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Aiob A, Mikhail SM, Sgayer I, Kalendaryov A, Odeh M, Lowenstein L, Sharon A. Diagnostic accuracy and characteristics of symptomatic versus asymptomatic retained products of conception: A retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2024; 299:278-282. [PMID: 38935997 DOI: 10.1016/j.ejogrb.2024.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/21/2024] [Accepted: 06/24/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVE To assess the accuracy of diagnosing retained products of conception (RPOC) in symptomatic versus asymptomatic women, and to identify potential divergent ultrasound features between these groups. METHODS This retrospective study included women aged 17-50 years who underwent hysteroscopy for suspected RPOC during 2018-2021. Clinical and sonographic data were analyzed, and multivariable linear regression models employed, to examine correlations between RPOC and sonographic findings, and to compare diagnostic accuracy between symptomatic and asymptomatic women. RESULTS Of the 225 women included, 123 (54.7 %) were symptomatic and 102 (45.3 %) were asymptomatic. Hysteroscopy complications were more frequent in asymptomatic women. Regarding sonography, statistically significant differences were not found between the groups in endometrial thickness or uterine fluid presence, but positive Doppler flow was more common in asymptomatic than symptomatic women. Endometrial thickness >1.49 cm demonstrated diagnostic utility, with similar sensitivity and specificity in the two groups. Multivariable models revealed significant associations of RPOC presence with endometrial thickness and Doppler flow in symptomatic women. In both groups, hysteroscopy enhanced diagnostic accuracy, with higher positive predictive values and lower false-positive rates compared to ultrasound alone. CONCLUSION An endometrial thickness cutoff of 1.49 cm aids diagnosing RPOC. Doppler flow enhances diagnostic value in symptomatic women. Integration of hysteroscopy improves diagnostic accuracy compared to ultrasound alone. Regular sonographic assessment for women with identifiable risk factors assists in RPOC detection irrespective of symptoms.
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Affiliation(s)
- Ala Aiob
- Raya Strauss Wing of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel.
| | - Susana Mustafa Mikhail
- Raya Strauss Wing of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Inshirah Sgayer
- Raya Strauss Wing of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | | | - Marwan Odeh
- Raya Strauss Wing of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Lior Lowenstein
- Raya Strauss Wing of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Avishalom Sharon
- Raya Strauss Wing of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
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Carpentier H, Delotte J, Gauci PA. Abortion medical management between 14-16 weeks' amenorrhea after French legislation deadline extension. J Gynecol Obstet Hum Reprod 2024; 53:102705. [PMID: 38013013 DOI: 10.1016/j.jogoh.2023.102705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/18/2023] [Accepted: 11/25/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND The National French Assembly promoted a law in 2022 allowing an extension of the period of abortion up to 16 week's amenorrhea. Medication protocols vary internationally, and there are no French data on medical management between 14- and 16-weeks' amenorrhea. OBJECTIVE To assess effectiveness and feasibility of a medical management abortion between 14 and 16 weeks of amenorrhea. STUDY DESIGN We retrospectively collected data from women undergoing medical abortion between 14 and 16 weeks' amenorrhea from April 2022 to April 2023 in Archet's University hospital, Nice, France. Medical protocol consisted in a single dose of oral mifepristone 600 mg and 36-48 h later, vaginal gemeprost 1 mg. Three hours after gemeprost, oral 400 µg of misoprostol were administered every three hours, to a maximum of three doses. Success was defined as fetal expulsion. RESULTS Thirty women were enrolled in the study. Twenty-nine (96.7 %) patients aborted successfully. The median dose of misoprostol required was 800 µg (400 µg -1200 µg) and the median induction-to-abortion interval after first prostaglandin administration was 7 h (5.5-11.6). One patient (3.3 %) didn't expulse the fetus after 3 doses of misoprostol. Nine patients (30.0 %) had additional surgical aspiration for retained product of conception within 24 h. We encountered one post-abortum hemorrhage controlled only with surgical intra uterine aspiration. We did not need complementary hemostatic procedure and we reported no immediate or late complication. CONCLUSIONS Medical abortion between 14 and 16 weeks of amenorrhea provides a noninvasive and effective management for a daycare mid trimester abortion in 96.7 % of cases, with a 36.7 % of risk of staying in hospital overnight and 30.0 % to have additional surgery for retained product of conception (RPOC).
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Affiliation(s)
- Hortense Carpentier
- Department of Obstetrics and Gynecology, Reproduction and Fetal Medicine, CHU de Nice, University of Côte d'Azur, Hôpital Archet 2, 151 Route de Saint-Antoine, CS 23079 06200 Nice, France.
| | - Jérôme Delotte
- Department of Obstetrics and Gynecology, Reproduction and Fetal Medicine, CHU de Nice, University of Côte d'Azur, Hôpital Archet 2, 151 Route de Saint-Antoine, CS 23079 06200 Nice, France
| | - Pierre-Alexis Gauci
- Department of Obstetrics and Gynecology, Reproduction and Fetal Medicine, CHU de Nice, University of Côte d'Azur, Hôpital Archet 2, 151 Route de Saint-Antoine, CS 23079 06200 Nice, France
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Manning S, Kuhn D. Spontaneous and Complicated Therapeutic Abortion in the Emergency Department. Emerg Med Clin North Am 2023; 41:295-305. [PMID: 37024165 DOI: 10.1016/j.emc.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Pregnancy-related emergency department visits are common in the United States. Although typically managed safely in the outpatient setting, patients with spontaneous abortion may also present with life-threatening hemorrhage or infection. Management strategies for spontaneous abortion are similarly wide-ranging from expectant management to emergent surgical intervention. Surgical management of complicated therapeutic abortion is similar to that of spontaneous abortion. The dramatic changes in the legal status of abortion in the United States may have significant influence on the incidence of complicated therapeutic abortion, and we encourage emergency physicians to familiarize themselves with the diagnosis and management of these conditions.
