1
|
Cohen A, Karavani G, Zamir A, Hadar A, Chill HH, Zini A. Does ultrasound guidance during dilation and curettage for first trimester missed abortion reduce complication rates? Minerva Obstet Gynecol 2024; 76:238-243. [PMID: 36345905 DOI: 10.23736/s2724-606x.22.05192-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Dilation and curettage (D&C) may be performed with or without transabdominal ultrasound guidance. The aim of this study was to evaluate the association between the use of ultrasound guidance during D&C for first trimester missed abortion (MA) and D&C related complication rates. METHODS A retrospective cohort study included women in the age of 20-45 years, who underwent D&C for first-trimester MA in a hospital-based setting between 2013-2019. The study population was divided into two groups: the study group which included women who underwent D&C with ultrasound guidance (US group) and the control group, which included women who underwent D&C without ultrasound guidance (N-US group). Gynecologic, obstetric, and operative related data were collected from electronic medical records. RESULTS Three-hundred and seventy-eight women were included in the study, 86 women in the US group and 292 women in N-US group. Baseline maternal characteristics and procedure-related characteristics did not differ between the groups. No significant difference between the US group and N-US group was shown when comparing D&C related complications, including retained products of conception rate (2.3% vs. 5.5%, respectively; P=0.385), uterine perforation rate (1.2% vs. 0.3%, respectively; P=0.404), and the total complication rate (8.1% vs. 12.3%, respectively; P=0.338). In a multivariate analysis, the use of ultrasound guidance during D&C was not found to be associated with lower complication rate (adjusted odds ratio [aOR] 95% confidence interval [CI] 1.468 [0.578-3.729], P=0.419). CONCLUSIONS Performance of D&C under ultrasound guidance for first-trimester MA, in a hospital-based setting, was not associated with lower complication rate, suggesting that the common practice of performing D&C without the use of ultrasound is an acceptable approach.
Collapse
Affiliation(s)
- Adiel Cohen
- Department of Obstetrics and Gynecology, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel -
| | - Gilad Karavani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Amit Zamir
- Department of Obstetrics and Gynecology, Kaplan Medical Center Affiliated to the Hebrew University-Hadassah School of Medicine, Rehovot, Israel
| | - Ayalon Hadar
- Department of Otolaryngology-Head and Neck Surgery, Shaare Zedek Medical Center, Hebrew University Medical School, Jerusalem, Israel
| | - Henry H Chill
- Pritzker School of Medicine, Division of Urogynecology, University of Chicago, NorthShore University Health System, Skokie, IL, USA
| | - Avraham Zini
- Faculty of Dental Medicine, Hebrew University Medical School, Jerusalem, Israel
| |
Collapse
|
2
|
Peters CE, Seideman CA, Kauderer S, Gore JL, Holt SK, Mehta A, Singer EA, Tabakin AL, Thavaseelan S, Vemulakonda V, Posid T, Velez D. Impact of Dobbs v. Jackson Women's Health Organization on Professional Decision-Making Among Urology Applicants. Urology 2024; 187:49-54. [PMID: 38431159 DOI: 10.1016/j.urology.2023.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 03/05/2024]
Abstract
MATERIALS AND METHODS An Institutional Review Board-exempt REDCap survey was distributed through the Society of Academic Urologists to all 508 applicants registered for the 2023 Urology Match following the rank list submission deadline on January 10, 2023. The survey closed on February 1, 2023. Responses were anonymized, aggregated, and characterized using descriptive statistics. Thematic mapping of open text comments was performed by 2 reviewers. RESULTS The response rate was 42% (215/508). Eighty-eight percent of respondents disapproved of the Dobbs ruling. Twenty percent of respondents (15% male/24% female) eliminated programs in states where abortion is illegal. Fifty-nine percent (51% male/70% female) would be concerned for their or their partner's health if they matched in a state where abortion was illegal, and 66% (55% male/82% female) would want their program to assist them or their partner if they required abortion care during residency. Due to the competitive nature of Urology, 68% of applicants reported feeling at least somewhat obligated to apply in states where abortion legislation conflicts with their beliefs. Of the 65 comments provided by respondents, 4 common themes emerged: (1) avoidance of states with restrictive abortion laws; (2) inability to limit applications because of the competitiveness of urology; (3) impacts on personal health care; and (4) desire for advocacy from professional urology organizations. CONCLUSION The Dobbs ruling will impact the urology workforce by affecting urology applicants' decision-making regarding residency selection and ranking. Although the competitiveness of the Urology Match pressures applicants to apply broadly, many are taking reproductive health care access into consideration.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Eric A Singer
- The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Alexandra L Tabakin
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Uniondale, NY.
| | | | | | - Tasha Posid
- The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Danielle Velez
- Robert Wood Johnson University Hospital, New Brunswick, NJ.
| |
Collapse
|
3
|
Karimi M, Alizadeh A, Mahmoodi M. Clinicopathological Pattern of Endometrial Specimens in Women with Abnormal Uterine Bleeding and Ultrasonography Correlation. ARCHIVES OF IRANIAN MEDICINE 2024; 27:216-222. [PMID: 38685848 PMCID: PMC11097308 DOI: 10.34172/aim.2024.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/28/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Abnormal uterine bleeding (AUB) refers to any symptomatic deviation from normal menstruation. AUB is a common gynecological disorder in non-pregnant women of reproductive age, accounting for approximately 33% of gynecological outpatient visits. The early diagnosis and management cause of AUB is important because of increased incidence of endometrial carcinoma with rapid growth. Transvaginal ultrasound is non-invasive imaging technique used to find endometrial carcinoma before referring patients for invasive techniques. Dilatation and curettage (D&C) and endometrial biopsy are surgical procedures that scrape the endometrial lining of the uterus for diagnosis and treatment. The aim of this study is to describe the clinicopathologic pattern of endometrial specimens in women with AUB and ultrasonographic correlation. METHODS Tissues from endometrial biopsy and curettage of 411 patients with AUB who referred to Shahid Mohammadi hospital were prospectively selected from 2021 to 2023. Patients were divided into three groups based on age and menstrual status including: premenopausal (18-39 years), perimenopausal (40-49 years) and postmenopausal (≥50 years). The results were correlated to patient's age and other data and evaluated with statistical analysis. RESULTS During the two-year study period, a total of 411 endometrial specimens with clinical diagnosis of AUB were submitted and the results were analyzed. The youngest patient presenting with AUB was 21 years old, while the oldest was 77 years old. The most common complaint was menorrhagia in 201 (48.0%) out of 411 patients. The most common pathology finding in three groups was polyp in 100 (24.3%) cases. Hormonal effect was the next commonly observed pattern seen in 70 (17.0%) cases. P value was calculated as 0.003 which was significant using chi-square for the trend seen in age. CONCLUSION Endometrial sampling is a useful tool for evaluation of women with AUB and referring patients for treatment. Histopathological evaluation of the endometrium is very useful in detecting the etiology of AUB. Transvaginal sonography has high sensitivity in detecting polyps.
Collapse
Affiliation(s)
- Mohadeseh Karimi
- Department of Pathology, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Anahita Alizadeh
- Department of Pathology, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Masoumeh Mahmoodi
- Department of Biostatistics, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| |
Collapse
|
4
|
Kelesidou V, Tsakiridis I, Virgiliou A, Dagklis T, Mamopoulos A, Athanasiadis A, Kalogiannidis I. Combination of Mifepristone and Misoprostol for First-Trimester Medical Abortion: A Comprehensive Review of the Literature. Obstet Gynecol Surv 2024; 79:54-63. [PMID: 38306292 DOI: 10.1097/ogx.0000000000001222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
Importance Several medications have been used to achieve medical abortion in the first trimester of pregnancy. The most commonly used is the combination of mifepristone and misoprostol; however, different doses and routes of administration have been proposed. Objective The aim of this study was to summarize published data on the effectiveness, adverse effects, and acceptability of the various combinations of mifepristone and misoprostol in medical abortion protocols in the first trimester of pregnancy. Evidence Acquisition This was a comprehensive review, synthesizing the findings of the literature on the current use of mifepristone and misoprostol for first-trimester abortion. Results The combination of mifepristone and misoprostol seems to be more effective than misoprostol alone. Regarding the dosages and routes, mifepristone is administered orally, and the optimal dose is 200 mg. The route of administration of misoprostol varies; the sublingual and buccal routes are more effective; however, the vaginal route (800 μg) is associated with fewer adverse effects. Finally, the acceptability rates did not differ significantly. Conclusions Different schemes for first-trimester medical abortion have been described so far. Future research needs to focus on identifying the method that offers the best trade-off between efficacy and safety in first-trimester medical abortion.
Collapse
Affiliation(s)
- Vera Kelesidou
- Resident, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Ioannis Tsakiridis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Andriana Virgiliou
- Consultant in Obstetrics and Gynecology, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Themistoklis Dagklis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Apostolos Mamopoulos
- Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Apostolos Athanasiadis
- Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Ioannis Kalogiannidis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| |
Collapse
|
5
|
Hayes-Ryan D, Cooley S, Cleary B. Medical management of first trimester miscarriage: a quality improvement initiative. Eur J Hosp Pharm 2023; 31:70-72. [PMID: 34426487 PMCID: PMC10800240 DOI: 10.1136/ejhpharm-2021-002840] [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: 04/13/2021] [Accepted: 08/03/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Medical management of first trimester pregnancy loss is a safe option that is well tolerated and affords women more autonomy in relation to their care. Recent trials provide robust evidence that mifepristone pretreatment is the optimal approach for women with missed miscarriage who desire medical management. METHODS Following a change in medical management of first trimester miscarriage in our unit, we conducted a retrospective audit over a 3-month period of all women who had elected medical management as their primary treatment option. We compared the results with a previous audit that had been undertaken prior to the change in practice. RESULTS The implementation of mifepristone resulted in an increased effectiveness of primary medical treatment for first trimester miscarriage from 53.8% to 85.2% (p=<0.001). DISCUSSION The results of our study support the introduction of mifepristone into routine clinical practice for medical management of first trimester pregnancy loss across all maternity units.
Collapse
Affiliation(s)
| | - Sharon Cooley
- Early Pregnancy Unit, Rotunda Hospital, Dublin, Ireland
| | - Brian Cleary
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
- Pharmacy, Rotunda Hospital, Dublin, Ireland
| |
Collapse
|
6
|
Silva TMD, Araujo MAGD, Simões ACZ, Oliveira RD, Medeiros KSD, Sarmento AC, Medeiros RDD, Costa APF, Gonçalves AK. Efficacy, Safety, and Acceptability of Misoprostol in the Treatment of Incomplete Miscarriage: A Systematic Review and Meta-analysis. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:e808-e817. [PMID: 38141602 DOI: 10.1055/s-0043-1776029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2023] Open
Abstract
OBJECTIVE To assess the efficacy, safety, and acceptability of misoprostol in the treatment of incomplete miscarriage. DATA SOURCES The PubMed, Scopus, Embase, Web of Science, Cochrane Library, and Clinical Trials databases (clinicaltrials.gov) were searched for the relevant articles, and search strategies were developed using a combination of thematic Medical Subject Headings terms and text words. The last search was conducted on July 4, 2022. No language restrictions were applied. SELECTION OF STUDIES Randomized clinical trials with patients of gestational age up to 6/7 weeks with a diagnosis of incomplete abortion and who were managed with at least 1 of the 3 types of treatment studied were included. A total of 8,087 studies were screened. DATA COLLECTION Data were synthesized using the statistical package Review Manager V.5.1 (The Cochrane Collaboration, Oxford, United Kingdom). For dichotomous outcomes, the odds ratio (OR) and 95% confidence interval (CI) were derived for each study. Heterogeneity between the trial results was evaluated using the standard test, I2 statistic. DATA SYNTHESIS When comparing misoprostol with medical vacuum aspiration (MVA), the rate of complete abortion was higher in the MVA group (OR = 0.16; 95%CI = 0.07-0.36). Hemorrhage or heavy bleeding was more common in the misoprostol group (OR = 3.00; 95%CI = 1.96-4.59), but pain after treatment was more common in patients treated with MVA (OR = 0.65; 95%CI = 0.52-0.80). No statistically significant differences were observed in the general acceptability of the treatments. CONCLUSION Misoprostol has been determined as a safe option with good acceptance by patients.
