Mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage (MifeMiso): a randomised, double-blind, placebo-controlled trial

A Review of Miscarriage and Healthcare Communication in the United States

Miscarriage is a pervasive and socioemotionally complex pregnancy complication. Evidence suggests that poor clinical management can worsen these experiences. Yet, assessments of healthcare communication during a miscarriage are limited and a systematic review of the literature is needed. This review identified and synthesized original research on miscarriage and healthcare communication in the United States from the past 20 years to identify existing knowledge gaps for future miscarriage research. The following databases were searched: PubMed, PsychINFO, and ERIC Database. Data were charted according to Arksey and O'Malley's Scoping Review Framework. Eleven articles were included in the review and three primary themes emerged: (a) patients overwhelmingly prefer patient-centered care; (b) miscarriage is often overmedicalized, which leads to poor communication; and (c) informed decision-making related to one's miscarriage can improve patient experiences. Several gaps were also identified, including studies seeking physician perspectives on miscarriage communication, evaluation of standard care guidelines, and studies evaluating diverse patients' perspectives. This review highlights the need for patient-centered care that utilizes compassionate and accessible language and promotes informed decision-making. Future research should use quantitative methodologies and longitudinal designs to build upon these findings and improve patient experiences of miscarriage.

Comparing the effectiveness of letrozole versus methotrexate for treatment of ectopic pregnancy: A randomized controlled trial

OBJECTIVE

To evaluate the efficacy of two different regimens of Letrozole, an aromatase inhibitor, in the management of ectopic pregnancy compared to methotrexate.

STUDY DESIGN

This randomized controlled trial was conducted on 88 women diagnosed with ectopic pregnancy with a baseline level of serum beta-human chorionic gonadotropin under 3000 mIU/mL between June 30, 2023, and December 30, 2023, at the Department of Obstetrics and Gynecology of the Vali-e-Asr Hospital affiliated with Tehran University of Medical Sciences. Participants were allocated into either methotrexate (n = 43), 5-day course Letrozole (n = 24), or 10-day course Letrozole (n = 21) treatments. The methotrexate group received a single dose of 50 mg/m2 dosage intramuscular methotrexate. The 5-day Letrozole group received a 2.5 mg Letrozole tablet three times daily for 5 days, whereas the 10-day Letrozole group received a 2.5 mg Letrozole tablet twice daily for 10 days. The primary outcome was the treatment response, defined as the achievement of a negative serum beta-human chorionic level without the need for additional methotrexate treatment or surgery. The secondary outcomes were the need for additional methotrexate dose or laparoscopic surgery intervention. The trial protocol was prospectively registered in ClinicalTrials.gov with code NCT05918718.

RESULTS

The treatment response rates in methotrexate, 5-day Letrozole, and 10-day Letrozole groups were 76.7 %, 75.0 %, and 90.5 %, respectively, with no significant differences between the groups (P-value = 0.358). A total of 10 (23.3 %) patients from the methotrexate group, 3 (12.5 %) from the 5-day Letrozole group, and 2 (9.5 %) from the 10-day Letrozole group required an additional methotrexate dose, with no significant differences between the groups (P-value = 0.307). Furthermore, only 3 (12.5 %) patients, all from the 5-day Letrozole group, were suspected of tubal rupture and underwent surgery (P-value = 0.016).

CONCLUSION

Our findings suggest Letrozole as a safe alternative to methotrexate in treating stable ectopic pregnancies, with a favorable treatment response rate. However, there is still a need for future larger studies to determine the applicability of Letrozole in the EP management. Also, the non-significant higher effectiveness of the 10-day Letrozole regimen than the 5-day Letrozole group underscores the need for future research to determine the optimal Letrozole regimen for the management of ectopic pregnancy.

The Success of Mifepristone and Misoprostol in the Management of Early Pregnancy Loss at a Community Hospital: A Prospective Study

BACKGROUND

This prospective single-arm study was conducted to understand the expulsion rate of the gestational sac in the management of early pregnancy loss (EPL).

METHODS

We recruited 441 participants; 188 met eligibility criteria. Participants were 18 years of age and older who experienced a confirmed early pregnancy loss (<12 weeks gestational age) defined by an intrauterine pregnancy with a non-viable embryonic or anembryonic gestational sac with no fetal heart activity. Participants were given 200 mg of mifepristone pretreatment orally followed by two doses of misoprostol 800 mcg vaginally after 24 and 48 hours. Participants were seen in follow-up on day 14 to confirm the absence of a gestational sac, classified as treatment success. For failed treatment (defined by retained gestational sac), we offered expectant management or a third dose of misoprostol and/or dilatation and curettage (D & C). We followed all participants for 30 days. We collected data on overtreatment for retained products of conception and hospital admissions for adverse events.

RESULTS

181 participants followed the protocol, and 169 (93.3%) participants had a complete expulsion of the gestational sac by the second visit (day 14). Twelve (6.6%) failed the treatment and one had an adverse event of heavy vaginal bleeding requiring D & C. Despite the expulsion of the gestational sac, 29 cases (17.1%) at subsequent follow-up were diagnosed as retained products of conception based on ultrasound assessment of thickened endometrium.

CONCLUSION

Pretreatment with mifepristone followed by 2 doses of misoprostol with a 14-day follow-up resulted in a high expulsion rate and is a safe management option for EPL.

Medical treatment for early pregnancy loss following in vitro fertilization compared to spontaneous pregnancies

BACKGROUND

Misoprostol is a well-studied medical treatment for early pregnancy loss (EPL), with success rates ranging between 70 and 90%. However, treatment failure is associated with major patient discomfort, including the need for surgical intervention to evacuate the uterus. It was previously reported that medical treatment was especially successful among women who conceived after in vitro fertilization (IVF). We aimed to study if there is a difference in rates of medical treatment failures for EPL between pregnancies conceived by IVF and spontaneous pregnancies.

METHODS

In this retrospective cohort study, we included all women who underwent medical treatment for EPL at our institute between 07/2015 and 12/2020. Treatment outcome was compared between IVF and spontaneous pregnancies. Treatment failure was defined as a need for surgical intervention, namely, dilation & curettage (D&C) and/or hysteroscopy, due to retained products of conception, which was defined as a gestational sac or endometrial thickness greater than 15 mm in a TVS scan.

RESULTS

Overall, 775 patients were included, of which 195 (169/775 = 25.1%) ultimately required surgical intervention. There was no difference between the study groups in the rate of treatment failure. However, among IVF pregnancies, the rate of emergency D&C was lower (3.6% vs. 9.8%, p = 0.001), compared to spontaneous group.

CONCLUSION

In cases of medical treatment for EPL, IVF pregnancies had no differences in rates of treatment failure compared to spontaneous pregnancies. That being said, IVF pregnancies have lower chances to undergo emergency D&C, compared to spontaneous pregnancies.

Retrospective cohort study comparing success of medical management of early pregnancy loss in pregnancies conceived with and without medical assistance

OBJECTIVE

To compare the success rates of medical management using a combined mifepristone and misoprostol protocol in cases of early pregnancy loss (EPL) between women who conceived without medical assistance and those who conceived through in vitro fertilization (IVF), after fresh or frozen embryo transfer, and evaluate for the predictive factors of success, time to first passage of tissue, and time to complete resolution of pregnancy.

DESIGN

Retrospective cohort study.

SETTING

University hospital.

PATIENT(S)

Women who presented with EPL below 13 weeks of gestation between June 2013 and July 2021 who were managed medically with mifepristone 200 mg orally and misoprostol 800 mcg vaginally were included in the study.

INTERVENTION(S)

Medical management with mifepristone and misoprostol; conception without medical assistance vs. post-IVF, after fresh or frozen embryo transfer.

MAIN OUTCOME MEASURE(S)

We evaluated overall success and performed subgroup analysis according to the mode of conception and compared fresh vs. frozen-thawed embryo transfers for IVF pregnancies. In all groups, we also calculated success according to gestational age and compared the time to first passage of tissue. The potential predictive factors of treatment success were analyzed. The side effects and complications of treatment were recorded.

RESULT(S)

A total of 930 women were included in the study, 99 (11%) of whom achieved pregnancy after IVF. The overall success of medical treatment was 89% with no statistically significant difference according to the mode of conception (89% vs. 89%) or type of transfer (fresh 89% vs. frozen 89%). Only lower gestational age by sonography was independently predictive of treatment success, showing a negative regression coefficient of β = -0.333 and an odds ratio of 0.717. The mean time to first passage of tissue was 5.0 ± 2.1 hours. Altogether, 666 women (72%) showed pregnancy resolution on the day of medication administration, an additional 110 women at 1-week follow-up, and a further 74 women after ≥4 weeks on ultrasound.

CONCLUSION(S)

Medical management of EPL with mifepristone and misoprostol is a highly successful treatment option that results in completed abortion in a timely fashion in both pregnancies conceived without medical assistance and those conceived after IVF.

Mifepristone Use Among Obstetrician-Gynecologists in Massachusetts: Prevalence and Predictors of Use

OBJECTIVES

We estimated the prevalence of mifepristone use for evidence-based indications among obstetrician-gynecologists in independent practice in Massachusetts and explored the demographic and practice-related factors associated with use.

