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Meta-Analysis
. 2011 Nov 9;2011(11):CD002855.
doi: 10.1002/14651858.CD002855.pub4.

Medical methods for first trimester abortion

Regina Kulier  1 , Nathalie Kapp, A Metin Gülmezoglu, G Justus Hofmeyr, Linan Cheng, Aldo Campana
Affiliations
Meta-Analysis

Medical methods for first trimester abortion

Regina Kulier et al. Cochrane Database Syst Rev. .

Update in

  • Medical methods for first trimester abortion.
    Zhang J, Zhou K, Shan D, Luo X. Zhang J, et al. Cochrane Database Syst Rev. 2022 May 24;5(5):CD002855. doi: 10.1002/14651858.CD002855.pub5. Cochrane Database Syst Rev. 2022. PMID: 35608608 Free PMC article.

Abstract

Background: Surgical abortion by vacuum aspiration or dilatation and curettage has been the method of choice for early pregnancy termination since the 1960s. Medical abortion became an alternative method of first trimester pregnancy termination with the availability of prostaglandins in the early 1970s and anti-progesterones in the 1980s. The most widely researched drugs are prostaglandins (PGs) alone, mifepristone alone, methotrexate alone, mifepristone with prostaglandins and methotrexate with prostaglandins.

Objectives: To compare different medical methods for first trimester abortion.

Search methods: The Cochrane Controlled Trials Register, MEDLINE and Popline were systematically searched. Reference lists of retrieved papers were also searched. Experts in WHO/HRP were contacted.

Selection criteria: Types of studies Randomised controlled trials comparing different medical methods for abortion during first trimester (e.g. single drug, combination) were considered. Trials were assessed and included if they had adequate concealment of allocation, randomisation procedure and follow-up. Women, pregnant during the first trimester, undergoing medical abortion were the participants. The outcomes were mortality, failure to achieve complete abortion, surgical evacuation, ongoing pregnancy at follow-up, time until passing of conceptus, blood transfusion, side effects and women's dissatisfaction with the procedure.

Data collection and analysis: Two reviewers independently selected trials for inclusion from the results of the search strategy described previously.The selection of trials for inclusion in the review was performed independently by two reviewers after employing the search strategy described previously. Trials under consideration were evaluated for appropriateness for inclusion and methodological quality without consideration of their results. Data were processed using Revman software.

Main results: Fifty-eight trials were included in the review. The effectiveness outcomes below refer to 'failure to achieve complete abortion' with the intended method unless otherwise stated. 1) Combined regimen mifepristone/prostaglandin: Mifepristone 600 mg compared to 200 mg shows similar effectiveness in achieving complete abortion (4 trials, RR 1.07, 95% CI 0.87 to 1.32). Misoprostol administered orally is less effective (more failures) than the vaginal route (RR 3.00, 95% CI 1.44 to 6.24) and may be associated with more frequent side effects such as nausea and diarrhoea. Sublingual and buccal routes were similarly effective compared to the vaginal route, but had higher rates of side effects. 2) Mifepristone alone is less effective when compared to the combined regimen mifepristone/prostaglandin (RR 3.76 95% CI 2.30 to 6.15). 3) Five trials compared prostaglandin alone to the combined regimen (mifepristone/prostaglandin). All but one reported higher effectiveness with the combined regimen. The results of these studies could not be combined but the RR of failure with prostaglandin alone is reportedly between 1.4 to 3.75 with the 95% confidence intervals indicating statistical significance. 4) In one trial comparing gemeprost 0.5 mg with misoprostol 800 mcg, misoprostol was more effective (failure with gemeprost: RR 2.86, 95% CI 1.14 to 7.18). 5) There was no difference in effectiveness with use of a divided dose compared to a single dose of prostaglandin. 6) Combined regimen methotrexate/prostaglandin demonstrates similar rates of failure to complete abortion when comparing intramuscular to oral methotrexate administration (RR 2.04, 95% CI 0.51 to 8.07). Similarly, day 3 vs. day 5 administration of prostaglandin following methotrexate administration showed no significant differences (RR 0.72, 95% CI 0.36 to 1.43). One trial compared the effect of tamoxifen vs. methotrexate and no statistically significant differences were observed in effectiveness between the groups.

