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Moradkhani A, Azami M, Assadi S, Ghaderi M, Azarnezhad A, Moradi Y. Association of vitamin D receptor genetic polymorphisms with the risk of infertility: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2024; 24:398. [PMID: 38816754 PMCID: PMC11138068 DOI: 10.1186/s12884-024-06590-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 05/17/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The causes of infertility have remained an important challenge. The relationship between VDR gene polymorphisms and infertility has been reported, with controversial findings. OBJECTIVE AND RATIONALE We aimed to determine this relationship by conducting a systematic review and meta-analysis. SEARCH METHODS The study was started with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration and the final draft was registered as a protocol in PROSPERO (ID: CRD42023416535). The international electronic databases including PubMed (Medline), Scopus, Web of Sciences, and Cumulative Index to Nursing and Allied Health Literature (CINHAL) were searched until January 30, 2023, by using appropriate keywords. The quality of the final studies was assessed using the NOS Checklist for case-control studies. The odds ratios (ORs) for each of the genetic models were pooled, and a subgroup analysis based on geographical region and types of infertility was carried out by the MetaGenyo online tool. OUTCOMES Case-control studies including 18 and 2 studies about infertility in women and men, respectively, and 4 miscarriage studies were entered into the meta-analysis. The VDR gene TaqI polymorphism was associated with infertility susceptibility in women in the allele contrast [OR = 1.2065, 95% CI (1.0846-1.3421); P = 0.0005], Recessive model [OR = 1.3836, 95% CI (1.1197-1.7096); P = 0.002], Dominant model [OR = 1.2146, 95% CI (0.0484-1.4072); P = 0.009], Homozygote [OR = 1.4596, 95% CI (1.1627-1.8325); P = 0.001], and TT vs. Tt [OR = 1.2853, 95% CI (1.0249-1.6117); P = 0.029. ApaI and FokI gene polymorphisms were found to be significantly protective SNPs against women and men infertility in the Dominant model [OR = 0.8379, 95% CI (0.7039- 0.9975); P = 0.046] and Recessive model [OR = 0.421, 95% CI (0.1821-0.9767); P = 0.043], respectively. Sub-group meta-analysis showed a protection association of ApaI in dominant [OR = 0.7738, 95% CI = 0.6249-0.9580; P = 0.018] and AA vs. aa [OR = 0.7404, 95 CI% (0.5860-0.9353) P = 0.011725] models in PCOS subgroup, however, a negative association with idiopathic infertility was found in AA vs. Aa [OR = 1.7063, 95% CI (1.1039-2.6375); P = 0.016187] and Aa vs. aa [OR = 0.6069, 95% CI (0.3761-0.9792); P = 0.040754]. TaqI SNP was significantly associated with infertility in the African population and BsmI was associated with the disease mostly in the Asian population. CONCLUSION This meta-analysis showed that the TaqI polymorphism may be linked to women's infertility susceptibility. However, ApaI and FokI might be the protective SNPs against infertility in Women and men, respectively.
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Affiliation(s)
- Asra Moradkhani
- Student of the Research Committee, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Mobin Azami
- Student of the Research Committee, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Srwa Assadi
- Student of the Research Committee, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Mobin Ghaderi
- Student of the Research Committee, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Asaad Azarnezhad
- Cellular and Molecular Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran.
- Liver and Digestive Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran.
| | - Yousef Moradi
- Social Determinants of the Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran.
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McKenna K, Sheridan G, Murray L. Compliance with a guideline on outpatient medical management of miscarriage in a gynaecology ED. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:202-208. [PMID: 36828566 DOI: 10.12968/bjon.2023.32.4.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
This article describes the clinical audit of the Outpatient Medical Management of Miscarriage Guideline (Guideline 2) within the Gynaecology Emergency Department (GED) at a single site dedicated Gynaecology and Maternity Hospital in the UK, the Liverpool Women's NHS Foundation Trust. Clinical audits are quality improvement processes used to identify areas of improvement against a set criterion and, as a result, implement any required change(s) (National Institute for Health and Care Excellence, 2002). An audit ensures that the guidelines have been followed to certify safe, effective treatment for women who have suffered a first trimester missed miscarriage and the audit described in this article analysed the success of treatment in avoiding admission to hospital and further intervention, such as surgery. The main findings of the audit were that the GED fell short on compliance rates against some standards, mainly standard 1 (performing a baseline point of care test to measure haemoglobin) and standard 5 (providing the patient with a follow-up phone call, with higher compliance levels to standards 3 and 4, which are in relation to prescribing and administering the treatment. The audit found that 15% of patients required further intervention such as admission to hospital for observation (9%) and surgical intervention to complete the miscarriage (6%). Further training in the clinical setting is required to ensure improved compliance with all standards. A checklist will also be created to ensure all standards are being met.
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Affiliation(s)
- Kerry McKenna
- Advanced Nurse Practitioner, Liverpool Women's NHS Foundation Trust
| | - Gemma Sheridan
- Clinical Supervisor, Liverpool Women's NHS Foundation Trust
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Castillo-Angeles M, Atkinson RB, Easter SR, Gosain A, Hu YY, Cooper Z, Kim ES, Rangel EL. Pregnancy During Surgical Training: Are Residency Programs Truly Supporting Their Trainees? JOURNAL OF SURGICAL EDUCATION 2022; 79:e92-e102. [PMID: 35842402 DOI: 10.1016/j.jsurg.2022.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/10/2022] [Accepted: 06/20/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Despite recent national improvements in family leave policies, there has been little focus on program-level support for surgical trainees. Trainees who may require clinical duty adjustments during pregnancy, who experience pregnancy loss, or who struggle with balancing work obligations with the demands of a new infant may face stigma when seeking schedule accommodations. The aim of this study was to describe program and colleague support of surgical trainees for pregnancy-related and postpartum health needs. DESIGN Survey questionnaire. Participants responded to multiple-choice questions about their history of pregnancy loss, their experience with reduction of clinical duties during pregnancy, and their breastfeeding experience. Those who took time off after miscarriages or reduced their clinical duties during pregnancy were asked whether they perceived their colleagues and/or program leadership to be supportive using a 4-point Likert scale (1-strongly agree, 4-strongly disagree) which was dichotomized to agree/disagree. SETTING Electronically distributed through social media and surgical societies from November 2020 to January 2021. PARTICIPANTS Female surgical residents and fellows. RESULTS 258 female surgical residents and fellows were included. Median age was 32 (IQR 30-35) years and 76.74% were white. Of the 52 respondents (20.2%) who reported a miscarriage, 38 (73.1%) took no time off after pregnancy loss, including 5 of 10 women (50%) whose loss occurred after 10 weeks' gestation. Of the 14 residents who took time off after a miscarriage, 4 (28.6%) disagreed their colleagues and/or leadership were supportive of time away from work. Among trainees who reported at least 1 live birth, only 18/114 (15.8%) reduced their work schedule during pregnancy. Of these, 11 (61.1%) described stigma and resentment from colleagues and 14 (77.8%) reported feeling guilty about burdening their colleagues. 100% of respondents reported a desire to breastfeed their infants, but nearly half (46.0%) were unable to reach their breastfeeding goals. 46 (80.7%) cited a lack of time to express breastmilk and 23 (40.4%) cited inadequate lactation facilities as barriers to achieving their breastfeeding goals. CONCLUSIONS A minority of female trainees takes time off or reduces their clinical duties for pregnancy or postpartum health needs. National parental leave policies are insufficient without complementary program-level strategies that support schedule adjustments for pregnant trainees without engendering a sense of resentment or guilt for doing so. Surgical program leaders should initiate open dialogue, proactively offer clinical duty reductions, and ensure time and space for lactation needs to safeguard maternal-fetal health and improve the working environment for pregnant residents.
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Affiliation(s)
- Manuel Castillo-Angeles
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rachel B Atkinson
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sarah Rae Easter
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ankush Gosain
- Department of Surgery, University of Tennessee Health Science Center, Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Ann & Robert Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Zara Cooper
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eugene S Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Erika L Rangel
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
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Barghazan SH, Hadian M, Rezapour A, Nassiri S. Economic evaluation of medical versus surgical strategies for first trimester therapeutic abortion: A systematic review. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2022; 11:184. [PMID: 36003248 PMCID: PMC9393924 DOI: 10.4103/jehp.jehp_1274_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 09/21/2021] [Indexed: 06/15/2023]
Abstract
Pregnancy termination and abortion-related complications are well-established problems among women at reproductive age and resulted in significant morbidity and mortality. Accordingly, a systematic study was performed to investigate the economic evaluation studies results on costs and benefits of medical and surgical abortion methods. PubMed, Web of Science, Scopus, Embase, Cochrane library, ProQuest, and ScienceDirect databases as well as Google scholar were searched through June 2021. Original full-text English language studies that performed an economic evaluation analysis comparing medical and surgical methods of pregnancy termination were included in this review. A critical quality assessment was conducted utilizing the Consolidated Health Economic Evaluation Standards checklist. The latest web-based tool adjusted the estimates of costs expressed in one specific currency and price year into a specific target currency (the year 2020 $US). Overall, 538 records were retrieved, and 20 studies were deemed eligible for qualitative synthesis. Among the reviewed studies, three studies investigated cost-minimization analysis, three studies investigated cost-utility analysis, and 14 studies investigated cost-effectiveness analysis. The directly comparison of medical with surgical abortion was most frequently studied. Medical abortion saved US$ 6 to US$ 2373 per patient's costs. Medical abortion was cost-effective and cost-saving option in compare to the surgical abortion across all perspectives (the incremental cost effectiveness ratio ranged from US$ 419 to US$ 4,044). Quality scores of included studies ranged from 54% to 100%, and 70% of studies received a score of above 85% and had "excellent" quality. According to the results, based on various economic and clinical effectiveness decision-making criteria used in different studies of health economic evaluation, the majority of research provided evidence on the advantage of pharmaceutical methods compared to surgical methods, as well as the advantages of using combinations therapy compared to single therapeutic interventions.
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Affiliation(s)
- Saeed Husseini Barghazan
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Hadian
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Aziz Rezapour
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Setare Nassiri
- Endometriosis Research Center, Iran University of Medical Sciences, Tehran, Iran
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Torres-Miranda MD, Duro Gómez J, Peña Lobo-Gonçalves S, De la Torre González AJ, Castelo-Branco C. Intravaginal misoprostol versus uterine curettage for missed abortion: A cost-effectiveness analysis. J Obstet Gynaecol Res 2022; 48:1110-1115. [PMID: 35218113 DOI: 10.1111/jog.15201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/06/2022] [Accepted: 02/10/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the cost-effectiveness of a strategy based on direct-acting uterine curettage (UC) versus a pre-direct-acting misoprostol (1600 mg) in patients with missed abortion (MA), from the perspective of a National Health System. METHODS An open prospective cohort study was carried out at Reina Sofía University Hospital (Córdoba, Spain) from January 1, 2019 to December 31, 2019 in 180 patients diagnosed with MA. The patients chose medical treatment with intravaginal misoprostol (800 μg/4 h) or UC after receiving complete and detailed information. The effectiveness, clinical characteristics of the patients, costs of treating and managing the disease, and satisfaction with the procedures were recorded. RESULTS One hundred and forty-five patients (80.6%) chose misoprostol versus 35 patients (19.4%) who chose UC. The effectiveness of misoprostol has been 42% evaluated at 48 h; UC success rate has been 100%. The incidence of side effects is significantly higher in patients treated with misoprostol (p < 0.05); as well as the number of care received by the patient (p < 0.05). Satisfaction is higher in patients treated with UC (p < 0.05). However, the cost is almost 5-folds higher in patients treated with UC (p < 0.05). CONCLUSION UC has a higher success rate, greater satisfaction, and a lower incidence of side effects, although significantly increases the cost compared to misoprostol in MA.
