Contemporary management of early pregnancy failure

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

OBJECTIVE

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

DESIGN

Prospective open-label non-inferiority randomised controlled trial.

SETTING

A university-affiliated hospital.

POPULATION

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Coagulation Status in Women with a History of Missed Abortion

The purpose of this study assess the status of coagulation function in a large series of reproductive-age women with a history of missed abortion in China. Likewise, we want to explore the association between coagulation and missed abortions, in order to evaluate whether they could be used as early predictive factors for missed abortions. A total of 11,182 women who suffered from missed abortion from Peking University Third Hospital and 5298 healthy age-matched reproductive-age women were enrolled in our study. Coagulation function tests (prothrombin time, activated partial thromboplastin time), fibrinolysis status detection (fibrinogen, D-Dimer), anticoagulation function tests (protein C, protein S and antithrombin III), and lupus anticoagulants (LAC) were examined. In addition, platelet counts were detected by automated hematology analyzer. Platelet aggregation (PAgT) was tested by light transmission aggregometry (LTA). Compared with healthy reproductive-age women, the level of D-Dimer, dRVVT-R, PC, PAgT, and platelet count was higher, and the antithrombin III (AT-III) activity was lower in women with a history of missed abortion. (P < 0.05). A total of 13.1% patients with a history of missed abortion were positive for LAC, and platelet aggregation rates were increased in 47.4% patients. Moreover, multivariate logistic regression analysis showed that D-Dimer, dRVVT-R, AT-III, PC, and PAgT had significant predictive value for missed abortion. In addition, a model based on coagulation function tests for predicting missed abortion was developed. These findings provide evidence of hypercoagulability in patients with a history of missed abortion. Lupus anticoagulant, PAgT, and D-Dimer were the strongest predictors of missed abortion.was to.

Outcomes of incomplete abortion related to treatment modality

PURPOSE

This study evaluated the differences in treatment outcomes between misoprostol and surgical evacuation for the management of incomplete abortion.

METHODS

This retrospective cohort study compared patients with a clinical diagnosis of incomplete abortion who underwent surgical or pharmaceutical (misoprostol) intervention, 2014-2017. Demographics, sonographic results, treatment follow-up, and post-intervention data on retained products of conception were retrieved. Women with incomplete abortion who underwent surgical versus pharmaceutical intervention were compared.

RESULTS

Among 589 spontaneous abortions, 198 were included in the study, of which 123 (62.1%) underwent surgical evacuation and 75 (37.9%) pharmaceutical intervention with misoprostol. Baseline characteristics were similar between groups. During 130.8 ± 91.7 days of follow-up, no patient who underwent surgical evacuation had retained products of conception or needed surgical hysteroscopy. Four cases (5.3%) in the misoprostol group had retained products of conception and needed hysteroscopy (p = 0.02). Patients who underwent surgical evacuation had higher hemoglobin levels during follow-up (12.1 mg/dL vs. 11.7 mg/dL, p = 0.05). There were no differences in post-treatment pregnancy rates between groups.

CONCLUSION

Long-term follow-up after incomplete abortion showed that hemodynamically stable patients treated with misoprostol achieved the desired results in 95% of cases without significant differences in pregnancy intervals compared to surgical management. Further prospective studies with larger sample sizes are required to confirm the outcomes described in this study.

The Influence of Threatened Miscarriage on Pregnancy Outcomes: A Retrospective Cohort Study in a Nigerian Tertiary Hospital

BACKGROUND

Pregnancies complicated by threatened miscarriage (TM) may be associated with adverse pregnancy outcomes. The objective of this study was to compare the differences in pregnancy outcomes between the women who experienced TM and asymptomatic controls.

METHODS

This was a 10-year retrospective review. Case records of 117 women who were managed for TM from January 1, 2010, to December 31, 2019, were retrieved and studied. The control group was developed from an equal number of asymptomatic clients matched for age, parity, and BMI who were receiving antenatal care (ANC) during the same period. Data on demography, clinical and ultrasound findings, treatment, and pregnancy outcomes were retrieved and analyzed.

RESULTS

Spontaneous abortion rate of 13.7% was recorded among the study group compared with 3.4% in the control (P-value [p] = 0.005, odds ratio [OR]: 4.475; 95% confidence interval [CI]: 1.445 - 13.827). Women with TM had higher odds for placenta previa (p = 0.049, OR: 4.77, 95% CI: 2.19 - 23.04), premature rupture of membranes (PROM) (p = 0.028, OR: 1.918, 95% CI: 1.419 - 2.592), postpartum hemorrhage (PPH) (p = 0.001, OR: 2.66, 95% CI: 20.8 - 8.94), and preterm birth (OR: 2.5, 95% CI: 1.75 - 3.65). They were also more likely to undergo cesarean section (p = 0.020, OR: 1.70, 95% CI: 1.053 - 2.964). There was no statistically significant difference in their infants' mean birth weight (3.113 ± 0.585kg for the TM group and 3.285± 0.536kg for the control, P=0.074). Other maternal and perinatal complications were similar. Admission for bed rest significantly improved fetal survival. Women who were not admitted for bed rest had higher odds of pregnancy loss (OR: 3.443, 95% CI: 1.701-7.99). Other treatment plans did not significantly contribute to a positive outcome.

CONCLUSION

Threatened miscarriage is a significant threat to fetal survival and may increase the risk for operative delivery. Bed rest improves the live birth rate.

Evaluating Vitamin D and foxp3 mRNA levels in women with recurrent spontaneous abortion

OBJECTIVE

This current survey investigated the role of the Forkhead 3 box protein (foxp3) gene and serum vitamin D levels in women with recurrent spontaneous abortion (RSA).

METHODS

The mRNA level of the foxp3 gene in peripheral blood was evaluated in women with a history of RSA (N=40) and in controls (N=40) via quantitative polymerase chain reaction. We employed the enzyme-linked immunosorbent assay to assess the serum levels of 1,25-dihydroxyvitamin D3 (1,25(OH)2 D) in both groups. The Mann-Whitney U test and Pearson's correlation coefficient were used to statistically compare study groups between and within themselves, respectively.

