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Bettencourt-Silva B, Rego MT, Miranda C, Cunha AI, Brás F, Lopes-Guerra C, Miguelote R, Sousa-Santos R, Furtado JM. The role of mifepristone on first trimester miscarriage treatment - A double-blind randomized controlled trial - MiFirsT. Eur J Obstet Gynecol Reprod Biol 2023; 289:145-151. [PMID: 37678127 DOI: 10.1016/j.ejogrb.2023.08.391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 08/26/2023] [Accepted: 08/30/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVES To evaluate the efficacy of combined mifepristone and misoprostol compared to misoprostol alone in outpatient medical treatment of first trimester miscarriage. Additionally, the study intends to compare the rate of complications, adverse effects, and treatment acceptability between groups. STUDY DESIGN Single-center double-blind randomized placebo-controlled trial including women with diagnosis of missed first trimester miscarriage up to 9 weeks of gestation. RESULTS Between April 2019 and November 2021, 216 women diagnosed with first trimester miscarriage up to 9 weeks of gestation were randomly assigned to mifepristone group or to misoprostol-alone group. Data from 105 women in mifepristone group and 103 women in misoprostol-alone group were analyzed, with no differences in baseline characteristics. The median time between medications (oral mifepristone/placebo and vaginal misoprostol) was nearly 43 h in both groups (p = 0.906). The median time to first follow-up was 2.6 weeks (IQR 1.0) in mifepristone group and 2.4 weeks (IQR 1.0) in misoprostol-alone group (p = 0.855). The overall success rate of medical treatment was significantly higher in the mifepristone-group comparing to misoprostol-alone group (94.3% vs. 82.5%, RR 1.14, 95% CI, 1.03-1.26; p = 0.008). Accordingly, the rate of surgical treatment was significantly lower in the mifepristone-group (5.7% vs.14.6%, RR 0.39, 95% CI, 0.16-0.97; p = 0.034). The composite complication rate was similar and lower than 4% in both groups. No case of complicated pelvic infection, hemodynamic instability or inpatient supportive treatment was reported. There were no significant differences in the rates of adverse events, median score for vaginal bleeding intensity or analgesics use. Despite the same median value, the score of abdominal pain intensity was significantly higher in the mifepristone-group (p = 0.011). In both groups, more than 65% of the women classified the treatment as "good" and 92% would recommend it to a friend on the same clinical situation. CONCLUSION The mifepristone plus vaginal misoprostol combined treatment for medical resolution of first trimester miscarriage resulted in significant higher success rate and lower rate of surgical uterine evacuation comparing to misoprostol-alone treatment, with no relevant differences in adverse events or treatment acceptability.
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Affiliation(s)
- Beatriz Bettencourt-Silva
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal.
| | - Maria Teresa Rego
- School of Health Science, University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal
| | - Cláudia Miranda
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal
| | - Ana Isabel Cunha
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal
| | - Filipa Brás
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal
| | - Cláudia Lopes-Guerra
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal
| | - Rui Miguelote
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal; School of Health Science, University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal; Life and Health Sciences Research Institute (ICVS), Campus de Gualtar, 4710-057 Braga, Portugal
| | - Ricardo Sousa-Santos
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal; Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine of Porto University, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - José Manuel Furtado
- Department of Obstetrics and Gynecology, Hospital Senhora da Oliveira, Rua dos Cutileiros, 4835-044 Guimarães, Portugal
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Benson LS, Magnusson SL, Gray KE, Quinley K, Kessler L, Callegari LS. Early pregnancy loss in the emergency department, 2006-2016. J Am Coll Emerg Physicians Open 2021; 2:e12549. [PMID: 34766105 PMCID: PMC8571073 DOI: 10.1002/emp2.12549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Women experiencing early pregnancy loss (EPL) frequently present to the emergency department (ED), but little is known about who receives EPL care in these settings. We aimed to estimate the proportion of ED visits for EPL-related care and determine characteristics associated with seeking care for EPL in the ED in a national sample. METHODS We conducted a secondary analysis of the 2006-2016 National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative survey of US ED visits. We identified women ages 15-44 years who presented to the ED for threatened or confirmed EPL based on diagnosis code or chief complaint. We estimated the proportion of ED visits attributable to EPL-related care among all ED visits and among women 15-44 years old. Using multivariable logistic regression, we evaluated patient and visit characteristics associated with receiving EPL-related care versus all other care. RESULTS The 2006-2016 NHAMCS dataset included 325,037 visits (weighted n = 1,447,144,423), including 82,871 visits among women ages 15-44 years (weighted n = 371,016,125). Of all ED visits for women ages 15-44 years, 2.7% (95% confidence interval, 2.5-2.9) were for EPL-related care. This equates to ≈900,000 visits annually. Compared with women ages 15-44 years presenting to the ED for other reasons, those presenting for EPL-related care were younger and more likely to be Black or Hispanic. CONCLUSIONS EPL-related care accounts for over 900,000 ED visits in the United States each year. These findings highlight the current burden of EPL visits upon EDs nationally.
