A prospective multicenter, randomized trial was performed to evaluate if moistened misoprostol results in a more rapid abortion and a higher rate of complete abortion compared with dry misoprostol when administered intravaginally for medical abortion after methotrexate. A total of 240 pregnant women < or = 49 days gestation seeking elective abortion received 50 mg/m2 methotrexate intramuscularly followed 5-6 days later by 800 micrograms misoprostol vaginally. The misoprostol dose was repeated in 1-2 days if the abortion did not occur. Group 1 moistened the misoprostol before administration and group 2 used dry tablets. There was no statistically significant difference in the cumulative rate of abortion after the first misoprostol dose (73.0% vs 71.3%, p = 0.87), second misoprostol dose (84.1% vs 81.1%, p = 0.65), or by 35 days after methotrexate administration (95.2% vs 91.8%, p = 0.40) between groups 1 and 2, respectively. The proportion of subjects with embryonic cardiac activity 2 weeks after methotrexate injection was greater in group 2 (5.7%, 95% confidence interval [CI] 1.0%, 9.9%) than in group 1 (2.4%, 95% CI 0%, 5.0%), although not statistically significant (p = 0.21). The immediate success rate in Pittsburgh was greater, albeit not statistically, for the women that moistened the misoprostol (87% vs 76%, p = 0.19); these rates were also not statistically different in Havana (82% vs 86%, p = 0.62). The rate of side effects after methotrexate was not different between groups but women in group 1 had significantly more diarrhea (36% vs 21%, p = 0.02) and fever/warmth/chills (44% vs 30%, p = 0.04). Moistening misoprostol before vaginal administration in a medical abortion regimen with methotrexate does not statistically improve efficacy. This trial demonstrates the importance of prospective, randomized studies to prove the relative efficacy of any medical abortion treatment regimen.
PIP: A randomized trial conducted in the US and Cuba assessed whether moistening misoprostol in advance of vaginal insertion enhances the efficacy of medical abortion after methotrexate administration. 240 abortion seekers from Pittsburgh, Pennsylvania (US), and Havana, Cuba, with pregnancies of 49 days' gestation or less were randomized either to dip the four 200-mcg misoprostol tablets in water before administration (group 1) or to insert the tablets dry (group 2). The misoprostol dose was repeated in 1-2 days if abortion did not occur. There were no statistically significant differences between groups 1 and 2 in the cumulative rate of abortion after the first misoprostol dose (73.0% vs. 71.3%), after the second misoprostol dose (84.1% vs. 81.1%), or by 35 days after methotrexate administration (95.2% vs. 91.8%). The proportion of women with a continuing pregnancy, defined as the presence of embryonic cardiac activity 2 weeks after methotrexate injection, was slightly but nonsignificantly higher in group 2 (5.7%) than in group 1 (2.4%). The immediate success rate in Pittsburgh was greater, although not significantly, for women who moistened the misoprostol (87% vs. 76%); in Havana, the opposite trend was observed (82% vs. 86%). Cramping began a mean of 2.8 hours after the first misoprostol administration in group 1 and a mean of 3.5 hours later in group 2. Women in group 1 had significantly more diarrhea (36% vs. 21%) and fever/chills (44% vs. 30%) than those in group 2, but rates of nausea, vomiting, dizziness, and headache did not differ. These findings suggest that moistening misoprostol before vaginal application does not significantly improve the efficacy of methotrexate abortion.