Authors' conclusions: Safe and effective medical abortion methods are available. Combined regimens are more effective than single agents. In the combined regimen, the dose of mifepristone can be lowered to 200 mg without significantly decreasing the method effectiveness. Vaginal misoprostol is more effective than oral administration, and has less side effects than sublingual or buccal. Some results are limited by the small numbers of participants on which they are based. Almost all trials were conducted in settings with good access to emergency services, which may limit the generalizability of these results.

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Conflict of interest statement

None

Figures

1
1
Forest plot of comparison: 1 combined regimen mifepristone/prostaglandin: dose of mifepristone, outcome: 1.1 failure to achieve complete abortion.
1.1
1.1. Analysis
Comparison 1 combined regimen mifepristone/prostaglandin: dose of mifepristone, Outcome 1 failure to achieve complete abortion.
1.2
1.2. Analysis
Comparison 1 combined regimen mifepristone/prostaglandin: dose of mifepristone, Outcome 2 side effects.
1.3
1.3. Analysis
Comparison 1 combined regimen mifepristone/prostaglandin: dose of mifepristone, Outcome 3 time until passing of conceptus > 3‐6 hours.
1.4
1.4. Analysis
Comparison 1 combined regimen mifepristone/prostaglandin: dose of mifepristone, Outcome 4 ongoing pregnancy.
1.5
1.5. Analysis
Comparison 1 combined regimen mifepristone/prostaglandin: dose of mifepristone, Outcome 5 surgical evacuation.
2.1
2.1. Analysis
Comparison 2 combined regimen mifepristone/prostaglandin: dose of prostaglandin, Outcome 1 failure to achieve complete abortion.
2.2
2.2. Analysis
Comparison 2 combined regimen mifepristone/prostaglandin: dose of prostaglandin, Outcome 2 side effects.
2.3
2.3. Analysis
Comparison 2 combined regimen mifepristone/prostaglandin: dose of prostaglandin, Outcome 3 women dissatisfied with the procedure.
2.4
2.4. Analysis
Comparison 2 combined regimen mifepristone/prostaglandin: dose of prostaglandin, Outcome 4 ongoing pregnancy.
2.5
2.5. Analysis
Comparison 2 combined regimen mifepristone/prostaglandin: dose of prostaglandin, Outcome 5 surgical evacuation.
3.1
3.1. Analysis
Comparison 3 combined regimen mifepristone/prostaglandin: type of prostaglandin, Outcome 1 failure to achieve complete abortion.
3.2
3.2. Analysis
Comparison 3 combined regimen mifepristone/prostaglandin: type of prostaglandin, Outcome 2 side effects.
3.3
3.3. Analysis
Comparison 3 combined regimen mifepristone/prostaglandin: type of prostaglandin, Outcome 3 ongoing pregnancy.
3.4
3.4. Analysis
Comparison 3 combined regimen mifepristone/prostaglandin: type of prostaglandin, Outcome 4 time until passing of conceptus > 3‐6 hours.
4.1
4.1. Analysis
Comparison 4 combined regimen mifepristone/prostaglandin: time of prostaglandin, Outcome 1 failure to achieve complete abortion.
4.2
4.2. Analysis
Comparison 4 combined regimen mifepristone/prostaglandin: time of prostaglandin, Outcome 2 side effects.
4.3
4.3. Analysis
Comparison 4 combined regimen mifepristone/prostaglandin: time of prostaglandin, Outcome 3 surgical evacuation.
4.4
4.4. Analysis
Comparison 4 combined regimen mifepristone/prostaglandin: time of prostaglandin, Outcome 4 ongoing pregnancy.
4.5
4.5. Analysis
Comparison 4 combined regimen mifepristone/prostaglandin: time of prostaglandin, Outcome 5 women dissatisfied with the procedure.
5.1
5.1. Analysis
Comparison 5 combined regimen mifepristone/prostaglandin: misoprostol po vs pv, Outcome 1 failure to achieve complete abortion.
5.2
5.2. Analysis
Comparison 5 combined regimen mifepristone/prostaglandin: misoprostol po vs pv, Outcome 2 side effects.
6.1
6.1. Analysis
Comparison 6 combined regimen mifepristone/prostaglandin: misoprostol buccal vs pv, Outcome 1 failure to achieve complete abortion.
6.2
6.2. Analysis
Comparison 6 combined regimen mifepristone/prostaglandin: misoprostol buccal vs pv, Outcome 2 side effects.
7.1
7.1. Analysis
Comparison 7 combined regimen mifepristone/prostaglandin: misoprostol buccal vs oral, Outcome 1 failure to achieve complete abortion.
7.2
7.2. Analysis
Comparison 7 combined regimen mifepristone/prostaglandin: misoprostol buccal vs oral, Outcome 2 ongoing pregnancy.
7.3
7.3. Analysis
Comparison 7 combined regimen mifepristone/prostaglandin: misoprostol buccal vs oral, Outcome 3 side effects.
7.4
7.4. Analysis
Comparison 7 combined regimen mifepristone/prostaglandin: misoprostol buccal vs oral, Outcome 4 women dissatisfied with the procedure.
8.1
8.1. Analysis
Comparison 8 combined regimen mifepristone/prostaglandin: misoprostol sublingual vs pv, Outcome 1 failure to achieve complete abortion.
8.2
8.2. Analysis