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Affiliation(s)
| | - Jorge Duro Gómez
- Department of Obstetrics and Gynecology, Reina Sofía University Hospital of Córdoba, Córdoba, Spain
| | | | | | - Camil Castelo-Branco
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine- University of Barcelona, Hospital Clinic-Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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6
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Devall A, Chu J, Beeson L, Hardy P, Cheed V, Sun Y, Roberts T, Ogwulu CO, Williams E, Jones L, Papadopoulos JLF, Bender-Atik R, Brewin J, Hinshaw K, Choudhary M, Ahmed A, Naftalin J, Nunes N, Oliver A, Izzat F, Bhatia K, Hassan I, Jeve Y, Hamilton J, Deb S, Bottomley C, Ross J, Watkins L, Underwood M, Cheong Y, Kumar C, Gupta P, Small R, Pringle S, Hodge F, Shahid A, Gallos I, Horne A, Quenby S, Coomarasamy A. Mifepristone and misoprostol versus placebo and misoprostol for resolution of miscarriage in women diagnosed with missed miscarriage: the MifeMiso RCT. Health Technol Assess 2021; 25:1-114. [PMID: 34821547 DOI: 10.3310/hta25680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Adam Devall
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Justin Chu
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Leanne Beeson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Versha Cheed
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yongzhong Sun
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Tracy Roberts
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Chidubem Okeke Ogwulu
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Eleanor Williams
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Laura Jones
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | | | | | - Kim Hinshaw
- Sunderland Royal Hospital, South Tyneside & Sunderland NHS Foundation Trust, Sunderland, UK
| | - Meenakshi Choudhary
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Amna Ahmed
- Sunderland Royal Hospital, South Tyneside & Sunderland NHS Foundation Trust, Sunderland, UK
| | - Joel Naftalin
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Natalie Nunes
- West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Isleworth, UK
| | - Abigail Oliver
- St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Feras Izzat
- University Hospital Coventry, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Kalsang Bhatia
- Burnley General Hospital, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - Ismail Hassan
- Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Yadava Jeve
- Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Judith Hamilton
- Guy's and St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Shilpa Deb
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Cecilia Bottomley
- Chelsea and Westminster Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Jackie Ross
- King's College Hospital, King's College Hospital NHS Foundation Trust, London, UK
| | - Linda Watkins
- Liverpool Women's Hospital, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Martyn Underwood
- Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
| | - Ying Cheong
- Department of Reproductive Medicine, University of Southampton, Southampton, UK
| | - Chitra Kumar
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Pratima Gupta
- Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rachel Small
- Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stewart Pringle
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Frances Hodge
- Singleton Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Anupama Shahid
- Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Ioannis Gallos
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Andrew Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Siobhan Quenby
- Biomedical Research Unit in Reproductive Health, University of Warwick, Coventry, UK
| | - Arri Coomarasamy
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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7
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Coomarasamy A, Harb HM, Devall AJ, Cheed V, Roberts TE, Goranitis I, Ogwulu CB, Williams HM, Gallos ID, Eapen A, Daniels JP, Ahmed A, Bender-Atik R, Bhatia K, Bottomley C, Brewin J, Choudhary M, Crosfill F, Deb S, Duncan WC, Ewer A, Hinshaw K, Holland T, Izzat F, Johns J, Lumsden MA, Manda P, Norman JE, Nunes N, Overton CE, Kriedt K, Quenby S, Rao S, Ross J, Shahid A, Underwood M, Vaithilingham N, Watkins L, Wykes C, Horne AW, Jurkovic D, Middleton LJ. Progesterone to prevent miscarriage in women with early pregnancy bleeding: the PRISM RCT. Health Technol Assess 2021; 24:1-70. [PMID: 32609084 DOI: 10.3310/hta24330] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Progesterone is essential for a healthy pregnancy. Several small trials have suggested that progesterone therapy may rescue a pregnancy in women with early pregnancy bleeding, which is a symptom that is strongly associated with miscarriage. OBJECTIVES (1) To assess the effects of vaginal micronised progesterone in women with vaginal bleeding in the first 12 weeks of pregnancy. (2) To evaluate the cost-effectiveness of progesterone in women with early pregnancy bleeding. DESIGN A multicentre, double-blind, placebo-controlled, randomised trial of progesterone in women with early pregnancy vaginal bleeding. SETTING A total of 48 hospitals in the UK. PARTICIPANTS Women aged 16-39 years with early pregnancy bleeding. INTERVENTIONS Women aged 16-39 years were randomly assigned to receive twice-daily vaginal suppositories containing either 400 mg of progesterone or a matched placebo from presentation to 16 weeks of gestation. MAIN OUTCOME MEASURES The primary outcome was live birth at ≥ 34 weeks. In addition, a within-trial cost-effectiveness analysis was conducted from an NHS and NHS/Personal Social Services perspective. RESULTS A total of 4153 women from 48 hospitals in the UK received either progesterone (n = 2079) or placebo (n = 2074). The follow-up rate for the primary outcome was 97.2% (4038 out of 4153 participants). The live birth rate was 75% (1513 out of 2025 participants) in the progesterone group and 72% (1459 out of 2013 participants) in the placebo group (relative rate 1.03, 95% confidence interval 1.00 to 1.07; p = 0.08). A significant subgroup effect (interaction test p = 0.007) was identified for prespecified subgroups by the number of previous miscarriages: none (74% in the progesterone group vs. 75% in the placebo group; relative rate 0.99, 95% confidence interval 0.95 to 1.04; p = 0.72); one or two (76% in the progesterone group vs. 72% in the placebo group; relative rate 1.05, 95% confidence interval 1.00 to 1.12; p = 0.07); and three or more (72% in the progesterone group vs. 57% in the placebo group; relative rate 1.28, 95% confidence interval 1.08 to 1.51; p = 0.004). A significant post hoc subgroup effect (interaction test p = 0.01) was identified in the subgroup of participants with early pregnancy bleeding and any number of previous miscarriage(s) (75% in the progesterone group vs. 70% in the placebo group; relative rate 1.09, 95% confidence interval 1.03 to 1.15; p = 0.003). There were no significant differences in the rate of adverse events between the groups. The results of the health economics analysis show that progesterone was more costly than placebo (£7655 vs. £7572), with a mean cost difference of £83 (adjusted mean difference £76, 95% confidence interval -£559 to £711) between the two arms. Thus, the incremental cost-effectiveness ratio of progesterone compared with placebo was estimated as £3305 per additional live birth at ≥ 34 weeks of gestation. CONCLUSIONS Progesterone therapy in the first trimester of pregnancy did not result in a significantly higher rate of live births among women with threatened miscarriage overall, but an important subgroup effect was identified. A conclusion on the cost-effectiveness of the PRISM trial would depend on the amount that society is willing to pay to increase the chances of an additional live birth at ≥ 34 weeks. For future work, we plan to conduct an individual participant data meta-analysis using all existing data sets. TRIAL REGISTRATION Current Controlled Trials ISRCTN14163439, EudraCT 2014-002348-42 and Integrated Research Application System (IRAS) 158326. 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. 24, No. 33. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Arri Coomarasamy
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Hoda M Harb
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Adam J Devall
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Versha Cheed
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Tracy E Roberts
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ilias Goranitis
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Chidubem B Ogwulu
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Helen M Williams
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Abey Eapen
- Carver College of Medicine, University of Iowa Health Care, Iowa City, IA, USA
| | - Jane P Daniels
- Faculty of Medicine and Health Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - Amna Ahmed
- Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | | | - Kalsang Bhatia
- Burnley General Hospital, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - Cecilia Bottomley
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Meenakshi Choudhary
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Fiona Crosfill
- Royal Preston Hospital, Lancashire Teaching Hospitals NHS Trust, Preston, UK
| | - Shilpa Deb
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - W Colin Duncan
- Medical Research Council Centre for Reproductive Health, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Andrew Ewer
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Kim Hinshaw
- Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - Thomas Holland
- St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Feras Izzat
- University Hospital Coventry, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Jemma Johns
- King's College Hospital, King's College Hospital NHS Foundation Trust, London, UK
| | - Mary-Ann Lumsden
- Reproductive & Maternal Medicine, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Padma Manda
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Jane E Norman
- Medical Research Council Centre for Reproductive Health, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Natalie Nunes
- West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Isleworth, UK
| | - Caroline E Overton
- St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Kathiuska Kriedt
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Siobhan Quenby
- Biomedical Research Unit in Reproductive Health, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sandhya Rao
- Whiston Hospital, St Helen's and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Jackie Ross
- King's College Hospital, King's College Hospital NHS Foundation Trust, London, UK
| | - Anupama Shahid
- Whipps Cross Hospital, Barts Health NHS Trust, London, UK
| | - Martyn Underwood
- Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
| | | | - Linda Watkins
- Liverpool Women's Hospital, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Catherine Wykes
- East Surrey Hospital, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
| | - Andrew W Horne
- Medical Research Council Centre for Reproductive Health, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Davor Jurkovic
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Lee J Middleton
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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8
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Ghosh J, Papadopoulou A, Devall AJ, Jeffery HC, Beeson LE, Do V, Price MJ, Tobias A, Tunçalp Ö, Lavelanet A, Gülmezoglu AM, Coomarasamy A, Gallos ID. Methods for managing miscarriage: a network meta-analysis. Cochrane Database Syst Rev 2021; 6:CD012602. [PMID: 34061352 PMCID: PMC8168449 DOI: 10.1002/14651858.cd012602.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime. An estimated 15% of pregnancies end in miscarriage. Miscarriage can lead to serious morbidity, including haemorrhage, infection, and even death, particularly in settings without adequate healthcare provision. Early miscarriages occur during the first 14 weeks of pregnancy, and can be managed expectantly, medically or surgically. However, there is uncertainty about the relative effectiveness and risks of each option. OBJECTIVES To estimate the relative effectiveness and safety profiles for the different management methods for early miscarriage, and to provide rankings of the available methods according to their effectiveness, safety, and side-effect profile using a network meta-analysis. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth's Trials Register (9 February 2021), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (12 February 2021), and reference lists of retrieved studies. SELECTION CRITERIA We included all randomised controlled trials assessing the effectiveness or safety of methods for miscarriage management. Early miscarriage was defined as less than or equal to 14 weeks of gestation, and included missed and incomplete miscarriage. Management of late miscarriages after 14 weeks of gestation (often referred to as intrauterine fetal deaths) was not eligible for inclusion in the review. Cluster- and quasi-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded non-randomised trials. DATA COLLECTION AND ANALYSIS At least three review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for the primary outcomes of complete miscarriage and composite outcome of death or serious complications. The certainty of evidence was assessed using GRADE. Relative effects for the primary outcomes are reported subgrouped by the type of miscarriage (incomplete and missed miscarriage). We also performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available methods. MAIN RESULTS Our network meta-analysis included 78 randomised trials involving 17,795 women from 37 countries. Most trials (71/78) were conducted in hospital settings and included women with missed or incomplete miscarriage. Across 158 trial arms, the following methods were used: 51 trial arms (33%) used misoprostol; 50 (32%) used suction aspiration; 26 (16%) used expectant management or placebo; 17 (11%) used dilatation and curettage; 11 (6%) used mifepristone plus misoprostol; and three (2%) used suction aspiration plus cervical preparation. Of these 78 studies, 71 (90%) contributed data in a usable form for meta-analysis. Complete miscarriage Based on the relative effects from the network meta-analysis of 59 trials (12,591 women), we found that five methods may be more effective than expectant management or placebo for achieving a complete miscarriage: · suction aspiration after cervical preparation (risk ratio (RR) 2.12, 95% confidence interval (CI) 1.41 to 3.20, low-certainty evidence), · dilatation and curettage (RR 1.49, 95% CI 1.26 to 1.75, low-certainty evidence), · suction aspiration (RR 1.44, 95% CI 1.29 to 1.62, low-certainty evidence), · mifepristone plus misoprostol (RR 1.42, 95% CI 1.22 to 1.66, moderate-certainty evidence), · misoprostol (RR 1.30, 95% CI 1.16 to 1.46, low-certainty evidence). The highest ranked surgical method was suction aspiration after cervical preparation. The highest ranked non-surgical treatment was mifepristone plus misoprostol. All surgical methods were ranked higher than medical methods, which in turn ranked above expectant management or placebo. Composite outcome of death and serious complications Based on the relative effects from the network meta-analysis of 35 trials (8161 women), we found that four methods with available data were compatible with a wide range of treatment effects compared with expectant management or placebo: · dilatation and curettage (RR 0.43, 95% CI 0.17 to 1.06, low-certainty evidence), · suction aspiration (RR 0.55, 95% CI 0.23 to 1.32, low-certainty evidence), · misoprostol (RR 0.50, 95% CI 0.22 to 1.15, low-certainty evidence), · mifepristone plus misoprostol (RR 0.76, 95% CI 0.31 to 1.84, low-certainty evidence). Importantly, no deaths were reported in these studies, thus this composite outcome was entirely composed of serious complications, including blood transfusions, uterine perforations, hysterectomies, and intensive care unit admissions. Expectant management and placebo ranked the lowest when compared with alternative treatment interventions. Subgroup analyses by type of miscarriage (missed or incomplete) agreed with the overall analysis in that surgical methods were the most effective treatment, followed by medical methods and then expectant management or placebo, but there are possible subgroup differences in the effectiveness of the available methods. AUTHORS' CONCLUSIONS: Based on relative effects from the network meta-analysis, all surgical and medical methods for managing a miscarriage may be more effective than expectant management or placebo. Surgical methods were ranked highest for managing a miscarriage, followed by medical methods, which in turn ranked above expectant management or placebo. Expectant management or placebo had the highest chance of serious complications, including the need for unplanned or emergency surgery. A subgroup analysis showed that surgical and medical methods may be more beneficial in women with missed miscarriage compared to women with incomplete miscarriage. Since type of miscarriage (missed and incomplete) appears to be a source of inconsistency and heterogeneity within these data, we acknowledge that the main network meta-analysis may be unreliable. However, we plan to explore this further in future updates and consider the primary analysis as separate networks for missed and incomplete miscarriage.