Collapse
Affiliation(s)
- Thiago Menezes da Silva
- Maternidade Escola Januário Cicco, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | | | | | - Ronnier de Oliveira
- Maternidade Escola Januário Cicco, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Kleyton Santos de Medeiros
- Centro de Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
- Instituto de Ensino, Pesquisa e Inovação, Liga Contra o Câncer, Natal, RN, Brazil
| | | | - Robinson Dias de Medeiros
- Department of Obstetrics and Gynecology, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | | | - Ana Katherine Gonçalves
- Centro de Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
- Department of Obstetrics and Gynecology, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| |
Collapse
|
7
|
George JS, Naert MN, Lanes A, Yin S, Bharadwa S, Ginsburg ES, Srouji SS. Utility of Office Hysteroscopy in Diagnosing Retained Products of Conception Following Early Pregnancy Loss After In Vitro Fertilization. Obstet Gynecol 2023; 142:1019-1027. [PMID: 37769303 DOI: 10.1097/aog.0000000000005382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/22/2023] [Indexed: 09/30/2023]
Abstract
OBJECTIVE To evaluate the utility of office hysteroscopy in diagnosing and treating retained products of conception in patients with infertility who experience early pregnancy loss (EPL) after in vitro fertilization (IVF). METHODS We evaluated a retrospective cohort of 597 pregnancies that ended in EPL in patients aged 18-45 years who conceived through fresh or frozen embryo transfer at an academic fertility practice between January 2016 and December 2021. All patients underwent office hysteroscopy after expectant, medical, or surgical management of the EPL. The primary outcome was presence of retained products of conception at the time of office hysteroscopy. Secondary outcomes included incidence of vaginal bleeding, presence of intrauterine adhesions, treatment for retained products of conception, and duration of time from EPL diagnosis to resolution. Log-binomial regression and Poisson regression were performed, adjusting for potential confounders including oocyte age, patient age, body mass index, prior EPL count, number of prior dilation and curettage procedures, leiomyomas, uterine anomalies, and vaginal bleeding. RESULTS Of the 597 EPLs included, 129 patients (21.6%) had retained products of conception diagnosed at the time of office hysteroscopy. The majority of individuals with EPL were managed surgically (n=427, 71.5%), in lieu of expectant management (n=140, 23.5%) or medical management (n=30, 5.0%). The presence of retained products of conception was significantly associated with vaginal bleeding (relative risk [RR] 1.72, 95% CI 1.34-2.21). Of the 41 patients with normal pelvic ultrasonogram results before office hysteroscopy, 10 (24.4%) had retained products of conception detected at the time of office hysteroscopy. When stratified by EPL management method, retained products of conception were significantly more likely to be present in individuals with EPL who were managed medically (adjusted RR 2.66, 95% CI 1.90-3.73) when compared with those managed surgically. Intrauterine adhesions were significantly less likely to be detected in individuals with EPL who underwent expectant management when compared with those managed surgically (RR 0.14, 95% CI 0.04-0.44). Of the 127 individuals with EPL who were diagnosed with retained products of conception at the time of office hysteroscopy, 30 (23.6%) had retained products of conception dislodged during the office hysteroscopy, 34 (26.8%) chose expectant or medical management, and 63 (49.6%) chose surgical management. The mean number of days from EPL diagnosis to resolution of pregnancy was significantly higher in patients who elected for expectant management (31 days; RR 1.18, 95% CI 1.02-1.37) or medical management (41 days; RR 1.54, 95% CI 1.25-1.90) when compared with surgical management (27 days). CONCLUSION In patients with EPL after IVF, office hysteroscopy detected retained products of conception in 24.4% of those with normal pelvic ultrasonogram results. Due to the efficacy of office hysteroscopy in diagnosing and treating retained products of conception, these data support considering office hysteroscopy as an adjunct to ultrasonography in patients with infertility who experience EPL after IVF.
Collapse
Affiliation(s)
- Jenny S George
- Center for Infertility and Reproductive Surgery, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | |
Collapse
|
8
|
Wang W, Gong B, Cai Y, Huang X, An J. Evaluation of different doses of Femoston therapy for incomplete abortion: A prospective observational trial. Medicine (Baltimore) 2023; 102:e35415. [PMID: 37904418 PMCID: PMC10615544 DOI: 10.1097/md.0000000000035415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/06/2023] [Indexed: 11/01/2023] Open
Abstract
This study aimed to compare the efficacy of different doses of femoston with expectant management in patients with incomplete abortions. Patients diagnosed with incomplete abortion were included if they chose to continue medical treatment after relevant contraindications were excluded. Participants were divided into 3 groups: the femoston (1/10) and femoston (2/10) groups received different doses of femoston, and patients in the control group received expectant treatment. The success rate of complete abortion and the rate of menstrual recovery among the 3 groups were compared to evaluate the efficacy of different doses of femoston in patients with incomplete abortions. A total of 197 patients were analyzed: 73 in the femoston (1/10) group, 73 in the femoston (2/10) group, and 51 patients were followed up without treatment in the control group. The femoston group was significantly more effective than the control group P < .0001). The adjusted odds ratio (OR) and 95% confidence interval (CI) were 3.103 and 1.153 to 8.350 (P = .025). The success rate of complete abortion in the femoston (2/10) group was significantly higher than that in the femoston (1/10) group (adjusted OR: 0.403, 95% CI: 0.145-1.118, P = .081). In addition, the rate of menstrual recovery in the femoston group was significantly higher than that in the control group (P = .007), and the rate in the femoston (2/10) group was also higher than the femoston (1/10) group with statistically significant (P = .001). Femoston is effective in treating incomplete abortion, with femostons containing 2 mg estrogen being more effective. Patients with incomplete abortion are treated with femoston, and menstrual recovery time may be shortened. Femostons may be a new option for pharmacological treatment of incomplete abortions.
Collapse
Affiliation(s)
- Wenrong Wang
- Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, P.R. China
| | - Bingchen Gong
- Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, P.R. China
| | - Yingying Cai
- Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, P.R. China
| | - Xueyao Huang
- Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, P.R. China
| | - Jian An
- Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, P.R. China
| |
Collapse
|
9
|
Cohen A, Gutman-Ido E, Karavani G, Albeck A, Rosenbloom JI, Shushan A, Chill HH. The association between history of retained placenta and success rate of misoprostol treatment for early pregnancy failure. BMC Womens Health 2023; 23:523. [PMID: 37794425 PMCID: PMC10552386 DOI: 10.1186/s12905-023-02666-9] [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: 06/02/2023] [Accepted: 09/21/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND To date, the association between retained placenta and treatment success rate of misoprostol for early pregnancy failure has yet to be evaluated. The aim of this study was to evaluate this association and further investigated the connection between medical, clinical and sonographic parameters and treatment success. METHODS We conducted a retrospective cohort study of women with early pregnancy failure treated with misoprostol from 2006 to 2021. The success rate of misoprostol treatment was compared between patients with history of retained placenta including women who underwent manual lysis of the placenta following delivery or patients who were found to have retained products of conception during their post-partum period (study group) and patients without such history (controls). Demographic, clinical, and sonographic characteristics as well as treatment outcomes were compared between the groups. RESULTS A total of 271 women were included in the study (34 women in the study group compared to 237 women in the control group). Two-hundred and thirty-three women (86.0%) presented with missed abortion, and 38 (14.0%) with blighted ovum. Success rates of misoprostol treatment were 61.8% and 78.5% for the study and control groups, respectively (p = 0.032). Univariate analysis performed comparing successful vs. failed misoprostol treatment showed advanced age, gravidity, parity and gestational sac size (mm) on TVUS were associated with higher misoprostol treatment failure rate. Following a multivariate logistic regression model these variables did not reach statistical significance. CONCLUSION Women who have an event of retained placenta following childbirth appear to have decreased success rate of treatment with misoprostol for early pregnancy failure. Larger studies are needed to confirm this finding.
Collapse
Affiliation(s)
- Adiel Cohen
- Department of Obstetrics and Gynecology, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Ein Kerem, Jerusalem, P.O.B. 12000, 91120, Israel.
| | - Einat Gutman-Ido
- Department of Obstetrics and Gynecology, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Ein Kerem, Jerusalem, P.O.B. 12000, 91120, Israel
| | - Gilad Karavani
- Department of Obstetrics and Gynecology, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Ein Kerem, Jerusalem, P.O.B. 12000, 91120, Israel
| | - Alon Albeck
- Department of Internal Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joshua I Rosenbloom
- Department of Obstetrics and Gynecology, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Ein Kerem, Jerusalem, P.O.B. 12000, 91120, Israel
| | - Asher Shushan
- Department of Obstetrics and Gynecology, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, Ein Kerem, Jerusalem, P.O.B. 12000, 91120, Israel
| | - Henry H Chill
- Division of Urogynecology, University of Chicago Pritzker School of Medicine, NorthShore University HealthSystem, Skokie, IL, USA
| |
Collapse
|
10
|
Peters CE, Lee J, Holt SK, Wolff E, Gore JL, Seideman CA. Attitudes Among Society of Women in Urology Members Toward Dobbs v. Jackson Women's Health Organization. Urology 2023; 180:295-302. [PMID: 37390972 DOI: 10.1016/j.urology.2023.04.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 07/02/2023]
Abstract
OBJECTIVE To evaluate attitudes of women in urology regarding the Supreme Court ruling Dobbs v. Jackson Women's Health Organization, including impacts on personal/professional decision-making and the urology workforce. METHODS An IRB-exempt survey including Likert questions on participant views and free text questions was distributed to 1200 members of the Society of Women in Urology on 9/2/2022. Participants were medical students, urology residents, fellows, and practicing/retired urologists over 18. Responses were anonymous and aggregated. Quantitative responses were characterized with descriptive statistics and free-text responses were analyzed using thematic mapping. To complement this analysis, urologist density was mapped by county using 2021 National Provider Identifier data. State abortion laws were categorized based on Guttmacher Institute data on 10/20/2022. Data were analyzed using logistic regression, Poisson regression, and multiple linear regression. RESULTS 329 respondents completed the survey. 88% disagree/strongly disagree with the Dobbs ruling. 42% of trainees may have changed their rank list if current abortion laws existed during their match. 60% of respondents said Dobbs will impact where they choose their next job. 61.5% of counties had zero urologists in 2021, 76% of which were in states with restrictive abortion laws. Urologist density was inversely associated with abortion law restrictiveness compared with the most protective counties. CONCLUSION The Dobbs ruling will significantly impact the urology workforce. Trainees may change how they rank programs in states with restrictive abortion laws, and urologists may consider abortion laws when choosing jobs. Restrictive states are at higher risk for worsening access to urologic care.
Collapse
Affiliation(s)
- Chloe E Peters
- University of Washington, Department of Urology, Seattle, WA.
| | - Jenney Lee
- University of Washington, Department of Urology, Seattle, WA
| | - Sarah K Holt
- University of Washington, Department of Urology, Seattle, WA
| | - Erika Wolff
- University of Washington, Department of Urology, Seattle, WA
| | - John L Gore
- University of Washington, Department of Urology, Seattle, WA
| | - Casey A Seideman
- Oregon Health and Science University, Department of Urology, Portland, OR
| |
Collapse
|
11
|
Gluck O, Barber E, Friedman M, Feldstein O, Tal O, Grinstein E, Mizrachi Y, Kerner R, Saidian M, Menasherof M, Sagiv R. Failure Rate of Medical Treatment for Miscarriage Correlated with the Difference between Gestational Age According to Last Menstrual Period and Gestational Size Calculated via Ultrasound. J Clin Med 2023; 12:6112. [PMID: 37834756 PMCID: PMC10573438 DOI: 10.3390/jcm12196112] [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: 08/07/2023] [Revised: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 10/15/2023] Open
Abstract
Objective: To study whether the interval between gestational age calculated using the last menstrual period (GA-LMP) and gestational age calculated via ultrasound (GA-US) is correlated with the success rate of medical treatment in cases of miscarriages. Methods: This was a retrospective cohort study conducted in a gynecology unit in a tertiary medical center. Women who underwent medical treatment with Misoprostol for miscarriage at the Edith Wolfson Medical Center between 07/2015 and 12/2020 were included. Incomplete or septic miscarriages, multiple pregnancies, patients with irregular periods, and cases of missing data were excluded. Failure of medical treatment was defined as the need for surgical intervention due to a retained gestational sac, severe bleeding or retained products of conception. The cohort study was divided into two groups: patients with successful treatment and patients for whom surgical intervention was eventually needed. We performed both a univariate and multivariate analysis in order to identify whether a correlation between GA-LMP and GA-US interval is indeed a factor in the success rate of a medical abortion. Results: Overall, 778 patients were included in the study. From this cohort 582 (74.9%) had undergone a successful medical treatment, while 196 (25.1%) required surgical intervention due to the failure of medical treatment, as defined above. The GA-LMP to GA-US interval (in weeks) was 2.6 ± 1.4 in the success group, while the GA in the failure group was 3.1 ± 1.6 (p < 0.001). After performing a multivariant regression analysis, we were able to show that the GA-LMP to GA-US interval was found to be independently correlated with an increase in the treatment failure rate (aOR = 1.24, CI 95% (1.01-1.51), p = 0.03). Conclusions: In cases of miscarriage, longer GA-LMP to GA-US interval has been shown to be an independently correlated factor to lower success rate of the medical treatment option.
Collapse
Affiliation(s)
- Ohad Gluck
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon 58100, Israel; (O.G.); (E.B.); (O.F.); (O.T.); (E.G.); (Y.M.); (R.K.); (R.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.S.); (M.M.)
| | - Elad Barber
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon 58100, Israel; (O.G.); (E.B.); (O.F.); (O.T.); (E.G.); (Y.M.); (R.K.); (R.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.S.); (M.M.)
| | - Matan Friedman
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon 58100, Israel; (O.G.); (E.B.); (O.F.); (O.T.); (E.G.); (Y.M.); (R.K.); (R.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.S.); (M.M.)
| | - Ohad Feldstein
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon 58100, Israel; (O.G.); (E.B.); (O.F.); (O.T.); (E.G.); (Y.M.); (R.K.); (R.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.S.); (M.M.)
| | - Ori Tal
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon 58100, Israel; (O.G.); (E.B.); (O.F.); (O.T.); (E.G.); (Y.M.); (R.K.); (R.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.S.); (M.M.)
| | - Ehud Grinstein
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon 58100, Israel; (O.G.); (E.B.); (O.F.); (O.T.); (E.G.); (Y.M.); (R.K.); (R.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.S.); (M.M.)
| | - Yossi Mizrachi
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon 58100, Israel; (O.G.); (E.B.); (O.F.); (O.T.); (E.G.); (Y.M.); (R.K.); (R.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.S.); (M.M.)
| | - Ram Kerner
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon 58100, Israel; (O.G.); (E.B.); (O.F.); (O.T.); (E.G.); (Y.M.); (R.K.); (R.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.S.); (M.M.)
| | - Michal Saidian
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.S.); (M.M.)
| | - Mai Menasherof
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.S.); (M.M.)
| | - Ron Sagiv
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon 58100, Israel; (O.G.); (E.B.); (O.F.); (O.T.); (E.G.); (Y.M.); (R.K.); (R.S.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.S.); (M.M.)
| |
Collapse
|
12
|
Flynn AN, McAllister A, Kete C, Koelper NC, Gallop RJ, Schreiber CA, Schapira MM, Sonalkar S. Evaluation of a decision aid for early pregnancy loss: A pilot randomized controlled trial in Philadelphia, Pennsylvania. Contraception 2023; 125:110077. [PMID: 37270163 DOI: 10.1016/j.contraception.2023.110077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To evaluate the effect of a decision aid on decisional conflict scale in patients choosing management for early pregnancy loss. STUDY DESIGN We conducted a pilot randomized control trial to assess the effect of the Healthwise patient decision aid on decisional conflict scale in patients with early pregnancy loss as compared with a control website. Patients 18years and older were eligible if they had an early pregnancy loss between 5 and 12 completed weeks of gestation. Participants completed surveys at baseline, poststudy intervention, after consultation, and 1week postconsultation. Surveys assessed participant scores on the decisional conflict scale (scale 0-100), knowledge, assessment of shared decision-making, satisfaction, and decision regret. Our primary outcome was the poststudy-intervention decisional conflict scale score. RESULTS From July 2020 through March 2021 we randomized 60 participants. After the intervention, the median decisional conflict scale score for the control group was 10 [0-30] and 0 [0-20] for the intervention group (p = 0.17). When assessing the decisional conflict scale subscales postintervention, the informed subscale for the control group was 16.7 [0-33.3] as opposed to 0 [0] for the patient decision aid group (p = 0.003). Knowledge remained significantly higher in the experimental arm from the postintervention to the 1-week follow-up. We found no differences between groups when assessing our other metrics. CONCLUSIONS Use of a validated decision aid did not result in statistically significant differences in the total decisional conflict scale scores as compared with the control. Participants allocated to the intervention were more informed postintervention and had consistently higher knowledge scores. IMPLICATIONS Use of a validated decision aid prior to early pregnancy loss management consultation did not affect overall decisional conflict but resulted in improved knowledge.
