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Kaufman AR, Ali Al-Djasim L, Rivkin AC, Al-Futais M, Venkataraman G, Vimalanathan M, Sahu A, Ahluwalia NS, Shakya R, Vajaranant TS, Wilensky JT, Edward DP, Aref AA. Pregnancy outcomes in the medical management of glaucoma: An international multicenter descriptive survey. Eur J Ophthalmol 2024; 34:471-479. [PMID: 37671417 DOI: 10.1177/11206721231199774] [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] [Indexed: 09/07/2023]
Abstract
PURPOSE To determine if glaucoma medications are associated with pregnancy and/or postnatal complications. METHODS Multicenter descriptive survey. Subjects were female patients 18-45 years who were previously pregnant with a diagnosis of glaucoma or ocular hypertension prior to pregnancy. Chart review queried diagnosis, glaucoma severity, and race. Survey questions were asked for each pregnancy and queried pregnancy age, medications used, and pregnancy outcomes/complications. RESULTS 114 pregnancies of 56 patients (mean 2.0 pregnancies per patient) were included. Three pregnancies with therapeutic abortion were excluded from further analysis. Mean age during pregnancy was 29.1 ± 5.7 years. Of the 111 pregnancies, 20 (18.0%) used no medications and 91 (82.0%) used at least one medication. Medications were topical carbonic anhydrase inhibitors (n = 45), beta-blockers (n = 55), alpha-agonists (n = 56), and prostaglandin analogues (n = 28). Outcomes were: preterm contractions/labour (6.3%), miscarriage (4.5%), stillbirth (4.5%), induction of labour (11.9%), emergency/unplanned caesarean delivery (13.9%), neonatal intensive care unit (NICU) stay (15.8%), congenital anomalies (8.1%), and low birth weight (10.9%). Fisher exact test assessed outcome associations with individual agents, use of any agent, and different number of agents. Alpha-agonist use was associated with NICU stay: 25.5% rate (p = 0.012) in alpha-agonist use. Most of the alpha-agonist use NICU stays occurred in pregnancies with third trimester use. All other associations were not statistically significant. CONCLUSIONS The data from this survey suggest an overall favourable safety profile for topical glaucoma medications in pregnancy, but further investigation is needed. Caution should be employed regarding third trimester alpha-agonist use owing to association with NICU stay.
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Affiliation(s)
- Aaron R Kaufman
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA
| | - Leyla Ali Al-Djasim
- Department of Ophthalmology, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Angeline C Rivkin
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA
| | - Muneera Al-Futais
- Department of Ophthalmology, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | | | | | - Abhipsa Sahu
- Department of Ophthalmology, Aravind Eye Hospital, Coimbatore, India
| | - Navjot Singh Ahluwalia
- Department of Ophthalmology, Shri Sadguru Seva Sangh Trust, Chitrakoot Centre, Chitrakoot, India
| | - Rakesh Shakya
- Department of Ophthalmology, Shri Sadguru Seva Sangh Trust, Chitrakoot Centre, Chitrakoot, India
| | - Thasarat Sutabutr Vajaranant
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA
| | - Jacob T Wilensky
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA
| | - Deepak P Edward
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA
| | - Ahmad A Aref
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA
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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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Vokes J, Lovett A, Sykes B. Equine Gastric Ulcer Syndrome: An Update on Current Knowledge. Animals (Basel) 2023; 13:1261. [PMID: 37048517 PMCID: PMC10093336 DOI: 10.3390/ani13071261] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/14/2023] [Accepted: 03/29/2023] [Indexed: 04/08/2023] Open
Abstract
Equine Gastric Ulcer Syndrome (EGUS) is a term that has been used since 1999, initially being used to describe all gastric mucosal disease in horses. Since this time, the identification of two distinct main disease entities of the equine gastric mucosa have been described under the umbrella of EGUS; these are Equine Squamous Gastric Disease (ESGD) and Equine Glandular Gastric Disease (EGGD). In 2015 the European College of Equine Internal Medicine (ECEIM) released a consensus statement defining these disease entities. This document highlighted the lack of evidence surrounding EGGD compared to ESGD, and identified knowledge gaps for further research to be directed. Subsequently, many studies on EGGD have been published, especially on pathophysiology, diagnosis, and treatment. This article updates current knowledge on both ESGD and EGGD as understanding has evolved since the last large-scale review.
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Affiliation(s)
- Jessica Vokes
- Equine Veterinary Clinic, School of Veterinary Sciences, Massey University, Palmerston North 4474, New Zealand
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Osuga Y, Shirasu K, Tsushima R, Ishitani K. Short-term efficacy and safety of early medical abortion in Japan: A multicenter prospective study. Reprod Med Biol 2023; 22:e12512. [PMID: 37013166 PMCID: PMC10066193 DOI: 10.1002/rmb2.12512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 04/03/2023] Open
Abstract
Purpose To evaluate the short-term efficacy and safety of a combined mifepristone-misoprostol regimen in individuals seeking medical abortion at up to 63 days of gestational age. Methods This open-label, multicenter, prospective study evaluated the short-term efficacy and safety of medical abortion, with the primary outcome being the abortion success rate 24 h after misoprostol administration. The participants received 200 mg of mifepristone orally and 800 μg of misoprostol buccally in the hospital/clinic 36-48 h later. Bleeding and lower abdominal pain, which are the main symptoms associated with medical abortion, were recorded. Results The abortion success rate was 93.3% (95% confidence interval [CI]: 87.3-97.1%) within 24 h of misoprostol administration, 63.3% (95% CI: 54.05-71.94%) within 4 h, and 90.0% (95% CI: 83.18-94.73%) within 8 h. The median time from misoprostol administration to a successful abortion was 3.93 h. Bleeding was most commonly observed 0-4 h prior to the confirmation of gestational sac (GS) expulsion. The most intense lower abdominal pain occurred 0-1 h before the confirmation of GS expulsion. Conclusion The combined regimen of mifepristone and buccal misoprostol for medical abortion showed short-term efficacy and a favorable safety profile.
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Affiliation(s)
- Yutaka Osuga
- Department of Obstetrics and Gynecology, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Kazuhiro Shirasu
- Division of Review Board ManagementKanagawa National Health Insurance OrganizationKanagawaJapan
| | - Ruriko Tsushima
- Tsushima Ruriko Women’s Life Clinic Ginza Medical Corporation Women’s WellnessTokyoJapan
| | - Ken Ishitani
- Department of Obstetrics and GynecologyNippon Koukan HospitalKanagawaJapan
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Ani VC, Enebe JT, Dim CC, Dim NR, Ozumba BC. Sublingual misoprostol versus manual vacuum aspiration for treatment of incomplete abortion in Nigeria: a randomized control study. Pan Afr Med J 2022; 41:90. [PMID: 35432695 PMCID: PMC8977358 DOI: 10.11604/pamj.2022.41.90.29364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 01/21/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction single-dose of sublingual misoprostol 400mcg with the participant followed-up at the gynecology clinic one week after with an ultrasound scan for the completeness of the uterine evacuation. Objective: to compare the effectiveness of single-dose sublingual misoprostol to manual vacuum aspiration in the treatment of incomplete spontaneous abortion in Enugu, Nigeria. Methods the primary outcome measure was the incidence of complete uterine evacuation (complete abortion) after one week of treatment while the secondary outcome measures included incidence, types, and tolerability of treatment side effects as well as participants' satisfaction with the treatment received. Results two hundred and three participants who met the study criteria and completed the study were randomised into the intervention group (n=102) received single-dose sublingual misoprostol 400mcg and the control group (n= 101) received manual vacuum aspiration. Incidence of complete abortion was 86.3% for the misoprostol group and 100.0% for the control group, RR = 0.86, (CI 95%: 0.80 - 0.93), p <0.001. The most common side effect was abdominal pain with an incidence of 27.5% versus 48.55 for the misoprostol and control groups respectively (p = 0.002). Most participants in each group (81.1% versus 77.6% for the misoprostol and control groups respectively) considered the side effects as tolerable. The mean visual analogue scale score for maternal satisfaction was higher in the misoprostol group (86.7 ± 14.11) than the control group (81.36 ± 11.10), p < 0.001. Conclusion the treatment of incomplete spontaneous abortion with single-dose sublingual misoprostol 400mcg produced a high rate of complete abortion among women in Enugu, Nigeria. Despite having a lower complete abortion rate, maternal satisfaction was higher when compared with women that had manual vacuum aspiration of the uterus. Trial registration: trial registration number - PACTR202009857889210, date of registration - September 23rd, 2020. Retrospectively registered.
