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Schmerold L, Martin C, Mehta A, Sobti D, Jaiswal AK, Kumar J, Feldberg I, Munro MG, Lee WC. A cost-effectiveness analysis of intrauterine spacers used to prevent the formation of intrauterine adhesions following endometrial cavity surgery. J Med Econ 2024; 27:170-183. [PMID: 38131367 DOI: 10.1080/13696998.2023.2298584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/20/2023] [Indexed: 12/23/2023]
Abstract
AIM To assess, from a United States (US) payer's perspective, the cost-effectiveness of gels designed to separate the endometrial surfaces (intrauterine spacers) placed following intrauterine surgery. MATERIALS AND METHODS A decision tree model was developed to estimate the cost-effectiveness of intrauterine spacers used to facilitate endometrial repair and prevent the formation (primary prevention) and reformation (secondary prevention) of intrauterine adhesions (IUAs) and associated pregnancy- and birth-related adverse outcomes. Event rates and costs were extrapolated from data available in the existing literature. Sensitivity analyses were conducted to corroborate the base case results. RESULTS In this model, using intrauterine spacers for adhesion prevention led to net cost savings for US payers of $2,905 per patient over a 3.5-year time horizon. These savings were driven by the direct benefit of preventing procedures associated with IUA formation ($2,162 net savings) and the indirect benefit of preventing pregnancy-related complications often associated with IUA formation ($3,002). These factors offset the incremental cost of intrauterine spacer use of $1,539 based on an assumed price of $1,800 and the related increase in normal deliveries of $931. Model outcomes were sensitive to the probability of preterm and normal deliveries. Budget impact analyses show overall cost savings of $19.96 per initial member within a US healthcare plan, translating to $20 million over a 5-year time horizon for a one-million-member plan. LIMITATIONS There are no available data on the effects of intrauterine spacers or IUAs on patients' quality of life. Resultingly, the model could not evaluate patients' utility related to treatment with or without intrauterine spacers and instead focused on costs and events avoided. CONCLUSION This analysis robustly demonstrated that intrauterine spacers would be cost-saving to healthcare payers, including both per-patient and per-plan member, through a reduction in IUAs and improvements to patients' pregnancy-related outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | - Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Wang Z, Meng Y, Shang X, Suo L, Zhao D, Han X, Yang M, Yin M, Miao H, Wang Y, Yang H, Yu Y, Wei D, Chen ZJ. Interpregnancy Interval After Clinical Pregnancy Loss and Outcomes of the Next Frozen Embryo Transfer. JAMA Netw Open 2023; 6:e2340709. [PMID: 37906188 PMCID: PMC10618845 DOI: 10.1001/jamanetworkopen.2023.40709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/18/2023] [Indexed: 11/02/2023] Open
Abstract
Importance The optimal interpregnancy interval (IPI) after a clinical pregnancy loss (CPL) remains controversial. Few studies have addressed the role of the IPI after a preceding CPL during in vitro fertilization (IVF) treatment. Objective To evaluate the association between different IPI lengths after a preceding CPL and pregnancy outcomes of the next frozen embryo transfer (FET). Design, Setting, and Participants This retrospective cohort study was conducted using data from the Center for Reproductive Medicine of Shandong University in China. The study included women who underwent frozen-thawed blastocyst transfer between July 1, 2017, and June 30, 2022, within 1 year after a preceding CPL during IVF treatment. Follow-up for pregnancy outcomes was completed for all participants on March 31, 2023. Data analysis was performed from April to May 2023. Exposures Interpregnancy interval length was classified as less than 3 months, 3 to less than 6 months, or 6 to 12 months. Main Outcomes and Measures Outcomes included live birth, conception, clinical pregnancy, pregnancy loss, preterm birth, small or large for gestational age, and low birth weight. Multivariable logistic regression analysis was conducted to evaluate the association between IPI and pregnancy outcomes by adjusted odds ratios (AORs). Results This study included 2433 women (mean [SD] age, 31.8 [4.6] years) who received IVF treatment. There were 338 women (13.9%) with an IPI of less than 3 months, 1347 (55.4%) with an IPI of 3 to less than 6 months, and 748 (30.7%) with an IPI of 6 to 12 months. The median (IQR) IPI lengths for the 3 groups were 77 (65-85), 128 (109-152), and 234 (202-288) days, respectively. Compared with an IPI of 6 to 12 months, shorter IPIs (<3 and 3 to <6 months) were associated with decreased odds of clinical pregnancy (AOR, 0.70 [95% CI, 0.53-0.92] and 0.79 [0.65-0.95]), live birth (AOR, 0.64 [95% CI, 0.48-0.85] and 0.74 [0.61-0.90]), and healthy live birth (AOR, 0.63 [95% CI, 0.46-0.87] and 0.79 [0.64-0.98]). Compared with women with an IPI of 6 to 12 months, women with shorter IPIs (<3 and 3 to <6 months) had a higher risk of total pregnancy loss (AOR, 1.87 [95% CI, 1.31-2.67] and 1.29 [1.00-1.66], respectively). Conclusions and Relevance The results of this study suggest that delaying the next FET for at least 6 months after a preceding CPL was associated with beneficial pregnancy outcomes, considering that a decreased likelihood of achieving clinical pregnancy and live birth was observed among women with shorter IPIs. Further prospective studies are needed to confirm these findings.
