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Torres-Miranda MD, Duro Gómez J, Peña Lobo-Gonçalves S, De la Torre González AJ, Castelo-Branco C. Intravaginal misoprostol versus uterine curettage for missed abortion: A cost-effectiveness analysis. J Obstet Gynaecol Res 2022; 48:1110-1115. [PMID: 35218113 DOI: 10.1111/jog.15201] [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: 09/02/2021] [Revised: 01/06/2022] [Accepted: 02/10/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the cost-effectiveness of a strategy based on direct-acting uterine curettage (UC) versus a pre-direct-acting misoprostol (1600 mg) in patients with missed abortion (MA), from the perspective of a National Health System. METHODS An open prospective cohort study was carried out at Reina Sofía University Hospital (Córdoba, Spain) from January 1, 2019 to December 31, 2019 in 180 patients diagnosed with MA. The patients chose medical treatment with intravaginal misoprostol (800 μg/4 h) or UC after receiving complete and detailed information. The effectiveness, clinical characteristics of the patients, costs of treating and managing the disease, and satisfaction with the procedures were recorded. RESULTS One hundred and forty-five patients (80.6%) chose misoprostol versus 35 patients (19.4%) who chose UC. The effectiveness of misoprostol has been 42% evaluated at 48 h; UC success rate has been 100%. The incidence of side effects is significantly higher in patients treated with misoprostol (p < 0.05); as well as the number of care received by the patient (p < 0.05). Satisfaction is higher in patients treated with UC (p < 0.05). However, the cost is almost 5-folds higher in patients treated with UC (p < 0.05). CONCLUSION UC has a higher success rate, greater satisfaction, and a lower incidence of side effects, although significantly increases the cost compared to misoprostol in MA.
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Affiliation(s)
| | - Jorge Duro Gómez
- Department of Obstetrics and Gynecology, Reina Sofía University Hospital of Córdoba, Córdoba, Spain
| | | | | | - Camil Castelo-Branco
- Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine- University of Barcelona, Hospital Clinic-Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Musik T, Grimm J, Juhasz-Böss I, Bäz E. Treatment Options After a Diagnosis of Early Miscarriage: Expectant, Medical, and Surgical. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:789-794. [PMID: 34696822 DOI: 10.3238/arztebl.m2021.0346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 04/21/2021] [Accepted: 09/23/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Approximately 12% of pregnancies end in an early miscarriage (up to week 12 + 0 of pregnancy). Over the past 10 to 15 years, two alternatives to curettage have appeared in the pertinent international treatment guidelines: expectant treatment and medical (drug) treatment. In this review, we discuss the advantages and disadvantages of each of these therapeutic options. METHODS This review is based on pertinent publications (January 2000 to February 2021) retrieved by a selective search in PubMed, as well as on the guidelines of the American College of Obstetrics and Gynecologists, the Association of the Scientific Medical Societies in Germany, the National Institute for Health and Care Excellence/Royal College of Obstetricians and Gynaecologists, and the International Federation of Gynaecology and Obstetrics. RESULTS Three effective and safe treatment options are available after a diagnosis of early miscarriage. Expectant treatment yields success rates of 66-91%, depending on the type of miscarriage. Its complications include hemorrhage requiring blood transfusion in 1-2% of cases. If expectant therapy fails, subsequent treatment with misoprostol or curettage is indicated. Drug therapy with misoprostol yields a complete termination in 81-95% of cases and is thus a valid alternative to expectant therapy, with the advantage of better planning capability. The vaginal application of misoprostol is the most effective means of administration, with the fewest side effects. Curettage is needed in 5-20% of cases. Suctional curettage has a success rate of 97-98%, with an associated anesthesia-related risk of 0.2%, a 0.1% risk of perforation, and a 2-3% rate of repeat curettage. CONCLUSION If there is no acute indication for the surgical treatment of an early miscarriage, the patient can choose among three treatment options. Expectant and medical treatment can be provided on an outpatient basis. Curettage is the treatment of choice in the presence of infection, marked and persistent bleeding, hemodynamic instability, or a pre-existing coagulopathy.
