Reproductive Health Matters 2008;16(31 Supplement):162–172 PII: S 0 9 6 8 - 8 0 8 0 ( 0 8 ) 31 3 71 - 8 Mifepristone–Misoprostol and Misoprostol Alone: Kristina Gemzell-Danielsson,a Sujata Lalitkumarb a Professor, Department of Woman and Child Health, Division of Obstetrics and Gynaecology, Karolinska Institutet, Karolinska University Hospital, Stockholm,Sweden. E-mail: b Specialist in Obstetrics and Gynaecology, Department of Woman and Child Health, Division of Obstetrics and Gynaecology, Karolinska Institutet, KarolinskaUniversity Hospital, Stockholm, Sweden Abstract: Second trimester abortions constitute 10–15% of all induced abortions worldwide butare responsible for two-thirds of major abortion-related complications. During the last decade,medical methods for second trimester induced abortion have been considerably improved andbecome safe and more accessible. Today, in most cases, safe and efficient medical abortion servicescan be offered or improved by minor changes in existing health care facilities. Second trimestermedical abortion can be provided by a nurse–midwife with the back-up of a gynaecologist. Becauseof the potential for heavy vaginal bleeding and serious complications, it is advisable that secondtrimester terminations take place in a health care facility where blood transfusion and emergencysurgery (including laparotomy) are available. This article provides basic information on regimensrecommended for second trimester medical abortion. The combination of mifepristone andmisoprostol is now an established and highly effective method for second trimester abortion. Wheremifepristone is not available or affordable, misoprostol alone has also been shown to be effective,although a higher total dose is needed and efficacy is lower than for the combined regimen.
Therefore, whenever possible, the combined regimen should be used. Efforts should be made toreduce unnecessary surgical evacuation of the uterus after expulsion of the fetus. Future studiesshould focus on improving pain management, the treatment of women with failed medical abortionafter 24 hours, and the safety of medical abortion regimens in women with a previous caesareansection or uterine scar. A2008 Reproductive Health Matters. All rights reserved.
Keywords: medical abortion, second trimester abortion, mifepristone, misoprostol, mid-level providers ALTHOUGH the majority of abortions are siblefortwo-thirdsofallmajorabortion-related performed in the first trimester, there is complications. Medical abortion, the termination still a need for second trimester abortion of pregnancy through the use of a drug or a com- because of delayed diagnosis of fetal anomalies, bination of drugs, has the potential to reduce logistic and financial difficulties in obtaining abor- complications and to expand access to abortion tion services, and failure to recognise an undesired provided not only by specially trained clinicians pregnancy in the first trimester, which all con- but also by other health care providers who may tribute to the continuing need for late abortion or may not have training in surgical methods Second trimester abortions constitute 10–15% of abortion. Today, in most cases, safe and effi- of all induced abortions worldwide but are respon- cient medical abortion services can be offered or K Gemzell-Danielsson, S Lalitkumar / Reproductive Health Matters 2008;16(31 Supplement):162–172 improved by minor changes in existing health question because of the disproportionate amount care facilities. This article aims to provide basic of abortion-related morbidity and mortality with second trimester terminations, especially with second trimester medical abortion and best prac- tion (D&E) is the standard method of second tri-mester surgical abortion in many parts of theworld. In the United States, in 2000, D&E was used for 99% of abortions between 13–15 weeks, Different surgical and medical methods of abor- 95% between 16–20 weeks and 85% at 21 weeks tion have been used since ancient times. Sur- or laterIn England and Wales, D&E has also gical abortion is one of the oldest and most been the main method of second trimester abor- commonly practised techniques in many parts of tion; however, medical abortion is more common the world. A matter of great concern in the past than in the US and is increasingly being used. In was that there were no safe drugs for inducing contrast, medical abortion is the standard method an abortion. Women have used various herbs, for second trimester abortion in the Scandinavian salts, douches and purgatives, all with question- and Nordic countries since the introduction of able success to achieve pregnancy termination.
the combined mifepristone–prostaglandin regi- Among the methods listed as outdated by WHO, men. In many other European countries, second but still commonly used in several developing trimester abortions due to fetal abnormalities countries (e.g. India, China and until recently are also performed using medical methods.