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Affiliation(s)
- Ze Wang
- Center for Reproductive Medicine, Shandong University, Jinan, China
| | - Yueru Meng
- Center for Reproductive Medicine, Shandong University, Jinan, China
| | - Xue Shang
- Center for Reproductive Medicine, Shandong University, Jinan, China
| | - Lu Suo
- Center for Reproductive Medicine, Shandong University, Jinan, China
| | - Dingying Zhao
- Center for Reproductive Medicine, Shandong University, Jinan, China
| | - Xinwei Han
- Center for Reproductive Medicine, Shandong University, Jinan, China
| | - Min Yang
- Center for Reproductive Medicine, Shandong University, Jinan, China
| | - Mengfei Yin
- Center for Reproductive Medicine, Shandong University, Jinan, China
| | - Haozhe Miao
- Center for Reproductive Medicine, Shandong University, Jinan, China
| | - Yixuan Wang
- Center for Reproductive Medicine, Shandong University, Jinan, China
| | - Huiming Yang
- Center for Reproductive Medicine, Shandong University, Jinan, China
| | - Yunhai Yu
- Department of Obstetrics and Gynecology, Second Hospital of Shandong University, Jinan, China
| | - Daimin Wei
- Center for Reproductive Medicine, Shandong University, Jinan, China
- Medical Integration and Practice Center, Shandong University, Jinan, China
| | - Zi-Jiang Chen
- Center for Reproductive Medicine, Shandong University, Jinan, China
- Medical Integration and Practice Center, Shandong University, Jinan, China
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Ratnam S, Kulasingam S, Kanagallingam A. Manual Vacuum Aspiration Versus Expectant Management for First Trimester Miscarriage: A Randomized Controlled Trial. Cureus 2023; 15:e45731. [PMID: 37868571 PMCID: PMC10590258 DOI: 10.7759/cureus.45731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 10/24/2023] Open
Abstract
Background Miscarriage is one of the common problems encountered in pregnancy. The treatment modalities are expectant, medical, and surgical management. This study compared the effectiveness and safety of manual vacuum aspiration (MVA) with expectant management for first trimester miscarriage. Method This randomized controlled trial was conducted in Teaching Hospital Jaffna, Jaffna, Sri Lanka, and 134 eligible patients with first trimester spontaneous miscarriage were randomized to expectant management (67) and MVA (67). Those allocated to expectant management were managed expectantly for up to two weeks, and those allocated to MVA underwent aspiration under a paracervical block in the ward. The primary outcome was complete evacuation of the uterus, and the secondary outcomes were duration of bleeding, duration of pain, level of pain, need for the second procedure, cervical or uterine injuries, and patient satisfaction. Results Of the 134 eligible women, seven were lost to follow-up and 127 were analyzed. The MVA was superior in achieving complete evacuation compared to expectant management (95.2% vs. 70.3%; p ≤ 0.001). Notably, in both groups, complete evacuation was more readily achievable in incomplete miscarriage than in missed miscarriage. Duration of bleeding (mean days, 1.6 vs. 4.3; p ≤ 0.0001), duration of pain (mean days, 1.0 vs. 4.2; p ≤ 0.0001), and the need for additional surgical procedure in the form of dilatation and curettage (4.8% vs. 29.7%; p ≤ 0.001) were lower in MVA. Patient satisfaction was higher in the MVA group than in the expectant group (93.7% vs. 65.6%; p ≤ 0.001). No statistically significant differences were observed between the groups in terms of blood transfusion and infection. There wasn't any incidence of cervical damage or uterine perforation. Conclusion MVA is an effective and safe treatment method for first trimester miscarriage with higher patient satisfaction.
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Affiliation(s)
- Sutharshan Ratnam
- Obstetrics and Gynaecology, Postgraduate Institute of Medicine, University of Colombo, Colombo, LKA
- Obstetrics and Gynaecology, Teaching Hospital Jaffna, Jaffna, LKA
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Muacevic A, Adler JR. Mental Health Amidst COVID-19: A Review Article. Cureus 2022; 14:e33030. [PMID: 36721587 PMCID: PMC9883055 DOI: 10.7759/cureus.33030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/28/2022] [Indexed: 12/30/2022] Open
Abstract
Outbreaks of infectious diseases confined to a particular locality are not unusual. Respiratory infections such as tuberculosis or community-acquired pneumonia are known in developing and underdeveloped countries. However, COVID-19 infection had globally created havoc due to its high rate of transmission and serious consequences on physical and mental health paralyzing the healthcare facilities of not only developing but also developed nations. This created a sense of uncertainty and insecurity in the public globally, adversely affecting the mental health of almost every individual. It is genuinely obtrusive that the COVID-19 pandemic brought about a global lockdown, adversely affecting the psychological health of the public. Some pandemic-related stressors affect nearly everyone. This review aims to study the effect of the COVID-19 pandemic in terms of psychological well-being and its overall effect on society, thereby making it essential to lend them a helping hand.
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Vieira de Mello P, Bruns RF, Fontoura Klas C, Raso Hammes L. Expectant management of viable cesarean scar pregnancies: a systematic review. Arch Gynecol Obstet 2022:10.1007/s00404-022-06835-3. [DOI: 10.1007/s00404-022-06835-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/21/2022] [Indexed: 11/18/2022]
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Margaliot Kalifa T, Lang Ben Nun E, Sela HY, Khatib F, Grisaru-Granovsky S, Rottenstreich M. Maternal and Neonatal Outcomes of Women Conceived Less Than 6 Months after First Trimester Dilation and Curettage. J Clin Med 2022; 11:2767. [PMID: 35628894 PMCID: PMC9147896 DOI: 10.3390/jcm11102767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/06/2022] [Accepted: 05/12/2022] [Indexed: 02/01/2023] Open
Abstract
Objective: To evaluate the maternal and neonatal outcomes of pregnancies conceived ≤6 months after first trimester (<14 weeks) dilation and curettage (D&C). Methods: A retrospective computerized database study of women who conceived ≤6 months following a missed abortion and delivered in a single tertiary medical center between 2016 and 2021. The maternal and neonatal outcomes of women who had D&C were compared to those of women who had non-medical or spontaneous miscarriages. The primary outcome of this study was the rate of preterm birth (<37 weeks). Secondary outcomes were adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression models; adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated. Results: During the study period, 1773 women met the inclusion criteria; of those, 1087 (61.3%) women gave birth following D&C. We found no differences between the study groups in any maternal or neonatal parameter examined including preterm birth (PTB), miscarriage to pregnancy interval, fertility treatments, hypertension disorders of pregnancy, placental complications, mode of delivery and neonatal birth weights. This was confirmed on a multivariate analysis as well [aOR 1.74 (0.89−3.40), p = 0.11] for preterm birth. Conclusion: Watchful waiting or the medical treatment of a first trimester missed abortion present no more risks than D&C to pregnancies conceived within six months of the index miscarriage. Further studies in other settings to strengthen these findings are needed.