Comparison 8 combined regimen mifepristone/prostaglandin: misoprostol sublingual vs pv, Outcome 2 surgical evacuation.
8.3
8.3. Analysis
Comparison 8 combined regimen mifepristone/prostaglandin: misoprostol sublingual vs pv, Outcome 3 ongoing pregnancy at follow‐up.
8.4
8.4. Analysis
Comparison 8 combined regimen mifepristone/prostaglandin: misoprostol sublingual vs pv, Outcome 4 side effects.
8.5
8.5. Analysis
Comparison 8 combined regimen mifepristone/prostaglandin: misoprostol sublingual vs pv, Outcome 5 women dissatisfied with the procedure.
8.6
8.6. Analysis
Comparison 8 combined regimen mifepristone/prostaglandin: misoprostol sublingual vs pv, Outcome 6 side effects.
9.1
9.1. Analysis
Comparison 9 combined regimen mifepristone/prostaglandin: misoprostol sublingual vs po, Outcome 1 failure to achieve complete abortion.
9.2
9.2. Analysis
Comparison 9 combined regimen mifepristone/prostaglandin: misoprostol sublingual vs po, Outcome 2 side effects.
9.3
9.3. Analysis
Comparison 9 combined regimen mifepristone/prostaglandin: misoprostol sublingual vs po, Outcome 3 women dissatisfied with the procedure.
10.1
10.1. Analysis
Comparison 10 combined regimen mifepristone/prostaglandin: single vs split dose prostaglandin, Outcome 1 failure to achieve complete abortion.
10.2
10.2. Analysis
Comparison 10 combined regimen mifepristone/prostaglandin: single vs split dose prostaglandin, Outcome 2 side effects.
11.1
11.1. Analysis
Comparison 11 combined regimen mifepristone/prostaglandin:single vs continuous prostaglandin, Outcome 1 failure to achieve complete abortion.
11.2
11.2. Analysis
Comparison 11 combined regimen mifepristone/prostaglandin:single vs continuous prostaglandin, Outcome 2 ongoing pregnancy at follow‐up.
11.3
11.3. Analysis
Comparison 11 combined regimen mifepristone/prostaglandin:single vs continuous prostaglandin, Outcome 3 nausea.
11.4
11.4. Analysis
Comparison 11 combined regimen mifepristone/prostaglandin:single vs continuous prostaglandin, Outcome 4 vomiting.
11.5
11.5. Analysis
Comparison 11 combined regimen mifepristone/prostaglandin:single vs continuous prostaglandin, Outcome 5 diarrhoea.
12.1
12.1. Analysis
Comparison 12 mifepristone alone vs combined regimen mifepristone/prostaglandin, Outcome 1 failure to achieve complete abortion.
13.1
13.1. Analysis
Comparison 13 prostaglandin alone vs combined regimen (all), Outcome 1 failure to achieve complete abortion.
13.2
13.2. Analysis
Comparison 13 prostaglandin alone vs combined regimen (all), Outcome 2 side effects.
14.1
14.1. Analysis
Comparison 14 prostaglandin alone: route of administration, Outcome 1 failure to achieve complete abortion.
14.2
14.2. Analysis
Comparison 14 prostaglandin alone: route of administration, Outcome 2 side effects.
15.1
15.1. Analysis
Comparison 15 mifepristone single ‐ high vs low dose, Outcome 1 failure to achieve complete abortion.
15.2
15.2. Analysis
Comparison 15 mifepristone single ‐ high vs low dose, Outcome 2 side effects.
16.1
16.1. Analysis
Comparison 16 combined regimen methotrexate/prostaglandin: timing of prostaglandin, Outcome 1 failure to achieve complete abortion.
17.1
17.1. Analysis
Comparison 17 combined regimen methotrexate/prostaglandin: methotrexate imi vs po, Outcome 1 failure to achieve complete abortion.
17.2
17.2. Analysis
Comparison 17 combined regimen methotrexate/prostaglandin: methotrexate imi vs po, Outcome 2 Side effects.
18.1
18.1. Analysis
Comparison 18 combined regimen methotrexate/prostaglandin: dose of methotrexate, Outcome 1 failure to achieve complete abortion.
19.1
19.1. Analysis
Comparison 19 combined regimen methotrexate/prostaglandin: route of prostaglandin (misoprostol), Outcome 1 failure to achieve complete abortion.
19.2
19.2. Analysis
Comparison 19 combined regimen methotrexate/prostaglandin: route of prostaglandin (misoprostol), Outcome 2 side effects.
20.1
20.1. Analysis
Comparison 20 tamoxifen vs methotrexate (combined with prostaglandin) : low dose tamoxifen (40), Outcome 1 failure to achieve complete abortion.
20.2
20.2. Analysis
Comparison 20 tamoxifen vs methotrexate (combined with prostaglandin) : low dose tamoxifen (40), Outcome 2 side effects.
21.1
21.1. Analysis
Comparison 21 tamoxifen vs methotrexate (combined with prostaglandin): high dose tamoxifen (160 mg), Outcome 1 failure to achieve complete abortion.
21.2
21.2. Analysis
Comparison 21 tamoxifen vs methotrexate (combined with prostaglandin): high dose tamoxifen (160 mg), Outcome 2 side effects.
22.1
22.1. Analysis
Comparison 22 combined regimen mifepristone/prostaglandin vs mifepristone/prostaglandin and tamoxifen, Outcome 1 failure to achieve complete abortion.
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References

