Medical abortion

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Medical abortion
Background
Abortion type Medical
First use United States 1979 (carboprost),
West Germany 1981 (sulprostone),
Japan 1984 (gemeprost),
France 1988 (mifepristone),
United States 1988 (misoprostol)
Gestation 3–24+ weeks
Usage
Medical abortions as a percentage of all abortions
France 64% (2016)
Sweden 92% (2016)
UK: Eng. & Wales 62% (2016)
UK: Scotland 83% (2016)
United States 30% (2014)
Infobox references

A medical abortion, also known as medication abortion, is a type of non-surgical abortion in which medication is used to bring about abortion. An oral preparation for medical abortion is commonly referred to as an abortion pill.

Medical abortion became an alternative method of abortion with the availability of prostaglandin analogs in the 1970s and the antiprogestogen mifepristone (also known as RU-486)[1] in the 1980s.[2][3][4]

Medical uses[edit]

  • For pregnancies of gestational age between 12-14 weeks, the World Health Organization recommends the following medications for abortions:[5]
    • oral mifepristone
    • oral misoprostol, when mifepristone is not available
  • Surgical abortion via vacuum aspiration is an alternative option recommended by WHO for pregnancies up to 12-14 weeks in gestational age.

Contraindications[edit]

Contraindications to a medical abortion may include:[6]

  • previous allergic reaction to one of the drugs involved;
  • inherited porphyria;
  • chronic adrenal failure;
  • ectopic pregnancy

Caution is required in a range of circumstances including:

Side effects[edit]

Mifepristone[edit]

  • Expected side effects[7]:
    • Cramping and vaginal bleeding within 24-48 hours of taking the medication are signs that the treatment is working
  • Common side effects:
    • nausea
    • weakness
    • fevers/chills
    • vomiting
    • headache
    • diarrhea
    • dizziness
  • Complications that require immediate medical attention:
    • Heavy bleeding (enough blood to soak through two sanitary pads in 2 hours)
    • Abdominal pain, nausea, vomiting, diarrhea, fever for more than 24 hours after taking mifepristone
    • Fever of 100.4° F or higher for more than 4 hours

Misoprostol[edit]

  • Common side effects[8]:
    • diarrhea
    • abdominal pain
    • nausea
    • flatulence
    • headache
    • dyspepsia
    • vomiting
    • constipation
  • Gynecological side effects:
    • spotting
    • cramps
    • hypermenorrhea
    • menstrual disorder
    • dysmenorrhea

Although medical abortion is associated with more bleeding than surgical abortion, overall bleeding for the two methods is minimal and not clinically different. In a large-scale prospective trial published in 1992 of more than 16,000 women undergoing medical abortion using mifepristone with varying doses of gemeprost or sulprostone, only 0.1% had hemorrhage requiring a blood transfusion. It is often advised to contact a health care provider if there is bleeding to such degree that more than two pads are soaked per hour for two consecutive hours.

Cases of deaths from clostridial toxic shock syndrome have occurred following medical abortions.

A retrospective study published in The New England Journal of Medicine in July 2009 of 227,823 women who underwent medical abortion at Planned Parenthood affiliate centers from January 2005 through June 2008, found that the rate of serious infection after medical abortion declined by 93% after a change from vaginal to buccal administration of misoprostol combined with the routine prophylactic administration of doxycycline antibiotics.[9]

Methods[edit]

There are three methods for medical abortion:

  • Mifepristone followed by misoprostol
    • The National Abortion Federation (NAF) recommends a mifepristone and misoprostol combination regimen, wherever mifepristone is legally available and accessible. This is an option for patients with gestations through 70 days. Mifepristone 200 mg is taken and followed by misoprostol 800 mcg buccally, vaginally, or sublingually 24 to 48 hours later.[10] A 2011 systematic review found that it was simpler and equally safe to administer mifepristone in clinic and have the pregnant woman later take misoprostol at home as it was to administer both drugs in the clinic.[11]
    • The World Health Organization recommends the combined use of mifeprostone followed by misoprostol for pregnancies of gestational age 9 weeks or less. This combination consists of 200mg mifeprostone followed by 800mcg of misoprostol to be taken within 24-48 hours. The misoprostol can be administered in the clinic or at home. For pregnancies that are 9-12 weeks of gestational age, the WHO recommends the initial 200mg mifeprostone dose to be followed by 800mcg misoprostol administered vaginally, which can be repeated every three hours up to 4 total doses. In this case, the misoprostol must be administered in the clinic.[12]
    • The early first-trimester medical abortion regimen (200 mg of oral mifepristone, followed 24–48 hours later by 800 mcg of buccal misoprostol) currently used by Planned Parenthood clinics in the United States since April 2006 is 98.3% effective through 59 days' gestation.[9]
  • Misoprostol alone
    • This is considered the second-line agent when mifepristone is not legally available or difficult to access. This is an appropriate option for gestations through 70 days.[10]
    • The WHO recommends this regimen only if mifeprostone is not available, as this method is less effective.[12][13]
  • Methotrexate followed by misoprostol
    • Though not a first line choice, a methotrexate/misoprostol combination regimen is appropriate. Methotrexate is given either orally or intramuscularly, followed by vaginal misoprostol 3-5 days later. This is an appropriate option for gestations through 63 days.[10]
    • Per the WHO, a methotrexate-misoprostol regimen can also be used;[14] but is not recommended as methotrexate may be teratogenic to the fetus in cases of incomplete abortion. However, this combination is considered more effective than misoprostol alone.[3]

Medical abortion regimens using mifepristone in combination with a prostaglandin analog are the most common methods used to induce second-trimester abortions in Canada, most of Europe, China and India;[4] in contrast to the United States where 96% of second-trimester abortions are performed surgically by dilation and evacuation.[15]

During the Committal[edit]

Mifepristone (mif-uh-PRIS-tone) blocks the hormone progesterone, causing the lining of the uterus to thin and preventing the embryo from staying implanted and growing. Misoprostol (my-so-PROS-tol), a different kind of medication, causes the uterus to contract and expel the embryo through the vagina. [16]

Recovery/Rehabilitation[edit]

Management of prolonged bleeding[edit]

According to the 2006 WHO Frequently asked clinical questions about medical abortion,[6] vaginal bleeding generally diminishes gradually over about two weeks after a medical abortion, but in individual cases spotting can last up to 45 days. If the woman is well, neither prolonged bleeding nor the presence of tissue in the uterus (as detected by obstetric ultrasonography) is an indication for surgical intervention (that is, vacuum aspiration or dilation and curettage). Remaining products of conception will be expelled during subsequent vaginal bleeding. Still, surgical intervention may be carried out on the woman's request, if the bleeding is heavy or prolonged, or causes anemia, or if there is evidence of endometritis.

Contraception[edit]

At the time of medical abortion, education regarding contraception must be provided by the abortion clinic per 2018 National Abortion Federation guidelines.[10] According to a 2011 study of 27 women who underwent a medical abortion with oral mifepristone 200mg and vaginal misoprostol 800mcg, average time-to-ovulation was about 3 weeks (20.6 days).[17]

A contraceptive implant may be placed with no difference in success of medical abortion on the day of administration of mifepristone.[18] In addition, a contraceptive pill, patch, or vaginal ring may be started on the same day of medical abortion without the need to confirm the completion of the abortion. In a 1999 study, oral contraceptive pills taken immediately after a medical abortion was shown to have no difference in duration of bleeding or completion of abortion rate compared to placebo.[19] The use of a depot medroxyprogesterone acetate injection as a form of contraception at the time of medical abortion was shown, however, to increase the risk of ongoing pregnancy following the medical abortion.[20] An IUD placed early (within 5-9 days of mifepristone) or delayed (3-4 weeks after mifepristone) had no significant difference in terms of IUD expulsion or medical abortion complications, thus an IUD may be placed once confirmation of the medical abortion is complete, which is typically about a week.[21]

Prevalence[edit]

Medical abortions as a percentage of all abortions
Country Percentage
Italy 17% in 2015[22]
Spain 19% in 2015[23]
Belgium 22% in 2011[24]
Netherlands 22% in 2015[25]
Germany 23% in 2016[26]
United States 30% in 2014[27]
England and Wales 62% in 2016[28]
France 64% in 2016[29]
Iceland 67% in 2015[30]
Denmark 70% in 2015[30]
Portugal 71% in 2015[31]
Switzerland 72% in 2016[32]
Scotland 83% in 2016[33]
Norway 87% in 2016[34]
Sweden 92% in 2016[35]
Finland 96% in 2015[36]