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Expectant versus medical management for retained products of conception after medical termination of pregnancy: A randomized controlled study. Am J Obstet Gynecol 2022; 227:599.e1-599.e9. [PMID: 35752301 DOI: 10.1016/j.ajog.2022.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 05/05/2022] [Accepted: 06/16/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Despite the rise of medical treatments for the termination of pregnancy, to-date no prospective trial has evaluated the efficacy of misoprostol in treating retained products of conception after induced termination of pregnancy. OBJECTIVE To compare medical management with misoprostol with expectant management for retained products of conception after first trimester medical termination of pregnancy. STUDY DESIGN An open-label randomized controlled trial conducted at a university-affiliated tertiary medical center. Consenting consecutive women who underwent a routine 3-week follow-up evaluation after medical termination of pregnancy and had a sonographic suspicion of retained products of conception, defined as sonographic evidence of intra-uterine remnant (>12 mm) with a positive Doppler flow, were recruited. The participants were randomized into a medical treatment group (800 mcg of sublingually administered misoprostol) or expectant management. They all underwent repeat ultrasound scans every 2 weeks until a maximum of 6 weeks, and those suspected for persistent retained products of conception were referred to operative hysteroscopy. The primary endpoint was successful treatment defined as no need for surgical intervention due to persistent retained products of conception within 8 weeks from pregnancy termination. RESULTS There were no significant differences in demographic characteristics between the study groups. The median sonographically demonstrated retained product length was 20 mm (interquartile range, [IQR] 17-25) in the medically managed group compared with 20 mm (IQR 17-26) in the expectantly managed group (P=.733). Treatment succeeded in 42/68 (61.8%) women in the medically managed group compared with 36/63 (57.1%) women in the expectantly managed group (relative risk [RR] = 1.12, 95% confidence interval [CI] 0.74-1.70; P=.590). There was no difference in adverse outcomes between the 2 groups. CONCLUSION There is no clinically meaningful advantage for medical treatment with misoprostol compared with expectant management after first trimester medical termination of pregnancy in women with suspected retained products of conception. Surgical intervention can be avoided in up to 60% of women who are managed expectantly over 8 weeks of follow-up.
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Ghosh J, Papadopoulou A, Devall AJ, Jeffery HC, Beeson LE, Do V, Price MJ, Tobias A, Tunçalp Ö, Lavelanet A, Gülmezoglu AM, Coomarasamy A, Gallos ID. Methods for managing miscarriage: a network meta-analysis. Cochrane Database Syst Rev 2021; 6:CD012602. [PMID: 34061352 PMCID: PMC8168449 DOI: 10.1002/14651858.cd012602.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime. An estimated 15% of pregnancies end in miscarriage. Miscarriage can lead to serious morbidity, including haemorrhage, infection, and even death, particularly in settings without adequate healthcare provision. Early miscarriages occur during the first 14 weeks of pregnancy, and can be managed expectantly, medically or surgically. However, there is uncertainty about the relative effectiveness and risks of each option. OBJECTIVES To estimate the relative effectiveness and safety profiles for the different management methods for early miscarriage, and to provide rankings of the available methods according to their effectiveness, safety, and side-effect profile using a network meta-analysis. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth's Trials Register (9 February 2021), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (12 February 2021), and reference lists of retrieved studies. SELECTION CRITERIA We included all randomised controlled trials assessing the effectiveness or safety of methods for miscarriage management. Early miscarriage was defined as less than or equal to 14 weeks of gestation, and included missed and incomplete miscarriage. Management of late miscarriages after 14 weeks of gestation (often referred to as intrauterine fetal deaths) was not eligible for inclusion in the review. Cluster- and quasi-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded non-randomised trials. DATA COLLECTION AND ANALYSIS At least three review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for the primary outcomes of complete miscarriage and composite outcome of death or serious complications. The certainty of evidence was assessed using GRADE. Relative effects for the primary outcomes are reported subgrouped by the type of miscarriage (incomplete and missed miscarriage). We also performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available methods. MAIN RESULTS Our network meta-analysis included 78 randomised trials involving 17,795 women from 37 countries. Most trials (71/78) were conducted in hospital settings and included women with missed or incomplete miscarriage. Across 158 trial arms, the following methods were used: 51 trial arms (33%) used misoprostol; 50 (32%) used suction aspiration; 26 (16%) used expectant management or placebo; 17 (11%) used dilatation and curettage; 11 (6%) used mifepristone plus misoprostol; and three (2%) used suction aspiration plus cervical preparation. Of these 78 studies, 71 (90%) contributed data in a usable form for meta-analysis. Complete miscarriage Based on the relative effects from the network meta-analysis of 59 trials (12,591 women), we found that five methods may be more effective than expectant