References to studies included in this review

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WHO 2001 GP1pv {published data only}
    1. World Health Organization Task Force on Post‐ovulatory Methods of Fertility Regulation. Medical abortion at 57 to 63 days' gestation with a lower dose of mifepristone and gemeprost. Acta Obstetrica et Gynecologica Scandinavica 2001;80:447‐451. - PubMed
WHO 1989 {published data only}
    1. WHO Task Force on Post‐Ovulatory Methods for Fertility Regulation. Termination of early human pregnancy with RU 486 (mifepristone) and the prostaglandin analogue sulprostone: a multi‐centre, randomized comparison between two treatment regimens. Human Reproduction 1989;4(6):718‐725. - PubMed
WHO 1991 {published data only}
    1. WHO Task Force on Post‐Ovulatory Methods for Fertility Regulation. Pregnancy termination with mifepristone and gemeprost: a multicenter comparison between repeated doses and a single dose of mifepristone. Fertility and Sterility 1991;56:32‐40. - PubMed
WHO 1993 GP1pv {published data only}
    1. WHO Task Force on Post‐Ovulatory Methods of Fertility Regulation. Termination of Pregnancy with reduced doses of mifepristone. British Medical Journal 1993;307:532‐537. - PMC - PubMed
WHO 2001 MI200/50 {published data only}
    1. WHO Task Force on Post‐ovulatory Methods for Fertility Regulation. Lowering the doses of mifepristone and gemeprost for early abortion: a randomised controlled trial. British Journal of Obstetrics and Gynaecology 2001;108:738‐742. - PubMed
Wiebe 1999 {published data only}
    1. Wiebe ER. Tamoxifen compared to methotrexate when used with misoprostol for abortion. Contraception 1999;59:265‐270. - PubMed
Wiebe 1999 A {published data only}
    1. Wiebe ER. Tamoxifen compared to methotrexate when used with misoprostol for abortion. Contraception 1999;59:265‐270. - PubMed
Wiebe 1999 B {published data only}
    1. Wiebe ER. Oral methotrexate compared with injected methotrexate when used with misoprostol for abortion. Am J Obstet Gynecol 1999;181:149‐152. - PubMed
Wiebe 2004 {published data only}
    1. Wiebe ER, Trouton K. Comparing vaginal and buccal misoprostol when used after methotrexate for early abortion. Contraception 2004;70:463‐466. - PubMed
Wiebe 2006 {published data only}
    1. Wiebe ER, Trouton KJ, Lima R. Misoprostol alone vs. methotrexate followed by misoprostol for early abortion. International Journal of Gynecology and Obstetrics 2006;95:286‐287. - PubMed
Winikoff 2008 {published data only}
    1. Winikoff B, Dzuba IG, Creinin MD, Crowden WA, Goldberg AB, Gonzales J, Howe M, Moskowitz J, Prine L, Shannon CS. Two distinct oral routes of misoprostol inmifepristone medical abortion: a randomized controlled trial. Obstet Gynecol 2008;112(6):1303‐1310. - PubMed
Wu 1993 {published data only}
    1. Wu YM, Li Y, Fan HM, Zhu XJ, Zheng S, Wang S, Liu B, Yan J, Lin H, Fang J. Clinical study of mifepristone in combination with tamoxifen and 15‐methyl‐PGF2alpha methylester for termination of early pregnancy. Sheng Zhi Yi Xue Za Zhi (Journal of reproductive medicine). 1993; Vol. 4:224‐227.
Zheng 1989 MI600PGF2pv {published data only}
    1. Zheng SR. RU486 (mifepristone): clinical trials in China. Acta Obstet Gynecol Scand Suppl 1989;149:19‐23. - PubMed