A Guttmacher Institute survey of abortion providers estimated that early medical abortions accounted for 31% of all nonhospital abortions and 45% of nonhospital abortions before 9 weeks' gestation in the United States in 2014.[27][37]

At Planned Parenthood clinics in the United States, medical abortions accounted for 32% of first trimester abortions in 2008,[38] 35% of all abortions in 2010 and 43% of all abortions in 2014.[39]

Cost[edit]

In the United States in 2009, the median price charged for a medical abortion up to 9 weeks' gestation was $490, four percent higher than the $470 median price charged for a surgical abortion at 10 weeks' gestation.[40] In the United States in 2008, 57% of women who had abortions paid for them out of pocket.[41]

In April 2013, the Australian government commenced an evaluation process to decide whether to list mifepristone (RU486) and misoprostol on the country's Pharmaceutical Benefits Scheme (PBS). If the listing is approved by the Health Minister Tanya Plibersek and the federal government, the drugs will become more accessible due to a dramatic reduction in retail price—the cost would be reduced from between AU$300 and AU$800, to AU$12 (subsidised rate for concession card holders) or AU$35.[42]

On 30 June 2013, the Australian Minister for Health, the Hon Tanya Plibersek MP, announced that the Australian Government had approved the listing of mifepristone and misoprostol on the PBS for medical terminations early in pregnancies consistent with the recommendation of the Pharmaceutical Benefits Advisory Committee (PBAC). These listings on the PBS occurred on 1 August 2013.

References[edit]