METHODS

We used data from a cross-sectional survey administered to Massachusetts obstetrician-gynecologists identified from the American Medical Association Physician Masterfile. We measured the prevalence of mifepristone use for four clinical scenarios: early pregnancy loss, medication abortion, cervical preparation before dilation and evacuation procedures, and cervical preparation before induction of labor. Multivariate regression was used to calculate the odds of mifepristone use for these scenarios based on practice type, years in practice, physician sex, and history of medication abortion training.

RESULTS

A total of 198 obstetrician-gynecologists responded to the survey (response rate = 29.0%); this analysis was limited to 158 respondents who were not in residency or fellowship. Overall, 46.0% used mifepristone for early pregnancy loss and 38.6% for medication abortion. Fewer used mifepristone for cervical preparation before dilation and evacuation (26.0%) or before induction of labor (26.4%). Respondents in academic practice settings, with more years in practice, of female sex, and with sufficient medication abortion training were significantly more likely to use mifepristone for one or more evidence-based clinical indications.

CONCLUSIONS

Sufficient medication abortion training during residency significantly predicts whether obstetrician-gynecologists use mifepristone in practice. The U.S. Supreme Court's overturning of Roe v. Wade will allow state-level abortion bans and restrictions to be in effect, which will reduce exposure to abortion training during residency. Increasing training in and utilization of mifepristone are critical for equitable access to reproductive health services. Further interventions may need to be developed to increase mifepristone use in nonacademic practice settings.

Development and validation of a visualized prediction model for early miscarriage risk in patients undergoing IVF/ICSI procedures: a real-world multi-center study

Background

This study focuses on the risk of early miscarriage in patients undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). These patients commonly experience heightened stress levels and may discontinue treatment due to emotional burdens associated with repeated failures. Despite the identification of numerous potential factors contributing to early miscarriage, there exists a research gap in integrating these factors into predictive models specifically for IVF/ICSI patients. The objective of this study is to develop a user-friendly nomogram that incorporates relevant risk factors to predict early miscarriage in IVF/ICSI patients. Through internal and external validation, the nomogram facilitates early identification of high-risk patients, supporting clinicians in making informed decisions.

Methods

A retrospective analysis was conducted on 20,322 first cycles out of 31,307 for IVF/ICSI treatment at Sun Yat-sen Memorial Hospital between January 2011 and December 2020. After excluding ineligible cycles, 6,724 first fresh cycles were included and randomly divided into a training dataset (n = 4,516) and an internal validation dataset (n = 2,208). An external dataset (n = 1,179) from another hospital was used for validation. Logistic and LASSO regression models identified risk factors, and a multivariable logistic regression constructed the nomogram. Model performance was evaluated using AUC, calibration curves, and decision curve analysis (DCA).

Results

Significant risk factors for early miscarriage were identified, including female age, BMI, number of spontaneous abortions, number of induced abortions and medical abortions, basal FSH levels, endometrial thickness on hCG day, and number of good quality embryos. The predictive nomogram demonstrated good fit and discriminatory power, with AUC values of 0.660, 0.640, and 0.615 for the training, internal validation, and external validation datasets, respectively. Calibration curves showed good consistency with actual outcomes, and DCA confirmed the clinical usefulness. Subgroup analysis revealed variations; for the elder subgroup (age ≥35 years), female age, basal FSH levels, and number of available embryos were significant risk factors, while for the younger subgroup (age <35 years), female age, BMI, number of spontaneous abortions, and number of good quality embryos were significant.

Conclusions

Our study provides valuable insights into the impact factors of early miscarriage in both the general study population and specific age subgroups, offering practical recommendations for clinical practitioners. We have taken into account the significance of population differences and regional variations, ensuring the adaptability and relevance of our model across diverse populations. The user-friendly visualization of results and subgroup analysis further enhance the applicability and value of our research. These findings have significant implications for informed decision-making, allowing for individualized treatment strategies and the optimization of outcomes in IVF/ICSI patients.

Comparing letrozole and mifepristone pre-treatment in medical management of first trimester missed miscarriage: a prospective open-label non-inferiority randomised controlled trial

OBJECTIVE

To investigate whether letrozole pre-treatment is non-inferior to mifepristone pre-treatment, followed by misoprostol, for complete evacuation in the medical treatment of first-trimester missed miscarriage.

DESIGN

Prospective open-label non-inferiority randomised controlled trial.

SETTING

A university-affiliated hospital.

POPULATION

We recruited 294 women diagnosed with first-trimester missed miscarriage who opted for medical treatment.

METHODS

Participants were randomly assigned to: (i) the mifepristone group, who received 200 mg mifepristone orally followed 24-48 h later by 800 μg misoprostol vaginally; or (ii) the letrozole group, who received 10 mg letrozole orally once-a-day for 3 days, followed by 800 μg misoprostol vaginally on the third (i.e. last) day of letrozole administration.

MAIN OUTCOME MEASURES

The primary outcome was the rate of complete evacuation without surgical intervention at 42 days post-treatment. Secondary outcomes included induction-to-expulsion interval, adverse effects, women's satisfaction, number of doses of misoprostol required, duration of vaginal bleeding, pain score on the day of misoprostol administration and other adverse events.

RESULTS

The complete evacuation rates were 97.8% (95% CI 95.1%-100%) and 97.2% (95% CI 94.4%-99.9%) in the letrozole and mifepristone groups, respectively (p ≤ 0.001 for non-inferiority). The mean induction-to-tissue expulsion interval in the letrozole group was longer compared with the mifepristone group (15.4 vs 9.0 h) (p = 0.03). The letrozole group had less heavy post-treatment bleeding and an earlier return of menses. There were no statistically significant differences in the number of doses of misoprostol required, the duration of vaginal bleeding, the pain score on the day of misoprostol administration and the rate of other adverse events between the two groups. The majority of the women (91.2% and 93.9% in the letrozole and mifepristone groups, respectively) were satisfied with their treatment option.

CONCLUSIONS

Letrozole is non-inferior to mifepristone as a pre-treatment, followed by misoprostol, for the medical treatment of first-trimester missed miscarriage.

Improving access, understanding, and dignity during miscarriage recovery in British Columbia, Canada: A patient-oriented research study

BACKGROUND

Approximately 15%-25% of clinical pregnancies end in miscarriage, with more than 15,000 miscarriages occurring annually in British Columbia, Canada. Despite the significant rates of loss, research and health care services for pregnancy loss remain scarce in British Columbia.

OBJECTIVES

This study aimed to (1) aid miscarriage recovery through the identification and sharing of equitable pregnancy loss care practices and supports and (2) present policy recommendations to improve prenatal care guidelines and employment standards for pregnancy loss.

DESIGN

This research took a patient-oriented methodological approach alongside people with lived/living experience(s) of miscarriage recovery in British Columbia to evaluate access to health care during pregnancy loss, societal understanding of miscarriage, and treatment options that foreground dignity.

METHODS

The mixed-methods design of this research included policy research on prenatal care guidelines, policy research on provincial and territorial employment legislation for bereavement leave, semi-structured interviews (n = 27), and a discovery action dialogue (n = 4).

RESULTS

The findings of this research demonstrate the need for improved prenatal care guidelines for early pregnancy loss, follow-up care after a miscarriage, mental health screening and supports, and bereavement leave legislation.

CONCLUSION

This article includes recommendations to improve equitable access to pregnancy loss care, bereavement leave legislation, and future research in this area.

Combination of Mifepristone and Misoprostol for First-Trimester Medical Abortion: A Comprehensive Review of the Literature

Importance

Several medications have been used to achieve medical abortion in the first trimester of pregnancy. The most commonly used is the combination of mifepristone and misoprostol; however, different doses and routes of administration have been proposed.

Objective

The aim of this study was to summarize published data on the effectiveness, adverse effects, and acceptability of the various combinations of mifepristone and misoprostol in medical abortion protocols in the first trimester of pregnancy.

Evidence Acquisition

This was a comprehensive review, synthesizing the findings of the literature on the current use of mifepristone and misoprostol for first-trimester abortion.

Results

The combination of mifepristone and misoprostol seems to be more effective than misoprostol alone. Regarding the dosages and routes, mifepristone is administered orally, and the optimal dose is 200 mg. The route of administration of misoprostol varies; the sublingual and buccal routes are more effective; however, the vaginal route (800 μg) is associated with fewer adverse effects. Finally, the acceptability rates did not differ significantly.

Conclusions

Different schemes for first-trimester medical abortion have been described so far. Future research needs to focus on identifying the method that offers the best trade-off between efficacy and safety in first-trimester medical abortion.

Medical management of first trimester miscarriage: a quality improvement initiative

INTRODUCTION

Medical management of first trimester pregnancy loss is a safe option that is well tolerated and affords women more autonomy in relation to their care. Recent trials provide robust evidence that mifepristone pretreatment is the optimal approach for women with missed miscarriage who desire medical management.

METHODS

Following a change in medical management of first trimester miscarriage in our unit, we conducted a retrospective audit over a 3-month period of all women who had elected medical management as their primary treatment option. We compared the results with a previous audit that had been undertaken prior to the change in practice.

RESULTS

The implementation of mifepristone resulted in an increased effectiveness of primary medical treatment for first trimester miscarriage from 53.8% to 85.2% (p=<0.001).

DISCUSSION

The results of our study support the introduction of mifepristone into routine clinical practice for medical management of first trimester pregnancy loss across all maternity units.

