1
|
Kaneda Y. Japan's approval of oral abortion pills: A new era of opportunities and challenges in aligning with global standards. Womens Health (Lond) 2023; 19:17455057231216533. [PMID: 38017657 PMCID: PMC10685794 DOI: 10.1177/17455057231216533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Affiliation(s)
- Yudai Kaneda
- School of Medicine, Hokkaido University, Sapporo, Japan
| |
Collapse
|
2
|
Ducarme G, Martin S, Chesnoy V, Planche L, Berte MP, Netier-Herault E. Prospective observational study investigating the effectiveness, safety, women’s experiences and quality of life at 3 months regarding cervical ripening methods for induction of labor at term—The MATUCOL study protocol. PLoS One 2022; 17:e0262292. [PMID: 35061804 PMCID: PMC8782477 DOI: 10.1371/journal.pone.0262292] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/20/2021] [Indexed: 11/19/2022] Open
Abstract
Background The purposes of successful induction of labor (IOL) are to shorten the time for IOL to delivery, increase the vaginal delivery rate, and reduce the rate of maternal and neonatal morbidity. In cases of unfavorable cervix (Bishop score <6), cervical ripening is advised to improve vaginal delivery rate. It may be initiated by mechanical (double balloon catheter (DBC), synthetic osmotic dilator) or pharmacologic (prostaglandins) methods, and the problem is complex due to the multitude of cervical ripening methods. We are constantly looking for the optimal protocol of cervical ripening for each woman. The present study aims to elucidate whether cervical ripening method is associated with increase rate of vaginal delivery, good women’s experience and unaltered long-term quality of life after cervical ripening at term regarding maternal and obstetric characteristics. Methods and design The MATUCOL study is a monocentric, prospective, observational study of all consecutive women who required cervical ripening (Bishop score <6) using different methods (DBC, vaginal dinoprostone, oral misoprostol) with a live fetus at term (≥37 weeks) between January 2020 and August 2021. The outcomes will be mode of delivery, maternal and neonatal morbidity, discomfort/pain assessments during cervical ripening, women’s experience and satisfaction, and the impact of cervical ripening on the health-related quality of life at 3 months. If it reports a significant efficacy/safety/perinatal morbidity/women’s satisfaction/quality of life at 3 months post-delivery associated with a method of cervical ripening in a specific situation (gestational and/or fetal disease) using a multivariate analysis, its use should be reconsidered in clinical practice. Discussion This study will reveal that some cervical ripening methods will be more effectiveness, safe, with good women’s experiences and QOL at 3 months compared to others regarding maternal and obstetric characteristics. Trial registration This study is being performed at La Roche sur Yon Hospital following registration as GNEDS on January 8, 2020.
Collapse
Affiliation(s)
- Guillaume Ducarme
- Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, 85000, La Roche sur Yon, France
- * E-mail:
| | - Stephanie Martin
- Clinical Research Center, Centre Hospitalier Departemental, 85000, La Roche sur Yon, France
| | - Veronique Chesnoy
- Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, 85000, La Roche sur Yon, France
| | - Lucie Planche
- Clinical Research Center, Centre Hospitalier Departemental, 85000, La Roche sur Yon, France
| | - Marie-Pierre Berte
- Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, 85000, La Roche sur Yon, France
| | - Elodie Netier-Herault
- Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, 85000, La Roche sur Yon, France
| |
Collapse
|
3
|
|
4
|
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 Obstet Gynecol 2022; 59:100-106. [PMID: 34523740 DOI: 10.1002/uog.24769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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
|
5
|
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 Obstet Gynecol 2021; 58:757-765. [PMID: 33798287 DOI: 10.1002/uog.23641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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
|
6
|
Wu L, Xiong W, Zeng M, Yan A, Song L, Chen M, Wei T, Zu Q, Zhang J. Different dosing intervals of mifepristone-misoprostol for second-trimester termination of pregnancy: A meta-analysis and systematic review. Int J Gynaecol Obstet 2021; 154:195-203. [PMID: 33332580 DOI: 10.1002/ijgo.13541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/25/2020] [Accepted: 12/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To compare 1- and 2-day drug administration interval between mifepristone and misoprostol for second-trimester pregnancy termination and provide evidence-based recommendations. METHODS Search strategy: the search was performed in Pubmed, EMBASE, and Cochrane Library for the relevant published studies from their establishment to March 2020. SELECTION CRITERIA randomized controlled trials (RCTs) comparing 1- and 2-day time interval of mifepristone-misoprostol for termination of pregnancy during second-trimester pregnancy were considered. Data were processed using Revman 5.3 software. RESULTS Meta-analyses of three RCTs showed no significant difference was reported in the induction-to-abortion time and successful abortion rate between 1- and 2-day mifepristone and misoprostol intervals. Statistical difference was not identified in the induction-to-abortion time between the two drug administration intervals in nulliparous or parous women. CONCLUSIONS Both 1- and 2-day dosing intervals between mifepristone and misoprostol are suitable for clinical use for second-trimester medical termination of pregnancy.
Collapse
Affiliation(s)
- Limei Wu
- Department of Obstetrics and Gynecology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Wanchun Xiong
- Department of Obstetrics and Gynecology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Manman Zeng
- Department of Gynecology, Women and Children's Hospital of Guangdong, Guangzhou, Guangdong, China
| | - Aihua Yan
- Department of Obstetrics and Gynecology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Ling Song
- Department of Obstetrics and Gynecology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Meng Chen
- Department of Obstetrics and Gynecology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Tianqin Wei
- Department of Obstetrics and Gynecology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Qian Zu
- Department of Neurology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Jiayin Zhang
- Department of Obstetrics and Gynecology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| |
Collapse
|
7
|
Karavani G, Alexandroni H, Sheinin D, Dior UP, Simon A, Ben-Meir A, Reubinoff B. Endometrial thickness following early miscarriage in IVF patients - is there a preferred management approach? Reprod Biol Endocrinol 2021; 19:93. [PMID: 34158067 PMCID: PMC8218428 DOI: 10.1186/s12958-021-00780-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/10/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Endometrial thickness (ET) has previously been shown to positively correlate with implantation and clinical pregnancy rates. Pregnancies achieved using in-vitro fertilization (IVF) technique are prone to higher rates of early miscarriage. The aim of this study was to compare the effects of expectant management, medical treatment (Misoprostol) and dilation and curettage (D&C) for early miscarriage following IVF cycles on the subsequent cycle outcomes - endometrial thickness and reproductive outcomes. METHODS A retrospective cohort study of women who underwent embryo transfer, conceived and had first trimester miscarriage with at least one subsequent embryo transfer. ET measurements during fresh or frozen-thawed IVF cycles were assessed for each patient. Comparisons of ET differences between the miscarriage and the subsequent cycles, as well as reproductive outcomes, were performed according to the initial miscarriage management approach. RESULTS A total of 223 women were included in the study. Seventy-eight women were managed conservatively, 61 were treated with Misoprostol and 84 women underwent D&C. Management by D&C, compared to conservative management and Misoprostol treatment was associated with higher prevalence of a significant (> 2 mm) ET decrease (29.8%% vs. 14.1and 6.6%, respectively; p < .001) and was the only approach associated with a significant increase in the rates of ET under 7 and 8 mm in the following cycle (p = 0.006 and 0.035; respectively). Clinical pregnancy rates were significantly lower following D&C compared with conservative management and Misoprostol (16.7% vs. 38.5 and 27.9%, respectively; p = 0.008) as well as implantation rate (11.1% vs. 30.5.% and 17.7, respectively; p < 0.001). CONCLUSION Our data suggest that D&C management of a miscarriage is associated with decreased ET and higher rates of thin endometrium in the subsequent IVF cycle, compared with conservative management and Misoprostol treatment. In addition, implantation and pregnancy rates were significantly lower after D&C.
Collapse
Affiliation(s)
- Gilad Karavani
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Hadassah Ein-Kerem Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Heli Alexandroni
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Daniel Sheinin
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Uri P Dior
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Hadassah Ein-Kerem Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alex Simon
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Hadassah Ein-Kerem Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Assaf Ben-Meir
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Hadassah Ein-Kerem Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Benjamin Reubinoff
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Hadassah Ein-Kerem Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| |
Collapse
|
8
|
Abstract
BACKGROUND Misoprostol given orally is a commonly used labour induction method. Our Cochrane Review is restricted to studies with low-dose misoprostol (initially ≤ 50 µg), as higher doses pose unacceptably high risks of uterine hyperstimulation. OBJECTIVES To assess the efficacy and safety of low-dose oral misoprostol for labour induction in women with a viable fetus in the third trimester of pregnancy. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (14 February 2021) and reference lists of retrieved studies. SELECTION CRITERIA Randomised trials comparing low-dose oral misoprostol (initial dose ≤ 50 µg) versus placebo, vaginal dinoprostone, vaginal misoprostol, oxytocin, or mechanical methods; or comparing oral misoprostol protocols (one- to two-hourly versus four- to six-hourly; 20 µg to 25 µg versus 50 µg; or 20 µg hourly titrated versus 25 µg two-hourly static). DATA COLLECTION AND ANALYSIS Using Covidence, two review authors independently screened reports, extracted trial data, and performed quality assessments. Our primary outcomes were vaginal birth within 24 hours, caesarean section, and hyperstimulation with foetal heart changes. MAIN RESULTS We included 61 trials involving 20,026 women. GRADE assessments ranged from moderate- to very low-certainty evidence, with downgrading decisions based on imprecision, inconsistency, and study limitations. Oral misoprostol versus placebo/no treatment (four trials; 594 women) Oral misoprostol may make little to no difference in the rate of caesarean section (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.59 to 1.11; 4 trials; 594 women; moderate-certainty evidence), while its effect on uterine hyperstimulation with foetal heart rate changes is uncertain (RR 5.15, 95% CI 0.25 to 105.31; 3 trials; 495 women; very low-certainty evidence). Vaginal births within 24 hours was not reported. In all trials, oxytocin could be commenced after 12 to 24 hours and all women had pre-labour ruptured membranes. Oral misoprostol versus vaginal dinoprostone (13 trials; 9676 women) Oral misoprostol probably results in fewer caesarean sections (RR 0.84, 95% CI 0.78 to 0.90; 13 trials, 9676 women; moderate-certainty evidence). Subgroup analysis indicated that 10 µg to 25 µg (RR 0.80, 95% CI 0.74 to 0.87; 9 trials; 8652 women) may differ from 50 µg (RR 1.10, 95% CI 0.91 to 1.34; 4 trials; 1024 women) for caesarean section. Oral misoprostol may decrease vaginal births within 24 hours (RR 0.93, 95% CI 0.87 to 1.00; 10 trials; 8983 women; low-certainty evidence) and hyperstimulation with foetal heart rate changes (RR 0.49, 95% CI 0.40 to 0.59; 11 trials; 9084 women; low-certainty evidence). Oral misoprostol versus vaginal misoprostol (33 trials; 6110 women) Oral use may result in fewer vaginal births within 24 hours (average RR 0.81, 95% CI 0.68 to 0.95; 16 trials, 3451 women; low-certainty evidence), and less hyperstimulation with foetal heart rate changes (RR 0.69, 95% CI 0.53 to 0.92, 25 trials, 4857 women, low-certainty evidence), with subgroup analysis suggesting that 10 µg to 25 µg orally (RR 0.28, 95% CI 0.14 to 0.57; 6 trials, 957 women) may be superior to 50 µg orally (RR 0.82, 95% CI 0.61 to 1.11; 19 trials; 3900 women). Oral misoprostol probably does not increase caesarean sections overall (average RR 1.00, 95% CI 0.86 to 1.16; 32 trials; 5914 women; low-certainty evidence) but likely results in fewer caesareans for foetal distress (RR 0.74, 95% CI 0.55 to 0.99; 24 trials, 4775 women). Oral misoprostol versus intravenous oxytocin (6 trials; 737 women, 200 with ruptured membranes) Misoprostol may make little or no difference to vaginal births within 24 hours (RR 1.12, 95% CI 0.95 to 1.33; 3 trials; 466 women; low-certainty evidence), but probably results in fewer caesarean sections (RR 0.67, 95% CI 0.50 to 0.90; 6 trials; 737 women; moderate-certainty evidence). The effect on hyperstimulation with foetal heart rate changes is uncertain (RR 0.66, 95% CI 0.19 to 2.26; 3 trials, 331 women; very low-certainty evidence). Oral misoprostol versus mechanical methods (6 trials; 2993 women) Six trials compared oral misoprostol to transcervical Foley catheter. Misoprostol may increase vaginal birth within 24 hours (RR 1.32, 95% CI 0.98 to 1.79; 4 trials; 1044 women; low-certainty evidence), and probably reduces the risk of caesarean section (RR 0.84, 95% CI 0.75 to 0.95; 6 trials; 2993 women; moderate-certainty evidence). There may be little or no difference in hyperstimulation with foetal heart rate changes (RR 1.31, 95% CI 0.78 to 2.21; 4 trials; 2828 women; low-certainty evidence). Oral misoprostol one- to two-hourly versus four- to six-hourly (1 trial; 64 women) The evidence on hourly titration was very uncertain due to the low numbers reported. Oral misoprostol 20 µg hourly titrated versus 25 µg two-hourly static (2 trials; 296 women) The difference in regimen may have little or no effect on the rate of vaginal births in 24 hours (RR 0.97, 95% CI 0.80 to 1.16; low-certainty evidence). The evidence is of very low certainty for all other reported outcomes. AUTHORS' CONCLUSIONS Low-dose oral misoprostol is probably associated with fewer caesarean sections (and therefore more vaginal births) than vaginal dinoprostone, and lower rates of hyperstimulation with foetal heart rate changes. However, time to birth may be increased, as seen by a reduced number of vaginal births within 24 hours. Compared to transcervical Foley catheter, low-dose oral misoprostol is associated with fewer caesarean sections, but equivalent rates of hyperstimulation. Low-dose misoprostol given orally rather than vaginally is probably associated with similar rates of vaginal birth, although rates may be lower within the first 24 hours. However, there is likely less hyperstimulation with foetal heart changes, and fewer caesarean sections performed due to foetal distress. The best available evidence suggests that low-dose oral misoprostol probably has many benefits over other methods for labour induction. This review supports the use of low-dose oral misoprostol for induction of labour, and demonstrates the lower risks of hyperstimulation than when misoprostol is given vaginally. More trials are needed to establish the optimum oral misoprostol regimen, but these findings suggest that a starting dose of 25 µg may offer a good balance of efficacy and safety.