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Affiliation(s)
- Jay Ghosh
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Argyro Papadopoulou
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Adam J Devall
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Hannah C Jeffery
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Leanne E Beeson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Vivian Do
- University of Birmingham, Birmingham, UK
| | - Malcolm J Price
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Aurelio Tobias
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Antonella Lavelanet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
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9
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Quenby S, Gallos ID, Dhillon-Smith RK, Podesek M, Stephenson MD, Fisher J, Brosens JJ, Brewin J, Ramhorst R, Lucas ES, McCoy RC, Anderson R, Daher S, Regan L, Al-Memar M, Bourne T, MacIntyre DA, Rai R, Christiansen OB, Sugiura-Ogasawara M, Odendaal J, Devall AJ, Bennett PR, Petrou S, Coomarasamy A. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet 2021; 397:1658-1667. [PMID: 33915094 DOI: 10.1016/s0140-6736(21)00682-6] [Citation(s) in RCA: 464] [Impact Index Per Article: 154.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 02/11/2021] [Accepted: 02/16/2021] [Indexed: 12/24/2022]
Abstract
Miscarriage is generally defined as the loss of a pregnancy before viability. An estimated 23 million miscarriages occur every year worldwide, translating to 44 pregnancy losses each minute. The pooled risk of miscarriage is 15·3% (95% CI 12·5-18·7%) of all recognised pregnancies. The population prevalence of women who have had one miscarriage is 10·8% (10·3-11·4%), two miscarriages is 1·9% (1·8-2·1%), and three or more miscarriages is 0·7% (0·5-0·8%). Risk factors for miscarriage include very young or older female age (younger than 20 years and older than 35 years), older male age (older than 40 years), very low or very high body-mass index, Black ethnicity, previous miscarriages, smoking, alcohol, stress, working night shifts, air pollution, and exposure to pesticides. The consequences of miscarriage are both physical, such as bleeding or infection, and psychological. Psychological consequences include increases in the risk of anxiety, depression, post-traumatic stress disorder, and suicide. Miscarriage, and especially recurrent miscarriage, is also a sentinel risk marker for obstetric complications, including preterm birth, fetal growth restriction, placental abruption, and stillbirth in future pregnancies, and a predictor of longer-term health problems, such as cardiovascular disease and venous thromboembolism. The costs of miscarriage affect individuals, health-care systems, and society. The short-term national economic cost of miscarriage is estimated to be £471 million per year in the UK. As recurrent miscarriage is a sentinel marker for various obstetric risks in future pregnancies, women should receive care in preconception and obstetric clinics specialising in patients at high risk. As psychological morbidity is common after pregnancy loss, effective screening instruments and treatment options for mental health consequences of miscarriage need to be available. We recommend that miscarriage data are gathered and reported to facilitate comparison of rates among countries, to accelerate research, and to improve patient care and policy development.
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Affiliation(s)
- Siobhan Quenby
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Warwick, UK; Tommy's National Centre for Miscarriage Research, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
| | - Ioannis D Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Rima K Dhillon-Smith
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Marcelina Podesek
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Mary D Stephenson
- University of Illinois Recurrent Pregnancy Loss Program, Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, IL, USA
| | - Joanne Fisher
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Jan J Brosens
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Warwick, UK; Tommy's National Centre for Miscarriage Research, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Jane Brewin
- Tommy's Charity, Laurence Pountney Hill, London, UK
| | - Rosanna Ramhorst
- CONICET, Universidad de Buenos Aires, Instituto de Química Biológica de la Facultad de Ciencias Exactas y Naturales IQUIBICEN, Buenos Aires, Argentina
| | - Emma S Lucas
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Warwick, UK; Tommy's National Centre for Miscarriage Research, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Rajiv C McCoy
- Department of Biology, Johns Hopkins University, Baltimore, MD, USA
| | - Robert Anderson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Shahd Daher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Lesley Regan
- Tommy's National Centre for Miscarriage Research, Imperial College London, London, UK
| | - Maya Al-Memar
- Tommy's National Centre for Miscarriage Research, Imperial College London, London, UK
| | - Tom Bourne
- Tommy's National Centre for Miscarriage Research, Imperial College London, London, UK
| | - David A MacIntyre
- Tommy's National Centre for Miscarriage Research, Imperial College London, London, UK
| | - Raj Rai
- Tommy's National Centre for Miscarriage Research, Imperial College London, London, UK
| | - Ole B Christiansen
- Centre for Recurrent Pregnancy Loss of Western Denmark, Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark
| | - Mayumi Sugiura-Ogasawara
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Joshua Odendaal
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Warwick, UK; Tommy's National Centre for Miscarriage Research, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Adam J Devall
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | | | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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10
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Allameh Z, Goharian M, Eslamian M. Effect of misoprostol with and without letrozole on the induction of abortion for women with first-trimester missed abortion. Int J Gynaecol Obstet 2020; 151:214-218. [PMID: 32700359 DOI: 10.1002/ijgo.13326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 05/28/2020] [Accepted: 07/20/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To determine whether addition of letrozole to a misoprostol-based abortion regimen can increase the rate of complete abortion. METHODS The randomized, placebo-controlled, double-blind trial enrolled women with missed abortion in the first trimester of pregnancy attending Sadooghi Hospital, Isfahan, Iran, from 2016 to 2018. The women were randomly assigned to the study group, which received 10 mg of letrozole daily for 3 days, followed by two doses of 800 μg of vaginal misoprostol at a 4-hour interval, or the control group, which received a placebo, followed by the same dose of misoprostol. Sonography was performed to check the abortion status. RESULTS In total, 120 women completed the study: 60 in the misoprostol plus letrozole group, and 60 in the misoprostol only group. Complete abortion was documented for 93 (77.5%) women: 48 (80.0%) in the misoprostol plus letrozole group and 45 (75.0%) in the misoprostol only group (P=0.80). The mean duration of induction in the misoprostol plus letrozole and misoprostol only groups was 7.35 ± 3.54 hours and 8.2 ± 3.8 4hours, respectively (P=0.21). CONCLUSION Administration of misoprostol alone was found to be as effective as the administration of misoprostol plus letrozole for first-trimester missed abortion.
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Affiliation(s)
- Zahra Allameh
- Department of Obstetrics & Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Goharian
- Department of Obstetrics & Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Eslamian
- Department of Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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11
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Effects of an Early Pregnancy Assessment Clinic (EPAC) on the Management of Spontaneous Abortions. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:1086-1092. [PMID: 32684348 DOI: 10.1016/j.jogc.2020.02.126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/23/2020] [Accepted: 02/24/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Patients who experience spontaneous abortion often present to the emergency department (ED), which may restrict the physician's recommendations for and the patient's choice of therapy. With support provided by an early pregnancy assessment clinic (EPAC), expectant and medical management may become more feasible options for spontaneous abortion. This study aimed to compare the therapeutic choices before and after the establishment of an EPAC and hypothesized that the proportion of miscarriages treated expectantly or medically would increase. METHODS We conducted a retrospective cohort study that compared patients presenting to the ED and the EPAC with spontaneous abortion. We excluded patients with hemodynamic instability, complete abortions, ectopic pregnancies, and molar pregnancies. The primary outcome was the initial chosen treatment. The retrospective chart review included demographics, type of spontaneous abortion and management, procedural dictations, ED notes, and EPAC clinic documentation. Secondary end points included wait times, repeat visits, and success rates for the initial treatment option. RESULTS We reviewed 103 ED and 92 EPAC patient records. Patients in the ED were 1.52 times more likely to choose surgery over expectant or medical management (P = 0.004). Patients in the ED were 1.41 times more likely to have surgery as their final treatment compared with patients in the EPAC (P = 0.006). There were no significant differences in length of stay, number of visits required, or adverse outcomes. CONCLUSION Our study demonstrates that an EPAC results in more patients choosing and successfully being treated by expectant or medical management for spontaneous abortion.
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12
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Zhang X, Zhang K, Zhang Y. Pigment epithelium‑derived factor facilitates NLRP3 inflammasome activation through downregulating cytidine monophosphate kinase 2: A potential treatment strategy for missed abortion. Int J Mol Med 2020; 45:1436-1446. [PMID: 32323732 PMCID: PMC7138263 DOI: 10.3892/ijmm.2020.4517] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/20/2019] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Xi Zhang
- Department of Gynecology and Obstetrics, Changning Maternity and Infant Health Hospital, Shanghai 200050, P.R. China
| | - Kun Zhang
- Department of Pediatrics, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, P.R. China
| | - Yi Zhang
- Department of Gynecology and Obstetrics, Changning Maternity and Infant Health Hospital, Shanghai 200050, P.R. China
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13
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Okeke Ogwulu CB, Goranitis I, Devall AJ, Cheed V, Gallos ID, Middleton LJ, Harb HM, Williams HM, Eapen A, Daniels JP, Ahmed A, Bender-Atik R, Bhatia K, Bottomley C, Brewin J, Choudhary M, Deb S, Duncan WC, Ewer AK, Hinshaw K, Holland T, Izzat F, Johns J, Lumsden M, Manda P, Norman JE, Nunes N, Overton CE, Kriedt K, Quenby S, Rao S, Ross J, Shahid A, Underwood M, Vaithilingham N, Watkins L, Wykes C, Horne AW, Jurkovic D, Coomarasamy A, Roberts TE. The cost-effectiveness of progesterone in preventing miscarriages in women with early pregnancy bleeding: an economic evaluation based on the PRISM trial. BJOG 2020; 127:757-767. [PMID: 32003141 PMCID: PMC7187468 DOI: 10.1111/1471-0528.16068] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess the cost-effectiveness of progesterone compared with placebo in preventing pregnancy loss in women with early pregnancy vaginal bleeding. DESIGN Economic evaluation alongside a large multi-centre randomised placebo-controlled trial. SETTING Forty-eight UK NHS early pregnancy units. POPULATION Four thousand one hundred and fifty-three women aged 16-39 years with bleeding in early pregnancy and ultrasound evidence of an intrauterine sac. METHODS An incremental cost-effectiveness analysis was performed from National Health Service (NHS) and NHS and Personal Social Services perspectives. Subgroup analyses were carried out on women with one or more and three or more previous miscarriages. MAIN OUTCOME MEASURES Cost per additional live birth at ≥34 weeks of gestation. RESULTS Progesterone intervention led to an effect difference of 0.022 (95% CI -0.004 to 0.050) in the trial. The mean cost per woman in the progesterone group was £76 (95% CI -£559 to £711) more than the mean cost in the placebo group. The incremental cost-effectiveness ratio for progesterone compared with placebo was £3305 per additional live birth. For women with at least one previous miscarriage, progesterone was more effective than placebo with an effect difference of 0.055 (95% CI 0.014-0.096) and this was associated with a cost saving of £322 (95% CI -£1318 to £673). CONCLUSIONS The results suggest that progesterone is associated with a small positive impact and a small additional cost. Both subgroup analyses were more favourable, especially for women who had one or more previous miscarriages. Given available evidence, progesterone is likely to be a cost-effective intervention, particularly for women with previous miscarriage(s). TWEETABLE ABSTRACT Progesterone treatment is likely to be cost-effective in women with early pregnancy bleeding and a history of miscarriage.