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Affiliation(s)
- Vincent Chinedu Ani
- Departments of Obstetrics and Gynaecology, College of Health Sciences Nnamdi Azikiwe University Nnewi Campus, Anambra State, Nigeria
| | - Joseph Tochukwu Enebe
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology, College of Medicine/ Teaching Hospital, Parklane, Enugu, Nigeria
| | - Cyril Chukwudi Dim
- Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Ituku-Ozalla, P.M.B. 01129, Enugu, Nigeria.,Institute of Maternal and Child Health, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria
| | - Ngozi Regina Dim
- Department of Radiation Medicine, College of Medicine, University of Nigeria Ituku-Ozalla Campus, Enugu, Nigeria
| | - Benjamin Chukwuma Ozumba
- Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Ituku-Ozalla, P.M.B. 01129, Enugu, Nigeria
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Vafaei H, Ajdari S, Hessami K, Hosseinkhani A, Foroughinia L, Asadi N, Faraji A, Abolhasanzadeh S, Bazrafshan K, Roozmeh S. Efficacy and safety of myrrh in patients with incomplete abortion: a randomized, double-blind, placebo-controlled clinical study. BMC Complement Med Ther 2020; 20:145. [PMID: 32397980 PMCID: PMC7218551 DOI: 10.1186/s12906-020-02946-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 05/07/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Myrrh (Commiphora myrrha (Nees) Engl.) has a long history of traditional use as a herbal medicine for different purposes. In ancient traditional Persian manuscripts, it has been noted that myrrh may act as uterine stimulant and probably cause complete abortion. However, there is no evidence to verify this comment. Therefore, the current study was carried out to evaluate the efficacy and safety of Myrrh in the treatment of incomplete abortion. MATERIALS AND METHODS In a randomized double-blinded placebo controlled clinical trial, 80 patients with ultrasound-documented retained products of conception (RPOC) were assigned to receive capsules containing 500 mg of Myrrh oleo-gum-resin or a placebo three times a day for 2 weeks. The existence of the retained tissue and its size were evaluated by ultrasound examination at the beginning and end of the study. RESULTS After 2 weeks, the mean diameter of the RPOC in the Myrrh group was significantly reduced compared with the placebo group (P < 0.001). Meanwhile, the rate of successful complete abortion was 82.9% in the intervention group and 54.3% in the placebo group (P = 0.01). The patients in both groups reported no serious drug-related adverse effects. CONCLUSION This study shows that Myrrh is effective and safe in the resolution of the RPOC and may be considered as an alternative option for treatment of patients with incomplete abortion. However, further studies on active compounds isolated from myrrh and their uterine stimulant effects are needed. TRIAL REGISTRATION This study was retrospectively registered at Iranian Registry of Clinical Trials (www.irct.ir) IRCT code: IRCT20140317017034N7.
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Affiliation(s)
- Homeira Vafaei
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Ajdari
- Obstetrics and Gynecology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kamran Hessami
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ayda Hosseinkhani
- Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Leila Foroughinia
- Obstetrics and Gynecology Department, Shiraz University of Medical Sciences, Shiraz, Iran
- Box Hill Hospital, FRANZCOG Eastern Health, Victoria, Australia
| | - Nasrin Asadi
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Maternal- Fetal Medicine (Perinatology), Hafez Hospital, Chamran Ave, Shiraz, Iran
| | - Azam Faraji
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Khadije Bazrafshan
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shohreh Roozmeh
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Muñoz-Franco FM, Lacunza-Ruiz FJ, Vázquez-Andrés DJ, Rodríguez-Hernández JR. Coronary artery vasospasm after misoprostol treatment for incomplete abortion: a case report. Contraception 2019; 100:498-501. [PMID: 31446021 DOI: 10.1016/j.contraception.2019.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 08/08/2019] [Accepted: 08/15/2019] [Indexed: 01/24/2023]
Abstract
Misoprostol is widely used for the medical management of incomplete abortion. Few serious adverse events have been reported, so it is considered a safe drug. We present a case of a 40-year-old woman in which misoprostol preceded coronary artery spasm.
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8
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Ibiyemi KF, Ijaiya MA, Adesina KT. Randomised Trial of Oral Misoprostol Versus Manual Vacuum Aspiration for the Treatment of Incomplete Abortion at a Nigerian Tertiary Hospital. Sultan Qaboos Univ Med J 2019; 19:e38-e43. [PMID: 31198594 PMCID: PMC6544063 DOI: 10.18295/squmj.2019.19.01.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/01/2018] [Accepted: 11/19/2018] [Indexed: 11/18/2022] Open
Abstract
Objectives This study aimed to compare the efficacy of oral misoprostol with manual vacuum aspiration (MVA) in first trimester incomplete abortions. Methods This randomised controlled trial study was conducted at the University of Ilorin Teaching Hospital, Ilorin, Nigeria between April 2014 and November 2015. Pregnant women who presented with clinical features of incomplete abortion at a gestational age of 13 weeks or less were included. Patients who had profuse vaginal bleeding, an intrauterine device in situ, signs of pelvic infections or who were younger than 18 years old and had no accompanying adults to give informed consent were excluded. A total of 200 participants were randomly and equally allocated to either the MVA or misoprostol treatment group. The treatment group were given 600 μg of misoprostol orally. The primary outcome measure was complete uterine evacuation, while secondary outcome measures included the need for additional surgical evacuation for failed treatment, adverse effects/complications, acceptability of and satisfaction with the treatment. Results Both misoprostol and MVA had high complete evacuation rates, yet MVA was significantly higher (99% versus 83%, relative risk [RR]: 0.84, confidence interval [CI]: 0.766–0.918; P <0.001). Significantly more women in the misoprostol group required additional MVA for failed treatment than in the MVA treatment group (17% versus 1%, RR: 16.67, CI: 2.260–12.279; P <0.001). No significant difference was found between the misoprostol and MVA treatment groups in terms of satisfaction (92.7% versus 89.8%, RR: 1.04, CI: 0.946–1.127; P = 0.473). Conclusion Treatments with misoprostol and MVA had high complete uterine evacuation rates, as well as high rates of acceptability and satisfaction. However, MVA had a significantly higher complete evacuation rate than misoprostol.
