a viable alternative to surgical vacuum aspiration: repeated doses of intravaginal misoprostol over...

A viable alternative to surgical vacuum aspiration: repeateddoses of intravaginal misoprostol over 9 hours for medical

termination of pregnancies up to eight weeks

Kuldip Singha,*, Y.F. Fonga, F. Dongb

Objective To study the efficacy of repeated doses of vaginal misoprostol over 9 hours in a day care setting forterminating pregnancies up to eight weeks of gestation.

Design An open, single arm prospective study conducted between January 2000 and December 2001.

Setting Fertility Control Clinic, National University Hospital, Singapore.

Population One hundred and fifty pregnant women with an unwanted pregnancy up to eight weeks ofgestation requesting medical abortion.

Methods The women were given an initial dose of 800 Ag of vaginal misoprostol. A further dose of 400 Agwas repeated every 3 hours for a maximum of three doses.

Main outcome measures The complete abortion rate defined as successful cases that did not require vacuumaspiration.

Results The complete abortion rate was 84.7% and 96.0% at 15 days and 43 days after initial administration ofvaginal misoprostol. The mean interval between first dose of misoprostol and the onset of expulsion ofproducts of conception (SD) was 8.1 hours (6.3). The mean and the median percentage changes in the serumh-hCG levels at day 15 as compared with pre-abortion levels were statistically significant ( P < 0.001) andwere a good predictor of the likely outcome of the medical abortion. The mean duration of bleeding (SD)was 11.7 days (4.7) and the mean duration between the onset of procedure and the return of normalmenstruation (SD) was 35.5 days (5.7). There was no significant change in haemoglobin concentration.Lower abdominal pain, fever (> 38.0jC) and diarrhoea were the most common side effects.

Conclusions This regimen of repeated doses of vaginal misoprostol every 3 hours over a period of 9 hours, inkeeping with the plasma level and pharmacokinetic of misoprostol administered vaginally, is an effectivemethod of medical abortion that approaches the efficacy of surgical vacuum aspiration. The regimen wouldoffer a suitable option for women requesting termination of pregnancy up to eight weeks of gestation incountries where mifespristone is and will never be made available.

INTRODUCTION

Surgical vacuum aspiration has traditionally been the

method of choice of successfully terminating unwanted

first trimester pregnancies and it should ideally be carried

out beyond seven weeks of gestation1. It has a success rate

of more than 95%2. Major morbidity is up to 1% and minor

morbidity is seen in 10% of women3. However, with the

advent of more sophisticated and sensitive pregnancy

diagnostic kits, women may seek induced abortion much

earlier (four to eight weeks of gestation) and may be not

willing to wait up to seven weeks of gestation for a surgical

vacuum aspiration.

Medical abortion using mifespristone and misoprostol

has been shown to be an effective method of abortion up to

63 days of gestation4. In fact, misoprostol, although not

licensed for medical abortion, is the prostaglandin of choice

and it is cheap, easily available and stable at room temper-

ature. Mifespristone, however, is expensive and is only

available in a limited number of developing countries,

including China, France, Sweden, the UK and the USA.

Thus, there is the pressing and important need to develop a

regimen of medical abortion without mifepristone. Com-

plete abortion rates varying from 20.0% to 93.9% have

been reported with the use of misoprostol alone5 – 9. How-

ever, in most of these studies, the dosing interval of

misoprostol has ranged from every 4 hours to every 48

hours. It would thus take several days to complete the

treatment, which is thus inconvenient and expensive.

Pharmacokinetics show that peak plasma levels of miso-

prostol are sustained for up to 4 hours after vaginal admin-

istration10. It would thus be logical to administer misoprostol

BJOG: an International Journal of Obstetrics and GynaecologyFebruary 2003, Vol. 110, pp. 175–180

D RCOG 2003 BJOG: an International Journal of Obstetrics and Gynaecology

PII: S 1 47 0 - 0 3 2 8 ( 0 2 ) 0 2 2 25 - 5 www.bjog-elsevier.com

aDepartment of Obstetrics and Gynaecology, National

University Hospital, SingaporebBiostatistics Consultancy Unit, National University of

Singapore Medical Institute, Singapore

* Correspondence: Professor K. Singh, Department of Obstetrics and

Gynaecology, National University Hospital, Lower Kent Ridge Road,

119074, Singapore.

repeatedly 3 hours. Thus, based on this pharmacokinetics,

we initiated this study of administering misoprostol every 3

hours for a maximum of four doses over 9 hours to present a

convenient and acceptable day care regimen for medical

abortion that did not require overnight stay nor need to return

for repeated administration.