References to studies excluded from this review

Ashok 2002 {published data only}
    1. Ashok PW, Templeton A, Wagaarchchi PT, Flett GM. Factors affecting the outcome of early medical abortion: a review of 4132 consecutive cases. BJOG 2002;109(11):1281‐1289. - PubMed
Aubeny 2000 {published data only}
    1. Aubeny E, Chatellier G. A randomized comparison of mifepristone and self‐administered oral or vaginal misoprostol for early abortion. European Journal of Contraception and Reproductive Health Care 2000;5(3):171‐176. - PubMed
Cheng 1999 {published data only}
    1. Cheng L. Termination of 10‐16 weeks' gestation with mifepristone plus misoprostol: a multicentre randomized clinical trial. Zhonghua Fu Chan Ke Za Zhi 1999;34(5):268‐271. - PubMed
Creinin 1996 A {published data only}
    1. Creinin MD, Burke AE. Methotrexate and misoprostol for early abortion: a multicenter trial. Acceptability. Contraception 1996;54:19‐22. - PubMed
Davis 1999 {published data only}
    1. Davis AR, Miller L, Tamimi H, Gown A. Methotrexate compared with mercaptopurine for early induced abortion. Obstetrics & Gynecology 1999;93:904‐909. - PubMed
De Nonno 2000 {published data only}
    1. Nonno LS, Westhoff C, Fielding S, Schaff E. Timing of pain and bleeding after mifepristone induced abortion. Contraception 2000;62(6):305‐309. - PubMed
ICMR 2000 {published data only}
    1. Indian Council of Medical Research Task Force. A multicentre randomized comparative clinical trial of 200 mg RU486 (mifepristone) single dose followed by either 5 mg 9‐methylene PGE2 Gel (meteneprost) or 600 mcg oral PGE1 (misoprostol) for termination of early pregnancy within 28 days of missed menstrual period. Contraception 2000;62:125‐130. - PubMed
Jacobson 1990 {published data only}
    1. Jacobson J, Bergquist C, Rydnert J, Bokstroem H, Huovinen K. No abortion‐inducing effect of the ulcer‐healing dose of the synthetic prostaglandin E2 analogue enprostil in first trimester. Acta Obstetrica Gynecologica Scandinavia 1990;69:135‐138. - PubMed
Martin 1998 {published data only}
    1. Martin CW, Brown AH, Baird DT. A pilot study of the effect of methotrexate or combined oral contraceptive on bleeding patterns after induction of abortion with mifepristone and a prostaglandin pessary. Contraception 1998;58(2):99‐103. - PubMed
Ngai 2000 {published data only}
    1. Ngai SW, Tang OS, Chan YM, Ho PC. Vaginal misoprostol alone for medical abortion up to 9 weeks of gestation: efficacy and acceptability. Human Reproduction 2000;15(5):1159‐1162. - PubMed
Norman 1992 {published data only}
    1. Norman JE, Thong KJ, Rodger MW, Baird DT. Medical abortion in women of <56 days amenorrhoea: a comparison between gemeprost (a PGE1 analogue) alone and mifepristone and gemeprost. British Journal of Obstetrics and Gynaecology 1992;99:601‐606. - PubMed
Swahn 1994 {published data only}
    1. Swahn ML, Kovacs L, Cekan SZ, Aedo AR, Westlund P. Termination of early pregnancy with ZK 98,734: pharmacokinetic behaviour and clinical effect. Human Reproduction 1994;9(1):57‐63. - PubMed
Tang 1999 {published data only}
    1. Tang OS, Gao PP, Cheng L, Lee SW, Ho PC. A randomized double‐blind placebo‐controlled study to assess the effect of oral contraceptive pills on the outcome of medical abortion with mifepristone and misoprostol. Human Reproduction 1999;14(3):722‐725. - PubMed
Wiebe 2001 {published data only}
    1. Wiebe ER. Misoprostol administration in medical abortion. A comparison of 3 regimens. Journal of Reproductive Medicine 2001;46(2):125‐129. - PubMed

