Expectant management of first-trimester miscarriage

Emergency physician gender is associated with early pregnancy loss management: a multisite retrospective cohort study

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.

Economic evaluation of medical versus surgical strategies for first trimester therapeutic abortion: A systematic review

Pregnancy termination and abortion-related complications are well-established problems among women at reproductive age and resulted in significant morbidity and mortality. Accordingly, a systematic study was performed to investigate the economic evaluation studies results on costs and benefits of medical and surgical abortion methods. PubMed, Web of Science, Scopus, Embase, Cochrane library, ProQuest, and ScienceDirect databases as well as Google scholar were searched through June 2021. Original full-text English language studies that performed an economic evaluation analysis comparing medical and surgical methods of pregnancy termination were included in this review. A critical quality assessment was conducted utilizing the Consolidated Health Economic Evaluation Standards checklist. The latest web-based tool adjusted the estimates of costs expressed in one specific currency and price year into a specific target currency (the year 2020 $US). Overall, 538 records were retrieved, and 20 studies were deemed eligible for qualitative synthesis. Among the reviewed studies, three studies investigated cost-minimization analysis, three studies investigated cost-utility analysis, and 14 studies investigated cost-effectiveness analysis. The directly comparison of medical with surgical abortion was most frequently studied. Medical abortion saved US$ 6 to US$ 2373 per patient's costs. Medical abortion was cost-effective and cost-saving option in compare to the surgical abortion across all perspectives (the incremental cost effectiveness ratio ranged from US$ 419 to US$ 4,044). Quality scores of included studies ranged from 54% to 100%, and 70% of studies received a score of above 85% and had "excellent" quality. According to the results, based on various economic and clinical effectiveness decision-making criteria used in different studies of health economic evaluation, the majority of research provided evidence on the advantage of pharmaceutical methods compared to surgical methods, as well as the advantages of using combinations therapy compared to single therapeutic interventions.

MPA given orally during the first trimester for threatened miscarriage carries no specific risk for foetal abnormalities albeit the rate is higher than non-threatened pregnancies

This observational study examines the outcomes of pregnancies arising in women referred for infertility, where those who experienced threatened miscarriage were treated with medroxyprogesterone acetate (MPA) tablets. The 14-year study period covers comprehensive real-time data entries into the validated electronic database including details of the infertility management, pregnancy outcomes and any foetal anomalies among the infants, each being tracked and recorded. Of 4057 clinical pregnancies, 1343 received MPA for threatened miscarriage; 934 (69.6 %) of which continued to livebirths. These were compared with the remaining 2714 clinical pregnancies without threatened miscarriage or MPA and which resulted in 2075 (76.5 %) livebirths. There were 134 developmental abnormalities recorded among the 3009 livebirths of which 78 (2.6 %) were categorised appropriate for the Western Australian Developmental Abnormalities Register; WARDA. These comprised 55 in the MPA group, 36 of which were categorised as serious (being 2.7 % of clinical pregnancies and 3.9 % of births). In the group without MPA, there were 79 abnormalities, of which 42 were categorised as serious (being 1.7 % of clinical pregnancies and 2.2 % of births). Specifically, there were no cases of androgenisation noted among the female infants. The abnormality rates were low overall and well within the annual WARDA ranges. We cautiously suggest that oral MPA can be considered for studies throughout pregnancy including the early first trimester to assess a potential role in reducing miscarriage, as well as advanced pregnancies to evaluate a potential role in reducing stillbirths and preterm delivery.

Comparison Between Sublingual and Vaginal Administration of Misoprostol in Management of Missed Abortion

AIM

The aim of the present study is to compare between sublingual administration of misoprostol and vaginal administration in the management of missed abortion.

MATERIALS AND METHODS

The study was conducted in El-Shatby Maternity Hospital on 160 patients diagnosed as missed abortion by ultrasonographic examination. Cases were divided into two groups according to the methods of misoprostol administration, whether sublingual or vaginal. Patients of the two groups were observed for the times of uterine colic starting, cervical dilation, and conceptus expulsion, along with recording of any side effects.

RESULT

During the follow-up of our cases we found that sublingual route is more effective than vaginal route in the management of missed abortion. The difference between the two groups in percentage of conceptus expulsion was statistically significant. The most common side effects were nausea which was present in 55 % of cases in group I (sublingual) and in 40 % of cases in group II (vaginal) then severe pain in 25 % of cases in group I (sublingual) and in 20 % of cases in group II (vaginal) and hyperpyrexia in 15 % of cases in group I (sublingual) and in 5 % of cases in group II (vaginal).