RESULTS

Although mRNA levels of foxp3 were higher in women with RSA than in controls, we observed no significant change in mRNA levels of foxp3 between the two groups (p=0.16). An important positive correlation was observed between foxp3 mRNA levels and 1,25(OH)2 D in controls (p=0.003). In contrast, the correlation between foxp3 expression and 1,25(OH)2 D was not significant in the case group (p=0.14). Serum vitamin D levels were lower in women with RSA than in controls (p<0.001).

CONCLUSIONS

Our findings demonstrated that 1,25Vitamin D3 along with other molecules might help prevent RSA by providing for an anti-inflammatory state not necessarily through foxp3 expression or T cell differentiation.

Predictive value of NLR and PLR in missed miscarriage

Background

The aim of the study was to investigate the predictive value of neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) in missed miscarriage.

Methods

In this retrospective cohort study, a total of 400 women (involving 200 with missed early miscarriage and 200 with normal pregnancy but terminate by artificial abortion) were included. General clinical data and complete blood count (CBC) such as white blood cells (WBC), red blood cells (RBC), platelet (PLT), red blood cell distribution width‐standard deviation (RDW‐SD), platelet distribution width (PDW), mean platelet volume (MPV), neutrophil count, and lymphocyte count were collected, and the NLR and PLR were calculated for both groups. Receiver operating characteristic curve (ROC) was used to calculate the predictive value.

Results

There was no significant difference in the WBC, RBC, PLT, RDW‐SD, PDW, neutrophil, lymphocyte, NLR, and PLR between the two groups (p > 0.05).But MPV was lower in the missed early miscarriage group than in the control group (p < 0.05), and the area under the working curve (AUC) of ROC was 0.58, specificity and sensitivity was 69% and 47%, respectively.

Conclusion

NLR and PLR were not the suitable indictor for missed miscarriage, but MPV should be a concern in the first trimester.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

ChiCTR2000041480.

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

TRIAL DESIGN

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

METHODS

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

RESULTS

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

LIMITATIONS

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

FUTURE WORK

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

CONCLUSIONS

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

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17405024.

FUNDING

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

Imbalance of the Gut Microbiota May Be Associated with Missed Abortions: A Perspective Study from a General Hospital of Hunan Province

OBJECTIVE

To conduct a preliminary investigation that shows the possible correlation between the change of gut microbiota and missed abortions (MAs), which further provides a new potential insight for the prevention and therapy of MAs.

METHOD

One hundred women, including 50 patients with MAs (case group) and 50 normal pregnant women (control group), were enrolled in the study. Fecal specimens were collected in the first trimester. Bacterial DNA was extracted, hybridized with primers of specific genes, and then detected by bacterial chip. The composition and the relative abundance of the gut microbiota were compared and analyzed. Furthermore, Kyoto Encyclopedia of Genes and Genomes enrichment analysis was used to explore the relative pathways.

RESULTS

(1) The α-diversity and β-diversity of the gut microbiota in patients with MAs were significantly lower than that those in normal pregnant women (P < 0.05). At the phylum level, Firmicutes, Proteobacteria, Actinomycetes, and Bacteroidetes accounted for the main proportion of intestinal flora in the 2 groups. Only Actinobacteria was high in the case group. Significant differences were found between the two groups at the phylum level (P < 0.05). Prevotella, Lactobacillus, and Paracoccus were significantly more abundant in the control group than in the case group at the genus level (P < 0.05). (2) KEGG pathway enrichment analysis found significant differences in 27 signaling pathways and metabolic pathways between the two groups of differentially expressed genes (all adjusted P < 0.05). (3) The positive rate of M. hominins (MH) detection in the control group was significantly higher in the MA group (χ ² = 7.853, P = 0.004).

CONCLUSION

The high abundance of Actinobacteria in the MA group was the first time found and reported in the study. The dysbiosis of the gut microbiota correlates with MAs. This study provided insights into the potential change of gut microbiota of MAs and the potential underlying mechanisms through certain impaired lipid metabolism and aroused inflammation pathways. Comprehensive insights regarding gut microbiota may facilitate improved understanding and the development of novel therapeutic and preventive strategies for MAs.

Pregnancy Zone Protein (PZP) is significantly upregulated in the decidua of recurrent and spontaneous miscarriage and negatively correlated to Glycodelin A (GdA)

BACKGROUND

Pregnancy Zone Protein (PZP) is an immunosuppressive protein that is expressed by the placenta and has also been identified in immune cells. When PZP and Glycodelin A (GdA) are combined, they act synergistically to inhibit Th-1 immune response. Little is known about its combined expression and role in normal and disturbed first trimester pregnancy.

PATIENTS AND METHODS

We investigated the expression of PZP and GdA in placental tissue obtained from spontaneous miscarriage (SM) (n = 19) and recurrent miscarriage (RM) (n = 17) at gestational weeks 6-13 by immunohistochemistry and on mRNA-level by either TaqMan PCR or in situ hybridization. Placental tissue from legal terminations of healthy pregnancies (n = 15) served as control group. Immunofluorescence double staining was used to analyse the combined expression of PZP and GdA in decidual tissue.

RESULTS

The protein level of PZP was significantly increased in decidual stroma of SM samples compared to the decidua of control specimens and also significantly upregulated in the decidual stroma cells in the RM group. Concerning GdA, the decidual stroma revealed a significantly decreased protein level in the group with spontaneous abortions than in the group with healthy pregnancies. There was also a significant downregulation of GdA in the decidual stroma of RM samples compared to the control group. We observed a significant negative correlation of PZP and GdA in decidual stromal tissue of recurrent abortion. We could confirm the staining results for PZP as well as for GdA on mRNA level. Both proteins are co-localized in decidual stroma as analysed by immunofluorescence double staining.

CONCLUSION

A balanced expression of GdA and its carrier protein PZP in the decidua seems crucial for a successful ongoing pregnancy. According to our data, these immunosuppressive proteins are co-localized in the decidual tissue and show a negative correlation only in patients suffering from recurrent abortion.