Collapse
Affiliation(s)
- Anne N Flynn
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Corinne Kete
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Nathanael C Koelper
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert J Gallop
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Marilyn M Schapira
- Department of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
13
|
Ratnam S, Kulasingam S, Kanagallingam A. Manual Vacuum Aspiration Versus Expectant Management for First Trimester Miscarriage: A Randomized Controlled Trial. Cureus 2023; 15:e45731. [PMID: 37868571 PMCID: PMC10590258 DOI: 10.7759/cureus.45731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 10/24/2023] Open
Abstract
Background Miscarriage is one of the common problems encountered in pregnancy. The treatment modalities are expectant, medical, and surgical management. This study compared the effectiveness and safety of manual vacuum aspiration (MVA) with expectant management for first trimester miscarriage. Method This randomized controlled trial was conducted in Teaching Hospital Jaffna, Jaffna, Sri Lanka, and 134 eligible patients with first trimester spontaneous miscarriage were randomized to expectant management (67) and MVA (67). Those allocated to expectant management were managed expectantly for up to two weeks, and those allocated to MVA underwent aspiration under a paracervical block in the ward. The primary outcome was complete evacuation of the uterus, and the secondary outcomes were duration of bleeding, duration of pain, level of pain, need for the second procedure, cervical or uterine injuries, and patient satisfaction. Results Of the 134 eligible women, seven were lost to follow-up and 127 were analyzed. The MVA was superior in achieving complete evacuation compared to expectant management (95.2% vs. 70.3%; p ≤ 0.001). Notably, in both groups, complete evacuation was more readily achievable in incomplete miscarriage than in missed miscarriage. Duration of bleeding (mean days, 1.6 vs. 4.3; p ≤ 0.0001), duration of pain (mean days, 1.0 vs. 4.2; p ≤ 0.0001), and the need for additional surgical procedure in the form of dilatation and curettage (4.8% vs. 29.7%; p ≤ 0.001) were lower in MVA. Patient satisfaction was higher in the MVA group than in the expectant group (93.7% vs. 65.6%; p ≤ 0.001). No statistically significant differences were observed between the groups in terms of blood transfusion and infection. There wasn't any incidence of cervical damage or uterine perforation. Conclusion MVA is an effective and safe treatment method for first trimester miscarriage with higher patient satisfaction.
Collapse
Affiliation(s)
- Sutharshan Ratnam
- Obstetrics and Gynaecology, Postgraduate Institute of Medicine, University of Colombo, Colombo, LKA
- Obstetrics and Gynaecology, Teaching Hospital Jaffna, Jaffna, LKA
| | | | | |
Collapse
|
14
|
Acharya A, Prabhu A, Negi S, Sharma K, Dwivedi R, Athe R. Spontaneous miscarriage/abortion in the first trimester and expectant management - a meta-analysis approach. PRZEGLAD MENOPAUZALNY = MENOPAUSE REVIEW 2023; 22:135-141. [PMID: 37829272 PMCID: PMC10566328 DOI: 10.5114/pm.2023.131307] [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: 02/10/2023] [Accepted: 05/09/2023] [Indexed: 10/14/2023]
Abstract
Introduction To determine effectiveness and side effects of expectant care in first-trimester miscarriage. An increase in the spontaneous miscarriage rate and its associated complications exerts a burden on the overall health and quality of life of women. Expectant care in a first-trimester miscarriage has shown success ranging 75-80%. This study was designed to search the literature for information on the clinical safety and effectiveness of expectant management on spontaneous miscarriage during the first trimester. Material and methods The review included studies that included women in expectant care for spontaneous miscarriage in the first trimester. Trial studies were recognized through a methodical and organized database search from PubMed, COCHRANE, MEDLINE, Embase, and bibliography from January 2000 until December 2022. The methodological assessment and risk of bias was assessed using the Joanna Briggs Institute criteria. Results Eleven studies in systematic review and 7 studies in the meta-analysis were included. The included studies showed a low to moderate risk of bias. The odds of success in expectant intervention were low when compared with surgical intervention (odds ratio - OR: OR: 0.37 [0.28, 0.48]) and medical management (OR: 0.47 [0.36, 0.61]), and the need for surgical evacuation was high (OR: 2.59 [1.88, 3.59]). Conclusions Future trials should consider women's opinions and the effect on quality of life along with clinical consequences, to provide improved suggestions on the efficiency and adverse effects.
Collapse
Affiliation(s)
- Anwesa Acharya
- Department of Computer Science and Engineering, CMR University, Bangalore, India
| | - Ananya Prabhu
- Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal, India
| | - Shivali Negi
- Centre for Public Health, Punjab University, Chandigarh, India
| | - Kavya Sharma
- Centre for Public Health, Punjab University, Chandigarh, India
| | - Rinshu Dwivedi
- Department of Science and Humanities, Indian Institute of Information Technology, Tiruchirappalli, India
| | - Ramesh Athe
- Department of Data Science and Intelligent Systems, Indian Institute of Information Technology, Dharwad, India
| |
Collapse
|
15
|
Phillips AM, Rachad S, Flink-Bochacki R. The association between abortion restrictions and patient-centered care for early pregnancy loss at US obstetrics-gynecology residency programs. Am J Obstet Gynecol 2023; 229:41.e1-41.e10. [PMID: 37003363 DOI: 10.1016/j.ajog.2023.03.038] [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: 11/10/2022] [Revised: 03/21/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Early pregnancy loss is a common medical problem, and the recommended treatments overlap with those used for induced abortions. The American College of Obstetricians and Gynecologists recommends the incorporation of clinical and patient factors when applying conservative published imaging guidelines to determine the timing of intervention for early pregnancy loss. However, in places where abortion is heavily regulated, clinicians who manage early pregnancy loss may cautiously rely on the strictest criteria to differentiate between early pregnancy loss and a potentially viable pregnancy. The American College of Obstetricians and Gynecologists also notes that specific treatment modalities that are frequently used to induce abortion, including the use of mifepristone in medical therapy and surgical aspiration in an office setting, are cost-effective and beneficial for patients with early pregnancy loss. OBJECTIVE This study aimed to determine how US-based obstetrics and gynecology residency training institutions adhere to the American College of Obstetricians and Gynecologists recommendations for early pregnancy loss management, including the timing and types of interventions, and to evaluate the relationship with institutional and state abortion restrictions. STUDY DESIGN From November 2021 to January 2022, we conducted a cross-sectional study of all 296 US-based obstetrics and gynecology residency programs by emailing them and requesting that a faculty member complete a survey about early pregnancy loss practices at their institution. We asked about location of diagnosis, use of imaging guidelines before offering intervention, treatment options available at their institution, and program and personal characteristics. We used chi-square tests and logistic regressions to compare the availability of early pregnancy loss care based on institutional indication-based abortion restrictions and state legislative hostility to abortion care. RESULTS Of the 149 programs that responded (50.3% response rate), 74 (49.7%) reported that they did not offer any intervention for suspected early pregnancy loss unless rigid imaging criteria were met, whereas the remaining 75 (50.3%) programs reported that they incorporated imaging guidelines with other factors. In an unadjusted analysis, programs were less likely to incorporate other factors with imaging criteria if they were in a state with legislative policies that were hostile toward abortion (33% vs 79%; P<.001) or if the institution restricted abortion by indication (27% vs 88%; P<.001). Mifepristone was used less often in programs located in hostile states (32% vs 75%; P<.001) or in institutions with abortion restrictions (25% vs 86%; P<.001). Similarly, office-based suction aspiration use was lower in hostile states (48% vs 68%; P=.014) and in institutions with restrictions (40% vs 81%; P<.001). After controlling for program characteristics, including state policies and affiliation with family planning training programs or religious entities, institutional abortion restrictions were the only significant predictor of rigid reliance on imaging guidelines (odds ratio, 12.3; 95% confidence interval, 3.2-47.9). CONCLUSION In training institutions that restrict access to induced abortion based on indication for care, residency programs are less likely to holistically incorporate clinical evidence and patient priorities in determining when to intervene in early pregnancy loss as recommended by the American College of Obstetricians and Gynecologists. Programs in restrictive institutional and state environments are also less likely to offer the full range of early pregnancy loss treatment options. With state abortion bans proliferating nationwide, evidence-based education and patient-centered care for early pregnancy loss may also be hindered.
Collapse
Affiliation(s)
- Aurora M Phillips
- Department of Obstetrics and Gynecology, Albany Medical Center, Albany, NY
| | | | | |
Collapse
|
16
|
Misoprostol use in obstetrics. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:356-368. [PMID: 37494579 PMCID: PMC10621739 DOI: 10.1055/s-0043-1770931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
|
17
|
Srajer A, Wylie M, Zaver F, Lonergan K, Brain P, Lang E. Emergency physician gender is associated with early pregnancy loss management: a multisite retrospective cohort study. Emerg Med J 2023; 40:242-247. [PMID: 36868812 DOI: 10.1136/emermed-2021-212214] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/05/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Patients experiencing early pregnancy loss often first present to the emergency department (ED) where they can be managed non-operatively through expectant or medical management, or surgically by the obstetrical team. Studies have reported that physician gender can influence clinical decision making, but there is limited research on this phenomenon in the ED. The objective of this study was to determine whether emergency physician gender is associated with early pregnancy loss management. METHODS Data were retrospectively collected from patients who presented to Calgary EDs with a non-viable pregnancy from 2014 to 2019. Pregnancies >12 weeks gestational age were excluded. The emergency physicians included saw at least 15 cases of pregnancy loss over the study period. The primary outcome was obstetrical consult rates by male versus female emergency physicians. Secondary outcomes included rates of initial surgical evacuation via dilation and curettage (D&C) procedures, ED returns, returns to care for D&Cs and total D&C rates. Data were analysed using χ2, Fisher's exact and Mann-Whitney U tests, as appropriate. Multivariable logistic regression models accounted for physician age, years of practice, training programme and type of pregnancy loss. RESULTS 98 emergency physicians and 2630 patients from 4 ED sites were included. 76.5% of the physicians were male accounting for 80.4% of pregnancy loss patients. Patients seen by female physicians were more likely to receive an obstetrical consultation (adjusted OR (aOR) 1.50, 95% CI 1.22 to 1.83) and initial surgical management (aOR 1.35, 95% CI 1.08 to 1.69). ED return rates and total D&C rates were not associated with physician gender. CONCLUSION Patients seen by female emergency physicians had higher rates of obstetrical consultation and initial operative management compared with those seen by male emergency physicians, but outcomes were similar. Additional research is required to determine why these gender differences exist and how these discrepancies may impact the care of early pregnancy loss patients.
Collapse
Affiliation(s)
- Amelia Srajer
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Megg Wylie
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fareen Zaver
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Philippa Brain
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
18
|
Ma SS, Yin WJ, Wang P, Wang HX, Zhang L, Jiang XM, Zhang Y, Tao R, Ge JF, Zhu P. Previous pregnancy loss and gestational cardiovascular health: A prospective cohort of nulliparous women. Front Public Health 2023; 11:1071706. [PMID: 37113178 PMCID: PMC10127104 DOI: 10.3389/fpubh.2023.1071706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 03/10/2023] [Indexed: 04/29/2023] Open
Abstract
Objectives To estimate the association of previous pregnancy loss with subsequent cardiovascular health during gestation and to examine the role of high-sensitivity C reactive protein (hs-CRP) in the association. Methods A total of 2,778 nulliparous pregnant women were recruited between March 2015 and November 2020 in Hefei city, China. Their cardiovascular health (CVH) including prepregnancy body mass index (BMI), blood pressure, total cholesterol, fasting plasma glucose, and smoke status were recorded at 24-28 weeks' gestation, as well as their reproductive history. Multivariate linear and logistic regression were performed to examine the association of pregnancy loss with cardiovascular health. And the role of hs-CRP between pregnancy loss and CVH was assessed by the mediation analysis. Results Compared with women who have no pregnancy loss, women with a history of spontaneous or induced abortions had higher BMI (β, 0.72, 95% CI, 0.50 to 0.94) and fasting plasma glucose (β, 0.04, 95% CI, 0.01 to 0.07), and had lower total CVH scores after adjusting for confounders (β, -0.09, 95% CI, -0.18 to -0.01). CVH scores were most significantly decreased among women with 3 or more induced abortions (β, -0.26, 95% CI, -0.49, -0.02). The contribution of pregnancy loss to poorer gestational CVH mediated by increased hs-CRP levels was 23.17%. Conclusion Previous pregnancy loss was associated with poorer cardiovascular health during gestation, which may be mediated by their gestational inflammatory status. Exposure to miscarriage alone was not a significant predictor of poorer CVH.