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Affiliation(s)
- Tal Margaliot Kalifa
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem 91031, Israel; (T.M.K.); (E.L.B.N.); (F.K.); (S.G.-G.); (M.R.)
| | - Eyal Lang Ben Nun
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem 91031, Israel; (T.M.K.); (E.L.B.N.); (F.K.); (S.G.-G.); (M.R.)
| | - Hen Y. Sela
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem 91031, Israel; (T.M.K.); (E.L.B.N.); (F.K.); (S.G.-G.); (M.R.)
| | - Fayez Khatib
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem 91031, Israel; (T.M.K.); (E.L.B.N.); (F.K.); (S.G.-G.); (M.R.)
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem 91031, Israel; (T.M.K.); (E.L.B.N.); (F.K.); (S.G.-G.); (M.R.)
| | - Misgav Rottenstreich
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem 91031, Israel; (T.M.K.); (E.L.B.N.); (F.K.); (S.G.-G.); (M.R.)
- Department of Nursing, Jerusalem College of Technology, Jerusalem 93721, Israel
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Foreste V, Gallo A, Manzi A, Riccardi C, Carugno J, Sardo ADS. Hysteroscopy and Retained Products of Conception: An Update. Gynecol Minim Invasive Ther 2021; 10:203-209. [PMID: 34909376 PMCID: PMC8613498 DOI: 10.4103/gmit.gmit_125_20] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/11/2021] [Accepted: 01/27/2021] [Indexed: 11/25/2022] Open
Abstract
Retained products of conception (RPOC) can occur after early or mid-trimester pregnancy termination and also following vaginal or cesarean delivery. It is frequently associated with continuous vaginal bleeding, pelvic pain, and infection. Late complications include intrauterine adhesions formation and infertility. Conventionally, the management of RPOC has been with blind dilation and suction curettage (D and C); however, hysteroscopic resection of RPOC is a safe and efficient alternative. In this review, we analyze the current available evidence regarding the use of hysteroscopic surgery for the treatment of RPOC comparing outcomes and complications of both traditional curettage and hysteroscopic technique. Data search has been conducted using the following databases MEDLINE, EMBASE, Web of Sciences, Scopus, Clinical Trial. Gov., OVID, and Cochrane Library interrogate all articles related to hysteroscopy and the preserved product of conception, updated through September 2020.
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Affiliation(s)
- Virginia Foreste
- Department of Neuroscience Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Alessandra Gallo
- Department of Neuroscience Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Alfonso Manzi
- Department of Neuroscience Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Carla Riccardi
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Jose Carugno
- Department of Gynecology and Reproductive Sciences, Minimally Invasive Gynecology Division, University of Miami, Miller School of Medicine, Miami, Florida, USA
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Kyriacou C, Cooper N, Robinson E, Parker N, Barcroft J, Kundu S, Letchworth P, Sur S, Gould D, Stalder C, Bourne T. Ultrasound characteristics, serum biochemistry and outcome of ectopic pregnancies presenting during COVID-19 pandemic. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:909-915. [PMID: 34605083 PMCID: PMC8661840 DOI: 10.1002/uog.24793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 09/14/2021] [Accepted: 09/28/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To describe and compare the characteristics of ectopic pregnancies (EPs) in the year prior to vs during the coronavirus disease 2019 (COVID-19) pandemic. METHODS This was a retrospective analysis of women diagnosed with an EP on transvaginal sonography conducted at a center in London, UK, providing early-pregnancy assessment, between 1 January 2019 and 31 December 2020. Women were identified via the Astraia ultrasound reporting system using coded and non-coded outcomes of EP or pregnancy outside the uterine cavity. Data related to predefined outcomes were collected using Astraia and Cerner electronic reporting systems. Main outcome measures included clinical, ultrasound and biochemical features of EP, in addition to reported complications and management. RESULTS There were 22 683 consultations over the 2-year period. Following consultation, a similar number and proportion of EPs were diagnosed in 2019 (141/12 657 (1%)) and 2020 (134/10 026 (1%)). Both cohorts were comparable in age, ethnicity, weight and method of conception. Gestational age at the first transvaginal sonography scan and at diagnosis were similar, and no difference in location, size or morphology of EP was found between the two cohorts. Serum human chorionic gonadotropin (hCG) levels at the time of EP diagnosis were higher in 2020 than in 2019 (1005 IU/L vs 665 IU/L; P = 0.03). The proportions of women according to type of final EP management were similar, but the rate of failed first-line management was higher during vs before the pandemic (16% vs 6%; P = 0.01). The rates of blood detected in the pelvis (hemoperitoneum) on ultrasound (23% vs 26%; P = 0.58) and of ruptured EP confirmed surgically (9% vs 3%; P = 0.07) were similar in 2019 vs 2020. CONCLUSIONS No difference was observed in the location, size, morphology or gestational age at the first ultrasound examination or at diagnosis of EP between women diagnosed before vs during the COVID-19 pandemic. Complication rates and final management strategy were also unchanged. However, hCG levels and the failure rate of first-line conservative management measures were higher during the pandemic. Our findings suggest that women continued to access appropriate care for EP during the COVID-19 pandemic, with no evidence of diagnostic delay or an increase in adverse outcome in our population. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C. Kyriacou
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
- Department of Metabolism, Digestion and ReproductionImperial College LondonLondonUK
| | - N. Cooper
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
| | - E. Robinson
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