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Affiliation(s)
- Kehinde F Ibiyemi
- Department of Obstetrics & Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
| | - Munir'deen A Ijaiya
- Department of Obstetrics & Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
| | - Kikelomo T Adesina
- Department of Obstetrics & Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
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Abstract
Patients commonly present with unintended pregnancy in the primary care setting, and 1 in 4 women has an abortion in her lifetime. Early abortion services can be safely provided in the primary care setting. Abortion options provided in primary care settings include both medication abortion and early uterine aspiration abortion. Medication abortion, provided up to 10 weeks' gestational age, includes mifepristone (a progestin antagonist) and misoprostol (a prostaglandin). Uterine aspiration can be provided via manual or electronic vacuum in the first trimester.
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Affiliation(s)
- Jennifer R Amico
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, MEB 262, New Brunswick, NJ 08901, USA.
| | - Terri L Cheng
- Department of Family Medicine and Public Health, University of California San Diego, 200 West Arbor Drive #8201A, San Diego, CA 92103, USA
| | - Emily M Godfrey
- Family Medicine, University of Washington, 4311 11th Avenue Northeast, Suite 210, Box 354982, Seattle, WA 98105, USA; Obstetrics and Gynecology, University of Washington, 4311 11th Avenue Northeast, Suite 210, Box 354982, Seattle, WA 98105, USA
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10
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Fernlund A, Jokubkiene L, Sladkevicius P, Valentin L. Misoprostol treatment vs expectant management in women with early non-viable pregnancy and vaginal bleeding: a pragmatic randomized controlled trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:24-32. [PMID: 29072372 DOI: 10.1002/uog.18940] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 10/19/2017] [Accepted: 10/23/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To compare vaginal misoprostol treatment with expectant management in early non-viable pregnancy with vaginal bleeding with regard to complete evacuation of the uterine cavity within 10 days after randomization. METHODS This was a parallel randomized controlled, open-label trial conducted in Skåne University Hospital, Sweden. Patients with anembryonic pregnancy or early fetal demise (crown-rump length ≤ 33 mm) and vaginal bleeding were randomly allocated to either expectant management or treatment with a single dose of 800 μg misoprostol administered vaginally. Patients were evaluated clinically and by ultrasound until complete evacuation of the uterus was achieved (no gestational sac in the uterine cavity and maximum anteroposterior diameter of the intracavitary contents < 15 mm as measured by transvaginal ultrasound on midsagittal view). Follow-up visits were planned at 10, 17, 24 and 31 days. Dilatation and evacuation (D&E) was recommended if miscarriage was not complete within 31 days, but was performed earlier at patient's request, or if there was excessive bleeding as judged clinically. Analysis was by intention to treat. The main outcome measure was number of patients with complete miscarriage without D&E ≤ 10 days. RESULTS Ninety-four patients were randomized to misoprostol treatment and 95 to expectant management. After exclusion of three patients and withdrawal of consent by two patients in the expectant management group, 90 women were included in this group. Miscarriage was complete ≤ 10 days in 62/94 (66%) of the patients in the misoprostol group and in 39/90 (43%) of those in the group managed expectantly (risk difference (RD) = 23%; 95% CI, 8-37%). At 31 days, the corresponding figures were 81/94 (86%) and 55/90 (61%) (RD = 25%; 95% CI, 12-38%). Two patients from each group underwent emergency D&E because of excessive bleeding and one of these in each group received blood transfusion. The number of patients undergoing D&E at their own request was higher in the expectantly managed group, 15/90 (17%) vs 3/94 (3%) in the misoprostol group (RD = 14%; 95% CI, 4-23%), as was the number of patients making out-of-protocol visits, 50/90 (56%) vs 27/94 (29%) (RD = 27%; 95% CI, 12-40%). Compared with the expectant management group, more patients in the misoprostol group experienced pain (71/77 (92%) vs 91/91 (100%); RD = 8%; 95% CI, 1-17%) and used painkillers (59/77 (77%) vs 85/91 (93%); RD = 17%; 95% CI, 5-29%). No major side effect was reported in any group. CONCLUSIONS In women with early non-viable pregnancy and vaginal bleeding, misoprostol treatment is more effective than is expectant management for complete evacuation of the uterus. Both methods are safe but misoprostol treatment is associated with more pain than is expectant management. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Fernlund
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - L Jokubkiene
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - P Sladkevicius
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - L Valentin
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund University, Malmö, Sweden
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Cleeve A, Byamugisha J, Gemzell-Danielsson K, Mbona Tumwesigye N, Atuhairwe S, Faxelid E, Klingberg-Allvin M. Women's Acceptability of Misoprostol Treatment for Incomplete Abortion by Midwives and Physicians - Secondary Outcome Analysis from a Randomized Controlled Equivalence Trial at District Level in Uganda. PLoS One 2016; 11:e0149172. [PMID: 26872219 PMCID: PMC4752492 DOI: 10.1371/journal.pone.0149172] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 01/26/2016] [Indexed: 11/28/2022] Open
Abstract
Objective This study aimed to assess women´s acceptability of diagnosis and treatment of incomplete abortion with misoprostol by midwives, compared with physicians. Methods This was an analysis of secondary outcomes from a multi-centre randomized controlled equivalence trial at district level in Uganda. Women with first trimester incomplete abortion were randomly allocated to clinical assessment and treatment with misoprostol by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and stratified for health care facility. Acceptability was measured in expectations and satisfaction at a follow up visit 14–28 days following treatment. Analysis of women’s overall acceptability was done using a generalized linear mixed-effects model with an equivalence range of -4% to 4%. The study was not masked. The trial is registered at ClinicalTrials.org, NCT 01844024. Results From April 2013 to June 2014, 1108 women were assessed for eligibility of which 1010 were randomized (506 to midwife and 504 to physician). 953 women were successfully followed up and included in the acceptability analysis. 95% (904) of the participants found the treatment satisfactory and overall acceptability was found to be equivalent between the two study groups. Treatment failure, not feeling calm and safe following treatment, experiencing severe abdominal pain or heavy bleeding following treatment, were significantly associated with non-satisfaction. No serious adverse events were recorded. Conclusions Treatment of incomplete abortion with misoprostol by midwives and physician was highly, and equally, acceptable to women. Trial Registration ClinicalTrials.gov NCT01844024
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Affiliation(s)
- Amanda Cleeve
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- WHO Center for Human Reproduction, Karolinska University Hospital, Stockholm, Sweden
- * E-mail:
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Mulago Hospital, Kampala, Uganda
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Kristina Gemzell-Danielsson
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- WHO Center for Human Reproduction, Karolinska University Hospital, Stockholm, Sweden
| | - Nazarius Mbona Tumwesigye
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Susan Atuhairwe
- Department of Obstetrics and Gynaecology, Mulago Hospital, Kampala, Uganda
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Elisabeth Faxelid
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
| | - Marie Klingberg-Allvin
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
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Tratamiento médico del aborto espontáneo del primer trimestre. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2015. [DOI: 10.1016/j.gine.2013.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Klingberg-Allvin M, Cleeve A, Atuhairwe S, Tumwesigye NM, Faxelid E, Byamugisha J, Gemzell-Danielsson K. Comparison of treatment of incomplete abortion with misoprostol by physicians and midwives at district level in Uganda: a randomised controlled equivalence trial. Lancet 2015; 385:2392-8. [PMID: 25817472 DOI: 10.1016/s0140-6736(14)61935-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Misoprostol is established for the treatment of incomplete abortion but has not been systematically assessed when provided by midwives at district level in a low-resource setting. We investigated the effectiveness and safety of midwives diagnosing and treating incomplete abortion with misoprostol, compared with physicians. METHODS We did a multicentre randomised controlled equivalence trial at district level at six facilities in Uganda. Eligibility criteria were women with signs of incomplete abortion. We randomly allocated women with first-trimester incomplete abortion to clinical assessment and treatment with misoprostol either by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and was stratified for study site. Primary outcome was complete abortion not needing surgical intervention within 14-28 days after initial treatment. The study was not masked. Analysis of the primary outcome was done on the per-protocol population with a generalised linear-mixed effects model. The predefined equivalence range was -4% to 4%. The trial was registered at ClinicalTrials.gov, number NCT01844024. FINDINGS From April 30, 2013, to July 21, 2014, 1108 women were assessed for eligibility. 1010 women were randomly assigned to each group (506 to midwife group and 504 to physician group). 955 women (472 in the midwife group and 483 in the physician group) were included in the per-protocol analysis. 452 (95·8%) of women in the midwife group had complete abortion and 467 (96·7%) in the physician group. The model-based risk difference for midwife versus physician group was -0·8% (95% CI -2·9 to 1·4), falling within the predefined equivalence range (-4% to 4%). The overall proportion of women with incomplete abortion was 3·8% (36/955), similarly distributed between the two groups (4·2% [20/472] in the midwife group, 3·3% [16/483] in the physician group). No serious adverse events were recorded. INTERPRETATION Diagnosis and treatment of incomplete abortion with misoprostol by midwives is equally safe and effective as when provided by physicians, in a low-resource setting. Scaling up midwives' involvement in treatment of incomplete abortion with misoprostol at district level would increase access to safe post-abortion care. FUNDING The Swedish Research Council, Karolinska Institutet, and Dalarna University.