management or placebo for achieving a complete miscarriage: · suction aspiration after cervical preparation (risk ratio (RR) 2.12, 95% confidence interval (CI) 1.41 to 3.20, low-certainty evidence), · dilatation and curettage (RR 1.49, 95% CI 1.26 to 1.75, low-certainty evidence), · suction aspiration (RR 1.44, 95% CI 1.29 to 1.62, low-certainty evidence), · mifepristone plus misoprostol (RR 1.42, 95% CI 1.22 to 1.66, moderate-certainty evidence), · misoprostol (RR 1.30, 95% CI 1.16 to 1.46, low-certainty evidence). The highest ranked surgical method was suction aspiration after cervical preparation. The highest ranked non-surgical treatment was mifepristone plus misoprostol. All surgical methods were ranked higher than medical methods, which in turn ranked above expectant management or placebo. Composite outcome of death and serious complications Based on the relative effects from the network meta-analysis of 35 trials (8161 women), we found that four methods with available data were compatible with a wide range of treatment effects compared with expectant management or placebo: · dilatation and curettage (RR 0.43, 95% CI 0.17 to 1.06, low-certainty evidence), · suction aspiration (RR 0.55, 95% CI 0.23 to 1.32, low-certainty evidence), · misoprostol (RR 0.50, 95% CI 0.22 to 1.15, low-certainty evidence), · mifepristone plus misoprostol (RR 0.76, 95% CI 0.31 to 1.84, low-certainty evidence). Importantly, no deaths were reported in these studies, thus this composite outcome was entirely composed of serious complications, including blood transfusions, uterine perforations, hysterectomies, and intensive care unit admissions. Expectant management and placebo ranked the lowest when compared with alternative treatment interventions. Subgroup analyses by type of miscarriage (missed or incomplete) agreed with the overall analysis in that surgical methods were the most effective treatment, followed by medical methods and then expectant management or placebo, but there are possible subgroup differences in the effectiveness of the available methods. AUTHORS' CONCLUSIONS: Based on relative effects from the network meta-analysis, all surgical and medical methods for managing a miscarriage may be more effective than expectant management or placebo. Surgical methods were ranked highest for managing a miscarriage, followed by medical methods, which in turn ranked above expectant management or placebo. Expectant management or placebo had the highest chance of serious complications, including the need for unplanned or emergency surgery. A subgroup analysis showed that surgical and medical methods may be more beneficial in women with missed miscarriage compared to women with incomplete miscarriage. Since type of miscarriage (missed and incomplete) appears to be a source of inconsistency and heterogeneity within these data, we acknowledge that the main network meta-analysis may be unreliable. However, we plan to explore this further in future updates and consider the primary analysis as separate networks for missed and incomplete miscarriage.
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Affiliation(s)
- Jay Ghosh
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Argyro Papadopoulou
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Adam J Devall
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Hannah C Jeffery
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Leanne E Beeson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Vivian Do
- University of Birmingham, Birmingham, UK
| | - Malcolm J Price
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Aurelio Tobias
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Antonella Lavelanet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
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Wada Y, Takahashi H, Suzuki H, Ohashi M, Ogoyama M, Nagayama S, Baba Y, Usui R, Suzuki T, Ohkuchi A, Fujiwara H. Expectant management of retained products of conception following abortion: A retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2021; 260:1-5. [PMID: 33689917 DOI: 10.1016/j.ejogrb.2021.02.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 02/01/2021] [Accepted: 02/25/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To clarify the natural history of retained products of conception (RPOC) following abortion at less than 22 weeks of gestation, and those who show major bleeding during course observation. STUDY DESIGN We retrospectively reviewed 640 patients who had spontaneous or artificial abortion at less than 22 weeks of gestation between January 2011 and August 2019 in our institute. Of those, patients with RPOC were included. The maternal background, RPOC characteristics, and subsequent complications including additional interventions were reviewed. RESULTS Fifty-four patients with RPOC were included. The incidence of RPOC was 6.7 %. The median (interquartile range: IQR) RPOC length was 29 (20-38) mm. RPOC hypervascularity was observed in 26 (48 %) patients. The median (IQR) periods of RPOC flow disappearance and RPOC disappearance on ultrasound from abortive treatment were 50 (28-76) and 84 (50-111) days, respectively. Of the 54, 44 patients were selected for expectant management. Of the 44, 34 (77 %) patients were observed without intervention (recovery group); the other 10 (23 %) patients required additional interventions associated with subsequent bleeding (intervention group). Compared with the recovery group, heavy bleeding (> 500 mL) at abortion (6/10: 60 %) and RPOC hypervascularity (8/10: 80 %) were more frequently observed in the intervention group. CONCLUSION Expectant management was successful in almost 80 % of patients with RPOC following abortion. The additional interventions were required in patients with heavy bleeding at abortion and RPOC hypervascularity.