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Wang XH, Wang HJ, Deng XH, Wang YL, Sun HL, Zhang XH, Li XX. Predictive value of ultrasound-related scoring system on embryo development in early pregnancy after IVF/ICSI: An observation of embryonic quality. Taiwan J Obstet Gynecol 2020; 58:501-504. [PMID: 31307741 DOI: 10.1016/j.tjog.2019.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2019] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE This study aims to evaluate the value of the ultrasound-related scoring system on pregnant patients receiving assisted reproductive technology (IVF/ICSI) and early pregnancy outcome. MATERIALS AND METHODS This prospective study included 208 pregnant women receiving assisted reproductive technology (IVF/ICSI). The following ultrasound parameters were measured: gestational sac size, the proportion of the embryo and gestational sac (embryo/gestational sac), yolk sac size, and fetal cardiac activity. The above data were assigned according to the ongoing pregnancy rate (up to 14 weeks), and the score increased parallel to the pregnancy rate. All patients were grouped according to their scores. RESULTS Patients with a score of 4-5 had a low ongoing pregnancy rate of 14.29%, while patients with a score of 6-7 had an ongoing pregnancy rate of 55.56%. Surprisingly, patients with a score of 8-9 had an ongoing pregnancy rate of 97.22%. In addition, it was found that the ongoing pregnancy rate was 100% (36/36) in patients with a score of 9. Conversely, there was no ongoing pregnancy in patients with a score of 4. CONCLUSION First, this scoring system is strongly associated with an ongoing pregnancy of over 14 weeks. Second, some reassurance can be given to patients with favorable ultrasound parameters, regardless of maternal age or previous pregnancy loss. Third, it would be meaningless to continue the pregnancy in patients with a score of 4, according to the scoring system. Fourth, patients without cardiac activity and embryos at days 33-35 after embryo transfer should discontinue the pregnancy, while patients with embryos should proceed with the pregnancy.
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Affiliation(s)
- Xin-Hua Wang
- Department of Reproductive Medical Center, Qilu Hospital, Shandong University, 107 Wenhua Xi Road, Jinan, 250012, PR China; Department of Reproductive Medicine, Binzhou Medical University Hospital, 661 Huanghe 2 Road, Binzhou, 256603, China
| | - Hui-Jun Wang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, 661 Huanghe 2 Road, Binzhou, 256603, China
| | - Xiao-Hui Deng
- Department of Reproductive Medical Center, Qilu Hospital, Shandong University, 107 Wenhua Xi Road, Jinan, 250012, PR China.
| | - Yan-Lin Wang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, 661 Huanghe 2 Road, Binzhou, 256603, China
| | - Hong-Liang Sun
- Department of Reproductive Medicine, Binzhou Medical University Hospital, 661 Huanghe 2 Road, Binzhou, 256603, China
| | - Xiang-Hui Zhang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, 661 Huanghe 2 Road, Binzhou, 256603, China
| | - Xiao-Xia Li
- Community Health Service Center of Pengli Subdistrict, 681 Bohai 9 Road, Binzhou, 256600, China
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Lazzarin S, Crippa I, Vaglio Tessitore I, Ornaghi S, Vergani P. Treatment of first trimester miscarriage: a prospective cohort study in a large tertiary care center in Northern Italy. J Matern Fetal Neonatal Med 2020; 35:110-115. [PMID: 31937151 DOI: 10.1080/14767058.2020.1712707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To assess acceptability, efficacy, and short- and medium-term complications of vaginal misoprostol therapy for the treatment of first trimester miscarriage.Study design: A prospective cohort study including women admitted to the Unit of Obstetrics, MBBM Foundation, San Gerardo Hospital (Monza, Italy) for medical or surgical treatment of first trimester miscarriage between October 2014 and March 2018. As per Institutional protocol, patients in the medical therapy group received 800 µg of misoprostol vaginally. A second dose could be considered 3 days after the first administration if that was ineffective. Surgical treatment consisted of uterine vacuum aspiration. Success of misoprostol treatment was defined as the expulsion of the gestational sac with no need for subsequent surgery.Results: During the study period, 967 patients were diagnosed with first trimester miscarriage and were included in the study. Of these, 514 (53.2%) women were eligible for and consented to medical therapy. Surgical treatment was performed in the remaining 453 (46.8%) patients due to either medical contraindication to misoprostol or patient's choice. Acceptance of misoprostol as first therapeutic choice increased over time, becoming the preferred treatment after approximately 18 months of use in clinical practice. One dose of misoprostol was successful in 69.8% (n = 359) of patients, whereas 20 women required urgent surgery for bleeding (n = 19) or suspected infection (n = 1). Among the remaining 135 patients, 20 (14.8%) refused the second dose of misoprostol and opted for surgery. Expulsion of the gestational sac was obtained in 74 additional cases who completed the medical protocol, for an overall success rate of 87.7% (433/494). The majority of women receiving misoprostol did not experience any short-term complication (92.0%) or side effect (93.8%). Eight (1.6%) cases requiring delayed surgery (hysteroscopy or vacuum aspiration) for retained product of conception were identified at the postmedical treatment follow up, thus leading to an actual success rate of misoprostol of 86.0% (n = 425).Conclusions: This is the first study assessing the acceptability, efficacy, and complication rate of medical management of first trimester miscarriage in an Italian tertiary care center. Our results confirm that misoprostol alone is an effective as well as a safe therapeutic option for the treatment of first trimester miscarriage.