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Affiliation(s)
- Lyndsey S. Benson
- Department of Obstetrics and GynecologyUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Sara L. Magnusson
- Department of Health ServicesUniversity of Washington School of Public HealthSeattleWashingtonUSA
| | - Kristen E. Gray
- Department of Health ServicesUniversity of Washington School of Public HealthSeattleWashingtonUSA
- Department of Veterans Affairs (VA) Puget Sound Health Care SystemHealth Services Research and DevelopmentSeattleWashingtonUSA
| | - Kelly Quinley
- Department of Emergency MedicineThe Permanente Medical GroupRichmondVirginiaUSA
| | - Larry Kessler
- Department of Health ServicesUniversity of Washington School of Public HealthSeattleWashingtonUSA
| | - Lisa S. Callegari
- Department of Obstetrics and GynecologyUniversity of Washington School of MedicineSeattleWashingtonUSA
- Department of Health ServicesUniversity of Washington School of Public HealthSeattleWashingtonUSA
- Department of Veterans Affairs (VA) Puget Sound Health Care SystemHealth Services Research and DevelopmentSeattleWashingtonUSA
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3
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The burden of the Risk Evaluation and Mitigation Strategy (REMS) on providers and patients experiencing early pregnancy loss: A commentary. Contraception 2021; 104:29-30. [PMID: 33895123 DOI: 10.1016/j.contraception.2021.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 11/22/2022]
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Flynn AN, Roe AH, Koelper N, McAllister A, Sammel MD, Schreiber CA. Timing and efficacy of mifepristone pretreatment for medical management of early pregnancy loss. Contraception 2021; 103:404-407. [PMID: 33476659 DOI: 10.1016/j.contraception.2021.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To determine the time interval between mifepristone and misoprostol administration associated with the most efficacious early pregnancy loss (EPL) management. STUDY DESIGN We performed a secondary analysis of a randomized trial. Participants with EPL were instructed to take 200 mg oral mifepristone followed by 800 mcg vaginal misoprostol 24 hours later. The primary outcome was gestational sac expulsion at the first follow-up visit (1-4 days after misoprostol use) after a single dose of misoprostol and no additional intervention within 30 days after treatment. Despite specification of drug timing, participants used the medication over a range of time. We graphed sliding average estimates of success and assessed the proportion of treatment successes over time to define timing interval cohorts for analysis. We used multivariable generalized linear regression to assess the association between time interval and success. RESULTS Of 139 eligible participants, 70 (50.4%) self-administered misoprostol before 24 hours, and 69 (49.6%) at or after 24 hours. We defined the following time intervals: 0 to 6 hours (n = 22); 7 to 20 hours (n = 29); and 21 to 48 hours (n = 88). Success occurred in 96.6% of the 7- to 20-hour cohort compared to 54.6% and 87.5% of the cohorts self-administering misoprostol earlier or later, respectively. When adjusting for race, gestational age, diagnosis, bleeding at presentation, insurance status, and enrollment site, participants administering misoprostol between 0 and 6 hours (adjusted risk ratio 0.58, 95% CI 0.40-0.85) and 21 to 48 hours (adjusted risk ratio 0.91, 95% CI 0.72-0.99) had a lower risk of success when compared to participants administering 7 to 20 hours after mifepristone. CONCLUSIONS These data suggest that medical management of EPL has the highest likelihood of success when misoprostol is self-administered 7 to 20 hours after mifepristone. IMPLICATIONS These preliminary data suggest that patients have the highest likelihood of success when misoprostol is taken between 7 and 20 hours after mifepristone. In contrast with medical abortion, simultaneous medication administration may not be as effective as delayed. Future research is needed to confirm the optimal medication time interval.