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Affiliation(s)
- Yoshimitsu Wada
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Hironori Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan.
| | - Hirotada Suzuki
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Mai Ohashi
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Manabu Ogoyama
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Shiho Nagayama
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Yosuke Baba
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Rie Usui
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Tatsuya Suzuki
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Akihide Ohkuchi
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Hiroyuki Fujiwara
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
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Linnakaari R, Helle N, Mentula M, Bloigu A, Gissler M, Heikinheimo O, Niinimäki M. Trends in the incidence, rate and treatment of miscarriage-nationwide register-study in Finland, 1998-2016. Hum Reprod 2020; 34:2120-2128. [PMID: 31747000 DOI: 10.1093/humrep/dez211] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/02/2019] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION What changes have occurred in the incidence of miscarriage, its treatment options, and the profile of the women having miscarriages in Finland between 1998 and 2016? SUMMARY ANSWER The annual incidence of registry-identified miscarriage has declined significantly between 1998 and 2016, and non-surgical management has become the dominant treatment. WHAT IS KNOWN ALREADY Miscarriage occurs in 8-15% of clinically recognized pregnancies and in ~30% of all pregnancies. Increasing maternal age is associated with an increasing risk of miscarriage. The treatment of miscarriage has evolved significantly in recent years: previously, surgical evacuation of the uterus was the standard of care, but nowadays medical and expectant management are increasingly used. STUDY DESIGN, SIZE, DURATION We conducted a nationwide retrospective cohort study of 128 381 women that had experienced a miscarriage that was managed in public healthcare between 1998 and 2016 in Finland. PARTICIPANTS/MATERIALS, SETTING, METHODS We used the National Hospital Discharge Registry for the data. Women aged 15-49 years that had experienced their first miscarriage during the follow-up period and had miscarriage-related diagnoses during their admission to public hospital were included in the study. Miscarriages were defined by the 10th Revision of the International Statistical Classification of Diseases and related Medical Problems (ICD-10) diagnostic codes O02*, O03* and O08*. Women with ectopic, molar and continuing pregnancies and induced abortions were excluded. Treatment was divided into surgical and non-surgical treatment using the surgical procedure codes. MAIN RESULTS AND THE ROLE OF CHANCE The annual incidence of registry-identified miscarriage has declined from 6.8/1000 15-49-year-old women in 1998 to 5.0/1000 in 2016 (P < 0.001). Also, the incidence rate of registry-identified miscarriage (i.e. the proportion of miscarriages of registry-identified pregnancies [i.e. deliveries, induced abortions, and miscarriages]) has declined from 112/1000 15-49-year-old pregnant women in 1998 to 83/1000 in 2016 (P < 0.001). The largest decrease in this proportion occurred among women over 40 years of age, among whom 26.5% of registry-identified pregnancies in 1998 ended in miscarriage compared to that of 16.4% in 2016. The proportion of missed abortion has increased (30.3 to 38.8%, P < 0.001) whereas that of blighted ovum has decreased (25.4 to 12.8%, P < 0.001). The proportion of registry-identified miscarriages seen among nulliparous women has increased from 43.7 to 49.6% (P < 0.001). Mean age at the time of miscarriage remained at 31 years throughout the study. Altogether, 29% of all miscarriages were treated surgically and 71% underwent medical or expectant management. The proportion of surgical management has decreased from 38.0 to 1.6% for spontaneous abortion, from 60.7 to 9.4% for blighted ovum and 70.9 to 11.2% for missed abortion between 1998 and 2016. LIMITATIONS, REASONS FOR CAUTION This study includes only women with registry-identified pregnancies, i.e. women who were treated in public hospitals. However, the number of women treated elsewhere is presumed to be small. Neither can this study estimate the number of women having spontaneous miscarriage with no hospital contact. WIDER IMPLICATIONS OF THE FINDINGS Both the annual incidence and incidence rate of miscarriage of all registry-identified pregnancies has decreased, and non-surgical management has become the standard of care. These findings are of value when planning allocation of healthcare resources and at individual level considering fertility and miscarriage questions. We speculate that improving ultrasound diagnostics explains the increasing proportion of missed abortion relative to other types of miscarriage. More investigation is needed to examine potential risk factors, complications and morbidity associated with miscarriages. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by the research funds of the Helsinki and Uusimaa hospital system, by a personal grant from Viipurin Tuberkuloosisäätiö to R.L. and by a personal grant from The Finnish Cultural Foundation to N.H. The authors have no conflicts of interest to declare.
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Affiliation(s)
- R Linnakaari
- Department of Obstetrics and Gynaecology, South Karelia Central Hospital, 53130 Lappeenranta, Finland.,Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | - N Helle
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | - M Mentula
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | - A Bloigu
- Department of Obstetrics and Gynaecology, Oulu University Hospital, 90220, Oulu, Finland.,PEDEGO Research Unit, University of Oulu, Oulu, Finland
| | - M Gissler
- National Institute for Health and Welfare (THL), 00300 Helsinki, Finland.,Department of Neurobiology, Care Sciences and Society, Karolinska Institute, SE-171 77 Stockholm, Sweden
| | - O Heikinheimo
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | - M Niinimäki
- Department of Obstetrics and Gynaecology, Oulu University Hospital, 90220, Oulu, Finland.,PEDEGO Research Unit, University of Oulu, Oulu, Finland.,Medical Research Center Oulu (MRC Oulu), University of Oulu, Oulu, Finland
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Early pregnancy loss: the default outcome for fertilized human oocytes. J Assist Reprod Genet 2020; 37:1057-1063. [PMID: 32193767 DOI: 10.1007/s10815-020-01749-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/12/2020] [Indexed: 01/08/2023] Open
Abstract
Early pregnancy loss is by far the most frequent outcome of human reproduction. It occurs when despite the timely interaction of gametes and initiation of embryogenesis and implantation of the conceptus, pregnancy continuance fails. From a clinical perspective, early pregnancy loss represents a neglected but relevant issue because of the high incidence, the evolving and yet not fully elucidated mechanism, the possible association with other relevant medical conditions, and the potential psychological sequelae. Our growing understanding of the dialog established between the embryo and the endometrium provides new insights into the etiology of pregnancy loss. Aneuploidies as a cause of early pregnancy loss are known for a long time, but there is now evidence that endometrium is not a passive player. An active selection aimed at impeding implantation of unhealthy embryos actually occurs at the endometrial interface. The concept of selectivity is substituting the one of mere receptivity.