YAP-mediated trophoblast dysfunction: the common pathway underlying pregnancy complications

Yes-associated protein (YAP) is a pivotal regulator in cellular proliferation, survival, differentiation, and migration, with significant roles in embryonic development, tissue repair, and tumorigenesis. At the maternal-fetal interface, emerging evidence underscores the importance of precisely regulated YAP activity in ensuring successful pregnancy initiation and progression. However, despite the established association between YAP dysregulation and adverse pregnancy outcomes, insights into the impact of aberrant YAP levels in fetal-derived, particularly trophoblast cells, and the ensuing dysfunction at the maternal-fetal interface remain limited. This review comprehensively examines YAP expression and its regulatory mechanisms in trophoblast cells throughout pregnancy. We emphasize its integral role in placental development and maternal-fetal interactions and delve into the correlations between YAP dysregulation and pregnancy complications. A nuanced understanding of YAP's functions during pregnancy could illuminate intricate molecular mechanisms and pave the way for innovative prevention and treatment strategies for pregnancy complications. Video Abstract.

Efficacy, Safety, and Acceptability of Misoprostol in the Treatment of Incomplete Miscarriage: A Systematic Review and Meta-analysis

OBJECTIVE

 To assess the efficacy, safety, and acceptability of misoprostol in the treatment of incomplete miscarriage.

DATA SOURCES

The PubMed, Scopus, Embase, Web of Science, Cochrane Library, and Clinical Trials databases (clinicaltrials.gov) were searched for the relevant articles, and search strategies were developed using a combination of thematic Medical Subject Headings terms and text words. The last search was conducted on July 4, 2022. No language restrictions were applied.

SELECTION OF STUDIES

 Randomized clinical trials with patients of gestational age up to 6/7 weeks with a diagnosis of incomplete abortion and who were managed with at least 1 of the 3 types of treatment studied were included. A total of 8,087 studies were screened.

DATA COLLECTION

 Data were synthesized using the statistical package Review Manager V.5.1 (The Cochrane Collaboration, Oxford, United Kingdom). For dichotomous outcomes, the odds ratio (OR) and 95% confidence interval (CI) were derived for each study. Heterogeneity between the trial results was evaluated using the standard test, I2 statistic.

DATA SYNTHESIS

 When comparing misoprostol with medical vacuum aspiration (MVA), the rate of complete abortion was higher in the MVA group (OR = 0.16; 95%CI = 0.07-0.36). Hemorrhage or heavy bleeding was more common in the misoprostol group (OR = 3.00; 95%CI = 1.96-4.59), but pain after treatment was more common in patients treated with MVA (OR = 0.65; 95%CI = 0.52-0.80). No statistically significant differences were observed in the general acceptability of the treatments.

CONCLUSION

 Misoprostol has been determined as a safe option with good acceptance by patients.

Approved but Unavailable: A Mystery-Caller Survey of Mifepristone Access in a Large Ontario City

OBJECTIVES

Mifepristone/misoprostol (mife/miso) has been approved in Canada since 2017, and is available since 2018. Mife/miso does not require witnessed administration in Canada, and therefore most patients obtain a prescription for home use. We sought to determine the proportion of pharmacies in Hamilton, Ontario, Canada, a city of over 500 000, that had combination mife/miso in stock at any given time.

METHODS

A mystery-caller approach was used to survey all pharmacies (n = 218) in Hamilton, Ontario, Canada between June 2022 and September 2022.

RESULTS

Of the 208 pharmacies that were successfully contacted, only 13 (6%) pharmacies had mife/miso in stock. The most commonly cited reasons for the medication being unavailable were low patient demand (38%), cost (22%), lack of familiarity with medication (13%), supplier issues (9%), training requirements (8%), and medication expiry (7%).

CONCLUSIONS

These findings suggest that while mife/miso has been available in Canada since 2017, significant barriers remain to patients accessing this medication. This study clearly demonstrates a need for further advocacy and clinician education to ensure mife/miso is accessible to the patients who require it.

Utility of Office Hysteroscopy in Diagnosing Retained Products of Conception Following Early Pregnancy Loss After In Vitro Fertilization

OBJECTIVE

To evaluate the utility of office hysteroscopy in diagnosing and treating retained products of conception in patients with infertility who experience early pregnancy loss (EPL) after in vitro fertilization (IVF).

METHODS

We evaluated a retrospective cohort of 597 pregnancies that ended in EPL in patients aged 18-45 years who conceived through fresh or frozen embryo transfer at an academic fertility practice between January 2016 and December 2021. All patients underwent office hysteroscopy after expectant, medical, or surgical management of the EPL. The primary outcome was presence of retained products of conception at the time of office hysteroscopy. Secondary outcomes included incidence of vaginal bleeding, presence of intrauterine adhesions, treatment for retained products of conception, and duration of time from EPL diagnosis to resolution. Log-binomial regression and Poisson regression were performed, adjusting for potential confounders including oocyte age, patient age, body mass index, prior EPL count, number of prior dilation and curettage procedures, leiomyomas, uterine anomalies, and vaginal bleeding.

RESULTS

Of the 597 EPLs included, 129 patients (21.6%) had retained products of conception diagnosed at the time of office hysteroscopy. The majority of individuals with EPL were managed surgically (n=427, 71.5%), in lieu of expectant management (n=140, 23.5%) or medical management (n=30, 5.0%). The presence of retained products of conception was significantly associated with vaginal bleeding (relative risk [RR] 1.72, 95% CI 1.34-2.21). Of the 41 patients with normal pelvic ultrasonogram results before office hysteroscopy, 10 (24.4%) had retained products of conception detected at the time of office hysteroscopy. When stratified by EPL management method, retained products of conception were significantly more likely to be present in individuals with EPL who were managed medically (adjusted RR 2.66, 95% CI 1.90-3.73) when compared with those managed surgically. Intrauterine adhesions were significantly less likely to be detected in individuals with EPL who underwent expectant management when compared with those managed surgically (RR 0.14, 95% CI 0.04-0.44). Of the 127 individuals with EPL who were diagnosed with retained products of conception at the time of office hysteroscopy, 30 (23.6%) had retained products of conception dislodged during the office hysteroscopy, 34 (26.8%) chose expectant or medical management, and 63 (49.6%) chose surgical management. The mean number of days from EPL diagnosis to resolution of pregnancy was significantly higher in patients who elected for expectant management (31 days; RR 1.18, 95% CI 1.02-1.37) or medical management (41 days; RR 1.54, 95% CI 1.25-1.90) when compared with surgical management (27 days).

CONCLUSION

In patients with EPL after IVF, office hysteroscopy detected retained products of conception in 24.4% of those with normal pelvic ultrasonogram results. Due to the efficacy of office hysteroscopy in diagnosing and treating retained products of conception, these data support considering office hysteroscopy as an adjunct to ultrasonography in patients with infertility who experience EPL after IVF.

Management of early pregnancy loss among obstetrician-gynecologists in Massachusetts and barriers to mifepristone use

OBJECTIVES

To measure the prevalence of early pregnancy loss management types among obstetrician-gynecologists in Massachusetts, and delineate barriers, facilitators, demographic and practice-related factors associated with mifepristone use for early pregnancy loss.

STUDY DESIGN

We surveyed a census of obstetrician-gynecologists in Massachusetts. Descriptive statistics measured the prevalence of offering expectant, misoprostol-alone, mifepristone and misoprostol, dilation and curettage in the office and operating room, and multivariate logistic regression analysis evaluated barriers and facilitators to mifepristone use. Data were weighted to account for nonresponders.

RESULTS

198 obstetrician-gynecologists responded to the survey (response rate=29%). Participants most commonly offered expectant management (98%), dilation and curettage in the operating room (94%), and misoprostol-only medication management (80%). Fewer offered mifepristone-misoprostol (51%) or dilation and curettage in an office setting (45%). Those in private practice or other practice types had lower odds of offering mifepristone-misoprostol than those in academic practice (private practice: aOR 0.34, 95% confidence interval [CI] [0.19, 0.61]). Female physicians had higher odds of offering mifepristone-misoprostol (aOR 1.97, 95% CI [1.11, 3.49]). Obstetrician-gynecologists who included medication abortion in their practice had much higher odds of using mifepristone for early pregnancy loss (aOR 25.06, 95% CI [14.52, 43.24]). The Food and Drug Administration Risk and Evaluation Management Strategies Program was a primary barrier among those not using mifepristone (54%).

CONCLUSIONS

Many obstetrician-gynecologists do not offer mifepristone-based regimens for early pregnancy loss, which are more efficacious than misoprostol-only regimens. The Food and Drug Administration Risk Evaluation and Mitigation Strategies Program is a major barrier to mifepristone use.

IMPLICATIONS

Half of obstetrician-gynecologists in Massachusetts do not use mifepristone for early pregnancy loss management. Major barriers include lack of experience with mifepristone and the Food and Drug Administration Risk Evaluation and Mitigation Strategies Program regulations. Removing medically unnecessary regulations and increasing education on mifepristone via access to abortion care experts may increase uptake of this practice.

Early pregnancy loss medical management in clinical practice

OBJECTIVES

This study aimed to review clinical practice outcomes of early pregnancy loss (EPL) medical management using mifepristone and misoprostol outside of a clinical trial setting.

