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Mehra VM, Farooqi S, Sriram P, Tunde-Byass M. Diagnosis and management of early pregnancy loss. CMAJ 2024; 196:E1162-E1168. [PMID: 39406415 PMCID: PMC11482652 DOI: 10.1503/cmaj.231489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2024] Open
Affiliation(s)
- Vrati M Mehra
- Temerty Faculty of Medicine (Mehra), and Department of Obstetrics and Gynecology (Farooqi, Tunde-Byass), University of Toronto; Obstetrics and Gynecology (Sriram, Tunde-Byass), North York General Hospital, Toronto, Ont
| | - Salwa Farooqi
- Temerty Faculty of Medicine (Mehra), and Department of Obstetrics and Gynecology (Farooqi, Tunde-Byass), University of Toronto; Obstetrics and Gynecology (Sriram, Tunde-Byass), North York General Hospital, Toronto, Ont
| | - Pallavi Sriram
- Temerty Faculty of Medicine (Mehra), and Department of Obstetrics and Gynecology (Farooqi, Tunde-Byass), University of Toronto; Obstetrics and Gynecology (Sriram, Tunde-Byass), North York General Hospital, Toronto, Ont
| | - Modupe Tunde-Byass
- Temerty Faculty of Medicine (Mehra), and Department of Obstetrics and Gynecology (Farooqi, Tunde-Byass), University of Toronto; Obstetrics and Gynecology (Sriram, Tunde-Byass), North York General Hospital, Toronto, Ont.
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Novatt H, Rockhill K, Baker K, Stickrath E, Alston M, Fabbri S. Clinic Versus the Operating Room: Determining the Optimal Setting for Dilation and Curettage for Management of First-Trimester Pregnancy Failure. Cureus 2024; 16:e56490. [PMID: 38638705 PMCID: PMC11026066 DOI: 10.7759/cureus.56490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/20/2024] Open
Abstract
Introduction There is no clear guidance for the optimal setting for dilation and curettage (D&C) for the management of first-trimester pregnancy failure. Identifying patients at risk of clinically significant blood loss at the time of D&C may inform a provider's decision regarding the setting for the procedure. We aimed to identify risk factors predictive for blood loss of 200mL or greater at the time of D&C. Methods This is a retrospective cohort study of patients diagnosed with first-trimester pregnancy failure at gestational age less than 11 weeks who underwent surgical management with D&C at a single safety net academic institution between 4/2016 and 4/2021. Patient characteristics and procedural outcomes were abstracted. Women with less than 200mL versus greater than or equal to 200mL blood loss were compared using descriptive statistics, chi-square for categorical variables, and Satterthwaite t-tests for continuous variables. Results A total of 350 patients were identified; 233 met inclusion criteria, and 228 had non-missing outcome data. Mean gestational age was 55 days (SD 9.4). Thirty-one percent (n=70) had estimated blood loss (EBL) ≥200mL. Younger patients (mean 28.7 years vs. 30.9, p=0.038), Latina patients (67.1% vs. 51.9%, p=0.006), patients with higher body mass index (BMI, mean 30.6 vs. 27.3 kg/m2, p=0.006), and patients with pregnancies at greater gestational age (59.5 days vs. 53.6 days, p<0.001) were more likely to have EBL ≥200mL. Additionally, patients with pregnancies dated by ultrasound (34.3% vs. 18.4%, p=0.007), those who underwent D&C in the operating room (81.4% vs. 48.7%, p<0.001), and those who underwent general anesthesia (81.4% vs. 44.3%, p<0.001) were more likely to have EBL ≥200mL. Discussion In this study, patients with EBL ≥200mL at the time of D&C differed significantly from those with EBL<200mL. This information can assist providers in planning the best setting for their patients' procedures.
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Affiliation(s)
- Hilary Novatt
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, USA
| | - Kari Rockhill
- Epidemiology and Public Health, Rocky Mountain Poison & Drug Safety, Denver, USA
| | - Kori Baker
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, USA
| | - Elaine Stickrath
- Obstetrics and Gynecology, UCHealth Women's Care Clinic, Steamboat Springs, USA
| | - Meredith Alston
- Obstetrics and Gynecology, Intermountain Health Saint Joseph Hospital, Denver, USA
| | - Stefka Fabbri
- Obstetrics and Gynaecology, Denver Health, Denver, USA
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Chung JPW, Chau OSY, Law TSM, Ng K, Ip PNP, Ng EYL, Tso TKY, Sahota DS, Li TC. Incidence of intrauterine adhesion after ultrasound-guided manual vacuum aspiration (USG-MVA) for first-trimester miscarriages: a prospective cohort study. Arch Gynecol Obstet 2024; 309:669-678. [PMID: 38030855 DOI: 10.1007/s00404-023-07280-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/22/2023] [Indexed: 12/01/2023]
Abstract
PURPOSE Ultrasound-guided manual vacuum aspiration (USG-MVA) is a feasible and effective outpatient treatment to treat early pregnancy loss. METHODS This was a prospective observational study at a university-affiliated hospital. All women undergoing either a USG-MVA or electric vacuum aspiration (EVA) were invited to return 3-6 months later for follow-up at which women completed a questionnaire to document their post-evacuation menstrual and reproductive history, and underwent a hysteroscopy if they were not pregnant. The severity of intrauterine adhesion (IUA), if present, was graded (Stage I-III) according to the American fertility society classification. RESULTS A total of 292 women had a hysteroscopy after their initial surgical evacuation, USG-MVA 169(57.9%) versus EVA 123(42.1%). Women undergoing EVA as opposed to a USG-MVA had a 12.9% higher incidence of IUA (24.1% vs. 37.0%, p = 0.042) equivalent to 1.84 times higher risk (95% CI 1.01-3.34; p = 0.048). Women having EVA continued to show an increased but not statistically significant trend towards an increased risk of IUA after adjusting for the type of miscarriage (aOR = 1.3; 95% CI 0.66-2.50; p = 0.46). CONCLUSION There were no significant differences in their reproductive outcomes and fewer women post-USG-MVA complained of hypomenorrhea. IUA may still occur in women undergoing USG-MVA but it is lower than the rate in women undergoing EVA. Clinical trials registry The trial was registered with the Centre for Clinical Research and Biostatistics - Clinical Trials Registry (CCRBCTR), a partner registry of the WHO Primary Registry-Chinese Clinical Trials Registry (ChiCTR) with a Unique Trial Number: CUHK_CCRB00541 on 22 Dec 2016.
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Affiliation(s)
- Jacqueline Pui Wah Chung
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Prince of Wales Hospital, 1/F, Block E, Special Block, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China.
