Interpretation to Medication Abortion Up to 70 Days of Gestation: ACOG Practice Bulletin, Number 225

doi:10.3877/cma.j.issn.1673-5250.2022.03.005

Medication abortion (MA) is a remedial measure for contraceptive failure in early pregnancy. The main medication regimen includes mifepristone and misoprostol, and rate of complete termination of pregnancy in first trimester could be about 90% by combination of them. However, problems, such as patients with vaginal bleeding caused by MA have a longer duration, a larger volume, or even a vaginal hemorrhaged badly, and need for emergency curettage than those of artificial termination of early pregnancy have not been completely solved yet. At home and abroad, how to safely and effectively terminate early pregnancy and protect women′s reproductive health are researched and focused in this field. American College of Obstetricians and Gynecologists (ACOG) released the Medical Abortion Up to 70 Days of Gestation, 2020 ACOG Practice Bulletins, Number 225 plays an important guiding role in terminating early pregnancy. This paper intends to evaluate and interpret the 2020 ACOG practice bulletins above mentioned by recommendation level evidence-based from 9 aspects, including scheme, contraindications and indications of MA, consultation and medical examination before MA, pain management of MA, and observation, preventive antibiotics, follow-up management and contraceptive measures after MA.

Key words: Abortion, induced, Pregnancy trimester, first, Artificial termination of pregnancy, early pregnancy, Medication abortion, early pregnancy, Mifepristone, Misoprostol, Reproductive health, women of childbearing age, Interpretation, guideline

表1 美国FDA批准的药物流产方案与WHO推荐方案比较

用药方案		米非司酮(mg，给药方式)	米索前列醇(μg，给药方式)	用药间隔时间
联合用药方案(首选)
	FDA批准方案	200(口服)	800(口服)	24~48 h
	WHO推荐方案	200(口服)	800(阴道、舌下或口腔含服)	24~48 h
单药方案(备选)		/	800(阴道、舌下或口腔含服)	1次/3 h×(1~3次)^a

表1 美国FDA批准的药物流产方案与WHO推荐方案比较

用药方案		米非司酮(mg，给药方式)	米索前列醇(μg，给药方式)	用药间隔时间
联合用药方案(首选)
	FDA批准方案	200(口服)	800(口服)	24~48 h
	WHO推荐方案	200(口服)	800(阴道、舌下或口腔含服)	24~48 h
单药方案(备选)		/	800(阴道、舌下或口腔含服)	1次/3 h×(1~3次)^a

表2 米非司酮(口服，200 mg)联合米索前列醇不同序贯用药方案对不同孕龄患者的完全终止妊娠率比较

米索前列醇给药途径/剂量(μg)	米索前列醇给药间隔时间(h)	不同孕龄患者的完全终止妊娠率(%)
米索前列醇给药途径/剂量(μg)	米索前列醇给药间隔时间(h)	≤49 d	50~56 d	57~63 d	64~70 d
口服给药/800	24~48	98.1	96.8	94.7	92.7
阴道给药/800	24~72	98.3~99.7	95.3~98.6	95.1~98.3	94.9
阴道给药/800	6~8	97.1	94.2	95.2	N/A
阴道给药/800	0~0.25	95.5~95.7	93.7~94.3	91.6~95.3	N/A
口服给药/400	24~48	95.4	N/A	94.8	91.9

表2 米非司酮(口服，200 mg)联合米索前列醇不同序贯用药方案对不同孕龄患者的完全终止妊娠率比较

米索前列醇给药途径/剂量(μg)	米索前列醇给药间隔时间(h)	不同孕龄患者的完全终止妊娠率(%)
米索前列醇给药途径/剂量(μg)	米索前列醇给药间隔时间(h)	≤49 d	50~56 d	57~63 d	64~70 d
口服给药/800	24~48	98.1	96.8	94.7	92.7
阴道给药/800	24~72	98.3~99.7	95.3~98.6	95.1~98.3	94.9
阴道给药/800	6~8	97.1	94.2	95.2	N/A
阴道给药/800	0~0.25	95.5~95.7	93.7~94.3	91.6~95.3	N/A
口服给药/400	24~48	95.4	N/A	94.8	91.9