STUDY DESIGN

In this retrospective cohort study, we reviewed a deidentified database of patients who received mifepristone-misoprostol for EPL from May 2018 to May 2021 at our academic center-based clinic, which was a study site for a multicenter mifepristone-misoprostol EPL trial completed in March 2018. All patients received mifepristone 200 mg orally and misoprostol 800 mcg vaginally or buccally, with clinic follow-up typically scheduled within 1 week. The primary outcome was successful medical management, defined as management without the need for aspiration, and the secondary outcomes included additional interventions and indications, follow-up ultrasonography findings, and adverse events requiring treatment.

RESULTS

We treated 90 patients with a median ultrasound-measured gestational size of 49 (range 30-80) days and median time from mifepristone to misoprostol of 24 (range 8-66) hours. Follow-up was completed in clinic by 80 (88.9%), completed remotely by five (5.6%), and not completed by five (5.6%) patients. Overall, 76 (95% CI 82.9%-96.0%) of 85 patients (89.4%) with follow-up were successfully managed without uterine aspiration. Eighty patients had initial follow-up ultrasonography interpreted as gestational sac expulsion; seven (8.8%) of these ultimately underwent aspiration, including one patient who had a previously undiagnosed cesarean scar ectopic pregnancy. Two patients had significant safety outcomes: one pelvic infection and one blood transfusion during aspiration in the patient with a cesarean scar ectopic pregnancy.

CONCLUSIONS

Outside of a clinical trial setting, medical management of EPL with mifepristone and misoprostol remains effective and safe.

IMPLICATIONS

Medical management of EPL with mifepristone and misoprostol is effective and safe outside of a clinical trial setting. A standardized protocol based on the best available clinical trial evidence can be used in clinical practice for the medical management of EPL.

The role of mifepristone on first trimester miscarriage treatment - A double-blind randomized controlled trial - MiFirsT

OBJECTIVES

To evaluate the efficacy of combined mifepristone and misoprostol compared to misoprostol alone in outpatient medical treatment of first trimester miscarriage. Additionally, the study intends to compare the rate of complications, adverse effects, and treatment acceptability between groups.

STUDY DESIGN

Single-center double-blind randomized placebo-controlled trial including women with diagnosis of missed first trimester miscarriage up to 9 weeks of gestation.

RESULTS

Between April 2019 and November 2021, 216 women diagnosed with first trimester miscarriage up to 9 weeks of gestation were randomly assigned to mifepristone group or to misoprostol-alone group. Data from 105 women in mifepristone group and 103 women in misoprostol-alone group were analyzed, with no differences in baseline characteristics. The median time between medications (oral mifepristone/placebo and vaginal misoprostol) was nearly 43 h in both groups (p = 0.906). The median time to first follow-up was 2.6 weeks (IQR 1.0) in mifepristone group and 2.4 weeks (IQR 1.0) in misoprostol-alone group (p = 0.855). The overall success rate of medical treatment was significantly higher in the mifepristone-group comparing to misoprostol-alone group (94.3% vs. 82.5%, RR 1.14, 95% CI, 1.03-1.26; p = 0.008). Accordingly, the rate of surgical treatment was significantly lower in the mifepristone-group (5.7% vs.14.6%, RR 0.39, 95% CI, 0.16-0.97; p = 0.034). The composite complication rate was similar and lower than 4% in both groups. No case of complicated pelvic infection, hemodynamic instability or inpatient supportive treatment was reported. There were no significant differences in the rates of adverse events, median score for vaginal bleeding intensity or analgesics use. Despite the same median value, the score of abdominal pain intensity was significantly higher in the mifepristone-group (p = 0.011). In both groups, more than 65% of the women classified the treatment as "good" and 92% would recommend it to a friend on the same clinical situation.

CONCLUSION

The mifepristone plus vaginal misoprostol combined treatment for medical resolution of first trimester miscarriage resulted in significant higher success rate and lower rate of surgical uterine evacuation comparing to misoprostol-alone treatment, with no relevant differences in adverse events or treatment acceptability.

Failure Rate of Medical Treatment for Miscarriage Correlated with the Difference between Gestational Age According to Last Menstrual Period and Gestational Size Calculated via Ultrasound

Objective: To study whether the interval between gestational age calculated using the last menstrual period (GA-LMP) and gestational age calculated via ultrasound (GA-US) is correlated with the success rate of medical treatment in cases of miscarriages. Methods: This was a retrospective cohort study conducted in a gynecology unit in a tertiary medical center. Women who underwent medical treatment with Misoprostol for miscarriage at the Edith Wolfson Medical Center between 07/2015 and 12/2020 were included. Incomplete or septic miscarriages, multiple pregnancies, patients with irregular periods, and cases of missing data were excluded. Failure of medical treatment was defined as the need for surgical intervention due to a retained gestational sac, severe bleeding or retained products of conception. The cohort study was divided into two groups: patients with successful treatment and patients for whom surgical intervention was eventually needed. We performed both a univariate and multivariate analysis in order to identify whether a correlation between GA-LMP and GA-US interval is indeed a factor in the success rate of a medical abortion. Results: Overall, 778 patients were included in the study. From this cohort 582 (74.9%) had undergone a successful medical treatment, while 196 (25.1%) required surgical intervention due to the failure of medical treatment, as defined above. The GA-LMP to GA-US interval (in weeks) was 2.6 ± 1.4 in the success group, while the GA in the failure group was 3.1 ± 1.6 (p < 0.001). After performing a multivariant regression analysis, we were able to show that the GA-LMP to GA-US interval was found to be independently correlated with an increase in the treatment failure rate (aOR = 1.24, CI 95% (1.01-1.51), p = 0.03). Conclusions: In cases of miscarriage, longer GA-LMP to GA-US interval has been shown to be an independently correlated factor to lower success rate of the medical treatment option.

Mifepristone use for early pregnancy loss: A qualitative study of barriers and facilitators among OB/GYNS in Massachusetts, USA

CONTEXT

Early pregnancy loss (EPL) affects 1 million patients in the United States (US) annually, but integration of mifepristone into EPL care may be complicated by regulatory barriers, practice-related factors, and abortion stigma.

METHODS

We conducted qualitative, semi-structured interviews among obstetrician-gynecologists in independent practice in Massachusetts, US on mifepristone use for EPL. We recruited participants via professional networks and purposively sampled for mifepristone use, practice type, time in practice, and geographic location within Massachusetts until we reached thematic saturation. We analyzed interviews using inductive and deductive coding under a thematic analysis framework to identify facilitators of and barriers to mifepristone use.

RESULTS

We interviewed 19 obstetrician-gynecologists; 12 had used mifepristone for EPL and 7 had not. Participants were in private practice (n = 12), academic practice (n = 6), or worked at a federally qualified health center (n = 1). Seven had fellowship training, including four in complex family planning. The most common facilitators of mifepristone use for EPL were access to the expertise or protocols of local-regional experts, leadership from a "champion," prior experience with abortion care, and hospital capacity constraints during the COVID-19 pandemic. The most common barriers were related to the Mifepristone Risk Evaluation and Mitigation Strategy (REMS) Program imposed by the US Food and Drug Administration (FDA). Additionally, mifepristone's affiliation with abortion was a barrier to its use in EPL for some obstetrician-gynecologists.

CONCLUSION

The FDA Mifepristone REMS Program presents substantial barriers to obstetrician-gynecologists incorporating mifepristone into their EPL care.

Trends in the Use of Mifepristone for Medical Management of Early Pregnancy Loss From 2016 to 2020

This study assesses the use of mifepristone plus misoprostol for miscarriage management among commercially insured adults in the US.

Have we overlooked the role of mifepristone for the medical management of tubal ectopic pregnancy?

Ectopic pregnancy is a risk of both spontaneous and assisted reproduction pregnancies. The majority of ectopic pregnancies abnormally implant within a fallopian tube (extrauterine pregnancies). In haemodynamically stable women, medical or expectant treatment can be offered. Currently accepted medical treatment is using a drug called methotrexate. However, methotrexate has potential adverse effects, and a significant proportion of women will still require emergency surgery (up to 30%) to remove the ectopic pregnancy. Mifepristone (RU-486) has anti-progesterone effects and has a role in managing intrauterine pregnancy loss and termination of pregnancy. On reviewing the literature and given progesterone's pivotal role in sustaining pregnancy, we propose that we may have overlooked the role of mifepristone in the medical management of tubal ectopic pregnancy in haemodynamically stable women.

Comparison of outpatient with inpatient mifepristone usage for cervical ripening: A randomised controlled trial

Purpose

The efficacy and safety of using mifepristone for the preinduction/induction of labour (IOL) as the only method or in combination with others has been confirmed in observational and randomised trials. However, there are currently no studies comparing the efficacy and safety of using mifepristone for the preinduction of labour on an inpatient and outpatient basis.

Objective

To evaluate whether the outpatient use of mifepristone for cervical ripening before IOL at term is as efficient and safe as in inpatients.

Study design

This open-label, prospective, two-arm, non-inferiority randomised controlled trial (ISRCTN26164110) with a 1:1 allocation ratio was conducted in a single tertiary referral hospital. Overall, 322 pregnant women (gestational age: 39-41 weeks; Bishop score < 6, intact membranes, no contraindications for vaginal delivery, and no contraindications for IOL) were included and randomised:162 to the outpatient group and 160 to the inpatient group for cervical ripening with mifepristone. Analyses were performed based on the intention-to-treat principle.