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Affiliation(s)
- Sara Lazzarin
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Obstetrics and Gynecology, MBBM Foundation, San Gerardo Hospital, Monza, Italy
| | - Isabella Crippa
- Department of Obstetrics and Gynecology, MBBM Foundation, San Gerardo Hospital, Monza, Italy
| | - Isadora Vaglio Tessitore
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Obstetrics and Gynecology, MBBM Foundation, San Gerardo Hospital, Monza, Italy
| | - Sara Ornaghi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Obstetrics and Gynecology, MBBM Foundation, San Gerardo Hospital, Monza, Italy
| | - Patrizia Vergani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Obstetrics and Gynecology, MBBM Foundation, San Gerardo Hospital, Monza, Italy
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Abdelshafy A, Awwad H, Abo-Gamra A, Alanwar A, Elkotb AM, Shahin M, Abd El-Razek M, Abbas AM. Sublingual vs vaginal misoprostol for completion of first trimester missed abortion: a randomised controlled trial. EUR J CONTRACEP REPR 2019; 24:134-139. [PMID: 30747547 DOI: 10.1080/13625187.2019.1569224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The study aimed to compare the efficacy and safety of sublingual and vaginal misoprostol for termination of pregnancy in women with first trimester missed abortion. METHODS A single-blind, parallel group, randomised clinical trial (ClinicalTrials.gov NCT02686840) was conducted in a university hospital between 1 February 2016 and 31 January 2017. All women who presented with first trimester missed abortion were invited to participate in the study and were randomised to one of two groups: one group received sublingual misoprostol in three doses of 800 μg every 4 h, while a second group received vaginal misoprostol in the same dosage regimen. The primary outcome of the study was the rate of complete abortion within 7 days after initiation of treatment. RESULTS The study included 200 women (100 in each arm). By day 7, successful complete abortion was significantly more frequent in the sublingual misoprostol group (71.4%) than in the vaginal misoprostol group (51.5%) (p = .006). By day 30, the rate of complete abortion was higher in the sublingual misoprostol group (90.6%) than in the vaginal misoprostol group (83.9%), but with no statistically significant difference (p = .164). The mean length of the induction-expulsion interval in the sublingual misoprostol group was significantly shorter compared with the vaginal misoprostol group (12.3 ± 3.1 h vs 16.4 ± 4.2 h, respectively; p = .001) and the sublingual misoprostol group had a smaller drop in haemoglobin level (p = .001). The side effects of misoprostol were significantly more frequent in the sublingual group compared with the vaginal group. CONCLUSION Sublingual misoprostol is more effective than vaginal misoprostol in completing first trimester missed abortion, with a shorter induction-expulsion time. Sublingual misoprostol is, however, associated with more side effects, such as unpleasant taste, gastrointestinal symptoms and fever, compared with vaginal misoprostol.
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Affiliation(s)
- Ahmed Abdelshafy
- a Ain Shams Maternity Hospital, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Hassan Awwad
- a Ain Shams Maternity Hospital, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Amgad Abo-Gamra
- a Ain Shams Maternity Hospital, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Ahmed Alanwar
- a Ain Shams Maternity Hospital, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Ahmed M Elkotb
- a Ain Shams Maternity Hospital, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Mohamed Shahin
- a Ain Shams Maternity Hospital, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Maya Abd El-Razek
- a Ain Shams Maternity Hospital, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Ahmed M Abbas
- b Women's Health Hospital, Faculty of Medicine , Assiut University , Assiut , Egypt
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Petersen SG, Perkins AR, Gibbons KS, Bertolone JI, Mahomed K. Utility of βhCG monitoring in the follow-up of medical management of miscarriage. Aust N Z J Obstet Gynaecol 2017; 57:358-365. [PMID: 28345139 DOI: 10.1111/ajo.12607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 12/18/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the percentage change in total βeta-unit human chorionic gonadotropin (βhCG) levels (%ΔβhCG) in the prediction of treatment outcomes following intravaginal misoprostol for missed miscarriage before 13 weeks. METHODS A secondary analysis of a randomised controlled study of medical management of miscarriage was performed. Total βhCG levels were collected before misoprostol (baseline) and after a planned seven day interval (follow-up), when a transvaginal ultrasound (TVUS) reported a gestational sac as present or not. If no sac at TVUS, surgery was indicated on clinical criteria. %ΔβhCG ((baseline βhCG - follow-up βhCG)/baseline βhCG × 100) was evaluated in the prediction of a sac at TVUS and surgery on clinical criteria. RESULTS %ΔβhCG was calculated for cases with βhCG levels within two days of misoprostol and TVUS; calculation interval determined case number. The median %ΔβhCG for 24 cases with a persistent sac (6-9 day interval) was significantly lower than for 145 with no sac (58.75% (interquartile range (IQR): 37.59-76.69; maximum 86.54) vs 97.65% (IQR: 95.44-98.43); P < 0.0001). The median %ΔβhCG for eight cases needing surgery on clinical criteria (5-9 day interval) was significantly lower than for 140 cases with no sac not needing surgery (79.68% (IQR: 64.63-91.15; maximum 94.06) vs 97.68% (IQR: 95.61-98.50); P < 0.0001). The area under the receiver-operator curve was 0.975 for prediction of a persistent sac and 0.944 for prediction of surgery on clinical criteria, respectively. %ΔβhCG > 87% predicted no sac at TVUS. %ΔβhCG > 94.5% predicted no surgery on clinical criteria. CONCLUSION %ΔβhCG calculation over one week reliably predicted treatment outcomes after medical management of missed miscarriage.