| | - Olivia See Yung Chau
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Prince of Wales Hospital, 1/F, Block E, Special Block, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Tracy Sze Man Law
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Prince of Wales Hospital, 1/F, Block E, Special Block, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Karen Ng
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Prince of Wales Hospital, 1/F, Block E, Special Block, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Patricia Nga Ping Ip
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Prince of Wales Hospital, 1/F, Block E, Special Block, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Elaine Yee Lee Ng
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Prince of Wales Hospital, 1/F, Block E, Special Block, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Tracy Kwan Yi Tso
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Prince of Wales Hospital, 1/F, Block E, Special Block, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Daljit Singh Sahota
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Prince of Wales Hospital, 1/F, Block E, Special Block, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Tin Chiu Li
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Prince of Wales Hospital, 1/F, Block E, Special Block, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
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Acharya A, Prabhu A, Negi S, Sharma K, Dwivedi R, Athe R. Spontaneous miscarriage/abortion in the first trimester and expectant management - a meta-analysis approach. PRZEGLAD MENOPAUZALNY = MENOPAUSE REVIEW 2023; 22:135-141. [PMID: 37829272 PMCID: PMC10566328 DOI: 10.5114/pm.2023.131307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/09/2023] [Indexed: 10/14/2023]
Abstract
Introduction To determine effectiveness and side effects of expectant care in first-trimester miscarriage. An increase in the spontaneous miscarriage rate and its associated complications exerts a burden on the overall health and quality of life of women. Expectant care in a first-trimester miscarriage has shown success ranging 75-80%. This study was designed to search the literature for information on the clinical safety and effectiveness of expectant management on spontaneous miscarriage during the first trimester. Material and methods The review included studies that included women in expectant care for spontaneous miscarriage in the first trimester. Trial studies were recognized through a methodical and organized database search from PubMed, COCHRANE, MEDLINE, Embase, and bibliography from January 2000 until December 2022. The methodological assessment and risk of bias was assessed using the Joanna Briggs Institute criteria. Results Eleven studies in systematic review and 7 studies in the meta-analysis were included. The included studies showed a low to moderate risk of bias. The odds of success in expectant intervention were low when compared with surgical intervention (odds ratio - OR: OR: 0.37 [0.28, 0.48]) and medical management (OR: 0.47 [0.36, 0.61]), and the need for surgical evacuation was high (OR: 2.59 [1.88, 3.59]). Conclusions Future trials should consider women's opinions and the effect on quality of life along with clinical consequences, to provide improved suggestions on the efficiency and adverse effects.
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Affiliation(s)
- Anwesa Acharya
- Department of Computer Science and Engineering, CMR University, Bangalore, India
| | - Ananya Prabhu
- Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal, India
| | - Shivali Negi
- Centre for Public Health, Punjab University, Chandigarh, India
| | - Kavya Sharma
- Centre for Public Health, Punjab University, Chandigarh, India
| | - Rinshu Dwivedi
- Department of Science and Humanities, Indian Institute of Information Technology, Tiruchirappalli, India
| | - Ramesh Athe
- Department of Data Science and Intelligent Systems, Indian Institute of Information Technology, Dharwad, India
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Ouedraogo R, Obure V, Kimemia G, Achieng A, Kadzo M, Shirima J, Dama SU, Wanjiru S, Both J. "I will never wish this pain to even my worst enemy": Lived experiences of pain associated with manual vacuum aspiration during post-abortion care in Kenya. PLoS One 2023; 18:e0289689. [PMID: 37619217 PMCID: PMC10449468 DOI: 10.1371/journal.pone.0289689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 07/23/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In Kenya, where abortion is legally restricted, most abortions are induced using unsafe procedures, and lead to complications treated in public health facilities. The introduction of Manual Vacuum Aspiration (MVA) to treat incomplete abortion has improved the management of abortion complications. However, this technology comes with pain whose management has been a challenge. This paper explores the lived experiences of pain (management) during MVA to document the contributing factors. METHODS We used an ethnographic approach to explore girls and healthcare providers' experiences in offering and accessing post-abortion care in Kilifi County, Kenya. The data collection approach included participant observation and informal conversations in public health facilities and neighboring communities, as well as in-depth interviews with 21 girls and young women treated for abortion complication and 12 healthcare providers. RESULTS Our findings show that almost all patients described the MVA as the most painful procedure they have ever experienced. The unbearable pain was explained by various factors, including the lack of preparedness of health facilities to offer PAC services (i.e. lack of pain medicine, lack of training, inadequate knowledge and grasp of pain medication guidelines, and malfunctioning MVA kits). Moreover, the attitudes of healthcare providers and facilities management toward the MVA device limited the supply and replacement of MVA kits. Moreover, the scarcity of pain medicines also gave some providers the opportunity to abuse patients guided by their values, whereby they would deny patients pain medication as a form of "punishment" if they were suspected of inducing their abortion, especially adolescent girls. CONCLUSION The study findings suggest the need for clearer guidelines on pain medication, value clarification and attitude transformation training for providers, systematizing the use of medical uterine evacuation using medical abortion drug and strengthening the supply chain of pain medication and MVA kits to reduce the pain and improve the quality of post-abortion care.
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Affiliation(s)
| | - Valleria Obure
- African Population and Health Research Center, Nairobi, Kenya
| | - Grace Kimemia
- African Population and Health Research Center, Nairobi, Kenya
| | - Anne Achieng
- African Population and Health Research Center, Nairobi, Kenya
| | - Mercy Kadzo
- African Population and Health Research Center, Nairobi, Kenya
| | - Jane Shirima
- African Population and Health Research Center, Nairobi, Kenya
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Wang K, Zhuang LL, Shen HL, Su RD, Luo ZY, Wang WR. The efficacy and influence factors analysis of Mifepristone combined with estrogen-progesterone in the treatment of incomplete abortion. Medicine (Baltimore) 2023; 102:e33532. [PMID: 37026901 PMCID: PMC10082238 DOI: 10.1097/md.0000000000033532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/24/2023] [Indexed: 04/08/2023] Open
Abstract
To analyze the efficacy and influencing factors of Mifepristone combined with estrogen-progesterone sequential therapy (Femoston) in the treatment of incomplete abortion. This retrospective cohort study included 93 patients with incomplete abortion. All patients took 50 mg of Mifepristone 2 times a day for 5 days and then took Femoston once a day (starting with estradiol tablets/2 mg) for 28 days. Without any indication of intrauterine residue by ultrasonic examination was judged to be effective. According to statistical analysis, this study calculated the effective rate and analyzed its influencing factors. A 2-sided value of P < .05 was considered statistically significant. The total response rate of the treatment regimen was 86.67%. body mass index was a significant influencing factor for treatment outcome (OR 0.818, 95% confidence interval 0.668-0.991, P = .041). For patients with incomplete abortion, Mifepristone combined with estrogen-progesterone sequential therapy has a remarkable therapeutic effect. Patients with a lower body mass index may respond much more significantly to this treatment regimen.
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Affiliation(s)
- Kai Wang
- Department of Family Planning, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Ling-Ling Zhuang
- Department of Family Planning, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Hai-Lan Shen
- Department of Family Planning, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Rui-De Su
- Department of Family Planning, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Zhen-Yu Luo
- Department of Family Planning, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Wen-Rong Wang
- Department of Family Planning, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
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Cárdenas-Arias EF, Escudero-Cardona DE, Noreña-Mosquera EA. Safety of voluntary interruption of pregnancy (VIP) in two healthcare institutions in Medellín, Colombia, in 2019. Historical cohort. REVISTA COLOMBIANA DE OBSTETRICIA Y GINECOLOGIA 2022; 73:39-47. [PMID: 35503301 PMCID: PMC9084360 DOI: 10.18597/rcog.3760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 03/29/2022] [Indexed: 11/04/2022]
Abstract
Objectives: To characterize a cohort of women with voluntary interruption of pregnancy (VIP) and to describe intraoperative complications according to the technique used. Materials and Methods: Descriptive study in a historical cohort of women undergoing VIP in two healthcare institutions in Medellín, Colombia, in 2019. Women with pelvic infection and STIs were excluded. Consecutive sampling was used. Sociodemographic, sexual and reproductive health, clinical characteristics of the pregnancy, legal cause of the VIP, characteristics of the care process and complications of the VIP techniques up to post-procedural day 7 were the measured variables. A descriptive analysis was carried out. Results: Overall, 1,520 women were identified as eligible during the study period. Of them, 46 were intervened in other institutions, leaving 1,474 candidates to enter the study. Of them, 30 were excluded because of pelvic or sexually transmitted infections. Ultimately, 1,444 pregnant women were included in the analysis. Risk to the mother’s health was the most frequent legal cause in 94.3% of cases. Ninety-nine percent of women received pre-procedural counseling, and 78.4% agreed to use some form of contraception after VIP. Manual vacuum aspiration (MVA) was used in 95.6% of women and dilation and curettage (D&C) in 4.4%. Complications up to postoperative day 7 occurred in 17.56%, and there were no complications in the MVA group; 80% of women attended the follow-up visit on post-VIP day 7. Conclusions: MVA is a safe procedure which was not associated with complications within the first seven post-VIP days in the studied patients. Prospective studies to assess the safety and cost of the different VIP options are required.