METHODS

This is an open, single arm prospective study. A total of

150 pregnant women with a period of amenorrhoea of up to

and including 56 days were recruited in the gynaecological

outpatient clinic among women requesting termination of

pregnancy at the National University Hospital, Singapore

between January 2000 and December 2001. All gave

informed consent after the study had been explained,

including their right to withdraw from the trial at any time

without prejudice to their future medical care. The study

was approved by the local hospital ethics committee.

The women were between 15 and 45 years of age and

they satisfied the following criteria: (i) normal general and

gynaecological examination; (ii) intrauterine pregnancy

with gestational age of �8 weeks as established by reliable

menstrual history, pelvic examination and confirmed by

ultrasound assessment on day one of study; (iii) haemo-

globin higher than 10 gm/dL. Exclusion criteria included:

(i) history or evidence of illnesses that represent a contra-

indication to the use of misoprostol—heart disease, hyper-

tension, bronchial asthma; (ii) history or evidence of

thromboembolism; (iii) severe or recurrent liver disease

or pruritus of pregnancy; (iv) presence of intrauterine

contraceptive device in uterus; (v) use of hormonal contra-

ception during the cycle before conception or during the

conception cycle itself; (vi) breastfeeding; (vii) heavy

smoking (smoking >10 cigarettes daily in the past two

years); or (viii) known allergy to misoprostol.

All the women were admitted to the day care ward of the

hospital at 0700 hours on day one of the treatment. Blood

was taken for serum h-hCG. Blood pressure and pulse rate

were recorded and the presence of any possible side effects

was noted. During vaginal examination, 800 Ag of miso-

prostol (Cytotec, Searle Pharmaceutical, USA) wet in water

was placed into the posterior vaginal fornix by one of the

two designated clinicians (KS or YFF). The decision by the

researchers to use this loading dose of 800 Ag was arrived

after a small pilot unpublished study comparing 400 and

800 Ag of misoprostol among 40 patients revealed a high

successful complete abortion rate with this higher dose.

Thereafter, blood pressure, pulse rate and temperature and

the occurrence of side effects such as abdominal pain,

vaginal bleeding, nausea, vomiting and diarrhoea were

monitored hourly.

Three hours later, vaginal assessment was done and

400 Ag of misoprostol wet in water was placed into the

posterior vaginal fornix. This 400 Ag misoprostol dose was

repeated every 3 hours for another two doses. All vaginal

assessment and insertion of the drug was done by one of the

two designated clinicians (KK or YFF) to reduce individual

variation in assessment. Throughout the period in the day

care ward, the women were monitored hourly for side

effects mentioned above and the passage of products of

conception. They were ambulatory and were allowed anal-

gesics for their abdominal pain if required.

At the end of 10 hours, an hour after the fourth and last

dose, the women were allowed home. A diary card was given

to them to record the duration of bleeding, passage of pro-

ducts of conception and side effects. They were reminded to

return to the hospital at any time if there was heavy bleeding,

severe abdominal pain or any evidence of infection.

All the women were followed up on days 15 and 43. On

both these follow up visits, pelvic examination, blood

serum h-hCG and haemoglobin estimation were conducted.

In addition, an ultrasound examination of the pelvis was

performed in all the women on day 15.

The outcome of treatment was classified as (i) complete

abortion, (ii) incomplete abortion, (iii) missed abortion and

(iv) live pregnancy. The initial assessment about the

outcome of therapy was made at the follow up visit on

day 15. If the ultrasound findings showed a live pregnancy

(i.e. fetal heart activity present on day 15), vacuum aspira-

tion would be performed and the aspirated would be sent

for histological examination. If the ultrasound findings on

day 15 were compatible with missed abortion (i.e. identifi-

able gestational sac without fetal heart activity), the women

had the option of either terminating the pregnancy by

vacuum aspiration or having a repeat of two dose of 400

Ag misoprostol at 3 hours interval on the same day in the

clinic and they were monitored for expulsion of products of

conception. If the ultrasound findings were compatible with

complete or incomplete abortion, no further action would

be taken unless there was heavy bleeding or pelvic infec-

tion. In these women, the final assessment would be made

on day 43. If no emergency or elective vacuum aspiration

was necessary during the period up to day 43 or the first

menstruation, the outcome was classified as complete

abortion. Bleeding patterns were recorded on both follow

up visits.