Results

In 16 % and 17 % of the cases, labour began spontaneously within 24-36 h after taking mifepristone tablets. The additional use of prostaglandin E2 or a balloon for cervical ripening occurred equally often in the compared groups. Oxytocin was used more frequently to induce labour in the inpatient group (P = 0.035). There was no difference in the length of the interval from the onset of cervical ripening to the onset of labour between the groups (38.6 vs. 38.8 h, P = 0.900). The failed induction rate was 1.85 % vs. 0.63 % (P = 0.346).Regional analgesia (P = 0.011) and abnormal foetal heart rate patterns (P = 0.027) were more common in the inpatient group. In the outpatient mifepristone preinduction group, the average time interval from hospitalisation to discharge was 25 h shorter (P < 0.001). No statistically significant differences were observed between the groups in terms of the rates of adverse side effects or perinatal outcomes.

Conclusion

Outpatient cervical ripening with mifepristone reduced the hospital stay duration compared to inpatient ripening, with no difference in efficacy in terms of improvement in the Bishop score, frequency of additional induction method usage, interval from start of preinduction to onset of labour, and labour duration.No differences in the delivery methods, failure rates, or perinatal outcomes were observed. The frequency of adverse effects was low and not related to the setting of the preinduction site. Cervical ripening with mifepristone can be performed on an outpatient basis, because it is as effective and safe as inpatient ripening.

Evaluation of clinical effects of Esketamine on depression in patients with missed miscarriage: A randomized, controlled, double-blind trial

BACKGROUND

Patients with missed miscarriages are usually accompanied by varying degrees of depression, which is closely related to the patient's prognosis. We investigated whether Esketamine could alleviate postoperative depression symptoms in patients with missed miscarriages who underwent painless curettage.

METHODS

This study was a randomized, parallel-controlled, double-blind, single-center trial. A total of 105 patients with preoperative 1d (EPDS) ≥ 10 were randomly assigned to the Propofol; Dezocine; Esketamine group. Patients record EPDS at 7 and 42 days after the operation. Secondary outcomes included VAS for 1 h postoperation, total propofol usage, adverse reactions, And the expressions of inflammatory factors of TNF-α, IL-1β, IL-6, IL-8, and IL-10.

RESULTS

Compared with the P and D group, patients in the S group had lower EPDS scores at 7 day (8.63 ± 3.14, 9.17 ± 3.23 vs. 6.34 ± 2.87 P = 0.0005) and 42 days (9.40 ± 2.67, 8.49 ± 3.05 vs.5.31 ± 2.49 P < 0.0001) after the operation. Respectively, Compared with the P group, the VAS scores (3.51 ± 1.12 vs. 2.80 ± 0.83, 2.40 ± 0.81, P = 0.0035) and the dosage of propofol used during operation (198.7 ± 47.48 vs. 145.5 ± 19.31, 142.9 ± 21.01 P < 0.0001) were lower in the D and S groups, and lower postoperative inflammatory response at 1 day after surgery. Other outcomes among the three groups were not found to the difference.

CONCLUSIONS

Esketamine effectively treated postoperative depressive symptoms of patients with a missed miscarriage, decreasing propofol consumption and inflammatory response.

Comparison of mifepristone plus misoprostol with misoprostol alone for first trimester medical abortion: A systematic review and meta-analysis

Objective

To compare mifepristone plus a misoprostol-combined regimen with misoprostol alone in the medical abortion of first trimester pregnancy.

Methods

An internet-based search of available literature was performed using text words contained in titles and abstracts. PubMed/Medline, Cochrane CENTRAL, EMBASE, and Google scholar were used to locate English-based articles published until December 2021. Studies fulfilling the inclusion criteria were selected, appraised, and assessed for methodological quality. The included studies were pooled for meta-analysis, and the results were presented in risk ratio at a 95% confidence interval.

Findings

Nine studies comprising 2,052 participants (1,035 intervention and 1,017 controls) were considered. Primary endpoints were complete expulsion, incomplete expulsion, missed abortion, and ongoing pregnancy. The intervention was found to more likely induce complete expulsion irrespective of gestational age (RR: 1.19; 95% CI: 1.14–1.25). The administration of misoprostol 800 mcg after 24 h of mifepristone pre-treatment in the intervention group more likely induced complete expulsion (RR: 1.23; 95% CI: 1.17–1.30) than after 48 h. The intervention group was also more likely to experience complete expulsion when misoprostol was used either vaginally (RR: 1.16; 95% CI: 1.09–1.17) or buccally (RR: 1.23; 95% CI: 1.16–1.30). The intervention was more effective in the subgroup with a negative foetal heartbeat at reducing incomplete abortion (RR: 0.45; 95% CI: 0.26–0.78) compared with the control group. The intervention more likely reduced both missed abortion (RR: 0.21; 95% CI: 0.08–0.91) and ongoing pregnancy (RR: 0.12; 95% CI: 0.05–0.26). Fever was less likely to be reported (RR: 0.78; 95% CI: 0.12–0.89), whereas the subjective experience of bleeding was more likely to be encountered (RR: 1.31; 95% CI: 1.13–1.53) by the intervention group.

Conclusion

The review strengthened the theory that a combined mifepristone and misoprostol regimen can be an effective medical management for inducing abortions during first trimester pregnancy in all contexts. Specifically, there is a high-level certainty of evidence on complete expulsion during the early stage and its ability to reduce both missed and ongoing pregnancies.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019134213, identifier CRD42019134213.

Comparison of Early Pregnancy Loss Management Between States With Restrictive and Supportive Abortion Policies

INTRODUCTION

Mifepristone-misoprostol and office uterine aspiration used for abortion care are also evidence-based, cost-effective strategies for early pregnancy loss management. We aimed to compare the provision of mifepristone-misoprostol and office uterine aspiration for early pregnancy loss between states with restrictive and supportive abortion policies.

METHODS

We conducted a cross-sectional, internet-based survey regarding early pregnancy loss management among obstetrician-gynecologists (OBGYNs) at academic medical centers. We assessed management offered along with facilitators and barriers to implementation of mifepristone-misoprostol and office uterine aspiration. We used χ² and multivariable logistic regression to compare practice patterns.

RESULTS

We analyzed responses from 350 physicians, 56% from states with restrictive abortion policies. OBGYNs in states with restrictive abortion policies were less likely than those in states with supportive abortion policies to offer both mifepristone-misoprostol and office uterine aspiration (33.2% vs. 51.3%; p = .001), to report having received induced abortion training (67.3% vs. 89.6%; p < .001), and to report perceived institutional support for abortion care (49.0% vs. 85.0%; p < .001). After adjusting for confounders, restrictive state policy was no longer associated with providing both mifepristone-misoprostol and office uterine aspiration for early pregnancy loss (adjusted odds ratio, 1.19; 95% confidence interval [CI], 0.58-2.45). However both prior induced abortion training and institutional support for abortion care remained significantly associated (adjusted odds ratio, 2.06; 95% CI, 1.07-3.97 and adjusted odds ratio, 3.91; 95% CI, 2.08-7.38, respectively).

CONCLUSIONS

OBGYNs practicing in states with restrictive abortion policies are less likely than those in states with supportive abortion policies to have received abortion training or perceive institutional support for abortion care, and they are less likely to offer mifepristone-misoprostol and office uterine aspiration for early pregnancy loss.

Mifepristone-misoprostol combination treatment for early pregnancy loss after embryo transfer: a case series

Objective

Evidence strongly supports the use of mifepristone-misoprostol combination treatment for early pregnancy loss (EPL) among pregnancies conceived without assisted reproductive technologies. No literature exists, however, regarding the efficacy of this treatment in the medical management of EPL among pregnancies after in vitro fertilization and embryo transfer (IVF-ET). These patients differ as some use exogenous hormonal supplementation to provide pregnancy support. Thus, the management for EPL may differ between unassisted conceptions and those after ET. Mifepristone, a progesterone receptor antagonist, may demonstrate an altered treatment effect when used with misoprostol to manage EPL in assisted reproductive technologie-conceived pregnancies.

Objective

To describe our institution's experience using mifepristone-misoprostol to manage EPL after in vitro fertilization with embryo transfer IVF-ET.

Design

Retrospective case series.

Setting

Single academic institution from 2020 to 2022.

Patientss

Nine patients with ultrasound confirmed EPL after IVF-ET.

Interventions

All 9 patients underwent in vitro fertilization followed by fresh or frozen embryo transfer. All 9 received 200 mg of mifepristone 24 hours before 800 μg of misoprostol.

Main Outcome Measurements

Incomplete abortion, need for surgical management, number of days to negative serum human chorionic gonadotropin (hCG).

Results

Of the 9 subjects included, one had a programmed frozen embryo transfer cycle, 6 had modified natural frozen embryo transfer cycles, and 2 underwent fresh ET. Eight subjects had successful expulsion of tissue with one dose of treatment, and one required uterine aspiration. No subjects required additional dosing of misoprostol. The mean number of days elapsed from mifepristone treatment to tissue expulsion was 4.89 ± 11.30 days and the mean days to negative-range serum hCG was 36.89 ± 18.59 days. At the initial ultrasound, all pregnancies had one gestational sac seen; 5/9 had a yolk sac; only 3 had fetal cardiac activity. The mean gestational age at the time of EPL diagnosis was 55.22 ± 8.77 days, with the majority (8/9) having completed 7 weeks gestation.