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Ahmed SI, Ammerdorffer A, Moakes CA, Cheshire J, Gülmezoglu AM, Coomarasamy A, Lissauer D, Wilson A. Prophylactic antibiotics for uterine evacuation procedures to treat miscarriage. Hippokratia 2022. [DOI: 10.1002/14651858.cd014844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - Catherine A Moakes
- Institute of Applied Health Research; University of Birmingham; Birmingham UK
| | | | | | - Arri Coomarasamy
- Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women’s Health Research; University of Birmingham; Birmingham UK
| | - David Lissauer
- Malawi-Liverpool-Wellcome Trust Research Institute; Queen Elizabeth Central Hospital, College of Medicine; Blantyre Malawi
- Institute of Lifecourse and Medical Sciences; University of Liverpool; Liverpool UK
| | - Amie Wilson
- Institute of Applied Health Research; University of Birmingham; Birmingham UK
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Grégoire-Briard F, Horwood G, Berger P, Gomes M, Davis L, Black A. A Patient-Centred Approach to Early Pregnancy Loss: The First 18 Months of a Canadian Outpatient Program for Early Pregnancy Loss (OPEL). JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 44:503-507. [PMID: 34973436 DOI: 10.1016/j.jogc.2021.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Manual vacuum aspiration is a safe surgical option for the management of early pregnancy loss. To provide rapid, patient-centred access to MVA, an Outpatient Program for Early pregnancy Loss ("OPEL") was established at our institution. Objectives were to (1) assess complete uterine evacuation rates; (2) assess complication rates, and (3) assess patient satisfaction with the program. METHODS With REB approval, a retrospective study was performed. Patient records from the first 18 months of OPEL (November 2015 to April 2017) were reviewed. Anonymous patient satisfaction questionnaires were completed immediately post-procedure. RESULTS A total of 162 patients received treatment. Missed abortions accounted for 94 cases (58%). Median delay from referral to clinic appointment was 4.0 (interquartile range [IQR] 2.0-6.0) days. Average length of stay was 3.0 (IQR 2.5-3.0) hours. Efficacy of the procedure was 95.1%. Complication rate (immediate and delayed) was 14.2% and included intraoperative hemorrhage (3.1%; 5/162), Asherman's syndrome (1.9%; 3/162), retained products of conception requiring further treatment (4.9%; 8/162), and postoperative infection requiring antibiotic therapy (1.9%; 3/162). A total of 151 post-procedure satisfaction surveys were completed (93%); 100% agreed/strongly agreed that the nursing staff and physicians provided professional and compassionate care; 99.3% were satisfied with their care overall. Qualitative feedback was positive. CONCLUSION Pregnant patients experiencing early pregnancy loss benefit from safe, timely, accessible, patient-centred care in the outpatient OPEL program. Similar models should be adopted nationally to ensure women experiencing this common pregnancy complication receive safe and compassionate care.
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Affiliation(s)
| | | | - Pamela Berger
- University of Ottawa, Dept of Obstetrics and Gynecology, Ottawa, ON; Ottawa Hospital Research Institute, Ottawa, ON
| | - Megan Gomes
- University of Ottawa, Dept of Obstetrics and Gynecology, Ottawa, ON; Ottawa Hospital Research Institute, Ottawa, ON
| | | | - Amanda Black
- University of Ottawa, Dept of Obstetrics and Gynecology, Ottawa, ON; Ottawa Hospital Research Institute, Ottawa, ON
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Strelow M, Maissiat J, Savaris MS, da Silva DM, Savaris RF. Lower and extended dosage of misoprostol for cervical ripening in 1st trimester miscarriage (MISO200): A randomized clinical trial. Eur J Obstet Gynecol Reprod Biol 2021; 269:30-34. [PMID: 34959148 DOI: 10.1016/j.ejogrb.2021.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/08/2021] [Accepted: 12/11/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To compare the efficacy of priming the uterine cervix before Manual Vaccum Aspiration (MVA) using 200 µg or 400 µg of vaginal misoprostol, inserted a mean time of 6 h before MVA in first trimester miscarriage. STUDY DESIGN Randomized, triple-blind, non-inferiority clinical trial. Patients between 18 and 50 years old, with a diagnosis of miscarriage, were eligible for the study. Patients were allocated to receive either 200 μg or 400 µg of misoprostol before the MVA. The primary outcome was the need to dilate the uterine cervix with mechanical dilators (Hegar dilators). As a secondary outcome, cervical dilatation ≥8 mm before the procedure was considered successful. A difference of <25% was considered as non-inferior. RESULTS Between December 21, 2016 and October 6, 2019, 269 women were screened. After screening, 105 and 106 women received 200 µg and 400 µg of misoprostol, respectively. Mechanical cervical dilatation was not necessary in 84.8% (95%CI 77% to 90%) and 96.2% (95%CI 91% to 99%), in the 200 µg and 400 µg groups, respectively [difference = 11.5% (95%CI 3.7% to 19.2%). Cervical dilatation of ≥8 mm was 52.4% (95%CI 42.9% to 61.7%) in the 200 µg misoprostol group, while in the 400 µg group was 71.7% (95%CI 62.5% to 79.4%) [difference = 19.3% (95%CI 6.5 to 32.2). CONCLUSION After a mean time of 6 h, 200 µg of vaginal misoprostol is not inferior to 400 µg of misoprostol for cervical priming before MVA, in first trimester miscarriage. This non-inferiority was not observed when the ≥8 mm criterion was considered.
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Affiliation(s)
- Michele Strelow
- Graduate School in Health Sciences: Gynecology and Obstetrics, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Jackson Maissiat
- Department of Obstetrics and Gynecology, Universidade Federal do Rio Grande do Sul, School of Medicine, Porto Alegre, RS, Brazil
| | | | - Daniel M da Silva
- Emergency Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Ricardo F Savaris
- Department of Obstetrics and Gynecology, Universidade Federal do Rio Grande do Sul, School of Medicine, Porto Alegre, RS, Brazil.
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Musik T, Grimm J, Juhasz-Böss I, Bäz E. Treatment Options After a Diagnosis of Early Miscarriage: Expectant, Medical, and Surgical. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:789-794. [PMID: 34696822 DOI: 10.3238/arztebl.m2021.0346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 04/21/2021] [Accepted: 09/23/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Approximately 12% of pregnancies end in an early miscarriage (up to week 12 + 0 of pregnancy). Over the past 10 to 15 years, two alternatives to curettage have appeared in the pertinent international treatment guidelines: expectant treatment and medical (drug) treatment. In this review, we discuss the advantages and disadvantages of each of these therapeutic options. METHODS This review is based on pertinent publications (January 2000 to February 2021) retrieved by a selective search in PubMed, as well as on the guidelines of the American College of Obstetrics and Gynecologists, the Association of the Scientific Medical Societies in Germany, the National Institute for Health and Care Excellence/Royal College of Obstetricians and Gynaecologists, and the International Federation of Gynaecology and Obstetrics. RESULTS Three effective and safe treatment options are available after a diagnosis of early miscarriage. Expectant treatment yields success rates of 66-91%, depending on the type of miscarriage. Its complications include hemorrhage requiring blood transfusion in 1-2% of cases. If expectant therapy fails, subsequent treatment with misoprostol or curettage is indicated. Drug therapy with misoprostol yields a complete termination in 81-95% of cases and is thus a valid alternative to expectant therapy, with the advantage of better planning capability. The vaginal application of misoprostol is the most effective means of administration, with the fewest side effects. Curettage is needed in 5-20% of cases. Suctional curettage has a success rate of 97-98%, with an associated anesthesia-related risk of 0.2%, a 0.1% risk of perforation, and a 2-3% rate of repeat curettage. CONCLUSION If there is no acute indication for the surgical treatment of an early miscarriage, the patient can choose among three treatment options. Expectant and medical treatment can be provided on an outpatient basis. Curettage is the treatment of choice in the presence of infection, marked and persistent bleeding, hemodynamic instability, or a pre-existing coagulopathy.