Is there a relationship between early pregnancy loss and maternal serum human X-box binding protein 1 level?

The human X-box binding protein 1 is a transcription factor that is expressed by cellular oxidative stress. We aimed to analyze the relationship between early pregnancy loss and maternal blood X-box binding protein 1 levels. Patients who presented to our Obstetrics and Gynecology clinic between October 2019 and February 2020 were included in this study. Patients were divided into two groups: Group 1 included healthy pregnant women and Group 2 included patients who were diagnosed with missed abortion. First, blood samples were taken from the patients in group 2 when they were diagnosed with missed abortion. While evaluating the patients in group 1, the average gestational weeks of the patients in group 1 were calculated and blood samples were taken between the same weeks. Next, patients with healthy pregnancy in group 1 were followed up prospectively and double screening test were performed at the perinatology outpatient clinic at the end of the 1st trimester, and the blood results of the patients with normal results were evaluated. Blood samples extracted from these patients were centrifuged at -80 °C and stored until analyses. Serum X-box binding protein 1 levels were measured using enzyme-linked immunosorbent assay kits (Cusabio, Wuhan, China). Eighty-five patients were included in this study: 42 in Group 1 and 43 in Group 2. There was no difference between the groups in terms of age, body mass index, ethnicity, and systemic illness. Serum X-box binding protein 1 levels were significantly higher in Group 2 (129.89 ± 7.58 ng/L) than in Group 1 (119.56 ± 5.99 ng/L) (p < 0.001). Serum X-box binding protein 1 levels higher than the cut-off value of 119.05 ng/L were associated with a higher risk of early pregnancy loss. Serum X-box binding protein 1 levels may be used to predict early pregnancy loss; however, additional comparative studies are required to confirm this result.

Comparative Study on Different Hormones between Normal Pregnant Women and Women Experiencing Miscarriage

Background:

Pregnancy leads to a complex alteration in hormonal levels and metabolism in the maternal and fetal system and if undesirable alteration is experienced, complications may be seen. Common complications of pregnancy include gestational diabetes, preeclampsia, preterm labor, and pregnancy loss or miscarriage. Miscarriage is defined as a spontaneous pregnancy loss occurring before 20 weeks of gestation. It has been seen in around 10%–15% of clinically recognized pregnancies.

Aim:

This study was designed to evaluate the levels of different serum hormones between cases and controls group.

Materials and Methods:

Pregnant women before 20 weeks of gestation were selected based on inclusion and exclusion criteria, visiting Adesh hospital Bathinda. After recording the history, blood was drawn and serum thyroid-stimulating hormones (TSH), total tri-iodothyronine (TT3), total thyroxine (TT4), prolactin and beta-human chorionic gonadotropin (β-hCG) were analyzed using TSOSH automated immunoassay analyzer.

Results:

Overall data and data of the 1^st trimester suggested significant differences in the mean level of serum TT3, TSH, β-hCG, and prolactin between controls and cases (P ≤ 0.05). However, serum TT4 did not show a significant difference (P > 0.05). In 2^nd-trimester significant difference in the mean level of serum TSH was only observed between controls and cases (P ≤ 0.05). Similarly, after applying Pearson's correlation, an inverse relation was only observed between serum TT3 and TSH of both control and cases (P ≤ 0.05).

Conclusion:

This study emphasized that screening of women during pregnancy for different serum hormones may provide useful lead about the fate of pregnancy and better understanding of different hormones may reduce the rate of miscarriages and other complications related to pregnancy.

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

BACKGROUND

The anti-progesterone drug mifepristone and the prostaglandin misoprostol can be used to treat missed miscarriage. However, it is unclear whether a combination of mifepristone and misoprostol is more effective than administering misoprostol alone. We investigated whether treatment with mifepristone plus misoprostol would result in a higher rate of completion of missed miscarriage compared with misoprostol alone.

METHODS

MifeMiso was a multicentre, double-blind, placebo-controlled, randomised trial in 28 UK hospitals. Women were eligible for enrolment if they were aged 16 years and older, diagnosed with a missed miscarriage by pelvic ultrasound scan in the first 14 weeks of pregnancy, chose to have medical management of miscarriage, and were willing and able to give informed consent. Participants were randomly assigned (1:1) to a single dose of oral mifepristone 200 mg or an oral placebo tablet, both followed by a single dose of vaginal, oral, or sublingual misoprostol 800 μg 2 days later. Randomisation was managed via a secure web-based randomisation program, with minimisation to balance study group assignments according to maternal age (<30 years vs ≥30 years), body-mass index (<35 kg/m²vs ≥35 kg/m²), previous parity (nulliparous women vs parous women), gestational age (<70 days vs ≥70 days), amount of bleeding (Pictorial Blood Assessment Chart score; ≤2 vs ≥3), and randomising centre. Participants, clinicians, pharmacists, trial nurses, and midwives were masked to study group assignment throughout the trial. The primary outcome was failure to spontaneously pass the gestational sac within 7 days after random assignment. Primary analyses were done according to intention-to-treat principles. The trial is registered with the ISRCTN registry, ISRCTN17405024.

FINDINGS

Between Oct 3, 2017, and July 22, 2019, 2595 women were identified as being eligible for the MifeMiso trial. 711 women were randomly assigned to receive either mifepristone and misoprostol (357 women) or placebo and misoprostol (354 women). 696 (98%) of 711 women had available data for the primary outcome. 59 (17%) of 348 women in the mifepristone plus misoprostol group did not pass the gestational sac spontaneously within 7 days versus 82 (24%) of 348 women in the placebo plus misoprostol group (risk ratio [RR] 0·73, 95% CI 0·54-0·99; p=0·043). 62 (17%) of 355 women in the mifepristone plus misoprostol group required surgical intervention to complete the miscarriage versus 87 (25%) of 353 women in the placebo plus misoprostol group (0·71, 0·53-0·95; p=0·021). We found no difference in incidence of adverse events between the study groups.