[16]	中华医学会计划生育学分会，中国优生优育协会生育健康与出生缺陷防控专业委员会. 合并子宫颈疾病的早期妊娠人工流产专家共识[J]. 中国实用妇科与产科杂志，2021, 37(3): 317-321. DOI: 10.19538/j.fk2021030113.
[17]	余江萍. 10~18周妊娠药物流产916例临床观察[J/OL]. 中华妇幼临床医学杂志(电子版), 2007, 3(2): 110-110. DOI: 10.3877/cma.j.issn.1673-5250.2007.02.120.
[18]	张琼冬. 米非司酮配伍米索前列醇终止中期妊娠108例[J/OL]. 中华妇幼临床医学杂志(电子版), 2007, 3(2): 107-107. DOI: 10.3877/cma.j.issn.1673-5250.2007.02.118.
[19]	程利南. 米非司酮配伍米索前列醇终止10~16周妊娠的临床多中心随机比较性研究 [J]. 中华妇产科杂志，1999, 34(5): 268-271.
[20]	Mizrachi Y, Ben-Ezry E, Kleiner I, et al. Reproductive outcome after early pregnancy loss treated with misoprostol versus surgical aspiration[J]. Reprod Biomed Online, 2020, 41(4): 707-713. DOI: 10.1016/j.rbmo.2020.07.004.
[21]	Männistö J, Mentula M, Bloigu A, et al. Induced abortion and future use of IVF treatment; A nationwide register study[J]. PLoS One, 2019, 14(11): e0225162. DOI: 10.1371/journal.pone.0225162.
[22]	Vayssière C, Gaudineau A, Attali L, et al. Elective abortion: clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF) [J]. Eur J Obstet Gynecol Reprod Biol, 2018, 222: 95-101. DOI: 10.1016/j.ejogrb.2018.01.017.
[23]	Magro Malosso ER, Saccone G, Simonetti B, et al. US trends in abortion and preterm birth[J]. J Matern Fetal Neonatal Med, 2018, 31(18): 2463-2467. DOI: 10.1080/14767058.2017.1344963.
[24]	Beuriat PA, Cattiaux L, Guibaud L, et al. Isolated antenatal hydrocephalus after foetal exposure to misoprostol: a teratogenic effect of the cytotec^®？[J]. World Neurosurg, 2019: S1878-8750(19)30047-6. DOI: 10.1016/j.wneu.2018.12.177.
[25]	Holmes LB. Memories of the teratology society: 1972-2020[J]. Birth Defects Res, 2020, 112(12): 935-941. DOI: 10.1002/bdr2.1667.
[26]	陶晶，李小洪，谭曦，等. 妊娠期药物致畸风险咨询技术规范[J/OL]. 中华妇幼临床医学杂志(电子版), 2021, 17(4): 393-401. DOI: 10.3877/cma.j.issn.1673-5250.2021.04.004.
[27]	Reeves MF, Kudva A, Creinin MD. Medical abortion outcomes after a second dose of misoprostol for persistent gestational sac[J]. Contraception, 2008, 78(4): 332-335. DOI: 10.1016/j.contraception.2008.06.002.
[28]	Colwill AC, Bayer LL, Bednarek P, et al. Opioid analgesia for medical abortion: a randomized controlled trial[J]. Obstet Gynecol, 2019, 134(6): 1163-1170. DOI: 10.1097/AOG.0000000000003576.
[29]	Dragoman MV, Grossman D, Nguyen MH, et al. Two prophylactic pain management regimens for medical abortion ≤63 days′ gestation with mifepristone and misoprostol: a multicenter, randomized, placebo-controlled trial[J]. Contraception, 2021, 103(3): 163-170. DOI: 10.1016/j.contraception.2020.12.004.
[30]	Friedlander EB, Soon R, Salcedo J, et al. Prophylactic pregabalin to decrease pain during medication abortion: a randomized controlled trial[J]. Obstet Gynecol, 2018, 132(3): 612-618. DOI: 10.1097/AOG.0000000000002787.
[31]	Creinin MD, Hou MY, Dalton L, et al. Mifepristone antagonization with progesterone to prevent medical abortion: a randomized controlled trial [J]. Obstet Gynecol, 2020, 135(1): 158-165. DOI: 10.1097/AOG.0000000000003620.
[32]	Shannon C, Brothers LP, Philip NM, et al. Infection after medical abortion: a review of the literature[J]. Contraception, 2004, 70(3): 183-90. DOI: 10.1016/j.contraception.2004.04.009.