Collapse
Affiliation(s)
- Robbie S Kerr
- Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Nimisha Kumar
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Myfanwy J Williams
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Anna Cuthbert
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Nasreen Aflaifel
- Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrew D Weeks
- Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| |
Collapse
|
9
|
Hijos-Mallada G, Sostres C, Gomollón F. NSAIDs, gastrointestinal toxicity and inflammatory bowel disease. Gastroenterol Hepatol 2021; 45:215-222. [PMID: 34157367 DOI: 10.1016/j.gastrohep.2021.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/11/2021] [Indexed: 01/06/2023]
Abstract
Non-steroidal antiinflammatory drugs (NSAIDs) are currently one of the most widely used drugs. The use of NSAIDs is associated with gastrointestinal toxicity, affecting both upper gastrointestinal tract (peptic ulcer disease) and lower gastrointestinal tract (NSAID-induced enteropathy). NSAIDs use has been associated with an increased risk of clinical relapse in inflammatory bowel disease patients. In this article, we review the upper and lower gastrointestinal toxicity of NSAIDs, with a focus on the risks and specific data of these drugs in inflammatory bowel disease patients, giving recommendations for its appropriate use in the clinical practice. Although evidence is scarce, short-term use of NSAIDs appears to be safe, and the data available suggest that selective COX-2 inhibitors are the safer option. NSAIDs should be avoided as long-term treatment or with high doses, especially in patients with active inflammation.
Collapse
Affiliation(s)
- Gonzalo Hijos-Mallada
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España; Instituto de Investigación Sanitaria (ISS) Aragón, Zaragoza, España.
| | - Carlos Sostres
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España; Instituto de Investigación Sanitaria (ISS) Aragón, Zaragoza, España
| | - Fernando Gomollón
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España; Instituto de Investigación Sanitaria (ISS) Aragón, Zaragoza, España; Departamento de Medicina, Facultad de Medicina, Universidad de Zaragoza, Zaragoza, España
| |
Collapse
|
10
|
Łoziński T, Ludwin A, Filipowska J, Zgliczyńska M, Węgrzyn P, Kluz T, Ciebiera M. Oxytocin and Misoprostol With Diclofenac in the Preparation for Magnetic Resonance-Guided High-Intensity Ultrasound Treatment of Symptomatic Uterine Fibroids: A Prospective Cohort Study. Ultrasound Med Biol 2021; 47:1573-1585. [PMID: 33785226 DOI: 10.1016/j.ultrasmedbio.2021.02.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 06/12/2023]
Abstract
Uterine fibroids (UFs) are very common benign tumors of the female reproductive tract. According to recent reports, magnetic resonance-guided high-intensity ultrasound (MR-HIFU) appears to be a well-tolerated and efficient treatment option for UFs. However, MR-HIFU still presents several limitations. The treatment is rarely associated with achieving complete non-perfused volume (NPV). Not all patients are qualified for a final procedure, and selected women obtain very good results in such treatment. The primary objective of this experimental study was to assess the effect of transvaginal misoprostol and intravenous oxytocin preparation on UF volume change, sonication time and NPV after MR-HIFU procedure in women of reproductive age with symptomatic UFs. Secondary outcomes included the effect on the peri-procedural effectiveness of misoprostol and oxytocin. This study enrolled 247 women with symptomatic UFs; based on gynecologic examinations and magnetic resonance imaging (MRI) scans, 128 women qualified for MR-HIFU without pharmacologic treatment, 57 women qualified for the misoprostol/diclofenac group and 62 women qualified for the oxytocin group. Pharmacologic pre-treatment improved NPV compared with non-pharmacologic treatment (average NPV: controls 61.9% ± 25.8%; oxytocin 76.8% ± 20.7%; misoprostol/diclofenac 85.2% ± 15.1%; average sonication time: controls 120 min ± 56.4%; oxytocin 111 min ± 45.4%; misoprostol/diclofenac 80 min ± 47.7%). Statistical analysis did not reveal significant intergroup differences in UF volume changes after 6 mo (controls: n = 40, 37.4% ± 27.5%; oxytocin n = 25, 45.8% ± 31%; misoprostol/diclofenac n = 19, 33.4% ± 23.2%). The misoprostol/diclofenac group, which achieved the highest NPV immediately after the MR-HIFU procedure, was characterized by the lowest UF volume change percentages 6 mo later. The administration of vasoconstrictor drugs (oxytocin and misoprostol/diclofenac) to support MR-HIFU in UF treatment is a new issue that may improve the total effectiveness of this method. Randomized controlled trials are necessary to estimate the real effect of vasoconstrictors on MR-HIFU.
Collapse
Affiliation(s)
- Tomasz Łoziński
- Department of Obstetrics and Gynecology Pro-Familia Hospital, Rzeszów, Poland.
| | - Artur Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Kraków, Poland
| | - Justyna Filipowska
- Department of Obstetrics and Gynecology Pro-Familia Hospital, Rzeszów, Poland; Institute of Nursing and Health Sciences, Faculty of Medicine, University of Rzeszów, Rzeszów, Poland
| | - Magdalena Zgliczyńska
- Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Piotr Węgrzyn
- Department of Obstetrics and Perinatology, Faculty of Health Sciences, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Kluz
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Rzeszów, Poland
| | - Michał Ciebiera
- Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, Warsaw, Poland
| |
Collapse
|
11
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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
|
12
|
Abstract
IMPORTANCE People in the US have been seeking self-managed abortions outside the formal health care system using medications obtained through online telemedicine. However, little is known about this practice, including potential motivating factors. OBJECTIVE To examine individual reasons for accessing medication abortion through an online telemedicine service as well as associations between state- and county-level factors and the rate of requests. DESIGN, SETTING, AND PARTICIPANTS This population-based cross-sectional study examined all requests for self-managed medication abortion through an online consultation form available from Aid Access, a telemedicine service in the US, between March 20, 2018, and March 20, 2020. MAIN OUTCOMES AND MEASURES Individual-level reasons for accessing the telemedicine service were examined as well as the rate of requests per 100 000 women of reproductive age by state. Zip code data provided by individuals making requests were used to examine county-level factors hypothesized to be associated with increased demand for self-managed abortion: distance to a clinic (calculated using location data for US abortion clinics) and the population proportion identifying as a member of a racial/ethnic minority group, living below the federal poverty level, and having broadband internet access (calculated using census data). RESULTS During the 2-year study period, 57 506 individuals in 2458 counties in 50 states requested self-managed medication abortion; 52.1% were aged 20 to 29 years (mean [SD] age, 25.9 [6.7] years), 50.0% had children, and 99.9% were 10 weeks' pregnant or less. The most common reasons cited by individuals making requests were the inability to afford in-clinic care (73.5%), privacy (49.3%), and clinic distance (40.4%). States with the highest rate of requests were Louisiana (202.7 per 100 000 women) and Mississippi (199.9 per 100 000 women). At the county level, an increase of 1 SD (47 miles) in distance to the nearest clinic was significantly associated with a 41% increase in requests (incidence rate ratio, 1.41; 95% CI, 1.31-1.51; P < .001), and a 10% increase in the population living below the federal poverty level was significantly associated with a 20% increase in requests (incidence rate ratio, 1.20; 95% CI, 1.13-1.28; P < .001). CONCLUSIONS AND RELEVANCE In this cross-sectional study, clinic access barriers were the most commonly cited reason for requesting self-managed medication abortion using an online telemedicine service. At the county level, distance to an abortion clinic and living below the federal poverty level were associated with a higher rate of requests. State and federal legislation could address these access barriers.
Collapse
Affiliation(s)
- Abigail R. A. Aiken
- LBJ School of Public Affairs, The University of Texas at Austin
- Population Research Center, The University of Texas at Austin
| | | | | |
Collapse
|
13
|
Gomez HB, Hoffman MK, Caplan R, Ruhstaller K, Young MHH, Sciscione AC. Buccal vs vaginal misoprostol combined with Foley catheter for cervical ripening at term (the BEGIN trial): a randomized controlled trial. Am J Obstet Gynecol 2021; 224:524.e1-524.e8. [PMID: 33617796 DOI: 10.1016/j.ajog.2021.02.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Combining pharmacologic agents with mechanical ripening achieves the shortest time to labor; however, there is no clear evidence on route of drug administration. Buccal administration of misoprostol has shown greater patient acceptance but remains understudied. OBJECTIVE This study aimed to evaluate the difference in time to delivery between buccal and vaginal administration of misoprostol along with a Foley catheter for induction of labor. STUDY DESIGN The BEGIN trial (buccal vs vaginal misoprostol combined with Foley catheter for cervical ripening at term) was an institutional review board-approved, randomized clinical trial conducted from June 2019 to January 2020 comparing identical doses (25 μg) of buccal misoprostol and vaginal misoprostol along with a Foley catheter for induction of labor. Randomization was stratified by parity. Labor management was standardized among participants. Individuals undergoing induction of labor at ≥37 weeks with a singleton gestation and needing cervical ripening were included. Our primary outcome was time to delivery. Kruskal-Wallis, Pearson chi-squared, and Cox survival analyses with intent-to-treat principles were performed. A sample size of 216 was planned to detect a 4-hour reduction in delivery time. RESULTS A total of 215 women (108 in the buccal drug administration group and 107 in the vaginal drug administration group) were randomized. The vaginal route of drug administration achieved a faster median time to delivery than the buccal route of drug administration (19.7 hours in the vaginal route vs 24.1 hours in the buccal route; P<.001). A greater percentage of women in the vaginal drug administration group delivered within 24 hours compared with the buccal drug administration group (65% vs 49%; P=.02). There was no difference in the cesarean delivery rate between the 2 groups (17% in the vaginal drug administration group vs 21% in the buccal drug administration group; P=.6). Individuals who received vaginal misoprostol with Foley catheter delivered 2 times faster than women who received buccal misoprostol with Foley catheter after censoring for cesarean delivery and adjusting for parity (hazard ratio, 2.13; 95% confidence interval, 1.44-3.17). There was no significant difference in maternal and neonatal outcomes. CONCLUSION We found that vaginal administration of misoprostol was superior to buccal administration of misoprostol along with a Foley catheter for induction of labor. Furthermore, vaginal administration of misoprostol resulted in twice the chance of delivering earlier compared with buccal administration of misoprostol with no difference in cesarean delivery rates. Therefore, the vaginal route of administration of misoprostol should be preferred among individuals undergoing a combined pharmacologic and mechanical induction.
Collapse
Affiliation(s)
- Helen B Gomez
- Department of Obstetrics and Gynecology, Christiana Care, Newark, DE.
| | - Matthew K Hoffman
- Department of Obstetrics and Gynecology, Christiana Care, Newark, DE
| | | | - Kelly Ruhstaller
- Department of Obstetrics and Gynecology, Christiana Care, Newark, DE; Delaware Center for Maternal-Fetal Medicine of Christiana Care, Newark, DE
| | - Matthew H H Young
- Department of Obstetrics and Gynecology, Christiana Care, Newark, DE
| | - Anthony C Sciscione
- Department of Obstetrics and Gynecology, Christiana Care, Newark, DE; Delaware Center for Maternal-Fetal Medicine of Christiana Care, Newark, DE
| |
Collapse
|
14
|
Macnaughton H, Nothnagle M, Early J. Mifepristone and Misoprostol for Early Pregnancy Loss and Medication Abortion. Am Fam Physician 2021; 103:473-480. [PMID: 33856168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Medication regimens using mifepristone and misoprostol are safe and effective for outpatient treatment of early pregnancy loss for up to 84 days' gestation and for medication abortion up to 77 days' gestation. Gestational age is determined using ultrasonography or menstrual history. Ultrasonography is needed when gestational dating cannot be confirmed using clinical data alone or when there are risk factors for ectopic pregnancy. The most effective regimens for medication management of early pregnancy loss and medication abortion include 200 mg of oral mifepristone (a progesterone receptor antagonist) followed by 800 mcg of misoprostol (a prostaglandin E1 analogue) administered buccally or vaginally. Cramping and bleeding are expected effects of the medications, with bleeding lasting an average of nine to 16 days. The adverse effects of misoprostol (e.g., low-grade fever, gastrointestinal symptoms) can be managed with nonsteroidal anti-inflammatory drugs or antiemetics. Ongoing pregnancy, infection, hemorrhage, undiagnosed ectopic pregnancy, and the need for unplanned uterine aspiration are rare complications. Clinical history, combined with serial quantitative beta human chorionic gonadotropin levels, urine pregnancy testing, or ultrasonography, is used to establish complete passage of the pregnancy tissue.
Collapse
Affiliation(s)
- Honor Macnaughton
- Tufts University Family Medicine Residency at Cambridge Health Alliance, Malden, MA, USA
| | | | - Jessica Early
- Tufts University Family Medicine Residency at Cambridge Health Alliance, Malden, MA, USA
| |
Collapse
|
15
|
Harden J, Ancian J, Cameron S, Boydell N. Women's experiences of self-administration of misoprostol at home as part of early medical abortion: a qualitative evaluation. BMJ Sex Reprod Health 2021; 47:144-149. [PMID: 32718985 DOI: 10.1136/bmjsrh-2020-200661] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/04/2020] [Accepted: 06/21/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Between 2017 and 2019, legislation was introduced in the UK that approved the home as a place for self-administration of misoprostol for early medical abortion. While research has shown that early medical abortion at home is as safe as in a clinical setting, women's experiences in the UK in the light of this change have not yet been investigated. This qualitative research explored the experiences of women in one region of Scotland, UK who accessed early medical abortion with home self-administration of misoprostol. METHODS Qualitative interviews were conducted with 20 women who had recently undergone early medical abortion (≤69 days' gestation) with home self-administration of misoprostol. The data were analysed thematically using an approach informed by the Framework analytic approach. RESULTS Women appreciated the flexibility that home administration of misoprostol offered, including the opportunity to control the timing of the abortion. This was particularly important for women who sought not to disclose the abortion to others. Most women valued being in the comfort and privacy of the home when preparing for self-administration, although a small number highlighted some concerns about being at home. Most women reported that self-administration of misoprostol was straightforward; however, some expressed concerns around assessing whether their experiences were 'normal'. CONCLUSIONS Women welcomed the opportunity for home self-administration of misoprostol. To further improve women's early medical abortion experience we suggest that the legislation be amended so that women can self-administer in an appropriate non-clinical setting, not just their home.