Collapse
Affiliation(s)
- Shuang-shuang Ma
- Department of Sleep Disorders, Affiliated Psychological Hospital of Anhui Medical University, Hefei, China
- Hefei Fourth People's Hospital, Hefei, China
- Anhui Mental Health Center, Hefei, Anhui, China
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Wan-jun Yin
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
- MOE Key Laboratory of Population Health Across Life Cycle, Anhui Medical University, Hefei, Anhui, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, Anhui, China
| | - Peng Wang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
- MOE Key Laboratory of Population Health Across Life Cycle, Anhui Medical University, Hefei, Anhui, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, Anhui, China
| | - Hai-xia Wang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
- MOE Key Laboratory of Population Health Across Life Cycle, Anhui Medical University, Hefei, Anhui, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, Anhui, China
| | - Lei Zhang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
- MOE Key Laboratory of Population Health Across Life Cycle, Anhui Medical University, Hefei, Anhui, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, Anhui, China
| | - Xiao-min Jiang
- Department of Obstetrics and Gynecology, Anhui Women and Child Health Care Hospital, Hefei, Anhui, China
| | - Ying Zhang
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ruixue Tao
- Department of Obstetrics and Gynecology, Hefei First People's Hospital, Hefei, Anhui, China
| | - Jin-fang Ge
- School of Pharmacy, Anhui Medical University, Hefei, Anhui, China
- *Correspondence: Jin-fang Ge,
| | - Peng Zhu
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
- MOE Key Laboratory of Population Health Across Life Cycle, Anhui Medical University, Hefei, Anhui, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, Anhui, China
- Peng Zhu,
| |
Collapse
|
19
|
Yang ST, Chang WH, Chao WT, Lai TJ, Lin WL, Lim HC, Liu CH, Wang PH. The timing of intravenous oxytocin administration is crucial to minimize perioperative blood loss during first-trimester suction curettage for missed abortion. J Chin Med Assoc 2022; 85:1061-1067. [PMID: 36083636 DOI: 10.1097/jcma.0000000000000808] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Oxytocin is commonly used to reduce blood loss during suction curettage for missed abortion. However, the potential of oxytocin to mitigate blood loss in early pregnancy remains controversial. Based on the hypothesis that the "timing" of oxytocin administration may be a critical factor, we investigated whether the timing of intravenous (IV) administration is associated with reduced perioperative blood loss during first-trimester suction curettage for missed abortion. METHODS The medical charts of 146 patients with ultrasound-confirmed first-trimester missed abortion who underwent suction curettage with IV oxytocin administration were retrospectively reviewed. RESULTS Among the patients, 67 received 10 IU of IV oxytocin before suction curettage (early-oxytocin administration group), while 79 patients received 10 IU of IV oxytocin after suction curettage (late-oxytocin administration group). The demographic features between the two groups did not significantly differ. However, there was a lower proportion of nulliparous patients in the early-oxytocin administration group than in the late-oxytocin administration group (38.8% vs 60.8%, p = 0.006). The perioperative blood loss amount was significantly lower in the early-oxytocin administration group than in the late-oxytocin administration group (60 [range: 50-100] vs 100 [range: 30-250] mL, p = 0.001). Moreover, the multivariate logistic regression analysis showed that the early-oxytocin administration group had a lower risk for a perioperative blood loss amount of ≥100 mL than the late-oxytocin administration group (0.23 [range: 0.10-0.55], p = 0.001); a gestational age of 9-12 weeks ( p = 0.009) was found to be associated with an increased risk for a perioperative blood loss amount of ≥100 mL. CONCLUSION Compared with late-oxytocin administration, early-oxytocin administration could reduce perioperative blood loss during first-trimester suction curettage for missed abortion. However, the results require further investigation.
Collapse
Affiliation(s)
- Szu-Ting Yang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Wen-Hsun Chang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wei-Ting Chao
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Ting-Jung Lai
- Department of Obstetrics and Gynecology, Cardinal Tien Hospital, New Taipei City, Taiwan, ROC
| | - Wei-Lin Lin
- Department of Obstetrics and Gynecology, Wan Fang Hospital, Taipei Medical University, New Taipei City, Taiwan, ROC
| | - Hong-Ci Lim
- Department of Obstetrics and Gynecology, Taipei Medical University Hospital, Taipei, Taiwan, ROC
| | - Chia-Hao Liu
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan, ROC
- Female Cancer Foundation, Taipei, Taiwan, ROC
| |
Collapse
|
20
|
Bridwell R, Long B, Montrief T, Gottlieb M. Post-abortion Complications: A Narrative Review for Emergency Clinicians. West J Emerg Med 2022; 23:919-925. [DOI: 10.5811/westjem.2022.8.57929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/23/2022] [Indexed: 11/15/2022] Open
Abstract
An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally “safe” (performed in a safe, clean environment with experienced providers and no legal restrictions) or “unsafe” (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.
Collapse
Affiliation(s)
- Rachel Bridwell
- Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington
| | - Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Tim Montrief
- Jackson Memorial Health System, Department of Emergency Medicine, Miami, Florida
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
| |
Collapse
|
21
|
Shaker M, Smith A. First Trimester Miscarriage. Obstet Gynecol Clin North Am 2022; 49:623-635. [PMID: 36122989 DOI: 10.1016/j.ogc.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
First trimester miscarriage, or early pregnancy loss, is a common occurrence in the United States. Miscarriage management includes expectant, medical, or surgical approaches. Decisions about management options should be approached through shared decision making between the patient and provider and with consideration of patient's preferences, hemodynamic stability, cost, gestational age, and effectiveness. Emergencies requiring immediate interventions are rare. Newer developments in management, including a more effective medical regimen with the addition of mifepristone and cost-effective and convenient in-office surgical interventions, have expanded treatment options.
Collapse
Affiliation(s)
- Maria Shaker
- University Hospitals Cleveland Medical Center - MacDonald Women's Hospital, 11100 Euclid Avenue, Cleveland, OH 44106, USA; Department of Reproductive Biology, Case Western Reserve University School of Medicine.
| | - Ayanna Smith
- University Hospitals Cleveland Medical Center - MacDonald Women's Hospital, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| |
Collapse
|
22
|
Lawani LO, Enebe JT, Eze P, Igboke FN, Ukaegbe CI, Ugwu MO, Agu UJ, Onyinye EN, Iyoke CA. Interpregnancy interval after a miscarriage and obstetric outcomes in the subsequent pregnancy in a low-income setting, Nigeria: A cohort study. SAGE Open Med 2022; 10:20503121221105589. [PMID: 35784667 PMCID: PMC9244931 DOI: 10.1177/20503121221105589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/18/2022] [Indexed: 11/18/2022] Open
Abstract
Objectives: The aim of this study was to determine and compare the occurrence of adverse pregnancy outcomes in a cohort of pregnant women with interpregnancy interval of < and ⩾6 months (short and normal interpregnancy interval, respectively) following a spontaneous miscarriage in their last pregnancies. Methods: This was a cohort study that involved pregnant women with a spontaneous pregnancy loss in their last pregnancies. They were recruited at a gestational age of 13–15 weeks and followed up to determine the obstetric and foetal outcomes of their pregnancies at four tertiary hospitals in Nigeria from July 2018 to September 2019. Data collected were analysed using SPSS version 26.0. A Chi-square and multivariate logistic regression analysis were done, and a p-value of less than 0.05 was assumed to be statistically significant. Results: A total of 705 participants were studied, out of which 448 (63.5%) and 257 (36.5%) of the participants had short and normal interpregnancy interval after a spontaneous miscarriage. Over 80% of the participants had first-trimester pregnancy losses and were managed with manual vacuum aspiration in 73.3% of the cases. The majority, 87.5% for the normal interpregnancy interval cohort and 86.4% for the short interpregnancy interval cohort, had live births, while 8.5% and 10.1% of the women in the normal and short interpregnancy interval cohorts, respectively, had repeat miscarriages. There was no statistical difference in the occurrence of live births and repeat miscarriages between both cohorts (p > 0.05). There was no increased risk of occurrence of adverse foetomaternal outcomes in both groups (p > 0.05). Multivariate logistic regression analysis showed that there was no statistical difference in the occurrence adverse foetomaternal outcomes between the studied cohorts (p > 0.05). Conclusion: There was no significant difference in the occurrence of adverse maternal and foetal outcomes in the cohorts of mothers with short and normal interpregnancy interval following miscarriages in their last previous pregnancies.
Collapse
Affiliation(s)
- Lucky Osaheni Lawani
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Obstetrics & Gynecology, Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Joseph Tochukwu Enebe
- Department of Obstetrics & Gynecology, College of Medicine, Enugu State University of Science and Technology Teaching Hospital, Enugu, Nigeria
| | - Paul Eze
- Department of Health Policy and Administration, Penn State University, University Park, PA, USA
| | - Francis Nwabueze Igboke
- Department of Obstetrics & Gynecology, Federal University Teaching Hospital, Abakaliki, Nigeria
| | | | - Monica Omosivie Ugwu
- Department of Obstetrics & Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Ujunwa Justina Agu
- Department of Paediatrics, Enugu State University Teaching Hospital, Enugu, Nigeria
| | - Enebe Nympha Onyinye
- Department of Community Medicine, University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria
| | | |
Collapse
|
23
|
Meshaal H, Salah E, Fawzy E, Abdel-Rasheed M, Maged A, Saad H. Hysteroscopic management versus ultrasound-guided evacuation for women with first-trimester pregnancy loss, a randomised controlled trial. BMC Womens Health 2022; 22:190. [PMID: 35614405 PMCID: PMC9131545 DOI: 10.1186/s12905-022-01774-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/12/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE We aimed to evaluate the hysteroscopic management of first-trimester pregnancy loss compared to surgical evacuation either blind or under ultrasonographic guidance. METHODS This clinical trial included 315 women with first-trimester pregnancy loss, divided equally into three groups. Group 1 underwent traditional blind surgical evacuation, group 2 underwent ultrasound-guided evacuation, and group 3 underwent hysteroscopic management. All women were assessed for retained products, surgical complications, the need for further management, and pregnancy occurrence after evacuation within 2 years of follow up. RESULTS The rate of presence of conception remnants and the need for further treatment was significantly higher in group 1 compared to groups 2 and 3 (4.8% vs. 0% vs. 0%, P = 0.012). The conception rate within 2 years was significantly lower in group 1 compared to groups 2 and 3 (57.4% vs. 73.2% vs. 82.7%, P = 0.002), and the duration needed to conceive was significantly prolonged in group 1 compared to groups 2 and 3 (9.8 vs. 8.3 vs. 6.9 months, P < 0.001). Interestingly, women who underwent hysteroscopic management needed a significantly shorter time to conceive than those who underwent ultrasound-guided evacuation (6.9 vs. 8.3 months, P = 0.006). CONCLUSIONS Hysteroscopic management of first-trimester pregnancy loss was superior to ultrasound-guided surgical evacuation regarding the time interval to conceive. Both techniques were superior to the blind evacuation technique regarding removal of the whole conception remnants, need for further treatment and fertility outcomes. Clinical trial registration: It was first registered at ClinicalTrials.gov on 16/03/2017 with registration number NCT03081104.
Collapse
Affiliation(s)
- Hadeer Meshaal
- Obstetrics and Gynecology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Emad Salah
- Obstetrics and Gynecology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Eman Fawzy
- Obstetrics and Gynecology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mazen Abdel-Rasheed
- Reproductive Health Research Department, National Research Centre, 33 El-Buhouth St, Dokki, Cairo, 12622, Egypt.
| | - Ahmed Maged
- Obstetrics and Gynecology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hany Saad
- Obstetrics and Gynecology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| |
Collapse
|
24
|
Margaliot Kalifa T, Lang Ben Nun E, Sela HY, Khatib F, Grisaru-Granovsky S, Rottenstreich M. Maternal and Neonatal Outcomes of Women Conceived Less Than 6 Months after First Trimester Dilation and Curettage. J Clin Med 2022; 11:2767. [PMID: 35628894 PMCID: PMC9147896 DOI: 10.3390/jcm11102767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/06/2022] [Accepted: 05/12/2022] [Indexed: 02/01/2023] Open
Abstract
Objective: To evaluate the maternal and neonatal outcomes of pregnancies conceived ≤6 months after first trimester (<14 weeks) dilation and curettage (D&C). Methods: A retrospective computerized database study of women who conceived ≤6 months following a missed abortion and delivered in a single tertiary medical center between 2016 and 2021. The maternal and neonatal outcomes of women who had D&C were compared to those of women who had non-medical or spontaneous miscarriages. The primary outcome of this study was the rate of preterm birth (<37 weeks). Secondary outcomes were adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression models; adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated. Results: During the study period, 1773 women met the inclusion criteria; of those, 1087 (61.3%) women gave birth following D&C. We found no differences between the study groups in any maternal or neonatal parameter examined including preterm birth (PTB), miscarriage to pregnancy interval, fertility treatments, hypertension disorders of pregnancy, placental complications, mode of delivery and neonatal birth weights. This was confirmed on a multivariate analysis as well [aOR 1.74 (0.89−3.40), p = 0.11] for preterm birth. Conclusion: Watchful waiting or the medical treatment of a first trimester missed abortion present no more risks than D&C to pregnancies conceived within six months of the index miscarriage. Further studies in other settings to strengthen these findings are needed.
Collapse
Affiliation(s)
- Tal Margaliot Kalifa
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem 91031, Israel; (T.M.K.); (E.L.B.N.); (F.K.); (S.G.-G.); (M.R.)
| | - Eyal Lang Ben Nun
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem 91031, Israel; (T.M.K.); (E.L.B.N.); (F.K.); (S.G.-G.); (M.R.)
| | - Hen Y. Sela
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem 91031, Israel; (T.M.K.); (E.L.B.N.); (F.K.); (S.G.-G.); (M.R.)
| | - Fayez Khatib
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem 91031, Israel; (T.M.K.); (E.L.B.N.); (F.K.); (S.G.-G.); (M.R.)
