Management of first-trimester miscarriage: a systematic review and network meta-analysis

Clinical factors associated with subsequent surgical intervention in women undergoing early medical termination of viable or non-viable pregnancies

Introduction

Mifepristone-misoprostol treatment for medical abortion and miscarriage are safe and effective. This study aimed to assess clinical factors associated with subsequent surgical intervention after medical termination of early viable or non-viable pregnancy.

Methods

This retrospective, single-center study included women who underwent medical abortion at Taipei Medical University between January 2010 and December 2019. A total of 1,561 subjects, with 1,080 viable and 481 non-viable pregnancies, who were treated with oral mifepristone 600 mg followed by misoprostol 600 mg 48 h later were included. Data of all pregnancies and medical termination of pregnancy were evaluated using regression analysis. The main outcome was successful termination of pregnancy.

Results

The success rate of medical abortion was comparable in women with viable and non-viable (92.13% vs. 92.93%) pregnancies. Besides retained tissue, more existing pregnancies with ultrasonographic findings were found in the non-viable pregnancy group than in the viable pregnancy group (29.4% vs. 14.1%, p = 0.011). Multivariate analysis showed that previous delivery was an independent risk factor for failed medical abortion among all included cases. In women with viable pregnancy, longer gestational age [adjusted odds ratio (aOR): 1.483, 95% confidence interval (CI): 1.224-1.797, p < 0.001] and previous Cesarean delivery (aOR: 2.177, 95% CI: 1.167-40.62, p = 0.014) were independent risk factors for failed medical abortion. Number of Cesarean deliveries (aOR: 1.448, 95% CI: 1.029-2.039, p = 0.034) was an independent risk factor for failed medication abortion in women with non-viable pregnancies.

Conclusion

This is the first cohort study to identify risk factors for subsequent surgical intervention in women with viable or non-viable pregnancies who had undergone early medically induced abortions. The success rate of medical abortion is comparable in women with viable and non-viable pregnancies. Previous delivery is an independent risk factor for failed medical abortion. Clinical follow-up may be necessary for women who are at risk of subsequent surgical intervention.

Pregnant nurses' experiences of working shifts: a qualitative systematic review

OBJECTIVE

The objective of this systematic review was to synthesize the experiences of nurses who work shifts during pregnancy.

INCLUSION CRITERIA

This review included studies that focused on the experiences of pregnant registered nurses, regardless of their level of qualification, working shifts in any workplace, including hospitals, nursing home facilities, or clinics, in any country. Nurses not involved in direct care (eg, advanced practice nurses, administrators, educators) were excluded.

METHODS

The review followed the JBI methodology for qualitative systematic reviews. Published and gray literature were searched for via CINAHL (EBSCOhost), MEDLINE (EBSCOhost), PsycINFO (EBSCOhost), Igaku Chuo Zasshi (Japan Medical Abstracts Society). No language restrictions were imposed, and the date limit was set for 2013 to 2021. Two independent reviewers performed data collection, extraction, critical appraisal, and analysis. Unequivocal and credible findings were used to develop categories, which were then synthesized to provide a set of comprehensive findings, which were graded according to ConQual.

RESULTS

Five qualitative studies were included (2 from the USA, 2 from Japan, and 1 from Korea), from which 23 findings with narrative illustrations were extracted. Of these findings, 22 were assessed as unequivocal and 1 as credible. The studies were low-to-moderate quality based on the JBI critical appraisal checklist for qualitative research. All studies used qualitative methodologies, including phenomenology, qualitative description, and the grounded theory approach. Results were integrated into 8 categories and 3 synthesized findings. The first synthesized finding was that nurses struggle with the physical burden of pregnancy and work environments that threaten continued pregnancy. The second was that nurses achieve work-pregnancy compatibility by disclosing their pregnancy and obtaining support. The third was that development as a nurse results from continuing to work during pregnancy.

CONCLUSIONS

Pregnant nurses face a harsh work environment; the support they receive after disclosing their pregnancy allows them to balance work and pregnancy; and they feel that they grow as professionals by continuing to work even if they are pregnant. More research is needed to inform support systems for them.