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Ghosh J, Papadopoulou A, Devall AJ, Jeffery HC, Beeson LE, Do V, Price MJ, Tobias A, Tunçalp Ö, Lavelanet A, Gülmezoglu AM, Coomarasamy A, Gallos ID. Methods for managing miscarriage: a network meta-analysis. Cochrane Database Syst Rev 2021; 6:CD012602. [PMID: 34061352 PMCID: PMC8168449 DOI: 10.1002/14651858.cd012602.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime. An estimated 15% of pregnancies end in miscarriage. Miscarriage can lead to serious morbidity, including haemorrhage, infection, and even death, particularly in settings without adequate healthcare provision. Early miscarriages occur during the first 14 weeks of pregnancy, and can be managed expectantly, medically or surgically. However, there is uncertainty about the relative effectiveness and risks of each option. OBJECTIVES To estimate the relative effectiveness and safety profiles for the different management methods for early miscarriage, and to provide rankings of the available methods according to their effectiveness, safety, and side-effect profile using a network meta-analysis. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth's Trials Register (9 February 2021), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (12 February 2021), and reference lists of retrieved studies. SELECTION CRITERIA We included all randomised controlled trials assessing the effectiveness or safety of methods for miscarriage management. Early miscarriage was defined as less than or equal to 14 weeks of gestation, and included missed and incomplete miscarriage. Management of late miscarriages after 14 weeks of gestation (often referred to as intrauterine fetal deaths) was not eligible for inclusion in the review. Cluster- and quasi-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded non-randomised trials. DATA COLLECTION AND ANALYSIS At least three review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for the primary outcomes of complete miscarriage and composite outcome of death or serious complications. The certainty of evidence was assessed using GRADE. Relative effects for the primary outcomes are reported subgrouped by the type of miscarriage (incomplete and missed miscarriage). We also performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available methods. MAIN RESULTS Our network meta-analysis included 78 randomised trials involving 17,795 women from 37 countries. Most trials (71/78) were conducted in hospital settings and included women with missed or incomplete miscarriage. Across 158 trial arms, the following methods were used: 51 trial arms (33%) used misoprostol; 50 (32%) used suction aspiration; 26 (16%) used expectant management or placebo; 17 (11%) used dilatation and curettage; 11 (6%) used mifepristone plus misoprostol; and three (2%) used suction aspiration plus cervical preparation. Of these 78 studies, 71 (90%) contributed data in a usable form for meta-analysis. Complete miscarriage Based on the relative effects from the network meta-analysis of 59 trials (12,591 women), we found that five methods may be more effective than expectant management or placebo for achieving a complete miscarriage: · suction aspiration after cervical preparation (risk ratio (RR) 2.12, 95% confidence interval (CI) 1.41 to 3.20, low-certainty evidence), · dilatation and curettage (RR 1.49, 95% CI 1.26 to 1.75, low-certainty evidence), · suction aspiration (RR 1.44, 95% CI 1.29 to 1.62, low-certainty evidence), · mifepristone plus misoprostol (RR 1.42, 95% CI 1.22 to 1.66, moderate-certainty evidence), · misoprostol (RR 1.30, 95% CI 1.16 to 1.46, low-certainty evidence). The highest ranked surgical method was suction aspiration after cervical preparation. The highest ranked non-surgical treatment was mifepristone plus misoprostol. All surgical methods were ranked higher than medical methods, which in turn ranked above expectant management or placebo. Composite outcome of death and serious complications Based on the relative effects from the network meta-analysis of 35 trials (8161 women), we found that four methods with available data were compatible with a wide range of treatment effects compared with expectant management or placebo: · dilatation and curettage (RR 0.43, 95% CI 0.17 to 1.06, low-certainty evidence), · suction aspiration (RR 0.55, 95% CI 0.23 to 1.32, low-certainty evidence), · misoprostol (RR 0.50, 95% CI 0.22 to 1.15, low-certainty evidence), · mifepristone plus misoprostol (RR 0.76, 95% CI 0.31 to 1.84, low-certainty evidence). Importantly, no deaths were reported in these studies, thus this composite outcome was entirely composed of serious complications, including blood transfusions, uterine perforations, hysterectomies, and intensive care unit admissions. Expectant management and placebo ranked the lowest when compared with alternative treatment interventions. Subgroup analyses by type of miscarriage (missed or incomplete) agreed with the overall analysis in that surgical methods were the most effective treatment, followed by medical methods and then expectant management or placebo, but there are possible subgroup differences in the effectiveness of the available methods. AUTHORS' CONCLUSIONS: Based on relative effects from the network meta-analysis, all surgical and medical methods for managing a miscarriage may be more effective than expectant management or placebo. Surgical methods were ranked highest for managing a miscarriage, followed by medical methods, which in turn ranked above expectant management or placebo. Expectant management or placebo had the highest chance of serious complications, including the need for unplanned or emergency surgery. A subgroup analysis showed that surgical and medical methods may be more beneficial in women with missed miscarriage compared to women with incomplete miscarriage. Since type of miscarriage (missed and incomplete) appears to be a source of inconsistency and heterogeneity within these data, we acknowledge that the main network meta-analysis may be unreliable. However, we plan to explore this further in future updates and consider the primary analysis as separate networks for missed and incomplete miscarriage.
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Affiliation(s)
- Jay Ghosh
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Argyro Papadopoulou
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Adam J Devall
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Hannah C Jeffery
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Leanne E Beeson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Vivian Do
- University of Birmingham, Birmingham, UK
| | - Malcolm J Price
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Aurelio Tobias
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Antonella Lavelanet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
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13
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Barat S, Yazdani S, Faramarzi M, Khafri S, Darvish M, Rad MN, Asnafi N. The Effect of Brief Supportive Psychotherapy on Prevention of Psychiatric Morbidity in Women with Miscarriage: A Randomized Controlled Trial about the First 24-hours of Hospitalization. Oman Med J 2020; 35:e130. [PMID: 32550017 PMCID: PMC7294535 DOI: 10.5001/omj.2020.48] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 08/20/2019] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES Miscarriage is a common pregnancy complication causing substantial psychiatric complications. This study was designed to investigate whether the administration of brief supportive psychotherapy (BSP) is effective on the management of women with miscarriage when conducted in the first 24 hours of hospitalization in order to prevent symptoms of anxiety, depression, and grief at four-months post-miscarriage. METHODS We conducted a randomized clinical trial on 79 women with miscarriage hospitalized in Ayatollah Rohani teaching hospital. The women were randomly assigned into two groups (39 in the experimental group and 40 in the control group). All interventions were implemented for two study groups during the first 24 hours of hospitalization in a private room in the hospital. The experimental group received a two-hour BSP. The objective outcomes were assessed using Hospital Anxiety and Depression Scale and Perinatal Grief Scale (PGS), which has three subscales (active grief, difficulty coping, and despair) and were measured before the intervention and at four-months post-miscarriage. RESULTS The results of pre-tests in the follow-up of the trial suggested that the participants who received BSP reported significant reductions in the mean scores of active grief (-34.2±9.7 vs. 28.1±-6.9), difficulty coping (27.1±6.4 vs. 23.3±4.3), despair (28.0±8.4 vs. 22.8±5.2), and total PGS (89.6±23.1 vs. 74.4±15.3), in contrast to participants in the control group who did not report such results. Further, the results of generalized estimating equations models revealed that brief supportive psychotherapy caused a significant decrease in the level of factors including active grief, difficulty coping, despair, total perinatal grief, anxiety symptoms, and depressive symptoms in subjects in the experimental group compared to those in the control group after miscarriage. Also, the frequency of anxiety symptoms (13.5% vs. 60.5%), depressive symptoms (32.4% vs. 71.1%), and grief symptoms (10.8% vs. 65.8%) was found to be significantly lower in the group receiving psychotherapy than in the control group at four-months follow-up. CONCLUSIONS Administration of BSP session during the first 24 hours of hospitalization for women with miscarriage can be considered a reliable method to prevent anxiety symptoms, depression symptoms, and perinatal grief at four-months follow-up.
