Termination of pregnancy at 9-13 weeks' amenorrhoea with mifepristone and misoprostol.

In England and Wales, nearly half of all abortions are done at 9–12 weeks’ gestation, whereas in Scotland a third are done at 10–13 weeks’ gestation. Combined mifepristone and a prostaglandin E1 analogue was licensed in the UK in 1991 for medical termination up to 9 weeks’ gestation, and in 1995 for abortion after 13 weeks. Between 9 weeks and 13 weeks, surgical methods are used almost exclusively. Based on our previous experience we have developed a regimen of mifepristone with vaginal and oral misoprostol for use at 9–13 weeks’ gestation. 120 women with pregnancies of 9–13 weeks’ amenorrhoea, confirmed by ultrasound, consented to participate in this study. Each was scheduled to have an abortion with routine care, including access to counselling and infection screening. Each woman received a single oral dose of 200 mg mifepristone and was admitted 36–48 h later to the ward as a day case, when she received 800 g misoprostol vaginally. Where indicated, a further two doses of misoprostol 400 g were given vaginally or orally every 3 h dependent on the amount of vaginal bleeding. If products of conception were passed on the ward and seemed to be complete, the women were observed for a further 4 h before being allowed home. To estimate the incidence and severity of bleeding and to assess satisfaction of patients, 73 consecutive women completed a questionnaire (midway in the study). Women were seen for follow-up in hospital or by their family physician (with additional telephone follow-up) 2 weeks after the procedure. 66 (55%) women were nulligravid and 54 (45%) multigravid (table). The median age of women was 22·1 years (range 15–43), and the median duration of amenorrhoea was 10·3 weeks (range 9–13; 38% at 9–10 weeks, 29% at 10–11 weeks, 14% at 11–12 weeks, and 19% at 12–13 weeks.) All 120 women aborted on the ward on the day of prostaglandin administration. Exploratory curettage was performed in six (5%) women after the procedure, in three women for a retained placenta on the day of the termination and in a further three on days 4, 15, and 26 (trophoblast was identified in two). The median dose of prostaglandin required was 1200 g (range 800–1600). The median time from administration of misoprostol to abortion was 4·33 h (range 1·3–16·0). 19 (15·8%) women required antiemetics. Diarrhoea was reported in 38 (32%). Four (3%) women developed heavy bleeding immediately after passing products of conception and required oxytocics. 34 (28%) women did not ask for pain relief, 60 (50%) required oral analgesia, and 26 (22%) required parenteral analgesia. Most women (93%) were managed as day cases. The analyser could not assess white or red blood cells properly. Blood smears showed rouleaux formation of red cells (figure) and a change in the shape of white cells. Manual blood-cell analyses using the same slides were normal. 48 h after Taxol, the automatic blood-cell analyses were normal. We investigated the effects of Taxol and polyoxyethylated castor oil on blood-cell analyses by adding 2, 3, 4, 5, 6, 7, 8, 9, and 10 L/mL whole blood of Taxol to whole blood obtained from one of the authors and incubated for 2–30 h at 37°C. We also added 1, 2, 3, 4, and 5 L/mL whole blood of polyoxyethylated castor oil to whole blood and incubated specimens as above. After incubation for 6–28 h, blood-smear samples of 3–10 L/mL whole blood of Taxol and 2–5 L/mL whole blood of polyoxyethylated castor oil showed the same changes as patients’ blood samples. These amounts of Taxol or polyoxyethylated castor oil were about the same as those in patients after intravenous infusion. Automatic blood cell analysers are widely used around the world. They may fail accurately to analyse blood cells in samples from patients with hyperlipidaemia. Taxol contains 2·5 mL of polyoxyethylated castor oil per vial (5·0 mL/vial). Our patients received 17·5–20·0 mL of polyoxyethylated castor oil within 24 h of blood analyses. The high concentration of polyoxyethylated castor oil appears to be responsible for the condition of the blood smears obtained from our patients. Our experience suggests caution in the use of automatic blood cell analysers in patients receiving Taxol.