REVIEW REGISTRATION

PROSPERO CRD42022309674.

SUPPLEMENTAL DIGITAL CONTENT

A Japanese-language version of the abstract of this review is available as Supplemental Digital Content: http://links.lww.com/SRX/A31.

Pregnant nurses' experiences of working shifts: a qualitative systematic review protocol

OBJECTIVE

The proposed systematic review will synthesize the experiences of nurses working in any shifts during pregnancy.

INTRODUCTION

Nurses are among the most burdened health care workers and are at risk of diseases of the circulatory system due to prolonged standing. For pregnant nurses, this could reduce blood circulation and blood flow to the uterus and placenta. Contributing factors include long working hours and frequent heavy lifting, which may induce uterine contractions and premature birth; irregular shifts, which exacerbate fatigue; and high levels of psychosocial stress. There is no qualitative evidence as to what nurses are experiencing while working shifts when pregnant. This review will evaluate and integrate the current available findings related to the experience of shift-working nurses who are pregnant.

INCLUSION CRITERIA

This review will include qualitative studies focusing on the experience of shift work among pregnant nurses. No language or date limits will be applied. All types of pregnancy among nurses will be included.

METHODS

The databases to be searched will include CINAHL (EBSCOhost), MEDLINE (EBSCOhost), PsycINFO (EBSCOhost), and Igaku Chuo Zasshi (the Japan Medical Abstracts Society). Sources of gray literature will include MedNar and DANS, as well as the websites of the American Nurses Association and the Japanese Nursing Association. Study selection, critical appraisal, data extraction, and data synthesis will be performed independently by 2 reviewers. The synthesized findings will be graded according to the ConQual approach for establishing confidence in findings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022309674.

Gestörte Frühgravidität

Eine Schwangerschaft kann intrauterin, ektop oder an einem unklaren Ort liegen und entwicklungsphysiologisch vital oder gestört sein. Die transvaginale Sonographie ermöglicht die Darstellung einer intrauterinen Schwangerschaft ab einem Schwellenwert des humanen Choriongonadotropins (hCG) von 1000 IU/l in der etwa sechsten Schwangerschaftswoche (SSW). Ektope Schwangerschaften sind abhängig von der SSW gegebenenfalls erschwert sonographisch erkennbar. Der Verlauf des hCG-Werts kann hilfreich dabei sein, eine physiologische von einer gestörten Frühschwangerschaft zu unterscheiden, muss aber immer in Zusammenschau mit der Klinik und dem Ultraschallbefund interpretiert werden. Bei einem frühen Abort kann abhängig von der Klinik exspektativ oder medikamentös vorgegangen werden. Die Indikation zur Kürettage sollte insgesamt zurückhaltend gestellt werden. Bei einer ektopen Schwangerschaft sollte abhängig von SSW und Klinik eine operative Therapie oder eine Methotrexattherapie durchgeführt werden.

Medical methods for first trimester abortion

BACKGROUND

Medical abortion became an alternative method of pregnancy termination following the development of prostaglandins and antiprogesterone in the 1970s and 1980s. Recently, synthesis inhibitors of oestrogen (such as letrozole) have also been used to enhance efficacy. The most widely researched drugs are prostaglandins (such as misoprostol, which has a strong uterotonic effect), mifepristone, mifepristone with prostaglandins, and letrozole with prostaglandins. More evidence is needed to identify the best dosage, regimen, and route of administration to optimise patient outcomes. This is an update of a review last published in 2011.