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Affiliation(s)
- Shahnaz Barat
- Department of Obstetrics and Gynecology, Cancer Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
- Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
- Department of Biostatistics and Epidemiology, Infertility and Reproductive Health Research Center, Health Research Institute, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran
- Clinical Research Development Unit of Rohani Hospital, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Shahla Yazdani
- Department of Obstetrics and Gynecology, Cancer Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Mahbobeh Faramarzi
- Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Soraya Khafri
- Department of Biostatistics and Epidemiology, Infertility and Reproductive Health Research Center, Health Research Institute, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Maryam Darvish
- Clinical Research Development Unit of Rohani Hospital, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Mojgan Naeimi Rad
- Clinical Research Development Unit of Rohani Hospital, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Nesa Asnafi
- Department of Obstetrics and Gynecology, Cancer Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
- Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
- Department of Biostatistics and Epidemiology, Infertility and Reproductive Health Research Center, Health Research Institute, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran
- Clinical Research Development Unit of Rohani Hospital, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
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14
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Abstract
Early pregnancy loss is the most common complication in pregnancy. Management options for miscarriage include expectant management, medical intervention, or surgical aspiration. Non-surgical and surgical management are all safe and acceptable options for medically uncomplicated patients. Patient and provider preferences contribute profoundly to clinical decisions about miscarriage management. Shared-decision making and evidence based counseling have been shown to significantly improve patient satisfaction with early pregnancy loss care. This review article will discuss the epidemiology and risk factors of early pregnancy loss, current evidence and clinical practice guidelines around management options, and provider and patient preferences for early pregnancy loss management.
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Affiliation(s)
- Jade M Shorter
- Department of Obstetrics and Gynecology, University of Pennsylvania, 3400 Spruce Street, 1000 Courtyard, Philadelphia, PA 19104, USA
| | - Jessica M Atrio
- Department of Obstetrics and Gynecology, Montefiore Hospital & Albert Einstein College of Medicine, 1695 Eastchester Road Bronx, NY 10461, USA.
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, University of Pennsylvania, 3400 Spruce Street, 1000 Courtyard, Philadelphia, PA 19104, USA
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15
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Odland ML, Membe-Gadama G, Kafulafula U, Odland JØ, Darj E. "Confidence comes with frequent practice": health professionals' perceptions of using manual vacuum aspiration after a training program. Reprod Health 2019; 16:20. [PMID: 30782201 PMCID: PMC6381708 DOI: 10.1186/s12978-019-0683-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 02/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malawi has one of the highest maternal mortality rates in the world, with unsafe abortion as a major contributor. Curettage is most frequently used as the surgical method for treating incomplete abortions, even though it is costly for an impoverished health system and the less expensive and safe manual vacuum aspiration (MVA) method is recommended. METHODS The aim of this 2016-17 study is to explore health worker's perception of doing MVA 1 year after an educational intervention. Focus group discussions were recorded, transcribed verbatim, and analyzed using content analysis for interpreting the findings. A knowledge, attitude and practice survey was administered to health professionals to obtain background information before the MVA training program was introduced. RESULTS Prior to the training sessions, the participants demonstrated knowledge on abortion practices and had positive attitudes about participating in the service, but preferred curettage over MVA. The training was well received, and participants felt more confident in doing MVA after the intervention. However, focus group discussions revealed obstacles to perform MVA such as broken equipment and lack of support. Additionally, the training could have been more comprehensive. Still, the participants appreciated task-sharing and team work. CONCLUSION Training sessions are considered useful in increasing the use of MVA. This study provides important insight on how to proceed in improving post-abortion care in a country where complications of unsafe abortion are common and the health system is low on resources.
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Affiliation(s)
- Maria Lisa Odland
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.
| | | | | | - Jon Øyvind Odland
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,College of Medicine, University of Malawi, Blantyre, Malawi.,University of Pretoria, Pretoria, South Africa
| | - Elisabeth Darj
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Obstetrics and Gynecology, St Olav's Hospital, Trondheim, Norway.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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16
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Sully EA, Madziyire MG, Riley T, Moore AM, Crowell M, Nyandoro MT, Madzima B, Chipato T. Abortion in Zimbabwe: A national study of the incidence of induced abortion, unintended pregnancy and post-abortion care in 2016. PLoS One 2018; 13:e0205239. [PMID: 30356264 PMCID: PMC6200425 DOI: 10.1371/journal.pone.0205239] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 09/21/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Zimbabwe has the highest contraceptive prevalence rate in sub-Saharan Africa, but also one of the highest maternal mortality ratios in the world. Little is known, however, about the incidence of abortion and post-abortion care (PAC) in Zimbabwe. Access to legal abortion is rare, and limited to circumstances of rape, incest, fetal impairment, or to save the woman's life. OBJECTIVES This paper estimates a) the national provision of PAC, b) the first-ever national incidence of induced abortion in Zimbabwe, and c) the proportion of pregnancies that are unintended. METHODS We use the Abortion Incidence Complications Method (AICM), which indirectly estimates the incidence of induced abortion by obtaining a national estimate of PAC cases, and then estimates what proportion of all induced abortions in the country would result in women receiving PAC. Three national surveys were conducted in 2016: a census of health facilities with PAC capacity (n = 227), a prospective survey of women seeking abortion-related care in a nationally-representative sample of those facilities (n = 127 facilities), and a purposive sample of experts knowledgeable about abortion in Zimbabwe (n = 118). The estimate of induced abortion, along with census and Demographic Health Survey data was used to estimate unintended pregnancy. RESULTS There were an estimated 25,245 PAC patients treated in Zimbabwe in 2016, but there were critical gaps in their care, including stock-outs of essential PAC medicines at half of facilities. Approximately 66,847 induced abortions (uncertainty interval (UI): 54,000-86,171) occurred in Zimbabwe in 2016, which translates to a national rate of 17.8 (UI: 14.4-22.9) abortions per 1,000 women 15-49. Overall, 40% of pregnancies were unintended in 2016, and one-quarter of all unintended pregnancies ended in abortion. CONCLUSION Zimbabwe has one of the lowest abortion rates in sub-Saharan Africa, likely due to high rates of contraceptive use. There are gaps in the health care system affecting the provision of quality PAC, potentially due to the prolonged economic crisis. These findings can inform and improve policies and programs addressing unsafe abortion and PAC in Zimbabwe.
