I read with interest the article by Oppegaard et al.1 on oral versus self-administered vaginal misoprostol at home before surgical termination of pregnancy (TOP).
In my opinion, this emphasises what many gynaecologists already know; oral prostaglandins are not as effective in cervical priming in early pregnancy as they are in late pregnancy and are also associated with more adverse effects, particularly gastrointestinal.
TOP is a very common operation in the UK, with about 185 400 procedures performed in the year 2004 and only 19% of cases were performed using the medical option.2
In my view, we should be aiming to demedicalise TOP, especially now that we have a variety of options for procuring it. As many parts of the procedure should be performed in familiar surroundings away from the hospital, I suggest that we should be looking for means of increasing the uptake of medical TOP. A previous study has shown the efficacy of self-administration of misoprostol vaginally in the hospital for medical TOP.3 The present study has shown the efficacy of self-administered vaginal misoprostol at home for cervical ripening in surgical TOP. The natural evolution should therefore be to study the results of self-administered vaginal misoprostol at home for medical TOP, as many women may prefer to undergo the process in familiar surroundings.
This will, however, have significant implications for organisation of services and costs, both positive (saving of theatre and operating time) and negative (need for more scans to investigate the possibility of retained products). If medical terminations are performed at home, we will have to organise follow up to confirm completion of the process. However, in an audit of medical TOP performed in my previous unit, we found that follow-up ultrasound scans were not required in most women, indeed, only 17/111 women (15.3%) required scanning. Persistent bleeding 2–3 weeks after the procedure was, in our experience, a better predictor of the need for surgical evacuation of the uterus than ultrasound scan.