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Arai T, Ozawa K, Muromoto J, Sugibayashi R, Wada S, Sago H. Outcomes and complications of second-trimester induction of labor using laminaria and gemeprost: A single-center experience in Japan. J Obstet Gynaecol Res 2024. [PMID: 39098827 DOI: 10.1111/jog.16043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 07/21/2024] [Indexed: 08/06/2024]
Abstract
AIM To document the outcomes of second-trimester induction of labor with laminaria cervical dilation followed by gemeprost vaginal tablets, with a particular emphasis on its complications. METHODS This was a single-center retrospective cohort study of women who experienced medical abortions between 12 and 21 weeks of gestation from January 2016 to July 2021. Procedures were performed with three laminaria cervical dilation for 2 days followed by the administration of gemeprost (1 mg, vaginal tablet) every 3 h with a maximum of five tablets per day. Epidural anesthesia was provided upon request. The primary outcome was successful labor induction, which was defined as fetal expulsion without assisted surgical procedures. Other maternal outcomes, complications and related interventions during and after the procedure were assessed. RESULTS Among 319 women, 313 (98.1%) experienced successful labor induction with a median of one gemeprost tablet. The median blood loss during the abortion was 145 mL, and three women (0.9%) required blood transfusion. Fever was observed in 19 women (6.0%) during hospitalization, although most cases were drug fever. Thirteen women (4.1%) had abnormal uterine bleeding ~24 days after the abortion. Eleven cases (3.4%) were associated with retained products of conception, of which three cases required uterine artery embolization and three needed surgical curettage. CONCLUSIONS Second-trimester induction of labor with laminaria cervical dilation and subsequent gemeprost vaginal tablets is a reliable method for completing medical abortions. Abnormal uterine bleeding several weeks after abortion is suspected to be a retained product of conception that could require invasive treatment.
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Affiliation(s)
- Tomohiro Arai
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
- Department of Development and Regeneration, Cluster Women and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Katsusuke Ozawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Jin Muromoto
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Rika Sugibayashi
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Seiji Wada
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
- Center for Medical Genetics, National Center for Child Health and Development, Tokyo, Japan
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Bakhbakhi D, Siassakos D, Davies A, Merriel A, Barnard K, Stead E, Shakespeare C, Duffy JMN, Hinton L, McDowell K, Lyons A, Fraser A, Burden C. Interventions, outcomes and outcome measurement instruments in stillbirth care research: A systematic review to inform the development of a core outcome set. BJOG 2023; 130:560-576. [PMID: 36655361 DOI: 10.1111/1471-0528.17390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/08/2022] [Accepted: 10/26/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND A core outcome set could address inconsistent outcome reporting and improve evidence for stillbirth care research, which have been identified as an important research priority. OBJECTIVES To identify outcomes and outcome measurement instruments reported by studies evaluating interventions after the diagnosis of a stillbirth. SEARCH STRATEGY Amed, BNI, CINAHL, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO, and WHO ICTRP from 1998 to August 2021. SELECTION CRITERIA Randomised and non-randomised comparative or non-comparative studies reporting a stillbirth care intervention. DATA COLLECTION AND ANALYSIS Interventions, outcomes reported, definitions and outcome measurement tools were extracted. MAIN RESULTS Forty randomised and 200 non-randomised studies were included. Fifty-eight different interventions were reported, labour and birth care (52 studies), hospital bereavement care (28 studies), clinical investigations (116 studies), care in a multiple pregnancy (2 studies), psychosocial support (28 studies) and care in a subsequent pregnancy (14 studies). A total of 391 unique outcomes were reported and organised into 14 outcome domains: labour and birth; postpartum; delivery of care; investigations; multiple pregnancy; mental health; emotional functioning; grief and bereavement; social functioning; relationship; whole person; subsequent pregnancy; subsequent children and siblings and economic. A total of 242 outcome measurement instruments were used, with 0-22 tools per outcome. CONCLUSIONS Heterogeneity in outcome reporting, outcome definition and measurement tools in care after stillbirth exists. Considerable research gaps on specific intervention types in stillbirth care were identified. A core outcome set is needed to standardise outcome collection and reporting for stillbirth care research.
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Affiliation(s)
| | | | - Anna Davies
- Centre for Academic Child Health, University of Bristol, Bristol, UK
| | | | | | - Emma Stead
- Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | | | | | - Lisa Hinton
- THIS Institute, University of Cambridge, Cambridge, UK
| | | | - Anna Lyons
- Northern General Hospital, Sheffield, UK
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Ghosh J, Papadopoulou A, Devall AJ, Jeffery HC, Beeson LE, Do V, Price MJ, Tobias A, Tunçalp Ö, Lavelanet A, Gülmezoglu AM, Coomarasamy A, Gallos ID. Methods for managing miscarriage: a network meta-analysis. Cochrane Database Syst Rev 2021; 6:CD012602. [PMID: 34061352 PMCID: PMC8168449 DOI: 10.1002/14651858.cd012602.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime. An estimated 15% of pregnancies end in miscarriage. Miscarriage can lead to serious morbidity, including haemorrhage, infection, and even death, particularly in settings without adequate healthcare provision. Early miscarriages occur during the first 14 weeks of pregnancy, and can be managed expectantly, medically or surgically. However, there is uncertainty about the relative effectiveness and risks of each option. OBJECTIVES To estimate the relative effectiveness and safety profiles for the different management methods for early miscarriage, and to provide rankings of the available methods according to their effectiveness, safety, and side-effect profile using a network meta-analysis. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth's Trials Register (9 February 2021), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (12 February 2021), and reference lists of retrieved studies. SELECTION CRITERIA We included all randomised controlled trials assessing the effectiveness or safety of methods for miscarriage management. Early miscarriage was defined as less than or equal to 14 weeks of gestation, and included missed and incomplete miscarriage. Management of late miscarriages after 14 weeks of gestation (often referred to as intrauterine fetal deaths) was not eligible for inclusion in the review. Cluster- and quasi-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded non-randomised trials. DATA COLLECTION AND ANALYSIS At least three review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for the primary outcomes of complete miscarriage and composite outcome of death or serious complications. The certainty of evidence was assessed using GRADE. Relative effects for the primary outcomes are reported subgrouped by the type of miscarriage (incomplete and missed miscarriage). We also performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available methods. MAIN RESULTS Our network meta-analysis included 78 randomised trials involving 17,795 women from 37 countries. Most trials (71/78) were conducted in hospital settings and included women with missed or incomplete miscarriage. Across 158 trial arms, the following methods were used: 51 trial arms (33%) used misoprostol; 50 (32%) used suction aspiration; 26 (16%) used expectant management or placebo; 17 (11%) used dilatation and curettage; 11 (6%) used mifepristone plus misoprostol; and three (2%) used suction aspiration plus cervical preparation. Of these 78 studies, 71 (90%) contributed data in a usable form for meta-analysis. Complete miscarriage Based on the relative effects from the network meta-analysis of 59 trials (12,591 women), we found that five methods may be more effective than expectant management or placebo for achieving a complete miscarriage: · suction aspiration after cervical preparation (risk ratio (RR) 2.12, 95% confidence interval (CI) 1.41 to 3.20, low-certainty evidence), · dilatation and curettage (RR 1.49, 95% CI 1.26 to 1.75, low-certainty evidence), · suction aspiration (RR 1.44, 95% CI 1.29 to 1.62, low-certainty evidence), · mifepristone plus misoprostol (RR 1.42, 95% CI 1.22 to 1.66, moderate-certainty evidence), · misoprostol (RR 1.30, 95% CI 1.16 to 1.46, low-certainty evidence). The highest ranked surgical method was suction aspiration after cervical preparation. The highest ranked non-surgical treatment was mifepristone plus misoprostol. All surgical methods were ranked higher than medical methods, which in turn ranked above expectant management or placebo. Composite outcome of death and serious complications Based on the relative effects from the network meta-analysis of 35 trials (8161 women), we found that four methods with available data were compatible with a wide range of treatment effects compared with expectant management or placebo: · dilatation and curettage (RR 0.43, 95% CI 0.17 to 1.06, low-certainty evidence), · suction aspiration (RR 0.55, 95% CI 0.23 to 1.32, low-certainty evidence), · misoprostol (RR 0.50, 95% CI 0.22 to 1.15, low-certainty evidence), · mifepristone plus misoprostol (RR 0.76, 95% CI 0.31 to 1.84, low-certainty evidence). Importantly, no deaths were reported in these studies, thus this composite outcome was entirely composed of serious complications, including blood transfusions, uterine perforations, hysterectomies, and intensive care unit admissions. Expectant management and placebo ranked the lowest when compared with alternative treatment interventions. Subgroup analyses by type of miscarriage (missed or incomplete) agreed with the overall analysis in that surgical methods were the most effective treatment, followed by medical methods and then expectant management or placebo, but there are possible subgroup differences in the effectiveness of the available methods. AUTHORS' CONCLUSIONS: Based on relative effects from the network meta-analysis, all surgical and medical methods for managing a miscarriage may be more effective than expectant management or placebo. Surgical methods were ranked highest for managing a miscarriage, followed by medical methods, which in turn ranked above expectant management or placebo. Expectant management or placebo had the highest chance of serious complications, including the need for unplanned or emergency surgery. A subgroup analysis showed that surgical and medical methods may be more beneficial in women with missed miscarriage compared to women with incomplete miscarriage. Since type of miscarriage (missed and incomplete) appears to be a source of inconsistency and heterogeneity within these data, we acknowledge that the main network meta-analysis may be unreliable. However, we plan to explore this further in future updates and consider the primary analysis as separate networks for missed and incomplete miscarriage.
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Affiliation(s)
- Jay Ghosh
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Argyro Papadopoulou
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Adam J Devall
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Hannah C Jeffery
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Leanne E Beeson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Vivian Do
- University of Birmingham, Birmingham, UK
| | - Malcolm J Price
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Aurelio Tobias
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Antonella Lavelanet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
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Lemmers M, Verschoor MAC, Kim BV, Hickey M, Vazquez JC, Mol BWJ, Neilson JP. Medical treatment for early fetal death (less than 24 weeks). Cochrane Database Syst Rev 2019; 6:CD002253. [PMID: 31206170 PMCID: PMC6574399 DOI: 10.1002/14651858.cd002253.pub4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In most pregnancies that miscarry, arrest of embryonic or fetal development occurs some time (often weeks) before the miscarriage occurs. Ultrasound examination can reveal abnormal findings during this phase by demonstrating anembryonic pregnancies or embryonic or fetal death. Treatment has traditionally been surgical but medical treatments may be effective, safe, and acceptable, as may be waiting for spontaneous miscarriage. This is an update of a review first published in 2006. OBJECTIVES To assess, from clinical trials, the effectiveness and safety of different medical treatments for the termination of non-viable pregnancies. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (24 October 2018) and reference lists of retrieved studies. SELECTION CRITERIA Randomised trials comparing medical treatment with another treatment (e.g. surgical evacuation), or placebo, or no treatment for early pregnancy failure. Quasi-randomised studies were excluded. Cluster-randomised trials were eligible for inclusion, as were studies reported in abstract form, if sufficient information was available to assess eligibility. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Forty-three studies (4966 women) were included. The main interventions examined were vaginal, sublingual, oral and buccal misoprostol, mifepristone and vaginal gemeprost. These were compared with surgical management, expectant management, placebo, or different types of medical interventions were compared with each other. The review includes a wide variety of different interventions which have been analysed across 23 different comparisons. Many of the comparisons consist of single studies. We limited the grading of the quality of evidence to two main comparisons: vaginal misoprostol versus placebo and vaginal misoprostol versus surgical evacuation of the uterus. Risk of bias varied widely among the included trials. The quality of the evidence varied between the different comparisons, but was mainly found to be very-low or low quality.Vaginal misoprostol versus placeboVaginal misoprostol may hasten miscarriage when compared with placebo: e.g. complete miscarriage (5 trials, 305 women, risk ratio (RR) 4.23, 95% confidence interval (CI) 3.01 to 5.94; low-quality evidence). No trial reported on pelvic infection rate for this comparison. Vaginal misoprostol made little difference to rates of nausea (2 trials, 88 women, RR 1.38, 95% CI 0.43 to 4.40; low-quality evidence), diarrhoea (2 trials, 88 women, RR 2.21, 95% CI 0.35 to 14.06; low-quality evidence) or to whether women were satisfied with the acceptability of the method (1 trial, 32 women, RR 1.17, 95% CI 0.83 to 1.64; low-quality evidence). It is uncertain whether vaginal misoprostol reduces blood loss (haemoglobin difference > 10 g/L) (1 trial, 50 women, RR 1.25, 95% CI 0.38 to 4.12; very-low quality) or pain (opiate use) (1 trial, 84 women, RR 5.00, 95% CI 0.25 to 101.11; very-low quality), because the quality of the evidence for these outcomes was found to be very low.Vaginal misoprostol versus surgical evacuation Vaginal misoprostol may be less effective in accomplishing a complete miscarriage compared to surgical management (6 trials, 943 women, average RR 0.40, 95% CI 0.32 to 0.50; Heterogeneity: Tau² = 0.03, I² = 46%; low-quality evidence) and may be associated with more nausea (1 trial, 154 women, RR 21.85, 95% CI 1.31 to 364.37; low-quality evidence) and diarrhoea (1 trial, 154 women, RR 40.85, 95% CI 2.52 to 662.57; low-quality evidence). There may be little or no difference between vaginal misoprostol and surgical evacuation for pelvic infection (1 trial, 618 women, RR 0.73, 95% CI 0.39 to 1.37; low-quality evidence), blood loss (post-treatment haematocrit (%) (1 trial, 50 women, mean difference (MD) 1.40%, 95% CI -3.51 to 0.71; low-quality evidence), pain relief (1 trial, 154 women, RR 1.42, 95% CI 0.82 to 2.46; low-quality evidence) or women's satisfaction/acceptability of method (1 trial, 45 women, RR 0.67, 95% CI 0.40 to 1.11; low-quality evidence).Other comparisonsBased on findings from a single trial, vaginal misoprostol was more effective at accomplishing complete miscarriage than expectant management (614 women, RR 1.25, 95% CI 1.09 to 1.45). There was little difference between vaginal misoprostol and sublingual misoprostol (5 trials, 513 women, average RR 0.84, 95% CI 0.61 to 1.16; Heterogeneity: Tau² = 0.10, I² = 871%; or between oral and vaginal misoprostol in terms of complete miscarriage at less than 13 weeks (4 trials, 418 women), average RR 0.68, 95% CI 0.45 to 1.03; Heterogeneity: Tau² = 0.13, I² = 90%). However, there was less abdominal pain with vaginal misoprostol in comparison to sublingual (3 trials, 392 women, RR 0.58, 95% CI 0.46 to 0.74). A single study (46 women) found mifepristone to be more effective than placebo: miscarriage complete by day five after treatment (46 women, RR 9.50, 95% CI 2.49 to 36.19). However the quality of this evidence is very low: there is a very serious risk of bias with signs of incomplete data and no proper intention-to-treat analysis in the included study; and serious imprecision with wide confidence intervals. Mifepristone did not appear to further hasten miscarriage when added to a misoprostol regimen (3 trials, 447 women, RR 1.18, 95% CI 0.95 to 1.47). AUTHORS' CONCLUSIONS Available evidence from randomised trials suggests that medical treatment with vaginal misoprostol may be an acceptable alternative to surgical evacuation or expectant management. In general, side effects of medical treatment were minor, consisting mainly of nausea and diarrhoea. There were no major differences in effectiveness between different routes of administration. Treatment satisfaction was addressed in only a few studies, in which the majority of women were satisfied with the received intervention. Since the quality of evidence is low or very low for several comparisons, mainly because they included only one or two (small) trials; further research is necessary to assess the effectiveness, safety and side effects, optimal route of administration and dose of different medical treatments for early fetal death.
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Affiliation(s)
- Marike Lemmers
- Academic Medical CenterDepartment of Obstetrics and GynaecologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Marianne AC Verschoor
- Academic Medical CenterDepartment of Obstetrics and GynaecologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Bobae Veronica Kim
- School of Medicine, The University of AdelaideRobinson Research InstituteAdelaideSAAustralia5006
| | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
| | - Juan C Vazquez
- Instituto Nacional de Endocrinologia (INEN)Departamento de Salud ReproductivaZapata y DVedadoHabanaCuba10 400
| | - Ben Willem J Mol
- Monash UniversityDepartment of Obstetrics and Gynaecology246 Clayton RoadClaytonVictoriaAustralia3168
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Koh DSC, Ang EPJ, Coyuco JC, Teo HZ, Huang X, Wei X, Ng MJ, Lim SL, Tan KH. Comparing two regimens of intravaginal misoprostol with intravaginal gemeprost for second-trimester pregnancy termination: a randomised controlled trial. ACTA ACUST UNITED AC 2017; 43:252-259. [PMID: 28432086 DOI: 10.1136/jfprhc-2016-101652] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/21/2017] [Accepted: 03/20/2017] [Indexed: 11/03/2022]
Abstract
AIM To compare the efficacy and safety of intravaginal misoprostol 200 µg, 400 µg and gemeprost regimens for second-trimester termination of pregnancy (TOP). METHODS A three- armed randomi sed controlled trial (Clinical Trial Certificate 1100015) where 116 women undergoing second-trimester TOP were given intravaginal misoprostol 200 µ g (n=37), misoprostol 400 µg (n=40) or gemeprost 1 mg (n=39) at 4- hour intervals until abortion occurred with a maximum of five doses. RESULTS The misoprostol 400 µg group had the highest incidence of successful abortions (92.5%) compared to the misoprostol 200 µg (70.3%; p=0.017) and gemeprost 1 mg (74.4%; p=0.037) within 48 hours. There was no significant difference in abortion rate between misoprostol 200 µg and gemeprost. The misoprostol 400 µg group had the highest incidence of fever (70.0%) compared to misoprostol 200 µg (24.3%; p<0.001) and gemeprost 1 mg (46.2%; p=0.041). The gemeprost group had the highest incidence of diarrhoea (38.5%) compared to misoprostol 400 µg (10.0%; p=0.004) and misoprostol 200 µg (8.1%; p=0.003) groups. CONCLUSIONS Intravaginal misoprostol 400 µ g at 4- hour intervals was the most effective regimen but was associated with a high incidence of fever. Misoprostol 200 µg demonstrated similar effectiveness as gemeprost and had lower incidence of diarrhoea. Gemeprost should not be first line for medical therapy given the cost, storage requirements and lower efficacy.