INTERPRETATION

Treatment with mifepristone plus misoprostol was more effective than misoprostol alone in the management of missed miscarriage. Women with missed miscarriage should be offered mifepristone pretreatment before misoprostol to increase the chance of successful miscarriage management, while reducing the need for miscarriage surgery.

FUNDING

UK National Institute for Health Research Health Technology Assessment Programme.

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.

Retrospective analysis of prognostic value of the neutrophil-to-lymphocyte ratio in early miscarriages: A 8-year survey

This study aims to identify prognostic value of neutrophil-to-lymphocyte ratio (NLR) in early miscarriages. A total of 260 pregnant women with vaginal spotting were recruited from the Department of Obstetrics and Gynecology of the Kyung Hee Medical Center from January 1, 2011, and December 31, 2018. Venous samples were obtained from the women for measurements of platelet-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, and NLR. All the patients were in < 14 gestational weeks of their pregnancy. Eighty-four patients were excluded because of incomplete data, loss of follow-up, and serious medical diseases. We enrolled 176 women for analysis and divided them into two groups. Group 1 included 104 women with threatened abortion; and group 2, 72 women with missed abortion. A significant difference in NLR was found between the groups (p = 0.001; P < .01). The multivariate analysis also revealed that NLR was the only prognostic factor of early miscarriage (odd ratio [OR], 0.732; 95% confidence interval [CI], 0.612-0.881, P = .001). The area under the Receiver-operating characteristic of NLR for distinguishing between the missed and threatened abortion groups was 0.792, and the best cutoff value was 5.72 (P < .05).

Evaluation of T cell cytokines and their role in recurrent miscarriage

Recurrent miscarriage (RM) is defined as two or more consecutive pregnancy losses that affect approximately 5% of conceived women worldwide. RM is a multi-factorial reproductive problem and has been associated with parental chromosomal abnormalities, embryonic chromosomal rearrangements, uterine anomalies, autoimmune disorders, endocrine dysfunction, thrombophilia, life style factors, and maternal infections. However, the exact cause is still undecided in remaining 50% of cases. Immunological rejection of the embryo due to exacerbated maternal immune reaction against paternal embryonic antigens has been set forth as one of the significant reason for RM. The accurate means that shield the embryo during normal pregnancy from the attack of maternal immune network and dismissal are inadequately implicit. However, it is suggested that the genetically irreconcilable embryo escapes maternal immune rejection due to communication among many vital cytokines exuded at maternal-embryonic interface both by maternal and embryonic cells. Previous investigations suggested the Th1/Th2 dominance in altered immunity of RM patients, according to which the allogenic embryo flees maternal T cell reaction by inclining the Th0 differentiation toward Th2 pathway resulting into diminished pro-inflammatory Th1 immunity. However, recently pro-inflammatory Th17 cells and immunoregulatory Treg cells have been discovered as essential immune players in RM besides Th1/Th2 components. Cytokines are believed to develop a complicated regulatory network so as to establish a state of homeostasis between the semi-allogenic embryo and the maternal immune system. However, an adverse imbalance among cytokines at maternal-embryonic interface perhaps due to their gene polymorphisms may render immunoregulatory means not enough to re-establish homeostasis and thus may collapse pregnancy.

Pigment epithelium‑derived factor facilitates NLRP3 inflammasome activation through downregulating cytidine monophosphate kinase 2: A potential treatment strategy for missed abortion

A number of conditions may underlie the occurrence of missed abortion (MA), including inflammation. Pigment epithelium‑derived factor (PEDF) is a novel mediator of the inflammation‑related nucleotide‑binding oligomerization domain‑like receptor protein 3 (NLRP3) inflammasome, which is associated with several human diseases. However, the association between MA and NLRP3 inflammasome, and whether PEDF is reduced in MA, remain unknown. In the present study, the decidua and chorion tissues of patients who had suffered a MA were examined, and a lipopolysaccharide (LPS)‑induced human chorionic trophoblast HTR8/SVneo cell model was established to mimic MA in vitro. The results revealed that cytidine monophosphate kinase 2 (CMPK2) expression and NLRP3 inflammasome activation, downstream pro‑IL‑18 and pro‑IL‑1β expression, and IL‑18 and IL‑1β release, were all significantly increased in MA tissues or LPS‑induced HTR8/SVneo cells. PEDF reversed the increase in CMPK2 expression and activation of the NLRP3 inflammasome axis and, thus, downregulated the production of mitochondrial reactive oxygen species and mitochondrial DNA release, resulting in reduced lactate dehydrogenase release, and a resultant decrease in cell viability. Recovery of CMPK2 expression abolished all the effects of PEDF, indicating that CMPK2 may be an effector downstream of PEDF. PEDF reduced CMPK2 protein levels but did not affect the mRNA levels, and treatment with the proteasomal inhibitor MG132 significantly reversed this reduction in CMPK2 protein levels. Furthermore, a ubiquitination assay of immunoprecipitation demonstrated that CMPK2 was polyubiquitinated in the presence of LPS, PEDF and MG132. These results indicated that the NLRP3 inflammasome is implicated in the pathogenesis of MA, and PEDF may reduce MA through ubiquitin‑dependent proteasomal degradation of CMPK2 to inhibit NLRP3 activation, which may serve as a novel strategy for preventing or reducing the risk of MA.

Influence of surgical evacuation on pregnancy outcomes of subsequent embryo transfer cycle following miscarriage in an initial IVF cycle: a retrospective cohort study

Background

It is still uncertain whether surgical evacuation adversely affects subsequent embryo transfer. The present study aims to assess the influence of surgical evacuation on the pregnancy outcomes of subsequent embryo transfer cycle following first trimester miscarriage in an initial in vitro fertilization and embryo transfer (IVF-ET) cycle.

Methods

A total of 645 patients who underwent their first trimester miscarriage in an initial IVF cycle between January 2013 and May 2016 in Nanjing Drum Tower Hospital were enrolled. Surgical evacuation was performed when the products of conception were retained more than 8 h after medical evacuation. Characteristics and pregnancy outcomes were compared between surgical evacuation patients and no surgical evacuation patients. The pregnancy outcomes following surgical evacuation were further compared between patients with ≥ 8 mm or < 8 mm endometrial thickness (EMT), and with the different EMT changes.