Collapse
Affiliation(s)
- Jeni Harden
- Usher Institute, The University of Edinburgh, Edinburgh, UK
| | | | - Sharon Cameron
- Chalmers Sexual and Reproductive Health Centre, NHS Lothian, Edinburgh, UK
- University of Edinburgh Division of Health Sciences, Edinburgh, UK
| | - Nicola Boydell
- University of Edinburgh Centre for Population Health Sciences, Edinburgh, UK
| |
Collapse
|
16
|
Abstract
ABSTRACT Lumbar spinal stenosis is one of the most commonly diagnosed spinal disorders worldwide and remains a major cause for surgery in older adults. Lumbar spinal stenosis is clinically defined as a progressive degenerative disorder with low back pain and associated neurogenic intermittent claudication. Conservative and surgical management of lumbar spinal stenosis has been shown to be minimally effective on its symptoms. A treatment option that has not been investigated in the United States is the utilization of prostaglandin E1 analogs, which have been used primarily in Japan for the treatment of lumbar spinal stenosis since the 1980s. The vasodilatory and antiplatelet aggregation effects of prostaglandin E1 presumably improve symptoms of lumbar spinal stenosis by increasing blood flow to the spinal nerve roots. This brief report examines the potential vascular pathology of lumbar spinal stenosis, reviews evidence on the use of prostaglandin E1 analog limaprost in Japan for lumbar spinal stenosis, and briefly discusses misoprostol as a possible alternative in the United States. The studies summarized in this report suggest that prostaglandin E1 analogs may provide benefit as a conservative treatment option for patients with lumbar spinal stenosis. However, higher-quality studies conducted in the United States and comparison with other currently used conservative treatments are required before it can be recommended for routine clinical use.
Collapse
Affiliation(s)
- Austin Marcolina
- From the Department of Physical Medicine & Rehabilitation (PM&R), UT Southwestern Medical Center, Dallas, Texas (AM, TMA); UT Southwestern Medical Center, Dallas, Texas (KV); and VA North Texas Health Care System, Dallas VA Medical Center, Dallas, Texas (TMA)
| | | | | |
Collapse
|
17
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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
|
18
|
Mary M, Jafarey S, Dabash R, Kamal I, Rabbani A, Abbas D, Durocher J, Tan YL, Winikoff B. The Safety and Feasibility of a Family First Aid Approach for the Management of Postpartum Hemorrhage in Home Births: A Pre-post Intervention Study in Rural Pakistan. Matern Child Health J 2020; 25:118-126. [PMID: 33242210 PMCID: PMC7822773 DOI: 10.1007/s10995-020-03047-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 12/03/2022]
Abstract
Objective To evaluate the safety and feasibility of a Family First Aid approach whereby women and their families are provided misoprostol in advance to manage postpartum hemorrhage (PPH) in home births. Methods A 12-month prospective, pre-post intervention study was conducted from February 2017 to February 2018. Women in their second and third trimesters were enrolled at home visits. Participants and their families received educational materials and were counseled on how to diagnose excessive bleeding and the importance of seeking care at a facility if PPH occurs. In the intervention phase, participants were also given misoprostol and counselled on how to administer the four 200 mcg tablets for first aid in case of PPH. Participants were followed-up postpartum to collect data on use of misoprostol for Family First Aid at home deliveries (primary outcome) and record maternal and perinatal outcomes. Results Of the 4008 participants enrolled, 97% were successfully followed-up postpartum. Half of the participants in each phase delivered at home. Among home deliveries, the odds of reporting PPH almost doubled among in the intervention phase (OR 1.98; CI 1.43, 2.76). Among those reporting PPH, women in the intervention phase were significantly more likely to have received PPH treatment (OR 10.49; CI 3.37, 32.71) and 90% administered the dose correctly. No maternal deaths, invasive procedures or surgery were reported in either phase after home deliveries. Conclusions The Family First Aid approach is a safe and feasible model of care that provides timely PPH treatment to women delivering at home in rural communities.
Collapse
Affiliation(s)
- Meighan Mary
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA.
| | - Sadiqua Jafarey
- National Committee for Maternal and Neonatal Health, Karachi, Pakistan
| | - Rasha Dabash
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Imtiaz Kamal
- National Committee for Maternal and Neonatal Health, Karachi, Pakistan
| | - Arjumand Rabbani
- National Committee for Maternal and Neonatal Health, Karachi, Pakistan
| | - Dina Abbas
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Jill Durocher
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Yi-Ling Tan
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Beverly Winikoff
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| |
Collapse
|
19
|
Schmidt-Hansen M, Lord J, Hasler E, Cameron S. Simultaneous compared to interval administration of mifepristone and misoprostol for medical abortion up to 10 +0 weeks' gestation: a systematic review with meta-analyses. BMJ Sex Reprod Health 2020; 46:270-278. [PMID: 32079651 DOI: 10.1136/bmjsrh-2019-200448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 12/17/2019] [Accepted: 01/06/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Medical abortion with mifepristone and misoprostol usually involves an interval of 36-48 hours between administering these drugs; however, it is possible that the clinical efficacy at early gestations may be maintained when the drugs are taken simultaneously. The objective of this systematic review was to determine the safety and effectiveness of simultaneous compared with interval administration of mifepristone and misoprostol for abortion up to 10+0 weeks' gestation. METHODS We searched Embase Classic, Embase; Ovid MEDLINE(R) including Daily, and Epub Ahead-of-Print, In-Process & Other Non-Indexed Citations; and Cochrane Library on 11 December 2019. We included randomised controlled trials (RCTs), published in English from 1985, comparing simultaneous to interval administration of mifepristone and misoprostol for early abortion. Risk of bias was assessed using the Cochrane Collaboration checklist for RCTs. Meta-analysis of risk ratios (RRs) using the Mantel-Haenszel method were performed. The quality of the evidence was assessed using GRADE. RESULTS Meta-analyses of three RCTs (n=1280) showed no differences in 'ongoing pregnancy' (RR 1.78, 95% CI 0.38 to 8.36), 'haemorrhage requiring transfusion or ≥500 mL blood loss' (RR 0.11, 95% CI 0.01 to 2.03) and 'incomplete abortion with the need for surgical intervention' (RR 1.30, 95% CI 0.76 to 2.25) between the interventions. Individual study results showed no difference in patient satisfaction, or 'need for repeat misoprostol', although 'time to onset of bleeding or cramping' was longer after simultaneous than interval administration. The quality of evidence was very low to moderate. CONCLUSION The published data support the use of simultaneous mifepristone and misoprostol for medical abortion up to 9+0 weeks in women who prefer this method of administration.
Collapse
Affiliation(s)
- Mia Schmidt-Hansen
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Jonathan Lord
- Department of Gynaecology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Elise Hasler
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Sharon Cameron
- Sexual and Reproductive Health Services, NHS Lothian, Edinburgh, UK
| |
Collapse
|
20
|
Moore AM, Blades N, Ortiz J, Whitehead H, Villarreal C. What does informal access to misoprostol in Colombia look like? A mystery client methodology in Bogotá and the Coffee Axis. BMJ Sex Reprod Health 2020; 46:294-300. [PMID: 32624479 PMCID: PMC7569367 DOI: 10.1136/bmjsrh-2019-200572] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/18/2020] [Accepted: 02/26/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION In 2006, abortion was decriminalised in Colombia under certain circumstances. Yet, women avail themselves of ways to terminate pregnancy outside of the formal health system. This study explored how drug sellers engage with women who attempt to purchase misoprostol from them. METHODS A mapping exercise was undertaken to list small-chain and independent drug stores in two regions in Colombia. A sample (n=558) of drug stores was selected from this list and visited by mystery clients between November and December 2017. Mystery clients sought to obtain a medication to bring back a delayed period, and described the experience, the information obtained and the medications proffered in exit interviews. RESULTS Misoprostol was offered for purchase in 15% of the visits; in half of visits, only information about misoprostol was shared, while no information about misoprostol was provided on the remaining visits. Over half of sellers who refused to sell any medication provided referrals, most commonly to an abortion provider. Among visits which included discussion of misoprostol, two out of five sellers provided dosage instructions with most recommending the minimum adequate dosage. Mystery clients received little information on the physical effects to expect with the use of misoprostol and possible complications. CONCLUSIONS As misoprostol is being obtained from some drug sellers without a prescription, capacitating this cadre with at least a minimum of standardised information on dosage, routes of administration and expected effects and outcomes have the potential to improve reproductive health outcomes for women who choose to terminate pregnancies this way in Colombia.
Collapse
Affiliation(s)
- Ann M Moore
- Division of Research, Guttmacher Institute, New York, New York, USA
| | - Nakeisha Blades
- Division of Research, Guttmacher Institute, New York, New York, USA
| | | | - Hannah Whitehead
- Division of Research, Guttmacher Institute, New York, New York, USA
| | | |
Collapse
|
21
|
Fix L, Seymour JW, Sandhu MV, Melville C, Mazza D, Thompson TA. At-home telemedicine for medical abortion in Australia: a qualitative study of patient experiences and recommendations. BMJ Sex Reprod Health 2020; 46:172-176. [PMID: 32665231 DOI: 10.1136/bmjsrh-2020-200612] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION This study aimed to explore patient experiences obtaining a medical abortion using an at-home telemedicine service operated by Marie Stopes Australia. METHODS From July to October 2017, we conducted semistructured in-depth telephone interviews with a convenience sample of medical abortion patients from Marie Stopes Australia. We analysed interview data for themes relating to patient experiences prior to service initiation, during an at-home telemedicine medical abortion visit, and after completing the medical abortion. RESULTS We interviewed 24 patients who obtained care via the at-home telemedicine medical abortion service. Patients selected at-home telemedicine due to convenience, ability to remain at home and manage personal responsibilities, and desires for privacy. A few telemedicine patients reported that a lack of general practitioner knowledge of abortion services impeded their access to care. Most telemedicine patients felt at-home telemedicine was of equal or superior privacy to in-person care and nearly all felt comfortable during the telemedicine visit. Most were satisfied with the home delivery of the abortion medications and would recommend the service. CONCLUSION Patient reports suggest that an at-home telemedicine model for medical abortion is a convenient and acceptable mode of service delivery that may reduce patient travel and out-of-pocket costs. Additional provider education about this model may be necessary in order to improve continuity of patient care. Further study of the impacts of this model on patients is needed to inform patient care and determine whether such a model is appropriate for similar geographical and legal contexts.
Collapse
Affiliation(s)
- Laura Fix
- Ibis Reproductive Health, Cambridge, Massachusetts, United States
| | - Jane W Seymour
- Ibis Reproductive Health, Cambridge, Massachusetts, United States
| | | | | | - Danielle Mazza
- Department of General Practice, Monash University, Notting Hill, Victoria, Australia
| | | |
Collapse
|
22
|
Marchand GJ. Misoprostol sleepover Camp - A review of the vicious cycle created by holding doses of prostaglandins during induction. Eur J Obstet Gynecol Reprod Biol 2020; 252:87-88. [PMID: 32585542 DOI: 10.1016/j.ejogrb.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/06/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Induction of labor using prostaglandins is a common and effective strategy for induction of labor. In order to improve safety associated with the administration of prostaglandins, health systems have developed protocols dictating when subsequent doses of prostaglandins must be held. Ideally, these criteria would prevent the administration of prostaglandins when they were likely to cause hyperstimulation. Unfortunately, these protocols are often "triggered" by uterine irritability that is not likely to contribute to hyperstimulation. This vicious cycle of prolonged hospitalization without medication administration to induce labor secondary to prostaglandins being held by hospital protocols has been coined "Misoprostol Sleepover Camp." METHODS We performed searches of all relevant literature and Pubmed, Medline and Google scholar. All articles that published a protocol of misoprostol usage for induction of labor were considered and reviewed. RESULTS Most published, described protocols for oral or vaginal misoprostol induction include parameters for holding doses, while very few of these protocols seem to take into consideration fetal status or maternal appreciation of the contractions. Most of the protocols reviewed out of simply used contractions in ten minutes as the absolute criteria for holding doses. CONCLUSION Initial review of the data seems to indicate that the described phenomenon seems inherent to the protocols described and unavoidable by obstetricians adhering to the protocols.
Collapse
Affiliation(s)
- Greg J Marchand
- Marchand Institute for Minimally Invasive Surgery, 10238 E. Hampton, Ste 212, Mesa, AZ, 85209, United States.
| |
Collapse
|
23
|
Watanabe T, Fujiwara Y, Chan FKL. Current knowledge on non-steroidal anti-inflammatory drug-induced small-bowel damage: a comprehensive review. J Gastroenterol 2020; 55:481-495. [PMID: 31865463 PMCID: PMC7188723 DOI: 10.1007/s00535-019-01657-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 12/10/2019] [Indexed: 02/04/2023]
Abstract
Recent advances in small-bowel endoscopy such as capsule endoscopy have shown that non-steroidal anti-inflammatory drugs (NSAIDs) frequently damage the small intestine, with the prevalence rate of mucosal breaks of around 50% in chronic users. A significant proportion of patients with NSAIDs-induced enteropathy are asymptomatic, but some patients develop symptomatic or complicated ulcers that need therapeutic intervention. Both inhibition of prostaglandins due to the inhibition of cyclooxygenases and mitochondrial dysfunction secondary to the topical effect of NSAIDs play a crucial role in the early process of injury. As a result, the intestinal barrier function is impaired, which allows enterobacteria to invade the mucosa. Gram-negative bacteria and endogenous molecules coordinate to trigger inflammatory cascades via Toll-like receptor 4 to induce excessive expression of cytokines such as tumor necrosis factor-α and to activate NLRP3 inflammasome, a multiprotein complex that processes pro-interleukin-1β into its mature form. Finally, neutrophils accumulate in the mucosa, resulting in intestinal ulceration. Currently, misoprostol is the only drug that has a proven beneficial effect on bleeding small intestinal ulcers induced by NSAIDs or low-dose aspirin, but its protection is insufficient. Therefore, the efficacy of the combination of misoprostol with other drugs, especially those targeting the innate immune system, should be assessed in the next step.
Collapse
Affiliation(s)
- Toshio Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Francis K L Chan
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| |
Collapse
|
24
|
Löwy I, Dias Villela Corrêa MC. The "Abortion Pill" Misoprostol in Brazil: Women's Empowerment in a Conservative and Repressive Political Environment. Am J Public Health 2020; 110:677-684. [PMID: 32191521 PMCID: PMC7144453 DOI: 10.2105/ajph.2019.305562] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2019] [Indexed: 11/04/2022]
Abstract
In the aftermath of the introduction of severe restrictions on abortion in several US states, some activists have argued that providing widespread access to an abortive drug, misoprostol, will transform an induced abortion into a fully private act and therefore will empower women. In Brazil, where abortion is criminalized, the majority of women who wish to terminate an unwanted pregnancy already use the illegal, but easily accessible, misoprostol. We examine the history of misoprostol as an abortifacient in Brazil from the late 1980s until today and the professional debates on the teratogenicity of this drug. The effects of a given pharmaceutical compound, we argue, are always articulated, elicited, and informed within dense networks of sociocultural, economic, legal, and political settings. In a conservative and repressive environment, the use of misoprostol for self-induced abortions, even when supported by formal or informal solidarity networks, is far from being a satisfactory solution to the curbing of women's reproductive rights.