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Affiliation(s)
- Scott G Petersen
- Department of Obstetrics and Gynaecology, Mater Mother's Hospital, Brisbane, Queensland, Australia.,Mater Research Institute-University of Queensland, Brisbane, Queensland, Australia
| | - Anneliese R Perkins
- Department of Obstetrics and Gynaecology, Mater Mother's Hospital, Brisbane, Queensland, Australia
| | - Kristen S Gibbons
- Mater Research Institute-University of Queensland, Brisbane, Queensland, Australia
| | - Julia I Bertolone
- Department of Obstetrics and Gynaecology, Mater Mother's Hospital, Brisbane, Queensland, Australia
| | - Kassam Mahomed
- Mater Research Institute-University of Queensland, Brisbane, Queensland, Australia
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Mcgee TM, Diplock H, Lucewicz A. Sublingual misoprostol for management of empty sac or missed miscarriage: The first two years’ experience at a metropolitan Australian hospital. Aust N Z J Obstet Gynaecol 2016; 56:414-9. [DOI: 10.1111/ajo.12481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 04/25/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Therese M. Mcgee
- Department of Obstetrics and Gynaecology; Westmead Hospital; Sydney New South Wales Australia
| | - Hayley Diplock
- Department of Obstetrics and Gynaecology; Westmead Hospital; Sydney New South Wales Australia
| | - Ania Lucewicz
- Department of Obstetrics and Gynaecology; Westmead Hospital; Sydney New South Wales Australia
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Tratamiento médico del aborto espontáneo del primer trimestre. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2015. [DOI: 10.1016/j.gine.2013.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Beucher G, Dolley P, Stewart Z, Lavoué V, Deffieux X, Dreyfus M. Obtention de la vacuité utérine dans le cadre d’une perte de grossesse. ACTA ACUST UNITED AC 2014; 43:794-811. [DOI: 10.1016/j.jgyn.2014.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Beucher G, Dolley P, Stewart Z, Carles G, Dreyfus M. Fausses couches du premier trimestre : bénéfices et risques des alternatives thérapeutiques. ACTA ACUST UNITED AC 2014; 42:608-21. [DOI: 10.1016/j.gyobfe.2014.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 06/06/2014] [Indexed: 10/24/2022]
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Beucher G, Dolley P, Carles G, Salaun F, Asselin I, Dreyfus M. Misoprostol : utilisation hors AMM au premier trimestre de la grossesse (fausses couches spontanées, interruptions médicales et volontaires de grossesse). ACTA ACUST UNITED AC 2014; 43:123-45. [DOI: 10.1016/j.jgyn.2013.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lousquy R, Morel O, Soyer P, Malartic C, Gayat E, Barranger E. Routine use of abdominopelvic ultrasonography in severe postpartum hemorrhage: retrospective evaluation in 125 patients. Am J Obstet Gynecol 2011; 204:232.e1-6. [PMID: 21111397 DOI: 10.1016/j.ajog.2010.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Revised: 08/16/2010] [Accepted: 10/06/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of this study was to analyze the potential of abdominopelvic ultrasonography at the initial examination in women with severe postpartum hemorrhage. STUDY DESIGN One hundred twenty-five women were included in the study. The therapeutic approaches that were performed to stop the bleeding were evaluated for each category of ultrasonographic finding. RESULTS Seventy-one women (56.8%) had normal ultrasonography; 30 women (24%) had echogenic endometrial lining; 17 women (13.6%) had echogenic intrauterine mass, and 7 women (5.6%) had abdominopelvic free fluid effusion. Medical therapies allowed the bleeding to stop in 90.1% of women with normal ultrasonography, in 66.6% of women with echogenic endometrial lining, and in 29.4% of women with echogenic intrauterine mass. Pelvic embolization and surgery were performed less frequently in women who had normal ultrasonography results (9.9%) than in women with abnormal ultrasonography results (46.8%; P < .0001). CONCLUSION A normal abdominopelvic ultrasonography is associated with a favorable outcome and can be considered to be a predictor for the effectiveness of conservative, noninvasive therapeutic approaches.