The number of women in the study has been calculated

using the Minitab Statistical Software on the basis of the

following considerations: (i) published evidence indicates

the success of surgical vacuum aspiration is about 97%

( P ¼ 0.97); (ii) type 1 error of 0.05; and (iii) power of 0.8.

The medical abortion regimen will be considered accept-

able if it can be demonstrated with a 95% confidence limit

that the regimen is at worst 10% inferior to surgical

vacuum aspiration. From the above considerations, the

number of woman needed is 140. Assuming 10% default

at follow up, the sample size chosen was 150.

The primary outcome measure was the complete abor-

tion rate defined as successful cases that did not require

vacuum aspiration. Failure was defined as the recourse to

176 K. SINGH ET AL.

D RCOG 2003 Br J Obstet Gynaecol 110, pp. 175–180

surgical abortion either as a result of method failure or

change of the woman’s decision. The change in hae-

moglobin concentration, the intervals between initial dose

of misoprostol and bleeding, and passage of production of

conception, duration of vaginal bleeding after abortion and

side effects were also noted.

Statistical analyses were performed using Student’s

t test, paired t test and Fisher’s exact test. Variables that

were normally distributed are presented by mean and

standard deviation of the mean. The percentage change of

the serum h-hCG levels were compared using the paired t

test. The frequency of side effects associated with use of

vaginal misoprostol was compared with using the Fisher’s

exact test (two-tailed).

RESULTS

Table 1 summarises the demographic characteristic of

the 150 women who underwent medical abortion with

vaginal misoprostol. The mean gestational age was 7.1

weeks. At the first follow up visit on day 15, 127 (84.7%)

had a complete abortion as determined by ultrasound

scanning. There was however no significant difference in

efficacy in relation to gestation (Table 2). Six women

(4.0%) had an ongoing pregnancy on this visit and had

surgical vacuum aspiration performed. Products of concep-

tion were confirmed on histology. Five women (3.3%) on

day 15 follow up showed a missed abortion in ultrasound.

All five of them opted for a repeat of two doses of 400 Ag

misoprostol at 3 hours interval on the same day in the

clinic. All five aborted or passed out products of conception

ranging from 2 to 6 hours after administration of the first

repeat dose of misoprostol. Complete abortion a week later

was confirmed by noting an empty uterine cavity on

ultrasound scanning and rapidly falling serum h-hCG

levels.

On the follow up on day 15, 12 women (8.0%) were on

ultrasound examination noted to have either retained pro-

ducts of conception and/or blood clots. They were diag-

nosed to have an incomplete abortion. No intact gestational

sac was seen in any of them. Because their bleeding was

not excessive, they had no signs of infection and their

h-hCG level had shown a more than 90% fall, they were

managed conservatively and told to return should they have

any excessive bleeding or signs of infection. All 12 women

remained well and were next seen on day 43. Thus, at

the end of the study with a 100.0% follow up, on day 43

(Table 2), 144 or 96.0% of the women had a complete

abortion as diagnosed by a return of their menses clinically

and a fall of their serum h-hCG to less than 2.5 mIU/mL.

Excluding the six women with a continuing pregnancy

and five women with a missed abortion on the day 15 follow

up, there were 139 women (i.e. 127 with a complete abortion

and 12 with an incomplete abortion) diagnosed by ultra-

sound scan on day 15. For these 139 women, the mean

interval between the first dose of misoprostol and the first

onset of bleeding (SD) was 4.9 hours (1.8) with a median

interval of 6.0 hours. Similarly, from Table 3, it can be seen

that the interval between the first dose of misoprostol and

the first expulsion of products of conception (SD) was

8.1 hours (6.3) with a median interval of 6.5 hours. In fact,

by the time the last and final dose of misoprostol was

inserted, 135 (97.1%) had passed out products of conception

Table 1. Demographic characteristic of woman in study.