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem 91031, Israel; (T.M.K.); (E.L.B.N.); (F.K.); (S.G.-G.); (M.R.)
| | - Misgav Rottenstreich
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem 91031, Israel; (T.M.K.); (E.L.B.N.); (F.K.); (S.G.-G.); (M.R.)
- Department of Nursing, Jerusalem College of Technology, Jerusalem 93721, Israel
| |
Collapse
|
25
|
Alshdaifat EH, El-Deen Al-Horani SS, Al-Sous MM, Al-Horani S, Sahawneh FE, Sindiani AM. Histopathological pattern of endometrial biopsies in patients with abnormal uterine bleeding in a tertiary referral hospital in Jordan. Ann Saudi Med 2022; 42:204-213. [PMID: 35658582 PMCID: PMC9167457 DOI: 10.5144/0256-4947.2022.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Abnormal uterine bleeding (AUB) is a symptom that deviates from the normal menstrual cycle. AUB is characterized by changes in the frequency, volume, and duration of the menstrual flow. The etiology of AUB, which varies with age, may be attributed to both structural and non-structural causes. OBJECTIVES Determine the histopathological pattern of endometrial biopsies in patients with AUB across different age and parity groups who have undergone dilation and curettage (D&C), along with the discrepancy between D&C and histopathological findings after hysterectomy. DESIGN Retrospective chart review SETTING: Tertiary referral hospital PATIENTS AND METHODS: We collected data on all patients diagnosed with AUB between January 2015 and December 2020. Histopathological findings of all D&C endometrial biopsy samples were examined after being categorized by age and parity groups. Sensitivity, specificity, positive predictive value, and NPV were calculated to evaluate the diagnostic accuracy of D&C. MAIN OUTCOME MEASURES Histopathological pattern of D&C endometrial biopsies by age and parity groups. SAMPLE SIZE 3233 patients. RESULTS Most patients were in the 18-39 year age group, with normal cyclical findings being the most common histopathological finding. Malignant lesions were observed in 42 patients with a majority being older than 50 years. In 13.3% (42/316) of patients, D&C failed to detect intrauterine disorder that was found on hysterectomy. The overall accuracy of D&C in determining the existence of normal versus pathological findings was 75.60%, the sensitivity was 72.90%, the specificity was 77.90%, the positive predictive value was 73.86% and the NPV was 77.05% in our patients. CONCLUSION Normal cyclic changes account for the highest proportion of histopathological findings. However, hyperplasia and malignancies are important causes of perimenopausal and postmenopausal bleeding. While the use of D&C as a sampling tool for AUB cases remains questionable, the use of D&C in diagnosing premalignant and malignant cases is highly effective. LIMITATIONS Single-center, retrospective design, incomplete medical records, and inter-rater reliability could not be determined. CONFLICT OF INTEREST None.
Collapse
Affiliation(s)
| | | | - Majd Mahmoud Al-Sous
- From the Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Sharaf Al-Horani
- From Department of Obstetrics and Gynecology, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Amer Mahmoud Sindiani
- From Department of Obstetrics and Gynecology, Jordan University of Science and Technology, Irbid, Jordan
| |
Collapse
|
26
|
Whittaker L, Pymar H, Liu XQ. Manual Uterine Aspiration in the Emergency Department as a first line therapy for early pregnancy loss: A single center retrospective study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:644-649. [PMID: 35248776 DOI: 10.1016/j.jogc.2022.02.009] [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: 11/10/2021] [Revised: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Manual uterine aspiration (MUA) is a currently underused management option for early pregnancy loss (EPL) in the emergency department (ED). This study addresses the safety and efficiency of MUA in the ED. METHODS We performed a single-site retrospective observational chart review of pregnant women presenting to the ED with vaginal bleeding and ED pathology submissions for products of conception (POC) between 2012 and 2016. Patients were excluded for gestational age >14 weeks, no evidence of pregnancy loss, uterine cavity anomaly, hemodynamic instability, or hemoglobin <80 g/L. We compared the frequencies of complications (need for blood transfusion, repeat ED visit, failed initial management, admission to hospital) and ED utilization time between 4 management options: expectant, misoprostol, MUA, and electric vacuum aspiration (EVA) outside the ED, as well as time to procedure between MUA and EVA. RESULTS A total of 162 patients were included with 123 (76%) having a pathology report positive for POC. The mean patient and gestational ages were 30 ± 7 years and 66 ± 17 days, respectively. One hundred and nine patients were managed expectantly, 9 were given misoprostol, 23 underwent MUA, and 21 underwent EVA. Composite complication rates were 40%, 33%, 9%, and 10% (P = 0.001), and mean ED times were 5.4, 4.9, 7.3, and 6.0 hours (P = 0.01), for expectant, misoprostol, MUA, and EVA, respectively. The mean time to procedure was 5.1 hours for MUA and 23.1 hours for EVA (p=0.002). CONCLUSIONS Integrating MUA in the ED has the potential to reduce health care resource utilization while improving patient care.
Collapse
Affiliation(s)
| | - Helen Pymar
- University of Manitoba ,WN5013 820 Sherbrook St Winnipeg, MB, R3H 1R9
| | - Xiao-Qing Liu
- University of Manitoba 807J- 715 McDermot Avenue. Winnipeg, MB. R3E 3P4
| |
Collapse
|
27
|
Collins A, Memtsa M, Kirk E, Othman M, Abdul Kadir R. The risk of venous thromboembolism in early pregnancy loss: Review of the literature and current guidelines and the need for guidance - Communication from the SSC on Women's Health Issues for thrombosis and haemostasis. J Thromb Haemost 2022; 20:767-776. [PMID: 34897975 DOI: 10.1111/jth.15621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 12/04/2021] [Accepted: 12/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thromboembolic disease is one of the major causes of mortality and morbidity in pregnancy and the puerperium, with 1 death per 100 000 births attributed to venous thromboembolism (VTE). Factors associated with development of thrombosis are all present in pregnancy, with some of these changes seen from conception. OBJECTIVE Given how common early pregnancy loss is, the aim of this review is to evaluate the uncertainty surrounding the risk of VTE following early pregnancy loss and termination of pregnancy. METHODS A structured literature search was conducted to identify existing evidence as well as international pregnancy-specific guidelines regarding assessment and prevention of VTE risk in pregnant women. This review was reviewed, critiqued, and approved by all members of the International Society on Thrombosis and Haemostasis subcommittee for Women's Health Issues in Thrombosis and Haemostasis. RESULTS Four published original research studies, one clinical comment paper, and six guidelines were reviewed. Despite clear evidence of the increased risk of VTE in pregnancy, there is a lack of guidance regarding evaluation and management after early pregnancy loss. CONCLUSION International collaborative research to determine the risk of VTE and its prevention in women undergoing surgical termination of pregnancy or following surgical management of early pregnancy loss is urgently needed. Pregnancy-specific risk assessment taking into account preexisting risk factors is advocated. Education of health care professionals involved in early pregnancy care and guidance on management, albeit based on limited existing evidence, are necessary to highlight the need for individualized care.
Collapse
Affiliation(s)
| | - Maria Memtsa
- Institute for Women's Health, University College London, London, UK
| | - Emma Kirk
- The Royal Free NHS Foundation Hospital, London, UK
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rezan Abdul Kadir
- Institute for Women's Health, University College London, London, UK
- The Royal Free NHS Foundation Hospital, London, UK
- Katharine Dormandy Haemophilia and Thrombosis Centre, Department of Obstetrics and Gynaecology, The Royal Free NHS Foundation Hospital, London, UK
| |
Collapse
|
28
|
Fernlund A, Jokubkiene L, Sladkevicius P, Valentin L. Reproductive outcome after early miscarriage: comparing vaginal misoprostol treatment with expectant management in a planned secondary analysis of a randomized controlled trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:100-106. [PMID: 34523740 DOI: 10.1002/uog.24769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/24/2021] [Accepted: 08/27/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To compare the reproductive outcome after early miscarriage between women managed expectantly and those treated with vaginal misoprostol. METHODS This study was a planned secondary analysis of data collected prospectively in a randomized controlled trial comparing expectant management with vaginal misoprostol treatment (single dose of 800 µg) in women with early embryonic or anembryonic miscarriage and vaginal bleeding. The outcome measures were the number of women with a clinical pregnancy conceived within 14 months after complete miscarriage and the outcome of these pregnancies in terms of live birth, miscarriage, ectopic pregnancy and legal termination of pregnancy. The participants replied to a questionnaire sent by post covering their reproductive history ≤ 14 months after the index miscarriage was complete. Supplementary information and data for women who did not return their questionnaire were retrieved from medical records. RESULTS Of 94 women randomized to misoprostol treatment and 95 allocated to expectant management, 94 and 90 women, respectively, were included for analysis. Information on reproductive outcome was available for 89/94 (95%) and 83/90 (92%) women, respectively. Complete miscarriage without surgical evacuation was achieved within 31 days in 85% (76/89) of the women in the misoprostol group and in 65% (54/83) of those managed expectantly. The proportion of women treated with surgical evacuation was 33% (27/83) in the expectant-management group vs 12% (11/89) in the misoprostol group. At 14 months after the index miscarriage was complete, 75% (67/89) of women treated with misoprostol and 75% (62/83) of those managed expectantly had achieved at least one clinical pregnancy, while 40% (36/89) and 35% (29/83), respectively, had had at least one live birth (mean difference, 5.5% (95% CI, -9.7 to 20.3%)). When considering the outcome of all pregnancies conceived within 14 months after the index miscarriage was complete, 63% (56/89) of women in the misoprostol group and 55% (46/83) of those in the expectant-management group delivered a live baby after a pregnancy (mean difference, 7.5% (95% CI, -7.9 to 22.4%)). CONCLUSION Women with early miscarriage can be reassured that fertility is similar after misoprostol treatment and expectant management. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- A Fernlund
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - L Jokubkiene
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - P Sladkevicius
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - L Valentin
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| |
Collapse
|
29
|
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.
Collapse
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
| |
Collapse
|
30
|
Musik T, Grimm J, Juhasz-Böss I, Bäz E. Treatment Options After a Diagnosis of Early Miscarriage: Expectant, Medical, and Surgical. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:789-794. [PMID: 34696822 DOI: 10.3238/arztebl.m2021.0346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 04/21/2021] [Accepted: 09/23/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Approximately 12% of pregnancies end in an early miscarriage (up to week 12 + 0 of pregnancy). Over the past 10 to 15 years, two alternatives to curettage have appeared in the pertinent international treatment guidelines: expectant treatment and medical (drug) treatment. In this review, we discuss the advantages and disadvantages of each of these therapeutic options. METHODS This review is based on pertinent publications (January 2000 to February 2021) retrieved by a selective search in PubMed, as well as on the guidelines of the American College of Obstetrics and Gynecologists, the Association of the Scientific Medical Societies in Germany, the National Institute for Health and Care Excellence/Royal College of Obstetricians and Gynaecologists, and the International Federation of Gynaecology and Obstetrics. RESULTS Three effective and safe treatment options are available after a diagnosis of early miscarriage. Expectant treatment yields success rates of 66-91%, depending on the type of miscarriage. Its complications include hemorrhage requiring blood transfusion in 1-2% of cases. If expectant therapy fails, subsequent treatment with misoprostol or curettage is indicated. Drug therapy with misoprostol yields a complete termination in 81-95% of cases and is thus a valid alternative to expectant therapy, with the advantage of better planning capability. The vaginal application of misoprostol is the most effective means of administration, with the fewest side effects. Curettage is needed in 5-20% of cases. Suctional curettage has a success rate of 97-98%, with an associated anesthesia-related risk of 0.2%, a 0.1% risk of perforation, and a 2-3% rate of repeat curettage. CONCLUSION If there is no acute indication for the surgical treatment of an early miscarriage, the patient can choose among three treatment options. Expectant and medical treatment can be provided on an outpatient basis. Curettage is the treatment of choice in the presence of infection, marked and persistent bleeding, hemodynamic instability, or a pre-existing coagulopathy.
Collapse
|
31
|
Fernlund A, Jokubkiene L, Sladkevicius P, Valentin L, Sjöström K. Psychological impact of early miscarriage and client satisfaction with treatment: comparison between expectant management and misoprostol treatment in a randomized controlled trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:757-765. [PMID: 33798287 DOI: 10.1002/uog.23641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/14/2021] [Accepted: 03/18/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To compare the short- and long-term emotional distress (grief, anxiety and depressive symptoms) after early miscarriage and satisfaction with treatment between women randomized to expectant management vs vaginal misoprostol treatment. METHODS This was a preplanned analysis of data collected during a randomized controlled trial comparing expectant management with misoprostol treatment in women with early anembryonic or embryonic miscarriage and vaginal bleeding. If the miscarriage was not complete on day 31 after inclusion, surgical evacuation was recommended. The main outcomes were levels of anxiety and grief, depressive symptoms and client satisfaction with the treatment, which were assessed using the following validated psychometric self-assessment instruments: Spielberger State-Trait Anxiety Inventory (STAI, Form Y), Perinatal Grief Scale (PGS), Montgomery-Åsberg Depression Rating Scale (MADRS-S; self-reported version) and Client Satisfaction Questionnaire (CSQ-8). All women were assessed at four timepoints: on the day of randomization, on the day when the miscarriage was judged to be complete, and at 3 months and 14 months after complete miscarriage. The psychometric and client satisfaction scores were compared between the misoprostol group and the expectant-management group at each assessment. Analysis was performed by the intention-to-treat principle. RESULTS Ninety women were randomized to expectant management and 94 to misoprostol treatment. The psychometric and client satisfaction scores were similar in the two treatment groups at all assessment timepoints. At inclusion, 41% (35/86) of the women managed expectantly and 37% (34/92) of those treated with misoprostol had a STAI-state score of > 46 ('high level of anxiety'), and 9% (8/86) and 10% (9/91), respectively, had symptoms of moderate or severe depression (MADRS-S score ≥ 20). In both treatment groups, symptom scores for anxiety and depression were significantly higher at inclusion than after treatment and remained low until 14 months after complete miscarriage. Grief reactions were mild in both groups, with a median PGS score of 40.0 at 3 months and 37.0 at 14 months after complete miscarriage in both treatment groups. Four women treated with misoprostol and two women managed expectantly had a PGS score of > 90 (indicating deep grief) 3 months after complete miscarriage, while one woman managed expectantly had a PGS score of > 90 14 months after complete miscarriage. Women in both treatment groups were satisfied with their management, as indicated by a median CSQ-8 score of > 25 at each assessment. More than 85% of participants in each of the two groups reported that they would recommend the treatment they received to a friend. CONCLUSIONS The psychological response to and recovery after early miscarriage did not differ between women treated with misoprostol and those managed expectantly. Satisfaction with treatment was high in both treatment groups. Our findings support patient involvement when deciding on the management of early miscarriage. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- A Fernlund
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - L Jokubkiene
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - P Sladkevicius
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - L Valentin
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - K Sjöström
- Department of Care Sciences, Malmö University, Malmö, Sweden
| |
Collapse
|
32
|
Enzelsberger SH, Wetzlmair D, Hermann P, Wagner H, Shebl O, Oppelt P, Trautner PS. Bleeding pattern after medical management of early pregnancy loss with mifepristone–misoprostol and its prognostic value: a prospective observational cohort study. Arch Gynecol Obstet 2021; 306:349-355. [PMID: 34694431 PMCID: PMC9349076 DOI: 10.1007/s00404-021-06291-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 10/13/2021] [Indexed: 10/26/2022]
Abstract
Abstract
Purpose
To improve counseling of women by reporting bleeding characteristics at home after medical management of an early pregnancy loss (EPL) with mifepristone and misoprostol, and to evaluate occurring bleeding patterns as a prognostic tool.