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Affiliation(s)
- Daniel Seow Choon Koh
- Associate Consultant, Division of Obstetrics & Gynecology, KK Women's and Children's Hospital, Singapore, Singapore
| | - Esther Pei Jing Ang
- Pharmacist, Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jurja Chua Coyuco
- Pharmacist, Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Hua Zhen Teo
- Clinical Pharmacist, Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Xiaoling Huang
- Clinical Pharmacist, Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Xing Wei
- Executive, Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Mor Jack Ng
- Manager, Division of Obstetrics & Gynecology, OBGYN Academic Clinical Program, KK Women's and Children's Hospital, Singapore, Singapore
| | - Serene Liqing Lim
- Associate Consultant, Division of Surgery, Singapore General Hospital, Singapore, Singapore
| | - Kok Hian Tan
- Senior Consultant, Division of Obstetrics & Gynecology, KK Women's and Children's Hospital, Singapore, Singapore
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Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe, and acceptable. OBJECTIVES To assess the effectiveness, safety, and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (13 May 2016) and reference lists of retrieved papers. SELECTION CRITERIA We included randomised controlled trials comparing medical treatment with expectant care or surgery, or alternative methods of medical treatment. We excluded quasi-randomised trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias, and carried out data extraction. Data entry was checked. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included 24 studies (5577 women). There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; 2 studies, 150 women, random-effects; very low-quality evidence), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. For unplanned surgical intervention, we did not identify any difference between misoprostol and expectant care (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence).Sixteen trials involving 4044 women addressed the comparison of misoprostol (7 studies used oral administration, 6 studies used vaginal, 2 studies sublingual, 1 study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.96, 95% CI 0.94 to 0.98; 15 studies, 3862 women, random-effects; very low-quality evidence) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.05, 95% CI 0.02 to 0.11; 13 studies, 3070 women, random-effects; very low-quality evidence) but more unplanned procedures (average RR 5.03, 95% CI 2.71 to 9.35; 11 studies, 2690 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.50, 95% CI 1.53 to 4.09; 11 studies, 3015 women, random-effects; low-quality evidence). We did not identify any difference in women's satisfaction between misoprostol and surgery (average RR 1.00, 95% CI 0.99 to 1.00; 9 studies, 3349 women, random-effects; moderate-quality evidence). More women had vomiting and diarrhoea with misoprostol compared with surgery (vomiting: average RR 1.97, 95% CI 1.36 to 2.85; 10 studies, 2977 women, random-effects; moderate-quality evidence; diarrhoea: average RR 4.82, 95% CI 1.09 to 21.32; 4 studies, 757 women, random-effects; moderate-quality evidence).Five trials compared different routes of administration, or doses, or both, of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Further studies, including long-term follow-up, are clearly needed to confirm these findings. There is an urgent need for studies on women who miscarry at more than 13 weeks' gestation.
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Affiliation(s)
- Caron Kim
- WHODepartment of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | | | | | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
| | - Juan C Vazquez
- Instituto Nacional de Endocrinologia (INEN)Departamento de Salud ReproductivaZapata y DVedadoHabanaCuba10 400
| | - Lixia Dou
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Bracken H, Ngoc NTN, Banks E, Blumenthal PD, Derman RJ, Patel A, Gold M, Winikoff B. Buccal misoprostol for treatment of fetal death at 14–28 weeks of pregnancy: a double-blind randomized controlled trial. Contraception 2014; 89:187-92. [DOI: 10.1016/j.contraception.2013.11.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 11/06/2013] [Accepted: 11/15/2013] [Indexed: 10/26/2022]
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8
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Clark W, Shannon C, Winikoff B. Misoprostol for uterine evacuation in induced abortion and pregnancy failure. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.2.1.67] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tanha FD, Golgachi T, Niroomand N, Ghajarzadeh M, Nasr R. Sublingual versus vaginal misoprostol for second trimester termination: a randomized clinical trial. Arch Gynecol Obstet 2012; 287:65-9. [DOI: 10.1007/s00404-012-2508-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 07/30/2012] [Indexed: 10/28/2022]
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Dilek TUK, Doruk A, Gozukara I, Durukan H, Dilek S. Effect of cervical length on second trimester pregnancy termination. J Obstet Gynaecol Res 2011; 37:505-10. [PMID: 21349126 DOI: 10.1111/j.1447-0756.2010.01391.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To evaluate the value of sonographic measurement of cervical length as a predictor of abortion or delivery within 24 h by misoprostol in second trimester termination of pregnancy (TOP). MATERIAL AND METHODS One hundred and sixty-three women underwent TOP between 14 and 26 weeks of pregnancy due to various indications. The primary outcome was abortion within 24 h. Cervical length was measured before transvaginal administration of misoprostol. The effects of cervical length, total misoprostol dose, parity, and gestational age at diagnosis on successful TOP were evaluated. RESULTS One hundred and sixty-three women were eligible who met the inclusion criteria. TOP occurred in 80.5% of patients within 24 h. Parous women had shorter prolonged induction to expulsion period over 24 h (14.1% vs 28.6%, P = 0.061). Total misoprostol dose and history of abortion were parameters that affected induction to delivery period (P = 0.002 and P = 0.041). Using an optimum cutoff of 36 mm, 58.2% sensitivity and 68.2% specificity were obtained. In addition, positive and negative predictive values were 85.36% and 33.3%, respectively. Pregnant women whose preinduction cervical length was shorter than 36 mm had a shorter induction time and needed a lower total misoprostol dose to achieve TOP than women with a cervical length longer than 36 mm (P = 0.027 and P = 0.011, respectively). CONCLUSION Transvaginal measurement of cervical length before administration of prostaglandin analogue was not correlated with successful TOP within 24 h. It cannot be used as a predictor in light of our findings.
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Affiliation(s)
- Talat Umut Kutlu Dilek
- Department of Obstetrics and Gynecology, School of Medicine, Mersin University, Mersin, Turkey.