Mongolia), is intra- or extra-amniotic adminis- There is a gradual increase in second trimester tration of ethacryidine lactate (Rivanol), especially abortion in some European countries because of to terminate late second trimester pregnancies.
wide-scale introduction of antenatal screening The drawbacks of older methods include long programmes to detect fetal abnormalities such duration of labour, hospitalisation for several days as anencephaly and cardiovascular and skeletal and the need for curettage. In recent years, effec- malformations. In these cases, examination of the tive medical abortion methods with low morbidity fetus could provide valuable information, which have emerged and are becoming more accessible.
medical abortion allows, to confirm the congen- With the introduction of prostaglandins and later ital anomaly, further evaluate the subsequent prostaglandin analogues, the efficacy of medi- risk of recurrence and provide information to cal abortion could be improved, and the risk of help in counselling of these patients.
complications and side effects reduced. Medicallyinduced abortion was further improved whenmifepristone became available in the 1980s Who can provide second trimester abortion? With mifepristone, the induction-to-abortion inter- Specialised training and a sufficient workload to val was shortened, and the dose of prostaglandin maintain the skills, as well as special instruments, analogues required (and thus side effects) was are required to perform D&E safely according to reduced. Today, medical abortion is the method of the World Health Organization (WHO) and the Royal College of Obstetricians & Gynaecologists Medical abortion during early pregnancy was first approved in France in 1988 (up to 49 days safety and efficacy of D&E in experienced of amenorrhoea) followed by approval in the UK (1991) and Sweden (1992) (up to 63 days to perform this procedure at an advanced gesta- of amenorrhoea in both the countries). A few tion. Furthermore, a report on the confidential years later approval followed in these countries inquires into maternal deaths in the UK ques- for second trimester medical abortion. However, tioned the appropriateness of D&E for second it was only in 1999–2000 that both early first trimester abortion when safe and effective and second trimester medical abortion with medical alternatives exist.In the Scandinavian mifepristone and a prostaglandin analogue were countries, the use of second trimester medical approved in several other European countries.
abortion assures wide access to induced abortion The optimal method of second trimester abor- since it can be performed in all gynaecological tion continues to be debated. This is an important clinics. Furthermore, in these settings mid-level K Gemzell-Danielsson, S Lalitkumar / Reproductive Health Matters 2008;16(31 Supplement):162–172 providers with adequate training and back-up The oral tablet is effective in different routes of can provide the abortion care. Because of the administration and the dose of prostaglandin potential for heavy vaginal bleeding and serious can be easily adjusted according to need. In complications in a small number of women, contrast to other prostaglandins, misoprostol has however, it is advisable for second trimester ter- limited effect in the bronchi or blood vessels.
minations to take place in health care facilities Side effects are dose dependent, usually mild and where gynaecologists, blood transfusion and access to emergency surgery (including laparot-omy) are available.
Indications and usageAlthough in most countries mifepristone fol- lowed by a prostaglandin analogue is approved For abortion at 13–24 weeks of gestation, medi- for medical termination of early first trimester cal abortion with mifepristone followed by a pregnancy (Mifepristone, Exelgyn, Paris, France), prostaglandin (PG) analogue is an appropriate mifepristone with repeated doses of a prosta- method and has been shown to be safe and effec- glandin analogue (most commonly misoprostol) is also licensed and widely used for abortion of misoprostol has synergistic effects and stimulates later pregnancies. Studies carried out in many dif- ferent countries provide evidence of the safety of medical abortion up to 24 weeks of pregnancy However, it should be noted that while the dose of mifepristone does not change, the dose of misoprostol needs to be modified according Mifepristone is the only antiprogestin ap- to gestational age. A higher total dose is often proved for the induction of abortion. It is a 19- needed in the late first trimester compared to the norsteroid, which binds with high affinity to the early first trimester. During the second trimester, progesterone receptor, thus inhibiting the effect due to increased sensitivity of the uterine mus- of progesterone. Progesterone is a key hormone cles to PGs, lower doses are sufficient. One needs in maintaining pregnancy by keeping the uterus to be very vigilant about hyperstimulation and in a quiescent state. It prevents softening and uterine rupture in cases with previous caesarean dilatation of the cervix, reduces PG output from section or any uterine scar in pregnancies beyond the decidua and suppresses uterine contractions.