Methods
This prospective two-center observational cohort study enrolled 197 women who presented with an EPL (embryonic or anembryonic miscarriage) from December 2017 to April 2019 and chose a home-based medical management with 200 mg mifepristone and 800 mcg misoprostol. From the day of mifepristone intake, the strength of vaginal bleeding was recorded daily for 2 weeks by the patient herself using a diary sheet. Treatment success was defined as no histologically confirmed retained products of conception (RPOC) within 3 months. After considering all drop-out criteria, 154 women were included in the analysis.
Results
40.0% of patients (95% CI 30.4–49.6) already reported bleeding onset in the time period between the intake of mifepristone and misoprostol. The median duration of vaginal bleeding including spotting was 13 days. The chance of RPOC was about sixfold (OR 6.06, 95% CI 2.15–17.10) in the group of persistent bleeding after 2 weeks compared to the group with a terminated bleeding at that time. Exploratory regression analysis indicated association of higher serum levels of leukocytes at treatment start with RPOC (p = 0.013).
Conclusions
Terminated bleeding after 2 weeks is a useful indicator for successful medical induction of EPL. Women undergoing medical treatment with mifepristone must be informed about the high frequency of bleeding onset before misoprostol intake.
Clinical trial registration
DRKS—German Clinical Trials Register, ID: DRKS00013515, registration date 05.12.2017. http://www.drks.de/DRKS00013515.
Collapse
|
33
|
The Burden of Abortion Restrictions and Conservative Diagnostic Guidelines on Patient-Centered Care for Early Pregnancy Loss. Obstet Gynecol 2021; 138:467-471. [PMID: 34352854 DOI: 10.1097/aog.0000000000004509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/10/2021] [Indexed: 11/26/2022]
Abstract
Intrauterine pregnancies of uncertain viability are common, and guidelines for diagnosing early pregnancy loss must balance the risk of interrupting a viable pregnancy with the anxiety and medical complications resulting from delayed diagnosis. Two cases of likely early pregnancy loss presenting as intrauterine pregnancies of uncertain viability are described, with stark differences in care availability related to state reproductive health care regulations. Onerous abortion restrictions, medical and societal stigma, and inherent pronatalism in diagnostic criteria interfere with the exercise of clinical judgment and can damage patients' physical or mental health.
Collapse
|
34
|
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.
Collapse
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
| |
Collapse
|
35
|
Kasuga Y, Ikenoue S, Tanaka Y, Tamagawa M, Hasegawa K, Oishi M, Endo T, Sato Y, Tanaka M, Ochiai D. Expectant management for early pregnancy miscarriage after radical trachelectomy: A single hospital-based study. Acta Obstet Gynecol Scand 2021; 100:1322-1325. [PMID: 33797065 DOI: 10.1111/aogs.14158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/14/2021] [Accepted: 03/27/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Women who have undergone radical trachelectomy as a fertility-sparing treatment for early-stage cervical cancer may be at higher risk for retained tissues after early-term miscarriage due to cervical cerclage or cervical necrosis. Dilatation and curettage or aspiration may present additional risks in these women. The aim of this study was to assess the efficacy of expectant management for early pregnancy miscarriage after radical trachelectomy. MATERIAL AND METHODS Keio University Hospital records were reviewed for women who conceived after abdominal radical trachelectomy and received perinatal care between 1 April 2012 and 31 March 2020. A total of 62 women (76 pregnancies) were identified, and 13 of these women experienced miscarriage before 12 gestational weeks. The management and outcome of these cases were reviewed in detail. RESULTS The median maternal age at miscarriage was 39 years (range 31-42 years) and the median duration from abdominal radical trachelectomy to conception was 2.60 years (range 0.49-7.30 years). Cervical necrosis before conception occurred in one case (8%). One patient requested treatment with aspiration and the remaining 12 cases were managed with observation for a median of 23 days (range 7-50 days). There were no cases of endometritis or cases requiring dilatation and curettage for residue tissue. Further, no cases developed laceration of the residual cervix and no loss of cerclage sutures after discharge was noted. CONCLUSIONS Expectant management seems to be safe and appropriate for first trimester miscarriage after abdominal radical trachelectomy.
Collapse
Affiliation(s)
- Yoshifumi Kasuga
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Satoru Ikenoue
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yuya Tanaka
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Masumi Tamagawa
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Keita Hasegawa
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Maki Oishi
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Toyohide Endo
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yu Sato
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Mamoru Tanaka
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Daigo Ochiai
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| |
Collapse
|
36
|
Lee JK, Zimrin AB, Sufrin C. Society of Family Planning clinical recommendations: Management of individuals with bleeding or thrombotic disorders undergoing abortion. Contraception 2021; 104:119-127. [PMID: 33766610 DOI: 10.1016/j.contraception.2021.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 02/06/2023]
Abstract
Individuals who have bleeding disorders, thrombophilias, a history of venous thromboembolism (VTE), or who are taking anticoagulation medication for other reasons may present for abortion. Clinicians should be aware of risk factors and histories concerning for excessive bleeding and thrombotic disorders around the time of abortion. This document will focus on how to approach abortion planning in these individuals. For first-trimester abortion, procedural abortion (sometimes called surgical abortion) is generally preferred over medical management for individuals with bleeding disorders or who are on anticoagulation. First-trimester procedural abortion in an individual on anticoagulation can generally be done without interruption of anticoagulation. The decision to interrupt anticoagulation for a second-trimester procedure should be individualized. Individuals at high risk for VTE can be offered anticoagulation post-procedure. Individuals with bleeding disorders or who are anticoagulated can safely be offered progestin intrauterine devices. Future research is needed to better assess quantitative blood loss and complications rates with abortion in these populations.
Collapse
Affiliation(s)
- Jessica K Lee
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Ann B Zimrin
- University of Maryland Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Carolyn Sufrin
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, United States
| |
Collapse
|
37
|
Mizrachi Y, Shoham G, Leong M, Sagiv R, Horowitz E, Raziel A, Weissman A. Misoprostol treatment for early pregnancy loss: an international survey. Reprod Biomed Online 2021; 42:997-1005. [PMID: 33785303 DOI: 10.1016/j.rbmo.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/09/2021] [Accepted: 02/12/2021] [Indexed: 12/12/2022]
Abstract
RESEARCH QUESTION What is the global variability in misoprostol treatment for the management of early pregnancy loss (EPL)? DESIGN An international web-based survey of fertility specialists and obstetrics and gynaecology clinicians was conducted between August and November 2020. The survey consisted of 16 questions addressing several aspects of misoprostol treatment for EPL. RESULTS Overall, 309 clinicians from 80 countries participated in the survey, of whom 67.3% were fertility specialists. Nearly one-half (47.9%) of the respondents let the patient choose the first line of treatment (expectant management, misoprostol treatment or surgical aspiration) according to her own preference. The 248 respondents who administer misoprostol in their daily practice were asked further questions; 59.7% of them advise patients to take the medication at home. The most common dose and route of administration is 800 µg administered vaginally. Only 28.6% of participants use mifepristone pretreatment. Variation in the timing of the first follow-up visit after misoprostol administration was wide, ranging from 24 h to 1 week in most clinics. In case of incomplete expulsion, only 42.3% of the respondents routinely administer a second dose. The timing of the final visit and the definition of successful treatment also differed greatly among respondents. CONCLUSIONS There is large variability in the use of misoprostol for the management of EPL. High-quality research is necessary to examine several aspects of the treatment. Particularly, the timing and effectiveness of a second dose administration and the criteria to decide on treatment failure or success deserve more research in the future.
Collapse
Affiliation(s)
- Yossi Mizrachi
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, PO Box 5, Holon 58100, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Gon Shoham
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Ron Sagiv
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, PO Box 5, Holon 58100, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eran Horowitz
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, PO Box 5, Holon 58100, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arieh Raziel
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, PO Box 5, Holon 58100, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ariel Weissman
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, PO Box 5, Holon 58100, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| |
Collapse
|
38
|
Hamel C, Coppus S, van den Berg J, Hink E, van Seeters J, van Kesteren P, Merién A, Torrenga B, van de Laar R, Terwisscha van Scheltinga J, Gaugler-Senden I, Graziosi P, van Rumste M, Nelissen E, Vandenbussche F, Snijders M. Mifepristone followed by misoprostol compared with placebo followed by misoprostol as medical treatment for early pregnancy loss (the Triple M trial): A double-blind placebo-controlled randomised trial. EClinicalMedicine 2021; 32:100716. [PMID: 33681738 PMCID: PMC7910666 DOI: 10.1016/j.eclinm.2020.100716] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Worldwide, millions of women seek treatment for early pregnancy loss (EPL) annually. Medical management with misoprostol is widely used, but only effective 60% of the time. Pre-treatment with mifepristone prior to misoprostol might improve the success rate of medical management. METHODS This was a multi-centre, double-blind, placebo-controlled randomised trial in 17 Dutch hospitals. Women with a non-viable pregnancy between 6 and 14 weeks of gestation were eligible for inclusion after at least one week of expectant management. Participants were randomised (1:1) between oral mifepristone 600 mg or an oral placebo tablet. Participants took 400 μg misoprostol orally, repeated after four hours on day two and, if necessary, day three. Primary outcome was expulsion of gestational sac and endometrial thickness <15 mm after 6-8 weeks. Analyses were done according to intention-to-treat principles. This trial is registered with ClinicalTrials.gov, NCT03212352. FINDINGS Between June 28th 2018 and January 8th 2020, 175 women were randomised to mifepristone and 176 to placebo, including 344 in the intention-to-treat analysis. In the mifepristone group 136 (79•1%) of 172 participants reached complete evacuation compared to 101 (58•7%) of 172 participants in the placebo group (p<0•0001, RR 1•35, 95% CI 1•16-1•56). Incidence of serious adverse events was significantly lower in the mifepristone group with 24 (14%) patients affected versus 55 (32%) in the placebo group (p = 0•0005) (Table 3). INTERPRETATION Pre-treatment with mifepristone prior to misoprostol was more effective than misoprostol alone in managing EPL. FUNDING Healthcare Insurers Innovation Foundation, Radboud University Medical Centre, Canisius Wilhelmina Hospital.
Collapse
Affiliation(s)
- Charlotte Hamel
- Department of Obstetrics and Gynaecology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
- Department of Obstetrics and Gynaecology, Radboud university medical centre, Nijmegen, the Netherlands
| | - Sjors Coppus
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, the Netherlands
| | - Joyce van den Berg
- Department of Obstetrics and Gynaecology, Gelderse Vallei Hospital, Ede, the Netherlands
| | - Esther Hink
- Department of Obstetrics and Gynaecology, Radboud university medical centre, Nijmegen, the Netherlands
| | - Jacoba van Seeters
- Department of Obstetrics and Gynaecology, Amphia Hospital, Breda, the Netherlands
| | | | - Ashley Merién
- Department of Obstetrics and Gynaecology, Rijnstate, Arnhem, the Netherlands
| | - Bas Torrenga
- Department of Obstetrics and Gynaecology, Ikazia Hospital, the Netherlands
| | - Rafli van de Laar
- Department of Obstetrics and Gynaecology, Vie Curi Medical Centre, the Netherlands
| | | | - Ingrid Gaugler-Senden
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, ‘s-Hertogenbosch, the Netherlands
| | - Peppino Graziosi
- Department of Obstetrics and Gynaecology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Minouche van Rumste
- Department of Obstetrics and Gynaecology, Catharina Hospital, Eindhoven, the Netherlands
| | - Ewka Nelissen
- Department of Obstetrics and Gynaecology, Laurentius Hospital, Roermond, the Netherlands
| | - Frank Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud university medical centre, Nijmegen, the Netherlands
- Department of Obstetrics and Gynaecology, Helios Klinikum Duisburg, Duisburg, Germany
| | - Marcus Snijders
- Department of Obstetrics and Gynaecology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| |
Collapse
|
39
|
Flynn AN, Roe AH, Koelper N, McAllister A, Sammel MD, Schreiber CA. Timing and efficacy of mifepristone pretreatment for medical management of early pregnancy loss. Contraception 2021; 103:404-407. [PMID: 33476659 DOI: 10.1016/j.contraception.2021.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To determine the time interval between mifepristone and misoprostol administration associated with the most efficacious early pregnancy loss (EPL) management. STUDY DESIGN We performed a secondary analysis of a randomized trial. Participants with EPL were instructed to take 200 mg oral mifepristone followed by 800 mcg vaginal misoprostol 24 hours later. The primary outcome was gestational sac expulsion at the first follow-up visit (1-4 days after misoprostol use) after a single dose of misoprostol and no additional intervention within 30 days after treatment. Despite specification of drug timing, participants used the medication over a range of time. We graphed sliding average estimates of success and assessed the proportion of treatment successes over time to define timing interval cohorts for analysis. We used multivariable generalized linear regression to assess the association between time interval and success. RESULTS Of 139 eligible participants, 70 (50.4%) self-administered misoprostol before 24 hours, and 69 (49.6%) at or after 24 hours. We defined the following time intervals: 0 to 6 hours (n = 22); 7 to 20 hours (n = 29); and 21 to 48 hours (n = 88). Success occurred in 96.6% of the 7- to 20-hour cohort compared to 54.6% and 87.5% of the cohorts self-administering misoprostol earlier or later, respectively. When adjusting for race, gestational age, diagnosis, bleeding at presentation, insurance status, and enrollment site, participants administering misoprostol between 0 and 6 hours (adjusted risk ratio 0.58, 95% CI 0.40-0.85) and 21 to 48 hours (adjusted risk ratio 0.91, 95% CI 0.72-0.99) had a lower risk of success when compared to participants administering 7 to 20 hours after mifepristone. CONCLUSIONS These data suggest that medical management of EPL has the highest likelihood of success when misoprostol is self-administered 7 to 20 hours after mifepristone. IMPLICATIONS These preliminary data suggest that patients have the highest likelihood of success when misoprostol is taken between 7 and 20 hours after mifepristone. In contrast with medical abortion, simultaneous medication administration may not be as effective as delayed. Future research is needed to confirm the optimal medication time interval.