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Affiliation(s)
- Ruben Lousquy
- Department of Obstetrics and Gynecology, Hôpital Lariboisière-AP-HP, 2 rue Ambroise Paré, Paris, France.
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Tanha FD, Feizi M, Shariat M. Sublingual versus vaginal misoprostol for the management of missed abortion. J Obstet Gynaecol Res 2010; 36:525-32. [PMID: 20598032 DOI: 10.1111/j.1447-0756.2010.01229.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To evaluate the efficacy of two routes of misoprostol administration (sublingual and vaginal) for the treatment of missed abortion. METHODS Two hundred and twenty women with confirmed missed abortion who received 400 microg/6 h misoprostol either sublingually or vaginally, were included in this randomized control trial. All women were admitted to hospital for follow-up care for 2 days. If the pregnancy was not completely evacuated during this time, the patient underwent immediate surgical completion. Efficacy was defined as the percentage of women discharged from the study without the need for surgical intervention. RESULTS The effectiveness was high in the sublingual group and statistically different (sublingual 84.5%, vaginal 46.4% P = 0.000 RR = 0.54 95%CI = 0.442-0.681). The groups differed in terms of complications like bleeding (88.2% vs 65.5%), pain (85.5% vs 56.4%), diarrhea (69.1% vs 36.4%) and fever (23.6% vs 13.3%) in the sublingual group versus the vaginal group, but the mean time to expulsion was shorter (9.68 h SD = 5.51 95%CI = 8.61-10.57) in the sublingual group than the vaginal group (16.64 h SD = 14.01 95%CI = 13.8-19.48), P = 0.000. Women in the sublingual group were highly satisfied with the method. CONCLUSION Sublingual misoprostol for the medical management of missed abortion is more effective and more acceptable than the vaginal route. However, it showed more adverse effects.
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Affiliation(s)
- Fateme Davari Tanha
- Department of Obstetrics and Gynecology, Tehran University of Medical Sciences, Mirza Kochak Khan Hospital, Valiasr Reproductive Health Research Center, Tehran, Iran.
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Fink NS, Urech C, Berger CT, Hoesli I, Holzgreve W, Bitzer J, Alder J. Maternal laboratory stress influences fetal neurobehavior: cortisol does not provide all answers. J Matern Fetal Neonatal Med 2010; 23:488-500. [PMID: 20298130 DOI: 10.3109/14767050903300985] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Maternal stress can have an impact on pregnancy. However, effects on fetal neurobehavior are not well understood. In this study, the effect of laboratory stress on maternal psychoneuroendocrinological response and on fetal neurobehavior was studied. Serum cortisol as a potential underlying mechanism was measured. METHODS Twenty-seven women made a single 1.5-h visit in their third trimester. The laboratory stressor involved an arithmetic task. Associations between maternal laboratory stress response and fetal neurobehavior were analyzed by studying 19 maternal-fetal dyads with high signal quality cardiotocograms. RESULTS Stress exposure changed participants stress perception (p < 0.0001). However, only half of the participants (responders) had an HPA-axis response. Fetuses responded to the stress exposure depending on their mothers' stress response: (i) there was a fetal heart rate (FHR) group effect at the level of trend (p = 0.06). Fetuses of responders had higher HR levels 20 min after the exposure (p = 0.043), (ii) there were interaction (p = 0.026) and group effects at the level of trend (p = 0.078) found for FHR short-term variation (STV). Fetuses of responders had lower FHR STV 20 min after stress exposure (p = 0.007). Cortisol as a potential underlying mechanism only seemed to be associated with short- and long-term variation of FHR. CONCLUSIONS An activation of the maternal stress-system could result in a child being born having a history of responding to maternal stress.
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Affiliation(s)
- Nadine Stephanie Fink
- Harvard Medical School, Children's Hospital, Child Development Unit, Boston, Massachusetts 02115, USA.
