1.2 Medical termination of intra-uterine pregnancy of 50– Mifepristone

. 7.1.2 Medical termination of intra-uterine pregnancy of 50– Mifepristone

63 days gestation, by mouth , mifepristone 600 mg (200 mg also effective) as a single dose under Mifepristone, an antiprogestogenic steroid, sensitises

medical supervision, followed 36–48 hours later the myometrium to prostaglandin-induced contractions

(unless abortion already complete) by gemeprost and ripens the cervix. For termination of pregnancy, a

1 mg by vagina ; observe for at least 3 hours (or until single dose of mifepristone is followed by administration

bleeding or pain at acceptable level); follow-up visit of a prostaglandin (gemeprost or misoprostol [unli-

within 2 weeks to verify complete expulsion (if censed]). Guidelines of the Royal College of Obstetri-

treatment fails essential that pregnancy be termi- cians and Gynaecologists (September 2004) include the

nated by another method) and to assess vaginal

following [unlicensed] regimens for inducing medical

bleeding

Obst

abortion: . Cervical ripening before mechanical cervical dilata-

. For gestation up to 9 weeks, mifepristone 200 mg by tion for termination of pregnancy of up to 84 days mouth followed 1–3 days later by misoprostol 800 micr-

etrics,

gestation, by mouth , mifepristone 200 mg as a single

ograms vaginally; in women at more than 7 weeks gestation (49–63 days), if the abortion has not occurred

dose under medical supervision 36–48 hours before 4 hours after misoprostol, a further dose of misoprostol

procedure . Termination of pregnancy of 13–24 weeks gestation

gynaec

400 micrograms may be given vaginally or by mouth .

For gestation between 9 and 13 weeks, mifepristone (in combination with a prostaglandin), by mouth , 200 mg by mouth followed 36–48 hours later by miso-

mifepristone 600 mg (200 mg may be effective) as a prostol 800 micrograms vaginally followed if necessary

ology

single dose under medical supervision followed 36–

48 hours later by gemeprost 1 mg by vagina every 3 .

by a maximum of 4 further doses at 3-hourly intervals of misoprostol 400 micrograms vaginally or by mouth

For gestation between 13 and 24 weeks, mifepristone hours up to max. 5 mg or misoprostol (see above

and

200 mg by mouth followed 36–48 hours later by miso- [unlicensed]); if abortion does not occur, 24 hours

prostol 800 micrograms vaginally then a maximum of 4 after start of treatment repeat course of gemeprost

urinary-tract

further doses at 3-hourly intervals of misoprostol

1 mg by vagina up to max. 5 mg (if treatment fails 400 micrograms by mouth

pregnancy should be terminated by another meth- od); follow-up visit after appropriate interval to

MIFEPRISTONE

assess vaginal bleeding recommended Note Careful monitoring of blood pressure and pulse essen-

Indications see under dose tial for 3 hours after administration of gemeprost pessary (risk of profound hypotension)

disor

Cautions asthma (avoid if severe and uncontrolled); haemorrhagic disorders and anticoagulant therapy;

. Labour induction in fetal death in utero where pros- taglandin or oxytocin inappropriate, by mouth ,

ders

prosthetic heart valve or history of endocarditis (see section 5.1 table 2); risk factors for or existing cardi-

mifepristone 600 mg daily as a single dose for 2 days ovascular disease; adrenal suppression (may require

under medical supervision; if labour not started corticosteroid); interactions: Appendix 1 (mife-

within 72 hours of first dose, another method should pristone)

be used

Important For warnings relating to use of gemeprost in a patient undergoing induction of abortion with mifepristone,

Mifegyne c (Exelgyn) A see under Gemeprost

Tablets , yellow, mifepristone 200 mg. Net price 3-tab Contra-indications uncontrolled severe asthma; sus-

pack = £41.83 (supplied to NHS hospitals and pre- pected ectopic pregnancy (use other specific means of

mises approved under Abortion Act 1967). Label: 10, termination); chronic adrenal failure; acute porphyria

patient information leaflet

7.1.3 Myometrial relaxants BNF 57

Tractocile c (Ferring) 7.1.3 A Myometrial relaxants

Injection , atosiban (as acetate) 7.5 mg/mL, net price 0.9-mL (6.75-mg) vial = £18.60

Tocolytic drugs postpone premature labour and they are used with the aim of reducing harm to the child. How-

Concentrate for intravenous infusion , atosiban (as ever, there is no satisfactory evidence that the use of

acetate) 7.5 mg/mL, net price 5-mL vial = £53.35 these drugs reduces mortality. The greatest benefit is

gained by using the delay to administer corticosteroid therapy or to implement other measures which improve

Beta 2 agonists

perinatal health (including transfer to a unit with neo- natal intensive care facility).

Cautions Beta agonists should be used with caution in patients with suspected cardiovascular disease (such

The oxytocin receptor antagonist, atosiban, is licensed patients should be assessed by a cardiologist before ders for the inhibition of uncomplicated premature labour initiating therapy—see also Contra-indications, below), between 24 and 33 weeks of gestation. Atosiban may be hypertension, mild to moderate pre-eclampsia, hyper- preferable to a beta agonist because it has fewer side-

disor thyroidism, and hypokalaemia (particular risk with

effects. potassium-depleting diuretics—see also CSM advice, The dihydropyridine calcium-channel blocker nife-

p. 153). It is important to monitor pulse rate (should dipine (section 2.6.2) also has fewer side-effects than

not exceed 140 beats per minute), ECG (discontinue

a beta agonist. Nifedipine [unlicensed indication] can treatment if signs of myocardial ischaemia develop), and

be given initially in a dose of 20 mg followed by 10– the patient’s fluid and electrolyte status (avoid over-

urinary-tract

20 mg 3–4 times daily adjusted according to uterine hydration—discontinue drug immediately and initiate activity.

diuretic therapy if pulmonary oedema occurs). Beta

and

agonists should also be used with caution in dia-

A beta agonist (ritodrine, salbutamol or terbutaline) betes—monitor blood glucose (risk of hyperglycaemia is used for inhibiting uncomplicated premature labour

and ketoacidosis, especially with intravenous beta ago- ology between 24 and 33 weeks of gestation and it may permit nists). a delay in delivery of at least 48 hours. Prolonged aec therapy should be avoided since risk to the mother Contra-indications Beta agonists are contra-indi- gyn increases after 48 hours and there is a lack of evidence cated in cardiac disease and in patients with significant of benefit from further treatment; maintenance treat-

ment is therefore not recommended. risk factors for myocardial ischaemia; they should also

be avoided in antepartum haemorrhage, intra-uterine etrics, Indometacin (indomethacin) (section 10.1.1), a cyclo- infection, intra-uterine fetal death, placenta praevia,

oxygenase inhibitor, also inhibits labour [unlicensed abruptio placenta, threatened miscarriage, cord com- Obst indication] and it can be useful in situations where a pression, and eclampsia or severe pre-eclampsia.