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Affiliation(s)
- Marie Klingberg-Allvin
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
| | - Amanda Cleeve
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Susan Atuhairwe
- Department of Obstetrics and Gynaecology, Mulago Hospital, Kampala, Uganda; Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Elisabeth Faxelid
- Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Mulago Hospital, Kampala, Uganda; Makerere University College of Health Sciences, Kampala, Uganda
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Karolinska University Hospital, Stockholm, Sweden
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Olavarrieta CD, Ganatra B, Sorhaindo A, Karver TS, Seuc A, Villalobos A, García SG, Pérez M, Bousieguez M, Sanhueza P. Nurse versus physician-provision of early medical abortion in Mexico: a randomized controlled non-inferiority trial. Bull World Health Organ 2015; 93:249-58. [PMID: 26229189 PMCID: PMC4431559 DOI: 10.2471/blt.14.143990] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 12/16/2014] [Accepted: 01/05/2015] [Indexed: 12/02/2022] Open
Abstract
Objective To examine the effectiveness, safety, and acceptability of nurse provision of early medical abortion compared to physicians at three facilities in Mexico City. Methods We conducted a randomized non-inferiority trial on the provision of medical abortion and contraceptive counselling by physicians or nurses. The participants were pregnant women seeking abortion at a gestational duration of 70 days or less. The medical abortion regimen was 200 mg of oral mifepristone taken on-site followed by 800 μg of misoprostol self–administered buccally at home 24 hours later. Women were instructed to return to the clinic for follow-up 7–15 days later. We did an intention-to-treat analysis for risk differences between physicians’ and nurses’ provision for completion and the need for surgical intervention. Findings Of 1017 eligible women, 884 women were included in the intention-to-treat analysis, 450 in the physician-provision arm and 434 in the nurse-provision arm. Women who completed medical abortion, without the need for surgical intervention, were 98.4% (443/450) for physicians’ provision and 97.9% (425/434) for nurses’ provision. The risk difference between the group was 0.5% (95% confidence interval, CI: −1.2% to 2.3%). There were no differences between providers for examined gestational duration or women’s contraceptive method uptake. Both types of providers were rated by the women as highly acceptable. Conclusion Nurses’ provision of medical abortion is as safe, acceptable and effective as provision by physicians in this setting. Authorizing nurses to provide medical abortion can help to meet the demand for safe abortion services.
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Affiliation(s)
- Claudia Diaz Olavarrieta
- Instituto Nacional de Salud Pública, Septima Cerrada de Fray Pedro de Gante No 50, Col Seccion XVI, Tlalpan, Mexico City, 14000, Mexico
| | - Bela Ganatra
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | | | - Armando Seuc
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Aremis Villalobos
- Instituto Nacional de Salud Pública, Septima Cerrada de Fray Pedro de Gante No 50, Col Seccion XVI, Tlalpan, Mexico City, 14000, Mexico
| | | | - Martha Pérez
- Mexico City Ministry of Health, Reproductive Health Program, Mexico City, Mexico
| | | | - Patricio Sanhueza
- Mexico City Ministry of Health, Reproductive Health Program, Mexico City, Mexico
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Mayi-Tsonga S, Minkobame U, Mbila A, Assoumou P, Diop A, Winikoff B. [First experience of the use of misoprostol as post-abortion care in Libreville, Gabon]. Pan Afr Med J 2014; 18:301. [PMID: 25469194 PMCID: PMC4247897 DOI: 10.11604/pamj.2014.18.301.4309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 07/27/2014] [Indexed: 11/11/2022] Open
Abstract
Introduction Une étude a été menée afin de déterminer le taux d'acceptabilité de 400µg de misoprostol par voie sublinguale comme traitement de première intention de l'avortement incomplet et de préciser le taux d'avortement complet ou vacuité utérine. Méthodes Les femmes éligibles avaient un diagnostic clinique d'avortement incomplet avec une taille utérine inférieure à celle d'un utérus de 12 semaines d'aménorrhées (SA). Chacune a reçu 400µg de misoprostol par voie sublinguale. Les femmes ont été revues après une semaine. A J7, celles qui n'avaient pas complètement expulsé ont eu le choix entre une nouvelle consultation de suivi à J14 et la pratique d'une évacuation chirurgicale immédiate. Résultats 145 patientes ont été éligibles et ont toutes accepté la méthode (100%). L’âge moyen était de 25,9 ± 6 ans. A J7, 120 patientes étaient guéries (85,7%). A J14, le taux de réussitea été de 95,7% soit 134 patientes guéries. Les patientes guéries ont déclaré être très satisfaites (57,5%), satisfaites (41,8%) et insatisfaite (0,7%). Au total,128 femmes (95,5%) ont dit être prêtes à utiliser de nouveau le misoprostol comme méthode d’évacuation utérine en cas d'avortement incomplet. Conclusion L’étude démontre que le 400µg misoprostol par voie sublinguale nous permet de prendre en charge d'une manière adéquate l'avortement incomplet surtout dans les pays à faible ressource et notamment dans les structures sanitaires de première ligne ou éloignées.