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Affiliation(s)
- C B Okeke Ogwulu
- Health Economics Unit, College of Medical and Dental Sciences, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - I Goranitis
- Health Economics Unit, College of Medical and Dental Sciences, Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic., Australia
| | - A J Devall
- College of Medical and Dental Sciences, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - V Cheed
- College of Medical and Dental Sciences, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - I D Gallos
- College of Medical and Dental Sciences, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - L J Middleton
- College of Medical and Dental Sciences, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - H M Harb
- College of Medical and Dental Sciences, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - H M Williams
- College of Medical and Dental Sciences, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - A Eapen
- Carver College of Medicine, University of Iowa Health Care, Iowa City, IA, USA
| | - J P Daniels
- Faculty of Medicine & Health Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - A Ahmed
- Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | | | - K Bhatia
- Burnley General Hospital, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - C Bottomley
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - M Choudhary
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - S Deb
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - W C Duncan
- MRC Centre for Reproductive Health, the Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - A K Ewer
- College of Medical and Dental Sciences, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - K Hinshaw
- Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - T Holland
- Guy's and St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - F Izzat
- University Hospital Coventry, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - J Johns
- Kings College Hospital, King's College Hospital NHS Foundation Trust, London, UK
| | - M Lumsden
- Academic Unit of Reproductive and Maternal Medicine, University of Glasgow, Glasgow, UK
| | - P Manda
- James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - J E Norman
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - N Nunes
- West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Isleworth, UK
| | - C E Overton
- St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - K Kriedt
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - S Quenby
- Biomedical Research Unit in Reproductive Health, University of Warwick, Warwick, UK
| | - S Rao
- Whiston Hospital, St Helen's and Knowsley Teaching Hospitals NHS Trust, Whiston, Prescot, UK
| | - J Ross
- Academic Unit of Reproductive and Maternal Medicine, University of Glasgow, Glasgow, UK
| | - A Shahid
- Whipps Cross Hospital, Barts Health NHS Trust, Leytonstone, London, UK
| | - M Underwood
- Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust, Apley, Telford, UK
| | - N Vaithilingham
- Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Cosham, Portsmouth, UK
| | - L Watkins
- Liverpool Women's Hospital, Liverpool Women's NHS Foundation Trust, Liverpool Women's Hospital, Liverpool, UK
| | - C Wykes
- East Surrey Hospital, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
| | - A W Horne
- MRC Centre for Reproductive Health, the Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - D Jurkovic
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - A Coomarasamy
- College of Medical and Dental Sciences, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - T E Roberts
- Health Economics Unit, College of Medical and Dental Sciences, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Lemmers M, Verschoor MAC, Kim BV, Hickey M, Vazquez JC, Mol BWJ, Neilson JP. Medical treatment for early fetal death (less than 24 weeks). Cochrane Database Syst Rev 2019; 6:CD002253. [PMID: 31206170 PMCID: PMC6574399 DOI: 10.1002/14651858.cd002253.pub4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In most pregnancies that miscarry, arrest of embryonic or fetal development occurs some time (often weeks) before the miscarriage occurs. Ultrasound examination can reveal abnormal findings during this phase by demonstrating anembryonic pregnancies or embryonic or fetal death. Treatment has traditionally been surgical but medical treatments may be effective, safe, and acceptable, as may be waiting for spontaneous miscarriage. This is an update of a review first published in 2006. OBJECTIVES To assess, from clinical trials, the effectiveness and safety of different medical treatments for the termination of non-viable pregnancies. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (24 October 2018) and reference lists of retrieved studies. SELECTION CRITERIA Randomised trials comparing medical treatment with another treatment (e.g. surgical evacuation), or placebo, or no treatment for early pregnancy failure. Quasi-randomised studies were excluded. Cluster-randomised trials were eligible for inclusion, as were studies reported in abstract form, if sufficient information was available to assess eligibility. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Forty-three studies (4966 women) were included. The main interventions examined were vaginal, sublingual, oral and buccal misoprostol, mifepristone and vaginal gemeprost. These were compared with surgical management, expectant management, placebo, or different types of medical interventions were compared with each other. The review includes a wide variety of different interventions which have been analysed across 23 different comparisons. Many of the comparisons consist of single studies. We limited the grading of the quality of evidence to two main comparisons: vaginal misoprostol versus placebo and vaginal misoprostol versus surgical evacuation of the uterus. Risk of bias varied widely among the included trials. The quality of the evidence varied between the different comparisons, but was mainly found to be very-low or low quality.Vaginal misoprostol versus placeboVaginal misoprostol may hasten miscarriage when compared with placebo: e.g. complete miscarriage (5 trials, 305 women, risk ratio (RR) 4.23, 95% confidence interval (CI) 3.01 to 5.94; low-quality evidence). No trial reported on pelvic infection rate for this comparison. Vaginal misoprostol made little difference to rates of nausea (2 trials, 88 women, RR 1.38, 95% CI 0.43 to 4.40; low-quality evidence), diarrhoea (2 trials, 88 women, RR 2.21, 95% CI 0.35 to 14.06; low-quality evidence) or to whether women were satisfied with the acceptability of the method (1 trial, 32 women, RR 1.17, 95% CI 0.83 to 1.64; low-quality evidence). It is uncertain whether vaginal misoprostol reduces blood loss (haemoglobin difference > 10 g/L) (1 trial, 50 women, RR 1.25, 95% CI 0.38 to 4.12; very-low quality) or pain (opiate use) (1 trial, 84 women, RR 5.00, 95% CI 0.25 to 101.11; very-low quality), because the quality of the evidence for these outcomes was found to be very low.Vaginal misoprostol versus surgical evacuation Vaginal misoprostol may be less effective in accomplishing a complete miscarriage compared to surgical management (6 trials, 943 women, average RR 0.40, 95% CI 0.32 to 0.50; Heterogeneity: Tau² = 0.03, I² = 46%; low-quality evidence) and may be associated with more nausea (1 trial, 154 women, RR 21.85, 95% CI 1.31 to 364.37; low-quality evidence) and diarrhoea (1 trial, 154 women, RR 40.85, 95% CI 2.52 to 662.57; low-quality evidence). There may be little or no difference between vaginal misoprostol and surgical evacuation for pelvic infection (1 trial, 618 women, RR 0.73, 95% CI 0.39 to 1.37; low-quality evidence), blood loss (post-treatment haematocrit (%) (1 trial, 50 women, mean difference (MD) 1.40%, 95% CI -3.51 to 0.71; low-quality evidence), pain relief (1 trial, 154 women, RR 1.42, 95% CI 0.82 to 2.46; low-quality evidence) or women's satisfaction/acceptability of method (1 trial, 45 women, RR 0.67, 95% CI 0.40 to 1.11; low-quality evidence).Other comparisonsBased on findings from a single trial, vaginal misoprostol was more effective at accomplishing complete miscarriage than expectant management (614 women, RR 1.25, 95% CI 1.09 to 1.45). There was little difference between vaginal misoprostol and sublingual misoprostol (5 trials, 513 women, average RR 0.84, 95% CI 0.61 to 1.16; Heterogeneity: Tau² = 0.10, I² = 871%; or between oral and vaginal misoprostol in terms of complete miscarriage at less than 13 weeks (4 trials, 418 women), average RR 0.68, 95% CI 0.45 to 1.03; Heterogeneity: Tau² = 0.13, I² = 90%). However, there was less abdominal pain with vaginal misoprostol in comparison to sublingual (3 trials, 392 women, RR 0.58, 95% CI 0.46 to 0.74). A single study (46 women) found mifepristone to be more effective than placebo: miscarriage complete by day five after treatment (46 women, RR 9.50, 95% CI 2.49 to 36.19). However the quality of this evidence is very low: there is a very serious risk of bias with signs of incomplete data and no proper intention-to-treat analysis in the included study; and serious imprecision with wide confidence intervals. Mifepristone did not appear to further hasten miscarriage when added to a misoprostol regimen (3 trials, 447 women, RR 1.18, 95% CI 0.95 to 1.47). AUTHORS' CONCLUSIONS Available evidence from randomised trials suggests that medical treatment with vaginal misoprostol may be an acceptable alternative to surgical evacuation or expectant management. In general, side effects of medical treatment were minor, consisting mainly of nausea and diarrhoea. There were no major differences in effectiveness between different routes of administration. Treatment satisfaction was addressed in only a few studies, in which the majority of women were satisfied with the received intervention. Since the quality of evidence is low or very low for several comparisons, mainly because they included only one or two (small) trials; further research is necessary to assess the effectiveness, safety and side effects, optimal route of administration and dose of different medical treatments for early fetal death.
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Affiliation(s)
- Marike Lemmers
- Academic Medical CenterDepartment of Obstetrics and GynaecologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Marianne AC Verschoor
- Academic Medical CenterDepartment of Obstetrics and GynaecologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Bobae Veronica Kim
- School of Medicine, The University of AdelaideRobinson Research InstituteAdelaideSAAustralia5006
| | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
| | - Juan C Vazquez
- Instituto Nacional de Endocrinologia (INEN)Departamento de Salud ReproductivaZapata y DVedadoHabanaCuba10 400
| | - Ben Willem J Mol
- Monash UniversityDepartment of Obstetrics and Gynaecology246 Clayton RoadClaytonVictoriaAustralia3168
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Smith PP, Dhillon-Smith RK, O'Toole E, Cooper N, Coomarasamy A, Clark TJ. Outcomes in prevention and management of miscarriage trials: a systematic review. BJOG 2019; 126:176-189. [PMID: 30461160 DOI: 10.1111/1471-0528.15528] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND There is a substantial body of research evaluating ways to prevent and manage miscarriage, but all studies do not report on the same outcomes. OBJECTIVE To review systematically, outcomes reported in existing miscarriage trials. SEARCH STRATEGY MEDLINE, Embase, CINAHL, and Cochrane were searched from inception until January 2017. SELECTION CRITERIA Randomised controlled trials (RCTs) reporting prevention or management of miscarriage. Miscarriage was defined as a pregnancy loss in the first trimester. DATA COLLECTION AND ANALYSIS Data about the study characteristics, primary, and secondary outcomes were extracted. MAIN RESULTS We retrieved 1553 titles and abstracts, from which 208 RCTs were included. For prevention of miscarriage, the most commonly reported primary outcome was live birth and the top four reported outcomes were pregnancy loss/stillbirth (n = 112), gestation of birth (n = 68), birth dimensions (n = 65), and live birth (n = 49). For these four outcomes, 58 specific measures were used for evaluation. For management of miscarriage, the most commonly reported primary outcome was efficacy of treatment. The top four reported outcomes were bleeding (n = 186), efficacy of miscarriage treatment (n = 105), infection (n = 97), and quality of life (n = 90). For these outcomes, 130 specific measures were used for evaluation. CONCLUSIONS Our review found considerable variation in the reporting of primary and secondary outcomes along with the measures used to assess them. There is a need for standardised patient-centred clinical outcomes through the development of a core outcome set; the work from this systematic review will form the foundation of the core outcome set for miscarriage. TWEETABLE ABSTRACT There is disparity in the reporting of outcomes and the measures used to assess them in miscarriage trials.
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Affiliation(s)
- P P Smith
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - R K Dhillon-Smith
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - E O'Toole
- Women's Voices Involvement Panel, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Nam Cooper
- Barts and the London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - A Coomarasamy
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - T J Clark
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
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16
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Lusink V, Wong C, de Vries B, Ludlow J. Medical management of miscarriage: Predictive factors of success. Aust N Z J Obstet Gynaecol 2018; 58:590-593. [PMID: 29624638 DOI: 10.1111/ajo.12808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 02/28/2018] [Indexed: 12/01/2022]
Abstract
Medical management of miscarriage is an acceptable option available to women, and has advantages of providing timely treatment, while avoiding exposure to surgery and anaesthesia. This retrospective cohort study aimed to determine factors predictive of successful medical management, utilising a single dose protocol of 800 µg vaginal misoprostol. In this cohort, the success rate was 67% (199/296), and smaller mean gestational sac diameter independent of gestational age predicted success (P = 0.046). Success is not significantly related to parity, miscarriage type, pelvic pain or vaginal bleeding at the outset of treatment.