Thus, the blocking of progesterone receptors bymifepristone results in vascular damage, decidualnecrosis and bleeding,which leads to cervi- cal softening, increased uterine sensitivity to PG and conversion of the quiet pregnant uterus into There are very few absolute contraindications an organ of spontaneous activity with maximal to medical abortion. When using a combination of mifepristone and misoprostol they include: Misoprostol is a synthetic PGE-1 analogue which induces cervical ripening as well as strong  Previous allergic reaction to any of the drugs uterine contractions and leads to expulsion of a pregnancy. Prostaglandins play an important role in the regulation of uterine contractility during pregnancyThe receptors are present through-out the pregnancy; hence, PGs and PG analogues are effective for termination of pregnancy. Miso- prostol has been shown to have several advan-tages over other prostaglandins; it is cheap, stable at room temperature and can be stored for a long time. Misoprostol is equally or more effective  has pre-existing heart disease or cardiovascular K Gemzell-Danielsson, S Lalitkumar / Reproductive Health Matters 2008;16(31 Supplement):162–172 It should be remembered that complications and prostol is dependent on the route of admin- side effects with medical abortion increase with istration. Vaginal misoprostol is more effective increasing length of pregnancy. To reduce such and has fewer side effects, but it may be less complications abortion should be performed as acceptable to some women. The sublingual route early as possible without unnecessary delay; health has therefore been investigated and shown to care professionals should receive adequate train- be convenient and acceptable although slightly ing; and back-up services, including uterine evac- uation and blood transfusion, should be available.
Interval between mifepristone and misopros- tol: Maximal priming effect on the myometriumis achieved 36–48 hours after pre-treatment with mifepristone. A shorter interval of 24 hours resulted in a slightly longer induction-to-abortion Mifepristone and misoprostol act synergistically interval, a higher total dose of misoprostol used in combination, and where both are available and a higher rate of uterine curettage (pb0.001) both should be used. Misoprostol alone should Similarly, retrospective data comparing 24- and be used in countries where mifepristone is not 48-hour intervals showed that when the interval available. As with early medical abortion, the was reduced to 24 hours, the induction-to abor- goal has been to find a regimen combining the tion interval was longer (9.8 hours vs. 7.5 hours) lowest doses of both drugs that is highly effec- (pb0.01)As both of these studies report sig- tive and has the fewest side effects, and which nificantly longer induction times, the 36–48 hour administration interval may be preferable if prac- For second trimester abortion (13–24 weeks of gestation), medical abortion with mifepristone fol- About 0.2–0.4% of women abort with mifep- lowed by a PG analogue is an appropriate method and has been shown to be safe and effective,according to WHO and the RCOG.It has been Misoprostol-alone regimen: if mifepristone is well proven that pre-treatment with mifepristone 24–48 h before PG administration increases the  Vaginal misoprostol 400 micrograms, every success rate, shortens the induction-to-abortion 3 hours, to a maximum of 5 vaginal doses.
interval and reduces the amount of PGs requiredin the second trimester– In countries where mifepristone is not avail- Second trimester abortion in prior caesarean able or affordable, gemeprost or misoprostol section patients should be carried out with caution.
alone have been shown to be effective, although Routine surgical evacuation of the uterus fol- a higher total dose is needed and is less effec- lowing medical abortion is not required.
Analgesics should be offered to all women induction-to-abortion interval, 10–15 hours, is longer than with the combined treatment with Vaginal misoprostol or gemeprost can be admin- mifepristone. Since a higher dose is required, istered either by the woman herself or by a clini- the abortion process may have more side effects, cian, according to the preference of the woman.
such as nausea, vomiting, abdominal pain, feverand shivering.There is also a higher rate of failed abortion and continuing live pregnancy.