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Affiliation(s)
| | - Mugove Gerald Madziyire
- University of Zimbabwe College of Health Science–Clinical Trials Unit (UZCHS-CTU), Harare, Zimbabwe
| | - Taylor Riley
- Guttmacher Institute, New York, New York, United States of America
| | - Ann M. Moore
- Guttmacher Institute, New York, New York, United States of America
| | - Marjorie Crowell
- Guttmacher Institute, New York, New York, United States of America
| | | | - Bernard Madzima
- Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe
| | - Tsungai Chipato
- University of Zimbabwe College of Health Science–Clinical Trials Unit (UZCHS-CTU), Harare, Zimbabwe
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17
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Odland ML, Membe-Gadama G, Kafulafula U, Jacobsen GW, Odland JØ, Darj E. Effects of refresher training on the use of manual vacuum aspiration in the treatment of incomplete abortions: a quasi-experimental study in Malawi. BMJ Glob Health 2018; 3:e000823. [PMID: 30271625 PMCID: PMC6157514 DOI: 10.1136/bmjgh-2018-000823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/29/2018] [Accepted: 07/02/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction The maternal mortality ratio is decreasing globally, although it remains high in Malawi. Unsafe abortion is a major cause and treatment of complications after abortion is a big burden on the health system. Even though manual vacuum aspiration (MVA) is the recommended surgical treatment of incomplete abortions in the first trimester, many hospitals in Malawi continue to use sharp curettage. It is known to have more complications and is more expensive in the long run. The purpose of this study was to determine the effectiveness of a structured MVA training programme in the treatment of incomplete abortions in Malawi. Methods A quasi-experimental before-and-after study design was employed in an MVA training programme for health personnel at three hospitals in Southern Malawi. A total of 53 health personnel at the Queen Elizabeth Central Hospital and the district hospitals of Chikwawa and Chiradzulu (intervention hospitals) were trained in the use of MVA. Kamuzu Central Hospital in Lilongwe and the Thyolo District Hospital served as control institutions. Medical files for all women treated for an incomplete abortion at the study hospitals were reviewed before and after the intervention. Information on demographic and obstetric data and the type of treatment was collected. Results There was a significant increase in the use of MVA from 7.8% (95% CI 5.8 to 10.3) to 29.1% (95% CI 25.9 to 32.5) 1 year after the intervention. In comparison, we found a mere 3% increase in the control hospitals. Conclusions By providing a refresher training programme to health personnel who treat women with incomplete abortions, it was possible to increase the use of MVA as recommended in the Malawi national guidelines.
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Affiliation(s)
- Maria Lisa Odland
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Ursula Kafulafula
- Kamuzu College of Nursing, University of Malawi, Blantyre, Southern Region, Malawi
| | - Geir Wenberg Jacobsen
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jon Øyvind Odland
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Elisabeth Darj
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
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18
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Lissauer D, Wilson A, Daniels J, Middleton L, Bishop J, Hewitt C, Merriel A, Weeks A, Mhango C, Mataya R, Taulo F, Ngalawesa T, Chirwa A, Mphasa C, Tambala T, Chiudzu G, Mwalwanda C, Mboma A, Qureshi R, Ahmed I, Ismail H, Gulmezoglu M, Oladapo OT, Mbaruku G, Chibwana J, Watts G, Simon B, Ditai J, Tom CO, Acam JF, Ekunait J, Uniza H, Iyaku M, Anyango M, Zamora J, Roberts T, Goranitis I, Desmond N, Coomarasamy A. Prophylactic antibiotics to reduce pelvic infection in women having miscarriage surgery - The AIMS (Antibiotics in Miscarriage Surgery) trial: study protocol for a randomized controlled trial. Trials 2018; 19:245. [PMID: 29685179 PMCID: PMC5914072 DOI: 10.1186/s13063-018-2598-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 03/16/2018] [Indexed: 11/30/2022] Open
Abstract
Background The estimated annual global burden of miscarriage is 33 million out of 210 million pregnancies. Many women undergoing miscarriage have surgery to remove pregnancy tissues, resulting in miscarriage surgery being one of the most common operations performed in hospitals in low-income countries. Infection is a serious consequence and can result in serious illness and death. In low-income settings, the infection rate following miscarriage surgery has been reported to be high. Good quality evidence on the use of prophylactic antibiotics for surgical miscarriage management is not available. Given that miscarriage surgery is common, and infective complications are frequent and serious, prophylactic antibiotics may offer a simple and affordable intervention to improve outcomes. Methods Eligible patients will be approached once the diagnosis of miscarriage has been made according to local practice. Once informed consent has been given, participants will be randomly allocated using a secure internet facility (1:1 ratio) to a single dose of oral doxycycline (400 mg) and metronidazole (400 mg) or placebo. Allocation will be concealed to both the patient and the healthcare providers. A total of 3400 women will be randomised, 1700 in each arm. The medication will be given approximately 2 hours before surgery, which will be provided according to local practice. The primary outcome is pelvic infection 2 weeks after surgery. Women will be invited to the hospital for a clinical assessment at 2 weeks. Secondary outcomes include overall antibiotic use, individual components of the primary outcome, death, hospital admission, unplanned consultations, blood transfusion, vomiting, diarrhoea, adverse events, anaphylaxis and allergy, duration of clinical symptoms, and days before return to usual activities. An economic evaluation will be performed to determine if prophylactic antibiotics are cost-effective. Discussion This trial will assess whether a single dose of doxycycline (400 mg) and metronidazole (400 mg) taken orally 2 hours before miscarriage surgery can reduce the incidence of pelvic infection in women up to 2 weeks after miscarriage surgery. Trial registration Registered with the ISRCTN (international standard randomised controlled trial number) registry: ISRCTN 97143849. (Registered on April 17, 2013). Electronic supplementary material The online version of this article (10.1186/s13063-018-2598-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Lissauer
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Amie Wilson
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Jane Daniels
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Lee Middleton
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Jon Bishop
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Catherine Hewitt
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Abi Merriel
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PS, UK
| | - Andrew Weeks
- Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3BX, UK
| | - Chisale Mhango
- Department of Obstetrics and Gynaecology, College of Medicine, Blantyre, Malawi
| | - Ronald Mataya
- Department of Obstetrics and Gynaecology, College of Medicine, Blantyre, Malawi
| | - Frank Taulo
- Department of Obstetrics and Gynaecology, College of Medicine, Blantyre, Malawi
| | - Theresa Ngalawesa
- Department of Obstetrics and Gynaecology, College of Medicine, Blantyre, Malawi
| | - Agatha Chirwa
- Department of Obstetrics and Gynaecology, College of Medicine, Blantyre, Malawi
| | - Colleta Mphasa
- Department of Obstetrics and Gynaecology, College of Medicine, Blantyre, Malawi
| | - Tayamika Tambala
- Department of Obstetrics and Gynaecology, College of Medicine, Blantyre, Malawi
| | | | | | | | - Rahat Qureshi
- The Aga Khan University Hospital and Medical College Foundation, Karachi, Pakistan
| | - Iffat Ahmed
- The Aga Khan University Hospital and Medical College Foundation, Karachi, Pakistan
| | - Humera Ismail
- The Aga Khan University Hospital and Medical College Foundation, Karachi, Pakistan
| | - Metin Gulmezoglu
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | | | - Grace Watts
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Beatus Simon
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - James Ditai
- Sanyu Africa Research Institute (SAfRI), Mbale, Uganda
| | | | | | - John Ekunait
- Soroti Regional Referral Hospital, Soroti, Uganda
| | - Helen Uniza
- Soroti Regional Referral Hospital, Soroti, Uganda
| | | | | | - Javier Zamora
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal, CIBER en Epidemiología y Salud Pública (CIBERESP) and Instituto de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Tracy Roberts
- Health Economics Unit, University of Birmingham, Birmingham, B15 2TT, UK
| | - Ilias Goranitis
- Health Economics Unit, University of Birmingham, Birmingham, B15 2TT, UK
| | - Nicola Desmond
- Malawi Liverpool Wellcome Trust, Chichiri, Blantyre, Malawi
| | - Arri Coomarasamy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
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19
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Effectiveness and safety of sublingual misoprostol in medical treatment of the 1st trimester miscarriage: experience of off-label use in Korea. Obstet Gynecol Sci 2018; 61:220-226. [PMID: 29564312 PMCID: PMC5854901 DOI: 10.5468/ogs.2018.61.2.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/27/2017] [Accepted: 09/29/2017] [Indexed: 11/26/2022] Open
Abstract
Objective This study was conducted to determine the effectiveness and safety of medical treatment with sublingual misoprostol (MS) in the 1st trimester miscarriage under the approval by Health Insurance Review and Assessment Service (HIRA) for off-label usage by the single medical center in Korea. Methods A retrospective cohort study was performed in one institution between April 2013 and June 2016. Ninety-one patients diagnosed with miscarriage before 14 weeks of gestation and wanted to try medical treatment were included. A detailed ultrasound scan was performed to confirm the diagnosis. Patients took 600 microgram (mcg) of MS sublingually at initial dose, and repeated the same dose 4–6 hours apart. Successful medical abortion was defined as spontaneous expulsion of gestational products (including gestational sac, embryo, fetus, and placenta). If gestational products were not expelled, surgical evacuation was performed at least 24 hours later from the initial dose. Information about side effects was obtained by medical records. Results About two-thirds of patients had a successful outcome. The median interval time from pill to expulsion was 18 hours in the successful medical treatment group. There was no serious systemic side effect or massive vaginal bleeding. Presence or absence of vaginal spotting before diagnosis of miscarriage, uterine leiomyomas, subchorionic hematoma, or distorted shape of gestational sac on ultrasound scan were not statistically different between the two groups. Conclusion Medical treatment with sublingual MS can be a proper option for the 1st trimester miscarriage, especially for the patient who want to avoid surgical procedure. We can reduce the unnecessary sedation or surgical intervention in the patients with the 1st trimester miscarriage.