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Affiliation(s)
- Anne N Flynn
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Andrea H Roe
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Nathanael Koelper
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Mary D Sammel
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, United States
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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5
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Shorter JM, Schreiber CA, Sonalkar S. Recent Advances in the Medical Management of Early Pregnancy Loss. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020. [DOI: 10.1007/s13669-020-00282-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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6
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van den Berg J, Hamel CC, Snijders MP, Coppus SF, Vandenbussche FP. Mifepristone and misoprostol versus misoprostol alone for uterine evacuation after early pregnancy failure: study protocol for a randomized double blinded placebo-controlled comparison (Triple M Trial). BMC Pregnancy Childbirth 2019; 19:443. [PMID: 31775677 PMCID: PMC6880504 DOI: 10.1186/s12884-019-2497-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 09/09/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Early pregnancy failure (EPF) is a common complication of pregnancy. If women do not abort spontaneously, they will undergo medical or surgical treatment in order to remove the products of conception from the uterus. Curettage, although highly effective, is associated with a risk of complications; medical treatment with misoprostol is a safe and less expensive alternative. Unfortunately, after 1 week of expectant management in case of EPF, medical treatment with misoprostol has a complete evacuation rate of approximately 50%. Misoprostol treatment results may be improved by pre-treatment with mifepristone; its effectiveness has already been proven for other indications of pregnancy termination. This study will test the hypothesis that, in EPF, the sequential combination of mifepristone with misoprostol is superior to the use of misoprostol alone in terms of complete evacuation (primary outcome), patient satisfaction, complications, side effects and costs (secondary outcomes). METHODS The trial will be performed multi-centred, prospectively, two-armed, randomised, double-blinded and placebo-controlled. Women with confirmed EPF by ultrasonography (6-14 weeks), managed expectantly for at least 1 week, can be included and randomised to pre-treatment with oral mifepristone (600 mg) or oral placebo (identical in appearance). Randomisation will take place after receiving written consent to participate. In both arms pre-treatment will be followed by oral misoprostol, which will start 36-48 h later consisting of two doses 400 μg (4 hrs apart), repeated after 24 h if no tissue is lost. Four hundred sixty-four women will be randomised in a 1:1 ratio, stratified by centre. Ultrasonography 2 weeks after treatment will determine short term treatment effect. When the gestational sac is expulsed, expectant management is advised until 6 weeks after treatment when the definitive primary endpoint, complete or incomplete evacuation, will be determined. A sonographic endometrial thickness < 15 mm using only the allocated therapy by randomisation is considered as successful treatment. Secondary outcome measures (patient satisfaction, complications, side effects and costs) will be registered using a case report form, patient diary and validated questionnaires (Short Form 36, EuroQol-VAS, Client Satisfaction Questionnaire, iMTA Productivity Cost Questionnaire). DISCUSSION This trial will answer the question if, in case of EPF, after at least 1 week of expectant management, sequential treatment with mifepristone and misoprostol is more effective than misoprostol alone to achieve complete evacuation of the products of conception. TRIAL REGISTRATION Clinicaltrials.gov (d.d. 02-07-2017): NCT03212352. Trialregister.nl (d.d. 03-07-2017): NTR6550. EudraCT number (d.d. 07-08-2017): 2017-002694-19. File number Commisie Mensgebonden Onderzoek (d.d. 07-08-2017): NL 62449.091.17.