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Affiliation(s)
- Vanessa Lusink
- Women and Babies Department, Royal Prince Alfred Hospital, Sydney, Australia
| | | | - Bradley de Vries
- Women and Babies Department, Royal Prince Alfred Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
| | - Joanne Ludlow
- Women and Babies Department, Royal Prince Alfred Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia.,Ultrasound Care, Sydney, Australia
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17
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Coomarasamy A, Williams H, Truchanowicz E, Seed PT, Small R, Quenby S, Gupta P, Dawood F, Koot YE, Atik RB, Bloemenkamp KW, Brady R, Briley A, Cavallaro R, Cheong YC, Chu J, Eapen A, Essex H, Ewies A, Hoek A, Kaaijk EM, Koks CA, Li TC, MacLean M, Mol BW, Moore J, Parrott S, Ross JA, Sharpe L, Stewart J, Trépel D, Vaithilingam N, Farquharson RG, Kilby MD, Khalaf Y, Goddijn M, Regan L, Rai R. PROMISE: first-trimester progesterone therapy in women with a history of unexplained recurrent miscarriages - a randomised, double-blind, placebo-controlled, international multicentre trial and economic evaluation. Health Technol Assess 2018; 20:1-92. [PMID: 27225013 DOI: 10.3310/hta20410] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Progesterone is essential to maintain a healthy pregnancy. Guidance from the Royal College of Obstetricians and Gynaecologists and a Cochrane review called for a definitive trial to test whether or not progesterone therapy in the first trimester could reduce the risk of miscarriage in women with a history of unexplained recurrent miscarriage (RM). The PROMISE trial was conducted to answer this question. A concurrent cost-effectiveness analysis was conducted. DESIGN AND SETTING A randomised, double-blind, placebo-controlled, international multicentre study, with economic evaluation, conducted in hospital settings across the UK (36 sites) and in the Netherlands (nine sites). PARTICIPANTS AND INTERVENTIONS Women with unexplained RM (three or more first-trimester losses), aged between 18 and 39 years at randomisation, conceiving naturally and giving informed consent, received either micronised progesterone (Utrogestan(®), Besins Healthcare) at a dose of 400 mg (two vaginal capsules of 200 mg) or placebo vaginal capsules twice daily, administered vaginally from soon after a positive urinary pregnancy test (and no later than 6 weeks of gestation) until 12 completed weeks of gestation (or earlier if the pregnancy ended before 12 weeks). MAIN OUTCOME MEASURES Live birth beyond 24 completed weeks of gestation (primary outcome), clinical pregnancy at 6-8 weeks, ongoing pregnancy at 12 weeks, miscarriage, gestation at delivery, neonatal survival at 28 days of life, congenital abnormalities and resource use. METHODS Participants were randomised after confirmation of pregnancy. Randomisation was performed online via a secure internet facility. Data were collected on four occasions of outcome assessment after randomisation, up to 28 days after birth. RESULTS A total of 1568 participants were screened for eligibility. Of the 836 women randomised between 2010 and 2013, 404 received progesterone and 432 received placebo. The baseline data (age, body mass index, maternal ethnicity, smoking status and parity) of the participants were comparable in the two arms of the trial. The follow-up rate to primary outcome was 826 out of 836 (98.8%). The live birth rate in the progesterone group was 65.8% (262/398) and in the placebo group it was 63.3% (271/428), giving a relative risk of 1.04 (95% confidence interval 0.94 to 1.15; p = 0.45). There was no evidence of a significant difference between the groups for any of the secondary outcomes. Economic analysis suggested a favourable incremental cost-effectiveness ratio for decision-making but wide confidence intervals indicated a high level of uncertainty in the health benefits. Additional sensitivity analysis suggested the probability that progesterone would fall within the National Institute for Health and Care Excellence's threshold of £20,000-30,000 per quality-adjusted life-year as between 0.7145 and 0.7341. CONCLUSIONS There is no evidence that first-trimester progesterone therapy improves outcomes in women with a history of unexplained RM. LIMITATIONS This study did not explore the effect of treatment with other progesterone preparations or treatment during the luteal phase of the menstrual cycle. FUTURE WORK Future research could explore the efficacy of progesterone supplementation administered during the luteal phase of the menstrual cycle in women attempting natural conception despite a history of RM. TRIAL REGISTRATION Current Controlled Trials ISRCTN92644181; EudraCT 2009-011208-42; Research Ethics Committee 09/H1208/44. 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. 20, No. 41. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Arri Coomarasamy
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Helen Williams
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ewa Truchanowicz
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Paul T Seed
- Department of Women's Health, King's College London and King's Health Partners, St Thomas' Hospital, London, UK
| | - Rachel Small
- Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Siobhan Quenby
- Biomedical Research Unit in Reproductive Health, University of Warwick, Coventry, UK
| | - Pratima Gupta
- Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Feroza Dawood
- Liverpool Women's Hospital, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Yvonne E Koot
- Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Kitty Wm Bloemenkamp
- Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Rebecca Brady
- Women's Health Research Centre, Imperial College at St Mary's Hospital Campus, London, UK
| | - Annette Briley
- Department of Women's Health, King's Health Partners, St Thomas' Hospital, London, UK
| | - Rebecca Cavallaro
- Women's Health Research Centre, Imperial College at St Mary's Hospital Campus, London, UK
| | - Ying C Cheong
- University of Southampton Faculty of Medicine, Princess Anne Hospital, Southampton University Hospital NHS Trust, Southampton, UK
| | - Justin Chu
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Abey Eapen
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Holly Essex
- Department of Health Sciences, University of York, York, UK
| | - Ayman Ewies
- Birmingham City Hospital, Sandwell and West Birmingham Hospitals NHS Teaching Trust, Birmingham, UK
| | - Annemieke Hoek
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Eugenie M Kaaijk
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Carolien A Koks
- Department of Obstetrics and Gynaecology, Maxima Medical Centre Veldhoven, Veldhoven, the Netherlands
| | - Tin-Chiu Li
- Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Marjory MacLean
- Ayrshire Maternity Unit, University Hospital of Crosshouse, Kilmarnock, UK
| | - Ben W Mol
- The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, SA, Australia
| | - Judith Moore
- Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
| | - Jackie A Ross
- Early Pregnancy and Gynaecology Assessment Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Lisa Sharpe
- Women's Health Research Centre, Imperial College at St Mary's Hospital Campus, London, UK
| | - Jane Stewart
- Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dominic Trépel
- Department of Health Sciences, University of York, York, UK
| | | | - Roy G Farquharson
- Liverpool Women's Hospital, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Mark David Kilby
- Centre for Women's and Children's Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yacoub Khalaf
- Assisted Conception Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mariëtte Goddijn
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - Lesley Regan
- Women's Health Research Centre, Imperial College at St Mary's Hospital Campus, London, UK
| | - Rajendra Rai
- Women's Health Research Centre, Imperial College at St Mary's Hospital Campus, London, UK
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Lemmers M, Verschoor MA, Bossuyt PM, Huirne JA, Spinder T, Nieboer TE, Bongers MY, Janssen IA, Van Hooff MH, Mol BW, Ankum WM, Bosmans JE. Cost-effectiveness of curettage vs. expectant management in women with an incomplete evacuation after misoprostol treatment for first-trimester miscarriage: a randomized controlled trial and cohort study. Acta Obstet Gynecol Scand 2018; 97:294-300. [DOI: 10.1111/aogs.13283] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 12/09/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Marike Lemmers
- Department of Obstetrics and Gynecology; Academic Medical Center; Amsterdam the Netherlands
- Department of Obstetrics and Gynecology; VU Medical Center; Amsterdam the Netherlands
| | | | - Patrick M. Bossuyt
- Clinical Research Unit; University of Amsterdam; Academic Medical Center; Amsterdam the Netherlands
| | - Judith A.F. Huirne
- Department of Obstetrics and Gynecology; VU Medical Center; Amsterdam the Netherlands
| | - Teake Spinder
- Department of Obstetrics and Gynecology; Leeuwarden Medical Center; Leeuwarden the Netherlands
| | - Theodoor E. Nieboer
- Department of Obstetrics and Gynecology; Radboud University Medical Center; Nijmegen the Netherlands
| | - Marlies Y. Bongers
- Department of Obstetrics and Gynecology; Grow-School for Oncology and Developmental Biology; Maastricht University; Maastricht the Netherlands
| | - Ineke A.H. Janssen
- Department of Obstetrics and Gynecology; Groene Hart Hospital; Gouda the Netherlands
| | - Marcel H.A. Van Hooff
- Department of Obstetrics and Gynecology; Sint Franciscus Gasthuis; Rotterdam the Netherlands
| | - Ben W.J. Mol
- The Robinson Research Institute; School of Pediatrics and Reproductive Health; University of Adelaide and The South Australian Health and Medical Research Institute; Adelaide Australia
| | - Willem M. Ankum
- Department of Obstetrics and Gynecology; Academic Medical Center; Amsterdam the Netherlands
| | - Judith E. Bosmans
- Department of Health Sciences; Faculty of Earth and Life Sciences; Free University Amsterdam; Amsterdam Public Health Research Institute; Amsterdam the Netherlands
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19
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Puget C, Joueidi Y, Bauville E, Laviolle B, Bendavid C, Lavoué V, Le Lous M. Serial hCG and progesterone levels to predict early pregnancy outcomes in pregnancies of uncertain viability: A prospective study. Eur J Obstet Gynecol Reprod Biol 2018; 220:100-105. [DOI: 10.1016/j.ejogrb.2017.11.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/21/2017] [Accepted: 11/26/2017] [Indexed: 12/17/2022]
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El Alili M, van Dongen JM, Huirne JAF, van Tulder MW, Bosmans JE. Reporting and Analysis of Trial-Based Cost-Effectiveness Evaluations in Obstetrics and Gynaecology. PHARMACOECONOMICS 2017; 35:1007-1033. [PMID: 28674846 PMCID: PMC5606992 DOI: 10.1007/s40273-017-0531-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND AND OBJECTIVES The aim was to systematically review whether the reporting and analysis of trial-based cost-effectiveness evaluations in the field of obstetrics and gynaecology comply with guidelines and recommendations, and whether this has improved over time. DATA SOURCES AND SELECTION CRITERIA A literature search was performed in MEDLINE, the NHS Economic Evaluation Database (NHS EED) and the Health Technology Assessment (HTA) database to identify trial-based cost-effectiveness evaluations in obstetrics and gynaecology published between January 1, 2000 and May 16, 2017. Studies performed in middle- and low-income countries and studies related to prevention, midwifery, and reproduction were excluded. DATA COLLECTION AND ANALYSIS Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) statement (a modified version with 21 items, as we focused on trial-based cost-effectiveness evaluations) and the statistical quality was assessed using a literature-based list of criteria (8 items). Exploratory regression analyses were performed to assess the association between reporting and statistical quality scores and publication year. RESULTS The electronic search resulted in 5482 potentially eligible studies. Forty-five studies fulfilled the inclusion criteria, 22 in obstetrics and 23 in gynaecology. Twenty-seven (60%) studies did not adhere to 50% (n = 10) or more of the reporting quality items and 32 studies (71%) did not meet 50% (n = 4) or more of the statistical quality items. As for the statistical quality, no study used the appropriate method to assess cost differences, no advanced methods were used to deal with missing data, and clustering of data was ignored in all studies. No significant improvements over time were found in reporting or statistical quality in gynaecology, whereas in obstetrics a significant improvement in reporting and statistical quality was found over time. LIMITATIONS The focus of this review was on trial-based cost-effectiveness evaluations in obstetrics and gynaecology, so further research is needed to explore whether results from this review are generalizable to other medical disciplines. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS The reporting and analysis of trial-based cost-effectiveness evaluations in gynaecology and obstetrics is generally poor. Since this can result in biased results, incorrect conclusions, and inappropriate healthcare decisions, there is an urgent need for improvement in the methods of cost-effectiveness evaluations in this field.