With the misoprostol alone regimen, 80–90% of Mifepristone 200 mg orally, followed 36– 48 hours later by misoprostol 800 micrograms A meta-analysis of randomised trials compar- vaginally and thereafter by repeated doses ing gemeprost with misoprostol (using various of 400 micrograms misoprostol orally, every dosage regimens of misoprostol) showed that 3 hours, to a maximum of 4 oral doses.
vaginal misoprostol compared with gemeprost was associated with a reduced need for narcotic misoprostol has an abortion rate as high as 97% analgesia and surgical evacuation of the uterus and the median induction-to-abortion interval When a regimen of 400 micrograms of vaginal K Gemzell-Danielsson, S Lalitkumar / Reproductive Health Matters 2008;16(31 Supplement):162–172 misoprostol every 3 hours was compared with number of misoprostol doses, whereas it is less 1 mg of gemeprost every 3 hours, the induction- in older, parous women and those at lower to-abortion interval was significantly shorter in the gestations.However, none of these factors is vaginal misoprostol groupMany misoprostol- sufficiently predictive to be useful in the man- alone regimens have been reported in the literature agement of individual cases. Non-steroidal anti- with good results. Most of the trials were conducted inflammatory drugs (NSAIDs) are a potential in pregnancies of 13–22 weeks. For this gestational first-line treatment. They inhibit the produc- period, a regimen of 400 micrograms of vaginal tion of endogenous PGs which are important misoprostol every 3 hours up to 5 doses is rec- messengers responsible for uterine contrac- ommended, as it appears to be effective without tions, cramps and pain sensation. NSAIDs do not interfere with the action of misoprostol and/or mifepristone on inducing cervical ripening, Mifepristone–gemeprost regimen: going out uterine contractilityor the time to abortion and expulsion of the products of conception.
The role of advance or prophylactic analgesia, Mifepristone 200 mg orally, followed 24– conscious sedation and para-cervical block and 48 hours later by gemeprost 1 mg vaginally their effectiveness, as well as women’s satisfac- every 6 hours to a maximum of five pessaries.
tion and acceptance, need further research.
in medical abortion and cervical priming untilmisoprostol became available.Vaginal geme- prost-only regimens have an abortion rate of Side effects, including nausea, vomiting and diar- 88–96.5% with a longer induction-to-abortion rhoea, are characteristics of PG administration interval compared to the combined regimen.
and are caused by PG’s stimulatory effect on the With pre-treatment with mifepristone, the abor- gastrointestinal tract. Diarrhoea is more common tion rate in 24 hours was increased from 72% in women using gemeprost, whereas fever is more to 95the induction-to-abortion interval was reduced from 15.7 to 6.6 hours and the PG dose cations, such as uterine rupture, major haemor- was also reduced without loss of clinical efficacy rhage and cervical tear, are rare.Uterine rupture cases are reported to occur with both shown to be highly effective, gemeprost has sev- gemeprost and misoprostol, with or without eral disadvantages compared with misoprostol (i.e.
cost and the need for refrigeration limits its usage uterine rupture in women without previous scar in developing countries), which has led to miso- is estimated to be 0.1–0.2% in the second tri- prostol replacing gemeprost for all indications.
mester of pregnancy using mifepristone andgemeprMajor bleeding is usually asso-ciated with prolonged retention of the placenta.
Heavy bleeding requiring transfusion has been adverse effects of medical abortIn routine tion may occur with any induced abortion. About clinical practice, analgesia should be offered to 3% of women required antibiotic treatment all women. The perception of pain and request because of suspected infections in a large series for pain relief has wide individual and cultural of over 1,000 women who had a second tri- variations. Services should make a range of oral and parenteral analgesics available to meetwomen’s needs.Pain is most likely to be feltin the first few hours after PG analogue admin- istration. Studies have shown that analgesic requirement and the perception of pain are sig- When medical abortion is chosen, in many set- nificantly higher in women of younger age and tings, clinicians are legally required to ensure those at a higher gestational age, with a longer that the fetus is dead at the time of abortion.
induction-to-abortion interval and with a greater According to the RCOG, a legal abortion must K Gemzell-Danielsson, S Lalitkumar / Reproductive Health Matters 2008;16(31 Supplement):162–172 not be allowed to result in a live birth, and at abortion. It should only be undertaken if there is terminations after 21 weeks, the method chosen clinical evidence that the abortion is incomplete should ensure that the fetus is not alive.This is After the fetus is aborted, the placenta is usu- especially important for late terminations (with ally expelled within a short time. An injection or without fetal malformation) if policy requires of oxytocin may be given to help the expulsion the provider to resuscitate if the fetus is born alive.
