks 74 (49.3)
No. of women <7 weeks 68 (45.4)
No. of parous women 104 (70.7)
Table 2. Outcome of medical abortion. Values are given in n (%).
Outcome Day 15 Day 43 (end of study)
Complete abortion
<6 weeks (n ¼ 8) 8 (100.0) 8 (100.0)
6 – 7 weeks (n ¼ 74) 60 (81.1) 70 (94.6)
>7 weeks (n ¼ 68) 59 (86.8) 66 (97.1)
Overall total (N ¼ 150) 127 (84.7) 144 (96.0)
Incomplete abortion
<6 weeks (n ¼ 8) 0 (0.0)
6 – 7 weeks (n ¼ 74) 6 (8.1)
>7 weeks (n ¼ 68) 6 (8.8)
Overall total (N ¼ 150) 12 (8.0)
Missed abortion
<6 weeks (n ¼ 8) 0 (0.0)
6 – 7 weeks (n ¼ 74) 4 (5.4)
>7 weeks (n ¼ 68) 1 (1.5)
Overall total (N ¼ 150) 5 (3.3)
Continuing or ongoing pregnancy
<6 weeks 0 (0.0)
6 – 7 weeks 4 (5.4)
>7 weeks 2 (2.9)
Overall total (N ¼ 150) 6 (4.0)
Table 3. Characteristics of medical abortion using vaginal misoprostol.
Characteristic Mean (SD) Median
Interval (hours) between first
dose of misoprostol and onset of bleeding
4.9 (1.8) 6.0
Interval (hours) between first dose
of misoprostol and onset of first expulsion
of products of conception
8.1 (6.3) 6.5
Duration of vaginal bleeding (days) 11.7 (4.7) 11.0
Duration between abortion procedure
and return of normal menses (days)
35.5 (5.7) 36
INTRAVAGINAL MISOPROSTOL AS ALTERNATIVE TO SURGICAL VACUUM ASPIRATION 177
D RCOG 2003 Br J Obstet Gynaecol 110, pp. 175–180
and in almost all of them the abortion process appeared to
be complete based on the visual inspection of the products
of conception. From Table 3, it can be seen that the mean
duration of vaginal bleeding (SD) in these women was
11.7 days (4.7) with a median interval of 11 days and the
mean duration between the onset of the procedure and
return of normal menses (SD) was 35.5 days (5.7) with a
median of 36 days. The mean haemoglobin (SD) was
12.4 g/dL (0.9) before abortion and 12.2 g/dL (0.9) on
both days 15 and 43 follow up after the medical abortion.
This difference was not statistically significant by the
paired t test and no women required any blood transfusion.
The mean and median percentage changes in the serum
h-hCG levels for the different categories after medical
abortion on day 15 are shown on Table 4. In the group
with complete abortion, this mean fall in h-hCG was 98%
( P < 0.001) and in the group with incomplete abortion this
change was 91% ( P < 0.001). In the group with missed
abortion, this mean and median percentage fall in h-hCG
was only 23% and 25%, respectively, on day 15 and this
was not statistically significant. In the group where the
pregnancy was continuing, there was a statistically signifi-
cant increase in the h-hCG level ( P < 0.01) as shown in
Table 4.
The incidence of side effects are shown in Table 5.
There was a significant increase in the incidence of lower
abdominal pain, fever (>38.0jC), diarrhoea and headache
after the administration of the first and second dose of
vaginal misoprostol as compared with that which occurred
before the administration of vaginal misoprostol. The
incidence of these side effects then continued to decrease
with the subsequent administration of the third and fourth
dose of misoprostol. Although 132 (88%) of the women
experienced some form of abdominal pain by the time of
administering the second dose of misoprostol, the pain was
tolerable and not severe. Despite analgesics being readily
available, only 10 women required paracetamol orally to
relieve the pain after the second misoprostol dose. No
parenteral analgesic was required. Another six women
required oral administration of paracetamol for temperature
>39.0jC. For the remaining women with a temperature of
<39.0jC, the management was expectant. However, in all
of them, the fever was below 38.0jC at the 1-hour obser-
vation after the fourth dose of vaginal misoprostol. The
incidence of side effects on the day 15 follow up was not
significant.