Collapse
Affiliation(s)
- Ilana Löwy
- Ilana Löwy is with the Centre de Recherche Médicine, Science, Santé et Societé- CERMES 3 (Institut national de la santé et de la recherche médicale, Centre national de la recherche scientifique, École des hautes études en sciences sociales, Paris V), Paris, France. Marilena Cordeiro Dias Villela Corrêa is with the Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marilena Cordeiro Dias Villela Corrêa
- Ilana Löwy is with the Centre de Recherche Médicine, Science, Santé et Societé- CERMES 3 (Institut national de la santé et de la recherche médicale, Centre national de la recherche scientifique, École des hautes études en sciences sociales, Paris V), Paris, France. Marilena Cordeiro Dias Villela Corrêa is with the Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| |
Collapse
|
25
|
Lueth GD, Kebede A, Medhanyie AA. Prevalence, outcomes and associated factors of labor induction among women delivered at public hospitals of MEKELLE town-(a hospital based cross sectional study). BMC Pregnancy Childbirth 2020; 20:203. [PMID: 32272905 PMCID: PMC7147044 DOI: 10.1186/s12884-020-02862-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 03/09/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Induction of labor refers to iatrogenic stimulation of uterine contractions before the onset of spontaneous labor as a therapeutic option when benefits of expeditious delivery outweigh the risks of continuing the pregnancy. This research was to study the prevalence, outcomes and associated factors of labor induction among women delivered at Ayder comprehensive specialized hospital and Mekelle general hospital in Mekelle town, Tigray, North Ethiopia. METHODS A hospital based cross sectional study was conducted on 346 laboring mothers who delivered after induction of labor, from January 1st, to July 31st, 2017. Using structured questionnaire and quota sampling techniques, all eligible participants were immediately enrolled upon admission until the desired sample size was achieved. SPSS windows version 23.0 was used for analysis and both descriptive and inferential statistics were conducted; statistical significance to declare relationship between the dependent and independent variables was set at p < 0.05. RESULTS Total of 3834 women delivered at the study area out of which 346 were induced making (9%) prevalence of induction. Out of this, 244 (70.5%) delivered vaginally, 19 (5.5%) were instrumental deliveries and 83 (24%) by Cesarean section, induction was successful in 263 (76%) while the failure rate was 25 (7.2%). All who failed induction (25) were delivered by cesarean section making a 3.3% contribution of failed induction into the overall rate of the institutions cesarean deliveries during the study period. Prolonged rupture of membranes was the commonest indication and Bishop's score after cervical ripening significantly predicted the success of induction [AOR = 8.150, 95% CI = (1.265, 52.526)]. CONCLUSION Our prevalence of labor induction is very low compared to the rate of other institutions in developed countries, rate of successful inductions (76%) is slightly higher than the rate of similar institutions in Ethiopia but comparable to the regional rates while failed induction is very low in comparison to both local and regional institutions. Bishop's score significantly predicted the success of induction.
Collapse
Affiliation(s)
- Garang Dakjur Lueth
- College of Medicine and Health Sciences, Juba University, Fellow of East, Central and Southern Africa college of Obstetrics and Gynecology, Juba, South Sudan
| | - Angesom Kebede
- Obstetrician and Gynecologist, Infertility and ART specialist and Gynecology Laparoscopic surgeon, Ayder comprehensive Specialized Hospital, College of Health Sciences, Mekelle University, Mekelle, Tigray Ethiopia
| | - Araya Abrha Medhanyie
- Global Health and Development, Head, MARCH Research Center and School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Tigray Ethiopia
| |
Collapse
|
26
|
Khan QQ, Liaqat N, Shafqat T, Bawar S. Efficacy Of Preoperative Misoprostol In Reducing Hemorrhage During Abdominal Myomectomy. J Ayub Med Coll Abbottabad 2020; 32:198-203. [PMID: 32583994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Uterine myomas are most common non-cancerous tumours in reproductive period. The fertility preserving surgery, i.e., myomectomy as compared to hysterectomy, is associated with massive blood loss due to dissection of huge fibroids making it technically difficult procedure. Misoprostol (a uterotonic) is an effective option amongst different interventions used to reduce intraoperative blood loss during myomectomy. This randomized control trial investigated effectiveness of single dose of rectal misoprostol given preoperatively in reducing intraoperative blood loss during abdominal myomectomy.. METHODS Fifty Patients undergoing abdominal myomectomy were selected for the study. Twenty-five patients were given 800 micrograms misoprostol per rectally half an hour before surgery while rest received placebo, i.e., control group. Number and weight of surgical packs were recorded both Pre and post operatively to assess blood loss. Preoperative and 24 hrs postoperative haemoglobin was also recorded. Data analysed by SPSS-20. RESULTS Mean of age, parity and myoma size were not statistically different between the two groups. However intraoperative blood loss (as measured by weighing and counting number of swabs used) and postoperative haemoglobin after 24 hours were significantly different between two groups with p-value <0.01. CONCLUSIONS Single dose of misoprostol given preoperatively via rectal route is effective in reducing intraoperative blood loss during abdominal myomectomy. Misoprostol must be used in different doses and routes in order to investigate its effectiveness in reducing intraoperative blood loss.
Collapse
Affiliation(s)
- Qudsia Qazi Khan
- Department of Gynaecology & Obstetrics, Lady Reading Hospital Peshawar, Pakistan
| | - Nazia Liaqat
- Department of Gynaecology & Obstetrics, Lady Reading Hospital Peshawar, Pakistan
| | - Tanveer Shafqat
- Department of Gynaecology & Obstetrics, Lady Reading Hospital Peshawar, Pakistan
| | - Shandana Bawar
- Department of Gynaecology & Obstetrics, Lady Reading Hospital Peshawar, Pakistan
| |
Collapse
|
27
|
Affiliation(s)
- Lisa H Harris
- From the Department of Obstetrics and Gynecology and the Department of Women's Studies, University of Michigan, Ann Arbor (L.H.H.); and the Department of Obstetrics, Gynecology, and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), and the Bixby Center for Global Reproductive Health, University of California, San Francisco, San Francisco (D.G.)
| | - Daniel Grossman
- From the Department of Obstetrics and Gynecology and the Department of Women's Studies, University of Michigan, Ann Arbor (L.H.H.); and the Department of Obstetrics, Gynecology, and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), and the Bixby Center for Global Reproductive Health, University of California, San Francisco, San Francisco (D.G.)
| |
Collapse
|
28
|
Abstract
BACKGROUND The advent of medical abortion has improved access to safe abortion procedures. Medical abortion procedures involve either administering mifepristone followed by misoprostol or a misoprostol-only regimen. The drugs are commonly administered in the presence of clinicians, which is known as provider-administered medical abortion. In self-administered medical abortion, drugs are administered by the woman herself without the supervision of a healthcare provider during at least one stage of the drug protocol. Self-administration of medical abortion has the potential to provide women with control over the abortion process. In settings where there is a shortage of healthcare providers, self-administration may reduce the burden on the health system. However, it remains unclear whether self-administration of medical abortion is effective and safe. It is important to understand whether women can safely and effectively terminate their own pregnancies when having access to accurate and adequate information, high-quality drugs, and facility-based care in case of complications. OBJECTIVES To compare the effectiveness, safety, and acceptability of self-administered versus provider-administered medical abortion in any setting. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials, MEDLINE in process and other non-indexed citations, Embase, CINAHL, POPLINE, LILACS, ClinicalTrials.gov, WHO ICTRP, and Google Scholar from inception to 10 July 2019. SELECTION CRITERIA We included randomized controlled trials (RCTs) and prospective cohort studies with a concurrent comparison group, using study designs that compared medical abortion by self-administered versus provider-administered methods. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted the data, and we performed a meta-analysis where appropriate using Review Manager 5. Our primary outcome was successful abortion (effectiveness), defined as complete uterine evacuation without the need for surgical intervention. Ongoing pregnancy (the presence of an intact gestational sac) was our secondary outcome measuring success or effectiveness. We assessed statistical heterogeneity with Chi2 tests and I2 statistics using a cut-off point of P < 0.10 to indicate statistical heterogeneity. Quality assessment of the data used the GRADE approach. We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified 18 studies (two RCTs and 16 non-randomized studies (NRSs)) comprising 11,043 women undergoing early medical abortion (≤ 9 weeks gestation) in 10 countries. Sixteen studies took place in low-to-middle income resource settings and two studies were in high-resource settings. One NRS study received analgesics from a pharmaceutical company. Five NRSs and one RCT did not report on funding; nine NRSs received all or partial funding from an anonymous donor. Five NRSs and one RCT received funding from government agencies, private foundations, or non-profit bodies. The intervention in the evidence is predominantly from women taking mifepristone in the presence of a healthcare provider, and subsequently taking misoprostol without healthcare provider supervision (e.g. at home). There is no evidence of a difference in rates of successful abortions between self-administered and provider-administered groups: for two RCTs, risk ratio (RR) 0.99, 95% confidence interval (CI) 0.97 to 1.01; 919 participants; moderate certainty of evidence. There is very low certainty of evidence from 16 NRSs: RR 0.99, 95% CI 0.97 to 1.01; 10,124 participants. For the outcome of ongoing pregnancy there may be little or no difference between the two groups: for one RCT: RR 1.69, 95% CI 0.41 to 7.02; 735 participants; low certainty of evidence; and very low certainty evidence for 11 NRSs: RR 1.28, 95% CI 0.65 to 2.49; 6691 participants. We are uncertain whether there are any differences in complications requiring surgical intervention, since we found no RCTs and evidence from three NRSs was of very low certainty: for three NRSs: RR 2.14, 95% CI 0.80 to 5.71; 2452 participants. AUTHORS' CONCLUSIONS This review shows that self-administering the second stage of early medical abortion procedures is as effective as provider-administered procedures for the outcome of abortion success. There may be no difference for the outcome of ongoing pregnancy, although the evidence for this is uncertain for this outcome. There is very low-certainty evidence for the risk of complications requiring surgical intervention. Data are limited by the scarcity of high-quality research study designs and the presence of risks of bias. This review provides insufficient evidence to determine the safety of self-administration when compared with administering medication in the presence of healthcare provider supervision. Future research should investigate the effectiveness and safety of self-administered medical abortion in the absence of healthcare provider supervision through the entirety of the medical abortion protocol (e.g. during administration of mifepristone or as part of a misoprostol-only regimen) and at later gestational ages (i.e. more than nine weeks). In the absence of any supervision from medical personnel, research is needed to understand how best to inform and support women who choose to self-administer, including when to seek clinical care.
Collapse
Affiliation(s)
- Katherine Gambir
- Population CouncilPoverty, Gender and Youth ProgramOne Dag Hammarskjöld PlazaNew YorkNew YorkUSA10017
| | - Caron Kim
- World Health OrganizationDepartment of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | | | - Bela Ganatra
- World Health OrganizationDepartment of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Thoai D Ngo
- Population CouncilPoverty, Gender and Youth ProgramOne Dag Hammarskjöld PlazaNew YorkNew YorkUSA10017
- Population CouncilThe GIRL CenterNew YorkNew YorkUSA
| | | |
Collapse
|
29
|
Abstract
More than 20% of pregnant women have their labor induced and at least half of them will require cervical ripening due to an unfavorable starting cervical exam. The use of cervical ripening methods has been shown to decrease the risk of cesarean delivery when compared to initiating an induction with oxytocin in women with an unfavorable cervix. However, among the different cervical ripening methods themselves, while there may be differences in time to delivery and differences in the safety profile of different cervical ripening methods, there is no clear evidence that any one cervical ripening method reduces the risk of cesarean compared to another method. The objectives of this manuscript are to discuss the pathophysiology of cervical ripening including the biochemical processes that lead to cervical ripening; to review the different methods of cervical ripening including both mechanical and pharmacologic methods, and to evaluate the evidence and efficacy for different doses, routes, and techniques employed when using various cervical ripening methods.
Collapse
|
30
|
Lopp CT, McCoy AM, Boothe D, Schaeffer DJ, Lascola K. Single-dose pharmacokinetics of orally and rectally administered misoprostol in adult horses. Am J Vet Res 2020; 80:1026-1033. [PMID: 31644339 DOI: 10.2460/ajvr.80.11.1026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To characterize the pharmacokinetics of a clinically relevant dose of misoprostol administered PO or per rectum (PR) to horses. ANIMALS 8 healthy adult horses. PROCEDURES In a randomized 3-way crossover design, horses received a single dose of misoprostol (5 μg/kg) administered PO (with horses fed and unfed) and PR, with a minimum 3-week washout period separating the experimental conditions. Blood samples were obtained before and at various points after drug administration (total, 24 hours), and plasma concentrations of misoprostol free acid were measured. RESULTS Mean maximum plasma concentration of misoprostol was significantly higher in the PR condition (mean ± SD, 967 ± 492 pg/mL) and unfed PO condition (655 ± 259 pg/mL) than in the fed PO condition (352 ± 109 pg/mL). Mean area under the concentration-versus-time curve was significantly lower in the PR condition (219 ± 131 pg•h/mL) than in the unfed (1,072 ± 360 pg•h/mL) and fed (518 ± 301 pg•h/mL) PO conditions. Mean time to maximum concentration was ≤ 30 minutes for all conditions. Mean disappearance half-life was shortest in the PR condition (21 ± 29 minutes), compared with values for the unfed (170 ± 129 minutes) and fed (119 ± 51 minutes) PO conditions. No adverse effects were noted. CONCLUSIONS AND CLINICAL RELEVANCE Misoprostol was rapidly absorbed and eliminated regardless of whether administered PO or PR to horses. Rectal administration may be a viable alternative for horses that cannot receive misoprostol PO, but this route may require more frequent administration to maintain therapeutic drug concentrations.