| | - N. Parker
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
| | - J. Barcroft
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
| | - S. Kundu
- Department of Metabolism, Digestion and ReproductionImperial College LondonLondonUK
| | - P. Letchworth
- St Mary's Hospital, Department of Obstetrics and GynaecologyImperial College LondonLondonUK
| | - S. Sur
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
| | - D. Gould
- St Mary's Hospital, Department of Obstetrics and GynaecologyImperial College LondonLondonUK
| | - C. Stalder
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
| | - T. Bourne
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
- Department of Metabolism, Digestion and ReproductionImperial College LondonLondonUK
- Department of Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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The implementation of routine procedural transvaginal sonography to decrease retained products of conception: a quality improvement initiative. BMC WOMENS HEALTH 2021; 21:347. [PMID: 34602062 PMCID: PMC8489076 DOI: 10.1186/s12905-021-01488-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022]
Abstract
Background Retained products of conception (POC) following uterine evacuation can lead to adverse sequelae, including hemorrhage, endometritis, intrauterine adhesions, and reoperation. Use of procedural transvaginal sonography (TVUS) in the operating room has been proposed to help decrease retained POC. Methods A retrospective review of all first trimester uterine evacuation procedures from 1/2015 to 2/2017 was performed, noting use of transabdominal ultrasonography, retained products of conception, and complications. A practice change was implemented in May 2018, in which routine intra-procedural TVUS use was initiated. A second retrospective chart review was conducted to assess for post-implementation incidence of retained POC, re-operation, and associated complications. Results Prior to intra-procedural TVUS implementation, 130 eligible procedures were performed during the specified timeframe, with 9/130 (6.9%) incidence of retained products of conception. TAUS was performed in 59/130 (45.4%) of procedures, and 4/9 (44.4%) of those with retained products. There were eight re-operative procedures in seven patients, and two patients were treated with misoprostol. Complications included hemorrhage, Asherman’s syndrome and endometritis. Following implementation, 95 first trimester procedures were performed with transvaginal sonography, with 0 (0%) cases of retained POC (p = 0.01), no incidences of re-operation (p = 0.02), and one case of Asherman’s syndrome. TVUS findings led to additional focused suction curettage in 20/95 (21.0%) of procedures. The endometrium was measured on procedure completion in 64 procedures, with a mean thickness of 5.5 mm (1–12 mm). Conclusion Implementation of routine TVUS during uterine evacuation may reduce the incidence of retained POC and associated reoperation rates. Further multi-center trials are needed to confirm this finding. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-021-01488-x.
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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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11
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Vafaei H, Ajdari S, Hessami K, Hosseinkhani A, Foroughinia L, Asadi N, Faraji A, Abolhasanzadeh S, Bazrafshan K, Roozmeh S. Efficacy and safety of myrrh in patients with incomplete abortion: a randomized, double-blind, placebo-controlled clinical study. BMC Complement Med Ther 2020; 20:145. [PMID: 32397980 PMCID: PMC7218551 DOI: 10.1186/s12906-020-02946-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 05/07/2020] [Indexed: 12/27/2022] Open
Abstract
Background Myrrh (Commiphora myrrha (Nees) Engl.) has a long history of traditional use as a herbal medicine for different purposes. In ancient traditional Persian manuscripts, it has been noted that myrrh may act as uterine stimulant and probably cause complete abortion. However, there is no evidence to verify this comment. Therefore, the current study was carried out to evaluate the efficacy and safety of Myrrh in the treatment of incomplete abortion. Materials and methods In a randomized double-blinded placebo controlled clinical trial, 80 patients with ultrasound-documented retained products of conception (RPOC) were assigned to receive capsules containing 500 mg of Myrrh oleo-gum-resin or a placebo three times a day for 2 weeks. The existence of the retained tissue and its size were evaluated by ultrasound examination at the beginning and end of the study. Results After 2 weeks, the mean diameter of the RPOC in the Myrrh group was significantly reduced compared with the placebo group (P < 0.001). Meanwhile, the rate of successful complete abortion was 82.9% in the intervention group and 54.3% in the placebo group (P = 0.01). The patients in both groups reported no serious drug-related adverse effects. Conclusion This study shows that Myrrh is effective and safe in the resolution of the RPOC and may be considered as an alternative option for treatment of patients with incomplete abortion. However, further studies on active compounds isolated from myrrh and their uterine stimulant effects are needed. Trial registration This study was retrospectively registered at Iranian Registry of Clinical Trials (www.irct.ir) IRCT code: IRCT20140317017034N7.
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Affiliation(s)
- Homeira Vafaei
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Ajdari
- Obstetrics and Gynecology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kamran Hessami
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ayda Hosseinkhani
- Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Leila Foroughinia
- Obstetrics and Gynecology Department, Shiraz University of Medical Sciences, Shiraz, Iran.,Box Hill Hospital, FRANZCOG Eastern Health, Victoria, Australia
| | - Nasrin Asadi
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. .,Maternal- Fetal Medicine (Perinatology), Hafez Hospital, Chamran Ave, Shiraz, Iran.