Conclusions

Mifepristone-misoprostol combination treatment appears to be a reasonable option for those with EPL after IVF-ET. Future, larger-scale studies are needed comparing combination treatment with misoprostol only among various ET protocols.

Compliance with a guideline on outpatient medical management of miscarriage in a gynaecology ED

This article describes the clinical audit of the Outpatient Medical Management of Miscarriage Guideline (Guideline 2) within the Gynaecology Emergency Department (GED) at a single site dedicated Gynaecology and Maternity Hospital in the UK, the Liverpool Women's NHS Foundation Trust. Clinical audits are quality improvement processes used to identify areas of improvement against a set criterion and, as a result, implement any required change(s) (National Institute for Health and Care Excellence, 2002). An audit ensures that the guidelines have been followed to certify safe, effective treatment for women who have suffered a first trimester missed miscarriage and the audit described in this article analysed the success of treatment in avoiding admission to hospital and further intervention, such as surgery. The main findings of the audit were that the GED fell short on compliance rates against some standards, mainly standard 1 (performing a baseline point of care test to measure haemoglobin) and standard 5 (providing the patient with a follow-up phone call, with higher compliance levels to standards 3 and 4, which are in relation to prescribing and administering the treatment. The audit found that 15% of patients required further intervention such as admission to hospital for observation (9%) and surgical intervention to complete the miscarriage (6%). Further training in the clinical setting is required to ensure improved compliance with all standards. A checklist will also be created to ensure all standards are being met.

A retrospective study of estrogen in the pretreatment for medical management of early pregnancy loss and the inference from intrauterine adhesion

Background

Estrogen has been usually used in clinic for medical pretreatment of early pregnancy loss. There was little reported the effect of estrogen combined with prostaglandin analogs in the medical management of early pregnancy loss. This retrospective study aimed to evaluate the efficacy of estrogen pretreatment for medical management of early pregnancy loss and explore the confounding factor of intrauterine adhesion (IUA) on the outcome of medical management.

Methods

A total of 226 early pregnancy loss patients who received pretreatment with estradiol valerate and/or mifepristone, followed by carboprost methylate suppositories (study groups), or carboprost methylate suppositories alone (control group) in a regional central institution from March 2020 to February 2021 were retrospectively studied. All patients were evaluated by hysteroscopy 6 h after carboprost methylate suppositories use to assess whether the gestational sac was complete expulsion and assess the morphology of uterine cavity.

Results

The complete expulsion rate was 56.94% in the mifepristone and estradiol valerate-pretreatment group, 20.69% in the estradiol valerate-pretreatment group, 62.5% in the mifepristone-pretreatment group, and 12.5% in the control group. Compared with the control group, pretreatment with estradiol valerate did not increase the complete expulsion rate significantly (P = 0.297), pretreatment with mifepristone increased the complete expulsion rate significantly (P < 0.001). Pretreatment with mifepristone combined with estradiol valerate did not increase the complete expulsion rate significantly comparing with pretreatment with mifepristone (P = 0.222). The data of IUA showed that the complete expulsion rate in patients with IUA was lower than that in those patients without IUA (P < 0.001).

Conclusions

Pretreatment with estrogen was not a sensible substitute for mifepristone in the medical management of early pregnancy loss. Mifepristone followed by carboprost methylate suppositories was likelihood of the ideal medical scheme in early pregnancy loss. IUA decreased the complete expulsion rate of medical management, it is cautious about medical management for early pregnancy loss with risk of IUA.

Trial Registration Number: ChiCTR2100046503. Date of registration (retrospectively registered): May 18, 2021. Trial registration website: http://www.chictr.org.cn/.

Distinct clinicopathological features of ovarian endometriosis after long-term exposure to mifepristone

Objective

Mifepristone has been used to treat endometriosis, but it can cause a constellation of endometrial alterations. Our study investigated the effects of long-term mifepristone on ovarian endometriosis.

Methods

We retrospectively analyzed the clinicopathological changes of ovarian endometriosis in 11 Chinese patients after long-term low-dose mifepristone therapy and compared these alterations with those observed in eutopic endometrium and adenomyosis side-by-side. Immunohistochemistry was applied to investigate estrogen receptor (ER), progesterone receptor (PR), and Ki67 expression in eutopic and ectopic endometrium.

Results

Nearly all patients had a pelvic mass and elevated serum CA125 levels. The ovarian lesions were grossly solid, cystic-solid, or cystic. They had a grayish–reddish appearance and a fleshy, honeycomb-like cut surface. The ovarian lesions shared morphological features with the uterine endometrium, and they were characterized by dilated, crowding endometrial glands with non-physiological changes. Immunostaining revealed consistent staining for ER and PR and a low Ki67 index in both eutopic and ectopic endometrium.

Conclusions

Our findings suggest that ovarian endometriosis can mimic an endometrioid borderline tumor after long-term mifepristone administration. Careful histological assessment and related clinical information are critical for the correct interpretation of these rare entities.

Medical Abortion before Confirmed Intrauterine Pregnancy: A Systematic Review

"Very early medical abortion" (VEMA) refers to medical abortion (with mifepristone and misoprostol) before intrauterine pregnancy is visualized on ultrasound. Our aim is to present the current evidence on efficacy, safety (focused on ectopic pregnancies), and how to assess treatment success of VEMA. We conducted a systematic review of studies reporting outcomes of VEMA. The field is small and so our objective was to map all relevant literature, without conducting meta-analysis. We searched PubMed, Medline, and Embase on April 19, 2022. We conducted a narrative synthesis of the evidence. A total of 373 articles were identified. Six articles (representing four observational and one pilot trial) were included in the final review. Across all included studies, treatment efficacy ranged between 91 and 100%. Prevalence of ectopic pregnancy was low and very few cases (n = 2) of ruptures were reported. Most studies used serial serum human chorionic gonadotrophin (s-hCG) levels to determine success of abortion; one study used low sensitivity urine hCG. From the available evidence, VEMA appears to be efficacious and does not appear to cause harm to ectopic pregnancies. Treatment can be assessed with pre- and postabortion s-hCG. Good quality, randomized controlled trial evidence is needed to best inform practice.

Clinical Update on Uses for Mifepristone in Obstetrics and Gynecology

IMPORTANCE

Mifepristone (RU-486) is a selective progesterone receptor modulator that has antagonist properties on the uterus and cervix. Mifepristone is an effective abortifacient, prompting limitations on its use in many countries. Mifepristone has many uses outside of induced abortion, but these are less well known and underutilized by clinicians because of challenges in accessing and prescribing this medication.

OBJECTIVES

To provide clinicians with a history of the development of mifepristone and mechanism of action and safety profile, as well as detail current research on uses of mifepristone in both obstetrics and gynecology.

EVIDENCE ACQUISITION

A PubMed search of mifepristone and gynecologic and obstetric conditions was conducted between January 2018 and December 2021. Other resources were also searched, including guidelines from the American College of Obstetricians and Gynecologists and the Society of Family Planning.

RESULTS

Mifepristone is approved by the Food and Drug Administration for first-trimester medication abortion but has other off-label uses in both obstetrics and gynecology. Obstetric uses that have been investigated include management of early pregnancy loss, intrauterine fetal demise, treatment of ectopic pregnancy, and labor induction. Gynecologic uses that have been investigated include contraception, treatment of abnormal uterine bleeding, and as an adjunct in treatment of gynecologic cancers.

CONCLUSIONS AND RELEVANCE

Mifepristone is a safe and effective medication both for its approved use in first-trimester medication abortion and other off-label uses. Because of its primary use as an abortifacient, mifepristone is underutilized by clinicians. Providers should consider mifepristone for other indications as clinically appropriate.

Clinical Utility of Mifepristone: Apprising the Expanding Horizons

Mifepristone is a progesterone and glucocorticoid receptor antagonist. Medical abortion with mifepristone and prostaglandin has revolutionized the abortion process extending abortion care to the doors of females. From as low as 2 mg/day to doses extending to 600 mg, from daily dosing to single dosage treatment, mifepristone has a wide perspective in the treatment of various pathologies. Cervical dilatation and myometrial contractility have made the utility of mifepristone feasible for second-trimester termination of pregnancy and induction of labor awaiting Food and Drug Administration approvals. Its anti-progesterone action on the menstrual cycle has a new dimension of use as a contraceptive, as well as use as a menstruation inductive agent. Its role in endometriosis, ectopic pregnancy, and adenomyosis requires more intensive research. Apoptotic action of mifepristone, interference of heterotypic cell adhesion to the basement membrane, cell migration, growth inhibition of various cancer cell lines, decreased epidermal growth factor expression, suppression of invasive and metastatic cancer potential, increase in tumor necrosis factor, downregulation of cyclin-dependent kinase 2, B-cell lymphoma 2, and Nuclear factor kappa B have opened its potential to be explored as anti-cancer treatment and its effects on leiomyoma. The drug needs to be studied more for the prospectus of its anti-glucocorticoid actions in a wider dimension beyond its acquiescence for the treatment of Cushing syndrome.

Selective progesterone receptor modulators and reproductive health

PURPOSE OF REVIEW

This review is intended to provide perspective on the history of selective progesterone receptor modulators (SPRMs) and progesterone antagonists, their current availability, therapeutic promise and safety concerns.