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Affiliation(s)
- Mohamed El Alili
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
| | - Johanna M van Dongen
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
| | - Judith A F Huirne
- Department of Obstetrics and Gynaecology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
| | - Judith E Bosmans
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
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Abstract
OBJECTIVE To describe the factors patients and physicians prioritize during first-trimester miscarriage management and assess what drives satisfaction with care. METHODS We conducted a mixed-methods study of clinically stable women seeking surgical, medical, or expectant miscarriage treatment. Women with first-trimester fetal demise or anembryonic gestation (N=55) completed demographic and psychosocial surveys. Using purposive sampling, 45 (82%) completed in-depth interviews. Fifteen obstetricians were interviewed. Participants described factors that informed their counseling (physicians) or decision-making (patients). Content analysis used an integrated approach with inductively and deductively derived codes. Patient-derived themes were stratified by treatment choice. Associations between variables and treatment choices were analyzed. RESULTS Thirty-four women (62%) received surgical management, 19 (35%) received medical, and two (4%) received expectant. Physicians expected that women with prior pregnancies have strong management preferences, and indeed, multigravid patients were less likely to change their initial treatment choice after counseling than primigravid patients (12% compared with 42%, odds ratio [OR] 0.18, 95% confidence interval [CI] 0.04-0.81, P=.03). Physicians favored patient-centered decisions and patients chose the treatment that they thought would least affect other responsibilities. Those ultimately receiving surgical management had a higher monthly income (adjusted OR 1.30, 95% CI 1.04-1.63, P=.023) and more social support (adjusted OR 2.45, 95% CI 1.07-5.61, P=.035) than the medical group. The surgical group cited loss acceptance, a favorable perception of surgery, and a desire to expedite the miscarriage as decisive factors. The medical group endorsed control over, and timed completion of, the miscarriage in a more intimate setting, an aversion to surgery or anesthesia, and a perception of improved fertility preservation as decisive factors. Regardless of treatment choice, satisfaction with treatment was linked to a supportive clinical team and expeditious resolution. CONCLUSION Prior pregnancy experiences, obligations, and sociodemographic factors influence miscarriage management decision-making. Structured counseling, especially for primigravid patients, could improve both the physician and the patient experience with miscarriage care.
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Wu HL, Marwah S, Wang P, Wang QM, Chen XW. Misoprostol for medical treatment of missed abortion: a systematic review and network meta-analysis. Sci Rep 2017; 7:1664. [PMID: 28490770 PMCID: PMC5431938 DOI: 10.1038/s41598-017-01892-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 04/05/2017] [Indexed: 12/13/2022] Open
Abstract
The efficacy and safety of misoprostol alone for missed abortion varied with different regimens. To evaluate existing evidence for the medical management of missed abortion using misoprostol, we undertook a comprehensive review and meta-analysis. The electronic literature search was conducted using PubMed, the Cochrane Library, Embase, EBSCOhost Online Research Databases, Springer Link, ScienceDirect, Web of Science, Ovid Medline and Google Scholar. 18 studies of 1802 participants were included in our analysis. Compared with vaginal misoprostol of 800 ug or sublingual misoprostol of 600 ug, lower-dose regimens (200 ug or 400 ug) by any route of administration tend to be significantly less effective in producing abortion within about 24 hours. In terms of efficacy, the most effective treatment was sublingual misoprostol of 600 ug and the least effective was oral misoprostol of 400 ug. In terms of tolerability, vaginal misoprostol of 400 ug was reported with fewer side effects and sublingual misoprostol of 600 ug was reported with more side effects. Misoprostol is a non-invasive, effective medical method for completion of abortion in missed abortion. Sublingual misoprostol of 600 ug or vaginal misoprostol of 800 ug may be a good choice for the first dose. The ideal dose and medication interval of misoprostol however needs to be further researched.
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Affiliation(s)
- Hang-Lin Wu
- Department of Obstetrics and Gynaecology, Hangzhou Women's Hospital, Hangzhou, 310008, Zhejiang, China.
| | - Sheeba Marwah
- Department of Obstetrics and Gynaecology, VMMC and Safdarjung Hospital, New Delhi, 110029, India
| | - Pei Wang
- Department of Obstetrics and Gynaecology, Hangzhou Women's Hospital, Hangzhou, 310008, Zhejiang, China
| | - Qiu-Meng Wang
- Department of Obstetrics and Gynaecology, Hangzhou Women's Hospital, Hangzhou, 310008, Zhejiang, China
| | - Xiao-Wen Chen
- Department of Obstetrics and Gynaecology, Hangzhou Women's Hospital, Hangzhou, 310008, Zhejiang, China
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MisoREST: Surgical versus expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage: A cohort study. Eur J Obstet Gynecol Reprod Biol 2017; 211:83-89. [DOI: 10.1016/j.ejogrb.2017.01.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/09/2017] [Accepted: 01/15/2017] [Indexed: 11/20/2022]
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Black KI, de Vries BS, Moses F, Pelosi M, Cong A, Ludlow J. The impact of introducing medical management on conservative and surgical management for early pregnancy miscarriage. Aust N Z J Obstet Gynaecol 2017; 57:93-98. [DOI: 10.1111/ajo.12573] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 10/20/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Kirsten I. Black
- Discipline of Obstetrics, Gynaecology and Neonatology; Central Clinical School; University of Sydney; Sydney New South Wales Australia
- Women's and Babies; Royal Prince Alfred Hospital; Camperdown New South Wales Australia
| | - Bradley S. de Vries
- Discipline of Obstetrics, Gynaecology and Neonatology; Central Clinical School; University of Sydney; Sydney New South Wales Australia
- Women's and Babies; Royal Prince Alfred Hospital; Camperdown New South Wales Australia
| | - Francis Moses
- Discipline of Obstetrics, Gynaecology and Neonatology; Central Clinical School; University of Sydney; Sydney New South Wales Australia
| | - Marilena Pelosi
- Women's and Babies; Royal Prince Alfred Hospital; Camperdown New South Wales Australia
| | - Angela Cong
- Women's and Babies; Royal Prince Alfred Hospital; Camperdown New South Wales Australia
| | - Joanne Ludlow
- Women's and Babies; Royal Prince Alfred Hospital; Camperdown New South Wales Australia
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Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe, and acceptable. OBJECTIVES To assess the effectiveness, safety, and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (13 May 2016) and reference lists of retrieved papers. SELECTION CRITERIA We included randomised controlled trials comparing medical treatment with expectant care or surgery, or alternative methods of medical treatment. We excluded quasi-randomised trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias, and carried out data extraction. Data entry was checked. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included 24 studies (5577 women). There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; 2 studies, 150 women, random-effects; very low-quality evidence), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. For unplanned surgical intervention, we did not identify any difference between misoprostol and expectant care (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence).Sixteen trials involving 4044 women addressed the comparison of misoprostol (7 studies used oral administration, 6 studies used vaginal, 2 studies sublingual, 1 study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.96, 95% CI 0.94 to 0.98; 15 studies, 3862 women, random-effects; very low-quality evidence) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.05, 95% CI 0.02 to 0.11; 13 studies, 3070 women, random-effects; very low-quality evidence) but more unplanned procedures (average RR 5.03, 95% CI 2.71 to 9.35; 11 studies, 2690 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.50, 95% CI 1.53 to 4.09; 11 studies, 3015 women, random-effects; low-quality evidence). We did not identify any difference in women's satisfaction between misoprostol and surgery (average RR 1.00, 95% CI 0.99 to 1.00; 9 studies, 3349 women, random-effects; moderate-quality evidence). More women had vomiting and diarrhoea with misoprostol compared with surgery (vomiting: average RR 1.97, 95% CI 1.36 to 2.85; 10 studies, 2977 women, random-effects; moderate-quality evidence; diarrhoea: average RR 4.82, 95% CI 1.09 to 21.32; 4 studies, 757 women, random-effects; moderate-quality evidence).Five trials compared different routes of administration, or doses, or both, of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Further studies, including long-term follow-up, are clearly needed to confirm these findings. There is an urgent need for studies on women who miscarry at more than 13 weeks' gestation.
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Affiliation(s)
- Caron Kim
- WHODepartment of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | | | | | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
| | - Juan C Vazquez
- Instituto Nacional de Endocrinologia (INEN)Departamento de Salud ReproductivaZapata y DVedadoHabanaCuba10 400
| | - Lixia Dou
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Lemmers M, Verschoor M, Oude Rengerink K, Naaktgeboren C, Opmeer B, Bossuyt P, Huirne J, Janssen C, Radder C, Klinkert E, Langenveld J, Catshoek R, Van der Voet L, Siemens F, Geomini P, Van Hooff M, Van der Ploeg J, Coppus S, Ankum W, Mol B. MisoREST: surgical versus expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage: a randomized controlled trial. Hum Reprod 2016; 31:2421-2427. [DOI: 10.1093/humrep/dew221] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 05/25/2016] [Accepted: 06/14/2016] [Indexed: 11/12/2022] Open
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Ussher M, Lewis S, Aveyard P, Manyonda I, West R, Lewis B, Marcus B, Riaz M, Taylor AH, Barton P, Daley A, Essex H, Esliger D, Coleman T. The London Exercise And Pregnant smokers (LEAP) trial: a randomised controlled trial of physical activity for smoking cessation in pregnancy with an economic evaluation. Health Technol Assess 2016; 19:vii-xxiv, 1-135. [PMID: 26491878 DOI: 10.3310/hta19840] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Smoking during pregnancy is the main preventable cause of poor birth outcomes. Improved methods are needed to help women to stop smoking during pregnancy. Pregnancy provides a compelling rationale for physical activity (PA) interventions as cessation medication is contraindicated or ineffective, and an effective PA intervention could be highly cost-effective. OBJECTIVE To examine the effectiveness and cost-effectiveness of a PA intervention plus standard behavioural support for smoking cessation relative to behavioural support alone for achieving smoking cessation at the end of pregnancy. DESIGN Multicentre, two-group, pragmatic randomised controlled trial and economic evaluation with follow-up at the end of pregnancy and 6 months postnatally. Randomisation was stratified by centre and a computer-generated sequence was used to allocate participants using a 1 : 1 ratio. SETTING 13 hospitals offering antenatal care in the UK. PARTICIPANTS Women between 10 and 24 weeks' gestation smoking five or more cigarettes a day before pregnancy and one or more during pregnancy. INTERVENTIONS Participants were randomised to behavioural support for smoking cessation (control) or behavioural support plus a PA intervention consisting of supervised treadmill exercise plus PA consultations. Neither participants nor researchers were blinded to treatment allocation. MAIN OUTCOME MEASURES The primary outcome was self-reported, continuous smoking abstinence between a quit date and end of pregnancy, validated by expired carbon monoxide and/or salivary cotinine. Secondary outcomes were maternal weight, depression, birth outcomes, withdrawal symptoms and urges to smoke. The economic evaluation investigated the costs of the PA intervention compared with the control intervention. RESULTS In total, 789 women were randomised (n = 394 PA, n = 395 control). Four were excluded post randomisation (two had been enrolled twice in sequential pregnancies and two were ineligible and randomised erroneously). The intention-to-treat analysis comprised 785 participants (n = 392 PA, n = 393 control). There was no significant difference in the rate of abstinence at the end of pregnancy between the PA group (7.7%) and the control group (6.4%) [odds ratio for PA group abstinence 1.21, 95% confidence interval (CI) 0.70 to 2.10]. For the PA group compared with the control group, there was a 33% (95% CI 14% to 56%), 28% (95% CI 7% to 52%) and 36% (95% CI 12% to 65%) significantly greater increase in self-reported minutes of moderate- and vigorous-intensity PA from baseline to 1 week, 4 weeks and 6 weeks respectively. Accelerometer data showed that there was no significant difference in PA levels between the groups. There were no significant differences between the groups for change in maternal weight, depression, withdrawal symptoms or urges to smoke. Adverse events and birth outcomes were similar between the groups except for there being significantly more caesarean births in the control group than in the PA group (28.7% vs. 21.3%; p < 0.023). The PA intervention was less costly than the control intervention by £35 per participant. This was mainly attributable to increased health-care usage in the control group. However, there was considerable statistical uncertainty around this estimate. CONCLUSIONS During pregnancy, offering an intervention combining supervised exercise and PA counselling does not add to the effectiveness of behavioural support for smoking cessation. Only 10% of participants had PA levels accessed by accelerometer and it is, therefore, unclear whether or not the lack of an effect on the primary outcome is the result of insufficient increases in PA. Research is needed to identify the smoking populations most suitable for PA interventions and methods for increasing PA adherence. TRIAL REGISTRATION Current Controlled Trials ISRCTN48600346. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 84. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Michael Ussher
- Population Health Research Institute, St George's, University of London, London, UK
| | - Sarah Lewis
- Division of Epidemiology and Public Health and UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Isaac Manyonda
- Department of Obstetrics and Gynaecology, St George's, University of London, and St George's Healthcare NHS Trust, London, UK
| | - Robert West
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, UK
| | - Beth Lewis
- School of Kinesiology, University of Minnesota, Minneapolis, MN, USA
| | - Bess Marcus
- Department of Family and Preventive Medicine, University of California, San Diego, San Diego, CA, USA
| | - Muhammad Riaz
- Population Health Research Institute, St George's, University of London, London, UK
| | - Adrian H Taylor
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Pelham Barton
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Amanda Daley
- Primary Care Clinical Sciences, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Holly Essex
- Department of Health Sciences, University of York, York, UK
| | - Dale Esliger
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Tim Coleman
- Division of Primary Care and UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, UK
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Marwah S, Gupta S, Batra NP, Bhasin V, Sarna V, Kaur N. A Comparative Study to Evaluate the Efficacy of Vaginal vs Oral Prostaglandin E1 Analogue (Misoprostol) in Management of First Trimester Missed Abortion. J Clin Diagn Res 2016; 10:QC14-8. [PMID: 27437309 PMCID: PMC4948485 DOI: 10.7860/jcdr/2016/18178.7891] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 04/02/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Missed miscarriages, occurring in upto 15% of all clinically recognized pregnancies are a cause of concern for the patients. Though many researchers in the past have compared the surgical and medical approaches in management of such patients, only a few have executed an appraisal of two routes of misoprostol at equal dosages in treatment of first trimester missed miscarriages. AIM To compare the efficacy of misoprostol by vaginal and oral route, for the management of first trimester missed abortion; and to recognize the utility of misoprostol for cervical dilation prior to any surgical termination of pregnancy. MATERIALS AND METHODS A randomized prospective trial, comparing the efficacy of misoprostol, by vaginal and oral routes, for termination of first trimester missed abortion was conducted in the Department of Obstetrics and Gynecology, Government Multi-Specialty Hospital, Chandigarh over one year. Hundred subjects satisfying the inclusion criteria from 213 consecutive women presenting to the institute with first trimester missed abortion were hospitalized. The study participants were randomly assigned to one of the two treatment groups, using sequentially numbered envelopes, to receive 400mcg misoprostol vaginally or orally to a maximum of three doses six hours apart, and outcome documented. Patients were followed up on Day 14 and 6 weeks after discharge. Primary outcome evaluated was drug-induced complete expulsion of Products of Conception (POCs). Secondary outcomes measured were induction expulsion interval, number of doses required, classification of failures, cervical canal permeability in women requiring surgical evacuation, side effects, hemoglobin drop, duration and amount of post-abortal bleeding, time of resumption of menses, experience with side effects, patient satisfaction and acceptability to treatment. RESULTS Both routes were highly effective (vaginal=92%, oral= 74%, p=0.032), safe and acceptable with tolerable side effects. The mean time to expulsion was longer (13.24hrs) in the oral than vaginal group (10.87hrs). All 4 unsuccessful cases in vaginal group and 12 of 13 in oral group had permeable cervices prior to surgical evacuation. Most women labeled the side effects as tolerable in both the groups. Overall acceptance rate to treatment was high in both the groups A and B (76% and 70%). CONCLUSION Vaginal misoprostol is more effective than oral misoprostol for first trimester missed abortion.