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Wildschut H, Both MI, Medema S, Thomee E, Wildhagen MF, Kapp N. Medical methods for mid-trimester termination of pregnancy. Cochrane Database Syst Rev 2011; 2011:CD005216. [PMID: 21249669 PMCID: PMC8557267 DOI: 10.1002/14651858.cd005216.pub2] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND With the improvement of ultrasound technology, the likelihood of detection of major fetal structural anomalies in mid-pregnancy has increased considerably. Upon the detection of serious anomalies, women typically are offered the option of pregnancy termination. Additionally, there are still many reasons other than fetal anomalies why women seek abortion in the mid-trimester. OBJECTIVES To compare different methods of second trimester medical termination of pregnancy for their efficacy and side-effects. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, Popline and reference lists of retrieved papers and other sources. SELECTION CRITERIA All randomised controlled trials (RCTs) examining medical regimens for termination of pregnancy of a singleton living fetus between 12-28 weeks' gestation were analysed. The outcome measures were the induction to abortion interval, abortion rate within 24 hours, need for surgical evacuation, blood loss, uterine rupture, pain, and side-effects.Trials including >20% fetal death, multiple pregnancies, previous uterine scars and regimens which involved cervical preparation were excluded. DATA COLLECTION AND ANALYSIS Two authors selected the trials and three authors extracted data. MAIN RESULTS Fourty RCTs were included, addressing various agents for pregnancy termination and methods of administration. When used alone, misoprostol was an effective inductive agent, though it appeared to be more effective in combination with mifepristone. However, the evidence from RCTs is limited.Misoprostol was preferably administered vaginally, although among multiparous women sublingual administration appeared equally effective. A range of doses of vaginally administered misoprostol has been used. No randomised trials comparing doses of misoprostol were identified; however low doses of misoprostol appear to be associated with fewer side-effects while moderate doses appear to be more efficient in completing abortion. Four RCTs showed that the induction to abortion interval with 3-hourly vaginal administration of prostaglandins is shorter than 6-hourly administration without an increase in side-effects.Many studies reported the need for surgical evacuation. Indications for surgical evacuation include retained products of the placenta and heavy vaginal bleeding. Fewer women required surgical evacuation when misoprostol was administrated vaginally compared with women receiving intra-amniotical PGF(2a) . Mild, self-limiting diarrhoea was more common among women who received misoprostol compared to other agents. AUTHORS' CONCLUSIONS Medical abortion in the second trimester using the combination of mifepristone and misoprostol appeared to have the highest efficacy and shortest abortion time interval. Where mifepristone is not available, misoprostol alone is a reasonable alternative. The optimal route for administering misoprostol is vaginally, preferably using tablets at 3-hourly intervals. Apart from pain, the side-effects of vaginal misoprostol are usually mild and self limiting. Conclusions from this review are limited by the gestational age ranges and variable medical regimens, including dosing, administrative routes and intervals of medication, of the included trials.
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Affiliation(s)
- Hajo Wildschut
- Erasmus Medical CenterDepartment of Obstetrics and GynaecologyPO Box 2040RotterdamNetherlands3000 CA
| | - Marieke I Both
- Erasmus Medical CenterDepartment of Obstetrics and GynaecologyPO Box 2040RotterdamNetherlands3000 CA
| | - Suzanne Medema
- Bouman GGZPieter de Hoogh Weg 14RotterdamNetherlands3024 BH
| | - Eeke Thomee
- The Royal Marsden HospitalFulham RoadLondonUKSW 3
| | - Mark F Wildhagen
- Erasmus Medical CenterDepartment of Urology and Obstetrics and GynecologyPO Box 2040RotterdamNetherlands3000 CA
| | - Nathalie Kapp
- World Health OrganizationDepartment of Reproductive Health and Research20 Rue AppiaGeneva 27SwitzerlandCH‐1211
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CABRERA Y, FERNÁNDEZ-GUISASOLA J, LOBO P, GÁMIR S, ÁLVAREZ J. Comparison of sublingual versus vaginal misoprostol for second-trimester pregnancy termination: A meta-analysis. Aust N Z J Obstet Gynaecol 2011; 51:158-65. [DOI: 10.1111/j.1479-828x.2010.01264.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Dodd JM, Crowther CA. Misoprostol for induction of labour to terminate pregnancy in the second or third trimester for women with a fetal anomaly or after intrauterine fetal death. Cochrane Database Syst Rev 2010; 2010:CD004901. [PMID: 20393941 PMCID: PMC6494643 DOI: 10.1002/14651858.cd004901.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND A woman may need to give birth prior to the spontaneous onset of labour in situations where the fetus has died in utero (also called a stillbirth), or for the termination of pregnancy where the fetus, if born alive would not survive or would have a permanent handicap. Misoprostol is a prostaglandin medication that can be used to induce labour in these situations. OBJECTIVES To compare the benefits and harms of misoprostol to induce labour to terminate pregnancy in the second and third trimester for women with a fetal anomaly or after intrauterine fetal death when compared with other methods of induction of labour. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2009). SELECTION CRITERIA Randomised controlled trials comparing misoprostol with placebo or no treatment, or any other method of induction of labour, for women undergoing induction of labour to terminate pregnancy in the second and third trimester following an intrauterine fetal death or for fetal anomalies. DATA COLLECTION AND ANALYSIS Both authors independently assessed trial quality and extracted data. MAIN RESULTS We included 38 studies (3679 women).Nine studies included pregnancies after intrauterine deaths, five studies included termination of pregnancies because of fetal anomalies when the fetus was still alive and the rest (24) presented the pooled data for intrauterine deaths, fetal anomalies and social reasons.When compared with agents that have traditionally been used to induce labour in this setting (for example, gemeprost, prostaglandin E(2) and prostaglandin F(2alpha)), vaginal misoprostol is as effective in ensuring vaginal birth within 24 hours, with a similar induction to birth interval. Vaginal misoprostol is associated with a reduction in the occurrence of maternal gastrointestinal side effects such as nausea, vomiting and diarrhoea when compared with other prostaglandin preparations. While the different treatments involving various prostaglandin preparations appear comparable for the reported outcomes, the information available regarding rare maternal complications, such as uterine rupture, is limited. AUTHORS' CONCLUSIONS The use of vaginal misoprostol in the termination of second and third trimester of pregnancy is as effective as other prostaglandin preparations (including cervagem, prostaglandin E(2) and prostaglandin F(2alpha)), and more effective than oral administration of misoprostol. However, important information regarding maternal safety, and in particular the occurrence of rare outcomes such as uterine rupture, remains limited. Future research efforts should be directed towards determining the optimal dose and frequency of administration, with particular attention to standardised reporting of all relevant outcomes and assessment of rare adverse events. Further information is required about the use of sublingual misoprostol in this setting.