DISCUSSION
Most regimens of medical abortion using a combination
of mifespristone and a prostaglandin have yielded a com-
plete abortion rate ranging from 90% to 95%11. Similarly, a
misoprostol-alone regimen of medical abortion will be
considered effective if the complete abortion reaches
90%. Different misoprostol-alone regimens have been
reported in the literature for medical abortion in the first
trimester. These studies are generally difficult to compare
as different doses and regimens of administering misopros-
tol were used. Moreover, the success of medical abortion is
different depending on the time period at which it is
measured. The regimens used by Carbonell et al.7 – 9
yielded the highest overall success rates (87 – 94%),
Table 4. Changes in serum h-hCG with outcome of therapy on day 15
after misoprostol administration.
Outcome of therapy No. Mean percentage change in
h-hCG (median) in reference
to baseline values
P
Complete abortion 127 �98 (�100) <0.001
Incomplete abortion 12 �91 (�98) <0.001
Missed abortion 5 �23 (�25) 0.12
Continuing pregnancy 6 þ252 (þ150) <0.01
Table 5. Side effects of repeated doses of vaginal misoprostol for medical abortion compared with that occurring during pregnancy. Values are given as
n (%); n ¼ 150.
Pre-misoprostol
administration
After first dose
of misoprostol
After second dose
of misoprostol
After third dose
of misoprostol
After fourth dose
of misoprostol
Day 15 follow up
Lower abdominal pain 2 (1.3) 76 (50.7)a 132 (88.0)a 115 (76.7)a 65 (43.3) 15 (10.0)
Fever (>38.0jC) 0 (0.0) 14 (9.3)a 31 (20.7)a 6 (4.0) – –
Diarrhoea 4 (2.7) 22 (14.7)a 40 (26.7)a 10 (6.7) 2 (1.3) 2 (1.3)
Headache 6 (4.0) 17 (11.3)c 20 (13.3)b 6 (4.0) 3 (2.0) 5 (3.3)
Nausea 42 (28.0) 46 (30.7) 51 (34.0) 3 (2.0) 1 (0.7) 3 (2.0)
Vomiting 25 (16.7) 26 (17.3) 31 (20.7) 2 (1.3) 1 (0.7) 1 (0.7)
Fatigue 12 (8.0) 6 (4.0) 14 (9.3) – – 1 (0.7)
Dizziness 10 (6.7) 7 (4.7) 13 (8.7) 2 (1.3) 2 (1.3) 2 (1.3)
Fainting 3 (1.3) 5 (3.3) – – – –
Breast tenderness 45 (30.0) 45 (30.0) 43 (28.7) 3 (2.0) 3 (2.0) 3 (2.0)
a P < 0.001 as compared with that occurring during pregnancy by Fisher’s exact test.b P < 0.05 as compared with that occurring during pregnancy by Fisher’s exact test.c P < 0.01 as compared with that occurring during pregnancy by Fisher’s exact test.
178 K. SINGH ET AL.
D RCOG 2003 Br J Obstet Gynaecol 110, pp. 175–180
whereas the success rates in the other studies ranged from
47% to 70%5,6,12. In Carbonell et al.’s studies, the women
received 800 Ag of vaginal misoprostol every 24–48 hours
up to a maximum of three doses. Ngai et al.13 yielded a
lower complete abortion rate of 94% in women <7 weeks
pregnant and 77% in women seven to nine weeks pregnant
using a similar regimen to Carbonell.
Only two studies have to date used regimens that could
be completed within a day. Koopersmith and Mishell5
reported a complete abortion rate of 60% using 200–
400 Ag of vaginal misoprostol every 4–8 hours for four
to five doses in women less than 10 weeks of gestation.
Tang et al.12 used a high initial dose of 800 Ag of vaginal
misoprostol followed by 400 Ag every 3 hours for a max-
imum of four doses. In this pilot study among 50 women,
the complete abortion rate was 70% in women <9 weeks
of gestation.