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Affiliation(s)
- Sosthène Mayi-Tsonga
- Université des Sciences de la Santé de Libreville, Libreville, Gabon ; Projet FIGO pour la lutte contre les avortements à risque au Gabon
| | - Ulysse Minkobame
- Service de Gynécologie Obstétrique du Centre Hospitalier Universitaire de Libreville, Libreville, Gabon
| | - Arielle Mbila
- Service de Gynécologie Obstétrique du Centre Hospitalier Universitaire de Libreville, Libreville, Gabon
| | - Pamphile Assoumou
- Service de Gynécologie Obstétrique du Centre Hospitalier Universitaire de Libreville, Libreville, Gabon
| | - Ayisha Diop
- Gynuity Health Projects, New York City, New York, USA
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Begum F, Zaidi S, Fatima P, Shamsuddin L, Anowar-ul-Azim A, Begum RA. Improving manual vacuum aspiration service delivery, introducing misoprostol for cases of incomplete abortion, and strengthening postabortion contraception in Bangladesh. Int J Gynaecol Obstet 2014; 126 Suppl 1:S31-5. [DOI: 10.1016/j.ijgo.2014.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Adisso S, Hounkpatin BI, Komongui GD, Sambieni O, Perrin RX. Introduction of misoprostol for the treatment of incomplete abortion beyond 12 weeks of pregnancy in Benin. Int J Gynaecol Obstet 2014; 126 Suppl 1:S36-9. [DOI: 10.1016/j.ijgo.2014.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Behnamfar F, Mahdian M, Rahimi F, Samimi M. Misoprostol Abortion: Ultrasonography versus Beta-hCG Testing for Verification of Effectiveness. Pak J Med Sci 2014; 29:1367-70. [PMID: 24550955 PMCID: PMC3905382 DOI: 10.12669/pjms.296.3361] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Revised: 08/05/2013] [Accepted: 08/28/2013] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Miscarriage is a common complication of early pregnancy with medical and psychological consequences. Dilation and Curettage are considered as two standard caring ways for early pregnancy failure. Alternatively misoprostol has been used as a single agent for termination of early pregnancy. Aim of the present study was to compare the usefulness of serum β-hCG measurement and ultrasound examination to predict complete abortion after medical induction. METHODS There were one hundred and thirty three patients experiencing missed abortion or blighted ovum. Ultrasound examination and serum β-hCG test were performed before treatment and during follow-up in all these patients. RESULTS Treatment was successful without any need for surgical intervention in 92.4% of the cases. Both methods could verify the complete abortion among all the patients at the end of the study (4(th) week). Kappa agreement coefficient for the two methods of diagnosis was 0.327 (P < 0.5). CONCLUSION Based on our results, β- hCG is as effective as ultrasound in confirming a successful medically induced abortion in early pregnancy, but it should be used as supplements to clinical assessments.
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Affiliation(s)
- Fariba Behnamfar
- Fariba Behnamfar, Associate Professor, Department of Obstetrics and Gynecology Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehrdad Mahdian
- Mehrdad Mahdian, Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Fereshteh Rahimi
- Fereshteh Rahimi, Department of Obstetrics and Gynecology, Kashan University of Medical Sciences, Kashan, Iran
| | - Mansoureh Samimi
- Mansoureh Samimi, Assistant Professor, Department of Obstetrics and Gynecology, Kashan University of Medical Sciences, Kashan, Iran
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Paul M, Gemzell-Danielsson K, Kiggundu C, Namugenyi R, Klingberg-Allvin M. Barriers and facilitators in the provision of post-abortion care at district level in central Uganda - a qualitative study focusing on task sharing between physicians and midwives. BMC Health Serv Res 2014; 14:28. [PMID: 24447321 PMCID: PMC3903434 DOI: 10.1186/1472-6963-14-28] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 01/17/2014] [Indexed: 11/30/2022] Open
Abstract
Background Abortion is restricted in Uganda, and poor access to contraceptive methods result in unwanted pregnancies. This leaves women no other choice than unsafe abortion, thus placing a great burden on the Ugandan health system and making unsafe abortion one of the major contributors to maternal mortality and morbidity in Uganda. The existing sexual and reproductive health policy in Uganda supports the sharing of tasks in post-abortion care. This task sharing is taking place as a pragmatic response to the increased workload. This study aims to explore physicians’ and midwives’ perception of post-abortion care with regard to professional competences, methods, contraceptive counselling and task shifting/sharing in post-abortion care. Methods In-depth interviews (n = 27) with health care providers of post-abortion care were conducted in seven health facilities in the Central Region of Uganda. The data were organized using thematic analysis with an inductive approach. Results Post-abortion care was perceived as necessary, albeit controversial and sometimes difficult to provide. Together with poor conditions post-abortion care provoked frustration especially among midwives. Task sharing was generally taking place and midwives were identified as the main providers, although they would rarely have the proper training in post-abortion care. Additionally, midwives were sometimes forced to provide services outside their defined task area, due to the absence of doctors. Different uterine evacuation skills were recognized although few providers knew of misoprostol as a method for post-abortion care. An overall need for further training in post-abortion care was identified. Conclusions Task sharing is taking place, but providers lack the relevant skills for the provision of quality care. For post-abortion care to improve, task sharing needs to be scaled up and in-service training for both doctors and midwives needs to be provided. Post-abortion care should further be included in the educational curricula of nurses and midwives. Scaled-up task sharing in post-abortion care, along with misoprostol use for uterine evacuation would provide a systematic approach to improving the quality of care and accessibility of services, with the aim of reducing abortion-related mortality and morbidity in Uganda.
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Affiliation(s)
- Mandira Paul
- Department of Women's and Children's Health, Karolinska Institutet, University Hospital, Stockholm, Sweden.
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Huda FA, Ngo TD, Ahmed A, Alam A, Reichenbach L. Availability and provision of misoprostol and other medicines for menstrual regulation among pharmacies in Bangladesh via mystery client survey. Int J Gynaecol Obstet 2013; 124:164-8. [PMID: 24268354 DOI: 10.1016/j.ijgo.2013.07.037] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 07/22/2013] [Accepted: 10/25/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To explore the availability and provision of misoprostol and other medicines for menstrual regulation (MR) among pharmacies in Bangladesh. METHODS Between March and November 2011, a cross-sectional study using mystery client visits was conducted among pharmacy workers in Dhaka and Gazipur Districts, Bangladesh. Mystery clients were trained to present 1 of 4 pre-developed situations to pharmacy workers to elicit information on the regimen, adverse effects, and complications of misoprostol use. RESULTS Mystery clients visited 331 pharmacies. Among the 331 pharmacy workers, 45.8% offered the mystery clients misoprostol and/or other medicines for MR; 25.7% referred them to private clinics or hospitals. Only 7% recommended an effective regimen of misoprostol for MR; 65% suggested administering vaginal and oral misoprostol together. Overall, 72.4% did not provide any advice on complications; the remainder suggested visiting trained providers for complications. Counseling on excessive bleeding as a danger sign was provided by 46% of pharmacy workers. Most (94%) did not provide or refer for post-MR family planning. CONCLUSION Pharmacy workers in urban Bangladesh are providing ineffective drugs and regimens for MR. A training package is needed to strengthen service delivery by providing accurate information, high-quality products, and referral mechanisms for women seeking MR through pharmacies.