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Affiliation(s)
- Joyce van den Berg
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Postbus 9015, Nijmegen, GS 6500 The Netherlands
| | - Charlotte C. Hamel
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Postbus 9015, Nijmegen, GS 6500 The Netherlands
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, GA 6525 The Netherlands
| | - Marcus P. Snijders
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Postbus 9015, Nijmegen, GS 6500 The Netherlands
| | - Sjors F. Coppus
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, De Run 4600, Veldhoven, DB 5504 The Netherlands
| | - Frank P. Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, GA 6525 The Netherlands
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7
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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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8
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Schreiber CA, Creinin MD, Atrio J, Sonalkar S, Ratcliffe SJ, Barnhart KT. Mifepristone Pretreatment for the Medical Management of Early Pregnancy Loss. N Engl J Med 2018; 378:2161-2170. [PMID: 29874535 PMCID: PMC6437668 DOI: 10.1056/nejmoa1715726] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Medical management of early pregnancy loss is an alternative to uterine aspiration, but standard medical treatment with misoprostol commonly results in treatment failure. We compared the efficacy and safety of pretreatment with mifepristone followed by treatment with misoprostol with the efficacy and safety of misoprostol use alone for the management of early pregnancy loss. METHODS We randomly assigned 300 women who had an anembryonic gestation or in whom embryonic or fetal death was confirmed to receive pretreatment with 200 mg of mifepristone, administered orally, followed by 800 μg of misoprostol, administered vaginally (mifepristone-pretreatment group), or 800 μg of misoprostol alone, administered vaginally (misoprostol-alone group). Participants returned 1 to 4 days after misoprostol use for evaluation, including ultrasound examination, by an investigator who was unaware of the treatment-group assignments. Women in whom the gestational sac was not expelled were offered expectant management, a second dose of misoprostol, or uterine aspiration. We followed all participants for 30 days after randomization. Our primary outcome was gestational sac expulsion with one dose of misoprostol by the first follow-up visit and no additional intervention within 30 days after treatment. RESULTS Complete expulsion after one dose of misoprostol occurred in 124 of 148 women (83.8%; 95% confidence interval [CI], 76.8 to 89.3) in the mifepristone-pretreatment group and in 100 of 149 women (67.1%; 95% CI, 59.0 to 74.6) in the misoprostol-alone group (relative risk, 1.25; 95% CI, 1.09 to 1.43). Uterine aspiration was performed less frequently in the mifepristone-pretreatment group than in the misoprostol-alone group (8.8% vs. 23.5%; relative risk, 0.37; 95% CI, 0.21 to 0.68). Bleeding that resulted in blood transfusion occurred in 2.0% of the women in the mifepristone-pretreatment group and in 0.7% of the women in the misoprostol-alone group (P=0.31); pelvic infection was diagnosed in 1.3% of the women in each group. CONCLUSIONS Pretreatment with mifepristone followed by treatment with misoprostol resulted in a higher likelihood of successful management of first-trimester pregnancy loss than treatment with misoprostol alone. (Funded by the National Institute of Child Health and Human Development; PreFaiR ClinicalTrials.gov number, NCT02012491 .).
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MESH Headings
- Abortifacient Agents, Nonsteroidal/administration & dosage
- Abortifacient Agents, Nonsteroidal/adverse effects
- Abortifacient Agents, Steroidal/administration & dosage
- Abortifacient Agents, Steroidal/adverse effects
- Abortion, Spontaneous/diagnostic imaging
- Abortion, Spontaneous/drug therapy
- Administration, Intravaginal
- Administration, Oral
- Adult
- Drug Therapy, Combination
- Embryo, Mammalian
- Female
- Fetal Death
- Gestational Sac/diagnostic imaging
- Hemorrhage/chemically induced
- Humans
- Mifepristone/administration & dosage
- Mifepristone/adverse effects
- Misoprostol/administration & dosage
- Misoprostol/adverse effects
- Pregnancy
- Pregnancy Trimester, First
- Ultrasonography
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Affiliation(s)
- Courtney A Schreiber
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Mitchell D Creinin
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Jessica Atrio
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Sarita Sonalkar
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Sarah J Ratcliffe
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
| | - Kurt T Barnhart
- From the Pregnancy Early Access Center (PEACE), Division of Family Planning (C.A.S., S.S.), Department of Obstetrics and Gynecology (C.A.S., S.S., K.T.B.), University of Pennsylvania, Philadelphia; the Department of Public Health Sciences, University of Virginia, Charlottesville (S.J.R.); the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento (M.D.C.); and the Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY (J.A.)
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Sinha P, Suneja A, Guleria K, Aggarwal R, Vaid NB. Comparison of Mifepristone Followed by Misoprostol with Misoprostol Alone for Treatment of Early Pregnancy Failure: A Randomized Double-Blind Placebo-Controlled Trial. J Obstet Gynaecol India 2017; 68:39-44. [PMID: 29391674 DOI: 10.1007/s13224-017-0992-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 04/07/2017] [Indexed: 12/01/2022] Open
Abstract
Objective To compare the efficacy and safety of mifepristone followed by misoprostol with misoprostol alone in the management of early pregnancy failure (EPF). Study Design A randomized double-blind placebo-controlled clinical trial. Methods Ninety-two women with EPF ≤12 weeks were recruited and randomly allocated to receive either mifepristone 200 mg (n = 46) or placebo (n = 46). Forty-eight hours later, patients in both the groups were given 800 µg misoprostol per-vaginum. If no expulsion occurred within 4 h, repeat doses of 400 µg misoprostol were given orally at 3-hourly interval to a maximum of 2 doses in women ≤9 weeks by scan and 4 doses in women >9 weeks by scan. Results Pre-treatment of misoprostol with mifepristone significantly increased the complete abortion rate (86.7 vs. 57.8%, p = 0.009) and, hence, reduced the need for surgical evacuation (13.3 vs. 42.2%, p = 0.002), induction to expulsion interval (4.74 ± 2.24 vs. 8.03 ± 2.77 h, p = 0.000), mean number of additional doses of misoprostol required (0.68 vs. 1.91, p = 0.000), and side effects. Conclusion Use of mifepristone prior to misoprostol in EPF significantly improves the efficacy and reduces the side effects of misoprostol alone.