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The Use of Manual Vacuum Aspiration in the Treatment of Incomplete Abortions: A Descriptive Study from Three Public Hospitals in Malawi. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15020370. [PMID: 29466308 PMCID: PMC5858439 DOI: 10.3390/ijerph15020370] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 02/14/2018] [Accepted: 02/19/2018] [Indexed: 11/17/2022]
Abstract
Malawi has a high maternal mortality rate, of which unsafe abortion is a major cause. About 140,000 induced abortions are estimated every year, despite there being a restrictive abortion law in place. This leads to complications, such as incomplete abortions, which need to be treated to avoid further harm. Although manual vacuum aspiration (MVA) is a safe and cheap method of evacuating the uterus, the most commonly used method in Malawi is curettage. Medical treatment is used sparingly in the country, and the Ministry of Health has been trying to increase the use of MVA. The aim of this study was to investigate the treatment of incomplete abortions in three public hospitals in Southern Malawi during a three-year period. All medical files from the female/gynecological wards from 2013 to 2015 were reviewed. In total, information on obstetric history, demographics, and treatment were collected from 7270 women who had been treated for incomplete abortions. The overall use of MVA at the three hospitals during the study period was 11.4% (95% CI, 10.7-12.1). However, there was a major increase in MVA application at one District Hospital. Why there was only one successful hospital in this study is unclear, but may be due to more training and dedicated leadership at this particular hospital. Either way, the use of MVA in the treatment of incomplete abortions continues to be low in Malawi, despite recommendations from the World Health Organization (WHO) and the Malawi Ministry of Health.
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Madziyire MG, Polis CB, Riley T, Sully EA, Owolabi O, Chipato T. Severity and management of postabortion complications among women in Zimbabwe, 2016: a cross-sectional study. BMJ Open 2018; 8:e019658. [PMID: 29440163 PMCID: PMC5829940 DOI: 10.1136/bmjopen-2017-019658] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Abortion complications cause significant morbidity and mortality. We aimed to assess the severity and factors associated with abortion complications (induced or spontaneous), and the management of postabortion care (PAC) in Zimbabwe. DESIGN Prospective, facility-based 28 day survey among women seeking PAC and their providers. SETTING 127 facilities in Zimbabwe with the capacity to provide PAC, including all central and provincial hospitals, and a sample of primary health centres (30%), district/general/mission hospitals (52%), private (77%) and non-governmental organisation (NGO) (68%) facilities. PARTICIPANTS 1002 women presenting with abortion complications during the study period. MAIN OUTCOME MEASURES Severity of abortion complications and associated factors, delays in care seeking, and clinical management of complications. RESULTS Overall, 59% of women had complications classified as mild, 19% as moderate, 19% as severe, 3% as near miss and 0.2% died. A median of 47 hours elapsed between experiencing complication and receiving treatment; many delays were due to a lack of finances. Women who were rural, younger, not in union, less educated, at later gestational ages or who had more children were significantly more likely to have higher severity complications. Most women were treated by doctors (91%). The main management procedure used was dilatation and curettage/dilatation and evacuation (75%), while 12% had manual vacuum aspiration (MVA) or electrical vacuum aspiration and 11% were managed with misoprostol. At discharge, providers reported that 43% of women received modern contraception. CONCLUSION Zimbabwean women experience considerable abortion-related morbidity, particularly young, rural or less educated women. Abortion-related morbidity and concomitant mortality could be reduced in Zimbabwe by liberalising the abortion law, providing PAC in primary health centres, and training nurses to use medical evacuation with misoprostol and MVA. Regular in-service training on PAC guidelines with follow-up audits are needed to ensure compliance and availability of equipment, supplies and trained staff.
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Affiliation(s)
- Mugove Gerald Madziyire
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | | | | | | | - Tsungai Chipato
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
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Gallos ID, Williams HM, Price MJ, Eapen A, Eyo MM, Tobias A, Deeks JJ, Tunçalp Ö, Gülmezoglu AM, Coomarasamy A. Methods for managing miscarriage: a network meta-analysis. Hippokratia 2017. [DOI: 10.1002/14651858.cd012602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Ioannis D Gallos
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Helen M Williams
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Malcolm J Price
- University of Birmingham; School of Health and Population Sciences; Birmingham UK B15 2TG
| | - Abey Eapen
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Mary M Eyo
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Aurelio Tobias
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Jonathan J Deeks
- University of Birmingham; Institute of Applied Health Research; Edgbaston Birmingham UK B15 2TT
| | - Özge Tunçalp
- World Health Organization; UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research; 20 Avenue Appia Geneva Switzerland 1211
| | - A Metin Gülmezoglu
- World Health Organization; UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research; 20 Avenue Appia Geneva Switzerland 1211
| | - Arri Coomarasamy
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
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Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe, and acceptable. OBJECTIVES To assess the effectiveness, safety, and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (13 May 2016) and reference lists of retrieved papers. SELECTION CRITERIA We included randomised controlled trials comparing medical treatment with expectant care or surgery, or alternative methods of medical treatment. We excluded quasi-randomised trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias, and carried out data extraction. Data entry was checked. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included 24 studies (5577 women). There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; 2 studies, 150 women, random-effects; very low-quality evidence), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. For unplanned surgical intervention, we did not identify any difference between misoprostol and expectant care (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence).Sixteen trials involving 4044 women addressed the comparison of misoprostol (7 studies used oral administration, 6 studies used vaginal, 2 studies sublingual, 1 study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.96, 95% CI 0.94 to 0.98; 15 studies, 3862 women, random-effects; very low-quality evidence) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.05, 95% CI 0.02 to 0.11; 13 studies, 3070 women, random-effects; very low-quality evidence) but more unplanned procedures (average RR 5.03, 95% CI 2.71 to 9.35; 11 studies, 2690 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.50, 95% CI 1.53 to 4.09; 11 studies, 3015 women, random-effects; low-quality evidence). We did not identify any difference in women's satisfaction between misoprostol and surgery (average RR 1.00, 95% CI 0.99 to 1.00; 9 studies, 3349 women, random-effects; moderate-quality evidence). More women had vomiting and diarrhoea with misoprostol compared with surgery (vomiting: average RR 1.97, 95% CI 1.36 to 2.85; 10 studies, 2977 women, random-effects; moderate-quality evidence; diarrhoea: average RR 4.82, 95% CI 1.09 to 21.32; 4 studies, 757 women, random-effects; moderate-quality evidence).Five trials compared different routes of administration, or doses, or both, of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Further studies, including long-term follow-up, are clearly needed to confirm these findings. There is an urgent need for studies on women who miscarry at more than 13 weeks' gestation.