OBJECTIVES

To compare the effectiveness and side effects of different medical methods for first trimester abortion.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Global Health, and LILACs on 28 February 2021. We also searched Clinicaltrials.gov and the World Health Organization's (WHO) International Clinical Trials Registry Platform, and reference lists of retrieved papers.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) that compared different medical methods for abortion before the 12th week of gestation. The primary outcome is failure to achieve complete abortion. Secondary outcomes are mortality, surgical evacuation, ongoing pregnancy at follow-up, time until passing of conceptus, blood transfusion, side effects and women's dissatisfaction with the method.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected and evaluated studies for inclusion, and assessed the risk of bias. We processed data using Review Manager 5 software. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 99 studies in the review (58 from the original review and 41 new studies). 1. Combined regimen mifepristone/prostaglandin Mifepristone dose: high-dose (600 mg) compared to low-dose (200 mg) mifepristone probably has similar effectiveness in achieving complete abortion (RR 1.07, 95% CI 0.87 to 1.33; I2 = 0%; 4 RCTs, 3494 women; moderate-certainty evidence). Prostaglandin dose: 800 µg misoprostol probably reduces abortion failure compared to 400 µg (RR 0.63, 95% CI 0.51 to 0.78; I2= 0%; 3 RCTs, 4424 women; moderate-certainty evidence). Prostaglandin timing: misoprostol administered on day one probably achieves more success on complete abortion than on day three (RR 1.94, 95% CI 1.05 to 3.58; 1489 women; 1 RCT; moderate-certainty evidence). Administration strategy: there may be no difference in failure of complete abortion with self-administration at home compared with hospital administration (RR 1.63, 95% CI 0.68 to 3.94; I2 = 84%; 2263 women; 4 RCTs; low-certainty evidence), but failure may be higher when administered by nurses in hospital compared to by doctors in hospital (RR 2.69, 95% CI 1.39 to 5.22; I2 = 66%; 3 RCTs, 3056 women; low-certainty evidence). Administration route: oral misoprostol probably leads to more failures than the vaginal route (RR 2.38, 95% CI 1.46 to 3.87; I2 = 39%; 3 RCTs, 1704 women; moderate-certainty evidence) and may be associated with more frequent side effects such as nausea (RR 1.14, 95% CI 1.03 to 1.26; I2 = 0%; 2 RCTs, 1380 women; low-certainty evidence) and diarrhoea (RR 1.80 95% CI 1.49 to 2.17; I2 = 0%; 2 RCTs, 1379 women). Compared with the vaginal route, complete abortion failure is probably lower with sublingual (RR 0.68, 95% CI 0.22 to 2.11; I2 = 59%; 2 RCTs, 3229 women; moderate-certainty evidence) and may be lower with buccal administration (RR 0.71, 95% CI 0.34 to 1.46; I2 = 0%; 2 RCTs, 479 women; low-certainty evidence), but sublingual or buccal routes may lead to more side effects. Women may experience more vomiting with sublingual compared to buccal administration (RR 1.33, 95% CI 1.01 to 1.77; low-certainty evidence). 2. Mifepristone alone versus combined regimen The efficacy of mifepristone alone in achieving complete abortion compared to combined mifepristone/prostaglandin up to 12 weeks is unclear (RR of failure 3.25, 95% CI 0.81 to 13.09; I2 = 83%; 3 RCTs, 273 women; very low-certainty evidence). 3. Prostaglandin alone versus combined regimen Nineteen studies compared prostaglandin alone to a combined regimen (prostaglandin combined with mifepristone, letrozole, estradiol valerate, tamoxifen, or methotrexate). Compared to any of the combination regimens, misoprostol alone may increase the risk for failure to achieve complete abortion (RR of failure 2.39, 95% CI 1.89 to 3.02; I2 = 64%; 18 RCTs, 3471 women; low-certainty evidence), and with more diarrhoea. 4. Prostaglandin alone (route of administration) Oral misoprostol alone may lead to more failures in complete abortion than the vaginal route (RR 3.68, 95% CI 1.56 to 8.71, 2 RCTs, 216 women; low-certainty evidence). Failure to achieve complete abortion may be slightly reduced with sublingual compared with vaginal (RR 0.69, 95% CI 0.37 to 1.28; I2 = 87%; 5 RCTs, 2705 women; low-certainty evidence) and oral administration (RR 0.58, 95% CI 0.11 to 2.99; I2 = 66%; 2 RCTs, 173 women). Failure to achieve complete abortion may be similar or slightly higher with sublingual administration compared to buccal administration (RR 1.11, 95% CI 0.71 to 1.74; 1 study, 401 women).