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Affiliation(s)
- Priya Sinha
- 1Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, 110095 India
| | - Amita Suneja
- 1Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, 110095 India
| | - Kiran Guleria
- 1Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, 110095 India
| | - Richa Aggarwal
- 1Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, 110095 India.,KL-99, Kavi Nagar, Ghaziabad, Uttar Pradesh India
| | - Neelam B Vaid
- 1Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, 110095 India
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10
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Colleselli V, Nell T, Bartosik T, Brunner C, Ciresa-Koenig A, Wildt L, Marth C, Seeber B. Marked improvement in the success rate of medical management of early pregnancy failure following the implementation of a novel institutional protocol and treatment guidelines: a follow-up study. Arch Gynecol Obstet 2016; 294:1265-1272. [PMID: 27554492 PMCID: PMC5071363 DOI: 10.1007/s00404-016-4179-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 08/09/2016] [Indexed: 11/30/2022]
Abstract
Purpose To analyze the success rate, time to passage of tissue and subjective patient experience of a newly implemented protocol for medical management of early pregnancy failure (EPF) over a 2-year period. Methods A retrospective chart review of all patients with early pregnancy failure primarily opting for medical management was performed. 200 mg mifepristone were administered orally, followed by a single vaginal dose of 800 mcg misoprostol after 36–48 h. We followed-up with our patients using a written questionnaire. Results 167 women were included in the present study. We observed an overall success rate of 92 %, defined as no need for surgical management after medication administration. We could not identify predictive values for success in a multivariate regression analysis. Most patients (84 %) passed tissue within 6 h after misoprostol administration. The protocol was well tolerated with a low incidence of side effects. Pain was managed well with sufficient analgesics. Responders to the questionnaire felt adequately informed prior to treatment and rated their overall experience as positive. Conclusion The adaption of the institutional medical protocol resulted in a marked improvement of success rate when compared to the previously used protocol (92 vs. 61 %). We credit this increase to the adjusted medication schema as well as to targeted physician education on the expected course and interpretation of outcome measures. Our results underscore that the medical management of EPF is a safe and effective alternative to surgical evacuation in the clinical setting.
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Affiliation(s)
- V Colleselli
- Department of Gynecology and Obstetrics, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - T Nell
- Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - T Bartosik
- Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - C Brunner
- Department of Gynecology and Obstetrics, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - A Ciresa-Koenig
- Department of Gynecology and Obstetrics, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - L Wildt
- Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - C Marth
- Department of Gynecology and Obstetrics, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - B Seeber
- Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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11
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van den Berg J, Gordon BB, Snijders MP, Vandenbussche FP, Coppus SF. The added value of mifepristone to non-surgical treatment regimens for uterine evacuation in case of early pregnancy failure: a systematic review of the literature. Eur J Obstet Gynecol Reprod Biol 2015; 195:18-26. [DOI: 10.1016/j.ejogrb.2015.09.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/15/2015] [Accepted: 09/17/2015] [Indexed: 11/15/2022]
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12
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Dzuba IG, Grossman D, Schreiber CA. Off-label indications for mifepristone in gynecology and obstetrics. Contraception 2015; 92:203-5. [PMID: 26141817 DOI: 10.1016/j.contraception.2015.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 06/24/2015] [Accepted: 06/25/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Ilana G Dzuba
- Gynuity Health Projects, 15 E. 26th Street, Suite 801, New York, NY 10010.
| | - Daniel Grossman
- Ibis Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612; Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA 94110.
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 1000 Courtyard, Philadelphia, PA 19104.