[33]	Chong E, Winikoff B, Charles D, et al. Vaginal and rectal Clostridium sordellii and Clostridium perfringens presence among women in the United States[J]. Obstet Gynecol, 2016, 127(2): 360-368. DOI: 10.1097/AOG.0000000000001239.
[34]	中华医学会计划生育学分会. 无支架固定式宫内节育器月经间期和人工流产后即时放置临床应用专家共识[J]. 中华妇产科杂志，2020, 55(7): 433-437. DOI: 10.3760/cma.j.cn112141-20200216-00108.
[35]	中华医学会计划生育学分会，国家卫生健康委科学技术研究所. 青少年避孕服务指南[J]. 中华妇产科杂志，2020, 55(2): 83-90. DOI: 10.3760/cma.j.issn.0529-567X.2020.02.005.
[1]	国家卫生健康委员会. 中国卫生健康统计年鉴[M]. 北京. 中国协和医科大学出版社，2020: 215-228.
[2]	中华医学会计划生育学分会. 临床诊疗指南与技术操作：计划生育分册[M]. 北京：人民卫生出版社，2017, 96-106.
[3]	中华医学会计划生育学分会. 不全流产保守治疗专家共识[J]. 中华生殖与避孕杂志，2019, 39(5): 345-348. DOI: 10.3760/cma.j.issn.2096-2916.2019.05.001.
[4]	American College of Obstetricians and Gynecologists′ Committee on Practice Bulletins—Gynecology, Society of Family Planning. Medication abortion up to 70 days of gestation: ACOG practice bulletin, number 225[J]. Obstet Gynecol, 2020, 136(4): e31-e47. DOI: 10.1097/AOG.0000000000004082.
[5]	WHO Guideline Development Group. Medical management of abortion.WHO guidelines approved by the guidelines review committee[S]. Geneva: World Health Organization, 2018.
[6]	National Clinicad Guideline Centre. Abortion care. National Institute for Health and Care Excellence: Clinical Guidelines[M]. London: National Institute for Health and Care Excellence (UK), 2019.
[7]	Chu JJ, Devall AJ, Beeson LE, et al. Mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage (MifeMiso): a randomised, double-blind, placebo-controlled trial[J]. Lancet, 2020, 396(10253): 770-778. DOI: 10.1016/S0140-6736(20)31788-8.
[8]	Berg J, Hamel CC, Snijders MP, et al. Mifepristone and misoprostol versus misoprostol alone for uterine evacuation after early pregnancy failure: study protocol for a randomized double blinded placebo-controlled comparison (triple M trial)[J]. BMC Pregnancy Childbirth, 2019, 19(1): 443. DOI: 10.1186/s12884-019-2497-y.
[9]	Kapp N, Eckersberger E, Lavelanet A, et al. Medical abortion in the late first trimester: a systematic review[J]. Contraception, 2019, 99(2): 77-86. DOI: 10.1016/j.contraception.2018.11.002.
[10]	Cirucci CA, Aultman KA, Harrison DJ. Mifepristone adverse events identified by planned parenthood in 2009 and 2010 compared to those in the FDA adverse event reporting system and those obtained through the freedom of information act[J]. Health Serv Res Manag Epidemiol, 2021, 8: 23333928211068919. DOI: 10.1177/23333928211068919.
[11]	谢幸，孔北华，段涛. 妇产科学[M]. 9版. 北京：人民卫生出版社，2018, 374-377.
[12]	Cleland K, Creinin MD, Nucatola D, et al. Significant adverse events and outcomes after medical abortion[J]. Obstet Gynecol, 2013, 121(1): 166-171. DOI: 10.1097/aog.0b013e3182755763.
[13]	Kapp N, Lohr PA. Modern methods to induce abortion: safety, efficacy and choice[J]. Best Pract Res Clin Obstet Gynaecol, 2020, 63: 37-44. DOI: 10.1016/j.bpobgyn.2019.11.008.
[14]	Mazza D, Burton G, Wilson S, et al. Medical abortion[J]. Aust J Gen Pract, 2020, 49(6): 324-330. DOI: 10.31128/AJGP-02-20-5223.
[15]	中华医学会计划生育学分会. 合并子宫体良性疾病的早期人工流产专家共识[J]. 中华生殖与避孕杂志，2020, 40(12): 972-977. DOI: 10.3760/cma.j.cn101441-20200917-00504.