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Beucher G. [Management of spontaneous miscarriage in the first trimester]. JOURNAL DE GYNECOLOGIE, OBSTETRIQUE ET BIOLOGIE DE LA REPRODUCTION 2010; 39:F3-10. [PMID: 20363567 DOI: 10.1016/j.jgyn.2010.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 12/18/2009] [Indexed: 10/19/2022]
Affiliation(s)
- G Beucher
- hôpital Georges-Clemenceau, CHU de Caen, France.
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Prise en charge des fausses couches spontanées du premier trimestre. ACTA ACUST UNITED AC 2009; 37:257-64. [DOI: 10.1016/j.gyobfe.2009.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 01/21/2009] [Indexed: 11/15/2022]
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Ultrasonographic endometrial thickness after medical and surgical management of early pregnancy failure. Obstet Gynecol 2008; 111:106-12. [PMID: 18165398 DOI: 10.1097/01.aog.0000296655.26362.6d] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to compare endometrial thickness after misoprostol or dilation and curettage (D&C) for early pregnancy failure and to assess the predictive value of endometrial thickness for subsequent D&C after misoprostol treatment. METHODS In a randomized trial of early pregnancy failure management, 491 women were treated with misoprostol vaginally, and 161 were treated with D&C. Transvaginal ultrasonography was planned for 2 and 14 days after misoprostol treatment, and 14 days after D&C. RESULTS The mean endometrial thickness 14 days after treatment was 9.0 mm for the misoprostol group and 6.9 mm for the D&C group, (difference 2.1 mm, 95% confidence interval [CI] 1.0-3.2). After the ultrasonograms 2 and 14 days after misoprostol, 13 (3.8%) and 12 (3.2%) women, respectively, subsequently underwent D&C. Women requiring D&C after successful expulsion had significantly greater endometrial thickness than those who did not at 2 days (mean difference 5.2 mm, 95% CI 1.6-8.8) and 14 days (mean difference 5.5 mm, 95% CI 2.3-8.8) after misoprostol. However, endometrial thickness was a poor predictor of subsequent D&C. The areas under the receiver operating characteristic curves for endometrial thickness at 2 and 14 days were 0.71 and 0.73, respectively. Regardless of cutoff values used for predicting subsequent D&C, endometrial thickness had a positive predictive value of 40% or less. CONCLUSION The difference in endometrial thickness between misoprostol treatment and D&C for early pregnancy failure is not clinically significant. Endometrial thickness is not a useful predictor of subsequent surgical intervention after successful expulsion of the gestational sac after misoprostol for early pregnancy failure. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov,www.clinicaltrials.gov, NCT00177333 LEVEL OF EVIDENCE I.
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Lohr PA, Reeves MF, Hayes JL, Harwood B, Creinin MD. Oral mifepristone and buccal misoprostol administered simultaneously for abortion: a pilot study. Contraception 2007; 76:215-20. [PMID: 17707719 DOI: 10.1016/j.contraception.2007.05.088] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Revised: 05/14/2007] [Accepted: 05/24/2007] [Indexed: 12/01/2022]
Abstract
BACKGROUND Simultaneous oral mifepristone and vaginal misoprostol has a 24-h expulsion rate of approximately 90% when used for abortion through 63 days' gestation. This pilot study sought to determine if a simultaneous regimen using buccal misoprostol would be similarly effective and merit further investigation. STUDY DESIGN One hundred twenty women were enrolled into three equal groups by gestational age: < or =49 days (Group 1), 50-56 days (Group 2) and 57-63 days (Group 3). After swallowing 200 mg of mifepristone, subjects received 800 mcg buccal misoprostol. Participants returned in 24+/-1 h for evaluation of expulsion by ultrasonography. Women with a persistent gestational sac received 800 mcg vaginal misoprostol. Further follow-up occurred at 1, 2 and 5 weeks by telephone or in person, as appropriate. Sample sizes for each group were estimated with the aim of establishing a 24-h expulsion rate of 90% (95% CI=76-95). RESULTS The 24-h expulsion rates for Groups 1, 2 and 3 were 73% (95% CI=56-85), 69% (95% CI=52-83) and 73% (95% CI=56-85), respectively. Common side effects were nausea (62%), vomiting (33%) and diarrhea (48%), which did not differ by gestational age. Forty-three percent of subjects found the taste of buccal misoprostol objectionable; 30% found buccal retention uncomfortable or inconvenient, and 10% reported oral irritation, sensitivity, numbness or oral ulcers. CONCLUSIONS Simultaneous oral mifepristone and buccal misoprostol had a lower-than-hypothesized expulsion rate at 24 h. Although overall success rates at 7 or 15 days could have been higher than those observed at 24 h, we believe that this regimen does not warrant further study.