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13
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Bouschbacher L, Maatouk A, Collin P, Welter E, Morel O, de Malartic CM. [Association of mifepristone and misoprostol for the medical management of early pregnancy failure]. ACTA ACUST UNITED AC 2014; 42:832-7. [PMID: 25458806 DOI: 10.1016/j.gyobfe.2014.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 09/30/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES A retrospective monocentric clinical trial was performed to evaluate the efficacy of the association of mifepristone and misoprostol for the management of early pregnancy failure. PATIENTS AND METHODS Ninety-two women with early pregnancy failure or anembryonic pregnancy were first treated with 600 mg of mifepristone and 48 hours later with 400 μg of misoprostol by oral administration. Successful treatment, defined as an empty uterus, was searched at day 3, with the association of misoprostol-mifepristone alone or with complementary medical treatment, prostaglandins or ocytocine. RESULTS The overall treatment success was 82% (75 of 92 women) with 69 successful cases at day 3 (75%). Six of 92 women (7%) needed a second-line medical treatment. For the last 17 women (18%), the failure of the associated tested medical treatment lead to a secondary surgery. No prognostic factor for the successful medical treatment has been highlighted. DISCUSSION AND CONCLUSION A high efficacy for the management of early pregnancy failure is demonstrated for the mifepristone and misoprostol medical treatment. The specific contribution of mifepristone, although proven in the cases of termination of evolutive pregnancies, should be further evaluated in the future for the specific management of early pregnancy failure. Nevertheless, no prognostic factor for the success of the propose treatment can be determined, as the amount of patients enrolled in this study was not sufficient.
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Affiliation(s)
- L Bouschbacher
- Service de gynécologie obstétrique, maternité Bel-Air, CHR Metz-Thionville, 2, rue de friscaty, BP 60327, 57126 Thionville, France; Service de gynécologie obstétrique et médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, université de Lorraine, 10, avenue Docteur Heydenreich, 54000 Nancy, France.
| | - A Maatouk
- Service de gynécologie obstétrique, maternité Bel-Air, CHR Metz-Thionville, 2, rue de friscaty, BP 60327, 57126 Thionville, France
| | - P Collin
- Service de gynécologie obstétrique, maternité Bel-Air, CHR Metz-Thionville, 2, rue de friscaty, BP 60327, 57126 Thionville, France
| | - E Welter
- Service de gynécologie obstétrique, maternité Bel-Air, CHR Metz-Thionville, 2, rue de friscaty, BP 60327, 57126 Thionville, France
| | - O Morel
- Service de gynécologie obstétrique et médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, université de Lorraine, 10, avenue Docteur Heydenreich, 54000 Nancy, France
| | - C Mezan de Malartic
- Service de gynécologie obstétrique et médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, université de Lorraine, 10, avenue Docteur Heydenreich, 54000 Nancy, France
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14
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van den Berg J, van den Bent JM, Snijders MP, de Heus R, Coppus SF, Vandenbussche FP. Sequential use of mifepristone and misoprostol in treatment of early pregnancy failure appears more effective than misoprostol alone: a retrospective study. Eur J Obstet Gynecol Reprod Biol 2014; 183:16-9. [PMID: 25461345 DOI: 10.1016/j.ejogrb.2014.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/26/2014] [Accepted: 10/04/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Is treatment of early pregnancy failure (EPF) with sequential use of mifepristone and misoprostol more effective than treatment with misoprostol alone? STUDY DESIGN In a retrospective cohort study at the Department of Obstetrics and Gynaecology of the Radboud University Medical Centre, 301 women with early pregnancy failure receiving medical treatment between January 2008 and March 2013 were included. Of these, 199 women were pre-treated with 200mg mifepristone (orally) followed by 2 consecutive doses of 800mcg misoprostol (vaginally) and 102 women were treated with 2 consecutive doses of 800mcg misoprostol (vaginally) alone. RESULTS Complete expulsion was achieved in 66.8% of the women treated with a sequential combination of mifepristone and misoprostol versus 54.9% of the women treated with misoprostol alone. The difference in rates of complete expulsion was 11.9% (P<0.05; 95% CI 0.3-23.6%). CONCLUSIONS Medical treatment of early pregnancy failure with a sequential combination of mifepristone and misoprostol was more effective than treatment with misoprostol alone. Our findings will have to be confirmed by a large prospective multicentre double blinded-randomized trial.