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Kumari P, Preethi R, Abraham A, Rathore S, Benjamin S, Gowri M, Mathews JE. A prospective observational study of the follow-up of medical management of early pregnancy failure. J Family Med Prim Care 2019; 8:3998-4002. [PMID: 31879649 PMCID: PMC6924238 DOI: 10.4103/jfmpc.jfmpc_585_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/20/2019] [Accepted: 08/26/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Medical termination for missed miscarriage with the use of 800 μg of vaginal misoprostol as a single agent is recommended as a cheap option before 14 weeks of gestation in developing countries. A few studies have looked at its efficacy. METHODS A prospective, observational study was done on women having medical termination with up to three doses of 800 μg vaginal misoprostol at 12 hourly intervals. The number of women who needed check curettage was collected. Ultrasound findings if done were collated. Follow-up was done telephonically at the end of first week, fourth week and sixth week. RESULTS The cohort comprised 145 women. The primary outcome was the need for curettage after expulsion of products following medical management and this was 49/145 (37.8%) of women. The induction expulsion interval was 36 hours. The mean endometrial thickness of the 113/145 women who had an ultrasound was 11 mm. The mean endometrial thickness in women who had check curettage was 18 mm. Persistent spotting was the only significant symptom at follow-up. Resumption of cycle at the end of the sixth week was seen in 105/132 (80.15%) of women who were followed up. CONCLUSION Findings of our study showed the check curettage rate of 37.8%. However, the regime which we used, that is, 800 μg vaginal misoprostol at 12 hourly intervals had a long induction to expulsion interval of 36 hours. In all, 80% of women resumed normal cycles at the end of the sixth week. No significant complications were noted on follow-up.
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Affiliation(s)
- Pushplata Kumari
- Department of Obstetrics and Gynaecology Unit - 3, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - R.N. Preethi
- Department of Obstetrics and Gynaecology Unit - 3, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - Anuja Abraham
- Department of Obstetrics and Gynaecology Unit - 3, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - Swati Rathore
- Department of Obstetrics and Gynaecology Unit - 5, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - Santosh Benjamin
- Department of Obstetrics and Gynaecology Unit - 5, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - M Gowri
- Department of Biostatistics, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - Jiji Elizabeth Mathews
- Department of Obstetrics and Gynaecology Unit - 5, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
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van den Berg J, Hamel CC, Snijders MP, Coppus SF, Vandenbussche FP. Mifepristone and misoprostol versus misoprostol alone for uterine evacuation after early pregnancy failure: study protocol for a randomized double blinded placebo-controlled comparison (Triple M Trial). BMC Pregnancy Childbirth 2019; 19:443. [PMID: 31775677 PMCID: PMC6880504 DOI: 10.1186/s12884-019-2497-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 09/09/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Early pregnancy failure (EPF) is a common complication of pregnancy. If women do not abort spontaneously, they will undergo medical or surgical treatment in order to remove the products of conception from the uterus. Curettage, although highly effective, is associated with a risk of complications; medical treatment with misoprostol is a safe and less expensive alternative. Unfortunately, after 1 week of expectant management in case of EPF, medical treatment with misoprostol has a complete evacuation rate of approximately 50%. Misoprostol treatment results may be improved by pre-treatment with mifepristone; its effectiveness has already been proven for other indications of pregnancy termination. This study will test the hypothesis that, in EPF, the sequential combination of mifepristone with misoprostol is superior to the use of misoprostol alone in terms of complete evacuation (primary outcome), patient satisfaction, complications, side effects and costs (secondary outcomes). METHODS The trial will be performed multi-centred, prospectively, two-armed, randomised, double-blinded and placebo-controlled. Women with confirmed EPF by ultrasonography (6-14 weeks), managed expectantly for at least 1 week, can be included and randomised to pre-treatment with oral mifepristone (600 mg) or oral placebo (identical in appearance). Randomisation will take place after receiving written consent to participate. In both arms pre-treatment will be followed by oral misoprostol, which will start 36-48 h later consisting of two doses 400 μg (4 hrs apart), repeated after 24 h if no tissue is lost. Four hundred sixty-four women will be randomised in a 1:1 ratio, stratified by centre. Ultrasonography 2 weeks after treatment will determine short term treatment effect. When the gestational sac is expulsed, expectant management is advised until 6 weeks after treatment when the definitive primary endpoint, complete or incomplete evacuation, will be determined. A sonographic endometrial thickness < 15 mm using only the allocated therapy by randomisation is considered as successful treatment. Secondary outcome measures (patient satisfaction, complications, side effects and costs) will be registered using a case report form, patient diary and validated questionnaires (Short Form 36, EuroQol-VAS, Client Satisfaction Questionnaire, iMTA Productivity Cost Questionnaire). DISCUSSION This trial will answer the question if, in case of EPF, after at least 1 week of expectant management, sequential treatment with mifepristone and misoprostol is more effective than misoprostol alone to achieve complete evacuation of the products of conception. TRIAL REGISTRATION Clinicaltrials.gov (d.d. 02-07-2017): NCT03212352. Trialregister.nl (d.d. 03-07-2017): NTR6550. EudraCT number (d.d. 07-08-2017): 2017-002694-19. File number Commisie Mensgebonden Onderzoek (d.d. 07-08-2017): NL 62449.091.17.