Collapse
Affiliation(s)
- Anne N Flynn
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Andrea H Roe
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Nathanael Koelper
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Mary D Sammel
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, United States
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
40
|
Schaffner M, Rochau U, Mühlberger N, Conrads-Frank A, Qerimi Rushaj V, Sroczynski G, Koukkou E, Thuesen BH, Völzke H, Oberaigner W, Siebert U. The economic impact of prevention, monitoring and treatment strategies for iodine deficiency disorders in Germany. Endocr Connect 2021; 10:1-12. [PMID: 33263563 PMCID: PMC7849460 DOI: 10.1530/ec-20-0384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/27/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE More than 30% of the German population suffers from mild to moderate iodine deficiency causing goiter and other iodine deficiency disorders (IDDs). The economic burden of iodine deficiency is still unclear. We aimed to assess costs for prevention, monitoring and treatment of IDDs in Germany. DESIGN We performed a comprehensive cost analysis. METHODS We assessed direct medical costs and direct non-medical costs for inpatient and outpatient care of IDDs and costs for productivity loss due to the absence of work in 2018. Additionally, we calculated total costs for an IDD prevention program comprising universal salt iodization (USI). We performed threshold analyses projecting how many cases of IDDs or related treatments would need to be avoided for USI to be cost-saving. RESULTS Annual average costs per case in the year of diagnosis were € 211 for goiter/thyroid nodules; € 308 for hyperthyroidism; and € 274 for hypothyroidism. Average one-time costs for thyroidectomy were € 4184 and € 3118 for radioiodine therapy. Average costs for one case of spontaneous abortion were € 916. Annual costs of intellectual disability were € 14,202. In the German population, total annual costs for USI would amount to 8 million Euro. To be cost-saving, USI would need to prevent, for example, 37,900 cases of goiter/thyroid nodules. CONCLUSION USI potentially saves costs, if a minimum amount of IDDs per year could be avoided. In order to recommend the implementation of USI, a full health-economic evaluation including a comprehensive benefit-harm assessment is needed.
Collapse
Affiliation(s)
- Monika Schaffner
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT – University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
- Correspondence should be addressed to S Monika:
| | - Ursula Rochau
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT – University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Nikolai Mühlberger
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT – University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Annette Conrads-Frank
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT – University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Vjollca Qerimi Rushaj
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT – University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
- Faculty of Pharmacy, School of PhD Studies, Ss. Cyril and Methodius University, Skopje, Macedonia
| | - Gaby Sroczynski
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT – University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | | | | | - Henry Völzke
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Wilhelm Oberaigner
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT – University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT – University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
- Center for Health Decision Science, Department of Health Policy and Management, Harvard Chan School of Public Health, Boston, Massachusetts, USA
- Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
41
|
Linnakaari R, Helle N, Mentula M, Bloigu A, Gissler M, Heikinheimo O, Niinimäki M. Trends in the incidence, rate and treatment of miscarriage-nationwide register-study in Finland, 1998-2016. Hum Reprod 2020; 34:2120-2128. [PMID: 31747000 DOI: 10.1093/humrep/dez211] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/02/2019] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION What changes have occurred in the incidence of miscarriage, its treatment options, and the profile of the women having miscarriages in Finland between 1998 and 2016? SUMMARY ANSWER The annual incidence of registry-identified miscarriage has declined significantly between 1998 and 2016, and non-surgical management has become the dominant treatment. WHAT IS KNOWN ALREADY Miscarriage occurs in 8-15% of clinically recognized pregnancies and in ~30% of all pregnancies. Increasing maternal age is associated with an increasing risk of miscarriage. The treatment of miscarriage has evolved significantly in recent years: previously, surgical evacuation of the uterus was the standard of care, but nowadays medical and expectant management are increasingly used. STUDY DESIGN, SIZE, DURATION We conducted a nationwide retrospective cohort study of 128 381 women that had experienced a miscarriage that was managed in public healthcare between 1998 and 2016 in Finland. PARTICIPANTS/MATERIALS, SETTING, METHODS We used the National Hospital Discharge Registry for the data. Women aged 15-49 years that had experienced their first miscarriage during the follow-up period and had miscarriage-related diagnoses during their admission to public hospital were included in the study. Miscarriages were defined by the 10th Revision of the International Statistical Classification of Diseases and related Medical Problems (ICD-10) diagnostic codes O02*, O03* and O08*. Women with ectopic, molar and continuing pregnancies and induced abortions were excluded. Treatment was divided into surgical and non-surgical treatment using the surgical procedure codes. MAIN RESULTS AND THE ROLE OF CHANCE The annual incidence of registry-identified miscarriage has declined from 6.8/1000 15-49-year-old women in 1998 to 5.0/1000 in 2016 (P < 0.001). Also, the incidence rate of registry-identified miscarriage (i.e. the proportion of miscarriages of registry-identified pregnancies [i.e. deliveries, induced abortions, and miscarriages]) has declined from 112/1000 15-49-year-old pregnant women in 1998 to 83/1000 in 2016 (P < 0.001). The largest decrease in this proportion occurred among women over 40 years of age, among whom 26.5% of registry-identified pregnancies in 1998 ended in miscarriage compared to that of 16.4% in 2016. The proportion of missed abortion has increased (30.3 to 38.8%, P < 0.001) whereas that of blighted ovum has decreased (25.4 to 12.8%, P < 0.001). The proportion of registry-identified miscarriages seen among nulliparous women has increased from 43.7 to 49.6% (P < 0.001). Mean age at the time of miscarriage remained at 31 years throughout the study. Altogether, 29% of all miscarriages were treated surgically and 71% underwent medical or expectant management. The proportion of surgical management has decreased from 38.0 to 1.6% for spontaneous abortion, from 60.7 to 9.4% for blighted ovum and 70.9 to 11.2% for missed abortion between 1998 and 2016. LIMITATIONS, REASONS FOR CAUTION This study includes only women with registry-identified pregnancies, i.e. women who were treated in public hospitals. However, the number of women treated elsewhere is presumed to be small. Neither can this study estimate the number of women having spontaneous miscarriage with no hospital contact. WIDER IMPLICATIONS OF THE FINDINGS Both the annual incidence and incidence rate of miscarriage of all registry-identified pregnancies has decreased, and non-surgical management has become the standard of care. These findings are of value when planning allocation of healthcare resources and at individual level considering fertility and miscarriage questions. We speculate that improving ultrasound diagnostics explains the increasing proportion of missed abortion relative to other types of miscarriage. More investigation is needed to examine potential risk factors, complications and morbidity associated with miscarriages. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by the research funds of the Helsinki and Uusimaa hospital system, by a personal grant from Viipurin Tuberkuloosisäätiö to R.L. and by a personal grant from The Finnish Cultural Foundation to N.H. The authors have no conflicts of interest to declare.
Collapse
Affiliation(s)
- R Linnakaari
- Department of Obstetrics and Gynaecology, South Karelia Central Hospital, 53130 Lappeenranta, Finland.,Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | - N Helle
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | - M Mentula
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | - A Bloigu
- Department of Obstetrics and Gynaecology, Oulu University Hospital, 90220, Oulu, Finland.,PEDEGO Research Unit, University of Oulu, Oulu, Finland
| | - M Gissler
- National Institute for Health and Welfare (THL), 00300 Helsinki, Finland.,Department of Neurobiology, Care Sciences and Society, Karolinska Institute, SE-171 77 Stockholm, Sweden
| | - O Heikinheimo
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | - M Niinimäki
- Department of Obstetrics and Gynaecology, Oulu University Hospital, 90220, Oulu, Finland.,PEDEGO Research Unit, University of Oulu, Oulu, Finland.,Medical Research Center Oulu (MRC Oulu), University of Oulu, Oulu, Finland
| |
Collapse
|
42
|
de Codt M, Balza C, Jadoul P, Forget P, Squifflet JL, Bernard P, Luyckx M. Hysteroscopic Resection for Missed Abortion: Feasibility, Operative Technique and Potential Benefit Compared to Curettage. Front Surg 2020; 7:64. [PMID: 33102514 PMCID: PMC7505996 DOI: 10.3389/fsurg.2020.00064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/03/2020] [Indexed: 11/23/2022] Open
Abstract
Objective: To evaluate the feasibility of hysteroscopic resection (HsR) for primary surgical management of missed abortion. Reproductive outcomes and potential benefit of this technique will be compared to traditional dilatation and curettage (D&C). Design: Retrospective cohort study in two Departments (Gynecology and Obstetrics) of a tertiary medical care center (Canadian Task Force classification II-2). Patients: Women with first trimester missed abortion. Intervention: Two techniques were used for the management of missed abortion: ultrasound-guided dilatation and curettage (D&C) and hysteroscopic resection (HsR). Results: We evaluated 358 patients who underwent primary surgical removal of missed abortion. Hundred seventy three patients have been treated by D&C and 185 underwent HsR. In the HsR group, 110 patients (59.5%) have obtained their pregnancy with in vitro fertilization (IVF) vs. 7 patients (4.0%) in the D&C group which make the HsR population hypofertile in comparison to the D&C population. The intra- and post-operative complication rates are low and comparable. Intrauterine anomalies were diagnosed during the HsR in 10 patients (5.4%) and could be investigated after the intervention as a possible cause of miscarriage. Because of the difference in term of fertility, the reproductive outcomes have been analyzed by multivariate analysis. The hazard ratio of pregnancy at 6 months, adjusted to the factor IVF for D&C compared to HsR is 0.69 [0.49–0.96] (p = 0.026). That could represent a significant benefit in the particular population followed in IVF, but regarding the retrospective analysis, and the very different population in the two groups, it doesn't allow us to draw any evidence based conclusion. Conclusion: Hysteroscopic resection is a feasible and safe procedure for the management of missed abortion that could increase the diagnosis of uterine abnormalities. With all the limitation of the design of our study, our data seems to show a trend to a potential benefit in term of reproductive outcomes for hypofertile patient undergoing IVF treatment.
Collapse
Affiliation(s)
- Matthieu de Codt
- Department of Gynecology and Andrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Claire Balza
- Department of Gynecology and Andrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Pascale Jadoul
- Department of Gynecology and Andrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Patrice Forget
- Clinical Chair in Anaesthesia, University of Aberdeen, Honorary Consultant, NHS Grampian, Aberdeen, United Kingdom
| | - Jean-Luc Squifflet
- Department of Gynecology and Andrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Pierre Bernard
- Department of Obstetrics, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Mathieu Luyckx
- Department of Gynecology and Andrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
43
|
Tzur Y, Samueloff O, Raz Y, Bar-On S, Laskov I, Tzur T. Conception rates after medical versus surgical evacuation of early miscarriage. Fertil Steril 2020; 115:118-124. [PMID: 32811672 DOI: 10.1016/j.fertnstert.2020.07.016] [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: 03/23/2020] [Revised: 07/02/2020] [Accepted: 07/10/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare short-term fertility rates after medical and surgical management of early miscarriage. DESIGN Observational cohort study. SETTING Academic tertiary-care medical center. PATIENT(S) A total of 203 patients were enrolled between June 2017 and May 2018, comprising 106 surgical evacuations and 97 medical evacuations. INTERVENTION(S) Either surgical or medical evacuation of the uterine cavity. MAIN OUTCOME MEASURE(S) Conception rates 6 months after miscarriage. RESULT(S) Conception rates 6 months after miscarriage among women who had attempted to become pregnant were similar between the medically and surgically evacuated groups (68.0% vs. 65.1%). There were no significant differences in background characteristics between the groups, apart from younger age and earlier gestational age among the medically treated group. There was no difference in the proportion of women using assisted reproductive technologies between the medically and surgically managed groups (15.5% vs. 12.6%, respectively). The median time-to-conception was 4 ± 2 months in both groups. Cumulative pregnancy rate 12 months after pregnancy loss, live birth rate, and repeat miscarriage rate also were similar between groups. CONCLUSION(S) Modality of uterine evacuation after early miscarriage does not affect short-term fertility outcomes.