AUTHORS' CONCLUSIONS

Safe and effective medical abortion methods are available. Combined regimens (prostaglandin combined with mifepristone, letrozole, estradiol valerate, tamoxifen, or methotrexate) may be more effective than single agents (prostaglandin alone or mifepristone alone). In the combined regimen, the dose of mifepristone can probably be lowered to 200 mg without significantly decreasing effectiveness. Vaginal misoprostol is probably more effective than oral administration, and may have fewer side effects than sublingual or buccal. Some results are limited by the small numbers of participants on which they are based. Almost all studies were conducted in settings with good access to emergency services, which may limit the generalisability of these results.

Management of incomplete and missed spontaneous abortions: a cohort study of trends in Calgary emergency departments

OBJECTIVES

Incomplete and missed spontaneous abortion cases often first present to the emergency department (ED), where they can be managed operatively via dilation and curettage (D&C) or non-operatively through medical or expectant management. The primary objective of this study was to determine how rates of operative management have changed over time across Calgary EDs. The secondary objective was to assess correlates of effectiveness and potential drivers in management including gynecological consults, ED return visits requiring admission, and subsequent D&Cs.

METHODS

Sunrise Clinical Manager (electronic medical system) was accessed to collect data for patients who presented to a Calgary ED with an incomplete or missed spontaneous abortion from 2014 to 2019. Patients requiring resuscitation and those with complications were excluded. Return to care for D&C and ED revisits requiring admission were used as a proxy for failed non-operative management. Trends in management are reported using 95% confidence intervals.

RESULTS

Of the 3845 patients included, 1110 (28.9%) received a D&C on initial ED visit. The remaining 2735 (71.1%) were initially managed non-operatively. Rates of D&Cs decreased 11.6% from 2014 to 2019, 95% CI (6.5%, 16.8%). There was minimal change in the rates of gynecological consults, ED returns requiring admission, and returns to care resulting in D&Cs over time.

CONCLUSIONS

The management of incomplete and missed spontaneous abortions has shifted toward non-operative management over 6 years in Calgary. As this is not associated with increased ED returns requiring admission or subsequent D&Cs, the shift appears to be appropriate. As gynecological consults were consistent over time, further knowledge translation around non-operative spontaneous abortion management may be useful for ED physicians.

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.

Treatment Options After a Diagnosis of Early Miscarriage: Expectant, Medical, and Surgical

BACKGROUND

Approximately 12% of pregnancies end in an early miscarriage (up to week 12 + 0 of pregnancy). Over the past 10 to 15 years, two alternatives to curettage have appeared in the pertinent international treatment guidelines: expectant treatment and medical (drug) treatment. In this review, we discuss the advantages and disadvantages of each of these therapeutic options.

METHODS

This review is based on pertinent publications (January 2000 to February 2021) retrieved by a selective search in PubMed, as well as on the guidelines of the American College of Obstetrics and Gynecologists, the Association of the Scientific Medical Societies in Germany, the National Institute for Health and Care Excellence/Royal College of Obstetricians and Gynaecologists, and the International Federation of Gynaecology and Obstetrics.

RESULTS

Three effective and safe treatment options are available after a diagnosis of early miscarriage. Expectant treatment yields success rates of 66-91%, depending on the type of miscarriage. Its complications include hemorrhage requiring blood transfusion in 1-2% of cases. If expectant therapy fails, subsequent treatment with misoprostol or curettage is indicated. Drug therapy with misoprostol yields a complete termination in 81-95% of cases and is thus a valid alternative to expectant therapy, with the advantage of better planning capability. The vaginal application of misoprostol is the most effective means of administration, with the fewest side effects. Curettage is needed in 5-20% of cases. Suctional curettage has a success rate of 97-98%, with an associated anesthesia-related risk of 0.2%, a 0.1% risk of perforation, and a 2-3% rate of repeat curettage.