| | - Azam Faraji
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Khadije Bazrafshan
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shohreh Roozmeh
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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12
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Affiliation(s)
- Justin Chu
- University of Birmingham, Institute of Metabolism and Systems Research, Birmingham, UK
- Tommy's Centre for Miscarriage Research, Birmingham, UK
| | - Pollyanna Hardy
- University of Birmingham, Birmingham Clinical Trials Unit, Birmingham, UK
| | - Leanne Beeson
- University of Birmingham, Birmingham Clinical Trials Unit, Birmingham, UK
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13
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Almeida M, Shrestha AD, Stojanac D, Miller LJ. The impact of the COVID-19 pandemic on women's mental health. Arch Womens Ment Health 2020; 23:741-748. [PMID: 33263142 PMCID: PMC7707813 DOI: 10.1007/s00737-020-01092-2] [Citation(s) in RCA: 246] [Impact Index Per Article: 61.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022]
Abstract
UNLABELLED The current worldwide outbreak of COVID-19 has changed the modus operandi of all segments of society. While some pandemic-related stressors affect nearly everyone, many especially affect women. PURPOSE To review what is known about the pandemic's effect on women's mental health, what makes them more predisposed to vulnerabilities and adverse impacts, and strategies for preventing and treating these mental health consequences in the female population during specific stages across the lifespan. METHODS The authors performed a narrative review in combination with their observations from clinical experience in the field of women's mental health and reproductive psychiatry. Articles on women's mental health and COVID-19 up to May 30, 2020, were searched using the electronic PubMed and PsychInfo databases, as well as publications by major health entities (e.g., World Health Organization, Centers for Disease Control and Prevention, the United Nations) and press releases from prime communication outlets (e.g., National Public Radio). RESULTS AND CONCLUSIONS Women who are pregnant, postpartum, miscarrying, or experiencing intimate partner violence are at especially high risk for developing mental health problems during the pandemic. Proactive outreach to these groups of women and enhancement of social supports could lead to prevention, early detection, and prompt treatment. Social support is a key protective factor. Similarly, parenting may be substantially more stressful during a pandemic. Gender disparities may be accentuated, particularly for employed women or single parents, as women are disproportionately responsible for the bulk of domestic tasks, including childcare and eldercare.
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Affiliation(s)
- Marcela Almeida
- Department of Psychiatry, Harvard Medical School;Cambridge Health Alliance, Cambridge, MA, 02139, USA.
- Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA, 02139, USA.
| | | | | | - Laura J Miller
- Loyola University Stritch School of Medicine, Maywood, IL, USA
- Edward Hines Jr. VA Hospital, Hines, IL, USA
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Meng J, Zhu M, Shen W, Huang X, Sun H, Zhou J. Influence of surgical evacuation on pregnancy outcomes of subsequent embryo transfer cycle following miscarriage in an initial IVF cycle: a retrospective cohort study. BMC Pregnancy Childbirth 2019; 19:409. [PMID: 31703714 PMCID: PMC6839260 DOI: 10.1186/s12884-019-2543-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/30/2019] [Indexed: 12/02/2022] Open
Abstract
Background It is still uncertain whether surgical evacuation adversely affects subsequent embryo transfer. The present study aims to assess the influence of surgical evacuation on the pregnancy outcomes of subsequent embryo transfer cycle following first trimester miscarriage in an initial in vitro fertilization and embryo transfer (IVF-ET) cycle. Methods A total of 645 patients who underwent their first trimester miscarriage in an initial IVF cycle between January 2013 and May 2016 in Nanjing Drum Tower Hospital were enrolled. Surgical evacuation was performed when the products of conception were retained more than 8 h after medical evacuation. Characteristics and pregnancy outcomes were compared between surgical evacuation patients and no surgical evacuation patients. The pregnancy outcomes following surgical evacuation were further compared between patients with ≥ 8 mm or < 8 mm endometrial thickness (EMT), and with the different EMT changes. Results The EMT in the subsequent embryo transfer cycle of surgical evacuation group was much thinner when compared with that in the no surgical evacuation group (9.0 ± 1.6 mm vs. 9.4 ± 1.9 mm, P = 0.01). There was no significant difference in implantation rate, clinical pregnancy rate, live birth rate or miscarriage rate between surgical evacuation group and no surgical evacuation group (P > 0.05). The live birth rate was higher in EMT ≥ 8 mm group when compared to < 8 mm group in surgical evacuation patients (43.0% vs. 17.4%, P < 0.05). Conclusions There was no significant difference in the pregnancy outcomes of subsequent embryo transfer cycle between surgical evacuation patients and no surgical evacuation patients. Surgical evacuation led to the decrease of EMT, especially when the EMT < 8 mm was association with a lower live birth rate.
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Affiliation(s)
- Junan Meng
- Reproductive Medicine Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321#, Nanjing, 210008, People's Republic of China
| | - Mengchen Zhu
- Reproductive Medicine Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321#, Nanjing, 210008, People's Republic of China
| | - Wenjuan Shen
- Department of Obstetrics and Gynecology, Suqian People's Hospital of Drum Tower Hospital Group, Suqian, 223800, China
| | - Xiaomin Huang
- Reproductive Medicine Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321#, Nanjing, 210008, People's Republic of China
| | - Haixiang Sun
- Reproductive Medicine Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321#, Nanjing, 210008, People's Republic of China.
| | - Jianjun Zhou
- Reproductive Medicine Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321#, Nanjing, 210008, People's Republic of China.
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15
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Kan E. The effect of systemic inflammation markers on predicting pregnancy results in patients admitted to emergency department with threatened miscarriage. ANKARA MEDICAL JOURNAL 2019. [DOI: 10.17098/amj.576455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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16
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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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Sundermann AC, Mukherjee S, Wu P, Velez Edwards DR, Hartmann KE. Gestational Age at Arrest of Development: An Alternative Approach for Assigning Time at Risk in Studies of Time-Varying Exposures and Miscarriage. Am J Epidemiol 2019; 188:570-578. [PMID: 30521025 PMCID: PMC6395168 DOI: 10.1093/aje/kwy267] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 03/12/2018] [Accepted: 12/04/2018] [Indexed: 11/12/2022] Open
Abstract
The time between arrest of pregnancy development and miscarriage represents a window in which the pregnancy is nonviable and not developing. In effect, the pregnancy loss has already occurred, and additional exposure cannot influence its outcome. However, epidemiologic studies of miscarriage traditionally use gestational age at miscarriage (GAM) to assign time in survival analyses, which overestimates duration of exposure and time at risk. In Right From the Start, a pregnancy cohort study (2000-2012), we characterized the gap between estimated gestational age at arrest of development (GAAD) and miscarriage using transvaginal ultrasound in 500 women recruited from 3 states (North Carolina, Tennessee, and Texas). We compared effect estimates from models using GAAD with GAM to assign time at risk through a simulation study of several exposure patterns with varying effect sizes. The median gap between GAAD and miscarriage was 23 days (interquartile range, 15-32). Use of GAAD decreased the bias and variance of the estimated association for time-varying exposures, whereas half the time using GAM led to estimates that differed from the true effect by more than 20%. Using GAAD to assign time at risk should result in more accurate and consistent characterization of miscarriage risk associated with time-varying exposures.