Collapse
|
31
|
Fuentes L, Baum S, Keefe-Oates B, White K, Hopkins K, Potter J, Grossman D. Texas women's decisions and experiences regarding self-managed abortion. BMC Womens Health 2020; 20:6. [PMID: 31906937 PMCID: PMC6945569 DOI: 10.1186/s12905-019-0877-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 12/30/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Prior research has shown that a small proportion of U.S. women attempt to self-manage their abortion. The objective of this study is to describe Texas women's motivations for and experiences with attempts to self-manage an abortion. The objective of this study is to describe Texas women's motivations for and experiences with attempts to self-manage an abortion. METHODS We report results from two data sources: two waves of surveys with women seeking abortion services at Texas facilities in 2012 and 2014 and qualitative interviews with women who reported attempting to self-manage their abortion while living in Texas at some time between 2009 and 2014. We report the prevalence of attempted self-managed abortion for the current pregnancy among survey respondents, and describe interview participants' decision-making and experiences with abortion self-management. RESULTS 6.9% (95% CI 5.2-9.0%) of abortion clients (n = 721) reported they had tried to end their current pregnancy on their own before coming to the clinic for an abortion. Interview participants (n = 18) described multiple reasons for their decision to attempt to self-manage abortion. No single reason was enough for any participant to consider self-managing their abortion; however, poverty intersected with and layered upon other obstacles to leave them feeling they had no other option. Ten interview participants reported having a complete abortion after taking medications, most of which was identified as misoprostol. None of the six women who used home remedies alone reported having a successful abortion; many described using these methods for several days or weeks which ultimately did not work, resulting in delays for some, greater distress, and higher costs. CONCLUSION These findings point to a need to ensure that women who may consider self-managed abortion have accurate information about effective methods, what to expect in the process, and where to go for questions and follow-up care. There is increasing evidence that given accurate information and access to clinical consultation, self-managed abortion is as safe as clinic-based abortion care and that many women find it acceptable, while others may prefer to use clinic-based abortion care.
Collapse
Affiliation(s)
- Liza Fuentes
- Ibis Reproductive Health, 1736 Franklin St, Suite 600, Oakland, CA 94612 USA
| | - Sarah Baum
- Ibis Reproductive Health, 1736 Franklin St, Suite 600, Oakland, CA 94612 USA
| | - Brianna Keefe-Oates
- Ibis Reproductive Health, 1736 Franklin St, Suite 600, Oakland, CA 94612 USA
| | - Kari White
- Steve Hicks School of Social Work, University of Texas at Austin, 1925 San Jacinto Blvd, Stop D3500, Austin, TX 78712 USA
| | - Kristine Hopkins
- Population Research Center and the Department of Sociology, University of Texas at Austin, 305 E. 23rd Street, Stop G1800, Austin, TX 78712 USA
| | - Joseph Potter
- Population Research Center and the Department of Sociology, University of Texas at Austin, 305 E. 23rd Street, Stop G1800, Austin, TX 78712 USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA 94612 USA
| |
Collapse
|
32
|
Abstract
Abortion is regulated in Mexico at the state level, and it is permitted under certain criteria in all 32 states, except in Mexico City where first-trimester abortion is decriminalized. Yet, more than a million abortions occur in Mexico each year. But most terminations occurring outside of Mexico City are clandestine and unsafe due to profound stigma against the procedure, lack of trained providers, lack of knowledge of where to find a safe abortion and poor knowledge of the laws. While this situation is moderated by the increasing use of misoprostol, a relatively safe method of abortion, the safety of the procedure cannot be assured in restrictive legal contexts. The purpose of this study is to explore women’s experiences with induced abortion in three federal entities with different legal contexts, and whether abortion seeking behavior and experiences differ across these settings. The study was carried out in three states, representing three different degrees of restrictiveness of abortion legislation. Queretaro with the “most restrictive” law, Tabasco with a “moderately restrictive” law, and Mexico state with the “least restrictive” law. We hypothesize that women living in more restrictive states will resort to the use of more unsafe and risky methods and providers for their abortion than their counterparts in less restrictive states. Women who recently obtained abortions were selected through snowball sampling and qualitative data were collected from them using semi-structured indepth interviews. Data collection took place between mid-2014 and mid-2015, with a final sample size N = 60 (20 from each state). Various themes involved in the process of abortion seeking behavior were developed from the IDIs and examined here: women’s knowledge of the abortion law in their state, reasons for having an abortion; the methods and providers used and women’s positive and negative experiences with abortion methods and providers used. Our results indicate that abortion safety is not associated with the restrictiveness of abortion legislation. Findings show that there is a new pattern of abortion service provision in Mexico, with misoprostol, a relatively safe and easy to use method, playing an important role. Nevertheless, while access to misoprostol tends to increase the safety of abortion, the improvement is moderated by women and their informants (relatives, friends and partners) not having accurate information on how to safely self-induce an abortion with misoprostol. On the other hand, some women manage to have safe abortion in illegal setting by going to Mexico City or with the support of NGOs knowlegeable on abortion. Findings demonstrate the importance of decriminalization of abortion, but meanwhile, harm reduction strategies, including promotion of accurate information about self-use of misoprostol where abortion is legally restricted will result in safe abortion.
Collapse
Affiliation(s)
- Fatima Juarez
- El Colegio de México, Tlalpan, Ciudad de México, Mexico
- Guttmacher Institute, New York, New York, United States of America
- * E-mail:
| | | | - Jose Luis Palma
- Investigación Salud y Demografia, S. C., Tlalpan, Ciudad de México, Mexico
| |
Collapse
|
33
|
Arteaga-Troncoso G, Chacon-Calderon AE, Martinez-Herrera FJ, Cruz-Nuñez SG, Lopez-Hurtado M, Belmont-Gomez A, Guzman-Grenfell AM, Farfan-Labonne BE, Neri-Méndez CJ, Zea-Prado F, Guerra-Infante FM. A randomized controlled trial comparing isosorbide dinitrate-oxytocin versus misoprostol-oxytocin at management of foetal intrauterine death. PLoS One 2019; 14:e0215718. [PMID: 31751343 PMCID: PMC6872136 DOI: 10.1371/journal.pone.0215718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 03/30/2019] [Indexed: 11/18/2022] Open
Abstract
Background The metabolic activity of endogenous nitric oxide (NO) and the medical use of nitrovasodilatory drugs like isosorbide dinitrate have been shown to be potential inducers inducers of cervical ripening prior to surgical evacuation of the uterus. Objective To assess the therapeutic efficacy and safety of combined isosorbide dinitrate-oxytocin in the management of intrauterine foetal death (IUFD). Methods Sixty women with IUFD after 20 weeks of gestation requesting uterine evacuation were randomly selected to receive isosorbide dinitrate gel solution (80 mg/1.5 mL; n = 30) or misoprostol gel solution (100 mcg/1.5 mL; n = 30) every 3 h with a maximum of four doses or until a Bishop score >7 was reached. Subsequently, patients received a high dose of intravenous oxytocin until complete uterus evacuation was achieved. Therapeutic efficacy was evaluated by mean the relative risk of the foetal expulsion based on comparison of event rates, and the proportion of women induced to labor at 7, 10 and 15 h after the administration of isosorbide dinitrate or misoprostol. Safety was assessed on the basis of woman´s vital signs and evaluation of adverse effects, including headache, abdominal pain, pelvic pain, lower back pain, nausea, dizziness and vomiting. Results The foetal expulsion rate using the isosorbide dinitrate-oxytocin combination was approximately 4.4 times, and at least 2.1 times, the foetal expulsion rate with the misoprostol-oxytocin regimen at any given point in time. The proportion of women achieved vaginal delivery at 15 hours was 100% for the isosorbide dinitrate-oxytocin group and 86.7% for the misoprostol-oxytocin group. The average delivery induction interval was significantly lower when isosorbide dinitrate-oxytocin was used (8.7 ± 3.1 h) than when misoprostol-oxytocin (11.9 ± 3.1 h) was used. A total of 20% of patients in the isosorbide dinitrate-oxytocin group recorded headache, and no cases of uterine tachysystole, haemorrhage or coagulopathy were recorded. Conclusion This study indicates that intravaginal isosorbide dinitrate followed by intravenous oxytocin was more effective than the conventional method used to induce labour in the medical management of foetal death in pregnancies after 20 weeks of gestation. Trial registration Clinicaltrials.gov NCT02488642.
Collapse
Affiliation(s)
- Gabriel Arteaga-Troncoso
- Department of Cellular Biology and Development, National Institute of Perinatology, Mexico City, Mexico
- * E-mail:
| | - Aide E. Chacon-Calderon
- Department of Obstetrics and Gynecology, Women’s Clinic and Neonatology, Secretariat for National Defense, Mexico City, Mexico
| | - Francisco J. Martinez-Herrera
- Department of Obstetrics and Gynecology, Women’s Clinic and Neonatology, Secretariat for National Defense, Mexico City, Mexico
| | - Sylvia G. Cruz-Nuñez
- Department of Obstetric and Gynecology, National Institute of Perinatology, Mexico City, Mexico
| | - Marcela Lopez-Hurtado
- Department of Infectology and Immunology, National Institute of Perinatology, Mexico City, Mexico
| | - Aurora Belmont-Gomez
- Department of Clinical Pharmacology, National Institute of Perinatology, Mexico City, Mexico
| | | | | | - Carlos J. Neri-Méndez
- Department of Obstetric and Gynecology, National Institute of Perinatology, Mexico City, Mexico
| | - Francisco Zea-Prado
- Department of Obstetric and Gynecology, National Institute of Perinatology, Mexico City, Mexico
| | | |
Collapse
|
34
|
Kapp N, Methazia J, Eckersberger E, Griffin R, Bessenaar T. Label comprehension of a combined mifepristone and misoprostol product for medical abortion: A pilot study in South Africa. Contraception 2019; 101:46-52. [PMID: 31655069 DOI: 10.1016/j.contraception.2019.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 09/26/2019] [Accepted: 09/29/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES As an important next step in developing an over-the-counter (OTC) misoprostol-mifepristone product, this study aims to assess the comprehension of a medical abortion label. STUDY DESIGN We conducted a pilot study utilizing convenience sampling to enroll women in rural and urban communities at four sites in two South African provinces. Trained, female recruiters prescreened and consented potential participants. Included women were aged 16-45 with some literacy (assessed by Rapid Estimate of Adult Literacy in Medicine). Exclusion criteria were having ever used or assisted someone with a medical abortion. Demographic data were collected after enrolment. We gave women time to read the prototype label, then asked a series of 35 questions to assess key concepts for correct use of the drug. For all questions but the indication, women could refer to the label while answering. We used descriptive, chi-square and regression analyses to assess comprehension of concepts. RESULTS 100 women aged 16-45 years participated. Most reported prior sexual intercourse (91%), pregnancy (75%), and prior contraceptive use (male condom, 45%). Messages clear to participants (>90%) regardless of literacy were: when to consult a doctor before use (history of anemia or ectopic pregnancy), to respect the mifepristone- misoprostol interval, when to seek medical attention (heavy, prolonged or no bleeding) and that fertility returns quickly after abortion. The average scores were moderate for comprehension of all medical abortion label comprehension concepts: 79% for questions about the indication of the product; 73% for assessment of appropriate gestational age; 76% for screening out ectopic pregnancy; 80% for identifying contraindications to the medicines; 69% for instructions on use; 76% for when and for what conditions to seek medical care; and 60% for how to follow-up after abortion with a pregnancy test. Questions with lowest comprehension regarded medication timing, where women with higher literacy were significantly more likely to understand the label than among lower literacy levels. CONCLUSIONS Our prototype over-the-counter label for a combined mifepristone-misoprostol product for medical abortion in early pregnancy was moderately understandable to participants. Comprehension scores were largely dependent on literacy levels. To demonstrate an understanding of at least 80% for key concepts, the prototype label for a combined medical abortion product requires revision.
Collapse
Affiliation(s)
- Nathalie Kapp
- Ipas, P.O Box 9990, Chapel Hill, NC 27701, United States.
| | | | | | - Risa Griffin
- Ipas, P.O Box 9990, Chapel Hill, NC 27701, United States
| | | |
Collapse
|
35
|
Yang Y, Wang Y, Du X, Duan J, Huang YM. Clinical application of low-dose misoprostol in the induced labor of 16 to 28 weeks pathological pregnancies (a STROBE-compliant article). Medicine (Baltimore) 2019; 98:e17396. [PMID: 31577749 PMCID: PMC6783242 DOI: 10.1097/md.0000000000017396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Oral mifepristone combined with rivanol lactate (rivanol) is commonly used in second-trimester pregnancy termination. However, rivanol is not suitable to premature rupture of membranes and oligohydramnios because amniocentesis is difficult. Mifepristone combined with misoprostol is suitable for the patients with oligohydramnios. In accordance with the misoprostol dosing recommendations by the International Federation of Gynecology and Obstetrics (FIGO), the incidences of uterine rupture and cervical laceration are relatively high in Chinese pregnant women. The aim of our study was to optimize misoprostol dosing regimen in terms of efficacy and safety in Chinese pregnant women.We modified the Bishop Score, and then gave patients low-dose misoprostol according to the modified Bishop score. Based on the amniotic fluid volume (AFV) indicated by type-B ultrasonic instrument, the cases with AFV ≤2 cm receiving low-dose misoprostol combined with mifepristone and the cases with amniocentesis failure followed by receiving low-dose misoprostol combined with mifepristone were enrolled into study group, and the cases with AFV >2 cm receiving rivanol combined with mifepristone were enrolled into control group. The start time of uterine contractions, time of fetal expulsion, birth process, hospital day, successful induced labor rate, complete induced labor rate, and incomplete induced labor rate were observed and compared between the 2 groups.There were significant differences in the start time of uterine contractions, time of fetal expulsion, birth process, and hospital day between the control group and the study group (all P < .05). The successful induced labor rate, complete induced labor rate, and incomplete induced labor rate were also significantly different between the 2 groups (all P < .05).In the induced labor of 16 to 28 weeks pathological pregnancy, low-dose misoprostol can markedly improve the successful induced labor rate and complete induced labor rate, shorten the birth process and hospital day, and decrease uterine curettage rate and uterine rupture risk. Low-dose misoprostol combined with mifepristone is suitable to the induced labor of 16 to 28 weeks pathological pregnancy in Chinese women.