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Affiliation(s)
- Sheeba Marwah
- Senior Resident, Department of Obstetrics and Gynaecology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Supriya Gupta
- Senior Medical Officer, Department of Obstetrics and Gynaecology, Government Multi Speciality Hospital, Sector-16, Chandigarh, India
| | - Neera Parothi Batra
- Senior Medical Officer and Head of Department, Department of Obstetrics and Gynaecology, Government Multi speciality Hospital, Sector-16, Chandigarh, India
| | - Vidhu Bhasin
- Ex-Senior Medical Officer, Department of Obstetrics and Gynaecology, Government Multi Speciality Hospital, Sector-16, Chandigarh, India
| | - Veena Sarna
- Ex-Senior Medical Officer, Department of Obstetrics and Gynaecology, Government Multi Speciality Hospital, Sector-16, Chandigarh, India
| | - Nirlep Kaur
- Senior Medical Officer and Medical Superintendant, Government Multi Speciality Hospital, Sector-16, Chandigarh, India
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Lemmers M, Verschoor M, Hooker A, Opmeer B, Limpens J, Huirne J, Ankum W, Mol B. Dilatation and curettage increases the risk of subsequent preterm birth: a systematic review and meta-analysis. Hum Reprod 2015; 31:34-45. [DOI: 10.1093/humrep/dev274] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 10/08/2015] [Indexed: 12/29/2022] Open
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Tratamiento médico del aborto espontáneo del primer trimestre. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2015. [DOI: 10.1016/j.gine.2013.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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31
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Strand EA. Increasing the management options for early pregnancy loss: the economics of miscarriage. Am J Obstet Gynecol 2015; 212:125-6. [PMID: 25634040 DOI: 10.1016/j.ajog.2014.09.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 09/29/2014] [Indexed: 11/26/2022]
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Dalton VK, Liang A, Hutton DW, Zochowski MK, Fendrick AM. Beyond usual care: the economic consequences of expanding treatment options in early pregnancy loss. Am J Obstet Gynecol 2015; 212:177.e1-6. [PMID: 25174796 DOI: 10.1016/j.ajog.2014.08.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 07/08/2014] [Accepted: 08/27/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The objective of this study was to estimate the economic consequences of expanding options for early pregnancy loss (EPL) treatment beyond expectant management and operating room surgical evacuation (usual care). STUDY DESIGN We constructed a decision model using a hypothetical cohort of women undergoing EPL management within a 30 day horizon. Treatment options under the usual care arm include expectant management and surgical uterine evacuation in an operating room (OR). Treatment options under the expanded care arm included all evidence-based safe and effective treatment options for EPL: expectant management, misoprostol treatment, surgical uterine evacuation in an office setting, and surgical uterine evacuation in an OR. Probabilities of entering various treatment pathways were based on previously published observational studies. RESULTS The cost per case was US $241.29 lower for women undergoing treatment in the expanded care model as compared with the usual care model (US $1033.29 per case vs US $1274.58 per case, expanded care and usual care, respectively). The model was the most sensitive to the failure rate of the expectant management arm, the cost of the OR surgical procedure, the proportion of women undergoing an OR surgical procedure under usual care, and the additional cost per patient associated with implementing and using the expanded care model. CONCLUSION This study demonstrates that expanding women's treatment options for EPL beyond what is typically available can result in lower direct medical expenditures.
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Nadarajah R, Quek YS, Kuppannan K, Woon SY, Jeganathan R. A randomised controlled trial of expectant management versus surgical evacuation of early pregnancy loss. Eur J Obstet Gynecol Reprod Biol 2014; 178:35-41. [PMID: 24813099 DOI: 10.1016/j.ejogrb.2014.02.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 02/02/2014] [Accepted: 02/08/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To show whether a clinically significant difference in success rates exists between expectant and surgical management of early pregnancy loss. STUDY DESIGN Randomised controlled trial comparing expectant versus surgical management of early pregnancy loss over a 1-year period from 1st January to 31st December 2009 at Sultanah Aminah Hospital, Johor Bahru. Pregnant women with missed or incomplete miscarriages at gestations up to 14 weeks were recruited in this study. The success rate in the surgical group was measured as curettage performed without any complications during or after the procedure, while the success rate in the expectant group was defined as complete spontaneous expulsion of products of conception within 6 weeks without any complication. RESULTS A total of 360 women were recruited and randomised to expectant or surgical management, with 180 women in each group. There was no statistically significant difference in the success rate between the groups and between the different types of miscarriage. With expectant management, 131 (74%) patients had a complete spontaneous expulsion of products of conception, of whom 106 (83%) women miscarried within 7 days. However, the rates of unplanned admissions (18.1%) and unplanned surgical evacuations (17.5%) in the expectant group were significantly higher than the rates (7.4% and 8% respectively) in the surgical group. The complications in both groups were similar.
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Affiliation(s)
- Ravichandran Nadarajah
- Department of Obstetrics and Gynaecology, Sultanah Aminah Hospital, 80100 Johor Bahru, Malaysia(1).
| | - Yek Song Quek
- Department of Obstetrics and Gynaecology, Sultanah Aminah Hospital, 80100 Johor Bahru, Malaysia(1)
| | - Kaliammah Kuppannan
- Department of Obstetrics and Gynaecology, Sultanah Aminah Hospital, 80100 Johor Bahru, Malaysia(1)
| | - Shu Yuan Woon
- Department of Obstetrics and Gynaecology, Sultanah Aminah Hospital, 80100 Johor Bahru, Malaysia(1)
| | - Ravichandran Jeganathan
- Department of Obstetrics and Gynaecology, Sultanah Aminah Hospital, 80100 Johor Bahru, Malaysia(1)
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Norman WV, Soon JA, Maughn N, Dressler J. Barriers to rural induced abortion services in Canada: findings of the British Columbia Abortion Providers Survey (BCAPS). PLoS One 2013; 8:e67023. [PMID: 23840578 PMCID: PMC3696020 DOI: 10.1371/journal.pone.0067023] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 05/14/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Rural induced abortion service has declined in Canada. Factors influencing abortion provision by rural physicians are unknown. This study assessed distribution, practice, and experiences among rural compared to urban abortion providers in the Canadian province of British Columbia (BC). METHODS We used mixed methods to assess physicians on the BC registry of abortion providers. In 2011 we distributed a previously-published questionnaire and conducted semi-structured interviews. RESULTS Surveys were returned by 39/46 (85%) of BC abortion providers. Half were family physicians, within both rural and urban cohorts. One-quarter (17/67) of rural hospitals offer abortion service. Medical abortions comprised 14.7% of total reported abortions. The three largest urban areas reported 90% of all abortions, although only 57% of reproductive age women reside in the associated health authority regions. Each rural physician provided on average 76 (SD 52) abortions annually, including 35 (SD 30) medical abortions. Rural physicians provided surgical abortions in operating rooms, often using general anaesthesia, while urban physicians provided the same services primarily in ambulatory settings using local anaesthesia. Rural providers reported health system barriers, particularly relating to operating room logistics. Urban providers reported occasional anonymous harassment and violence. CONCLUSIONS Medical abortions represented 15% of all BC abortions, a larger proportion than previously reported (under 4%) for Canada. Rural physicians describe addressable barriers to service provision that may explain the declining accessibility of rural abortion services. Moving rural surgical abortions out of operating rooms and into local ambulatory care settings has the potential to improve care and costs, while reducing logistical challenges facing rural physicians.
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Affiliation(s)
- Wendy V Norman
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
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An approach to evaluate the efficacy of vaginal misoprostol administered for a rapid management of first trimester spontaneous onset incomplete abortion, in comparison to surgical curettage. Arch Gynecol Obstet 2013; 288:1243-8. [PMID: 23708389 DOI: 10.1007/s00404-013-2894-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 05/13/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this study is to evaluate the efficacy and safety of the medical method in the management of first trimester spontaneous onset incomplete abortion, by using misoprostol vaginal tablets, in comparison to surgical evacuation, with an intention of completing the procedure within 24 h. METHODS In this prospective, randomised study of 100 women admitted with features suggestive of incomplete abortion, 50 women received misoprostol vaginal tablets, while another 50 underwent suction curettage of products of conceptus. They were followed up after 24 h of last dosage of misoprostol or surgical intervention. Statistical analysis was done with respect to efficacy, safety and procedure-related side effects. RESULTS In this study, when analysed after 24 h of treatment allocation, the efficacy of misoprostol was 91.3%, and the efficacy of the surgical method was 96%, with the statistical difference being insignificant. Procedure-related blood loss and pain perception between the two groups were statistically insignificant. However, the incidence of fever in the misoprostol group statistically appeared higher. CONCLUSIONS Misoprostol could be a safe and easily accessible alternative to surgical evacuation, in cases of first trimester spontaneous onset incomplete miscarriage, and could be administered by the patient herself at home.
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Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable. OBJECTIVES To assess the effectiveness, safety and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2012) and reference lists of retrieved papers. SELECTION CRITERIA Randomised controlled trials comparing medical treatment with expectant care or surgery or alternative methods of medical treatment. Quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. MAIN RESULTS Twenty studies (4208 women) were included. There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no statistically significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women, random-effects), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women, random-effects). There were few data on 'deaths or serious complications'.Twelve studies involving 2894 women addressed the comparison of misoprostol (six studies used oral administration, four studies used vaginal, one study sub-lingual, one study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.97, 95% CI 0.95 to 0.99, 11 studies, 2493 women, random-effects) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.06, 95% CI 0.02 to 0.13; 11 studies, 2654 women, random-effects) but more unplanned procedures (average RR 5.82, 95% CI 2.93 to 11.56; nine studies, 2274 women, random-effects). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.41, 95% CI 1.44 to 4.03; nine studies, 2179 women, random-effects).Five trials compared different routes of administration and/or doses of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice. Future studies should include long-term follow-up.