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Affiliation(s)
- Alexandra C Sundermann
- Vanderbilt Epidemiology Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Quantitative Sciences, Department of Obstetrics and Gynecology, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Sudeshna Mukherjee
- Vanderbilt Epidemiology Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pingsheng Wu
- Department of Biostatistics, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Digna R Velez Edwards
- Vanderbilt Epidemiology Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Quantitative Sciences, Department of Obstetrics and Gynecology, School of Medicine, Vanderbilt University, Nashville, Tennessee
- Department of Bioinformatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katherine E Hartmann
- Vanderbilt Epidemiology Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Quantitative Sciences, Department of Obstetrics and Gynecology, School of Medicine, Vanderbilt University, Nashville, Tennessee
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Abstract
Early pregnancy loss is the most common complication in pregnancy. Management options for miscarriage include expectant management, medical intervention, or surgical aspiration. Non-surgical and surgical management are all safe and acceptable options for medically uncomplicated patients. Patient and provider preferences contribute profoundly to clinical decisions about miscarriage management. Shared-decision making and evidence based counseling have been shown to significantly improve patient satisfaction with early pregnancy loss care. This review article will discuss the epidemiology and risk factors of early pregnancy loss, current evidence and clinical practice guidelines around management options, and provider and patient preferences for early pregnancy loss management.
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Affiliation(s)
- Jade M Shorter
- Department of Obstetrics and Gynecology, University of Pennsylvania, 3400 Spruce Street, 1000 Courtyard, Philadelphia, PA 19104, USA
| | - Jessica M Atrio
- Department of Obstetrics and Gynecology, Montefiore Hospital & Albert Einstein College of Medicine, 1695 Eastchester Road Bronx, NY 10461, USA.
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, University of Pennsylvania, 3400 Spruce Street, 1000 Courtyard, Philadelphia, PA 19104, USA
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Therapeutisches Vorgehen bei verhaltenem Abort – Plädoyer für ein risikoarmes Vorgehen. GYNAKOLOGISCHE ENDOKRINOLOGIE 2018. [DOI: 10.1007/s10304-018-0199-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kling C, Hedderich J, Kabelitz D. Fertility after recurrent miscarriages: results of an observational cohort study. Arch Gynecol Obstet 2017; 297:205-219. [PMID: 29038842 PMCID: PMC5762794 DOI: 10.1007/s00404-017-4532-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 09/12/2017] [Indexed: 11/24/2022]
Abstract
Purpose Recurrent pregnancy losses (RPL) are considered a pathological condition associated with heterogeneous laboratory and clinical findings, and are also linked to subfertility. We attempt to rank parameters derived from past history and diagnostic results with regard to the prognosis. Methods Observational trial on 719 consecutive couples who were referred to a tertiary immunological care centre (2006–2014) after three or more primary miscarriages. Information on past obstetric history and diagnostic procedures at baseline were correlated with cumulative pregnancy and delivery rates using Kaplan–Meier estimation, logistic regression and multivariate analysis. Results At baseline, median female age was 34.1 years, waiting time 3 years (1–17), number of preceding miscarriages 3 (3–9), 147 women (20.4%) had conceived at least once in ART or AIH cycles. After a median follow-up of 33.7 (1.7–123.0) months, 5-year pregnancy and delivery rates were 86.1 and 64.5%. Female age (< 35 years), waiting time (< 3 years) until baseline, tubal competence, and male factor fertility significantly correlated with favourable outcome (p < 0.001), while body mass index (> 29 kg/m2), number of preceding miscarriages (> 4), late miscarriages, preclinical losses and smoking revealed non-significant negative trends. Mode of conception until baseline (spontaneously or ART/AIH) and classification into idiopathic and non-idiopathic RPL showed no prognostic relevance. Conclusion Although in general, chances to conceive a child are retained after three or more miscarriages, factors related to subfertility of both partners have an important impact on the outcome. Therefore, prolonged time to pregnancy (> 6–9 months) should result in preventive gynaecological care from the first miscarriage on, so that fertility can be preserved as best as possible.
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Affiliation(s)
- Christiane Kling
- Institute of Immunology, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus 17, 24105, Kiel, Germany. .,MVZ Dr. Fenner and Colleagues, Bergstr. 14, 20095, Hamburg, Germany.
| | - Jürgen Hedderich
- Institute of Medical Statistics and Informatics, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus 31, 24105, Kiel, Germany
| | - Dieter Kabelitz
- Institute of Immunology, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus 17, 24105, Kiel, Germany
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Kassam Z, Petkovska I, Wang CL, Trinh AM, Kamaya A. Benign Gynecologic Conditions of the Uterus. Magn Reson Imaging Clin N Am 2017; 25:577-600. [DOI: 10.1016/j.mric.2017.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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曾 文, 安 胜, 黄 浩, 黄 启, 李 飞, 王 海, 蔡 丹, 高 云. [Expectant therapy versus curettage for retained products of conception after second trimester termination of pregnancy: analysis of outcomes and complications]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017; 37:569-574. [PMID: 28539276 PMCID: PMC6780480 DOI: 10.3969/j.issn.1673-4254.2017.05.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 01/12/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To evaluate the prognosis and complications of expectant therapy and curettage for retained product of conception (RPOC) after second trimester termination of pregnancy (TOP). METHODS A total of 270 patients with RPOC following second trimester TOP in Nanfang Hospital between January, 2014 and December, 2015 were included in this study. The duration of vaginal bleeding time and menstruation recovery interval were compared between patients receiving expectant therapy and curettage for RPOC, and binary logistic regression was used to assess the risk factors for complications in bivariate and multivariate analyses. RESULTS The duration of vaginal bleeding time was significantly longer in expectant therapy group than in curettage group (P=0.005), while the menstruation recovery interval did not differ significantly between the two groups. The incidence of vaginal bleeding time for over 42 days was significantly higher in curettage group than in expectant therapy group (P=0.040), and the incidence of a menstruation recovery interval beyond 60 days was comparable between them. The incidence of complications was significantly higher in curettage group than in expectant therapy group either with adjustment of age, gravidity, parity, history of uterine surgery status, gestational age, type of indications, regimens for TOP and induction-abortion interval (OR=18.26[95% CI: 3.57-93.42], P < 0.001) or without adjustment (OR=10.60, [95% CI: 2.36-47.66], P=0.002). CONCLUSION Expectant therapy and curettage for RPOC after second trimester TOP have comparable prognosis, but curettage is associated with a significantly higher rate of complications.