Additional references

Bachelot 1992
    1. Bachelot A, Cludy L, Spira A. Conditions for chosing between drug‐induced and surgical abortions. Contraception 1992;45:547‐559. - PubMed
Beaulieu 1997
    1. Beaulieu EE. RU 486 (Mifepristone) ‐ A short overview of its mechanisms of action and clinical uses at the end of 1996. Annals New York Academy of Sciences. New York Academy of Sciences, 1997:47‐58. - PubMed
Blanchard 1999
    1. Blanchard K, Winikoff B, Ellertson C. Misoprostol used alone for the termination of early pregnancy. Contraception 1999;59:209‐217. - PubMed
Bugalho 1996
    1. Bugalho A, Faundes A, Jamisse L, Usfa M, Maria E, Bique C. Evaluation of the effectiveness of vaginal misoprostol to induce first trimester abortion. Contraception 1996;53:243‐246. - PubMed
Bygdeman 1985
    1. Bygdeman M, Swahn ML. Progesterone receptor blockage. Effect on uterine contractility and early pregnancy. Contraception 1985;32:45‐51. - PubMed
Bygdeman 2002
    1. Bygdeman M, Danielsson KG. Options for early therapeutic abortion. Drugs 2002;62(17):2459‐2470. - PubMed
Carbonell 1997b
    1. Carbonell JLL, Varela L, Velazco A, Fernandez C. The use of misoprostol for termination of early pregnancy. Contraception 1997;55:165‐168. - PubMed
Costa 1998
    1. Costa SH. Commercial availability od misoprostol and induced abortion in Brazil. International Journal of Gynaecology and Obstetrics 1998;63 (suppl 1):S:131‐139. - PubMed
Creinin 1993
    1. Creinin MD, Darney PD. Methotrexate and misoprostol for early abortion. Contraception 1993;48:339‐348. - PubMed
Creinin 1996b
    1. Creinin MD, Burke AE. Methotrexate and misoprostol for early abortion: a multicenter trial. Acceptability. Contraception 1996;54:19‐22. - PubMed
Grimes 1997
    1. Grimes DA. Medical abortion in early pregnancy: a review of the evidence. Obstetrics Gynecology 1997;89:790‐796. - PubMed
Henshaw 1994
    1. Henshaw RC, Naji SA, Russell IT, Templeton AA. A comparison of medical abortion (using mifepristone and gemeprost) with surgical vacuum aspiration: efficacy and early medical sequelae. Human Reproduction 1994;9(11):2167‐2172. - PubMed
Honkanen 2002
    1. Honkanen H, Hertzen H. Users' perspectives on medical abortion in Finland. Contraception 2002;65(6):419‐23. - PubMed
Say 2002, updated 2010
    1. Say L, Brahmi D, Kulier R, Campana A, Gulmezoglu AM. Medical versus surgical methods for first trimester termination of pregnancy. Cochrane Database of Systematic Reviews 2002, Issue 4. [DOI: 10.1002/14651858.CD003037.pub2.] - PubMed
Sedgh 2007
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United 1990
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Urquhart 1997
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WHO 1997
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Winikoff 1997
    1. Winikoff B, Irving S, Coyaji K, Caberas E, Bilian X, Sujuan G, Ming‐ Kun D, Krishna U, Eschen A, Ellertson C. Safety, efficacy and acceptability of medical abortion in China, Cuba and India: a comparative trial of mifepristone ‐ misoprostol versus surgical abortion. American Journal of Obstetrics and Gynecology 1997;176:431‐437. - PubMed

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