RECENT FINDINGS

Despite keen interest in synthesis of these compounds, only a handful have had clinical test results allowing for commercialization. Mifepristone is well tolerated and effective for single dose first trimester at-home pregnancy termination and is available in much of the world. Ulipristal acetate, at single doses, is well tolerated and effective for emergency contraception, with less availability. Chronic use of these agents has been associated with abnormal liver enzymes, and rarely, with hepatic failure; causality is not understood.

SUMMARY

SPRMs and progesterone antagonists have great therapeutic promise for use in other reproductive disorders, including breast cancer, endometriosis, adenomyosis, estrogen-free contraception and cervical ripening but require additional study. Alternative formulations, whether local (topical breast or intrauterine) or extended-release may reduce the incidence of liver function abnormalities and should be explored.

The efficacy of Shenghua Decoction supplementation after early medical abortion: A meta-analysis of randomized controlled trials

AIMS

Shenghua Decoction (SHD) is a well-known classic herbal formula documented in traditional Chinese medicine (TCM) that has been widely applied during the postpartum period in Chinese communities for several years. We conducted this systematic review and meta-analysis to explore the influence of SHD as an adjuvant treatment for early medical abortion using a combination of mifepristone followed by misoprostol.

METHODS

This systematic review and meta-analysis was reported using 2020 PRISMA guidelines. Eight databases were searched from their establishment to February 28, 2022, for randomized controlled trials (RCTs): PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, the Chinese BioMedical database, the Chinese Scientific Journal Database, and the Wanfang database. The Grading of Recommendations Assessment, Development, and Evaluation estimated the quality of evidence.

RESULTS

Sixteen RCTs involving 3016 patients were included in the meta-analysis. Overall, compared with no treatment as the control group after early medical abortion, patients treated with SHD were associated with a higher complete abortion rate (RR: 1.14; 95% CI: 1.10 - 1.18; P < 0.01, I² = 26%, moderate quality), lower incomplete abortion rate (RR: 0.31; 95% CI: 0.24 - 0.41; P < 0.01, I² = 0%, moderate quality), and lower viable pregnancy rate (RR: 0.26; 95% CI: 0.11 - 0.62; P < 0.01, I² = 0%, moderate quality). Additionally, SHD supplementation was associated with reduced the induction-abortion time, duration of vaginal bleeding and menstrual recovery time.

CONCLUSION

Our findings suggest that SHD supplementation may be beneficial for women seeking a medical abortion before the 7-week gestational period and no adverse events in the experimental group were reported. However, the methodological quality of the included RCTs was unsatisfactory, and therefore it is necessary to further verify the effectiveness of SHD using standardized studies of rigorous design.

Manual Uterine Aspiration in the Emergency Department as a first line therapy for early pregnancy loss: A single center retrospective study

OBJECTIVES

Manual uterine aspiration (MUA) is a currently underused management option for early pregnancy loss (EPL) in the emergency department (ED). This study addresses the safety and efficiency of MUA in the ED.

METHODS

We performed a single-site retrospective observational chart review of pregnant women presenting to the ED with vaginal bleeding and ED pathology submissions for products of conception (POC) between 2012 and 2016. Patients were excluded for gestational age >14 weeks, no evidence of pregnancy loss, uterine cavity anomaly, hemodynamic instability, or hemoglobin <80 g/L. We compared the frequencies of complications (need for blood transfusion, repeat ED visit, failed initial management, admission to hospital) and ED utilization time between 4 management options: expectant, misoprostol, MUA, and electric vacuum aspiration (EVA) outside the ED, as well as time to procedure between MUA and EVA.

RESULTS

A total of 162 patients were included with 123 (76%) having a pathology report positive for POC. The mean patient and gestational ages were 30 ± 7 years and 66 ± 17 days, respectively. One hundred and nine patients were managed expectantly, 9 were given misoprostol, 23 underwent MUA, and 21 underwent EVA. Composite complication rates were 40%, 33%, 9%, and 10% (P = 0.001), and mean ED times were 5.4, 4.9, 7.3, and 6.0 hours (P = 0.01), for expectant, misoprostol, MUA, and EVA, respectively. The mean time to procedure was 5.1 hours for MUA and 23.1 hours for EVA (p=0.002).

CONCLUSIONS

Integrating MUA in the ED has the potential to reduce health care resource utilization while improving patient care.

A Sixty-Year Research and Development of Trichosanthin, a Ribosome-Inactivating Protein

Tian Hua Fen, a herbal powder extract that contains trichosanthin (TCS), was used as an abortifacient in traditional Chinese medicine. In 1972, TCS was purified to alleviate the side effects. Because of its clinical applications, TCS became one of the most active research areas in the 1960s to the 1980s in China. These include obtaining the sequence information in the 1980s and the crystal structure in 1995. The replication block of TCS on human immunodeficiency virus in lymphocytes and macrophages was found in 1989 and started a new chapter of its development. Clinical studies were subsequently conducted. TCS was also found to have the potential for gastric and colorectal cancer treatment. Studies on its mechanism showed TCS acts as an rRNA N-glycosylase (EC 3.2.2.22) by hydrolyzing and depurinating A-4324 in α-sarcin/ricin loop on 28S rRNA of rat ribosome. Its interaction with acidic ribosomal stalk proteins was revealed in 2007, and its trafficking in mammalian cells was elucidated in the 2000s. The adverse drug reactions, such as inducing immune responses, short plasma half-life, and non-specificity, somehow became the obstacles to its usage. Immunotoxins, sequence modification, or coupling with polyethylene glycerol and dextran were developed to improve the pharmacological properties. TCS has nicely shown the scientific basis of traditional Chinese medicine and how its research and development have expanded the knowledge and applications of ribosome-inactivating proteins.

Prospective open-label non-inferiority randomised controlled trial comparing letrozole and mifepristone pretreatment in medical management of first trimester missed miscarriage: study protocol

INTRODUCTION

Medical treatment is a less invasive alternative to surgical management of missed miscarriage. Studies have shown that pretreatment with mifepristone can increase the complete abortion rate in management of first-trimester missed miscarriage compared with misoprostol alone. Two studies have also shown that pretreatment with letrozole could increase the efficacy compared with misoprostol alone. So far, there is no trial comparing letrozole and mifepristone pretreatment for missed miscarriage. We designed this randomised controlled trial to test the hypothesis that for first-trimester missed miscarriage, letrozole pretreatment is non-inferior to mifepristone pretreatment followed by misoprostol in terms of complete abortion rate.

METHODS AND ANALYSIS

This is a prospective open-label non-inferiority randomised controlled trial conducted in a single centre. In total, 294 women diagnosed with first-trimester missed miscarriage opting for medical treatment is recruited with informed consent. They are randomly assigned to receive mifepristone or letrozole pretreatment. In the mifepristone group, each woman takes 200 mg mifepristone orally followed 24-48 hours later by 800 µg misoprostol vaginally. In the letrozole group, each woman takes 10 mg letrozole orally per day for 3 days, followed by 800 µg misoprostol vaginally on the third day of letrozole administration. Follow-up is conducted on days 15 and 42 after misoprostol administration. The primary outcome is the overall complete abortion rate. Secondary outcomes include side effects and complications during the study period. Data will be analysed with both intention-to-treat and per protocol approaches. A p<0.05 will be considered as indicating statistical significance.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Institutional Review Board of the University of Hong Kong-Shenzhen Hospital with approval number: (2020)166. Findings will be disseminated in a peer-reviewed journal and in national and/or international meetings to guide future practice.

TRIAL REGISTRATION NUMBER

ChiCTR2000041480.

Mifepristone and misoprostol versus placebo and misoprostol for resolution of miscarriage in women diagnosed with missed miscarriage: the MifeMiso RCT

TRIAL DESIGN

A randomised, parallel-group, double-blind, placebo-controlled multicentre study with health economic and nested qualitative studies to determine if mifepristone (Mifegyne^®, Exelgyn, Paris, France) plus misoprostol is superior to misoprostol alone for the resolution of missed miscarriage.

METHODS

Women diagnosed with missed miscarriage in the first 14 weeks of pregnancy were randomly assigned (1 : 1 ratio) to receive 200 mg of oral mifepristone or matched placebo, followed by 800 μg of misoprostol 2 days later. A web-based randomisation system allocated the women to the two groups, with minimisation for age, body mass index, parity, gestational age, amount of bleeding and randomising centre. The primary outcome was failure to pass the gestational sac within 7 days after randomisation. The prespecified key secondary outcome was requirement for surgery to resolve the miscarriage. A within-trial cost-effectiveness study and a nested qualitative study were also conducted. Women who completed the trial protocol were purposively approached to take part in an interview to explore their satisfaction with and the acceptability of medical management of missed miscarriage.

RESULTS

A total of 711 women, from 28 hospitals in the UK, were randomised to receive either mifepristone plus misoprostol (357 women) or placebo plus misoprostol (354 women). The follow-up rate for the primary outcome was 98% (696 out of 711 women). The risk of failure to pass the gestational sac within 7 days was 17% (59 out of 348 women) in the mifepristone plus misoprostol group, compared with 24% (82 out of 348 women) in the placebo plus misoprostol group (risk ratio 0.73, 95% confidence interval 0.54 to 0.98; p = 0.04). Surgical intervention to resolve the miscarriage was needed in 17% (62 out of 355 women) in the mifepristone plus misoprostol group, compared with 25% (87 out of 353 women) in the placebo plus misoprostol group (risk ratio 0.70, 95% confidence interval 0.52 to 0.94; p = 0.02). There was no evidence of a difference in the incidence of adverse events between the two groups. A total of 42 women, 19 in the mifepristone plus misoprostol group and 23 in the placebo plus misoprostol group, took part in an interview. Women appeared to have a preference for active management of their miscarriage. Overall, when women experienced care that supported their psychological well-being throughout the care pathway, and information was delivered in a skilled and sensitive manner such that women felt informed and in control, they were more likely to express satisfaction with medical management. The use of mifepristone and misoprostol showed an absolute effect difference of 6.6% (95% confidence interval 0.7% to 12.5%). The average cost per woman was lower in the mifepristone plus misoprostol group, with a cost saving of £182 (95% confidence interval £26 to £338). Therefore, the use of mifepristone and misoprostol for the medical management of a missed miscarriage dominated the use of misoprostol alone.