Collapse
|
36
|
Maged AM, Fawzi T, Shalaby MA, Samy A, Rabee MA, Ali AS, Hussein EA, Hammad B, Deeb WS. A randomized controlled trial of the safety and efficacy of preoperative rectal misoprostol for prevention of intraoperative and postoperative blood loss at elective cesarean delivery. Int J Gynaecol Obstet 2019; 147:102-107. [PMID: 31304593 DOI: 10.1002/ijgo.12922] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/18/2019] [Accepted: 07/12/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of preoperative rectal misoprostol for the prevention of intraoperative and postoperative blood loss in women undergoing elective cesarean delivery. METHODS A single-blind randomized controlled trial of 200 full-term pregnant women scheduled for elective cesarean delivery. Computer-generated randomization allocated women to receive 400 μg rectal misoprostol at urinary catheter insertion plus 400 μg rectally after abdominal closure (preoperative group, n=100) or 800 μg of rectal misoprostol after abdominal closure (postoperative group, n=100). Primary outcome was intraoperative blood loss. RESULTS Intraoperative blood loss was significantly lower in the preoperative misoprostol group compared with the postoperative group (528.7 ± 114.8 mL vs 788.6 ± 165.8 mL; P<0.001). Blood loss during the first 24 hours after delivery was also lower in the preoperative group (199.3 ± 84.5 mL vs 302.9 ± 125.6 mL; P<0.001). Fewer women in the preoperative group needed additional uterotonics (7 vs 21; P<0.001). After delivery, the decrease in both hemoglobin and hematocrit levels was significantly less in the preoperative group (-6.8 vs -12.8% and -6.05 vs -17.8%, respectively; P<0.001). CONCLUSION Preoperative rectal administration of misoprostol significantly reduced intraoperative and postoperative blood loss during and after elective cesarean delivery. ClinicalTrial.gov ID: NCT03680339. Date of registration 9/2018.
Collapse
Affiliation(s)
- Ahmed M Maged
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Tarek Fawzi
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Mohamed A Shalaby
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Ahmed Samy
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Mohamed A Rabee
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | | | - Eman A Hussein
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Bahaa Hammad
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Wesam S Deeb
- Department of Obstetrics and Gynecology, Fayoum University, Fayoum, Egypt
| |
Collapse
|
37
|
Harman Crowell EH, Crowell AM, Theiler RN. Effect of delayed misoprostol dosing interval for induction of labor: a retrospective study. BMC Pregnancy Childbirth 2019; 19:309. [PMID: 31455215 PMCID: PMC6712846 DOI: 10.1186/s12884-019-2454-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 08/12/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Induction of labor occurs in greater than 22% of all pregnancies in the United States. Previous studies have shown that misoprostol is more effective for induction than oxytocin or dinoprostone alone. The World Health Organization recommends vaginal misoprostol 25mcg every 6 hours and the American Congress of Obstetricians and Gynecologists recommends 25mcg vaginal misoprostol every three to 6 hours. Although route of administration and dosage of misoprostol has been extensively studied, little is known about the optimal dosing interval of vaginal misoprostol. METHODS The primary objective of this study is to determine the effect of delayed vaginal misoprostol dosing, defined as any interval longer than 4.5 h, on time to vaginal delivery. Our hypothesis is that the routine dosing interval of 4 hours shortens times to vaginal delivery compared to delayed dosing, even when adjusted for the time of delay. Secondary objectives include the effect of delayed vaginal misoprostol dosing on cesarean section rate, operative vaginal delivery rate, maternal outcomes, and neonatal outcomes. We conducted a retrospective chart review of 323 inductions of labor at one academic institution. The primary outcome was the proportion of patients who achieved a vaginal delivery within 24 h. The group who received all doses of misoprostol within a 4.5 h dosing window (Routine Dosing Interval Group) was compared with the group who had any dosing deviation (Delayed Dosing Interval Group). RESULTS Of 133 included patients, 64 subjects received routine interval dosing and 69 subjects received delayed interval dosing. The vaginal delivery rates within 24 h were 56% (36/64) and 20% (14/69), respectively (P < 10- 4). Spontaneous vaginal delivery rates were 86% (55/64) vs. 75% (52/69), respectively (P = .13). Kaplan Meier curves demonstrated statistically significant difference in time to vaginal delivery between groups, with a Cox Proportional Hazard ratio for routine dosing interval of 1.73 (P < 10- 5) unadjusted and 1.34 (P = .01) when adjusted for dosing delay. CONCLUSIONS This retrospective study demonstrates a significant increase in delay-adjusted time to vaginal delivery when doses of vaginal misoprostol are delayed past 4.5 h.
Collapse
Affiliation(s)
| | | | - Regan N. Theiler
- Department of Obstetrics and Gynecology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
| |
Collapse
|
38
|
Zackular JP, Kirk L, Trindade BC, Skaar EP, Aronoff DM. Misoprostol protects mice against severe Clostridium difficile infection and promotes recovery of the gut microbiota after antibiotic perturbation. Anaerobe 2019; 58:89-94. [PMID: 31220605 PMCID: PMC6697607 DOI: 10.1016/j.anaerobe.2019.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/15/2019] [Indexed: 01/13/2023]
Abstract
Clostridium difficile infection (CDI) is one of the most common nosocomial infections worldwide and an urgent public health threat. Epidemiological and experimental studies have demonstrated an association between nonsteroidal anti-inflammatory drug (NSAID) exposure and enhanced susceptibility to, and severity of, CDI. NSAIDs target cyclooxygenase enzymes and inhibit the production of prostaglandins (PGs), but the therapeutic potential of exogenous introduction of PGs for the treatment of CDI has not been explored. In this study, we report that treatment with the FDA-approved stable PGE1 analogue, misoprostol, protects mice against C. difficile-associated mortality, intestinal pathology, and CDI-mediated intestinal permeability. Furthermore, we report that the effect of misoprostol on the gastrointestinal tract contributes to increased recovery of the gut microbiota following antibiotic perturbation. Together, these data implicate PGs as an important host-factor associated with recovery to C. difficile-associated disease and demonstrate the potential for misoprostol in the treatment of CDI. Further studies to explore the safety and efficacy of misoprostol treatment of CDI in humans is needed.
Collapse
Affiliation(s)
- Joseph P Zackular
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, United States; Division of Protective Immunity, Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States; Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Leslie Kirk
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Bruno C Trindade
- Department of Pathology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Eric P Skaar
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - David M Aronoff
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States.
| |
Collapse
|
39
|
Morfaw F, Fundoh M, Pisoh C, Ayaba B, Mbuagbaw L, Anderson LN, Thabane L. Misoprostol as an adjunct to oxytocin can reduce postpartum-haemorrhage: a propensity score-matched retrospective chart review in Bamenda-Cameroon, 2015-2016. BMC Pregnancy Childbirth 2019; 19:257. [PMID: 31331275 PMCID: PMC6647290 DOI: 10.1186/s12884-019-2407-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 07/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is some evidence that suggests misoprostol may supplement the action of oxytocin in preventing post-partum haemorrhage (PPH). The primary objective of this study was to determine the effect of the administration of 600 μg misoprostol in addition to oxytocin versus oxytocin alone, on the risk of PPH among pregnant women after delivery. The secondary objectives were to determine the effects of the above combination on maternal death and blood transfusion among pregnant women after delivery; and to determine the incidence of PPH, its case fatality, and the maternal mortality ratio in our hospital. METHODS Design and setting: Retrospective chart review of 1736 women delivering at the Regional Hospital Bamenda Cameroon, between 2015 and 2016. This was a pre versus post study following a policy change in the prevention of PPH. Exposure groups: One group received oxytocin-misoprostol (January-April 2016: period after policy change), and the second group received oxytocin-only (January-April 2015: period before policy change) after delivery. OUTCOMES The primary outcome was PPH, and the secondary outcomes were maternal death and blood transfusion. STATISTICAL ANALYSIS A 1:1 matching with replacement was done with the propensity score (PS). The groups were compared using PS matching with conditional logistic regression on the matched pairs as the main analysis. A sensitivity analysis was done using other PS adjustment methods and multiple regression. RESULTS Of the 1736 women included in this study, 1238 were matched and compared. Women who received oxytocin-misoprostol were less likely to have PPH as compared to those receiving oxytocin-only (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.08, 0.59, p = 0.003). This reduced odds of PPH was upheld in the different sensitivity analyses. There were no significant differences in the odds of maternal death and the use of blood transfusions between the two groups: OR 3.91, 95% CI [0.44, 35.08], p = 0.22, and OR 0.89, 95% CI [0.14-5.63], p = 0.91, respectively. Sensitivity analyses showed similar results. The incidence of PPH was 2.9% (before adding misoprostol the incidence was 4.4% and after adding misoprostol it was 1.5%), the case fatality rate of PPH was 1.96%, and the overall maternal mortality ratio in the hospital was 293 maternal deaths/100000 life births. CONCLUSION Our evidence suggests that using 600 μg misoprostol as an add-on to oxytocin in the prevention of post-partum haemorrhage significantly reduces the odds of PPH without affecting other maternal outcomes.
Collapse
Affiliation(s)
- Frederick Morfaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON Canada
- Department of Obstetrics and Gynaecology, Faculty of Medicines and Biomedical Sciences University of Yaounde 1, Yaoundé, Cameroon
- Department of Clinical Sciences, Faculty of Health Sciences, University of Bamenda, Bamenda, Cameroon
| | - Mercy Fundoh
- Department of Clinical Sciences, Faculty of Health Sciences, University of Bamenda, Bamenda, Cameroon
| | - Christopher Pisoh
- Department of Clinical Sciences, Faculty of Health Sciences, University of Bamenda, Bamenda, Cameroon
| | - Bi Ayaba
- Regional Hospital Bamenda, Bamenda, Cameroon
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON Canada
- Biostatistics Unit, St Joseph Healthcare—Hamilton, Hamilton, ON Canada
- Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Laura N. Anderson
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON Canada
- Biostatistics Unit, St Joseph Healthcare—Hamilton, Hamilton, ON Canada
| |
Collapse
|
40
|
Abstract
BACKGROUND In most pregnancies that miscarry, arrest of embryonic or fetal development occurs some time (often weeks) before the miscarriage occurs. Ultrasound examination can reveal abnormal findings during this phase by demonstrating anembryonic pregnancies or embryonic or fetal death. Treatment has traditionally been surgical but medical treatments may be effective, safe, and acceptable, as may be waiting for spontaneous miscarriage. This is an update of a review first published in 2006. OBJECTIVES To assess, from clinical trials, the effectiveness and safety of different medical treatments for the termination of non-viable pregnancies. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (24 October 2018) and reference lists of retrieved studies. SELECTION CRITERIA Randomised trials comparing medical treatment with another treatment (e.g. surgical evacuation), or placebo, or no treatment for early pregnancy failure. Quasi-randomised studies were excluded. Cluster-randomised trials were eligible for inclusion, as were studies reported in abstract form, if sufficient information was available to assess eligibility. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Forty-three studies (4966 women) were included. The main interventions examined were vaginal, sublingual, oral and buccal misoprostol, mifepristone and vaginal gemeprost. These were compared with surgical management, expectant management, placebo, or different types of medical interventions were compared with each other. The review includes a wide variety of different interventions which have been analysed across 23 different comparisons. Many of the comparisons consist of single studies. We limited the grading of the quality of evidence to two main comparisons: vaginal misoprostol versus placebo and vaginal misoprostol versus surgical evacuation of the uterus. Risk of bias varied widely among the included trials. The quality of the evidence varied between the different comparisons, but was mainly found to be very-low or low quality.Vaginal misoprostol versus placeboVaginal misoprostol may hasten miscarriage when compared with placebo: e.g. complete miscarriage (5 trials, 305 women, risk ratio (RR) 4.23, 95% confidence interval (CI) 3.01 to 5.94; low-quality evidence). No trial reported on pelvic infection rate for this comparison. Vaginal misoprostol made little difference to rates of nausea (2 trials, 88 women, RR 1.38, 95% CI 0.43 to 4.40; low-quality evidence), diarrhoea (2 trials, 88 women, RR 2.21, 95% CI 0.35 to 14.06; low-quality evidence) or to whether women were satisfied with the acceptability of the method (1 trial, 32 women, RR 1.17, 95% CI 0.83 to 1.64; low-quality evidence). It is uncertain whether vaginal misoprostol reduces blood loss (haemoglobin difference > 10 g/L) (1 trial, 50 women, RR 1.25, 95% CI 0.38 to 4.12; very-low quality) or pain (opiate use) (1 trial, 84 women, RR 5.00, 95% CI 0.25 to 101.11; very-low quality), because the quality of the evidence for these outcomes was found to be very low.Vaginal misoprostol versus surgical evacuation Vaginal misoprostol may be less effective in accomplishing a complete miscarriage compared to surgical management (6 trials, 943 women, average RR 0.40, 95% CI 0.32 to 0.50; Heterogeneity: Tau² = 0.03, I² = 46%; low-quality evidence) and may be associated with more nausea (1 trial, 154 women, RR 21.85, 95% CI 1.31 to 364.37; low-quality evidence) and diarrhoea (1 trial, 154 women, RR 40.85, 95% CI 2.52 to 662.57; low-quality evidence). There may be little or no difference between vaginal misoprostol and surgical evacuation for pelvic infection (1 trial, 618 women, RR 0.73, 95% CI 0.39 to 1.37; low-quality evidence), blood loss (post-treatment haematocrit (%) (1 trial, 50 women, mean difference (MD) 1.40%, 95% CI -3.51 to 0.71; low-quality evidence), pain relief (1 trial, 154 women, RR 1.42, 95% CI 0.82 to 2.46; low-quality evidence) or women's satisfaction/acceptability of method (1 trial, 45 women, RR 0.67, 95% CI 0.40 to 1.11; low-quality evidence).Other comparisonsBased on findings from a single trial, vaginal misoprostol was more effective at accomplishing complete miscarriage than expectant management (614 women, RR 1.25, 95% CI 1.09 to 1.45). There was little difference between vaginal misoprostol and sublingual misoprostol (5 trials, 513 women, average RR 0.84, 95% CI 0.61 to 1.16; Heterogeneity: Tau² = 0.10, I² = 871%; or between oral and vaginal misoprostol in terms of complete miscarriage at less than 13 weeks (4 trials, 418 women), average RR 0.68, 95% CI 0.45 to 1.03; Heterogeneity: Tau² = 0.13, I² = 90%). However, there was less abdominal pain with vaginal misoprostol in comparison to sublingual (3 trials, 392 women, RR 0.58, 95% CI 0.46 to 0.74). A single study (46 women) found mifepristone to be more effective than placebo: miscarriage complete by day five after treatment (46 women, RR 9.50, 95% CI 2.49 to 36.19). However the quality of this evidence is very low: there is a very serious risk of bias with signs of incomplete data and no proper intention-to-treat analysis in the included study; and serious imprecision with wide confidence intervals. Mifepristone did not appear to further hasten miscarriage when added to a misoprostol regimen (3 trials, 447 women, RR 1.18, 95% CI 0.95 to 1.47). AUTHORS' CONCLUSIONS Available evidence from randomised trials suggests that medical treatment with vaginal misoprostol may be an acceptable alternative to surgical evacuation or expectant management. In general, side effects of medical treatment were minor, consisting mainly of nausea and diarrhoea. There were no major differences in effectiveness between different routes of administration. Treatment satisfaction was addressed in only a few studies, in which the majority of women were satisfied with the received intervention. Since the quality of evidence is low or very low for several comparisons, mainly because they included only one or two (small) trials; further research is necessary to assess the effectiveness, safety and side effects, optimal route of administration and dose of different medical treatments for early fetal death.