CONCLUSION

Sublingual administration of misoprostol is more effective than its vaginal administration in missed abortion management. Side effect of misoprostol as nausea, vomiting, fever is more common with sublingual administration in comparison with its vaginal administration.

Population-based estimates of still birth, induced abortion and miscarriage in the Indian state of Bihar

Background

We report population-based data on still birth, induced abortion and miscarriage from the Indian state of Bihar to assess the magnitude of the problem and to inform corrective action.

Methods

A representative sample of women from all districts of Bihar with a pregnancy outcome in the last 12 months was obtained through multistage sampling in early 2012. Still birth rate was calculated as fetuses born with no sign of life at 7 or more months of gestation per 1,000 births. Induced abortion and miscarriage rates were defined as expulsion of dead fetuses at less than 7 months of gestation induced by any means or without inducement, respectively, per 1000 pregnancies that had an outcome. Multiple regression models were used to explore possible associations with stillbirths, induced abortions and miscarriages. Multi-level models were developed for the relatively less developed north zone and for the south zone of Bihar to examine contextual factors associated with still births, induced abortions and miscarriages.

Results

Still birth rate was estimated as 20 per 1,000 births (95% CI 15.6-24.5), and induced abortion and miscarriage rates as 8.6 (6.6-10.6), and 46 (40.8-51.3) per 1,000 pregnancies with outcome, respectively. The odds of induced abortion and miscarriage were significantly higher in the south zone (odds ratio 2.53 [95% CI 1.79-3.57] and 1.27 [95% CI 1.10-1.47], respectively). In the multi-level model for the north zone, the odds of induced abortion were higher for women with husband’s having mean years of education higher than the state mean (2.62; 95% CI 1.47-4.69). Among the nine divisions of Bihar, comprising of groups of districts, higher induced abortion rate was associated with lower neonatal mortality rate (R² = 0.68, p = 0.01).

Conclusions

These population-based data show a significant burden of still births in Bihar, suggesting that addressing these must become an important part of maternal and child health initiatives. The higher induced abortion in the more developed districts, and the inverse trend between induced abortion and neonatal mortality rates, have programmatic implications.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-014-0413-z) contains supplementary material, which is available to authorized users.

Miscarriage, preterm delivery, and stillbirth: large variations in rates within a cohort of Australian women

Objectives

We aimed to use simple clinical questions to group women and provide their specific rates of miscarriage, preterm delivery, and stillbirth for reference. Further, our purpose was to describe who has experienced particularly low or high rates of each event.

Methods

Data were collected as part of the Australian Longitudinal Study on Women's Health, a national prospective cohort. Reproductive histories were obtained from 5806 women aged 31–36 years in 2009, who had self-reported an outcome for one or more pregnancy. Age at first birth, number of live births, smoking status, fertility problems, use of in vitro fertilisation (IVF), education and physical activity were the variables that best separated women into groups for calculating the rates of miscarriage, preterm delivery, and stillbirth.

Results

Women reported 10,247 live births, 2544 miscarriages, 1113 preterm deliveries, and 113 stillbirths. Miscarriage was correlated with stillbirth (r = 0.09, P<0.001). The calculable rate of miscarriage ranged from 11.3 to 86.5 miscarriages per 100 live births. Women who had high rates of miscarriage typically had fewer live births, were more likely to smoke and were more likely to have tried unsuccessfully to conceive for ≥12 months. The highest proportion of live preterm delivery (32.2%) occurred in women who had one live birth, had tried unsuccessfully to conceive for ≥12 months, had used IVF, and had 12 years education or equivalent. Women aged 14–19.99 years at their first birth and reported low physical activity had 38.9 stillbirths per 1000 live births, compared to the lowest rate at 5.5 per 1000 live births.

Conclusion

Different groups of women experience vastly different rates of each adverse pregnancy event. We have used simple questions and established reference data that will stratify women into low- and high-rate groups, which may be useful in counselling those who have experienced miscarriage, preterm delivery, or stillbirth, plus women with fertility intent.

Cost-effectiveness of ultrasound use by on-call registrars in an acute gynaecology setting

Ultrasound, and in particular transvaginal sonography (TVS), plays an important role in the management of women with acute gynaecology conditions. This study compared the cost-effectiveness of two models of out-of-hours care for women in an acute gynaecology setting. In the ultrasound-based model, the on-call registrar with ultrasound experience managed such patients after performing pelvic ultrasound as a part of the initial assessment. On the other hand, in the traditional model of care the on-call registrar managed the patients without the use of ultrasound. The conclusion is that the use of ultrasound by the on-call registrars has significant cost implications through reduced hospital admissions. It leads to improved outcomes of such patients through timely diagnosis and treatment.