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Affiliation(s)
- James P Neilson
- Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK.
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Abstract
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.
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Affiliation(s)
- Kavita Nanda
- Clinical Sciences, FHI, Research Triangle Park, North Carolina, USA.
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Immediate versus delayed medical treatment for first-trimester miscarriage: a randomized trial. Am J Obstet Gynecol 2012; 206:215.e1-6. [PMID: 22381604 DOI: 10.1016/j.ajog.2011.12.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 09/11/2011] [Accepted: 12/12/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare immediate vs delayed medical treatment for first-trimester miscarriage. STUDY DESIGN Randomized open-label trial in a university hospital gynecologic emergency department. Between April 2003 and April 2006, 182 women diagnosed with spontaneous abortion before 14 weeks' gestation were assigned to immediate medical treatment (oral mifepristone, followed 48 hours later by vaginal misoprostol, n = 91) or sequential management (1 week of watchful waiting followed, if necessary, by the above-described medical treatment, n = 91). Vacuum aspiration was performed in case of treatment failure, hemorrhage, pain, infection, or patient request. RESULTS Compared with immediate medical treatment, sequential management resulted in twice as many vacuum aspirations overall (43.5% vs 19.1%; P < .001), 4 times as many emergent vacuum aspirations (20% vs 4.5%; P = .001), and twice as many unplanned visits to the emergency department (34.1% vs 16.9%; P = .009). CONCLUSION Delaying medical treatment of first-trimester miscarriage increases the rate of unplanned surgical uterine evacuation.
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Rausch M, Lorch S, Chung K, Frederick M, Zhang J, Barnhart K. A cost-effectiveness analysis of surgical versus medical management of early pregnancy loss. Fertil Steril 2011; 97:355-60. [PMID: 22192348 DOI: 10.1016/j.fertnstert.2011.11.044] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 11/28/2011] [Accepted: 11/29/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the cost-effectiveness of medical and surgical management of early pregnancy loss. DESIGN Analyses of cost, effectiveness, and incremental cost-effectiveness ratios and utilities of a multicenter trial with 652 women with first-trimester pregnancy failure randomized to medical or surgical management. SETTING Analysis of data from a multicenter trial. PATIENT(S) Secondary analysis of a multicenter trial. INTERVENTION(S) Cost-effectiveness analysis. MAIN OUTCOME MEASURE(S) Cost and effectiveness of competing treatment strategies. RESULT(S) Cost analysis of treatment demonstrates an increased cost of US$336 for 13% increased efficacy of surgical management. This analysis was sensitive to the probability of an extra office visit, the cost of the visit, and the probability of success. When the surgical arm is divided into outpatient manual vacuum aspiration (MVA) versus inpatient electric vacuum aspiration (EVA), there is an increased cost of $745 for EVA but a decreased cost of $202 for MVA compared with medical management. In general, MVA was found to be more cost-effective than medical management. For treatment of incomplete or inevitable abortion, medical management was found to be less costly and more efficacious. Utilities studies demonstrated that a patient would need to prefer surgery 14% less than medication for its treatment efficacy to be outweighed by the desire to avoid surgery. CONCLUSION(S) Surgical or medical management of early pregnancy failure can be cost effective, depending on the circumstances. Surgery is cost effective and more efficacious when performed in an outpatient setting. For incomplete or inevitable abortion, medical management is cost effective and more efficacious.
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Affiliation(s)
- Mary Rausch
- North Shore University Hospital, Manhasset, New York, USA
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Pearson GAH, Ortashi O. Cervical intraepithelial neoplasia grade III diagnosed at ERPC. J OBSTET GYNAECOL 2011; 31:358. [PMID: 21534772 DOI: 10.3109/01443615.2011.561382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- G A H Pearson
- Department of Obstetrics and Gynaecology, North Devon District Hospital, Devon, UK.
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Kollitz KM, Meyn LA, Lohr PA, Creinin MD. Mifepristone and misoprostol for early pregnancy failure: a cohort analysis. Am J Obstet Gynecol 2011; 204:386.e1-6. [PMID: 21306697 DOI: 10.1016/j.ajog.2010.12.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 10/15/2010] [Accepted: 12/10/2010] [Indexed: 11/26/2022]
Abstract
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.
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Neilson JP, Gyte GML, Hickey M, Vazquez JC, Dou L. Medical treatments for incomplete miscarriage (less than 24 weeks). Cochrane Database Syst Rev 2010:CD007223. [PMID: 20091626 PMCID: PMC4042279 DOI: 10.1002/14651858.cd007223.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining pregnancy tissues in the uterus. However, it has been suggested that drug-based medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable. OBJECTIVES To assess the effectiveness, safety and acceptability of any medical treatment for early incomplete miscarriage (before 24 weeks). SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009). SELECTION CRITERIA Randomised controlled trials comparing medical treatment with expectant care or surgery. Quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. MAIN RESULTS Fifteen studies (2750 women) were included, there were no studies on women over 13 weeks' gestation. Studies addressed a number of comparisons and data are therefore limited.Three trials compared misoprostol treatment (all vaginally administered) with expectant care. There was no significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women). There were few data on 'deaths or serious complications'.Nine studies involving 1766 women addressed the comparison of misoprostol (four oral, four vaginal, one vaginal + oral) with surgical evacuation. There was no statistically significant difference in complete miscarriage (average RR 0.96, 95% CI 0.92 to 1.00, eight studies, 1377 women) with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.07, 95% CI 0.03 to 0.18; eight studies, 1538 women) but more unplanned procedures (average RR 6.32, 95% CI 2.90 to 13.77; six studies, 1158 women). There were few data on 'deaths or serious complications'. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice.
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Affiliation(s)
- James P Neilson
- Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
| | - Gillian ML Gyte
- Cochrane Pregnancy and Childbirth Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
| | - Martha Hickey
- The University of Melbourne, The Royal Women’s Hospital, Melbourne, Australia
| | - Juan C Vazquez
- Departamento de Salud Reproductiva, Instituto Nacional de Endocrinologia (INEN), Habana, Cuba
| | - Lixia Dou
- Cochrane Pregnancy and Childbirth Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
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El-Sayed MM, Mohamed SA, Jones MH. Expectant management of first-trimester miscarriage. J OBSTET GYNAECOL 2010; 29:681-5. [PMID: 19821656 DOI: 10.3109/01443610903215399] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Miscarriage is the most common complication of pregnancy, which creates a significant workload for health-care professionals. For decades, surgical evacuation of the uterus has remained the conventional treatment of first-trimester miscarriage. Recently, non surgical treatments have been introduced with increasing popularity. This review explores the evidence in support of expectant management of first-trimester miscarriage. It is safe, effective and well-tolerated by women. It enhances women's choice and control. It generates significant cost savings compared with the traditional surgical management. Accurate diagnosis, counselling, 24/7 telephone advice and follow-up are among the important aspects of expectant management. More studies are needed to develop methods for identifying miscarriages suitable for expectant management.
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Affiliation(s)
- M M El-Sayed
- Department of Obstetrics and Gynaecology, Darent Valley Hospital, Dartford, UK.
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Smith LFP, Ewings PD, Quinlan C. Incidence of pregnancy after expectant, medical, or surgical management of spontaneous first trimester miscarriage: long term follow-up of miscarriage treatment (MIST) randomised controlled trial. BMJ 2009; 339:b3827. [PMID: 19815581 PMCID: PMC2759436 DOI: 10.1136/bmj.b3827] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To compare fertility rates after the three methods of managing early miscarriage in women recruited to the MIST (miscarriage treatment) randomised controlled trial. SETTING Early pregnancy clinics of acute hospitals in the south west region of England. PARTICIPANTS 1199 women who had had an early miscarriage (<13 weeks) confirmed by scan. INTERVENTION Expectant, medical, or surgical management. MAIN OUTCOME MEASURES Self reported pregnancy rates and live birth rates. RESULTS Of 1199 women recruited to the trial, 1128 consented to follow-up. Of these, 762 women replied giving pregnancy details (68% response rate). Respondents were representative of the trial participants. The live birth rate five years after the index miscarriage was similar in the three management groups: 177/224 (79%, 95% confidence interval 73% to 84%) in the expectant management group, 181/230 (79%, 73% to 84%) in the medical group, and 192/235 (82%, 76% to 86%) in the surgical group. There was also no significant difference according to previous birth history. Older women and those with previous miscarriages were significantly less likely to subsequently give birth. CONCLUSION Method of miscarriage management does not affect subsequent pregnancy rates with around four in five women giving birth within five years of the index miscarriage. Women can be reassured that long term fertility concerns need not affect their choice of miscarriage management. TRIAL REGISTRATION National Research Register N0467011677/N0467073587.
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Affiliation(s)
- Lindsay F P Smith
- East Somerset Research Consortium, Westlake Surgery, West Coker, Somerset BA22 9AH.
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Sur SD, Raine-Fenning NJ. The management of miscarriage. Best Pract Res Clin Obstet Gynaecol 2009; 23:479-91. [DOI: 10.1016/j.bpobgyn.2009.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Accepted: 01/29/2009] [Indexed: 10/21/2022]
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Petrou S, McIntosh E. Women's preferences for attributes of first-trimester miscarriage management: a stated preference discrete-choice experiment. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2009; 12:551-559. [PMID: 18798807 DOI: 10.1111/j.1524-4733.2008.00459.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To elicit women's preferences for attributes of alternative management options for first-trimester miscarriage. METHODS A stated preference discrete-choice experiment was conducted among 1198 women with a confirmed pregnancy of less than 13 weeks gestation, who had been diagnosed with either an incomplete miscarriage or missed miscarriage/early fetal demise and who had been recruited as part of a randomized controlled trial (miscarriage treatment [MIST] trial) comparing expectant, medical, and surgical miscarriage. Six attributes, each with three or four levels, were used in the statistical design. An orthogonal main effects design was generated (i.e., a design where the attributes are independent of each other) and the choice sets devised according to the principles of minimum overlap and level balance. A cost attribute was included to allow estimation of willingness to pay (WTP) values. Three different questionnaires were designed such that women were asked their preferences for attributes of the two management options they had not been allocated to in the trial. RESULTS A total of 630 women completed the stated preference discrete-choice survey questionnaires: 189 out of 398 women (47.5%) allocated to expectant management, 223 out of 398 women (56.0%) allocated to medical management, and 218 out of 402 women (54.2%) allocated to surgical management. For each of the three discrete-choice survey questionnaires, women expressed a clear preference for decreased levels of all six attributes (time spent at the hospital receiving treatment, level of pain experienced, number of days of bleeding after treatment, time taken to return to normal activities after treatment, cost of treatment to women, and chance of complications requiring more time or readmission to hospital). For each of the three discrete-choice survey questionnaires, the highest valued attribute in terms of WTP was for a reduction in pain levels followed by time taken to return to normal activities after treatment. On aggregate, surgical management was valued more highly than expectant and medical management by women allocated to medical and expectant management, respectively, and medical management was valued more highly than expectant management by women allocated to surgical management. This held true regardless of the application of either hypothetical data for each attribute generated by the pretrial-designed discrete-choice experiment questionnaires or actual data for each attribute observed in the MIST trial. CONCLUSIONS The preference results generated by this study suggest that many women undergoing management of first-trimester miscarriage would value being offered alternatives to expectant management. The data from this study should be considered by decision-makers in conjunction with the clinical and cost-effectiveness evidence base in this area as well as consideration of the budgets available to them for such services.
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Affiliation(s)
- Stavros Petrou
- Health Economics Research Centre, Department of Public Health, University of Oxford, Oxford, UK.
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Niinimäki M, Karinen P, Hartikainen AL, Pouta A. Treating miscarriages: a randomised study of cost-effectiveness in medical or surgical choice. BJOG 2009; 116:984-90. [DOI: 10.1111/j.1471-0528.2009.02161.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Affiliation(s)
- Willem M Ankum
- Department of Obstetrics and Gynecology (H4-205), Academic Medical Centre, University of Amsterdam, 1100 DE Amsterdam, The Netherlands
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Sagili H, Divers M. Economic evaluation of alternative management methods of first-trimester miscarriage based on results from the miscarriage treatment (MIST) trial by Petrou et al. BJOG 2007; 114:116-7. [PMID: 17233871 DOI: 10.1111/j.1471-0528.2006.01164.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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