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Affiliation(s)
- Jodie M Dodd
- School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Women's and Children's Hospital, 72 King William Road, Adelaide, South Australia, Australia, 5006
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Neilson JP, Gyte GML, Hickey M, Vazquez JC, Dou L. Medical treatments for incomplete miscarriage (less than 24 weeks). Cochrane Database Syst Rev 2010:CD007223. [PMID: 20091626 PMCID: PMC4042279 DOI: 10.1002/14651858.cd007223.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining pregnancy tissues in the uterus. However, it has been suggested that drug-based medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable. OBJECTIVES To assess the effectiveness, safety and acceptability of any medical treatment for early incomplete miscarriage (before 24 weeks). SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009). SELECTION CRITERIA Randomised controlled trials comparing medical treatment with expectant care or surgery. Quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. MAIN RESULTS Fifteen studies (2750 women) were included, there were no studies on women over 13 weeks' gestation. Studies addressed a number of comparisons and data are therefore limited.Three trials compared misoprostol treatment (all vaginally administered) with expectant care. There was no significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women). There were few data on 'deaths or serious complications'.Nine studies involving 1766 women addressed the comparison of misoprostol (four oral, four vaginal, one vaginal + oral) with surgical evacuation. There was no statistically significant difference in complete miscarriage (average RR 0.96, 95% CI 0.92 to 1.00, eight studies, 1377 women) with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.07, 95% CI 0.03 to 0.18; eight studies, 1538 women) but more unplanned procedures (average RR 6.32, 95% CI 2.90 to 13.77; six studies, 1158 women). There were few data on 'deaths or serious complications'. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice.
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Affiliation(s)
- James P Neilson
- Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
| | - Gillian ML Gyte
- Cochrane Pregnancy and Childbirth Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
| | - Martha Hickey
- The University of Melbourne, The Royal Women’s Hospital, Melbourne, Australia
| | - Juan C Vazquez
- Departamento de Salud Reproductiva, Instituto Nacional de Endocrinologia (INEN), Habana, Cuba
| | - Lixia Dou
- Cochrane Pregnancy and Childbirth Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
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Yilmaz B, Ertas IE, Kelekci S, Sut N, Mollamahmutoglu L, Danisman N. Moistening of misoprostol tablets with acetic acid prior to vaginal administration for mid-trimester termination of anomalous pregnancy: A randomised comparison of three regimens. EUR J CONTRACEP REPR 2010; 15:54-9. [DOI: 10.3109/13625180903417486] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gómez Ponce de León R, Wing DA. Misoprostol for termination of pregnancy with intrauterine fetal demise in the second and third trimester of pregnancy — a systematic review. Contraception 2009; 79:259-71. [DOI: 10.1016/j.contraception.2008.10.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Revised: 10/13/2008] [Accepted: 10/15/2008] [Indexed: 11/25/2022]
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Lo TK, Lau WL, Lai FK, Lam H, Tse HY, Leung WC, Chin RKH. The effect of gestational age on the outcome of second-trimester termination of pregnancies for foetal abnormalities. Prenat Diagn 2008; 28:508-11. [DOI: 10.1002/pd.2012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Khazardoost S, Hantoushzadeh S, Madani MM. A randomised trial of two regimens of vaginal misoprostol to manage termination of pregnancy of up to 16 weeks. Aust N Z J Obstet Gynaecol 2007; 47:226-9. [PMID: 17550491 DOI: 10.1111/j.1479-828x.2007.00721.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the efficacy and side-effects of two regimens of vaginal misoprostol for pregnancy termination of up to 16 weeks. METHODS A randomised clinical trial of medical pregnancy termination of up to 16 weeks was conducted. A hundred pregnant women requesting legal termination of pregnancy were randomised into two groups to receive either 200 microg (50 women) or 400 microg (50 women)--vaginal misoprostol every six hours up to four doses. Outcome of abortion and side-effects were assessed. RESULTS The groups were similar in maternal age, gestational age, parity and indication for pregnancy termination. There were no statistically significant differences between the two groups in abortion (P = 0.084) and mean induction to abortion time (P = 0.35). However, the side-effects in the 400 microg group were significantly higher than in the 200 microg group (P = 0.000). CONCLUSION In pregnancy termination of up to 16 weeks, 200 microg vaginal misoprostol every six hours up to four doses was as effective as 400 microg, but side-effects were more common in 400 microg regimen.
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Affiliation(s)
- Soghra Khazardoost
- Perinatalogy Department, Vali-e-Asr Reproductive Health Research Centre, Tehran University of Medical Sciences, Tehran, Iran.
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20
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Lalitkumar S, Bygdeman M, Gemzell-Danielsson K. Mid-trimester induced abortion: a review. Hum Reprod Update 2006; 13:37-52. [PMID: 17050523 DOI: 10.1093/humupd/dml049] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Mid-trimester abortion constitutes 10-15% of all induced abortion. The aim of this article is to provide a review of the current literature of mid-trimester methods of abortion with respect to efficacy, side effects and acceptability. There have been continuing efforts to improve the abortion technology in terms of effectiveness, technical ease of performance, acceptability and reduction of side effects and complications. During the last decade, medical methods for mid-trimester induced abortion have shown a considerable development and have become safe and more accessible. The combination of mifepristone and misoprostol is now an established and highly effective method for termination of pregnancy (TOP). Advantages and disadvantages of medical versus surgical methods are discussed. Randomized studies are lacking, and more studies on pain treatment and the safety of any method used in patients with a previous uterine scar are debated, and data are scarce. Pain management in abortion requires special attention. This review highlights the need for randomized studies to set guidelines for mid-trimester abortion methods in terms of safety and acceptability as well as for better analgesic regimens.