Collapse
Affiliation(s)
- Marike Lemmers
- Academic Medical CenterDepartment of Obstetrics and GynaecologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Marianne AC Verschoor
- Academic Medical CenterDepartment of Obstetrics and GynaecologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Bobae Veronica Kim
- School of Medicine, The University of AdelaideRobinson Research InstituteAdelaideSAAustralia5006
| | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
| | - Juan C Vazquez
- Instituto Nacional de Endocrinologia (INEN)Departamento de Salud ReproductivaZapata y DVedadoHabanaCuba10 400
| | - Ben Willem J Mol
- Monash UniversityDepartment of Obstetrics and Gynaecology246 Clayton RoadClaytonVictoriaAustralia3168
| | | | | |
Collapse
|
41
|
Coutant T, Vergneau-Grosset C, Lair S. Effect of a Misoprostol/Phenytoin Gel on Experimentally Induced Wounds in Brook Trout-A Preliminary Study. J Aquat Anim Health 2019; 31:214-221. [PMID: 30980421 DOI: 10.1002/aah.10071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 04/07/2019] [Indexed: 06/09/2023]
Abstract
Topical treatment for wound management in fish is challenging due to their aquatic life. The objective of the present study was to assess the effect of a topical gel containing misoprostol and phenytoin on the healing of skin wounds in Brook Trout Salvelinus fontinalis. Four 16- × 8-mm, full-thickness wounds were created in each trout. Fish were randomly assigned either to the misoprostol/phenytoin group (14 fish) or to the untreated control group (5 fish). In fish from the misoprostol/phenytoin group, two randomly selected wounds were topically treated with a misoprostol/phenytoin gel, while the other two wounds were left without topical treatment. Follow-up and treatment were performed every 5 d for 120 d. Different macroscopic healing indexes were recorded over time, and histological characteristics of each wound were scored at the end of the study. Treatment with misoprostol/phenytoin was associated with delayed epithelialization and wound maturation in comparison with contralateral untreated wounds. The treatment was also associated with lower histological inflammation scores and increased dermal neovascularization. The untreated wounds of fish in the misoprostol/phenytoin group showed delayed maturation and decreased healing speed and had lower inflammation scores and increased neovascularization compared to untreated control wounds. Topical treatment of wounds in Brook Trout with misoprostol/phenytoin gel at the concentration used had a local and systemic deleterious effect on wound healing. The results of the present study do not support the use of this gel at this dosage for the treatment of wounds in Brook Trout.
Collapse
Affiliation(s)
- Thomas Coutant
- Faculté de Médecine Vétérinaire, Université de Montréal, 3200 Rue Sicotte, Saint-Hyacinthe, Québec, J2S2M2, Canada
- Aquarium du Québec, Société des Établissements de Plein air du Québec, 1675 Avenue des Hôtels, Québec, Québec, G1W 4S3, Canada
| | - Claire Vergneau-Grosset
- Faculté de Médecine Vétérinaire, Université de Montréal, 3200 Rue Sicotte, Saint-Hyacinthe, Québec, J2S2M2, Canada
- Aquarium du Québec, Société des Établissements de Plein air du Québec, 1675 Avenue des Hôtels, Québec, Québec, G1W 4S3, Canada
| | - Stéphane Lair
- Faculté de Médecine Vétérinaire, Université de Montréal, 3200 Rue Sicotte, Saint-Hyacinthe, Québec, J2S2M2, Canada
- Aquarium du Québec, Société des Établissements de Plein air du Québec, 1675 Avenue des Hôtels, Québec, Québec, G1W 4S3, Canada
| |
Collapse
|
42
|
Srivastava A, Saxena M, Percher J, Diamond-Smith N. Pathways to seeking medication abortion care: A qualitative research in Uttar Pradesh, India. PLoS One 2019; 14:e0216738. [PMID: 31083665 PMCID: PMC6513085 DOI: 10.1371/journal.pone.0216738] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 04/26/2019] [Indexed: 11/19/2022] Open
Abstract
Introduction Abortion is legal in India and medication abortion (MA) using a combined regimen of mifepristone and misoprostol is the preferred method. Users increasingly purchase MA kits directly from pharmacies, in some cases experiencing perceived complications and approaching a facility for care. We present findings of a qualitative research tracing the decision-making pathway(s) of MA users in Uttar Pradesh, India, to help understand knowledge and behaviour gaps, and recommend ways to improve the overall quality of care at these service delivery points. Methods Forty in-depth interviews were conducted with recent MA users (20 each of clinic and pharmacy clients) across three districts. Providers were purposively selected in collaboration with an international organization selling MA kits, using their list of pharmacies and clinics. MA users were identified from the clients of the selected providers, and additionally through the snow ball method. Interviews were conducted in Hindi with verbal informed consent in a private place convenient to the respondent. Transcripts were translated to English and analysed thematically. Results Users first sought MA kits at pharmacies out of convenience, low cost and customer anonymity. Men often purchased kits for their partners and trusted the chemist for guidance on dosage, progression and side effects. For side effects or other concerns after using an MA kit, users first visited their neighbourhood doctor or traditional practitioner. These providers either attempted to treat the issue and failed, or directly advised her to consult a gynaecologist. The final point of care was gynaecologists, preferably female private practitioners with their own clinics. They diagnosed most abortion-related cases as incomplete abortions, emptying the uterus using the dilation and curettage method. Comparatively low cost and convenience made users inclined towards repeat use of MA. Conclusion There are information gaps at various stages in the MA pathway that need to be addressed. Large scale public information programmes are required on safe abortion care- when is it legal, where to obtain MA, dosage, side effects and signs of possible complications. Pharmacists could be trained or incentivized to improve their quality of care to facilitate adequate exchange of information on MA. Since, for most couples, the male partner purchases MA, information approaches or tools are needed that pharmacists can give men to share directly with the MA user.
Collapse
Affiliation(s)
- Aradhana Srivastava
- Maternal and Child Health, Public Health Foundation of India, Gurgaon, Haryana, India
- * E-mail:
| | - Malvika Saxena
- Maternal and Child Health, Public Health Foundation of India, Gurgaon, Haryana, India
| | - Joanna Percher
- Bixby Center for Population, Health, and Sustainability, University of California, Berkeley, CA, United States of America
| | - Nadia Diamond-Smith
- Department of Epidemiology and Biostatistics, Institute for Global Health Sciences, University of California, San Francisco, CA, United States of America
| |
Collapse
|
43
|
Meaidi A, Friedrich S, Gerds TA, Lidegaard O. Risk factors for surgical intervention of early medical abortion. Am J Obstet Gynecol 2019; 220:478.e1-478.e15. [PMID: 30763542 DOI: 10.1016/j.ajog.2019.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/16/2019] [Accepted: 02/09/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND By being noninvasive, medical termination of pregnancy has increased worldwide access to abortion and improved safety of unsafe abortion. However, secondary surgical intervention is the most frequent complication to medical abortion. OBJECTIVE We aimed to identify and quantify risk factors for surgical intervention in women undergoing medically induced termination of pregnancy before 9 completed weeks of gestation. STUDY DESIGN We conducted a nationwide cohort study, including all pregnancies terminated before 63 gestational days in women aged 15-49 years during the period 2005-2015. Induction regimen was 200 mg mifepristone followed 24-48 hours later by 0.8 mg vaginal misoprostol. All included pregnancies were followed up for 8 weeks from mifepristone administration. Data were retrieved from national health registers. Multiple logistic regression provided adjusted odds ratios of surgical intervention with 95% confidence intervals. The discriminative ability of the risk factors in identifying surgical intervention was assessed by cross-validated area under the receiver operating characteristic curve. RESULTS Of 86,437 early medical abortions, 5320 (6.2%) underwent a surgical intervention within 8 weeks after induction. The proportion of surgical interventions increased from 3.5% in the 5th to 6th gestational week to 10.3% in week 9, odds ratio, 3.2 (95% confidence interval, 2.9-3.6). Compared with women aged 15-19 years, the risk of surgical intervention increased with increasing maternal age until the age of 30-34 years, odds ratio, 1.7 (95% confidence interval, 1.5-1.9), where after the risk decreased to an odds ratio for age group 40-49 of 1.2 (95% confidence interval, 1.0-1.4). Compared with nulliparous women, a history of only vaginal deliveries with spontaneous delivery of placenta implied an odds ratio of 1.1 (95% confidence interval, 1.0-1.2), women with a history of at least 1 cesarean delivery, an odds ratio of 1.5 (95% confidence interval, 1.3-1.6), and women having experienced a manual removal of placenta after a vaginal birth, an odds ratio of 2.0 (95% confidence interval, 1.7-2.4). Previous medically induced abortion decreased the risk of surgical intervention, odds ratio 0.84 (95% confidence interval, 0.78-0.91), whereas previous early (before 56 days of gestation) surgically induced abortion implied a 53% (95% confidence interval, 1.4-1.7) increased risk of surgical intervention. Previous surgical abortion after 55 days of gestation increased the risk by 17% (95% confidence interval, 1.1-1.3). The area under the receiver operating characteristic curve of the model including all quantified risk factors was 63% (95% confidence interval, 62-64%). CONCLUSION Gestational age, maternal age, previous deliveries, and history of medically and surgically induced abortions all had a significant influence on the risk of surgical intervention of early medical abortion. However, inclusion of all quantified risk factors still left most interventions unpredictable.
Collapse
Affiliation(s)
- Amani Meaidi
- Department of Gynaecology, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | | | - Thomas Alexander Gerds
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Oejvind Lidegaard
- Department of Gynaecology, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
44
|
Martin EM, Schirmer JM, Jones SL, Davis JL. Pharmacokinetics and ex vivo anti-inflammatory effects of oral misoprostol in horses. Equine Vet J 2019; 51:415-421. [PMID: 30256450 PMCID: PMC6587934 DOI: 10.1111/evj.13024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 08/14/2018] [Accepted: 09/18/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Misoprostol is an E prostanoid (EP) 2, 3 and 4 receptor agonist that is anecdotally used to treat and prevent NSAID-induced GI injury in horses. Misoprostol elicits anti-inflammatory effects in vivo in men and rodents, and inhibits TNFα production in equine leucocytes in vitro. OBJECTIVE Define the pharmacokinetic parameters of oral misoprostol in horses, and determine the inhibitory effect of oral misoprostol administration on equine leucocyte TNFα production in an ex vivo inflammation model. STUDY DESIGN Pharmacokinetic study, ex vivo experimental study. METHODS Six healthy adult horses of mixed breeds were used. In phase one, horses were given 5 μg/kg misoprostol orally, and blood was collected at predetermined times for determination of misoprostol free acid (MFA) by UHPLC-MS/MS. Pharmacokinetic parameters were calculated. In phase two, horses were dosed as in phase one, and blood was collected at T0, 0.5, 1 and 4 h following misoprostol administration for leucocyte isolation. Leucocytes were stimulated with 100 ng/mL LPS, and TNFα mRNA concentrations were determined via quantitative real-time PCR. RESULTS About 5 μg/kg oral misoprostol produced a rapid time to maximum concentration (Tmax ) of 23.4 ± 2.4 min, with a maximum concentration (Cmax ) of 0.29 ± 0.07 ng/mL and area under the curve (AUC0-∞ ) of 0.4 ± 0.12 h ng/mL. LPS stimulation of equine leucocytes ex vivo significantly increased TNFα mRNA concentrations, and there was no significant effect of misoprostol even at the Tmax . MAIN LIMITATIONS Only a single dose was used, and sample size was small. CONCLUSIONS Misoprostol is rapidly absorbed following oral administration in horses, and a single 5 μg/kg dose had no significant inhibitory effect on ex vivo LPS-stimulated TNFα mRNA production in leucocytes. Further studies analysing different dosing strategies, including repeat administration or combination with other anti-inflammatory drugs, are warranted.
Collapse
Affiliation(s)
- E. M. Martin
- North Carolina State University College of Veterinary MedicineRaleighNorth CarolinaUSA
| | - J. M. Schirmer
- North Carolina State University College of Veterinary MedicineRaleighNorth CarolinaUSA
| | - S. L. Jones
- North Carolina State University College of Veterinary MedicineRaleighNorth CarolinaUSA
| | - J. L. Davis
- VA‐MD College of Veterinary MedicineBlacksburgVirginiaUSA
| |
Collapse
|
45
|
Abdelshafy A, Awwad H, Abo-Gamra A, Alanwar A, Elkotb AM, Shahin M, Abd El-Razek M, Abbas AM. Sublingual vs vaginal misoprostol for completion of first trimester missed abortion: a randomised controlled trial. EUR J CONTRACEP REPR 2019; 24:134-139. [PMID: 30747547 DOI: 10.1080/13625187.2019.1569224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The study aimed to compare the efficacy and safety of sublingual and vaginal misoprostol for termination of pregnancy in women with first trimester missed abortion. METHODS A single-blind, parallel group, randomised clinical trial (ClinicalTrials.gov NCT02686840) was conducted in a university hospital between 1 February 2016 and 31 January 2017. All women who presented with first trimester missed abortion were invited to participate in the study and were randomised to one of two groups: one group received sublingual misoprostol in three doses of 800 μg every 4 h, while a second group received vaginal misoprostol in the same dosage regimen. The primary outcome of the study was the rate of complete abortion within 7 days after initiation of treatment. RESULTS The study included 200 women (100 in each arm). By day 7, successful complete abortion was significantly more frequent in the sublingual misoprostol group (71.4%) than in the vaginal misoprostol group (51.5%) (p = .006). By day 30, the rate of complete abortion was higher in the sublingual misoprostol group (90.6%) than in the vaginal misoprostol group (83.9%), but with no statistically significant difference (p = .164). The mean length of the induction-expulsion interval in the sublingual misoprostol group was significantly shorter compared with the vaginal misoprostol group (12.3 ± 3.1 h vs 16.4 ± 4.2 h, respectively; p = .001) and the sublingual misoprostol group had a smaller drop in haemoglobin level (p = .001). The side effects of misoprostol were significantly more frequent in the sublingual group compared with the vaginal group. CONCLUSION Sublingual misoprostol is more effective than vaginal misoprostol in completing first trimester missed abortion, with a shorter induction-expulsion time. Sublingual misoprostol is, however, associated with more side effects, such as unpleasant taste, gastrointestinal symptoms and fever, compared with vaginal misoprostol.