Characteristic Mean (SD) [Range] n (%)

Age (years) 28.5 (6.7) [15– 45]

Weight (kg) 53.0 (8.9) [36– 94]

Height (cm) 159.8 (6.1) [144– 177]

Gestational age (weeks) 7.1 (0.6) [5.9– 8.0]

No. of women <6 weeks 8 (5.3)

No. of women 6– 7 weeks 74 (49.3)

No. of women <7 weeks 68 (45.4)

No. of parous women 104 (70.7)

Table 2. Outcome of medical abortion. Values are given in n (%).

Outcome Day 15 Day 43 (end of study)

Complete abortion

<6 weeks (n ¼ 8) 8 (100.0) 8 (100.0)

6 – 7 weeks (n ¼ 74) 60 (81.1) 70 (94.6)

>7 weeks (n ¼ 68) 59 (86.8) 66 (97.1)

Overall total (N ¼ 150) 127 (84.7) 144 (96.0)

Incomplete abortion

<6 weeks (n ¼ 8) 0 (0.0)

6 – 7 weeks (n ¼ 74) 6 (8.1)

>7 weeks (n ¼ 68) 6 (8.8)

Overall total (N ¼ 150) 12 (8.0)

Missed abortion

<6 weeks (n ¼ 8) 0 (0.0)

6 – 7 weeks (n ¼ 74) 4 (5.4)

>7 weeks (n ¼ 68) 1 (1.5)


Continuing or ongoing pregnancy

<6 weeks 0 (0.0)

6 – 7 weeks 4 (5.4)

>7 weeks 2 (2.9)


Table 3. Characteristics of medical abortion using vaginal misoprostol.

Characteristic Mean (SD) Median

Interval (hours) between first

dose of misoprostol and onset of bleeding

4.9 (1.8) 6.0

Interval (hours) between first dose

of misoprostol and onset of first expulsion

of products of conception

8.1 (6.3) 6.5

Duration of vaginal bleeding (days) 11.7 (4.7) 11.0

Duration between abortion procedure

and return of normal menses (days)

35.5 (5.7) 36

INTRAVAGINAL MISOPROSTOL AS ALTERNATIVE TO SURGICAL VACUUM ASPIRATION 177


and in almost all of them the abortion process appeared to

be complete based on the visual inspection of the products

of conception. From Table 3, it can be seen that the mean

duration of vaginal bleeding (SD) in these women was

11.7 days (4.7) with a median interval of 11 days and the

mean duration between the onset of the procedure and

return of normal menses (SD) was 35.5 days (5.7) with a

median of 36 days. The mean haemoglobin (SD) was

12.4 g/dL (0.9) before abortion and 12.2 g/dL (0.9) on

both days 15 and 43 follow up after the medical abortion.

This difference was not statistically significant by the

paired t test and no women required any blood transfusion.

The mean and median percentage changes in the serum

h-hCG levels for the different categories after medical

abortion on day 15 are shown on Table 4. In the group

with complete abortion, this mean fall in h-hCG was 98%

( P < 0.001) and in the group with incomplete abortion this

change was 91% ( P < 0.001). In the group with missed

abortion, this mean and median percentage fall in h-hCG

was only 23% and 25%, respectively, on day 15 and this

was not statistically significant. In the group where the

pregnancy was continuing, there was a statistically signifi-

cant increase in the h-hCG level ( P < 0.01) as shown in

Table 4.

The incidence of side effects are shown in Table 5.

There was a significant increase in the incidence of lower

abdominal pain, fever (>38.0jC), diarrhoea and headache

after the administration of the first and second dose of

vaginal misoprostol as compared with that which occurred

before the administration of vaginal misoprostol. The

incidence of these side effects then continued to decrease

with the subsequent administration of the third and fourth

dose of misoprostol. Although 132 (88%) of the women

experienced some form of abdominal pain by the time of

administering the second dose of misoprostol, the pain was

tolerable and not severe. Despite analgesics being readily

available, only 10 women required paracetamol orally to

relieve the pain after the second misoprostol dose. No

parenteral analgesic was required. Another six women

required oral administration of paracetamol for temperature

>39.0jC. For the remaining women with a temperature of

<39.0jC, the management was expectant. However, in all

of them, the fever was below 38.0jC at the 1-hour obser-

vation after the fourth dose of vaginal misoprostol. The

incidence of side effects on the day 15 follow up was not

significant.