Collapse
Affiliation(s)
- Yossi Tzur
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
| | - Ofri Samueloff
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Raz
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Shikma Bar-On
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ido Laskov
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Tamar Tzur
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| |
Collapse
|
44
|
Cox R, Khalid S, Brierly G, Forsyth A, McNamara R, Heppell V, Granne I. Implementing a community model of early pregnancy care. BMC Health Serv Res 2020; 20:664. [PMID: 32680503 PMCID: PMC7367246 DOI: 10.1186/s12913-020-05524-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 07/08/2020] [Indexed: 11/25/2022] Open
Abstract
Background In the UK Early Pregnancy Assessment Units (EPAUs) are usually situated alongside hospital maternity and gynaecology services. In June 2018, the Oxford EPAU relocated from the John Radcliffe Hospital to a community clinic. This is to our knowledge, the UK’s first community-based EPAU. This change was inspired by our patient feedback describing the co-location of the EPAU with maternity services as distressing. Methods Following the introduction of the community EPAU we developed a database to capture information on the patients seen in the clinic. This is a retrospective observational study of a single cohort of patients attending the clinic over an 8 month period. Data was collected from 1st July 2018 to 28th February 2019. This data included clinical, safety and patient experience outcomes. Results Two thousand nine hundred and twenty patient episodes were recorded, 1,932 were new patients. Mean waiting time to be seen in clinic was 1.3 days. When miscarriage was confirmed 48.6% chose conservative management, 19.9% chose medical management, and 31.5% chose surgical management. The mean rate of ambulance transfers to hospital was 3.1 per month. Of all patients seen in EPAU 32 had unplanned admissions, which accounted for 2.7% of all patients seen in EPAU. Patient feedback questionnaires have been consistently positive. Conclusion The development of a community EPAU has improved services to allow care closer to home in an environment separate from maternity care. Our data shows that a community EPAU can deliver timely, good quality patient care, is safe, and a service valued by patients. Further research is indicated to evaluate the cost-effectiveness of community EPAUs and the long term safety and effectiveness of care.
Collapse
Affiliation(s)
- Rebecca Cox
- Nuffield Department of Primary Care Health Science, Oxford, UK.
| | - Somia Khalid
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gemma Brierly
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Annie Forsyth
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ruth McNamara
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Ingrid Granne
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
45
|
Predictors of complete miscarriage after expectant management or misoprostol treatment of non-viable early pregnancy in women with vaginal bleeding. Arch Gynecol Obstet 2020; 302:1279-1296. [PMID: 32638095 PMCID: PMC7524815 DOI: 10.1007/s00404-020-05672-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/25/2020] [Indexed: 01/04/2023]
Abstract
Purpose To identify predictors of complete miscarriage after expectant management or misoprostol treatment of non-viable early pregnancy in women with vaginal bleeding. Methods This was a planned secondary analysis of data from a published randomized controlled trial comparing expectant management with vaginal single dose of 800 µg misoprostol treatment of women with embryonic or anembryonic miscarriage. Predefined variables—serum-progesterone, serum-β-human chorionic gonadotropin, parity, previous vaginal deliveries, gestational age, clinical symptoms (bleeding and pain), mean diameter and shape of the gestational sac, crown-rump-length, type of miscarriage, and presence of blood flow in the intervillous space—were tested as predictors of treatment success (no gestational sac in the uterine cavity and maximum anterior–posterior intracavitary diameter was ≤ 15 mm as measured with transvaginal ultrasound on a sagittal view) in univariable and multivariable logistic regression. Results Variables from 174 women (83 expectant management versus 91 misoprostol) were analyzed for prediction of complete miscarriage at ≤ 17 days. In patients managed expectantly, the rate of complete miscarriage was 62.7% (32/51) in embryonic miscarriages versus 37.5% (12/32) in anembryonic miscarriages (P = 0.02). In multivariable logistic regression, the likelihood of success increased with increasing gestational age, increasing crown-rump-length and decreasing gestational sac diameter. Misoprostol treatment was successful in 80.0% (73/91). No variable predicted success of misoprostol treatment. Conclusions Complete miscarriage after expectant management is significantly more likely in embryonic miscarriage than in anembryonic miscarriage. Gestational age, crown-rump-length, and gestational sac diameter are independent predictors of success of expectant management. Predictors of treatment success may help counselling women with early miscarriage.
Collapse
|
46
|
H Al Wattar B, Murugesu N, Tobias A, Zamora J, Khan KS. Management of first-trimester miscarriage: a systematic review and network meta-analysis. Hum Reprod Update 2020; 25:362-374. [PMID: 30753490 DOI: 10.1093/humupd/dmz002] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/13/2018] [Accepted: 01/09/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND First-trimester miscarriage affects up to a quarter of women worldwide. With many competing treatment options available, there is a need for a comprehensive evidence synthesis. OBJECTIVES AND RATIONALE We conducted a systematic review and network meta-analysis to assess the effectiveness and safety of treatment options for first-trimester miscarriage: expectant management (EXP), sharp dilation and curettage (D+C), electric vacuum aspiration (EVAC), manual vacuum aspiration (MVA), misoprostol alone (MISO), mifepristone+misoprostol (MIFE+MISO) and misoprostol plus electric vacuum aspiration (MISO+EVAC). SEARCH METHODS We searched MEDLINE, Embase, CINAHL, AMED and Cochrane Library from inception till June 2018. We included randomized trials of women with first-trimester miscarriage (<14 weeks gestation) and conducted a network meta-analysis generating both direct and mixed evidence on the effectiveness and side effects of available treatment options. The primary outcome was complete evacuation of products of conception. We assessed the risk of bias and the global network inconsistency. We compared the surface under the cumulative ranking curve (SUCRA) for each treatment. OUTCOMES A total of 46 trials (9250 women) were included. The quality of included studies was overall moderate with some studies demonstrating a high risk of bias. We detected unexplained inconsistency in evidence loops involving MIFE+MISO and adjusted for it. EXP had lower effectiveness compared to other treatment options. The effectiveness of medical treatments was similar compared to surgery. Mixed evidence of low confidence suggests increased effectiveness for MIFE+MISO compared to MISO alone (RR 1.49, 95% CI: 1.09-2.03). Side effects were similar among all options. Fewer women needed analgesia following EVAC compared to MISO (RR for MISO 0.43, 95% CI: 0.27-0.68) and in the EXP group compared to EVAC (RR 2.07, 95% CI: 1.25-3.41). MVA had higher ranking (low likelihood) for post-treatment infection and serious complications (SUCRA 87.6 and 79.2%, respectively) with the highest likelihood for post-treatment satisfaction (SUCRA 98%). WIDER IMPLICATIONS Medical treatments for first-trimester miscarriage have similar effectiveness and side effects compared to surgery. The addition of MIFE could increase the effectiveness of MISO and reduce side effects, although evidence is limited due to inconsistency. EXP has lower effectiveness compared to other treatment options.Systematic review registration: Prospero CRD42016048920.
Collapse
Affiliation(s)
- Bassel H Al Wattar
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK.,Warwick Medical School, University of Warwick, Coventry, UK
| | - Nilaani Murugesu
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK
| | - Aurelio Tobias
- Institute of Environmental Assessment and Water Research, Spanish Council for Scientific Research (CSIC), Barcelona, Spain
| | - Javier Zamora
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK.,Clinical Biostatistics Unit, Ramon y Cajal Hospital (IRYCIS) and CIBER Epidemiology and Public Health, Madrid, Spain
| | - Khalid S Khan
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK.,Multidisciplinary Evidence Synthesis Hub (mEsh), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| |
Collapse
|
47
|
Shorter JM, Schreiber CA, Sonalkar S. Recent Advances in the Medical Management of Early Pregnancy Loss. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020. [DOI: 10.1007/s13669-020-00282-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
48
|
Ehrnstén L, Altman D, Ljungblad A, Kopp Kallner H. Efficacy of mifepristone and misoprostol for medical treatment of missed miscarriage in clinical practice—A cohort study. Acta Obstet Gynecol Scand 2020; 99:488-493. [DOI: 10.1111/aogs.13780] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 11/25/2019] [Accepted: 11/27/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Lisa Ehrnstén
- Department of Clinical Sciences Danderyd Hospital Karolinska Institutet Stockholm Sweden
- Stockholm Urogyn Clinic Solna Sweden
| | - Daniel Altman
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
| | - Anton Ljungblad
- Gynecology and Surgery Sophiahemmet Hospital Stockholm Sweden
| | - Helena Kopp Kallner
- Department of Clinical Sciences Danderyd Hospital Karolinska Institutet Stockholm Sweden
- Stockholm Urogyn Clinic Solna Sweden
- Department of Obstetrics and Gynecology Danderyd Hospital Stockholm Sweden
| |
Collapse
|
49
|
Lazzarin S, Crippa I, Vaglio Tessitore I, Ornaghi S, Vergani P. Treatment of first trimester miscarriage: a prospective cohort study in a large tertiary care center in Northern Italy. J Matern Fetal Neonatal Med 2020; 35:110-115. [PMID: 31937151 DOI: 10.1080/14767058.2020.1712707] [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: 10/25/2022]
Abstract
Objective: To assess acceptability, efficacy, and short- and medium-term complications of vaginal misoprostol therapy for the treatment of first trimester miscarriage.Study design: A prospective cohort study including women admitted to the Unit of Obstetrics, MBBM Foundation, San Gerardo Hospital (Monza, Italy) for medical or surgical treatment of first trimester miscarriage between October 2014 and March 2018. As per Institutional protocol, patients in the medical therapy group received 800 µg of misoprostol vaginally. A second dose could be considered 3 days after the first administration if that was ineffective. Surgical treatment consisted of uterine vacuum aspiration. Success of misoprostol treatment was defined as the expulsion of the gestational sac with no need for subsequent surgery.Results: During the study period, 967 patients were diagnosed with first trimester miscarriage and were included in the study. Of these, 514 (53.2%) women were eligible for and consented to medical therapy. Surgical treatment was performed in the remaining 453 (46.8%) patients due to either medical contraindication to misoprostol or patient's choice. Acceptance of misoprostol as first therapeutic choice increased over time, becoming the preferred treatment after approximately 18 months of use in clinical practice. One dose of misoprostol was successful in 69.8% (n = 359) of patients, whereas 20 women required urgent surgery for bleeding (n = 19) or suspected infection (n = 1). Among the remaining 135 patients, 20 (14.8%) refused the second dose of misoprostol and opted for surgery. Expulsion of the gestational sac was obtained in 74 additional cases who completed the medical protocol, for an overall success rate of 87.7% (433/494). The majority of women receiving misoprostol did not experience any short-term complication (92.0%) or side effect (93.8%). Eight (1.6%) cases requiring delayed surgery (hysteroscopy or vacuum aspiration) for retained product of conception were identified at the postmedical treatment follow up, thus leading to an actual success rate of misoprostol of 86.0% (n = 425).Conclusions: This is the first study assessing the acceptability, efficacy, and complication rate of medical management of first trimester miscarriage in an Italian tertiary care center. Our results confirm that misoprostol alone is an effective as well as a safe therapeutic option for the treatment of first trimester miscarriage.
Collapse
Affiliation(s)
- Sara Lazzarin
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Obstetrics and Gynecology, MBBM Foundation, San Gerardo Hospital, Monza, Italy
| | - Isabella Crippa
- Department of Obstetrics and Gynecology, MBBM Foundation, San Gerardo Hospital, Monza, Italy
| | - Isadora Vaglio Tessitore
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Obstetrics and Gynecology, MBBM Foundation, San Gerardo Hospital, Monza, Italy
| | - Sara Ornaghi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Obstetrics and Gynecology, MBBM Foundation, San Gerardo Hospital, Monza, Italy
| | - Patrizia Vergani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Obstetrics and Gynecology, MBBM Foundation, San Gerardo Hospital, Monza, Italy
| |
Collapse
|
50
|
Kumari P, Preethi R, Abraham A, Rathore S, Benjamin S, Gowri M, Mathews JE. A prospective observational study of the follow-up of medical management of early pregnancy failure. J Family Med Prim Care 2019; 8:3998-4002. [PMID: 31879649 PMCID: PMC6924238 DOI: 10.4103/jfmpc.jfmpc_585_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/20/2019] [Accepted: 08/26/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Medical termination for missed miscarriage with the use of 800 μg of vaginal misoprostol as a single agent is recommended as a cheap option before 14 weeks of gestation in developing countries. A few studies have looked at its efficacy. METHODS A prospective, observational study was done on women having medical termination with up to three doses of 800 μg vaginal misoprostol at 12 hourly intervals. The number of women who needed check curettage was collected. Ultrasound findings if done were collated. Follow-up was done telephonically at the end of first week, fourth week and sixth week. RESULTS The cohort comprised 145 women. The primary outcome was the need for curettage after expulsion of products following medical management and this was 49/145 (37.8%) of women. The induction expulsion interval was 36 hours. The mean endometrial thickness of the 113/145 women who had an ultrasound was 11 mm. The mean endometrial thickness in women who had check curettage was 18 mm. Persistent spotting was the only significant symptom at follow-up. Resumption of cycle at the end of the sixth week was seen in 105/132 (80.15%) of women who were followed up. CONCLUSION Findings of our study showed the check curettage rate of 37.8%. However, the regime which we used, that is, 800 μg vaginal misoprostol at 12 hourly intervals had a long induction to expulsion interval of 36 hours. In all, 80% of women resumed normal cycles at the end of the sixth week. No significant complications were noted on follow-up.
Collapse
Affiliation(s)
- Pushplata Kumari
- Department of Obstetrics and Gynaecology Unit - 3, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - R.N. Preethi
- Department of Obstetrics and Gynaecology Unit - 3, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - Anuja Abraham
- Department of Obstetrics and Gynaecology Unit - 3, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - Swati Rathore
- Department of Obstetrics and Gynaecology Unit - 5, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - Santosh Benjamin
- Department of Obstetrics and Gynaecology Unit - 5, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - M Gowri
- Department of Biostatistics, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - Jiji Elizabeth Mathews
- Department of Obstetrics and Gynaecology Unit - 5, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| |
Collapse
|