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Affiliation(s)
- Joyce van den Berg
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Postbus 9015, Nijmegen, GS 6500 The Netherlands
| | - Charlotte C. Hamel
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Postbus 9015, Nijmegen, GS 6500 The Netherlands
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, GA 6525 The Netherlands
| | - Marcus P. Snijders
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Postbus 9015, Nijmegen, GS 6500 The Netherlands
| | - Sjors F. Coppus
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, De Run 4600, Veldhoven, DB 5504 The Netherlands
| | - Frank P. Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, GA 6525 The Netherlands
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van den Berg J, Hamel CC, Coppus SF, Snijders MP, Vandenbussche FP. Current and future expectations of mifepristone treatment in early pregnancy failure: a survey among Dutch gynaecologists. J OBSTET GYNAECOL 2019; 39:1006-1011. [PMID: 31215270 DOI: 10.1080/01443615.2019.1602598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To investigate the current and future addition of mifepristone to misoprostol treatment in case of early pregnancy failure (EPF), a digital questionnaire was distributed to a representative sample of all Dutch hospitals (25/79). In non-teaching centres, the presence of a local protocol was significantly lower compared to academic and teaching hospitals (p=.012). If a local protocol was present, the first choice of treatment was medical in 54.5%. Four respondents (16%) always prescribed mifepristone in case of EPF. The most common reason not prescribing mifepristone was the lack of sufficient scientific evidence. An average increase in success rate of 21.7% was desired to prescribe mifepristone in the future for EPF. Completeness of evacuation of products of conception from the uterus was usually assessed after 1 week by ultrasonography combined with clinical signs. If a complete evacuation was not achieved by the initial medical treatment, expectant management was proposed just as often as surgical intervention. Impact Statement What is already known on this subject? In case of early pregnancy failure (EPF), women can choose from both expectant medical (misoprostol, whether or not combined with mifepristone) and surgical (D and C) treatment. In The Netherlands, a national guideline concerning the treatment of EPF is still lacking. A questionnaire performed by Verschoor et al. ( 2014 ) showed there was a large practice variety between Dutch clinics. What the results of this study add? In this study, a representative sample of all Dutch clinics received a questionnaire about the treatment of EPF. The results confirm a large practice variation regarding treatment of EPF. The first choice of treatment, the medical treatment regimen, and the assessment of whether or not the treatment have been variations of successful between clinics. With regards to the addition of mifepristone to the medical treatment regime with misoprostol, gynaecologists are willing to consider mifepristone if an improvement of efficacy of approximately 20% is scientifically proven. What the implications are of these findings for clinical practice and/or further research? In our opinion, these results emphasise the need for a national guideline concerning the treatment of EPF. Our results also demonstrate that, if the addition of mifepristone to medical treatment with misoprostol proves to be more efficient than misoprostol alone, gynaecologists are willing to prescribe mifepristone in the future. Whether the addition is indeed more effective than misoprostol alone, will be the subject of a multicentre, double-blind, placebo-controlled randomised controlled trial, planned to begin in the first half of 2018.