LIMITATIONS

The results from this trial are not generalisable to women diagnosed with incomplete miscarriage and the study does not allow for a comparison with expectant or surgical management of miscarriage.

FUTURE WORK

Future work should use existing data to assess and rank the relative clinical effectiveness and safety profiles for all methods of management of miscarriage.

CONCLUSIONS

Our trial showed that pre-treatment with mifepristone followed by misoprostol resulted in a higher rate of resolution of missed miscarriage than misoprostol treatment alone. Women were largely satisfied with medical management of missed miscarriage and would choose it again. The mifepristone and misoprostol intervention was shown to be cost-effective in comparison to misoprostol alone.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17405024.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 68. See the NIHR Journals Library website for further project information.

Bleeding pattern after medical management of early pregnancy loss with mifepristone–misoprostol and its prognostic value: a prospective observational cohort study

Purpose

To improve counseling of women by reporting bleeding characteristics at home after medical management of an early pregnancy loss (EPL) with mifepristone and misoprostol, and to evaluate occurring bleeding patterns as a prognostic tool.

Methods

This prospective two-center observational cohort study enrolled 197 women who presented with an EPL (embryonic or anembryonic miscarriage) from December 2017 to April 2019 and chose a home-based medical management with 200 mg mifepristone and 800 mcg misoprostol. From the day of mifepristone intake, the strength of vaginal bleeding was recorded daily for 2 weeks by the patient herself using a diary sheet. Treatment success was defined as no histologically confirmed retained products of conception (RPOC) within 3 months. After considering all drop-out criteria, 154 women were included in the analysis.

Results

40.0% of patients (95% CI 30.4–49.6) already reported bleeding onset in the time period between the intake of mifepristone and misoprostol. The median duration of vaginal bleeding including spotting was 13 days. The chance of RPOC was about sixfold (OR 6.06, 95% CI 2.15–17.10) in the group of persistent bleeding after 2 weeks compared to the group with a terminated bleeding at that time. Exploratory regression analysis indicated association of higher serum levels of leukocytes at treatment start with RPOC (p = 0.013).

Conclusions

Terminated bleeding after 2 weeks is a useful indicator for successful medical induction of EPL. Women undergoing medical treatment with mifepristone must be informed about the high frequency of bleeding onset before misoprostol intake.

Clinical trial registration

DRKS—German Clinical Trials Register, ID: DRKS00013515, registration date 05.12.2017. http://www.drks.de/DRKS00013515.

Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso trial

OBJECTIVE

To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage.

DESIGN

Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS).

SETTING

Twenty-eight UK NHS early pregnancy units.

SAMPLE

A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage.

METHODS

Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets.

MAIN OUTCOME MEASURES

Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs).

RESULTS

For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management.

CONCLUSIONS

The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage.

TWEETABLE ABSTRACT

The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.

Methods for managing miscarriage: a network meta-analysis

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.

Management of pregnancy after radical trachelectomy

Radical trachelectomy (RT) is a surgery for early-stage cervical cancer treatment that preserves the childbearing ability, and its use has become increasingly common worldwide. Thus, the rate of conception in women who have undergone RT is increasing. However, pregnancy after RT is associated with a higher risk of several obstetric complications such as preterm delivery, preterm premature membrane rupture, and abnormal bleeding from varices at the site of uterovaginal anastomosis. Furthermore, since RT have a residual prophylactic cerclage, it is difficult to manage first- and second-trimester miscarriages. There is little previous data on the management of pregnancy after RT. In this review article, we summarize various management methods and experiences to provide a guide to clinicians for perinatal management after RT.

Expectant management for early pregnancy miscarriage after radical trachelectomy: A single hospital-based study

INTRODUCTION

Women who have undergone radical trachelectomy as a fertility-sparing treatment for early-stage cervical cancer may be at higher risk for retained tissues after early-term miscarriage due to cervical cerclage or cervical necrosis. Dilatation and curettage or aspiration may present additional risks in these women. The aim of this study was to assess the efficacy of expectant management for early pregnancy miscarriage after radical trachelectomy.

MATERIAL AND METHODS

Keio University Hospital records were reviewed for women who conceived after abdominal radical trachelectomy and received perinatal care between 1 April 2012 and 31 March 2020. A total of 62 women (76 pregnancies) were identified, and 13 of these women experienced miscarriage before 12 gestational weeks. The management and outcome of these cases were reviewed in detail.

RESULTS

The median maternal age at miscarriage was 39 years (range 31-42 years) and the median duration from abdominal radical trachelectomy to conception was 2.60 years (range 0.49-7.30 years). Cervical necrosis before conception occurred in one case (8%). One patient requested treatment with aspiration and the remaining 12 cases were managed with observation for a median of 23 days (range 7-50 days). There were no cases of endometritis or cases requiring dilatation and curettage for residue tissue. Further, no cases developed laceration of the residual cervix and no loss of cerclage sutures after discharge was noted.

CONCLUSIONS

Expectant management seems to be safe and appropriate for first trimester miscarriage after abdominal radical trachelectomy.

Results of a national web-based survey on the SARS-CoV-2 infectious state of otorhinolaryngologists in Germany

PURPOSE

SARS-CoV-2 is detected on the mucosa of the upper airways to a high degree. In the course of the COVID-19 pandemic, otorhinolaryngologists (ORL) are assumed to be at high risk due to close contact with the mucosa of the upper airways. No data are yet available providing evidence that ORLs have an increased risk of infection.

METHODS

German ORLs were invited via e-mail through the German Society of ORL, Head and Neck Surgery and the German ENT Association to participate in a web-based survey about infection with SARS-CoV-2 and development of COVID-19. Data of infections and concomitant parameters in German ORLs were collected and compared to the total number of infections in Germany.

RESULTS

Out of 6383 German ORLs, 970 (15%) participated. 54 ORLs reported testing positive for SARS-CoV-2. Compared to the total population of Germany, ORLs have a relative risk of 3.67 (95% CI 2.82; 4.79) of contracting SARS-CoV-2. Domestic quarantine was conducted in 96.3% of cases. Two individuals were admitted to hospital without intensive care. No casualties were reported. In 31 cases, the source of infection was not identifiable whereas 23 had a clear medical aetiology: infected patients: n = 5, 9.26%; medical staff: n = 13, 14.1%. 9.26% (n = 5) of the identified cases were related to contact to infected family members (n = 3), closer neighbourhood (n = 1) or general public (n = 1). There was no identified increased risk of infection due to performing surgery.

CONCLUSION

German ORLs have an almost 3.7-fold risk of contracting SARS-CoV-2 compared to the population baseline level. Appropriate protection appears to be necessary for this occupational group.

[Field investigations of SARS-CoV-2-outbreaks in Germany by the Robert Koch Institute, February-October 2020]

Das Robert Koch-Institut (RKI) bietet den Gesundheitsämtern in Deutschland bei Ausbrüchen von Infektionserkrankungen Beratung und praktische Unterstützung vor Ort an. Die Feldeinsätze werden von speziell geschultem Personal durchgeführt. Auch im Rahmen der COVID-19-Pandemie leistet das RKI regelmäßig diese Form der Amtshilfe in unterschiedlichen Settings. Dabei handelt es sich beispielsweise um Ausbrüche in Wohngebäuden, Arztpraxen, Alten- und Pflegeheimen, Kliniken, Erstaufnahmeeinrichtungen für Asylsuchende, aber auch in einem Nachtclub oder auf einem Kreuzfahrtschiff.

Der vorliegende Beitrag berichtet exemplarisch von Feldeinsätzen, die im Zeitraum Februar bis Oktober 2020 im Rahmen der COVID-19-Pandemie stattgefunden haben. Die daraus gewonnenen Erkenntnisse tragen dazu bei, das Wissen zu SARS-CoV‑2 zu erweitern, z. B. zur Übertragung und Ausbreitung des Erregers, RKI-Empfehlungen zu formulieren oder zu untermauern und das Management komplexer Situationen zu unterstützen. Die Praxisbeispiele zeigen, wie vielfältig die RKI-Teams nicht nur vor Ort unterstützen, sondern auch die epidemiologische Evidenzbasis bereichern.

Im September 2020 wurde im RKI die „Kontaktstelle für den öffentlichen Gesundheitsdienst (ÖGD)“ eingerichtet, die unter anderem die Amtshilfe durch Feldeinsätze koordiniert und erweiterte Beratungsmöglichkeiten bietet. Damit der ÖGD langfristig noch besser auf Ausbrüche von Infektionserregern reagieren kann, soll das interdisziplinäre Trainingsangebot intensiviert werden.