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Affiliation(s)
- 文娟 曾
- 南方医科大学南方医科妇产科,广东 广州 510515Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515
| | - 胜利 安
- 南方医科大学公共卫生学院生物统计学系,广东 广州 510515Department of Biostatistics School of Public Health,Southern Medical University, Guangzhou 510515
| | - 浩 黄
- 耶鲁大学公共卫生学院生物统计学系, 美国 纽黑文Southern Medical University, Guangzhou 510515, China,Department of Biostatistics, School of Public Health, Yale University, New Haven, USA
| | - 启涛 黄
- 南方医科大学南方医科妇产科,广东 广州 510515Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515
| | - 飞凤 李
- 南方医科大学南方医科妇产科,广东 广州 510515Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515
| | - 海臻 王
- 南方医科大学南方医科妇产科,广东 广州 510515Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515
| | - 丹纯 蔡
- 南方医科大学南方医科妇产科,广东 广州 510515Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515
| | - 云飞 高
- 南方医科大学南方医科妇产科,广东 广州 510515Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515
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Yamada K, Iso H, Cui R, Tamakoshi A. Recurrent Pregnancy Loss and Cardiovascular Disease Mortality in Japanese Women: A Population-Based, Prospective Cohort Study. J Stroke Cerebrovasc Dis 2017; 26:1047-1054. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.12.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 12/16/2016] [Accepted: 12/23/2016] [Indexed: 01/19/2023] Open
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Le Gouic S, Lavoué V, Mimouni M, Levêque J, Huchon C. Evaluation of adherence to French clinical practice guidelines in the management of pregnancy loss issued by the French College of Obstetricians and Gynecologists, one year after publication: A vignette-based study. J Gynecol Obstet Hum Reprod 2017; 46:393-398. [DOI: 10.1016/j.jogoh.2017.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 03/15/2017] [Accepted: 03/23/2017] [Indexed: 12/16/2022]
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Gallos ID, Williams HM, Price MJ, Eapen A, Eyo MM, Tobias A, Deeks JJ, Tunçalp Ö, Gülmezoglu AM, Coomarasamy A. Methods for managing miscarriage: a network meta-analysis. Hippokratia 2017. [DOI: 10.1002/14651858.cd012602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Ioannis D Gallos
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Helen M Williams
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Malcolm J Price
- University of Birmingham; School of Health and Population Sciences; Birmingham UK B15 2TG
| | - Abey Eapen
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Mary M Eyo
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Aurelio Tobias
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
| | - Jonathan J Deeks
- University of Birmingham; Institute of Applied Health Research; Edgbaston Birmingham UK B15 2TT
| | - Özge Tunçalp
- World Health Organization; UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research; 20 Avenue Appia Geneva Switzerland 1211
| | - A Metin Gülmezoglu
- World Health Organization; UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research; 20 Avenue Appia Geneva Switzerland 1211
| | - Arri Coomarasamy
- University of Birmingham; Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research; C/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation Trust Mindelsohn Way Birmingham UK B15 2TG
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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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Alfa-Wali M, Osaghae S. Practice, training and safety of laparoscopic surgery in low and middle-income countries. World J Gastrointest Surg 2017; 9:13-18. [PMID: 28138364 PMCID: PMC5237818 DOI: 10.4240/wjgs.v9.i1.13] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 07/03/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
Surgical management of diseases is recognised as a major unmet need in low and middle-income countries (LMICs). Laparoscopic surgery has been present since the 1980s and offers the benefit of minimising the morbidity and potential mortality associated with laparotomies. Laparotomies are often carried out in LMICs for diagnosis and management, due to lack of radiological investigative and intervention options. The use of laparoscopy for diagnosis and treatment is globally variable, with high-income countries using laparoscopy routinely compared with LMICs. The specific advantages of minimally invasive surgery such as lower surgical site infections and earlier return to work are of great benefit for patients in LMICs, as time lost not working could result in a family not being able to sustain themselves. Laparoscopic surgery and training is not cheap. Cost is a major barrier to healthcare access for a significant population in LMICs. Therefore, cost is usually seen as a major barrier for laparoscopic surgery to be integrated into routine practice in LMICs. The aim of this review is to focus on the practice, training and safety of laparoscopic surgery in LMICs. In addition it highlights the barriers to progress in adopting laparoscopic surgery in LMICs and how to address them.
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Dennis A, Fuentes L, Douglas-Durham E, Grossman D. Barriers to and Facilitators of Moving Miscarriage Management Out of the Operating Room. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2015; 47:141-149. [PMID: 26153842 DOI: 10.1363/47e4315] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
CONTEXT Miscarriage care can safely and effectively be offered in appropriately equipped offices and emergency departments. However, it is often treated in the operating room, which limits access to timely, cost-effective and high-quality care. METHODS Between May 2013 and January 2014, in-depth interviews were conducted with 30 staff holding diverse roles at 15 medical offices and emergency departments with the aim of exploring barriers to and facilitators of offering miscarriage care, and identifying methods for expanding care. On-site observations were also conducted at four facilities. All data were transcribed, iteratively coded and analyzed using qualitative techniques. RESULTS Similar barriers to and facilitators of providing miscarriage care were identified across facility types. Barriers were physician preference for providing care in the operating room, the similarity of miscarriage management and abortion procedures, the limited availability of support staff, difficulties integrating miscarriage management into patient scheduling and flow, and uncertainty about responding to women's emotional needs. Facilitators were a commitment to evidence-based medicine, insurance coverage of miscarriage, offering other procedures of similar complexity and the minimal resources needed for miscarriage care. Resources needed to expand miscarriage services included a medically trained "champion," best practices for implementing services, persistence and patience, training, clear protocols, and systems for tracking equipment and supplies. CONCLUSIONS Miscarriage care was viewed as neither resource-intensive nor technically complex to provide. Although it may be emotionally and politically challenging to offer, effective strategies are available for expanding the scope of miscarriage care offered in multiple settings.