Results

The EMT in the subsequent embryo transfer cycle of surgical evacuation group was much thinner when compared with that in the no surgical evacuation group (9.0 ± 1.6 mm vs. 9.4 ± 1.9 mm, P = 0.01). There was no significant difference in implantation rate, clinical pregnancy rate, live birth rate or miscarriage rate between surgical evacuation group and no surgical evacuation group (P > 0.05). The live birth rate was higher in EMT ≥ 8 mm group when compared to < 8 mm group in surgical evacuation patients (43.0% vs. 17.4%, P < 0.05).

Conclusions

There was no significant difference in the pregnancy outcomes of subsequent embryo transfer cycle between surgical evacuation patients and no surgical evacuation patients. Surgical evacuation led to the decrease of EMT, especially when the EMT < 8 mm was association with a lower live birth rate.

Management of early pregnancy loss, with a focus on patient centered care

Early pregnancy loss is the most common complication in pregnancy. Management options for miscarriage include expectant management, medical intervention, or surgical aspiration. Non-surgical and surgical management are all safe and acceptable options for medically uncomplicated patients. Patient and provider preferences contribute profoundly to clinical decisions about miscarriage management. Shared-decision making and evidence based counseling have been shown to significantly improve patient satisfaction with early pregnancy loss care. This review article will discuss the epidemiology and risk factors of early pregnancy loss, current evidence and clinical practice guidelines around management options, and provider and patient preferences for early pregnancy loss management.

Biochemical clinical factors associated with missed abortion independent of maternal age: A retrospective study of 795 cases with missed abortion and 694 cases with normal pregnancy

The incidence of fertile women with missed abortion dramatically increased in recent years, while very few serum indices have been identified for the diagnosis of missed abortion. The aim of this study was to identify related factors for missed abortion through a retrospective study of serum indices.A total of 795 cases of women with missed abortion and 694 cases of women with normal pregnancy between March 2014 and March 2017 were included in the present study. The diagnosis of missed abortion was based on clinical history, clinical examination, and transvaginal ultrasound findings. The final diagnosis of missed abortion was based on assessment of pregnancy structures (i.e., a gestational sac without fetal heart rate) via transvaginal ultrasound. We evaluated the clinical values of 4 serum indices and their relationship to missed abortion: gamma-glutamyltransferase (GGT), lactate dehydrogenase (LDH), adenosine deaminase (ADA), and fibrinogen (FIB).The serum levels of GGT, ADA, and FIB showed statistically significant differences comparing women who experienced missed abortion with women who had normal pregnancies (controls). Among women with missed abortion, the levels of GGT and ADA were dramatically increased (GGT: P < .0001; ADA: P = .0459), while FIB levels were slightly lower (P = .0084) compared to controls. The LDH levels exhibited a non-significant trend toward lower levels in the missed abortion group (P = .3951). Interestingly, the observed significant increase in serum GTT levels among women with missed abortion was not affected by maternal age.This study found that GTT may be a useful marker which was associated with missed abortion, indicating its potential clinical roles in missed abortion.

Mifepristone Pretreatment for the Medical Management of Early Pregnancy Loss

BACKGROUND

Medical management of early pregnancy loss is an alternative to uterine aspiration, but standard medical treatment with misoprostol commonly results in treatment failure. We compared the efficacy and safety of pretreatment with mifepristone followed by treatment with misoprostol with the efficacy and safety of misoprostol use alone for the management of early pregnancy loss.

METHODS

We randomly assigned 300 women who had an anembryonic gestation or in whom embryonic or fetal death was confirmed to receive pretreatment with 200 mg of mifepristone, administered orally, followed by 800 μg of misoprostol, administered vaginally (mifepristone-pretreatment group), or 800 μg of misoprostol alone, administered vaginally (misoprostol-alone group). Participants returned 1 to 4 days after misoprostol use for evaluation, including ultrasound examination, by an investigator who was unaware of the treatment-group assignments. Women in whom the gestational sac was not expelled were offered expectant management, a second dose of misoprostol, or uterine aspiration. We followed all participants for 30 days after randomization. Our primary outcome was gestational sac expulsion with one dose of misoprostol by the first follow-up visit and no additional intervention within 30 days after treatment.

RESULTS

Complete expulsion after one dose of misoprostol occurred in 124 of 148 women (83.8%; 95% confidence interval [CI], 76.8 to 89.3) in the mifepristone-pretreatment group and in 100 of 149 women (67.1%; 95% CI, 59.0 to 74.6) in the misoprostol-alone group (relative risk, 1.25; 95% CI, 1.09 to 1.43). Uterine aspiration was performed less frequently in the mifepristone-pretreatment group than in the misoprostol-alone group (8.8% vs. 23.5%; relative risk, 0.37; 95% CI, 0.21 to 0.68). Bleeding that resulted in blood transfusion occurred in 2.0% of the women in the mifepristone-pretreatment group and in 0.7% of the women in the misoprostol-alone group (P=0.31); pelvic infection was diagnosed in 1.3% of the women in each group.

CONCLUSIONS

Pretreatment with mifepristone followed by treatment with misoprostol resulted in a higher likelihood of successful management of first-trimester pregnancy loss than treatment with misoprostol alone. (Funded by the National Institute of Child Health and Human Development; PreFaiR ClinicalTrials.gov number, NCT02012491 .).

Women's experiences with early pregnancy loss in the emergency room: A qualitative study

OBJECTIVES

To understand the reasons why women present to the Emergency Room (ER) for Early Pregnancy Loss (EPL)-related care, how they perceive care and counseling there, and their overall experience during and after their visit.

STUDY DESIGN

This qualitative study utilized semi-structured telephone interviews. Participants were recruited in a large urban ER; women who experienced EPL were interviewed by telephone about their experiences 1-3 weeks after their visit. Audio recordings were transcribed and coded by two independent coders.