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Affiliation(s)
- Patricia A Lohr
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, 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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Abstract
PURPOSE OF REVIEW This paper reviews the current management of early pregnancy failure with particular emphasis on the use of misoprostol. RECENT FINDINGS Medical management using misoprostol is effective for the management of miscarriages. The success rate ranged from 84 to 93% depending on the regimen of misoprostol, the duration of waiting period and the types of miscarriage. SUMMARY Miscarriages occur in 10 to 20% of all pregnancies. Surgical evacuation has been used to empty the uterus. Recently, medical treatment using misoprostol has been studied for the management of miscarriage. It avoids surgery and its associated complications. Compared to expectant management, the success rate is higher. Nonsurgical management takes a longer period to reach the endpoint and medical management is associated with side effect of medication. Studies have shown that medical management is safe and acceptable to women. The optimal regimen of medical management, however, is yet to be determined.
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Affiliation(s)
- Oi Shan Tang
- Department of Obstetrics and Gynaecology, The University of Hong Kong, Hong Kong SAR, China.
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Stockheim D, Machtinger R, Wiser A, Dulitzky M, Soriano D, Goldenberg M, Schiff E, Seidman DS. A randomized prospective study of misoprostol or mifepristone followed by misoprostol when needed for the treatment of women with early pregnancy failure. Fertil Steril 2006; 86:956-60. [PMID: 17027362 DOI: 10.1016/j.fertnstert.2006.03.032] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2005] [Revised: 03/10/2006] [Accepted: 03/10/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To compare the effectiveness and safety of misoprostol and mifepristone, followed when needed by misoprostol, for the treatment of women with early pregnancy failure. DESIGN Prospective randomized nonblinded controlled trial. SETTING University-affiliated tertiary medical center. PATIENT(S) One hundred fifteen consecutive women diagnosed as having a blighted ovum or missed abortion of <9 weeks of gestation enrolled. INTERVENTION(S) The patients received orally 600 mg mifepristone (group I) or orally 800 microg misoprostol (group II). Most patients in both groups subsequently received 48 hours later orally 800 microg misoprostol. MAIN OUTCOME MEASURE(S) Failure was defined as surgical intervention due to retained gestational sac 48 hours after completion of the drug protocol, severe symptoms, or suspected retained products of conception after the menstrual period. RESULT(S) The success rate was similar in groups I and II: 38 of 58 patients (65.5%) versus 42 of 57 patients (73.6%), respectively. No cases of severe infection or bleeding necessitating blood transfusion occurred. CONCLUSION(S) Misoprostol is an effective and safe treatment for early pregnancy failure and could replace surgical curettage in over two-thirds of the patients. Mifepristone offers no advantage compared with misoprostol as initial treatment.
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Affiliation(s)
- David Stockheim
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Israel.
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Creinin MD, Huang X, Westhoff C, Barnhart K, Gilles JM, Zhang J. Factors related to successful misoprostol treatment for early pregnancy failure. Obstet Gynecol 2006; 107:901-7. [PMID: 16582130 PMCID: PMC1761999 DOI: 10.1097/01.aog.0000206737.68709.3e] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify potential predictors for treatment success in medical management with misoprostol for early pregnancy failure. METHODS We conducted a planned secondary analysis of data from a multicenter trial that compared medical and surgical management of early pregnancy failure. Medical management consisted of misoprostol 800 mug vaginally on study day 1, with a repeat dose if indicated on day 3. Women returned on days 3 and 15, and a telephone interview was conducted on day 30. Failure was defined as suction aspiration for any reason within 30 days. Demographic, historical, and outcome variables were included in univariable analyses of success. Multivariable analyses were conducted using clinical site, gestational age, and variables for which the univariable analysis resulted in a P < .1 to determine predictors of overall treatment success and first-dose success. RESULTS Of the 491 women who received misoprostol, 485 met the criteria for this secondary analysis. Lower abdominal pain or vaginal bleeding within the last 24 hours, Rh-negative blood type, and nulliparity were predictive of overall success. However, only vaginal bleeding within the last 24 hours and parity of 0 or 1 were predictive of first-dose success. Overall success exceeds 92% in women who have localized abdominal pain within the last 24 hours, Rh-negative blood type, or the combination of vaginal bleeding in the past 24 hours and nulliparity. CONCLUSION Misoprostol treatment for early pregnancy failure is highly successful in select women, primarily those with active bleeding and nulliparity. Clinicians and patients should be aware of these differences when considering misoprostol treatment. LEVEL OF EVIDENCE II-2.
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Affiliation(s)
- Mitchell D Creinin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, and Magee-Womens Research Institute, Pittsburgh, Pennsylvania 15213-3180, USA.