CONCLUSION

If there is no acute indication for the surgical treatment of an early miscarriage, the patient can choose among three treatment options. Expectant and medical treatment can be provided on an outpatient basis. Curettage is the treatment of choice in the presence of infection, marked and persistent bleeding, hemodynamic instability, or a pre-existing coagulopathy.

Maternal non-steroidal anti-inflammatory drug exposure during pregnancy and risk of miscarriage: a systematic review and meta-analysis

BACKGROUND

Numerous studies have suggested that non-steroidal anti-inflammatory drugs (NSAIDs) might be associated with increased risk of miscarriage. However, these results are conflicting and inconclusive.

METHODS

We performed this systematic review and meta-analysis to assess the relationship between NSAIDs exposure and risk of miscarriage. A systematic literature search was conducted to identify relevant studies published from the time of database inception until June 2021.

RESULTS

A total of ten studies involving 207,341 pregnant women were subjected to meta-analysis. There was no statistically significantly increased risk of miscarriage with the use of NSAIDs during pregnancy (OR = 1.37, 95% CI 0.99-1.88, p = 0.057). However, our findings showed that women exposed to NSAIDs around the time of conception were at increased risk of miscarriage (OR 2.32, 95% CI 1.16-4.66, p = 0.018). Furthermore, no significant association between NSAID use and miscarriage was evident during the first trimester of pregnancy (OR = 1, 95% CI = 0.83-1.2, p = 0.996), possibly attributable to the small sample size.

CONCLUSION

Our findings indicate that NSAID exposure around the time of conception might be a risk factor for miscarriage. Further studies are needed to evaluate whether the risk varies by the type, dosage, or timing of NSAID exposure.

Survey on spontaneous miscarriage and induced abortion surgery safety at less than 12 weeks of gestation in Japan

AIM

In Japan, dilatation and curettage (D&C) is a common procedure for spontaneous miscarriage and induced abortion, and its safety has long been an issue. Electric vacuum aspiration (EVA) is also common, but manual vacuum aspiration (MVA) was introduced recently, with medical abortions using mifepristone or misoprostol which are not yet legally accepted. This nationwide retrospective study surveyed the surgical methods and complications associated with spontaneous miscarriage and induced abortion at less than 12 weeks of gestation in Japan to assess their safety, in comparison with a similar survey for induced abortions in 2012.

METHODS

Questionnaires were sent to 4176 facilities with a license for induced abortion surgeries in 2019. The questions included were the methods used, number of spontaneous miscarriages and induced abortions, and number of complications (uterine perforation, incomplete abortion, and gross bleeding requiring blood transfusion).

RESULTS

Responses were received from 1706 facilities (40.9%). Although EVA with sharp curettage was the most common surgical method, which was used for 11 953 spontaneous miscarriages (28.9%) and 24 045 induced abortions (37.3%), the most common surgical method per facility was D&C, and the rates of D&C for spontaneous miscarriages (38.4%) and induced abortions (44.7%) performed in general hospitals were significantly higher than those in clinics (24.1% and 22.0%, respectively). There was no significant difference in the complication incidence rate among surgical methods for spontaneous miscarriages. However, in induced abortion surgery, the total complication and incomplete abortion incidence rates for D&C were significantly higher than those for EVA without sharp curettage (47/15 162 [0.31%] vs. 29/18 693 [0.16%], p = 0.00362, 45/15 162 [0.30%] vs. 27/18 693 [0.14%], p = 0.00285, respectively). There was no significant difference in the complication incidence rate between MVA and other surgical methods for each abortion surgery.

CONCLUSION

In Japan, especially in general hospitals, D&C is still widely used for miscarriage and induced abortion surgery. Its complication-incidence rates significantly decreased compared with that of the nationwide survey in 2012, but were still significantly higher than EVA without sharp curettage. Few facilities used MVA, but its complication rate was comparable with those of other surgical methods.

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.

Misoprostol treatment for early pregnancy loss: an international survey

RESEARCH QUESTION

What is the global variability in misoprostol treatment for the management of early pregnancy loss (EPL)?

DESIGN

An international web-based survey of fertility specialists and obstetrics and gynaecology clinicians was conducted between August and November 2020. The survey consisted of 16 questions addressing several aspects of misoprostol treatment for EPL.