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Affiliation(s)
- S Lalitkumar
- Department of Woman and Child Health, Division for Obstetrics and Gynaecology, Karolinska University Hospital/Karolinska Institute, Stockholm, Sweden
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21
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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 before 14 weeks has traditionally been surgical but medical treatments may be effective, safe, and acceptable, as may be waiting for spontaneous miscarriage. OBJECTIVES To assess the effectiveness, safety and acceptability of any medical treatment for early pregnancy failure (anembryonic pregnancies or embryonic and fetal deaths before 24 weeks). SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 November 2005). SELECTION CRITERIA Randomised trials comparing medical treatment with another treatment (e.g. surgical evacuation), or placebo, or no treatment for early pregnancy failure. Quasi-random studies were excluded. DATA COLLECTION AND ANALYSIS Data were extracted unblinded. MAIN RESULTS Twenty four studies (1888 women) were included. Vaginal misoprostol hastens miscarriage (complete or incomplete) when compared with placebo: e.g. miscarriage less than 24 hours (two trials, 138 women, relative risk (RR) 4.73, 95% confidence interval (CI) 2.70 to 8.28), with less need for uterine curettage (two trials, 104 women, RR 0.40, 95% CI 0.26 to 0.60) and no significant increase in nausea or diarrhoea. Lower-dose regimens of vaginal misoprostol tend to be less effective in producing miscarriage (three trials, 247 women, RR 0.85, 95% CI 0.72 to 1.00) with similar incidence of nausea. There seems no clear advantage to administering a 'wet' preparation of vaginal misoprostol or of adding methotrexate, or of using laminaria tents after 14 weeks. Vaginal misoprostol is more effective than vaginal prostaglandin E in avoiding surgical evacuation. Oral misoprostol was less effective than vaginal misoprostol in producing complete miscarriage (two trials, 218 women, RR 0.90, 95% CI 0.82 to 0.99). Sublingual misoprostol had equivalent efficacy to vaginal misoprostol in inducing complete miscarriage but was associated with more frequent diarrhoea. The two trials of mifepristone treatment generated conflicting results. There was no statistically significant difference between vaginal misoprostol and gemeprost in the induction of miscarriage for fetal death after 13 weeks. AUTHORS' CONCLUSIONS Available evidence from randomised trials supports the use of vaginal misoprostol as a medical treatment to terminate non-viable pregnancies before 24 weeks. Further research is required to assess effectiveness and safety, optimal route of administration and dose. Conflicting findings about the value of mifepristone need to be resolved by additional study.
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Affiliation(s)
- J P Neilson
- University of Liverpool, Division of Perinatal and Reproductive Medicine, First Floor, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool, UK L8 7SS.
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Dodd JM, Crowther CA. Misoprostol versus cervagem for the induction of labour to terminate pregnancy in the second and third trimester: A systematic review. Eur J Obstet Gynecol Reprod Biol 2006; 125:3-8. [PMID: 16466671 DOI: 10.1016/j.ejogrb.2005.10.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2004] [Revised: 05/27/2005] [Accepted: 10/26/2005] [Indexed: 11/15/2022]
Abstract
AIMS to compare the benefits and harms of misoprostol to induce labour in the second and third trimester of pregnancy with cervagem. METHODS MEDLINE was searched using the terms abortion, induced; abortifacient agents; pregnancy, second trimester; pregnancy, third trimester; misoprostol; cervagem; and gemeprost to identify randomised controlled trials in which misoprostol was compared with cervagem, for induction of labour to terminate pregnancy in the second or third trimester. Outcomes included vaginal birth not achieved within 24h; induction to delivery interval; analgesia requirements; blood loss; blood transfusion; surgical evacuation of the uterus; maternal death or serious maternal morbidity; side effects. RESULTS Six randomised trials were included. Five compared vaginal misoprostol with cervagem [el Refaey H, Hinshaw K, Templeton A. The abortifacient effect of misoprostol in the second trimester: a randomized comparison with gemeprost in patients pre-treated with mifepristone (RU486). Hum Reprod 1993;8(10):1744-6; Ho PC, Chan YF, Lau W. Misoprostol is as effective as gemeprost in termination of second trimester pregnancy when combined with mifepristone: a randomised comparative trial. Contraception 1996;53(5):281-3; Nuutila M, Toivonen J, Ylikorkala O, Halmesmaki E. A comparison between two doses of intravaginal misoprostol and gemeprost for induction of second trimester abortion. Obstetr Gynecol 1997;90(6):896-900; Wong KS, Ngai CS, Wong AY, Tang LC, Ho PC. Vaginal misoprostol compared with vaginal gemeprost in termination of pregnancy: a randomized controlled trial. Contraception 1998;58(4):207-10; Dickinson JE, Godfrey M, Evans SF. Efficacy of intravaginal misoprostol in second trimester termination of pregnancy: a randomized controlled trial. J Mater Fetal Med 1999;7(3):115-9], and one oral misoprostol with gemeprost [Bartley J, Baird DT. A randomised study of misoprostol and gemeprost in combination with mifepristone for induction of abortion in the second trimester of pregnancy. Br J Obstetr Gynaecol 2002;109(11):1290-4]. Vaginal misoprostol compared with cervagem was associated with reduced narcotic analgesia (3 studies, 169 women, RR 0.64 95% CI 0.49-0.84), and surgical evacuation of the uterus (5 studies, 319 women, RR 0.71 95% CI 0.53-0.95). No other statistically significant differences were observed for other outcomes with reported data. In the single trial comparing oral misoprostol with gemeprost, reported outcomes were similar. CONCLUSIONS Vaginal misoprostol for the termination of second and third trimester of pregnancy appears as effective as cervagem, but information about maternal safety is limited.
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Affiliation(s)
- Jodie M Dodd
- Maternal Fetal Medicine Specialist, Department of Obstetrics & Gynaecology, The University of Adelaide, 72 King William Road, North Adelaide 5006, Australia.
