Wildschut Hajo, Both Marieke I, Medema Suzanne, Thomee Eeke, Wildhagen Mark F, Kapp Nathalie
Department of Obstetrics and Gynaecology, Erasmus Medical Center, PO Box 2040, Rotterdam, Netherlands, 3000 CA.
Cochrane Database Syst Rev. 2011 Jan 19;2011(1):CD005216. doi: 10.1002/14651858.CD005216.pub2.
With the improvement of ultrasound technology, the likelihood of detection of major fetal structural anomalies in mid-pregnancy has increased considerably. Upon the detection of serious anomalies, women typically are offered the option of pregnancy termination. Additionally, there are still many reasons other than fetal anomalies why women seek abortion in the mid-trimester.
To compare different methods of second trimester medical termination of pregnancy for their efficacy and side-effects.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, Popline and reference lists of retrieved papers and other sources.
All randomised controlled trials (RCTs) examining medical regimens for termination of pregnancy of a singleton living fetus between 12-28 weeks' gestation were analysed. The outcome measures were the induction to abortion interval, abortion rate within 24 hours, need for surgical evacuation, blood loss, uterine rupture, pain, and side-effects.Trials including >20% fetal death, multiple pregnancies, previous uterine scars and regimens which involved cervical preparation were excluded.
Two authors selected the trials and three authors extracted data.
Fourty RCTs were included, addressing various agents for pregnancy termination and methods of administration. When used alone, misoprostol was an effective inductive agent, though it appeared to be more effective in combination with mifepristone. However, the evidence from RCTs is limited.Misoprostol was preferably administered vaginally, although among multiparous women sublingual administration appeared equally effective. A range of doses of vaginally administered misoprostol has been used. No randomised trials comparing doses of misoprostol were identified; however low doses of misoprostol appear to be associated with fewer side-effects while moderate doses appear to be more efficient in completing abortion. Four RCTs showed that the induction to abortion interval with 3-hourly vaginal administration of prostaglandins is shorter than 6-hourly administration without an increase in side-effects.Many studies reported the need for surgical evacuation. Indications for surgical evacuation include retained products of the placenta and heavy vaginal bleeding. Fewer women required surgical evacuation when misoprostol was administrated vaginally compared with women receiving intra-amniotical PGF(2a) . Mild, self-limiting diarrhoea was more common among women who received misoprostol compared to other agents.
AUTHORS' CONCLUSIONS: Medical abortion in the second trimester using the combination of mifepristone and misoprostol appeared to have the highest efficacy and shortest abortion time interval. Where mifepristone is not available, misoprostol alone is a reasonable alternative. The optimal route for administering misoprostol is vaginally, preferably using tablets at 3-hourly intervals. Apart from pain, the side-effects of vaginal misoprostol are usually mild and self limiting. Conclusions from this review are limited by the gestational age ranges and variable medical regimens, including dosing, administrative routes and intervals of medication, of the included trials.
随着超声技术的进步，孕中期检测出主要胎儿结构异常的可能性显著增加。一旦检测到严重异常，通常会为女性提供终止妊娠的选择。此外，除了胎儿异常外，还有许多其他原因导致女性在孕中期寻求堕胎。
比较孕中期药物终止妊娠的不同方法的疗效和副作用。
我们检索了Cochrane对照试验中心注册库（CENTRAL）（Cochrane图书馆）、MEDLINE、Popline以及检索到的论文和其他来源的参考文献列表。
分析了所有研究妊娠12 - 28周单活胎终止妊娠药物方案的随机对照试验（RCT）。结局指标包括引产至流产间隔时间、24小时内流产率、手术清宫需求、失血量、子宫破裂、疼痛和副作用。排除胎儿死亡>20%、多胎妊娠、既往子宫瘢痕以及涉及宫颈准备的方案的试验。
两名作者选择试验，三名作者提取数据。
纳入了40项RCT，涉及各种终止妊娠的药物和给药方法。单独使用时，米索前列醇是一种有效的引产药物，不过与米非司酮联合使用似乎更有效。然而，RCT的证据有限。米索前列醇最好经阴道给药，尽管在经产妇中舌下给药似乎同样有效。已使用了一系列经阴道给药的米索前列醇剂量。未发现比较米索前列醇剂量的随机试验；然而，低剂量米索前列醇似乎副作用较少，而中等剂量在完成流产方面似乎更有效。四项RCT表明，每3小时经阴道给予前列腺素的引产至流产间隔时间比每6小时给药短，且副作用未增加。许多研究报告了手术清宫的需求。手术清宫的指征包括胎盘组织残留和大量阴道出血。与接受羊膜腔内注射前列腺素F2α的女性相比，经阴道给予米索前列醇的女性需要手术清宫的较少。与其他药物相比，接受米索前列醇的女性中轻度、自限性腹泻更为常见。
孕中期使用米非司酮和米索前列醇联合进行药物流产似乎疗效最高且流产时间间隔最短。如果没有米非司酮，单独使用米索前列醇是一个合理的选择。米索前列醇的最佳给药途径是经阴道，最好每3小时使用片剂。除疼痛外，经阴道使用米索前列醇的副作用通常较轻且为自限性。本综述的结论受到纳入试验的孕周范围以及包括给药剂量、给药途径和用药间隔在内的可变药物方案的限制。