MAIN OUTCOME MEASURES

This qualitative study utilized semi-structured interviews without the use of formal outcome measurement tools.

RESULTS

Of the sixty-seven women recruited, ten completed the full telephone interview. Interview participants' responses were grouped into four categories: Feelings about EPL, reasons for going to the ER, experience in the ER, and experience after leaving the ER. Women had mixed feelings about their ER experiences; many reported chaos, lack of information or lack of emotional support, while a few felt informed and supported. Many did not know much about EPL before their experience.

CONCLUSIONS

ER care for women experiencing suspected or confirmed EPL may not be addressing the emotional needs and knowledge gaps of women. Patient education, emotional support, and clear plans for outpatient follow up are critical. Further research is needed to guide interventions to improve care.

Misoprostol treatment vs expectant management in women with early non-viable pregnancy and vaginal bleeding: a pragmatic randomized controlled trial

OBJECTIVE

To compare vaginal misoprostol treatment with expectant management in early non-viable pregnancy with vaginal bleeding with regard to complete evacuation of the uterine cavity within 10 days after randomization.

METHODS

This was a parallel randomized controlled, open-label trial conducted in Skåne University Hospital, Sweden. Patients with anembryonic pregnancy or early fetal demise (crown-rump length ≤ 33 mm) and vaginal bleeding were randomly allocated to either expectant management or treatment with a single dose of 800 μg misoprostol administered vaginally. Patients were evaluated clinically and by ultrasound until complete evacuation of the uterus was achieved (no gestational sac in the uterine cavity and maximum anteroposterior diameter of the intracavitary contents < 15 mm as measured by transvaginal ultrasound on midsagittal view). Follow-up visits were planned at 10, 17, 24 and 31 days. Dilatation and evacuation (D&E) was recommended if miscarriage was not complete within 31 days, but was performed earlier at patient's request, or if there was excessive bleeding as judged clinically. Analysis was by intention to treat. The main outcome measure was number of patients with complete miscarriage without D&E ≤ 10 days.

RESULTS

Ninety-four patients were randomized to misoprostol treatment and 95 to expectant management. After exclusion of three patients and withdrawal of consent by two patients in the expectant management group, 90 women were included in this group. Miscarriage was complete ≤ 10 days in 62/94 (66%) of the patients in the misoprostol group and in 39/90 (43%) of those in the group managed expectantly (risk difference (RD) = 23%; 95% CI, 8-37%). At 31 days, the corresponding figures were 81/94 (86%) and 55/90 (61%) (RD = 25%; 95% CI, 12-38%). Two patients from each group underwent emergency D&E because of excessive bleeding and one of these in each group received blood transfusion. The number of patients undergoing D&E at their own request was higher in the expectantly managed group, 15/90 (17%) vs 3/94 (3%) in the misoprostol group (RD = 14%; 95% CI, 4-23%), as was the number of patients making out-of-protocol visits, 50/90 (56%) vs 27/94 (29%) (RD = 27%; 95% CI, 12-40%). Compared with the expectant management group, more patients in the misoprostol group experienced pain (71/77 (92%) vs 91/91 (100%); RD = 8%; 95% CI, 1-17%) and used painkillers (59/77 (77%) vs 85/91 (93%); RD = 17%; 95% CI, 5-29%). No major side effect was reported in any group.

CONCLUSIONS

In women with early non-viable pregnancy and vaginal bleeding, misoprostol treatment is more effective than is expectant management for complete evacuation of the uterus. Both methods are safe but misoprostol treatment is associated with more pain than is expectant management. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Correlation of enhanced oxidative stress with altered thyroid profile: Probable role in spontaneous abortion

Background:

Spontaneous abortion or miscarriage is defined as the loss of a clinically recognized pregnancy that occurs before 20 weeks of gestational age. Changes in thyroid function can impact greatly on reproductive function before, during, and after conception. Oxidative stress affects both implantation and early embryo development by modifying the key of transcription. Malondialdehyde (MDA) is a major breakdown product of split off from lipid peroxidation. Superoxide dismutase (SOD) is responsible for detoxification of superoxide anion and required for normal health and reproduction.

Aim:

The aim of this study was to define the involvement of thyroid hormones, MDA and SOD levels and to establish MDA levels as an index of lipid peroxidation in women with spontaneous abortion by comparing the results with healthy pregnant females as controls.

Materials and Methods:

A cross-sectional case-control study was designed with two groups of women with 30 each in healthy pregnancy and with spontaneous abortion.

Results:

Demographic characteristics such as maternal age, paternal age, gestational age, body mass index, waist-hip ratio as well as biochemical parameters such as blood pressure, hemoglobin (Hb), sugar levels were found to be similar in both the participating groups. Characteristics like gravida and parity were found to be higher in the study group and differ significantly from control group. Spontaneous abortion before 24 weeks of gestational age was found to be associated with significant increase in mean serum thyroid stimulating hormone (TSH) (P = 0.0115) and MDA (P = 0.0001) levels and a significant decrease in mean serum T3 (P = 0.0003) and SOD (P = 0.0005) levels. The linear (Pearson) correlation analysis demonstrated a significant positive correlation of TSH with MDA and negative correlation with SOD in women with spontaneous abortion.

Conclusion:

The study demonstrates that altered thyroid profile, increased lipid peroxidation in terms of increased MDA levels and decreased SOD levels might be involved in the termination of otherwise wanted pregnancy.

Marked improvement in the success rate of medical management of early pregnancy failure following the implementation of a novel institutional protocol and treatment guidelines: a follow-up study

Purpose

To analyze the success rate, time to passage of tissue and subjective patient experience of a newly implemented protocol for medical management of early pregnancy failure (EPF) over a 2-year period.

Methods

A retrospective chart review of all patients with early pregnancy failure primarily opting for medical management was performed. 200 mg mifepristone were administered orally, followed by a single vaginal dose of 800 mcg misoprostol after 36–48 h. We followed-up with our patients using a written questionnaire.