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Affiliation(s)
- Fauzia A Huda
- Centre for Reproductive Health, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
| | - Thoai D Ngo
- Research, Monitoring and Evaluation Team, Health System Department, Marie Stopes International, London, UK
| | - Anisuddin Ahmed
- Centre for Reproductive Health, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Anadil Alam
- Centre for Reproductive Health, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Laura Reichenbach
- Centre for Reproductive Health, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
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Casikar I, Lu C, Reid S, Condous G. Does symptomatology at presentation correlate with successful expectant management of first trimester miscarriage: a prospective observational study. Aust N Z J Obstet Gynaecol 2013; 53:178-83. [PMID: 23521011 DOI: 10.1111/ajo.12068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 01/26/2013] [Indexed: 11/29/2022]
Abstract
AIMS To evaluate whether symptomatology at presentation correlates with successful expectant management of first-trimester miscarriage. METHODS Data were collected prospectively on women managed expectantly for two weeks with first-trimester miscarriage. Women diagnosed with incomplete, missed and empty sac miscarriage were included. The overall rate of successful expectant management was evaluated in terms of symptomatology. The rates of successful expectant management for each miscarriage group were also evaluated in terms of the type of symptoms. Main outcome measure was success of expectant management at two weeks. RESULTS Spontaneous completion of miscarriage was observed in 76.7% (161/210) women. The overall rates of successful expectant management were significantly different between the symptomatic (79.1%) and asymptomatic (42.9%) groups (P-value = 0.0003). In the incomplete miscarriage group, higher rates of success were associated with vaginal bleeding than without (89.4 vs 56.3%; P-value = 0.0027). The presence or absence of pain was not found to be significant. CONCLUSIONS Symptomatology does appear to be a consistent predictor of outcome for expectant management of miscarriage. Overall, vaginal bleeding at presentation was associated with an increase in success of expectant management; but individually, only significant in the incomplete miscarriage group. The presence or absence of pain at presentation was not a predictor for the various types of miscarriage.
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Affiliation(s)
- Ishwari Casikar
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Centre for Perinatal Care, Nepean Clinical School, University of Sydney, Nepean Hospital, Sydney, New South Wales, Australia.
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Reif P, Tappauf C, Panzitt T, Haas J, Lang U, Klaritsch P. Efficacy of misoprostol in relation to uterine position in the treatment of early pregnancy failure. Int J Gynaecol Obstet 2013; 121:137-40. [DOI: 10.1016/j.ijgo.2012.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 11/08/2012] [Accepted: 01/22/2013] [Indexed: 10/27/2022]
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Shochet T, Diop A, Gaye A, Nayama M, Sall AB, Bukola F, Blandine T, Abiola OM, Dao B, Olayinka O, Winikoff B. Sublingual misoprostol versus standard surgical care for treatment of incomplete abortion in five sub-Saharan African countries. BMC Pregnancy Childbirth 2012; 12:127. [PMID: 23150927 PMCID: PMC3545859 DOI: 10.1186/1471-2393-12-127] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 11/10/2012] [Indexed: 11/10/2022] Open
Abstract
Background In low-resource settings, where abortion is highly restricted and self-induced abortions are common, access to post-abortion care (PAC) services, especially treatment of incomplete terminations, is a priority. Standard post-abortion care has involved surgical intervention but can be hard to access in these areas. Misoprostol provides an alternative to surgical intervention that could increase access to abortion care. We sought to gather additional evidence regarding the efficacy of 400 mcg of sublingual misoprostol vs. standard surgical care for treatment of incomplete abortion in the environments where need for economical non-surgical treatments may be most useful. Methods A total of 860 women received either sublingual misoprostol or standard surgical care for treatment of incomplete abortion in a multi-site randomized trial. Women with confirmed incomplete abortion, defined as past or present history of vaginal bleeding during pregnancy and an open cervical os, were eligible to participate. Participants returned for follow-up one week later to confirm clinical status. If abortion was incomplete at that time, women were offered an additional follow-up visit or immediate surgical evacuation. Results Both misoprostol and surgical evacuation are highly effective treatments for incomplete abortion (misoprostol: 94.4%, surgical: 100.0%). Misoprostol treatment resulted in a somewhat lower chance of success than standard surgical practice (RR = 0.90; 95% CI: 0.89-0.92). Both tolerability of side effects and women’s satisfaction were similar in the two study arms. Conclusion Misoprostol, much easier to provide than surgery in low-resource environments, can be used safely, successfully, and satisfactorily for treatment of incomplete abortion. Focus should shift to program implementation, including task-shifting the provision of post-abortion care to mid- and low- level providers, training and assurance of drug availability. Trial registration This study has been registered at clinicaltrials.gov as NCT00466999 and NCT01539408
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Affiliation(s)
- Tara Shochet
- Gynuity Health Projects, 15 E, 26th St, Suite 801, New York, NY 10010, USA
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Petersen SG, Perkins A, Gibbons K, Bertolone J, Devenish-Meares P, Cave D, Mahomed K. Can we use a lower intravaginal dose of misoprostol in the medical management of miscarriage? A randomised controlled study. Aust N Z J Obstet Gynaecol 2012; 53:64-73. [PMID: 23106243 DOI: 10.1111/ajo.12009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Accepted: 09/08/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND The optimal dose of misoprostol to be used in the medical management of miscarriage before 13 weeks has not been resolved. AIM To evaluate the effectiveness and side effect profile of two different dosages of misoprostol. METHODS A randomised controlled, equivalence study comparing 400 vs 800 μg misoprostol per vaginum (PV) on an outpatient basis. The allocated dose was repeated the next day if clinically the products of conception had not been passed. Complete miscarriage was evaluated using two methods: ultrasound criteria on Day 7 and the need for surgical management (clinical criteria). Equivalence was demonstrated if the 95% confidence interval [CI] of the observed risk difference between the two doses for complete miscarriage lay between -15.0 and 15.0%. Differences in side effects and patient satisfaction were evaluated using patient-completed questionnaires. RESULTS One hundred and fifty-eight women were allocated to receive 400 μg and 152 women to 800 μg misoprostol for the management of missed (91.3%) or incomplete (8.7%) miscarriage. The rate of induced complete miscarriage was equivalent using both ultrasound criteria (observed risk difference (ORD) -4.6%, 95% CI -12.8 to 3.7%; P = 0.313) and clinical criteria (ORD -5.6%, 95% CI -14.8 to 3.6%; P = 0.273). Following the 400 μg dose, the reported rate of fever/rigors was lower (ORD -15.6%, 95% CI -28.1 to -3.0%; P = 0.015), and more women reported their decision to undergo medical management as a good decision (ORD 15.2%, 95% CI 2.8 to 27.7%; P = 0.018). CONCLUSION Four hundred-microgram misoprostol PV can be recommended for the medical management of miscarriage on an outpatient basis.
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Affiliation(s)
- Scott G Petersen
- Department of Obstetrics and Gynaecology, Mater Mother's Hospital, Southern Medical School, University of Queensland, Brisbane, Queensland, Australia.