DISCUSSION

Most regimens of medical abortion using a combination

of mifespristone and a prostaglandin have yielded a com-

plete abortion rate ranging from 90% to 95%11. Similarly, a

misoprostol-alone regimen of medical abortion will be

considered effective if the complete abortion reaches

90%. Different misoprostol-alone regimens have been

reported in the literature for medical abortion in the first

trimester. These studies are generally difficult to compare

as different doses and regimens of administering misopros-

tol were used. Moreover, the success of medical abortion is

different depending on the time period at which it is

measured. The regimens used by Carbonell et al.7 – 9

yielded the highest overall success rates (87 – 94%),

Table 4. Changes in serum h-hCG with outcome of therapy on day 15

after misoprostol administration.

Outcome of therapy No. Mean percentage change in

h-hCG (median) in reference

to baseline values

P

Complete abortion 127 �98 (�100) <0.001

Incomplete abortion 12 �91 (�98) <0.001

Missed abortion 5 �23 (�25) 0.12

Continuing pregnancy 6 þ252 (þ150) <0.01

Table 5. Side effects of repeated doses of vaginal misoprostol for medical abortion compared with that occurring during pregnancy. Values are given as

n (%); n ¼ 150.

Pre-misoprostol

administration

After first dose

of misoprostol

After second dose

of misoprostol

After third dose

of misoprostol

After fourth dose

of misoprostol

Day 15 follow up

Lower abdominal pain 2 (1.3) 76 (50.7)a 132 (88.0)a 115 (76.7)a 65 (43.3) 15 (10.0)

Fever (>38.0jC) 0 (0.0) 14 (9.3)a 31 (20.7)a 6 (4.0) – –

Diarrhoea 4 (2.7) 22 (14.7)a 40 (26.7)a 10 (6.7) 2 (1.3) 2 (1.3)

Headache 6 (4.0) 17 (11.3)c 20 (13.3)b 6 (4.0) 3 (2.0) 5 (3.3)

Nausea 42 (28.0) 46 (30.7) 51 (34.0) 3 (2.0) 1 (0.7) 3 (2.0)

Vomiting 25 (16.7) 26 (17.3) 31 (20.7) 2 (1.3) 1 (0.7) 1 (0.7)

Fatigue 12 (8.0) 6 (4.0) 14 (9.3) – – 1 (0.7)

Dizziness 10 (6.7) 7 (4.7) 13 (8.7) 2 (1.3) 2 (1.3) 2 (1.3)

Fainting 3 (1.3) 5 (3.3) – – – –

Breast tenderness 45 (30.0) 45 (30.0) 43 (28.7) 3 (2.0) 3 (2.0) 3 (2.0)

a P < 0.001 as compared with that occurring during pregnancy by Fisher’s exact test.b P < 0.05 as compared with that occurring during pregnancy by Fisher’s exact test.c P < 0.01 as compared with that occurring during pregnancy by Fisher’s exact test.

178 K. SINGH ET AL.


whereas the success rates in the other studies ranged from

47% to 70%5,6,12. In Carbonell et al.’s studies, the women

received 800 Ag of vaginal misoprostol every 24–48 hours

up to a maximum of three doses. Ngai et al.13 yielded a

lower complete abortion rate of 94% in women <7 weeks

pregnant and 77% in women seven to nine weeks pregnant

using a similar regimen to Carbonell.

Only two studies have to date used regimens that could

be completed within a day. Koopersmith and Mishell5

reported a complete abortion rate of 60% using 200–

400 Ag of vaginal misoprostol every 4–8 hours for four

to five doses in women less than 10 weeks of gestation.

Tang et al.12 used a high initial dose of 800 Ag of vaginal

misoprostol followed by 400 Ag every 3 hours for a max-

imum of four doses. In this pilot study among 50 women,

the complete abortion rate was 70% in women <9 weeks

of gestation.

The results of our study using an initial loading dose of

800 Ag of vaginal misoprostol followed by three subsequent

doses of 400 Ag vaginal misoprostol at 3 hourly interval

achieved a complete abortion rate of 84.7% at day 15 and

96.0% at day 43 or six weeks after the onset of medical

abortion using vaginal misoprostol. The complete abortion

rate of 84.7% at day 15 is much better than the rate of 70%

reported by Tang et al.12 in a pilot study of 50 women. In

fact, in this pilot study, Tang et al.12 used four doses of

400 Ag of vaginal misoprostol at 3 hourly interval after the

initial loading dose of 800 Ag of vaginal misoprostol12. We

have used only three subsequent doses of vaginal miso-

prostol. Besides achieving a higher complete abortion rate

with a lower dose of misoprostol at day 15, we achieved a

96.0% success rate of complete abortion at day 43 or six

weeks after the initial administration of vaginal misoprostol

in our regimen for medical abortion. This compares favour-

ably with the success rate of more than 95% for surgical

vacuum aspiration in the first trimester2.