RESULTS

Overall, 309 clinicians from 80 countries participated in the survey, of whom 67.3% were fertility specialists. Nearly one-half (47.9%) of the respondents let the patient choose the first line of treatment (expectant management, misoprostol treatment or surgical aspiration) according to her own preference. The 248 respondents who administer misoprostol in their daily practice were asked further questions; 59.7% of them advise patients to take the medication at home. The most common dose and route of administration is 800 µg administered vaginally. Only 28.6% of participants use mifepristone pretreatment. Variation in the timing of the first follow-up visit after misoprostol administration was wide, ranging from 24 h to 1 week in most clinics. In case of incomplete expulsion, only 42.3% of the respondents routinely administer a second dose. The timing of the final visit and the definition of successful treatment also differed greatly among respondents.

CONCLUSIONS

There is large variability in the use of misoprostol for the management of EPL. High-quality research is necessary to examine several aspects of the treatment. Particularly, the timing and effectiveness of a second dose administration and the criteria to decide on treatment failure or success deserve more research in the future.

Mifepristone followed by misoprostol compared with placebo followed by misoprostol as medical treatment for early pregnancy loss (the Triple M trial): A double-blind placebo-controlled randomised trial

BACKGROUND

Worldwide, millions of women seek treatment for early pregnancy loss (EPL) annually. Medical management with misoprostol is widely used, but only effective 60% of the time. Pre-treatment with mifepristone prior to misoprostol might improve the success rate of medical management.

METHODS

This was a multi-centre, double-blind, placebo-controlled randomised trial in 17 Dutch hospitals. Women with a non-viable pregnancy between 6 and 14 weeks of gestation were eligible for inclusion after at least one week of expectant management. Participants were randomised (1:1) between oral mifepristone 600 mg or an oral placebo tablet. Participants took 400 μg misoprostol orally, repeated after four hours on day two and, if necessary, day three. Primary outcome was expulsion of gestational sac and endometrial thickness <15 mm after 6-8 weeks. Analyses were done according to intention-to-treat principles. This trial is registered with ClinicalTrials.gov, NCT03212352.

FINDINGS

Between June 28th 2018 and January 8th 2020, 175 women were randomised to mifepristone and 176 to placebo, including 344 in the intention-to-treat analysis. In the mifepristone group 136 (79•1%) of 172 participants reached complete evacuation compared to 101 (58•7%) of 172 participants in the placebo group (p<0•0001, RR 1•35, 95% CI 1•16-1•56). Incidence of serious adverse events was significantly lower in the mifepristone group with 24 (14%) patients affected versus 55 (32%) in the placebo group (p = 0•0005) (Table 3).

INTERPRETATION

Pre-treatment with mifepristone prior to misoprostol was more effective than misoprostol alone in managing EPL.

FUNDING

Healthcare Insurers Innovation Foundation, Radboud University Medical Centre, Canisius Wilhelmina Hospital.

A comprehensive review of the impact of COVID-19 on human reproductive biology, assisted reproduction care and pregnancy: a Canadian perspective

Currently, the world is in the seventh month of the COVID-19 pandemic. Globally, infections with novel SARS-CoV-2 virus are continuously rising with mounting numbers of deaths. International and local public health responses, almost in synchrony, imposed restrictions to minimize spread of the virus, overload of health system capacity, and deficit of personal protective equipment (PPE). Although in most cases the symptoms are mild or absent, SARS-CoV-2 infection can lead to serious acute respiratory disease and multisystem failure. The research community responded to this new disease with a high level of transparency and data sharing; with the aim to better understand the origin, pathophysiology, epidemiology and clinical manifestations. The ultimate goal of this research is to develop vaccines for prevention, mitigation strategies, as well as potential therapeutics.The aim of this review is to summarize current knowledge regarding the novel SARS CoV-2, including its pathophysiology and epidemiology, as well as, what is known about the potential impact of COVID-19 on reproduction, fertility care, pregnancy and neonatal outcome. This summary also evaluates the effects of this pandemic on reproductive care and research, from Canadian perspective, and discusses future implications.In summary, reported data on pregnant women is limited, suggesting that COVID-19 symptoms and severity of the disease during pregnancy are similar to those in non-pregnant women, with pregnancy outcomes closely related to severity of maternal disease. Evidence of SARS-CoV-2 effects on gametes is limited. Human reproduction societies have issued guidelines for practice during COVID-19 pandemic that include implementation of mitigation practices and infection control protocols in fertility care units. In Canada, imposed restrictions at the beginning of the pandemic were successful in containing spread of the infection, allowing for eventual resumption of assisted reproductive treatments under new guidelines for practice. Canada dedicated funds to support COVID-19 research including a surveillance study to monitor outcomes of COVID-19 during pregnancy and assisted reproduction. Continuous evaluation of new evidence must be in place to carefully adjust recommendations on patient management during assisted reproductive technologies (ART) and in pregnancy.