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Affiliation(s)
- Joyce van den Berg
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.
| | - Johan M van den Bent
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marcus P Snijders
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Roel de Heus
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Sjors F Coppus
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Frank P Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
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15
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Colleselli V, Schreiber CA, D'Costa E, Mangesius S, Wildt L, Seeber BE. Medical management of early pregnancy failure (EPF): a retrospective analysis of a combined protocol of mifepristone and misoprostol used in clinical practice. Arch Gynecol Obstet 2013; 289:1341-5. [PMID: 24305748 DOI: 10.1007/s00404-013-3105-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 11/18/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the efficacy of a combined protocol of mifepristone and misoprostol in the management of early pregnancy failure (EPF) and the average time to expulsion of tissue and rate of side effects. METHODS Retrospective chart review of all consecutive women treated with primary medical management for EPF at our institution from 2006 to 2012. RESULTS 168 patients were included in the present study. The overall success rate, defined as the absence of the need for surgical intervention, was 61 % and did not differ by calendar year. There was no difference in success rate grouped by diagnosis [intrauterine embryonic/fetal demise (IUED/IUFD) vs. anembryonic gestation; p = 0.30] or gestational age (<9 or ≥9 weeks; p = 0.48). The success rate varied significantly according to the required dose of misoprostol, ≤800 or >800 μg (68 vs. 50 %, p = 0.029). Of the possible predictive factors of success, only the dose of misoprostol required was a significant independent negative predictor. Mean and median time to tissue expulsion after the first dose of misoprostol were 8.4 and 5.5 h, respectively. The incidence of side effects was low with no blood transfusions required. CONCLUSIONS The success rate in this study is markedly below published data. This can possibly be attributed to retrospective study design, allowing for physician subjectivity and patients' wishes in the absence of strict study requirements. The protocol was well tolerated with a paucity of side effects. We make suggestions for enhancing success rates in the clinical setting by optimizing medication protocols, establishing precise treatment guidelines and training physicians in the accurate interpretation of treatment outcomes.
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Affiliation(s)
- Valeria Colleselli
- Department of Gynecologic Endocrinology and Reproductive Medicine, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
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16
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Kollitz KM, Meyn LA, Lohr PA, Creinin MD. Mifepristone and misoprostol for early pregnancy failure: a cohort analysis. Am J Obstet Gynecol 2011; 204:386.e1-6. [PMID: 21306697 DOI: 10.1016/j.ajog.2010.12.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 10/15/2010] [Accepted: 12/10/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to examine outcomes of mifepristone and misoprostol for early pregnancy failure (EPF) treatment in a nonresearch setting. STUDY DESIGN A protocol was developed for physicians to use mifepristone 200 mg orally and misoprostol 800 μg vaginally for EPF. Success rates were analyzed and an adjusted multivariable regression was used to identify factors predictive of success. RESULTS Treatment success occurred in 99 (80%; 95% confidence interval, 72-87%) of 123 patients after mifepristone and a single dose of misoprostol and 102 (83%; 95% confidence interval, 75-89%) patients overall. The odds of successful medical treatment were increased in women with a diagnosis of intrauterine embryonic/fetal demise (odds ratio, 3.80) and decreased in women who made additional emergency department visits (odds ratio, 0.12). CONCLUSION Patients and clinicians may be more likely to intervene surgically with an EPF when a strict study protocol is not being followed.
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Im A, Appleman LJ. Mifepristone: pharmacology and clinical impact in reproductive medicine, endocrinology and oncology. Expert Opin Pharmacother 2010; 11:481-8. [PMID: 20102310 DOI: 10.1517/14656560903535880] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Mifepristone is a synthetic selective progesterone-receptor modulator (SPRM) that is widely used around the globe in the field of reproductive medicine. At present mifepristone is approved in a number of countries for early termination of pregnancy (TOP), cervical dilatation before surgical TOP, and management of early embryonic loss or fetal death. A number of new clinical applications are being developed in gynecology, endocrinology and oncology. Mifepristone has also served as an invaluable tool in the study of steroid hormone biology. AREAS COVERED IN THIS REVIEW Current indications for mifepristone are reviewed. New applications for mifepristone under clinical investigation are discussed. In addition, the unique molecular and cellular effects of mifepristone are described. WHAT THE READER WILL GAIN The reader will understand the mechanisms of action of mifepristone and the underlying steroid hormone biology. The reader will know the approved clinical indications for mifepristone and appreciate the ongoing basic and clinical research into new applications. TAKE HOME MESSAGE Mifepristone is the first-discovered and still most widely used antiprogestin. It has several indications in reproductive medicine and is under investigation for a variety of potential applications in other fields of medicine. The molecular and cellular effects of mifepristone illuminate important aspects of steroid hormone biology.