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Affiliation(s)
- Joyce van den Berg
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital , Nijmegen , The Netherlands
| | - Charlotte C Hamel
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital , Nijmegen , The Netherlands
| | - Sjors F Coppus
- Department of Obstetrics and Gynaecology, Maxima Medical Centre , Eindhoven , The Netherlands
| | - Marcus P Snijders
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital , Nijmegen , The Netherlands
| | - Frank P Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre , Nijmegen , The Netherlands
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Hentzen JEKR, Verschoor MA, Lemmers M, Ankum WM, Mol BWJ, van Wely M. Factors influencing women's preferences for subsequent management in the event of incomplete evacuation of the uterus after misoprostol treatment for miscarriage. Hum Reprod 2018; 32:1674-1683. [PMID: 28575402 DOI: 10.1093/humrep/dex216] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 05/18/2017] [Indexed: 11/15/2022] Open
Abstract
STUDY QUESTION What affects women's treatment preferences in the management of an incomplete evacuation of the uterus after misoprostol treatment for a first-trimester miscarriage? SUMMARY ANSWER Women's treatment preferences in the management of an incomplete evacuation of the uterus after misoprostol treatment for miscarriage are most strongly influenced by 'the risk of a reduced fertility' followed by 'the probability of success'. WHAT IS KNOWN ALREADY Available treatment options in miscarriage are surgical, medical or expectant management. Treatment with misoprostol leads to an incomplete evacuation of the uterus and additional surgical treatment in 20-50% of women. To our knowledge, women's preferences for subsequent treatment of an incomplete evacuation of the uterus after misoprostol treatment for miscarriage have not been studied yet. STUDY DESIGN, SIZE, DURATION Between April 2014 and January 2015, we conducted a prospective nationwide multicentre discrete-choice experiment (DCE). DCEs have become the most frequently applied approach for studying patient preferences in health care. In our DCE, which considerers five attributes, a target sample size was calculated including 20 patients per attribute for the main analysis. We intended to include 25% more patients, i.e. a total of 125 thus enabling us to assess heterogeneity of treatment choices. PARTICIPANTS/MATERIALS, SETTING, METHODS All women visiting the outpatient clinic with first-trimester miscarriage or incomplete miscarriage were invited to participate in the study. Women under 18 years of age, women who were unable to understand the Dutch questionnaire or women who already had received a treatment for the current miscarriage were excluded. Women's preferences were assessed using a DCE. A literature review, expert opinions and interviews with women from the general population were used to define relevant treatment characteristics. Five attributes were selected: (i) certainty about the duration of convalescence; (ii) number of days of bleeding after treatment; (iii) probability of success (empty uterus after treatment); (iv) risk of reduced fertility and (v) risk of complications requiring more time or readmission to hospital. Fourteen scenarios using these attributes were selected in the DCE. Each of these scenarios presented two treatment options, while treatment characteristics varied between the 14 scenarios. For each scenario, respondents were asked to choose the preferred treatment option. The importance of each attribute was analysed, and preference heterogeneity was investigated through latent-class analysis. MAIN RESULTS AND THE ROLE OF CHANCE One hundred and eighty-six women were included of whom 128 completed the DCE (69% response rate). The two attributes with the greatest effect on their preference were, probability of success and risk of reduced fertility. The latent-class analysis revealed two subgroups of patients with different preference patterns. Forty per cent of women were more influenced by treatment success and 59% were more influenced by risk. LIMITATIONS, REASONS FOR CAUTION Most women were highly educated and were of Dutch origin, which limits the generalizability of our findings. Women with lower education levels, other cultural backgrounds and/or different previous experiences may differ from our findings. WIDER IMPLICATIONS OF THE FINDINGS Patients preferences should be addressed when counselling patients with an incomplete miscarriage after misoprostol treatment. STUDY FUNDING/COMPETING INTEREST(S) This study was embedded in the MisoREST trial, and funded by ZonMw, a Dutch organization for Health Research and Development, project number 80-82310-97-12066. There were no conflicts of interests. TRIAL REGISTRATION NUMBER Dutch Trial Register NTR3310, http://www.trialregister.nl. TRIAL REGISTRATION DATE 27 February 2012. DATE OF FIRST PATIENT'S ENROLMENT 12 June 2012.
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Affiliation(s)
- Judith E K R Hentzen
- Department of Obstetrics and Gynaecology, Academic Medical Center, PO Box 22770, 1100 DE, Amsterdam, The Netherlands
| | - Marianne A Verschoor
- Department of Obstetrics and Gynaecology, Academic Medical Center, PO Box 22770, 1100 DE, Amsterdam, The Netherlands
| | - Marike Lemmers
- Department of Obstetrics and Gynaecology, Academic Medical Center, PO Box 22770, 1100 DE, Amsterdam, The Netherlands
| | - Willem M Ankum
- Department of Obstetrics and Gynaecology, Academic Medical Center, PO Box 22770, 1100 DE, Amsterdam, The Netherlands
| | - Ben Willem J Mol
- The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, 55 King William Road, SA 5006 North Adelaide, Australia.,The South Australian Health and Medical Research Institute, North Terrace, SA 5000 Adelaide, Australia
| | - Madelon van Wely
- Centre of Reproductive Medicine, Academic Medical Center-University, PO Box 22770, 1100 DE Amsterdam, The Netherlands
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Lemmers M, Verschoor MA, Bossuyt PM, Huirne JA, Spinder T, Nieboer TE, Bongers MY, Janssen IA, Van Hooff MH, Mol BW, Ankum WM, Bosmans JE. Cost-effectiveness of curettage vs. expectant management in women with an incomplete evacuation after misoprostol treatment for first-trimester miscarriage: a randomized controlled trial and cohort study. Acta Obstet Gynecol Scand 2018; 97:294-300. [DOI: 10.1111/aogs.13283] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 12/09/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Marike Lemmers