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Wicherek L, Galazka K, Popiela TJ, Dutsch-Wicherek M, Czekierdowski A, Pabian W, Banas T, Migdal M, Klimek M. Metallothionein expression and infiltration of cytotoxic lymphocytes in uterine and tubal implantation sites. J Reprod Immunol 2006; 70:119-31. [PMID: 16427139 DOI: 10.1016/j.jri.2005.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Revised: 11/21/2005] [Accepted: 12/06/2005] [Indexed: 11/21/2022]
Abstract
INTRODUCTION In spite of increasing number of immune cells in the endometrium during the decidualization, the integrity of endometrial tissue in each menstrual cycle is maintained by adaptive changes in expression of several factors that regulate activity of immune cells and concomitant hormonal alterations during the menstrual cycle. This regulatory function of endometrium is also related to resistance to apoptosis, in which metallothionein (MT) may play a role. MATERIALS AND METHODS Study group included 26 women with spontaneous abortion and 18 patients with tubal ectopic pregnancy. Control group included 17 women whose endometrial tissue samples were taken during the normal secretory cycle phase. Expression of metallothionein (MT), CD56 and CD69 were assessed in tissue samples by immunohistochemistry. RESULTS The number of CD56-positive cells was significantly higher in women with ruptured than unruptured ectopics. MT expression was higher in tubal mucosa distant from the implantation site in ruptured compared to unruptured ectopics. It was found also to be significantly lower than in decidua taken from women with spontaneous abortion. CD69 expression was similar in women with spontaneous abortion as well as patients with ruptured ectopics compared to the control group. On the other hand, CD69 expression in unruptured ectopics was significantly lower than in women with spontaneous abortion and the control group. CONCLUSION The concentration of immune cells and increase of their activity in tubal mucosa, with insufficient protection against immune-mediated apoptosis assessed by MT expression, might result in tubal rupture during ectopic pregnancy.
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MESH Headings
- Abortion, Spontaneous/immunology
- Abortion, Spontaneous/metabolism
- Adult
- Antigens, CD/biosynthesis
- Antigens, CD/immunology
- Antigens, Differentiation, T-Lymphocyte/biosynthesis
- Antigens, Differentiation, T-Lymphocyte/immunology
- Apoptosis/immunology
- Apoptosis/physiology
- CD56 Antigen/biosynthesis
- CD56 Antigen/immunology
- Decidua/immunology
- Decidua/metabolism
- Embryo Implantation/immunology
- Embryo Implantation/physiology
- Fallopian Tubes/immunology
- Fallopian Tubes/microbiology
- Female
- Humans
- Immunohistochemistry
- Lectins, C-Type
- Lymphocytes/cytology
- Lymphocytes/immunology
- Metallothionein/biosynthesis
- Metallothionein/immunology
- Pregnancy
- Pregnancy, Ectopic/immunology
- Pregnancy, Ectopic/metabolism
- Uterus/immunology
- Uterus/metabolism
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Affiliation(s)
- Lukasz Wicherek
- Gynecology and Infertility Department, Jagiellonian University, 23 Kopernik Street, 30-501 Krakow, Poland.
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Lister MS, Shaffer LET, Bell JG, Lutter KQ, Moorma KH. Randomized, double-blind, placebo-controlled trial of vaginal misoprostol for management of early pregnancy failures. Am J Obstet Gynecol 2005; 193:1338-43. [PMID: 16202723 DOI: 10.1016/j.ajog.2005.05.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2005] [Revised: 04/20/2005] [Accepted: 04/25/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine whether misoprostol medical management of early pregnancy failures is more effective than expectant management. STUDY DESIGN Patients diagnosed with early pregnancy failures, closed cervix, and minimal vaginal bleeding were randomized to 800 microg of misoprostol or placebo placed vaginally. Patients were evaluated by ultrasound imaging 24 hours and 48 hours after study drug administration, with repeat administration if 24-hour imaging showed a persistent gestational sac. Treatment success was defined as expulsion of uterine contents within 48 hours. Patient follow-up occurred 2 weeks after expulsion of uterine contents. RESULTS Treatment success occurred in 15 of 18 (83%) misoprostol patients and 2 of 16 (13%) placebo patients (P < .0001). Side effects were similar between groups except for vaginal bleeding, which was more common in the misoprostol group (P = .001). Patient satisfaction and pain perception were similar between groups. CONCLUSION Misoprostol appears to be highly effective for treating early pregnancy failures, with few side effects and high patient satisfaction.
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Affiliation(s)
- Margit S Lister
- Department of Obstetrics and Gynecology, Riverside Methodist Hospitals, Columbus, OH 43214, USA
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