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Kaasen A, Naes T, Haugen G. Which factors influence the number of gemeprost pessaries used in inducing second-trimester abortions? Acta Obstet Gynecol Scand 2005; 84:371-5. [PMID: 15762968 DOI: 10.1111/j.0001-6349.2005.00503.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The course of second-trimester abortions with the intention to use gemeprost as the only abortifacient is described. METHODS The report is based on 278 consecutive second-trimester abortions, excluding missed abortions, during a 12-year period in a tertiary referral center. The women were treated with 1 mg gemeprost pessaries every fourth hour with a maximum of five applications during 24 h. If abortion had not occurred, a new treatment of gemeprost was prescribed after an interval of 12 h. RESULTS The median number of gemeprost pessaries used was 4 (range 1-16) and the mean number (+/-SD) 4.09 (+/-1.90). Abortion occurred within 24 h in 78% of the women and within 48 h in 96%. The efficiency of gemeprost was highly dependent on previous vaginal deliveries (p<0.001), with a mean number of applications of 4.63 (+/-2.04), 3.93 (+/-1.74), and 3.13 (+/-1.26) in those with none, one, and two or more previous vaginal deliveries, respectively. Previous spontaneous abortions were associated with a lower number of applications. Including previous vaginal deliveries and spontaneous abortions in a two-way analysis of variance (anova), only the number of spontaneous abortions was marginally significant (p=0.05). After excluding four patients with three or more spontaneous abortions from the analysis, the number of previous vaginal deliveries was significant (p=0.010) whereas that of spontaneous abortions became nonsignificant. Postprocedure complications were reported in 13% of the women. CONCLUSION The course of the abortions was dependent on previous vaginal deliveries and spontaneous abortions.
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Affiliation(s)
- Anne Kaasen
- Department of Obstetrics and Gynecology, The National Hospital, University of Oslo, Oslo, Norway.
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Dailland P, Legros C, Berl M, Dubois L, Lamour O. Prise en charge des interruptions médicales tardives de grossesse. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s1279-7960(05)83655-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Dodd J, O'Brien L, Coffey J. Misoprostol for second and third trimester termination of pregnancy: A review of practice at the Women's and Children's Hospital, Adelaide, Australia. Aust N Z J Obstet Gynaecol 2005; 45:25-9. [PMID: 15730361 DOI: 10.1111/j.1479-828x.2005.00338.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To assess clinical outcomes for women undergoing induction of labour either for fetal anomaly or following intrauterine fetal death using intravaginal misoprostol. METHODS Between January 1999 and December 2002, clinical outcomes for women who were admitted to the delivery suite of the Women's and Children's Hospital, South Australia, were prospectively collected and entered onto a database by the attending midwife. The effect of cumulative dose of misoprostol, indication for induction of labour, parity and gestational age were assessed. RESULTS One hundred and ninety nine women were admitted during the study period. Women who required in excess of 800 microg of misoprostol were more likely to have side-effects (57/78 women dose > 800 microg misoprostol versus 71/121 women dose < or = 800 microg, RR 0.80 95% CI 0.66-0.98), in particular diarrhoea (12/78 women dose > 800 microg misoprostol versus 5/121 women dose < or = 800 microg, RR 0.27 95% CI 0.10-0.73) and elevated temperature (46/78 women dose > 800 microg misoprostol versus 36/121 women dose < or = 800 microg, RR 0.50 95% CI 0.36-0.70). Women with an intrauterine fetal death (IUFD) were less likely to require in excess of 800 microg of misoprostol to effect the termination (10/56 women IUFD versus 70/143 women fetal anomaly, RR 0.36 95% CI 0.20-0.66), had a shorter induction to birth interval (mean 13.2 h +/- 7.5 h, women IUFD versus 21.2 +/- 17.5 h, women fetal anomaly, WMD -8.02 95% CI -11.49 to -4.55) and were more likely to give birth within 24 h of the induction process commencing (48/56 women IUFD versus 106/143 women fetal anomaly, RR 1.16 95% CI 1.00-1.34). CONCLUSIONS Side-effects increase with increasing dose of misoprostol. Induction following intrauterine fetal death is associated with a need for lower doses of misoprostol and a shorter induction to birth interval.
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Affiliation(s)
- Jodie Dodd
- Department of Obstetrics and Gynaecology, The University of Adelaide, Australia.
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Grimes DA, Smith MS, Witham AD. Mifepristone and misoprostol versus dilation and evacuation for midtrimester abortion: a pilot randomised controlled trial. BJOG 2003; 111:148-53. [PMID: 14723752 DOI: 10.1046/j.1471-0528.2003.00044.x-i1] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To test the feasibility of mounting a randomised controlled trial comparing mifepristone-misoprostol versus dilation and evacuation (D&E) for midtrimester abortion. DESIGN Pilot randomised controlled trial. SETTING University of North Carolina Hospitals, Chapel Hill, North Carolina. POPULATION Women aged 18 years or older and without prior uterine operations who requested abortion at 14-19 menstrual weeks of gestation from January 2002 to January 2003. METHODS Participants received either mifepristone 200 mg by mouth followed in two days by vaginal then oral misoprostol (Aberdeen regimen) or D&E after one or two days of laminaria preparation. Care was provided by residents under faculty supervision. MAIN OUTCOME MEASURES Enrolment rate and acceptability of and adverse events associated with methods. RESULTS The trial was stopped at one year because of slow enrolment. Of 47 women eligible for the trial, 29 (62%) declined participation, primarily because of a preference for D&E abortion. Among the 18 participants enrolled, nine were randomised to treatment with mifepristone-misoprostol and 9 to D&E. Compared with D&E, mifepristone-misoprostol abortion caused more pain and adverse events, although none was serious. CONCLUSIONS Our findings concerning acceptability and adverse events should be considered hypothesis-generating; they may prove useful in planning a larger randomised controlled trial. Such a trial will be difficult to mount in the US. Hence, we suggest that it be done in a setting where labour-induction abortion is the norm.
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Affiliation(s)
- David A Grimes
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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A Comparison of Oral Misoprostol With Vaginal Misoprostol Administration in Second-Trimester Pregnancy Termination for Fetal Abnormality. Obstet Gynecol 2003. [DOI: 10.1097/00006250-200306000-00026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Women who receive abnormal prenatal diagnosis results potentially face two emotionally difficult decisions. In this article, the first decision--whether or not to terminate the pregnancy--is presented with a discussion of the factors that may influence a women's choice. Women who choose to terminate the pregnancy face a second decision when more than one type of abortion procedure is available. Two second trimester abortion procedures--dilation and evacuation and labor induction--are compared and contrasted to delineate potential advantages and disadvantages of each. The decision-making process is examined, emphasizing the individual ways in which women may weigh this information to make a fully informed decision. In addition, a number of recommendations are offered to health care providers in the role of discussing options and supporting women in their choices.
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