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Affiliation(s)
- Annie Im
- University of Pittsburgh, Division of Hematology/Oncology, Department of Medicine, 5150 Centre Avenue, Pittsburgh, PA 15232, USA
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18
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Miao MH, Gao ES, Chen AM, Luo L, Cheng YM, Yuan W. Mifepristone-induced abortion and duration of third stage labour in a subsequent pregnancy. Paediatr Perinat Epidemiol 2010; 24:125-30. [PMID: 20415767 DOI: 10.1111/j.1365-3016.2010.01102.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To evaluate the impact of mifepristone-induced abortion (MA) on the duration of third stage labour in a subsequent pregnancy, an observational cohort study was conducted from 1998 to 2001 at antenatal clinics in Shanghai, Beijing and Chengdu, China. A total of 4925 pregnant women with no history of induced abortion (NA) and 4931 pregnant women with one previous MA were enrolled and followed until delivery. Of these, 5139 women who delivered singletons vaginally were used in the present analyses, including 2614 with NA and 2525 with a history of MA. Maternal characteristics, labour duration and other obstetric and gynaecological information were obtained. The incidence rates of prolonged third stage of labour were 1.55% and 1.49% in NA and MA, respectively. After adjusting for age at delivery, maternal education, maternal occupation, area of residence, duration of gestational, type of delivery and pregnancy-induced hypertension, MA was not associated with the risk of prolonged third stage of labour (odds ratios = 0.92, 95% confidence interval 0.58, 1.44). Subgroup analysis of women with MA showed similar results regardless of gestational age at abortion, woman's age at abortion, subsequent curettage/complications and the interpregnancy interval. In conclusion, the data did not provide evidence that one MA was associated with the risk of prolonged third stage of labour in a subsequent pregnancy in primiparae.
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Affiliation(s)
- Mao-Hua Miao
- Department of Reproductive Epidemiology and Social Science, National Population and Family Planning Key Laboratory of Contraceptive Drugs and Devices, Shanghai Institute of Planned Parenthood Research, Shanghai, China
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Harwood B, Nansel T. Quality of life and acceptability of medical versus surgical management of early pregnancy failure. BJOG 2008; 115:501-8. [PMID: 18271887 DOI: 10.1111/j.1471-0528.2007.01632.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study compares quality of life (QOL) and acceptability of medical versus surgical treatment of early pregnancy failure (EPF). DESIGN A randomised clinical trial of treatment for EPF compared misoprostol vaginally versus vacuum aspiration (VA). SETTING A multisite trial at four US Urban University Hospitals. POPULATION A total of 652 women with an EPF were randomised to treatment. METHODS Participants completed a daily symptom diary and a questionnaire 2 weeks after treatment. MAIN OUTCOME MEASURES The questionnaire assessment included subscales of the Short Form-36 Health Survey Revised for QOL and measures of wellbeing, recovery difficulties, and treatment acceptability. RESULTS The two groups did not differ in mean scores for QOL except bodily pain; medical treatment was associated with higher levels of bodily pain than VA (P < 0.001). Success of treatment was not related to QOL, but acceptability of the procedure was decreased for medical therapy if unsuccessful (P = 0.003). Type of treatment was not associated with differences in recovery, and the two groups reported similar acceptability except for cramping (P = 0.02), bleeding (P < 0.001), and symptom duration (P = 0.03). CONCLUSIONS Despite reporting greater pain and lower acceptability of treatment-related symptoms, QOL and treatment acceptability were similar for medical and surgical treatment of EPF. Acceptability, but not QOL, was influenced by success or failure of medical management.
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Affiliation(s)
- B Harwood
- Department of Obstetrics and Gynecology, University of Illinois at Chicago College of Medicine, Chicago, IL 60612, USA.
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Abstract
Early pregnancy failure is a common pregnancy complication. This paper reviews the terminology, diagnosis, and treatment of early pregnancy failure. Although surgical curettage has been the standard of care for more than 50 years, additional treatment options exist which appear to be satisfactory to patients. Manual vacuum curettage in the office is an effective alternative to electric vacuum curettage in an operating room. Nonsurgical treatments, including expectant and medical management, are reasonable alternatives depending on the clinical situation and the patient's desires. Clinicians need to understand how these options compare to provide appropriate counseling to patients.
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Affiliation(s)
- Beatrice A Chen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA.
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