Network meta-analyses in reproductive medicine: challenges and opportunities

Network meta-analysis allows researchers to synthesise both direct and indirect evidence, thus enabling simultaneous comparisons of multiple treatments. A relatively recent addition to evidence synthesis in reproductive medicine, this approach has become increasingly popular. Yet, the underlying assumptions of network meta-analyses, which drive the validity of their findings, have been frequently ignored. In this article, we discuss the strengths and limitations of network meta-analyses. In addition, we present an overview of published network meta-analyses in reproductive medicine, summarize their challenges and provide insights into future research opportunities.

Medication to Manage Abortion and Miscarriage

Abortion and miscarriage are common, affecting millions of US women each year. By age 45, one in four women in the USA will have had an abortion, and at least as many will have had a miscarriage. Most individuals seeking abortion services do so before 10 weeks' gestation when medication abortions are a safe and effective option, using a regimen of oral mifepristone followed by misoprostol tablets. When a pregnancy is non-viable before 13 weeks' gestation, it is referred to as an early pregnancy loss or miscarriage and can be managed using the same mifepristone and misoprostol regimen. Given their safety and efficacy, mifepristone and misoprostol can be offered in ambulatory settings without special equipment or on-site emergency services. As more patients find it difficult to access clinical care when faced with an undesired pregnancy or a miscarriage, it is important for general internists and primary care providers to become familiar with how to use medications to manage these common conditions. We summarize the most recent evidence regarding the use of mifepristone with misoprostol for early abortion and miscarriage. We discuss clinical considerations and resources for integrating mifepristone and misoprostol into clinical practice. By learning to prescribe mifepristone and misoprostol, clinicians can expand access to time-sensitive health services for vulnerable populations.

Coronavirus disease 2019 in pregnant women: a report based on 116 cases

Background

The coronavirus disease 2019, caused by severe acute respiratory syndrome coronavirus 2, is a global public health emergency. Data on the effect of coronavirus disease 2019 in pregnancy are limited to small case series.

Objective

To evaluate the clinical characteristics and outcomes in pregnancy and the vertical transmission potential of severe acute respiratory syndrome coronavirus 2 infection.

Study Design

Clinical records were retrospectively reviewed for 116 pregnant women with coronavirus disease 2019 pneumonia from 25 hospitals in China between January 20, 2020, and March 24, 2020. Evidence of vertical transmission was assessed by testing for severe acute respiratory syndrome coronavirus 2 in amniotic fluid, cord blood, and neonatal pharyngeal swab samples.

Results

The median gestational age on admission was 38⁺⁰ (interquartile range, 36⁺⁰–39⁺¹) weeks. The most common symptoms were fever (50.9%, 59/116) and cough (28.4%, 33/116); 23.3% (27/116) patients presented without symptoms. Abnormal radiologic findings were found in 96.3% (104/108) of cases. Of the 116 cases, there were 8 cases (6.9%) of severe pneumonia but no maternal deaths. One of 8 patients who presented in the first trimester and early second trimester had a missed spontaneous abortion. Of 99 patients, 21 (21.2%) who delivered had preterm birth, including 6 with preterm premature rupture of membranes. The rate of spontaneous preterm birth before 37 weeks’ gestation was 6.1% (6/99). One case of severe neonatal asphyxia resulted in neonatal death. Furthermore, 86 of the 100 neonates tested for severe acute respiratory syndrome coronavirus 2 had negative results; of these, paired amniotic fluid and cord blood samples from 10 neonates used to test for severe acute respiratory syndrome coronavirus 2 had negative results.