  1. ^ Rowan, Andrea (2015). "Prosecuting Women for Self-Inducing Abortion: Counterproductive and Lacking Compassion". Guttmacher Policy Review. 18 (3): 70–76. Retrieved 12 October 2015.
  2. ^ Kulier, Regina; Kapp, Nathalie; Gülmezoglu, A. Metin; Hofmeyr, G. Justus; Cheng, Linan; Campana, Aldo (November 9, 2011). "Medical methods for first trimester abortion". Cochrane Database of Systematic Reviews (11): CD002855. doi:10.1002/14651858.CD002855.pub4. PMID 22071804.
  3. ^ a b Creinin, Mitchell D.; Danielsson, Kristina Gemzell (2009). "Medical abortion in early pregnancy". In Paul, Maureen; Lichtenberg, E. Steve; Borgatta, Lynn; Grimes, David A.; Stubblefield, Phillip G.; Creinin, Mitchell D. Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 111–134. ISBN 978-1-4051-7696-5.
  4. ^ a b Kapp, Nathalie; von Hertzen, Helena (2009). "Medical methods to induce abortion in the second trimester". In Paul, Maureen; Lichtenberg, E. Steve; Borgatta, Lynn; Grimes, David A.; Stubblefield, Phillip G.; Creinin, Mitchell D. Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 178–192. ISBN 978-1-4051-7696-5.
  5. ^ The World Health Organization (2012). "Safe abortion:technical and policy guidance for health systems".
  6. ^ a b International Consensus Conference on Non-surgical (Medical) Abortion in Early First Trimester on Issues Related to Regimens and Service Delivery (2006). Frequently asked clinical questions about medical abortion (PDF). Geneva: World Health Organization. ISBN 978-92-4-159484-4.
  7. ^ "Mifepristone Prescribing Information" (PDF). FDA.
  8. ^ "Cytotec (misoprostol) Prescribing Information" (PDF). FDA.
  9. ^ a b Fjerstad, Mary; Sivin, Irving; Lichtenberg, E. Steve; Trussell, James; Cleland, Kelly; Cullins, Vanessa (September 2009). "Effectiveness of medical abortion with mifepristone and buccal misoprostol through 59 gestational days". Contraception. 80 (3): 282–286. doi:10.1016/j.contraception.2009.03.010. PMC 3766037. PMID 19698822.
    The medical abortion regimen (200 mg of oral mifepristone, followed 24–48 hours later by 800 mcg of vaginal misoprostol) previously used by Planned Parenthood clinics in the United States from 2001 to March 2006 was 98.5% effective through 63 days' gestation—with an ongoing pregnancy rate of about 0.5%, and an additional 1% of patients having uterine evacuation for various reasons, including problematic bleeding, persistent gestational sac, clinician judgment or patient request.
  10. ^ a b c d National Abortion Federation. (2018). Clinical Policy Guidelines for Abortion Care. Retrieved from https://www.prochoice.org
  11. ^ Ngo, Thoai D.; Park, Min Hae; Shakur, Haleema; Free, Caroline (2011). "Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: a systematic review". Bulletin of the World Health Organization. 89 (5): 360–370. doi:10.2471/BLT.10.084046. PMC 3089386. PMID 21556304.
  12. ^ a b WHO Department of Reproductive Health and Research (2012). Safe abortion: technical and policy guidance for health systems (PDF) (2nd ed.). Geneva: World Health Organization. pp. 1–9, 46. ISBN 978-92-4-154843-4.
  13. ^ Dunn, Shelia; Cook, Rebecca (January 7, 2014). "Medical abortion in Canada: behind the times". Canadian Medical Association Journal. 186 (1): 13–14. doi:10.1503/cmaj.131320. PMC 3883814. PMID 24277708.
  14. ^ "Women's Health".
  15. ^ Hammond, Cassing; Chasen, Stephen T. (2009). "Dilation and evacuation". In Paul, Maureen; Lichtenberg, E. Steve; Borgatta, Lynn; Grimes, David A.; Stubblefield, Phillip G.; Creinin, Mitchell D. Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 178–192. ISBN 978-1-4051-7696-5.
  16. ^ Cite error: The named reference https://www.mayoclinic.org/tests-procedures/medical-abortion/about/pac-20394687 was invoked but never defined (see the help page).
  17. ^ Schreiber, Courtney A.; Sober, Stephanie; Ratcliffe, Sarah; Creinin, Mitchell D. (2011-09-01). "Ovulation resumption after medical abortion with mifepristone and misoprostol". Contraception. 84 (3): 230–233. doi:10.1016/j.contraception.2011.01.013. ISSN 1879-0518. PMID 21843685.