of the placenta. If the placenta is not delivered Agents used for feticide are hypertonic saline, within 1–2 hours, an infusion of 10 units oxyto- 1% lidocaine and potassium chloride or intra- cin in 500 ml of normal saline at a rate of 20– 30 drops/min may be given to help the expulsion 21 weeks of pregnancy, the contractions induced of the placenta or other uterotonic drugs accord- ing to local guidelineAfter expulsion, theplacenta should be examined to see whether it iscomplete. If the placenta is incomplete, evacua- tion of the uterus may be needed. If the placenta Day-care abortion is recognised as a patient- is not delivered after more than 1–2 hours obser- centred and cost-effective form of service pro- vation, or the woman starts bleeding excessively, vision. In the era of older methods for inducing evacuation of the uterus may be required.
second trimester abortion, a majority of women After abortion, the woman should be observed had to be inpatients for a couple of days to in the hospital for at least 4 hours to monitor the achieve abortion. The availability of abortion as vital signs and the amount of vaginal bleeding. If a day-care procedure can minimise disruption there is heavy vaginal bleeding, a careful specu- to the lives of women and their families. The lum and pelvic examination should be performed introduction of mifepristone treatment prior to to exclude the possibility of lacerations of the PG analogue has reduced induction-to-abortion cervix. If there is no evidence of lacerations in the intervals sufficiently such that many women lower genital tract but the uterus is not contract- (more than 75%) undergoing these procedures can ing well and the bleeding persists, the uterine be managed as day cases. With the regimen of a cavity should be explored to see whether there combination of mifepristone and vaginal miso- are any retained products of conception.
prostol, as described above, the median induction- In recent large case series of second trimester abortion only 2.5–11% of women needed surgicalevacuation following medical abortion.Complete abortion is achieved with increasing There are only a few studies reporting regimens ing a routine evacuation, however, does not pro- for women who do not abort within 24 hours.
tect against the need for hospital readmission for According to some protocols, if abortion does post-abortion bleeding and uterine curettage. A not occur, mifepristone is given again, followed more determined approach – using surgical evac- uation only when needed – can be practised by who fails to abort during the second day would training staff in assessing placental completeness get a third dose of mifepristone followed by gemeprost 1 mg every 3 hours. There is still insuf-ficient consensus to set a guideline for the failedor delayed group of abortion patients, but it could be argued that for women going on to a second or third day, D&E would be a more appropriate The caesarean section rate is generally increas- approach.If a choice is available, the women ing worldwide. Although many studies have demonstrated the small risk of complications forvaginal birth at term after a prior caesarean sec-tion, experience with second trimester abortion in women with prior uterine scar is limite Routine surgical evacuation of the uterus is Uterine rupture, haemorrhage and hysterotomy/ not required following second trimester medical hysterectomy remain uncommon but are possible K Gemzell-Danielsson, S Lalitkumar / Reproductive Health Matters 2008;16(31 Supplement):162–172 complications of any second trimester termina- tion method used. A literature review found that Treatment with mifepristone and misoprostol uterine rupture is associated with the use of high typically involves two visits to the clinic by a dose oxytocinAmong 23 women with a history woman for pregnancy above nine weeks.It may of prior caesarean section treated with the combi- also include a follow-up visit a few weeks after nation of mifepristone and gemeprost, one case of asymptomatic uterine rupture was reported.Inaddition, there are case reports of uterine rupture with the use of misoprostol in the scarred uterus A single 200 mg tablet of mifepristone is takenorally. The woman is advised to return after 36– 48 hours for day-care admission to complete theabortion procedure with misoprostol. It is very seldom that women abort with mifepristone Both counselling and abortion should be pro- (0.2–0.4% of cases), but the woman should be vided without undue delay. Women should be informed that this may occur. She should also be free to choose to be counselled alone or with a informed regarding expected effects of the drugs partner, parent or friend. Ideally, pre-abortion and possible side effects. In case of significant counselling should also include contraceptive bleeding and/or contractions the woman should counselling and provision, making it possible to begin the chosen method of contraception imme-diately after the abortion.