[1]	Ning Li, Shujing Sun, Tong Hao, Shuiping Yao, Yue Jiao. Clinical effects of mifepristone combined with oxytocin in the treatment of patients with intrauterine residual after artificial termination of pregnancy[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2018, 14(05): 578-583.
[2]	Xin Feng, Jinfang Xu, Jie Xu, Zhonghua Shi. Research of clinical effects of low dose of misoprostol combined with compound mifepristone tablets in treatment of induced labor in second pregnancy trimester[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2016, 12(06): 690-693.
[3]	Run He, Lina Yang, Hong Zhang, Hanmei Xu, Yan Lyu, Xueqiong Yin. Clinical study of low-dose misoprostol for labor induction with low-bishop-score pregnancy[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2015, 11(01): 37-40.
[4]	Ji-mei GUO, Ling LYU, Yu-huan GONG. One- and Two-Day Dosing Intervals Between Mifepristone and Misoprostol in Second Trimester Medical Termination of Pregnancy[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2013, 09(04): 507-511.
[5]	Yu-ling HU, Lin QIAO, Lin YANG, Lan-pin ZHONG, Ke-hui XU. Effect of Different Doses and Courses of Mifepristone in the Treatment of Rats' Endometriosis[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2012, 08(06): 696-699.
[6]	Yu-bin HAN. Clinical Study on the Value of Mifepristone Combined With Rivanol Used in Induction of Labor in the Second Trimester for Scarred Uterus[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2009, 05(06): 590-593.
[7]	Xiao-yin WANG, Jing-tao LIU, Zhou XU. Application of Misoprostol Before Artificial Abortion for the Early Pregnancy[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2009, 05(05): 516-518.
[8]	Yangqi Liu, Weiyan Lin, Weilin Ou, Zhjifeng Lin, Li Ke, Lin Lin, Yanhong Chen. The application of ethacridine and its combination regimen in inducing labor in the second trimester[J]. Chinese Journal of Obstetric Emergency(Electronic Edition), 2021, 10(04): 242-246.
[9]	Jianshuang Wang, Haijing Zhang, Xuesong Wang, Ying Wen, Zijing Zhou. Efficacy and safety of different preconditioning methods combined with dilatation & curettage under ultrasonic monitoring in the treatment of exogenous cesarean scar pregnancy[J]. Chinese Journal of Interventional Radiology(Electronic Edition), 2021, 09(04): 371-375.
[10]	Zhanxing Lu, Lupeng Li, Youtao Yu. Curative effect of uterine artery embolization combined with mifepristone in treatment of hysteromyoma[J]. Chinese Journal of Interventional Radiology(Electronic Edition), 2014, 02(03): 5-7.

Viewed

Full text

Abstract

Please choose a citation manager

Content to export