The success rate of medical abortion is often monitored

in most studies on clinical data (passage of products of

conception and no vaginal bleeding on follow up). Ultra-

sonographic evaluation of the uterine cavity, measurement

of the endometrial thickness or endometrial echo complex

has also been reported. This does not pose a problem in

diagnosing a continuing pregnancy or a missed abortion

where the gestation sac is still intact. However, what poses a

tricky situation are the cases of incomplete abortion sug-

gested on ultrasound evaluation. Does one resort to a

surgical evacuation of the uterus or does one wait and

monitor the natural course of events? Harwood et al.14 in

their study has shown that in the first week following

medical abortion, the median decline in h-hCG levels from

the level at the time of misoprostol administration was

94.6%. The h-hCG level reached <50 mIU/mL between

two and eight weeks after abortion and the time to reach

these minimal levels was directly related to the initial

h-hCG with higher levels requiring a longer time to clear14.

Similarly, Creinin15 showed that an aborting pregnancy,

if medical abortion has occurred, should have a h-hCG

decrease of approximately 50% within 24 hours. How-

ever, this decline does not guarantee that the abortion is

complete14.

The usefulness of monitoring h-hCG levels is clearly

demonstrated in our study. In the group with continuing

pregnancy, there was a statistically significant percentage

increase in the mean and median h-hCG levels. (Table 4) In

the group where the diagnosis was missed abortion on

ultrasound, this mean and median percentage fall in h-hCG

was only 23% and 25%, respectively. Based on these

findings, two doses of 400 Ag of vaginal misoprostol

repeated 3 hours apart were given and this successfully

aborted the missed abortion in all five cases. In the group

where the abortion was complete on ultrasound, the mean

percentage fall in h-hCG was 98%; the fall was 91% in the

group diagnosed to have an incomplete abortion on ultra-

sound. It would thus appear to make sense that if there is a

significant mean percentage change in the serum h-hCG at

day 15 follow up, one can confidently manage the women

conservatively even if the ultrasound assessment suggests

incomplete abortion. In fact, rightly all 12 women diag-

nosed to have an incomplete abortion in ultrasound were

managed conservatively without any complications. At day

43 or six weeks after the start of misoprostol administra-

tion, the mean h-hCG levels were all less than 2.5 mIU/mL

in all three groups (i.e. complete, incomplete and missed

abortion) and the menses had returned in all of them.

However, in practice, where products of conception is

noted to have been passed prior to discharge and in women

who are asymptomatic with no vaginal bleeding on follow

up, it may not be cost effective to perform h-hCG levels

and ultrasound scanning. It should be reserved for women

who have failed to pass products of conception and are

symptomatic on follow up.

The side effects of various misoprostol-alone regimens

are also important factors determining their acceptability

and usefulness. The mean duration of vaginal bleeding

of approximately 12 days in our study is comparable

with regimens using a combination of mifepristone and

misoprostol11. The incidence of the three most important

side effects (i.e. lower abdominal pain, fever >38.0jC and

diarrhoea on the day of treatment) were comparable to that

reported in other studies using repeated doses of vaginal

misoprostol12 and was even lower than that reported by the

use of a regimen of 600 Ag misoprostol given sublingually

every 3 hours for a maximum of five doses16.

CONCLUSION

Our regimen of using repeated doses of vaginal miso-

prostol alone, over a period of 9 hours on a day care basis,

with a success rate of 96.0% at six weeks post-misoprostol

administration, is an effective method of medical abortion

with tolerable side effects.

INTRAVAGINAL MISOPROSTOL AS ALTERNATIVE TO SURGICAL VACUUM ASPIRATION 179


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2002;17(3):654– 664.

Accepted 12 November 2002

180 K. SINGH ET AL.


a viable alternative to surgical vacuum aspiration: repeated doses of intravaginal misoprostol over...

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