Second visitDuring the second visit the woman is admitted to the clinic for misoprostol administration. An In most cases, pregnancy is confirmed and its initial dose of 800 micrograms vaginally fol- length estimated on the basis of the woman’s his- lowed by 400 micrograms orally every 3 hours, tory and physical examination. Ultrasound exami- to a maximum of 4 oral doses, is administered.
nation is not necessary in the majority of women, Appropriate pain relief should be given during although commonly used. It may be helpful to the abortion. Abortion may take place after any use ultrasound to diagnose pathologies or a non- of the doses of misoprostol. After expulsion, the placenta should be examined to see whether it iscomplete. If the placenta is incomplete, evacua- Clinical assessment and laboratory investigations A clinical history should be obtained to identify The woman is kept under observation for at contraindications and risk factors for compli- least 4 hours after the expulsion to monitor the cations. History of a patient should include per- vital signs and the amount of vaginal bleeding.
sonal and family history of relevant diseases; At discharge from the clinic, women should be current use of any medications, allergies; obstetric informed regarding expected effects and possi- and gynaecological history; any bleeding tenden- cies; and history of sexual transmitted infections.
From 15 weeks of pregnancy onwards, lacta- Social history should include a risk assessment for tion inhibition medication should be given.
sexually transmitted diseases, taking into accountlocal prevalence rates. Any genital infection shouldbe excluded or treatment started prior to the abor- tion. The clinician must be alert to the possibil- ity of violence or coercion in the context of the start bleeding after the administration of miso- prostol. Usually the amount of bleeding is not Vital signs like pulse, blood pressure and excessive. The cramps are due to uterine contrac- temperature should be recorded at baseline and tions, which are needed to abort the pregnancy.
during treatment. Haemoglobin level, blood Appropriate information and pain medication group and Rhesus (Rh) typing should be deter- allow the woman to relax, which reduces dis- mined. Rh-negative women should receive anti- comfort. NSAIDs for pain relief can be given together with misoprostol. Some women may K Gemzell-Danielsson, S Lalitkumar / Reproductive Health Matters 2008;16(31 Supplement):162–172 require narcotic analgesics or a para-cervical block with regard to evaluation of the fetus and placenta in cases of fetal malformation. This would help in future research to develop better emetics. Fever and chills are fairly common ways to deal with complicated pregnancies.
after administration of misoprostol. These do not Further studies are also needed on the treat- indicate that the woman has an infection. Anti- ment of women with failed medical abortion pyretics may be given if necessary. These side after 24 hours. There is also a need to further effects usually subside or resolve 24 hours after reduce unnecessary surgical evacuation of the uterus after expulsion of the fetus and forguidelines on regimens to help the expulsionof the placenta. More studies are also needed to evaluate the optimal combination of mife- Future studies should focus on improving pain pristone and misoprostol in women with prior management. Medical abortion is advantageous K Gemzell-Danielsson, S Lalitkumar / Reproductive Health Matters 2008;16(31 Supplement):162–172 K Gemzell-Danielsson, S Lalitkumar / Reproductive Health Matters 2008;16(31 Supplement):162–172 45. Wong KS, Ngai CS, Yeo EL, et al.
67. Bhide A, Sairam S, Hollis B, et al.
51. Bartley J, Brown A, Elton R, et al.
K Gemzell-Danielsson, S Lalitkumar / Reproductive Health Matters 2008;16(31 Supplement):162–172 Les avortements du deuxie`me trimestre repre´sentent Los abortos de segundo trimestre constituyen de 10 a` 15% des interruptions de grossesse del 10 al 15% de todos los abortos inducidos dans le monde, mais ils sont responsables des mundialmente pero son responsables de dos deux tiers des plus graves complications lie´es terceras partes de las complicaciones ma´s graves a` l’avortement. Ces dix dernie`res anne´es, les relacionadas con el aborto. Durante la u´ltima me´thodes me´dicamenteuses d’avortement du de´cada, los me´todos me´dicos para el aborto deuxie`me trimestre se sont sensiblement ame´liore´es inducido en el segundo trimestre han mejorado et sont devenues plus suˆres et plus accessibles.
considerablemente y son seguros y ma´s accesibles.