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Quinley KE, Falck A, Kallan MJ, Datner EM, Carr BG, Schreiber CA. Validation of ICD-9 Codes for Stable Miscarriage in the Emergency Department. West J Emerg Med 2015; 16:551-6. [PMID: 26265967 PMCID: PMC4530913 DOI: 10.5811/westjem.2015.4.24946] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/28/2015] [Accepted: 04/26/2015] [Indexed: 11/16/2022] Open
Abstract
Introduction International Classification of Disease, Ninth Revision (ICD-9) diagnosis codes have not been validated for identifying cases of missed abortion where a pregnancy is no longer viable but the cervical os remains closed. Our goal was to assess whether ICD-9 code “632” for missed abortion has high sensitivity and positive predictive value (PPV) in identifying patients in the emergency department (ED) with cases of stable early pregnancy failure (EPF). Methods We studied females ages 13–50 years presenting to the ED of an urban academic medical center. We approached our analysis from two perspectives, evaluating both the sensitivity and PPV of ICD-9 code “632” in identifying patients with stable EPF. All patients with chief complaints “pregnant and bleeding” or “pregnant and cramping” over a 12-month period were identified. We randomly reviewed two months of patient visits and calculated the sensitivity of ICD-9 code “632” for true cases of stable miscarriage. To establish the PPV of ICD-9 code “632” for capturing missed abortions, we identified patients whose visits from the same time period were assigned ICD-9 code “632,” and identified those with actual cases of stable EPF. Results We reviewed 310 patient records (17.6% of 1,762 sampled). Thirteen of 31 patient records assigned ICD-9 code for missed abortion correctly identified cases of stable EPF (sensitivity=41.9%), and 140 of the 142 patients without EPF were not assigned the ICD-9 code “632”(specificity=98.6%). Of the 52 eligible patients identified by ICD-9 code “632,” 39 cases met the criteria for stable EPF (PPV=75.0%). Conclusion ICD-9 code “632” has low sensitivity for identifying stable EPF, but its high specificity and moderately high PPV are valuable for studying cases of stable EPF in epidemiologic studies using administrative data.
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Affiliation(s)
- Kelly E Quinley
- Highland Hospital of Alameda Health System, Department of Emergency Medicine, Oakland, California
| | - Ailsa Falck
- James Madison University, Harrisonburg, Virginia
| | - Michael J Kallan
- Perelman School of Medicine, University of Pennsylvania, Center for Clinical Epidemiology and Biostatistics, Philadelphia, Pennsylvania
| | - Elizabeth M Datner
- Perelman School of Medicine, University of Pennsylvania, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Brendan G Carr
- Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Courtney A Schreiber
- Perelman School of Medicine, University of Pennsylvania, Department of Obstetrics and Gynecology, Philadelphia, Pennsylvania
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Legendre G, Gicquel M, Lejeune V, Iraola E, Deffieux X, Séjourné N, Bydlowski S, Gillard P, Sentilhes L, Descamps P. Psychologie et perte de grossesse. ACTA ACUST UNITED AC 2014; 43:908-17. [DOI: 10.1016/j.jgyn.2014.09.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Borrell A, Stergiotou I. Miscarriage in contemporary maternal-fetal medicine: targeting clinical dilemmas. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:491-497. [PMID: 23436575 DOI: 10.1002/uog.12442] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 02/04/2013] [Accepted: 02/07/2013] [Indexed: 06/01/2023]
Affiliation(s)
- A Borrell
- Prenatal Diagnosis Unit, Maternal Fetal Department, Hospital Clinic Barcelona, Maternitat Campus, Sabino Arana 1, 08028, Barcelona, Catalonia, Spain
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32
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Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable. OBJECTIVES To assess the effectiveness, safety and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2012) and reference lists of retrieved papers. SELECTION CRITERIA Randomised controlled trials comparing medical treatment with expectant care or surgery or alternative methods of medical treatment. Quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. MAIN RESULTS Twenty studies (4208 women) were included. There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no statistically significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women, random-effects), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women, random-effects). There were few data on 'deaths or serious complications'.Twelve studies involving 2894 women addressed the comparison of misoprostol (six studies used oral administration, four studies used vaginal, one study sub-lingual, one study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.97, 95% CI 0.95 to 0.99, 11 studies, 2493 women, random-effects) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.06, 95% CI 0.02 to 0.13; 11 studies, 2654 women, random-effects) but more unplanned procedures (average RR 5.82, 95% CI 2.93 to 11.56; nine studies, 2274 women, random-effects). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.41, 95% CI 1.44 to 4.03; nine studies, 2179 women, random-effects).Five trials compared different routes of administration and/or doses of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice. Future studies should include long-term follow-up.
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Affiliation(s)
- James P Neilson
- Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK.
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Bickhaus J, Perry E, Schust DJ. Re-examining Sonographic Cut-off Values for Diagnosing Early Pregnancy Loss. GYNECOLOGY & OBSTETRICS (SUNNYVALE, CALIF.) 2013; 3:141. [PMID: 25045591 DOI: 10.4172/2161-0932.1000141] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jennifer Bickhaus
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri, USA
| | - Erin Perry
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri, USA
| | - Danny J Schust
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri, USA
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