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Affiliation(s)
- Caron Kim
- WHODepartment of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | | | | | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
| | - Juan C Vazquez
- Instituto Nacional de Endocrinologia (INEN)Departamento de Salud ReproductivaZapata y DVedadoHabanaCuba10 400
| | - Lixia Dou
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Bonfill X, Roqué M, Aller MB, Osorio D, Foradada C, Vives À, Rigau D. Development of quality of care indicators from systematic reviews: the case of hospital delivery. Implement Sci 2013; 8:42. [PMID: 23574918 PMCID: PMC3626798 DOI: 10.1186/1748-5908-8-42] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 04/01/2013] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The objective of this research is to generate quality of care indicators from systematic reviews to assess the appropriateness of obstetric care in hospitals. METHODS A search for systematic reviews about hospital obstetric interventions, conducted in The Cochrane Library, clinical evidence and practice guidelines, identified 303 reviews. We selected 48 high-quality evidence reviews, which resulted in strong clinical recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The 255 remaining reviews were excluded, mainly due to a lack of strong evidence provided by the studies reviewed. RESULTS A total of 18 indicators were formulated from these clinical recommendations, on antepartum care (8), care during delivery and postpartum (9), and incomplete miscarriage (1). Authors of the systematic reviews and specialists in obstetrics were consulted to refine the formulation of indicators. CONCLUSIONS High-quality systematic reviews, whose conclusions clearly claim in favour or against an intervention, can be a source for generating quality indicators of delivery care. To make indicators coherent, the nuances of clinical practice should be considered. Any attempt made to evaluate the extent to which delivery care in hospitals is based on scientific evidence should take the generated indicators into account.
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Affiliation(s)
- Xavier Bonfill
- Service of Clinical Epidemiology, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), c/Sant Quintí 89, Barcelona, 08026, Spain
- Iberoamerican Cochrane Centre, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
- Department of Paediatrics, Obstetrics and Gynaecology and Preventive Medicine., Universitat Autònoma de Barcelona, Bellaterra, Spain
- CIBERESP (CIBER de Epidemiología y Salud Pública), Barcelona, Spain
| | - Marta Roqué
- Iberoamerican Cochrane Centre, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
- CIBERESP (CIBER de Epidemiología y Salud Pública), Barcelona, Spain
| | - Marta Beatriz Aller
- Research Unit. Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
| | - Dimelza Osorio
- Service of Clinical Epidemiology, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), c/Sant Quintí 89, Barcelona, 08026, Spain
| | - Carles Foradada
- Department of Paediatrics, Obstetrics and Gynaecology and Preventive Medicine., Universitat Autònoma de Barcelona, Bellaterra, Spain
- Department of Gynaecology and Obstetrics, Corporació Sanitària Parc Taulí, Sabadell, Spain
| | - Àngels Vives
- Department of Gynaecology and Obstetrics, Consorci Sanitari de Terrassa, Terrassa, Spain
| | - David Rigau
- Service of Clinical Epidemiology, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), c/Sant Quintí 89, Barcelona, 08026, Spain
- Iberoamerican Cochrane Centre, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
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Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable. OBJECTIVES To assess the effectiveness, safety and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2012) and reference lists of retrieved papers. SELECTION CRITERIA Randomised controlled trials comparing medical treatment with expectant care or surgery or alternative methods of medical treatment. Quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. MAIN RESULTS Twenty studies (4208 women) were included. There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no statistically significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women, random-effects), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women, random-effects). There were few data on 'deaths or serious complications'.Twelve studies involving 2894 women addressed the comparison of misoprostol (six studies used oral administration, four studies used vaginal, one study sub-lingual, one study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.97, 95% CI 0.95 to 0.99, 11 studies, 2493 women, random-effects) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.06, 95% CI 0.02 to 0.13; 11 studies, 2654 women, random-effects) but more unplanned procedures (average RR 5.82, 95% CI 2.93 to 11.56; nine studies, 2274 women, random-effects). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.41, 95% CI 1.44 to 4.03; nine studies, 2179 women, random-effects).Five trials compared different routes of administration and/or doses of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice. Future studies should include long-term follow-up.
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Affiliation(s)
- James P Neilson
- Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK.
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Bickhaus J, Perry E, Schust DJ. Re-examining Sonographic Cut-off Values for Diagnosing Early Pregnancy Loss. GYNECOLOGY & OBSTETRICS (SUNNYVALE, CALIF.) 2013; 3:141. [PMID: 25045591 DOI: 10.4172/2161-0932.1000141] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jennifer Bickhaus
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri, USA
| | - Erin Perry
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri, USA
| | - Danny J Schust
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri, USA
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Kittiwatanakul W, Weerakiet S. Comparison of efficacy of modified electric vacuum aspiration with sharp curettage for the treatment of incomplete abortion: randomized controlled trial. J Obstet Gynaecol Res 2012; 38:681-5. [PMID: 22380491 DOI: 10.1111/j.1447-0756.2011.01762.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM The aim of this study was to compare the efficacy of modified electric vacuum aspiration (mEVA) and sharp curettage (SC) for treatment of incomplete abortion. MATERIAL AND METHODS A randomized controlled trial was conducted between 1 March 2005 and 15 December 2009. Ninety-four women with incomplete abortion were randomly allocated into two groups, group A (n = 47) underwent mEVA and group B (n=47) underwent SC. The procedures were performed using the paracervical block with 20 mL of lidocaine. Successful management and complication were assessed. Successful management was defined as complete uterine evacuation with no need for the second surgical procedure. RESULTS There were differences in women characteristics between groups. The successful rate of management was 100% for both groups. However, the operative time and estimated blood loss were less in the mEVA group than in the SC group. Severe pain was significantly less prevalent in group A than group B. Suspected endometritis was found in two (4.3%) patients in each group. CONCLUSIONS The efficacy of mEVA was the same as that of SC in successful management of incomplete abortion, but pain was experienced more often in the SC group.
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Affiliation(s)
- Wichai Kittiwatanakul
- Department of Obstetrics and Gynecology, Dumnernsaduak Hospital, Ratchaburi Province, Thailand
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Fullerton JT, Thompson JB, Severino R. The International Confederation of Midwives essential competencies for basic midwifery practice. an update study: 2009-2010. Midwifery 2011; 27:399-408. [PMID: 21601321 DOI: 10.1016/j.midw.2011.03.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 03/16/2011] [Accepted: 03/21/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE a 2-year study was conducted to update the core competencies for basic midwifery practice, first delineated by the International Confederation of Midwives in 2002. A competency domain related to abortion-related care services was newly developed. DESIGN a modified Delphi survey process was conducted in two phases: a pilot item affirmation study, and a global field survey. SETTING a global survey conducted in 90 countries. PARTICIPANTS midwifery educators or clinicians associated with midwifery education schools and programmes located in any of the ICM member association countries. Additional participants represented the fields of nursing, medicine, and midwifery regulatory authorities. A total of 232 individuals from 63 member association and five non-member countries responded to one or both of the surveys. The achieved sample represented 42% of member association countries, which was less than the 51% target. However, the sample was proportionally representative of ICM's nine global regions. MEASUREMENTS survey respondents expressed an opinion whether to retain or to delete any of 255 statements of midwifery knowledge, skill, or professional behaviour. They also indicated whether the item should be a basic (core) item of midwifery knowledge or skill that would be included as mandatory content in a programme of midwifery pre-service education, or whether the item could be added to the fund of knowledge or acquired as an additional skill by those who would need or wish to include the item within the scope of their clinical practice. FINDINGS a majority consensus of .85 was required to accept the item without further deliberation. An expert panel made final decisions in all instances where consensus was not achieved. The panel also amended the wording of selected items, or added new items based on feedback received from survey respondents. The final document contains 268 items organised within seven competency domains.
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