Aujourd’hui, dans la plupart des cas, des services Hoy, en la mayorı´a de los casos, es posible d’avortement me´dicamenteux suˆrs et efficaces ofrecer o mejorar servicios seguros y eficientes peuvent eˆtre propose´s ou n’exigent que quelques de aborto con medicamentos haciendo pequen˜os changements dans les e´tablissements sanitaires cambios a los establecimientos de salud. El existants. L’avortement me´dicamenteux du deuxie`me aborto con medicamentos puede ser efectuado trimestre peut eˆtre assure´ par une infirmie`re-sage- en el segundo trimestre por una enfermera–partera femme, avec l’appui d’un gyne´cologue ; en raison profesional con el respaldo de un gineco´logo.
du risque d’abondants saignements vaginaux et Dado el potencial de hemorragia vaginal y graves de graves complications, il est souhaitable qu’il se complicaciones, se aconseja que el aborto de de´roule dans un centre de sante´ pouvant pratiquer segundo trimestre se efectu´e en una unidad donde une transfusion sanguine ou une intervention sea posible realizar una transfusio´n sanguı´nea o chirurgicale d’urgence (y compris une laparotomie).
cirugı´a de urgencia (incluida la laparotomı´a). En Cet article donne des informations de base sur este artı´culo se proporciona informacio´n ba´sica les sche´mas recommande´s pour les avortements sobre los regı´menes recomendados para el aborto me´dicamenteux du deuxie`me trimestre. L’association con medicamentos en el segundo trimestre. La de mife´pristone et de misoprostol est maintenant combinacio´n de mifepristona y misoprostol ahora une me´thode confirme´e et tre`s efficace. Quand la es un me´todo establecido y muy eficaz para el mife´pristone n’est pas disponible ou trop one´reuse, aborto de segundo trimestre. En los lugares donde le misoprostol seul s’est aussi re´ve´le´ efficace, no se dispone de mifepristona o donde no es meˆme si la dose doit eˆtre augmente´e et si asequible, se ha mostrado que misoprostol solo l’efficacite´ est moindre. Par conse´quent, chaque tambie´n es eficaz, aunque se necesita una dosis fois que possible, il convient d’utiliser l’association total ma´s alta y su eficacia es menor que la del des deux me´dicaments. Il faut s’efforcer de re´duire re´gimen combinado. Por tanto, siempre que sea les e´vacuations chirurgicales inutiles de l’ute´rus posible, se debe utilizar el re´gimen combinado. Se apre`s l’expulsion du fKtus. Les e´tudes futures deben realizar esfuerzos por reducir el nu´mero devraient porter sur l’ame´lioration de la prise de procedimientos innecesarios de evacuacio´n en charge de la douleur, le traitement des e´checs endouterina quiru´rgica despue´s de la expulsio´n del de l’avortement me´dicamenteux dans les 24 feto. Futuros estudios deberı´an centrarse en mejorar heures et la se´curite´ des sche´mas d’avortement el manejo del dolor, el tratamiento de mujeres me´dicamenteux chez les femmes ayant subi une cuyo aborto con medicamentos fracase despue´s de ce´sarienne ou pre´sentant une cicatrice ute´rine.
24 horas y la seguridad de los regı´menes de abortocon medicamentos en mujeres con antecedentesde cesa´reas o cicatrices uterinas.



Publikationen Originalarbeiten Blättner B, Kohlenberg-Müller K, Grewe A: Prävention von Adipositas bei Kindern und Jugendlichen: Neue Strategien sind erforderlich. Prävention 29, 42 – 46, Blättner B, Kohlenberg-Müller K, : Evaluation von zwei Adipositas-Programmen für Kinder und Jugendliche. Public Health Forum (51), 25, 2006 Blättner B, Kohlenberg-Müller K, Grewe A: Adiposi

Bryssel den 12.9.2012 COM(2012) 512 final EUROPAPARLAMENTETS OCH RÅDETS FÖRORDNING om ändring av förordning (EU) nr 1093/2010 om inrättande av en europeisk tillsynsmyndighet (Europeiska bankmyndigheten), när det gäller dess samspel med rådets förordning (EU) nr …/… om tilldelning av särskilda uppgifter till Europeiska centralbanken i fråga om politiken för tillsyn

Copyright ©2018 Sedative Dosing Pdf