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Sublingual [corrected] misoprostol as first-line care for incomplete abortion in Burkina Faso. Int J Gynaecol Obstet 2012; 119:166-9. [PMID: 22935621 DOI: 10.1016/j.ijgo.2012.05.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 05/23/2012] [Accepted: 07/18/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To explore 400-μg sublingual misoprostol as primary treatment in lower-level facilities with no previous experience providing postabortion care. METHODS Women presenting with incomplete abortion were offered a single dose of 400-μg sublingual misoprostol. Incomplete abortion was defined as uterine size consistent with fewer than 12 weeks of gestation, open cervical os, and reports of past or present history of vaginal bleeding. Women returned to the clinic 1 week after misoprostol administration for follow-up. At that time, they were discharged if the uterine evacuation was a success or were offered a second follow-up visit or surgical completion if still incomplete. RESULTS One-hundred women received misoprostol; outcome data were unavailable for 1 woman. Complete uterine evacuation was achieved for 97 (98.0%) women. Satisfaction was high, with nearly all women indicating that they were "satisfied" (n=57 [57.6%]) or "very satisfied" (n=41 [41.4%]) with their experience. Adverse effects were considered "tolerable" by 72 of 97 (74.2%) women. Ninety-seven of 99 (98.0%) participants indicated that they would choose misoprostol for incomplete abortion care in the future and 95 of 97 (97.9%) stated that they would recommend it to a friend. CONCLUSION Misoprostol is a viable option for treatment of incomplete abortion at mid-level facilities.
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Prata N, Passano P, Bell S, Rowen T, Potts M. New hope: community-based misoprostol use to prevent postpartum haemorrhage. Health Policy Plan 2012; 28:339-46. [PMID: 22879523 DOI: 10.1093/heapol/czs068] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The wide gap in maternal mortality ratios worldwide indicates major inequities in the levels of risk women face during pregnancy. Two priority strategies have emerged among safe motherhood advocates: increasing the quality of emergency obstetric care facilities and deploying skilled birth attendants. The training of traditional birth attendants, a strategy employed in the 1970s and 1980s, is no longer considered a best practice. However, inadequate access to emergency obstetric care and skilled birth attendants means women living in remote areas continue to die in large numbers from preventable maternal causes. This paper outlines an intervention to address the leading direct cause of maternal mortality, postpartum haemorrhage. The potential for saving maternal lives might increase if community-based birth attendants, women themselves, or other community members could be trained to use misoprostol to prevent postpartum haemorrhage. The growing body of evidence regarding the safety and efficacy of misoprostol for this indication raises the question: if achievement of the fifth Millennium Development Goal is truly a priority, why can policy makers and women's health advocates not see that misoprostol distribution at the community level might have life-saving benefits that outweigh risks?
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Affiliation(s)
- Ndola Prata
- Bixby Center for Population, Health and Sustainability, University of California at Berkeley, CA 94720, USA.
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Moran M, Ortega J, Hodoglugil NNS. Osur et al.'s Implementation of misoprostol for postabortion care in Kenya and Uganda: a qualitative evaluation. Glob Health Action 2012; 6:21786. [PMID: 23870184 PMCID: PMC3717088 DOI: 10.3402/gha.v6i0.21786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Molly Moran
- Venture Strategies Innovations, Irvine, CA, USA
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Chaves JHB, Pessini L, Bezerra AFDS, Rego G, Nunes R. A interrupção da gravidez na adolescência: aspectos epidemiológicos numa maternidade pública no nordeste do Brasil. SAUDE E SOCIEDADE 2012. [DOI: 10.1590/s0104-12902012000100023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
O abortamento provocado é praticado amplamente pelas mulheres, em contexto clandestino, no Brasil, sendo considerado uma questão de saúde pública. Neste estudo, propõe-se a conhecer aspectos socio-demográficos, comportamentais, clínicos, complicações, e o tipo de abortamento praticado por adolescentes submetidas à curetagem uterina. Foi utilizada metodologia descritiva, através de entrevistas por meio de questionário estruturado no atendimento a 201 adolescentes com abortamento incompleto submetidas à curetagem uterina, em um hospital do Sistema Único de Saúde (SUS), em Maceió, Alagoas. Os principais determinantes para o abortamento foram: idade acima de dezesseis anos, com parceiro estável; pardas; não planejaram a gestação; desejavam a gestação, primigestas; idade gestacional menor que 15 semanas; raras complicações relacionadas ao abortamento, e utilizando a classificação da Organização Mundial da Saúde, observou-se abortamento provocado em 98,01% dos casos. Entre os casos de abortamentos certamente provocados, 89,19% reportaram o uso do misoprostol, o que reforça maior investimento público na assistência ao uso de métodos contraceptivos entre os adolescentes respeitando seus direitos sexuais e reprodutivos.
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Oral misoprostol for the management of incomplete abortion in Ecuador. Int J Gynaecol Obstet 2011; 115:135-9. [PMID: 21872244 DOI: 10.1016/j.ijgo.2011.06.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 06/06/2011] [Accepted: 07/27/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To assess the feasibility of introducing misoprostol for the treatment of incomplete abortion in Quito, Ecuador. METHODS In a randomized prospective study conducted at a large tertiary-level maternity hospital and a private secondary-level clinic between November 2006 and November 2007, women with incomplete abortion were treated with either 600 μg of oral misoprostol (n=122) or manual vacuum aspiration (MVA) (n=120). All participants were requested to return for follow-up care on day 7 to determine the success of the treatment and to document their satisfaction with the method and the adverse effects experienced. RESULTS Sixteen percent of women (39/242) did not return for their follow-up visit and their outcomes are unknown. Among those who did return, 94% (100/106) of women showed successful completion of abortion after treatment with misoprostol, as compared with 100% (97/97) of women treated with MVA. Most women described their adverse effects after treatment as tolerable (misoprostol, 95%; MVA, 91%). Nearly all women reported being satisfied with their treatment (196/203); there were no differences among the women's reports of satisfaction according to treatment received. CONCLUSION An oral dose of 600 μg of misoprostol was found to be an acceptable and effective non-surgical option for treating incomplete abortion. Clinical trials.gov NCT00674232.
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Abstract
Forty per cent of the world's women are living in countries with restrictive abortion laws, which prohibit abortion or only allow abortion to protect a woman's life or her physical or mental health. In countries where abortion is restricted, women have to resort to clandestine interventions to have an unwanted pregnancy terminated. As a consequence, high rates of unsafe abortion are seen, such as in Sub-Saharan Africa where unsafe abortion occurs at rates of 18-39 per 1 000 women. The circumstances under which women obtain unsafe abortion vary and depend on traditional methods known and types of providers present. Health professionals are prone to use instrumental procedures to induce the abortion, whereas traditional providers often make a brew of herbs to be drunk in one or more doses. In countries with restrictive abortion laws, high rates of maternal death must be expected, and globally an estimated 66 500 women die every year as a result of unsafe abortions. In addition, a far larger number of women experience short- and long-term health consequences. To address the harmful health consequences of unsafe abortion, a postabortion care model has been developed and implemented with success in many countries where women do not have legal access to abortion. Postabortion care focuses on treatment of incomplete abortion and provision of postabortion contraceptive services. To enhance women's access to postabortion care, focus is increasingly being placed on upgrading midlevel providers to provide emergency treatment as well as implementing misoprostol as a treatment strategy for complications after unsafe abortion.
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Affiliation(s)
- Vibeke Rasch
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark.