  18. ^ Raymond, Elizabeth G.; Weaver, Mark A.; Tan, Yi-Ling; Louie, Karmen S.; Bousiéguez, Manuel; Lugo-Hernández, Elba M.; Aranguré-Peraza, Ana Gabriela; Sanhueza, Patricio; Kaplan, Clair (2016-02-01). "Effect of Immediate Compared With Delayed Insertion of Etonogestrel Implants on Medical Abortion Efficacy and Repeat Pregnancy: A Randomized Controlled Trial". Obstetrics and Gynecology. 127 (2): 306–312. doi:10.1097/AOG.0000000000001274. ISSN 1873-233X. PMID 26942358.
  19. ^ Tang, O. S. (1999-03-01). "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. 14 (3): 722–725. doi:10.1093/humrep/14.3.722. ISSN 1460-2350.
  20. ^ Raymond, Elizabeth G.; Weaver, Mark A.; Louie, Karmen S.; Tan, Yi-Ling; Bousiéguez, Manuel; Aranguré-Peraza, Ana Gabriela; Lugo-Hernández, Elba M.; Sanhueza, Patricio; Goldberg, Alisa B. (2016-10-01). "Effects of Depot Medroxyprogesterone Acetate Injection Timing on Medical Abortion Efficacy and Repeat Pregnancy: A Randomized Controlled Trial". Obstetrics and Gynecology. 128 (4): 739–745. doi:10.1097/AOG.0000000000001627. ISSN 1873-233X. PMID 27607859.
  21. ^ Sääv, Ingrid; Stephansson, Olof; Gemzell-Danielsson, Kristina (2012-11-14). "Early versus Delayed Insertion of Intrauterine Contraception after Medical Abortion — A Randomized Controlled Trial". PLoS ONE. 7 (11): e48948. doi:10.1371/journal.pone.0048948. ISSN 1932-6203. PMC 3498342. PMID 23155432.
  22. ^ . (December 15, 2016). "Relazione Ministro Salute attuazione Legge 194/78 tutela sociale maternità e interruzione volontaria di gravidanza - dati definitivi 2014 e 2015 [Ministry of Health report implementation Act 194/78 social protection maternity and voluntary interruption of pregnancy - definitive data 2014 and 2015]". Rome: Ministero della Salute [Ministry of Health]. Table 25 - IVG and type of intervention, 2015: mifepristone + mifepristone+prostaglandin + prostaglandin = 17%.
  23. ^ . (December 30, 2016). "Interrupción Voluntaria del Embarazo; Datos definitivos correspondientes al año 2015 (Voluntary interruption of pregnancy; final data for 2015" (PDF). Madrid: Ministerio de Sanidad, Politica Social e Igualdad (Ministry of Health and Social Policy). Table G.15: 17,916 (sum of the greater of mifepristone or prostaglandin abortions by gestation period) / 94,188 (total abortions) = 19.0%.
  24. ^ Commission Nationale d'Evaluation des Interruptions de Grossesse (August 27, 2012). "Rapport Bisannuel 2010-2011". Brussels: Commission Nationale d'Evaluation des Interruptions de Grossesse. prostaglandin 0.40% + mifepristone 21.23% = 21.63% medical abortions
  25. ^ . (February 9, 2017). "Jaarrapportage 2015 van de Wet afbreking zwangerschap [Annual Report 2015 of the Discontinuation of Pregnancy Act]". Utrecht, Netherlands: Inspectie voor de Gezondheidszorg (IGZ) [Health Care Inspectorate], Ministerie van Volksgezondheid, Welzijn en Sport (VWS) [Ministry of Health, Welfare and Sport].
  26. ^ . (March 9, 2017). "Schwangerschaftsabbrüche 2016 (Abortions 2016)" (PDF). Wiesbaden: Statistisches Bundesamt (Federal Statistical Office), Germany. 20.237% Mifegyne + 3.021% Medikamentöser Abbruch = 23.257% medical abortions
  27. ^ a b Jones, Rachel K.; Jerman, Jenna (January 17, 2017). "Abortion incidence and service availability in the United States, 2014". Perspectives on Sexual and Reproductive Health. 49 (1): 17–27. doi:10.1363/psrh.12015. PMC 5487028. PMID 28094905.
    96% of all abortions performed in nonhospital facilities × 31% early medical abortions of all nonhospital abortions = 30% early medical abortions of all abortions; 97% of nonhospital medical abortions used mifepristone and misoprostol—3% used methotrexate and misoprostol, or misoprostol alone—in the United States in 2014.
  28. ^ . (May 30, 2017). "Abortion statistics, England and Wales: 2016" (PDF). London: Department of Health, United Kingdom.
    Medical abortion accounted for 72% of abortions under 10 weeks' gestation—in England and Wales in 2016.
  29. ^ Vilain, Annick (June 26, 2017). "211 900 interruptions volontaires de grossesse en 2016 (211,900 voluntary terminations of pregnancies in 2016)" (PDF). Paris: DREES (Direction de la Recherche, des Études, de l'Évaluation et des Statistiques), Ministère de la Santé (Ministry of Health), France.