Collapse
Affiliation(s)
- Ahmed Abdelshafy
- a Ain Shams Maternity Hospital, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Hassan Awwad
- a Ain Shams Maternity Hospital, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Amgad Abo-Gamra
- a Ain Shams Maternity Hospital, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Ahmed Alanwar
- a Ain Shams Maternity Hospital, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Ahmed M Elkotb
- a Ain Shams Maternity Hospital, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Mohamed Shahin
- a Ain Shams Maternity Hospital, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Maya Abd El-Razek
- a Ain Shams Maternity Hospital, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Ahmed M Abbas
- b Women's Health Hospital, Faculty of Medicine , Assiut University , Assiut , Egypt
| |
Collapse
|
46
|
Sweed M, El-Said M, Abou-Gamrah A, Ali M. Comparison between 200, 400 and 600 microgram rectal misoprostol before cesarian section: A randomized clinical trial. J Obstet Gynaecol Res 2019; 45:585-591. [PMID: 30618101 DOI: 10.1111/jog.13883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 11/18/2018] [Indexed: 11/29/2022]
Abstract
AIM Compare the effectiveness of administration of different doses of rectal misoprostol before cesarean section to reduce intra- and postoperative blood loss. METHODS A double-blind randomized clinical trial including 453 term pregnant woman scheduled for elective cesarean section where participants received either 200-, 400- or 600-μg misoprostol rectally before cesarean section. Study medications were administered after catheter insertion and shortly before skin incision. Primary outcome measures were intraoperative blood loss. RESULTS The intraoperative blood loss was higher in patients who received 200-μg misoprostol (464.6 ± 143.1 mL) than those who received 400 or 600 μg, yet, no statistical difference was found between the 400- (359.3 ± 120.9 mL) and 600-μg groups (330.8 ± 133.8 mL). The incidence of side effects as fever and chills increases with increasing the dose of misoprostol. CONCLUSION Rectal administration of misoprostol for the prevention of post-partum hemorrhage and decreasing intraoperative blood loss during caesarian section is a good alternative to other uterotonics. Yet, the best dose to be used needs further research to be agreed upon.
Collapse
Affiliation(s)
- Mohamed Sweed
- Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
| | - Mourad El-Said
- Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
| | - Amgad Abou-Gamrah
- Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
| | - Mohamad Ali
- Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
| |
Collapse
|
47
|
Abstract
Backround A retrospective (case-controlled) study was conducted with the aim of identifying the effect of the use of misoprostol on termination time in patients who did and did not undergo feticide procedures in second trimester pregnancy terminations. Methods The sampling of the study consisted of 144 pregnant women who were diagnosed as having major fetal anomalies incompatible with life, and were recommended for termination of pregnancy. The investigation showed that feticide procedures were performed for 99 women, and feticide procedures were not performed for 45 women. Misoprostol protocol was administered for 48 hours in the termination period; whether the feticide procedure directly affected the termination duration in patients who did and did not undergo feticide was evaluated. Results Abortion/birth was achieved in 103 (71.5%) women during the first 48 hours. There was no significant difference between the termination duration of the misoprostol protocol among the women who did and did not undergo feticide. There was no significant difference between the termination durations and fetal biometric measurements (BPD, HC) except head diameters (p=0.020 and p=0.015). Conclusions The misoprostol protocol is shown to be effective and safe for the termination of pregnancies during the second trimester. Feticide has no affect on the duration of termination.
Collapse
Affiliation(s)
- Aytek Şık
- Istanbul Aydın University, Department of Obstetrics and Gynaecology, Istanbul, Turkey
| | - Sedat Bilecan
- Süleymaniye Research and Education Hospital, Department of Obstetrics and Gynaecology, Istanbul, Turkey
| | - Serkan Kumbasar
- Sakarya University School of Medicine, Sakarya Research and Education Hospital, Department of Obstetrics and Gynaecology, Sakarya, Turkey
| | - Yaşam Kemal Akpak
- Ankara Mevki Military Hospital, Department of Obstetrics and Gynaecology, Ankara, Turkey
| | - Yilda Arzu Aba
- Bandırma Onyedi Eylül Üniversitesi, Health Science Faculty, Balikesir, Turkey
| |
Collapse
|
48
|
Saleem HT, Narasimhan M, Ganatra B, Kennedy CE. Medical and surgical abortion for women living with HIV. Cochrane Database Syst Rev 2018; 12:CD012834. [PMID: 30566226 PMCID: PMC6516981 DOI: 10.1002/14651858.cd012834.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The World Health Organization (WHO) guidelines for safe abortion recommend medical abortion with mifepristone and misoprostol or surgical abortion with vacuum aspiration or dilation and evacuation as safe and effective options for women. However, no specific clinical considerations are stipulated within these guidelines for women living with HIV. Concerns have been raised that women living with HIV may be at greater risk of adverse abortion outcomes compared to HIV-uninfected women due to immunosuppression, high rates of co-infection with other sexually transmitted infections, and possible contraindications between medications used for medical abortion and antiretroviral therapy regimens. OBJECTIVES Our primary objective was to assess the effectiveness and safety of medical versus surgical abortion among women living with HIV. Our secondary objectives were to: (1) compare outcomes of medical and surgical abortion between women living with HIV and women without HIV and (2) describe outcomes of medical and surgical abortion among women living with HIV. SEARCH METHODS We conducted our search on 17 April 2018. We searched for all published and unpublished trials and observational studies of medical and surgical abortion among women living with HIV. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform using a combination of terms for abortion and HIV. We searched conference websites for relevant abstracts. We also sought unpublished data stratified by HIV status that could be newly analyzed. SELECTION CRITERIA We considered randomized controlled trials (RCTs), non-RCTs, and observational studies. We considered: (1) studies on the effectiveness and safety of medical versus surgical abortion among women living with HIV; (2) studies comparing outcomes of abortion for both methods between women living with HIV and women without HIV; and (3) studies that described outcomes of abortion among women living with HIV. DATA COLLECTION AND ANALYSIS One review author screened the titles, abstracts, citation information, and descriptor terms for citations initially identified by the search. We obtained the full-text articles of all potentially eligible studies when these were available. Two review authors independently examined the full-text articles for compliance with the inclusion criteria and determination of final study selection. We planned to conduct meta-analysis if a sufficient number of studies (at least three) addressed the same research question and presented data on sufficiently comparable outcomes. MAIN RESULTS Of 3840 records screened, we identified just one conference abstract that met our inclusion criteria. This prospective cohort study assessed the efficacy and acceptability of home administration of misoprostol for early medical abortion among women living with HIV who were of less than 63 days amenorrhea in Ukraine. Medical abortion was effective in 65 of 68 cases (96%) examined. The small number of failures included incomplete abortion (n = 1), heavy bleeding (n = 1), and ongoing pregnancy (n = 1). There were no serious infections. AUTHORS' CONCLUSIONS Due to the paucity of studies, we were unable to determine if outcome differences exist between women living with HIV and women without HIV who undergo medical or surgical abortion. We found no evidence suggesting that medical or surgical abortions are unsafe for women living with HIV. While additional research would strengthen the evidence base, healthcare providers should not be deterred from providing access to safe abortion to their patients living with HIV.
Collapse
Affiliation(s)
- Haneefa T Saleem
- Johns Hopkins Bloomberg School of Public HealthDepartment of International Health, Social and Behavioral Interventions Program615 N. Wolfe Street, Suite E5033BaltimoreMarylandUSA21205
| | - Manjulaa Narasimhan
- World Health OrganizationDepartment of Reproductive Health and ResearchGenevaSwitzerland
| | - Bela Ganatra
- World Health OrganizationDepartment of Reproductive Health and ResearchGenevaSwitzerland
| | - Caitlin E Kennedy
- Johns Hopkins Bloomberg School of Public HealthDepartment of International Health, Social and Behavioral Interventions Program615 N. Wolfe Street, Suite E5033BaltimoreMarylandUSA21205
| | | |
Collapse
|
49
|
Leigh S, Granby P, Haycox A, Mundle S, Bracken H, Khedikar V, Mulik J, Faragher B, Easterling T, Turner MA, Alfirevic Z, Winikoff B, Weeks AD. Foley catheter vs. oral misoprostol to induce labour among hypertensive women in India: a cost-consequence analysis alongside a clinical trial. BJOG 2018; 125:1734-1742. [PMID: 29782065 PMCID: PMC6282740 DOI: 10.1111/1471-0528.15285] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the effectiveness and economic impact of two methods for induction of labour in hypertensive women, in low-resource settings. DESIGN Cost-consequence analysis of a previously reported multicentre, parallel, open-label randomised trial. SETTING & POPULATION A total of 602 women with a live fetus, aged ≥18 years requiring delivery for pre-eclampsia or hypertension, in two public hospitals in Nagpur, India. METHODS We performed a formal economic evaluation alongside the INFORM clinical trial. Women were randomised to receive transcervical Foley catheterisation or oral misoprostol 25 mcg. Healthcare expenditure was calculated using a provider-side microcosting approach. MAIN OUTCOME MEASURES Rates of vaginal this delivery within 24 hours of induction, healthcare expenditure per completed treatment episode. RESULTS Induction with oral misoprostol resulted in a (mean difference) $20.6USD reduction in healthcare expenditure [95% CI (-) $123.59 (-) $72.49], and improved achievement of vaginal delivery within 24 hours of induction, mean difference 10% [95% CI (-2 to 17.9%), P = 0.016]. Oxytocin administration time was reduced by 135.3 minutes [95% CI (84.4-186.2 minutes), P < 0.01] and caesarean sections by 9.1% [95% CI (1.1-17%), P = 0.025] for those receiving oral misoprostol. Following probabilistic sensitivity analysis, oral misoprostol was cost-saving in 63% of 5,000 bootstrap replications and achieved superior rates of vaginal delivery, delivery within 24 hours of induction and vaginal delivery within 24 hours of induction in 98.7%, 90.7%, and 99.4% of bootstrap simulations. Based on univariate threshold analysis, the unit price of oral misoprostol 25 mcg could feasibly increase 31-fold from $0.24 to $7.50 per 25 mcg tablet and remain cost-saving. CONCLUSION Compared to Foley catheterisation for the induction of high-risk hypertensive women, oral misoprostol improves rates of vaginal delivery within 24 hours of induction and may also reduce costs. Additional research performed in other low-resource settings is required to determine their relative cost-effectiveness. TWEETABLE ABSTRACT Oral misoprostol less costly and more effective than Foley catheter for labour induction in hypertension.
Collapse
Affiliation(s)
- S Leigh
- University of Liverpool Management SchoolLiverpoolUK
| | - P Granby
- University of Liverpool Management SchoolLiverpoolUK
| | - A Haycox
- University of Liverpool Management SchoolLiverpoolUK
| | - S Mundle
- Department of Obstetrics & GynaecologyGovernment Medical CollegeNagpurIndia
| | - H Bracken
- Gynuity Health ProjectsNew YorkNYUSA
| | - V Khedikar
- Daga Memorial Women's Government HospitalNagpurIndia
| | - J Mulik
- Department of Obstetrics & GynaecologyGovernment Medical CollegeNagpurIndia
| | - B Faragher
- Medical Statistics UnitDepartment of Clinical SciencesLiverpool School of Tropical MedicineLiverpoolUK
| | - T Easterling
- Department of Obstetrics and GynecologyUniversity of WashingtonSeattleWAUSA
| | - MA Turner
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpool Women's HospitalLiverpoolUK
| | - Z Alfirevic
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpool Women's HospitalLiverpoolUK
| | | | - AD Weeks
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpool Women's HospitalLiverpoolUK
| |
Collapse
|
50
|
Sweed MS, El-Saied MM, Abou-Gamrah AE, El-Sabaa HA, Abdel-Hamid MM, Hemeda H, Mansour AM, Shawky ME, El-Sayed MA, Mohamed RM. Rectal vs. sublingual misoprostol before cesarean section: double-blind, three-arm, randomized clinical trial. Arch Gynecol Obstet 2018; 298:1115-1122. [PMID: 30291483 DOI: 10.1007/s00404-018-4894-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 09/06/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The commonest surgical procedure for women is cesarean delivery. Postpartum hemorrhage and intra-operative blood during cesarean delivery is a major concern to all obstetricians. This study was conducted to assess the efficacy of the adjuvant use of misoprostol and oxytocin in decreasing intra-operative blood loss in cesarean delivery. METHODS This was a double-blinded randomized clinical trial including 636 term pregnant woman scheduled for cesarean section at Ain Shams University Maternity Hospital, Cairo, Egypt, between February 2013 and February 2014. Participants received either 400-μg misoprostol rectally or sublingually or placebo before cesarean section together with 5-IU oxytocin IV. The main outcome measure was intra-operative blood loss. Difference between the three groups was analyzed using one-way ANOVA test (for numeric variables) and Chi-square test (for categorical variables). P < 0.05 was considered statistically significant. RESULTS Intra-operative blood loss was higher in patients who did not receive misoprostol (Placebo Group) (295-1075 ml, 641.7 ± 135.7) than those who received it, regardless the route of administration, rectal (135-830 ml, 457.5 ± 140.7; P < 0.001), and sublingual (135-680 ml, 357.8 ± 129.7; P < 0.001). In addition, sublingual route was associated with significantly lower estimated intra-operative blood loss compared to rectal administration (P < 0.001). CONCLUSIONS Misoprostol with oxytocin is an effective drug-combination for decreasing intra-operative blood loss during cesarian section with clinical superiority to sublingual over rectal route.
Collapse
Affiliation(s)
- Mohamed S Sweed
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt.
| | - Mourad M El-Saied
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| | - Amgad E Abou-Gamrah
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| | - Haitham A El-Sabaa
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| | | | - Hossam Hemeda
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| | - Ahmed M Mansour
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| | - Mohamed E Shawky
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| | - Medhat A El-Sayed
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| | - Radwa M Mohamed
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| |
Collapse
|