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Dabash R, Ramadan MC, Darwish E, Hassanein N, Blum J, Winikoff B. A randomized controlled trial of 400-μg sublingual misoprostol versus manual vacuum aspiration for the treatment of incomplete abortion in two Egyptian hospitals. Int J Gynaecol Obstet 2011; 111:131-5. [PMID: 20801444 DOI: 10.1016/j.ijgo.2010.06.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 06/02/2010] [Accepted: 07/20/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare the safety, efficacy, and acceptability of 400-μg sublingual misoprostol with that of manual vacuum aspiration (MVA) in 2 Egyptian hospitals. METHODS Participating women were randomized to either MVA or misoprostol treatment for incomplete abortion. The primary outcome, complete uterine evacuation, was determined 1 week later, as were adverse effects, change in hemoglobin, acceptability, and satisfaction. RESULTS Complete uterine evacuation was achieved in 98.3% of women who received misoprostol and 99.7% who underwent MVA (relative risk [RR] 0.99; 95% confidence interval [CI], 0.97-1.00). A decrease in hemoglobin of 2g/dL or more was comparably rare in the 2 groups (0.3% misoprostol vs 0.9% MVA; RR 0.34 [95% CI, 0.04-3.21]). Mean change in hemoglobin was also clinically similar (-0.5 g/dL misoprostol vs -0.4 g/dL MVA; P<0.01). Heavy bleeding was rare (2.4% misoprostol vs 1.6% MVA; RR 1.55 [95% CI, 0.51-4.68]) following treatment. Nearly all women (96.8% misoprostol vs 98.3% MVA) were satisfied with their treatment but those who received misoprostol were significantly more likely to prefer that method in the future (81.9% vs 62.8%; RR 1.30 [95% CI, 1.19-1.43]). CONCLUSION The high efficacy, safety, and acceptability of 400-μg sublingual misoprostol indicate that it is analogous to surgery as a first-line treatment for incomplete abortion. Misoprostol might improve post-abortion care when resources are limited and surgical treatment is unavailable.
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Oral misoprostol as an alternative to surgical management for incomplete abortion in Ghana. Int J Gynaecol Obstet 2010; 112:40-4. [PMID: 21122848 DOI: 10.1016/j.ijgo.2010.08.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 08/24/2010] [Accepted: 10/29/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate whether 600-μg oral misoprostol is an effective alternative to manual vacuum aspiration (MVA) for the treatment of incomplete abortion. METHODS From June 16, 2004, to July 20, 2005, 230 women of reproductive age presenting with incomplete abortion were randomized in an open-label trial to either 600-μg oral misoprostol or MVA for the treatment of incomplete abortion. RESULTS Regardless of the assigned method, more than 98% of participants experienced complete uterine evacuation following initial treatment. Efficacy, acceptability, and satisfaction ratings were similar and high for both methods. CONCLUSION 600-μg oral misoprostol is a safe, effective, and acceptable alternative to MVA for the treatment of incomplete abortion.
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Abstract
BACKGROUND Incomplete miscarriage is a major problem that should be effectively managed with safe and appropriate procedures. Surgical evacuation of the uterus for management of incomplete miscarriage usually involves vacuum aspiration or sharp curettage. OBJECTIVES To compare the safety and effectiveness of surgical uterine evacuation methods for management of incomplete miscarriage. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2010). SELECTION CRITERIA Randomized trials where different surgical methods were used to manage incomplete miscarriage were eligible for inclusion. DATA COLLECTION AND ANALYSIS We extracted population characteristics, settings, and exclusion criteria, in addition to outcomes such as complications of the procedure, duration, need for re-evacuation, blood transfusion, and analgesia/anesthesia. MAIN RESULTS Two trials (involving 550 women) were included. Vacuum aspiration was associated with statistically significantly decreased blood loss (mean difference (MD) -17.10 ml, 95% confidence interval (CI) -24.05 to -10.15 ml), less pain during the procedure (risk ratio (RR) 0.74, 95% CI 0.61 to 0.90), and shorter duration of the procedure (MD -1.20 minutes, 95% CI -1.53 to -0.87 minutes), than sharp metal curettage, in the single study that evaluated these outcomes in 357 women. Serious complications such as uterine perforation and other morbidity were rare and the sample sizes of the trials were not large enough to evaluate small or moderate differences. AUTHORS' CONCLUSIONS Although the review indicates that vacuum aspiration is safe, quick to perform, and less painful than sharp curettage, and should be recommended for use in the management of incomplete miscarriage, the results are based on data from only one study. Analgesia and sedation should be provided as necessary for the procedure.
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Affiliation(s)
- Özge Tunçalp
- Johns Hopkins Bloomberg School of Public HealthPopulation, Family and Reproductive Health615 N Wolfe StBaltimoreMDUSA21205
| | - A Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - João Paulo Souza
- World Health OrganizationDepartment of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
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Tsu VD, Coffey PS. New and underutilised technologies to reduce maternal mortality and morbidity: what progress have we made since Bellagio 2003? BJOG 2009; 116:247-56. [PMID: 19076957 DOI: 10.1111/j.1471-0528.2008.02046.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In 2003, maternal health experts met in Bellagio, to consider new and underutilised technologies vital to pregnancy-related health services in low-resource settings. Five years later, we examine what progress has been made and what new opportunities may be on the horizon. Based on a review of literature and consultation with experts, we consider technologies addressing the five leading causes of maternal mortality: postpartum haemorrhage, eclampsia, obstructed labour, puerperal sepsis, and unsafe abortion (pregnancy termination and miscarriage). In addition, we consider technologies related to obstetric fistula, which has received more attention in recent years.
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Affiliation(s)
- V D Tsu
- PATH, Seattle, WA 98107, USA.
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Prata N, Sreenivas A, Vahidnia F, Potts M. Saving maternal lives in resource-poor settings: facing reality. Health Policy 2008; 89:131-48. [PMID: 18620778 DOI: 10.1016/j.healthpol.2008.05.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2007] [Revised: 04/30/2008] [Accepted: 05/06/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Evaluate safe-motherhood interventions suitable for resource-poor settings that can be implemented with current resources. METHODS Literature review to identify interventions that require minimal treatment/infrastructure and are not dependent on skilled providers. Simulations were run to assess the potential number of maternal lives that could be saved through intervention implementation according to potential program impact. Regional and country level estimates are provided as examples of settings that would most benefit from proposed interventions. RESULTS Three interventions were identified: (i) improve access to contraception; (ii) increase efforts to reduce deaths from unsafe abortion; and (iii) increase access to misoprostol to control postpartum hemorrhage (including for home births). The combined effect of postpartum hemorrhage and unsafe abortion prevention would result in the greatest gains in maternal deaths averted. DISCUSSION/CONCLUSIONS Bold new initiatives are needed to achieve the Millennium Development Goal of reducing maternal mortality by three-quarters. Ninety-nine percent of maternal deaths occur in developing countries and the majority of these women deliver alone, or with a traditional birth attendant. It is time for maternal health program planners to reprioritize interventions in the face of human and financial resource constraints. The three proposed interventions address the largest part of the maternal health burden.
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Affiliation(s)
- Ndola Prata
- Bixby Program in Population, Family Planning, and Maternal Health, School of Public Health, University of California, Berkeley, United States.
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Shannon C, Winikoff B. How much Supervision is Necessary for Women Taking Mifepristone and Misoprostol for Early Medical Abortion? WOMENS HEALTH 2008; 4:107-11. [DOI: 10.2217/17455057.4.2.107] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Caitlin Shannon
- Gynuity Health Projects, 15 East 26th Street, Suite 1617, NY 10010, USA, Tel.: +1 212 448 1230; Fax: +1 212 448 1260
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Misoprostol for the termination of pregnancy up to 12 completed weeks of pregnancy. Int J Gynaecol Obstet 2007; 99 Suppl 2:S172-7. [DOI: 10.1016/j.ijgo.2007.09.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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