  30. ^ a b Heino, Anna; Gissler, Mika (March 7, 2017). "Pohjoismaiset raskaudenkeskeytykset 2015 (Induced abortions in the Nordic countries 2015)" (PDF). Helsinki: Terveyden ja hyvinvoinnin laitos (National Institute for Health and Welfare), Finland. ISSN 1798-0887. Appendix table 6. Drug-induced abortions in Nordic countries 1993–2015, %
  31. ^ . (September 20, 2016). "Relatório dos Registos das Interrupções da Gravidez - Dados de 2015 [Report of the Interruptions of Pregnancy - Data of 2015]". Lisbon: Divisão de Saúde Sexual, Reprodutiva, Infantil e Juvenil [Division of Sexual, Reproductive, Child and Juvenile Health], Direção de Serviços de Prevenção da Doença e Promoção da Saúde [Directorate of Disease Prevention and Health Promotion Services], Direção-Geral da Saúde (DGS) [Directorate-General for Health].
  32. ^ . (June 13, 2017). "Interruptions de grossesse en Suisse en 2016 (Abortions in Switzerland 2016)". Neuchâtel: Office of Federal Statistics, Switzerland.
  33. ^ . (May 30, 2017). "Termination of pregnancy statistics, year ending December 2016" (PDF). Edinburgh: Information Services Division (ISD), NHS National Services Scotland.
    Medical abortions accounted for 89% of abortions before 9 weeks' gestation in Scotland in 2016.
  34. ^ Løkeland, Mette; Mjaatvedt, Aase Gunn; Akerkar, Rupali; Pedersen, Yngve; Bøyum, Bjug; Hornæs, Mona Tornensis; Seliussen, Ingvei; Ebbing, Marta (March 8, 2017). "Rapport om svangerskapsavbrot for 2016 (Report on pregnancy terminations for 2016)" (PDF). Oslo: Divisjon for epidemiologi (Division of Epidemiology), Nasjonalt Folkehelseinstitutt (Norwegian Institute of Public Health), Norway. ISSN 1891-6392.
    Medical abortions accounted for 90% of abortions before 9 weeks' gestation in Norway in 2016.
  35. ^ Öman, Maria; Gottvall, Karin (May 10, 2017). "Statistik om aborter 2016 (Statistics on abortions in 2016)" (PDF). Stockholm: Socialstyrelsen (National Board of Health and Welfare), Sweden.
    Medical abortions accounted for 94% of abortions before 9 weeks' gestation in Sweden in 2016.
  36. ^ Heino, Anna; Gissler, Mika (October 20, 2016). "Raskaudenkeskeytykset 2015 (Induced abortions 2015)" (PDF). Helsinki: Suomen virallinen tilasto (Official Statistics of Finland), Terveyden ja hyvinvoinnin laitos (National Institute for Health and Welfare), Finland.
  37. ^ Jatlaoui, Tara C.; Ewing, Alexander; Mandel1, Michele G.; Simmons, Katharine B.; Suchdev, Danielle B.; Jamieson, Denise J.; Pazol, Karen (November 25, 2016). "Abortion Surveillance — United States, 2013" (PDF). MMWR Surveillance Summaries. 65 (12): 1–44. doi:10.15585/mmwr.ss6512a1. PMID 27880751.
    Medical abortions accounted for 22.2% of abortions—and 32.8% of abortions at ≤8 weeks' gestation—in the United States in 2013 that were voluntarily reported to the CDC by 43 reporting areas (excluding California, Florida, Hawaii, Illinois, Louisiana, Maryland, New Hampshire, Tennessee, and Wyoming).
  38. ^ Fjerstad, Mary; Trussell, James; Sivin, Irving; Lichtenberg, E. Steve; Cullins, Vanessa (July 9, 2009). "Rates of serious infection after changes in regimens for medical abortion". New England Journal of Medicine. 361 (2): 145–151. doi:10.1056/NEJMoa0809146. PMC 3568698. PMID 19587339.
    Allday, Erin (July 9, 2009). "Change cuts infections linked to abortion pill". San Francisco Chronicle. p. A1.
  39. ^ Mindock, Clark (31 October 2016). "Abortion Pill Statistics: Medication Pregnancy Termination Rivals Surgery Rates In The United States". International Business Times. Retrieved 19 April 2018.
  40. ^ Jones, Rachel K.; Kooistra, Kathryn (March 2011). "Abortion incidence and access to services in the United States, 2008" (PDF). Perspectives on Sexual and Reproductive Health. 43 (1): 41–50. doi:10.1363/4304111. PMID 21388504.
    Stein, Rob (January 11, 2011). "Decline in U.S. abortion rate stalls". The Washington Post. p. A3.
  41. ^ Jones, Rachel K.; Finer, Lawrence B.; Singh, Shusheela (May 4, 2010). "Characteristics of U.S. abortion patients, 2008" (PDF). New York: Guttmacher Institute.
    Mathews, Anna Wilde (May 4, 2010). "Most women pay for their own abortions". The Wall Street Journal.
  42. ^ Peterson, Kerry (30 April 2013). "Abortion drugs closer to being subsidised but some states still lag". The Conversation Australia. The Conversation Media Group. Retrieved April 29, 2013.

External links[edit]