- Department of Obstetrics and Gynecology; Academic Medical Center; Amsterdam the Netherlands
- Department of Obstetrics and Gynecology; VU Medical Center; Amsterdam the Netherlands
| | | | - Patrick M. Bossuyt
- Clinical Research Unit; University of Amsterdam; Academic Medical Center; Amsterdam the Netherlands
| | - Judith A.F. Huirne
- Department of Obstetrics and Gynecology; VU Medical Center; Amsterdam the Netherlands
| | - Teake Spinder
- Department of Obstetrics and Gynecology; Leeuwarden Medical Center; Leeuwarden the Netherlands
| | - Theodoor E. Nieboer
- Department of Obstetrics and Gynecology; Radboud University Medical Center; Nijmegen the Netherlands
| | - Marlies Y. Bongers
- Department of Obstetrics and Gynecology; Grow-School for Oncology and Developmental Biology; Maastricht University; Maastricht the Netherlands
| | - Ineke A.H. Janssen
- Department of Obstetrics and Gynecology; Groene Hart Hospital; Gouda the Netherlands
| | - Marcel H.A. Van Hooff
- Department of Obstetrics and Gynecology; Sint Franciscus Gasthuis; Rotterdam the Netherlands
| | - Ben W.J. Mol
- The Robinson Research Institute; School of Pediatrics and Reproductive Health; University of Adelaide and The South Australian Health and Medical Research Institute; Adelaide Australia
| | - Willem M. Ankum
- Department of Obstetrics and Gynecology; Academic Medical Center; Amsterdam the Netherlands
| | - Judith E. Bosmans
- Department of Health Sciences; Faculty of Earth and Life Sciences; Free University Amsterdam; Amsterdam Public Health Research Institute; Amsterdam the Netherlands
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Smorgick N, Levinsohn-Tavor O, Ben-Ami I, Maymon R, Pansky M, Vaknin Z. Hysteroscopic removal of retained products of conception following first trimester medical abortion. Gynecol Minim Invasive Ther 2017; 6:183-185. [PMID: 30254910 PMCID: PMC6135206 DOI: 10.1016/j.gmit.2017.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 03/15/2017] [Accepted: 05/23/2017] [Indexed: 11/28/2022] Open
Abstract
Study Objective: To investigate the use of operative hysteroscopy instead of traditional curettage in women with retained products of conception (RPOC) following first trimester medical abortion, with the aim of reducing post-operative intrauterine adhesions. Design: Retrospective study. Setting: Gynecology department in a University affiliated hospital. Patients: All women treated by hysteroscopy for RPOC following first trimester medical abortion using the mifepristone-misoprostol protocol for pregnancy termination or the misoprostol protocol for early missed abortion from January 2013 to August 2016. Intervention: Operative hysteroscopy for removal of RPOC. Post-operative intrauterine adhesions were assessed by diagnostic office hysteroscopy after 6–8 weeks. Measurements and Main Results: 50 cases were identified. The mean time from medication administration to the operative hysteroscopy was 1.7 ± 0.7 months. Operative hysteroscopy with blunt use of the resectoscopic loop was used to remove all specimens, and all procedures were completed without intra-operative complications. Two patients (4.0%) were readmitted for fever. Pathology confirmed the presence of RPOC in 45 (90.0%) cases. On follow-up office hysteroscopy, a normal uterine cavity without evidence of intrauterine adhesions was seen in 29/29 (100%) women. Conclusion: Hysteroscopy for removal of RPOC following medical abortion is associated with low rates of complications and post-operative intrauterine adhesions.
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Affiliation(s)
- Noam Smorgick
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Israel
| | - Orna Levinsohn-Tavor
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Israel
| | - Ido Ben-Ami
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Israel
| | - Moty Pansky
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Israel
| | - Zvi Vaknin
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Israel
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MisoREST: Surgical versus expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage: A cohort study. Eur J Obstet Gynecol Reprod Biol 2017; 211:83-89. [DOI: 10.1016/j.ejogrb.2017.01.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/09/2017] [Accepted: 01/15/2017] [Indexed: 11/20/2022]
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Fertility and obstetric outcomes after curettage versus expectant management in randomised and non-randomised women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage. Eur J Obstet Gynecol Reprod Biol 2017; 211:78-82. [PMID: 28199872 DOI: 10.1016/j.ejogrb.2017.01.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 01/24/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess fertility and obstetric outcomes in women treated with curettage or undergoing expectant management for an incomplete miscarriage after misoprostol treatment. STUDY DESIGN Between June 2012 and July 2014, we conducted a multicentre randomised clinical trial (RCT) with a parallel cohort study for non-randomised women, treated according to their preference. In the RCT 30 women were allocated curettage and 29 expectant management. In the cohort 197 women participated; 65 underwent curettage and 132 women underwent expectant management. Primary outcome was curation, defined as either an empty uterus on sonography at six weeks or an uneventful clinical follow-up. We used questionnaires to assess fertility and obstetric outcome of the first new pregnancy subsequent to study enrolment. RESULTS Curation was seen in 91/95 women treated with curettage (95.8%) versus 134/161 women managed expectantly (83.2%) (p=0.003). The response rate was 211/255 (82%). In 198 women pursuing a new pregnancy, conception rates were 92% (67/73) in the curettage group versus 96% (120/125) in the expectant management group (OR 0.96, 95% CI 0.89;1.03, p=0.34), with ongoing pregnancy rates of 87% (58/67) versus 78% (94/120), respectively (OR 1.12, 95% CI 0.99;1.28, p=0.226). Preterm birth rates were 1/46 in the curettage group versus 8/81 in the expectant management group (OR 0.22, 95% CI 0.03;1.71 P=0.15). Caesarean section rates were 23% and 24% for women in the curettage group and expectant management group respectively. CONCLUSION In women with an incomplete evacuation of the uterus after misoprostol treatment, curettage and expectant management does not lead to different fertility and pregnancy outcomes, as compared to expectant management.
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