Conclusion

Severe acute respiratory syndrome coronavirus 2 infection during pregnancy is not associated with an increased risk of spontaneous abortion and spontaneous preterm birth. There is no evidence of vertical transmission of severe acute respiratory syndrome coronavirus 2 infection when the infection manifests during the third trimester of pregnancy.

Artificial intelligence and automation of systematic reviews in women's health

PURPOSE OF REVIEW

Evidence-based women's healthcare is underpinned by systematic reviews and guidelines. Generating an evidence synthesis to support guidance for clinical practice is a time-consuming and labour-intensive activity that delays transfer of research into practice. Artificial intelligence has the potential to rapidly collate, combine, and update high-quality medical evidence with accuracy and precision, and without bias.

RECENT FINDINGS

This article describes the main fields of artificial intelligence with examples of its application to systematic reviews. These include the capabilities of processing natural language texts, retrieving information, reasoning, and learning. The complementarity and interconnection of the various artificial intelligence techniques can be harnessed to solve difficult problems in automation of reviews. Computer science can advance evidence-based medicine through development, testing, and refinement of artificial intelligence tools to deploy automation, creating 'living' evidence syntheses.

SUMMARY

Groundbreaking, high-quality, and impactful artificial intelligence will accelerate the transfer of individual research studies seamlessly into evidence syntheses for contemporaneously improving the quality of healthcare.

Early pregnancy loss: the default outcome for fertilized human oocytes

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.

Treatment of first trimester miscarriage: a prospective cohort study in a large tertiary care center in Northern Italy

Objective: To assess acceptability, efficacy, and short- and medium-term complications of vaginal misoprostol therapy for the treatment of first trimester miscarriage.Study design: A prospective cohort study including women admitted to the Unit of Obstetrics, MBBM Foundation, San Gerardo Hospital (Monza, Italy) for medical or surgical treatment of first trimester miscarriage between October 2014 and March 2018. As per Institutional protocol, patients in the medical therapy group received 800 µg of misoprostol vaginally. A second dose could be considered 3 days after the first administration if that was ineffective. Surgical treatment consisted of uterine vacuum aspiration. Success of misoprostol treatment was defined as the expulsion of the gestational sac with no need for subsequent surgery.Results: During the study period, 967 patients were diagnosed with first trimester miscarriage and were included in the study. Of these, 514 (53.2%) women were eligible for and consented to medical therapy. Surgical treatment was performed in the remaining 453 (46.8%) patients due to either medical contraindication to misoprostol or patient's choice. Acceptance of misoprostol as first therapeutic choice increased over time, becoming the preferred treatment after approximately 18 months of use in clinical practice. One dose of misoprostol was successful in 69.8% (n = 359) of patients, whereas 20 women required urgent surgery for bleeding (n = 19) or suspected infection (n = 1). Among the remaining 135 patients, 20 (14.8%) refused the second dose of misoprostol and opted for surgery. Expulsion of the gestational sac was obtained in 74 additional cases who completed the medical protocol, for an overall success rate of 87.7% (433/494). The majority of women receiving misoprostol did not experience any short-term complication (92.0%) or side effect (93.8%). Eight (1.6%) cases requiring delayed surgery (hysteroscopy or vacuum aspiration) for retained product of conception were identified at the postmedical treatment follow up, thus leading to an actual success rate of misoprostol of 86.0% (n = 425).Conclusions: This is the first study assessing the acceptability, efficacy, and complication rate of medical management of first trimester miscarriage in an Italian tertiary care center. Our results confirm that misoprostol alone is an effective as well as a safe therapeutic option for the treatment of first trimester miscarriage.