Results

167 women were included in the present study. We observed an overall success rate of 92 %, defined as no need for surgical management after medication administration. We could not identify predictive values for success in a multivariate regression analysis. Most patients (84 %) passed tissue within 6 h after misoprostol administration. The protocol was well tolerated with a low incidence of side effects. Pain was managed well with sufficient analgesics. Responders to the questionnaire felt adequately informed prior to treatment and rated their overall experience as positive.

Conclusion

The adaption of the institutional medical protocol resulted in a marked improvement of success rate when compared to the previously used protocol (92 vs. 61 %). We credit this increase to the adjusted medication schema as well as to targeted physician education on the expected course and interpretation of outcome measures. Our results underscore that the medical management of EPF is a safe and effective alternative to surgical evacuation in the clinical setting.

Endocrine dysfunction and recurrent spontaneous abortion: An overview

Miscarriage is the spontaneous loss of a fetus before it is viable, occurring at a rate of 15–20%. Recurrent spontaneous abortion (RSA) or habitual miscarriage is defined as repeated occurrence of 3 or more miscarriages before 20^th week of gestation accounting for the most common complication of early pregnancy in humans. Various etiological factors responsible for recurrent miscarriage are anatomical, genetical, endocrinological, immunological, and infectious. The endocrinological abnormalities may be polycystic ovarian syndrome, hyperprolactinemia, luteal phase defect, thyroid dysfunction, diabetes, or hyperandrogenism contributing to recurrent pregnancy loss. In the present article, the role of endocrinological disorders in patients with RSA has been reviewed. The article search was done using electronic databases, Google scholarly articles, and PubMed based on different key words. We have further combined the searches and made grouping as per various endocrine abnormalities, which might be responsible to cause spontaneous loss of fetus.

Ischemia-modified albumin as an oxidative stress biomarker in early pregnancy loss

BACKGROUND/AIMS

This study aimed to determine the association between early pregnancy loss and serum ischemia-modified albumin (IMA) concentrations.

METHODS

Serum samples of 180 women that included healthy pregnant women, women admitted for termination of pregnancy due to the absence of fetal cardiac activity or absence of fetal pole on ultrasonographic examination, and healthy non-pregnant women attending for gynecological examination. Each group included 60 patients. Serum concentrations of IMA were compared among the groups, and the correlations with patients' age, gravidity, BMI, gestational age and total serum albumin concentrations were calculated.

RESULTS

When the groups were compared with respect to IMA concentrations, the group with early pregnancy loss was found to have significantly higher IMA concentrations (p < 0.001). An IMA threshold of >163 ng/mL had a sensitivity of 75%, specificity of 55% to discriminate between healthy pregnant patients and patients with early pregnancy loss in first trimester.

CONCLUSION

Our findings support the theory that possible oxidative stress, a more hypoxic environment and defective placentation lead to increased serum IMA concentrations. These findings may help to shed light on the complicated pathogenesis of early pregnancy loss.

Validation of ICD-9 Codes for Stable Miscarriage in the Emergency Department

Introduction

International Classification of Disease, Ninth Revision (ICD-9) diagnosis codes have not been validated for identifying cases of missed abortion where a pregnancy is no longer viable but the cervical os remains closed. Our goal was to assess whether ICD-9 code “632” for missed abortion has high sensitivity and positive predictive value (PPV) in identifying patients in the emergency department (ED) with cases of stable early pregnancy failure (EPF).

Methods

We studied females ages 13–50 years presenting to the ED of an urban academic medical center. We approached our analysis from two perspectives, evaluating both the sensitivity and PPV of ICD-9 code “632” in identifying patients with stable EPF. All patients with chief complaints “pregnant and bleeding” or “pregnant and cramping” over a 12-month period were identified. We randomly reviewed two months of patient visits and calculated the sensitivity of ICD-9 code “632” for true cases of stable miscarriage. To establish the PPV of ICD-9 code “632” for capturing missed abortions, we identified patients whose visits from the same time period were assigned ICD-9 code “632,” and identified those with actual cases of stable EPF.

Results

We reviewed 310 patient records (17.6% of 1,762 sampled). Thirteen of 31 patient records assigned ICD-9 code for missed abortion correctly identified cases of stable EPF (sensitivity=41.9%), and 140 of the 142 patients without EPF were not assigned the ICD-9 code “632”(specificity=98.6%). Of the 52 eligible patients identified by ICD-9 code “632,” 39 cases met the criteria for stable EPF (PPV=75.0%).

Conclusion

ICD-9 code “632” has low sensitivity for identifying stable EPF, but its high specificity and moderately high PPV are valuable for studying cases of stable EPF in epidemiologic studies using administrative data.

Serum biomarkers may help predict successful misoprostol management of early pregnancy failure

In order to simplify management of early pregnancy loss, our goal was to elucidate predictors of successful medical management of miscarriage with a single dose of misoprostol. In this secondary analysis of data from a multicenter randomized controlled trial, candidate biomarkers were compared between 49 women with missed abortion who succeeded in passing their pregnancy with a single dose of misoprostol and 46 women who did not pass their pregnancy with a misoprostol single dose. We computed the precision of trophoblastic protein and hormone concentrations to discriminate between women who succeed or fail single dose misoprostol management. We also included demographic factors in our analyses. We found overlap in the concentrations of the individual markers between women who succeeded and failed single-dose misoprostol. However, hCG levels ≥ 4000 mIU/mL and ADAM-12 levels ≥ 2500 pg/mL were independently associated with complete uterine expulsion after one dose of misoprostol in our population. A multivariable logistic model for success included non-Hispanic ethnicity and parity <2 in addition to hCG ≥ 4000 mIU/mL and ADAM-12 ≥ 2500 pg/mL and had an area under the receiver operating characteristic (ROC) of 0.81 (95% confidence interval: 72-90%). Categorizing women with a predicted probability of ≥ 0.65 resulted in a sensitivity of 75.0%, specificity 77.1% and positive predictive value of 81.8%. While preliminary, our data suggest that serum biomarkers, especially when combined with demographic characteristics, may be helpful in guiding patient decision-making regarding the management of early pregnancy failure (EPF). Further study is warranted.