The results of our study using an initial loading dose of
800 Ag of vaginal misoprostol followed by three subsequent
doses of 400 Ag vaginal misoprostol at 3 hourly interval
achieved a complete abortion rate of 84.7% at day 15 and
96.0% at day 43 or six weeks after the onset of medical
abortion using vaginal misoprostol. The complete abortion
rate of 84.7% at day 15 is much better than the rate of 70%
reported by Tang et al.12 in a pilot study of 50 women. In
fact, in this pilot study, Tang et al.12 used four doses of
400 Ag of vaginal misoprostol at 3 hourly interval after the
initial loading dose of 800 Ag of vaginal misoprostol12. We
have used only three subsequent doses of vaginal miso-
prostol. Besides achieving a higher complete abortion rate
with a lower dose of misoprostol at day 15, we achieved a
96.0% success rate of complete abortion at day 43 or six
weeks after the initial administration of vaginal misoprostol
in our regimen for medical abortion. This compares favour-
ably with the success rate of more than 95% for surgical
vacuum aspiration in the first trimester2.
The success rate of medical abortion is often monitored
in most studies on clinical data (passage of products of
conception and no vaginal bleeding on follow up). Ultra-
sonographic evaluation of the uterine cavity, measurement
of the endometrial thickness or endometrial echo complex
has also been reported. This does not pose a problem in
diagnosing a continuing pregnancy or a missed abortion
where the gestation sac is still intact. However, what poses a
tricky situation are the cases of incomplete abortion sug-
gested on ultrasound evaluation. Does one resort to a
surgical evacuation of the uterus or does one wait and
monitor the natural course of events? Harwood et al.14 in
their study has shown that in the first week following
medical abortion, the median decline in h-hCG levels from
the level at the time of misoprostol administration was
94.6%. The h-hCG level reached <50 mIU/mL between
two and eight weeks after abortion and the time to reach
these minimal levels was directly related to the initial
h-hCG with higher levels requiring a longer time to clear14.
Similarly, Creinin15 showed that an aborting pregnancy,
if medical abortion has occurred, should have a h-hCG
decrease of approximately 50% within 24 hours. How-
ever, this decline does not guarantee that the abortion is
complete14.
The usefulness of monitoring h-hCG levels is clearly
demonstrated in our study. In the group with continuing
pregnancy, there was a statistically significant percentage
increase in the mean and median h-hCG levels. (Table 4) In
the group where the diagnosis was missed abortion on
ultrasound, this mean and median percentage fall in h-hCG
was only 23% and 25%, respectively. Based on these
findings, two doses of 400 Ag of vaginal misoprostol
repeated 3 hours apart were given and this successfully
aborted the missed abortion in all five cases. In the group
where the abortion was complete on ultrasound, the mean
percentage fall in h-hCG was 98%; the fall was 91% in the
group diagnosed to have an incomplete abortion on ultra-
sound. It would thus appear to make sense that if there is a
significant mean percentage change in the serum h-hCG at
day 15 follow up, one can confidently manage the women
conservatively even if the ultrasound assessment suggests
incomplete abortion. In fact, rightly all 12 women diag-
nosed to have an incomplete abortion in ultrasound were
managed conservatively without any complications. At day
43 or six weeks after the start of misoprostol administra-
tion, the mean h-hCG levels were all less than 2.5 mIU/mL
in all three groups (i.e. complete, incomplete and missed
abortion) and the menses had returned in all of them.
However, in practice, where products of conception is
noted to have been passed prior to discharge and in women
who are asymptomatic with no vaginal bleeding on follow
up, it may not be cost effective to perform h-hCG levels
and ultrasound scanning. It should be reserved for women
who have failed to pass products of conception and are
symptomatic on follow up.
The side effects of various misoprostol-alone regimens
are also important factors determining their acceptability
and usefulness. The mean duration of vaginal bleeding
of approximately 12 days in our study is comparable
with regimens using a combination of mifepristone and
misoprostol11. The incidence of the three most important
side effects (i.e. lower abdominal pain, fever >38.0jC and
diarrhoea on the day of treatment) were comparable to that
reported in other studies using repeated doses of vaginal
misoprostol12 and was even lower than that reported by the
use of a regimen of 600 Ag misoprostol given sublingually
every 3 hours for a maximum of five doses16.
CONCLUSION
Our regimen of using repeated doses of vaginal miso-
prostol alone, over a period of 9 hours on a day care basis,
with a success rate of 96.0% at six weeks post-misoprostol
administration, is an effective method of medical abortion
with tolerable side effects.
INTRAVAGINAL MISOPROSTOL AS ALTERNATIVE TO SURGICAL VACUUM ASPIRATION 179
D RCOG 2003 Br J Obstet Gynaecol 110, pp. 175–180
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Accepted 12 November 2002
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