24-hour Mifepristone and Buccal Versus Mifepristone and Vaginal Misoprostol for Cervical Preparation for D&E

A Randomized Double-blinded Comparison of 24-hour Interval-Mifepristone and Buccal Misoprostol Versus Mifepristone and Vaginal Misoprostol for Cervical Preparation in Second-Trimester Surgical Abortion

This study aims to compare mifepristone and buccal misoprostol to mifepristone and vaginal misoprostol for cervical preparation for second trimester dilation and evacuation (D&E).

Study Overview

• Status: Completed
• Conditions: Abortion, Second Trimester
• Intervention / Treatment: Drug: Vaginal Misoprostol; Drug: Buccal Misoprostol

Detailed Description

Standard of care for cervical preparation prior to second trimester surgical abortion has traditionally been a pelvic exam with speculum, a paracervical block with lidocaine, and placement of a number of osmotic dilators through the cervical canal. Dilators obtain maximal expansion within 4-6 hours and patients experience cramping with this process. This cervical preparation allows for a faster procedure for the patient (limiting time for anesthesia) and an easier procedure for the provider (decreasing necessity for further dilation, decreasing risk of cervical laceration, and decreasing blood loss). Following cervical preparation, trained providers use instruments to remove the pregnancy per standard of care. Several studies have examined the use of medication (mifepristone and/or misoprostol) to dilate the cervix as an alternative to osmotic dilators . Patients prefer medication to dilators as medication is associated with less discomfort. Medications alone can achieve adequate cervical preparation but the optimal timing and routes of these medications has not been sufficiently evaluated.

The addition of mifepristone, a progesterone antagonist, to a misoprostol regimen has been shown to significantly decrease the medication-to-abortion interval in second-trimester induction terminations. Vaginal administration has demonstrated improved dilation as compared to buccal administration but it is known that patients prefer buccal administration. A comparison of mifepristone and vaginal versus mifepristone and buccal misoprostol has not been studied prior to second-trimester surgical abortion.

A review of cervical preparation for second-trimester D&E did not recommend mifepristone and misoprostol for cervical priming due to high rates of pre-procedural expulsions. However, the primary basis for this conclusion is a trial in which the 48-hour interval between the medications accounts for the high out-of-facility expulsion risk. A retrospective cohort of over 200 women between 14 and 19 6/7 weeks gestation showed no difference in difficulty of cervical dilation for patients receiving mifepristone 24-48 hours misoprostol as compared to osmotic dilators prior to surgical abortion. Two out of facility expulsions occurred in the mifepristone-misoprostol arms but the timing of medication to expulsion interval is not reported.

More recent studies have limited the timing of mifepristone to 24 hours or less prior to procedure. Mifepristone only has been shown to provide adequate cervical dilation as compared to osmotic dilators to 16 weeks gestation with noninferiority design to detect a 3-minute difference in procedure time. A 24-hour interval between 200mg mifepristone and 400mcg buccal misoprostol has been shown as non-inferior to osmotic dilators for total procedure time for 15-18 week surgical abortions. Mifepristone and one-set of osmotic dilators was found to be non-inferior for total procedure time as compared to two sets of osmotic dilators for surgical abortion 19-23 6/7 weeks gestation.

The addition of mifepristone has benefit as a cervical priming agent as an adjunct or alternative to osmotic dilators for surgical abortion, but it is not known whether the addition of vaginal versus buccal misoprostol changes cervical dilation and thus procedure time outcomes.

• Study Type: Interventional
• Enrollment (Actual): 70
• Phase: Phase 4

Contacts and Locations

Study Locations

• United States
  • Virginia
    • Richmond, Virginia, United States, 23298
      • Virginia Commonwealth University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years to 48 years (Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Female

Description

Inclusion Criteria:

• The study will enroll healthy English or Spanish-speaking women, over 18 years of age, eligible for non-urgent D&E at 16 0/7 weeks to 20 6/7 weeks gestation, confirmed by sonogram, and willing/able to undergo informed consent.

Exclusion Criteria:

• Emergent need for D&E, intrauterine infection, fetal demise, molar pregnancy, intolerance, allergy or contraindication to mifepristone or misoprostol

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Vaginal Misoprostol; Intervention is misoprostol versus placebo 400mcg misoprostol formulated within cocoa butter suppository	Drug: Vaginal Misoprostol; Mifepristone 200mg orally 20-24 hours prior and misoprostol 400mcg (two 200mcg tablets) vaginally 1-2 hours prior and placebo (buccal mint powder) buccally 1-2 hours prior to D&E; Other Names: cytotec
Experimental: Buccal Misoprostol; Intervention is misoprostol versus placebo 400mcg misoprostol formulated within mint flavored powder	Drug: Buccal Misoprostol; Mifepristone 200mg orally 20-24 hours prior and misoprostol 400mcg (two 200mcg tablets) ground with mint into buccal powder and placebo (two lactose tablets designed to appear similar to misoprostol) vaginally 1-2 hours prior to D&E; Other Names: cytotec

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Procedure Time	Time from initial uterine instrumentation to speculum out	At end of procedure

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Cervical Dilation	Pratt Dilator initially accepted without resistance starting from 65 and working down	At end of procedure

Collaborators and Investigators

• Sponsor: Virginia Commonwealth University
• Investigators: Principal Investigator: Frances Casey, MD, Virginia Commonwealth University

Study record dates

Study Major Dates

• Study Start (Actual): November 19, 2016
• Primary Completion (Actual): August 1, 2017
• Study Completion (Actual): August 1, 2017

Study Registration Dates

• First Submitted: April 25, 2017
• First Submitted That Met QC Criteria: April 25, 2017
• First Posted (Actual): April 28, 2017

Study Record Updates

• Last Update Posted (Actual): July 18, 2018
• Last Update Submitted That Met QC Criteria: June 25, 2018
• Last Verified: June 1, 2018

More Information

Terms related to this study

• Keywords: mifepristone; misoprostol; abortion; dilation and evacuation; D&E; second trimester
• Additional Relevant MeSH Terms: Physiological Effects of Drugs; Gastrointestinal Agents; Reproductive Control Agents; Anti-Ulcer Agents; Abortifacient Agents, Nonsteroidal; Abortifacient Agents; Oxytocics; Misoprostol
• Other Study ID Numbers: HM20005740

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No