[Association of mifepristone and misoprostol for the medical management of early pregnancy failure]

OBJECTIVES

A retrospective monocentric clinical trial was performed to evaluate the efficacy of the association of mifepristone and misoprostol for the management of early pregnancy failure.

PATIENTS AND METHODS

Ninety-two women with early pregnancy failure or anembryonic pregnancy were first treated with 600 mg of mifepristone and 48 hours later with 400 μg of misoprostol by oral administration. Successful treatment, defined as an empty uterus, was searched at day 3, with the association of misoprostol-mifepristone alone or with complementary medical treatment, prostaglandins or ocytocine.

RESULTS

The overall treatment success was 82% (75 of 92 women) with 69 successful cases at day 3 (75%). Six of 92 women (7%) needed a second-line medical treatment. For the last 17 women (18%), the failure of the associated tested medical treatment lead to a secondary surgery. No prognostic factor for the successful medical treatment has been highlighted.

DISCUSSION AND CONCLUSION

A high efficacy for the management of early pregnancy failure is demonstrated for the mifepristone and misoprostol medical treatment. The specific contribution of mifepristone, although proven in the cases of termination of evolutive pregnancies, should be further evaluated in the future for the specific management of early pregnancy failure. Nevertheless, no prognostic factor for the success of the propose treatment can be determined, as the amount of patients enrolled in this study was not sufficient.

Expectant care versus surgical treatment for miscarriage

BACKGROUND

Miscarriage is a common complication of early pregnancy that can have both medical and psychological consequences such as depression and anxiety. The need for routine surgical evacuation with miscarriage has been questioned because of potential complications such as cervical trauma, uterine perforation, hemorrhage, or infection.

OBJECTIVES

To compare the safety and effectiveness of expectant management versus surgical treatment for early pregnancy failure.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 February 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 4 of 4), PubMed (2005 to 11 January 2012), POPLINE (inception to 11 January 2012), LILACS (2005 to 11 January 2012) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomized trials comparing expectant care and surgical treatment (vacuum aspiration or dilation and curettage) for miscarriage were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial quality and extracted data. We contacted study authors for additional information. For dichotomous data, we calculated the Mantel-Haenszel risk ratio (RR) with 95% confidence interval (CI). For continuous data, we computed the mean difference (MD) and 95% CI. We entered additional data such as medians into 'Other data' tables.

MAIN RESULTS

We included seven trials with 1521 participants in this review. The expectant-care group was more likely to have an incomplete miscarriage by two weeks (RR 3.98; 95% CI 2.94 to 5.38) or by six to eight weeks (RR 2.56; 95% CI 1.15 to 5.69). The need for unplanned surgical treatment was greater for the expectant-care group (RR 7.35; 95% CI 5.04 to 10.72). The mean percentage needing surgical management in the expectant-care group was 28%, while 4% of the surgical-treatment group needed additional surgery. The expectant-care group had more days of bleeding (MD 1.59; 95% CI 0.74 to 2.45). Further, more of the expectant-care group needed transfusion (RR 6.45; 95% CI 1.21 to 34.42). The mean percentage needing blood transfusion was 1.4% for expectant care compared with none for surgical management. Results were mixed for pain. Diagnosis of infection was similar for the two groups (RR 0.63; 95% CI 0.36 to 1.12), as were results for various psychological outcomes. Pregnancy data were limited. Costs were lower for the expectant-care group (MD -499.10; 95% CI -613.04 to -385.16; in UK pounds sterling).

AUTHORS' CONCLUSIONS

Expectant management led to a higher risk of incomplete miscarriage, need for unplanned (or additional) surgical emptying of the uterus, bleeding and need for transfusion. Risk of infection and psychological outcomes were similar for both groups. Costs were lower for expectant management. Given the lack of clear superiority of either approach, the woman's preference should be important in decision making. Pharmacological ('medical') management has added choices for women and their clinicians and has been examined in other reviews.

Private medical providers' knowledge and practices concerning medical abortion in Nigeria

To investigate the knowledge and practices regarding medical abortion and postabortion care in northern Nigeria among private physicians--the principal providers of such services in the area--122 doctors operating separate clinics in five states--Bauchi, Borno, Kaduna, Niger, and Taraba--were interviewed by means of a structured questionnaire. The results showed that 22 percent of the doctors reported that they terminate unwanted pregnancies, whereas nearly all reported that they manage complications of unsafe abortion. Manual vacuum aspiration and dilatation and curettage performed singly or in combination were the most common methods of abortion and postabortion care reported by the doctors. Only one doctor reported exclusive use of medical abortion in the first trimester, and three reported its exclusive use in the second trimester. Only 35 percent of the doctors listed misoprostol as a drug that they knew could be used for abortion and postabortion care, and only 12 percent listed mifepristone. By contrast, 49 percent listed inappropriate or dangerous drugs for use in abortion provision in the first and second trimesters of pregnancy. We conclude that private practitioners in northern Nigeria have limited knowledge of medical abortion and postabortion care, and that a capacity-building program on the subject should be instituted for them.

Mifepristone and misoprostol for early pregnancy failure: a cohort analysis

OBJECTIVE

We sought to examine outcomes of mifepristone and misoprostol for early pregnancy failure (EPF) treatment in a nonresearch setting.

STUDY DESIGN

A protocol was developed for physicians to use mifepristone 200 mg orally and misoprostol 800 μg vaginally for EPF. Success rates were analyzed and an adjusted multivariable regression was used to identify factors predictive of success.

RESULTS

Treatment success occurred in 99 (80%; 95% confidence interval, 72-87%) of 123 patients after mifepristone and a single dose of misoprostol and 102 (83%; 95% confidence interval, 75-89%) patients overall. The odds of successful medical treatment were increased in women with a diagnosis of intrauterine embryonic/fetal demise (odds ratio, 3.80) and decreased in women who made additional emergency department visits (odds ratio, 0.12).

CONCLUSION

Patients and clinicians may be more likely to intervene surgically with an EPF when a strict study protocol is not being followed.