Comparison of misoprostol and manual vacuum aspiration for the treatment of incomplete abortion

Introducing misoprostol for treatment of incomplete abortion: A feasibility and acceptability study in secondary-level health facilities in Myanmar

OBJECTIVE

To assess the feasibility and acceptability of misoprostol as a treatment option for incomplete abortion in secondary hospitals in Yangon and Mandalay, Myanmar.

METHODS

An explanatory sequential mixed methods study was conducted. Women seeking treatment for an incomplete abortion with a uterine size <12 weeks were eligible to participate in the prospective cohort including sublingual administration of 400 μg misoprostol, clinical assessment 7-10 days after administration, and patient interview. Treatment efficacy was assessed, defined as proportion of participants with complete uterine evacuation with misoprostol alone. After the cohort, provider interviews were conducted to understand how their experiences with misoprostol may have influenced cohort findings. Study sites included seventeen secondary health facilities in four townships in Yangon and Mandalay, Myanmar.

RESULTS

A total of 110 women were enrolled from July 2018 to January 2019; 96 completed follow-up. In 75 % of cases, incomplete abortion was successfully treated with misoprostol. Treatment efficacy varied significantly by region (Yangon 85 %, Mandalay 67 %; p = 0.048), driven by providers' variable comfort with misoprostol and proclivity to intervene with additional treatment. With experience, all were willing to incorporate the protocol into practice by study end. Patient acceptability and satisfaction were high.

CONCLUSION

Misoprostol is an acceptable and feasible treatment option for women seeking postabortion care at secondary facilities in Myanmar. Extensive health provider training and support systems and continued implementation experience are crucial to effectively translate clinical PAC guidelines into practice in Myanmar.

Health care providers’ perceptions of using misoprostol in the treatment of incomplete abortion in Malawi

Background

In Malawi, abortion is only legal to save a pregnant woman’s life. Treatment for complications after unsafe abortions has a massive impact on the already impoverished health care system. Even though manual vacuum aspiration (MVA) and misoprostol are the recommended treatment options for incomplete abortion in the first trimester, surgical management using sharp curettage is still one of the primary treatment methods in Malawi. Misoprostol and MVA are safer and cheaper, whilst sharp curettage has more risk of complications such as perforation and bleeding and requires general anesthesia and a clinician. Currently, efforts are being made to increase the use of misoprostol in the treatment of incomplete abortions in Malawi. To achieve successful implementation of misoprostol, health care providers’ perceptions on this matter are crucial.

Methods

A qualitative approach was used to explore health care providers’ perceptions of misoprostol for the treatment of incomplete abortion using semi-structured in-depth interviews. Ten health care providers were interviewed at one urban public hospital. Each interview lasted 45 min on average. Health care providers of different cadres were interviewed in March and April 2021, nine months after taking part in a training intervention on the use of misoprostol. Interviews were recorded, transcribed verbatim and analyzed using ‘Systematic Text Condensation’.

Results

The health care providers reported many advantages with the increased use of misoprostol, such as reduced workload, less hospitalization, fewer infections, and task-shifting. Availability of the drug and benefits for the patients were also highlighted as important. However, some challenges were revealed, such as deciding who was eligible for the drug and treatment failure. For these reasons, some health care providers still choose surgical treatment as their primary method.

Conclusion

Findings in this study support the recommendation of increased use of misoprostol as a treatment for incomplete abortion in Malawi, as the health care providers interviewed see many advantages with the drug. To scale up its use, proper training and supervision are essential. A sustainable and predictable supply is needed to change clinical practice.

Plain English Summary

Unsafe abortion is a major contributor to maternal mortality worldwide. Unsafe abortion is the termination of an unintended pregnancy by a person without the required skills or equipment, which might lead to serious complications. In Malawi, post-abortion complications are common, and the maternal mortality ratio is among the highest in the world. Retained products of conception, referred to as an incomplete abortion, are common after spontaneous miscarriages and unsafe induced abortions. There are several ways to treat incomplete abortion, and the drug misoprostol has been successful in the treatment of incomplete abortion in other low-income countries. This study explored perceptions among health care providers using misoprostol to treat incomplete abortions and whether the drug can be fully embraced by Malawian health care professionals. Health personnel at a Malawian hospital were interviewed individually regarding the use of the drug for treating incomplete abortions. This study revealed that health care providers interviewed are satisfied with the increased use of misoprostol. They highlighted several benefits, such as reduced workload and that it enabled task-shifting so that various hospital cadres could now treat patients with incomplete abortions. The health care workers also observed benefits for women treated with the drug compared to other treatments. The challenges mentioned were finding out who was eligible for the drug and drug failure. This study supports scaling up the use of misoprostol in the treatment of incomplete abortions in Malawi; the Ministry of Health and policymakers should support future interventions to increase its use.

A Patient-Centred Approach to Early Pregnancy Loss: The First 18 Months of a Canadian Outpatient Program for Early Pregnancy Loss (OPEL)

OBJECTIVE

Manual vacuum aspiration is a safe surgical option for the management of early pregnancy loss. To provide rapid, patient-centred access to MVA, an Outpatient Program for Early pregnancy Loss ("OPEL") was established at our institution. Objectives were to (1) assess complete uterine evacuation rates; (2) assess complication rates, and (3) assess patient satisfaction with the program.

METHODS

With REB approval, a retrospective study was performed. Patient records from the first 18 months of OPEL (November 2015 to April 2017) were reviewed. Anonymous patient satisfaction questionnaires were completed immediately post-procedure.

RESULTS

A total of 162 patients received treatment. Missed abortions accounted for 94 cases (58%). Median delay from referral to clinic appointment was 4.0 (interquartile range [IQR] 2.0-6.0) days. Average length of stay was 3.0 (IQR 2.5-3.0) hours. Efficacy of the procedure was 95.1%. Complication rate (immediate and delayed) was 14.2% and included intraoperative hemorrhage (3.1%; 5/162), Asherman's syndrome (1.9%; 3/162), retained products of conception requiring further treatment (4.9%; 8/162), and postoperative infection requiring antibiotic therapy (1.9%; 3/162). A total of 151 post-procedure satisfaction surveys were completed (93%); 100% agreed/strongly agreed that the nursing staff and physicians provided professional and compassionate care; 99.3% were satisfied with their care overall. Qualitative feedback was positive.

CONCLUSION

Pregnant patients experiencing early pregnancy loss benefit from safe, timely, accessible, patient-centred care in the outpatient OPEL program. Similar models should be adopted nationally to ensure women experiencing this common pregnancy complication receive safe and compassionate care.

Methods for managing miscarriage: a network meta-analysis

BACKGROUND

Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime. An estimated 15% of pregnancies end in miscarriage. Miscarriage can lead to serious morbidity, including haemorrhage, infection, and even death, particularly in settings without adequate healthcare provision. Early miscarriages occur during the first 14 weeks of pregnancy, and can be managed expectantly, medically or surgically. However, there is uncertainty about the relative effectiveness and risks of each option.

OBJECTIVES

To estimate the relative effectiveness and safety profiles for the different management methods for early miscarriage, and to provide rankings of the available methods according to their effectiveness, safety, and side-effect profile using a network meta-analysis.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth's Trials Register (9 February 2021), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (12 February 2021), and reference lists of retrieved studies.

SELECTION CRITERIA

We included all randomised controlled trials assessing the effectiveness or safety of methods for miscarriage management. Early miscarriage was defined as less than or equal to 14 weeks of gestation, and included missed and incomplete miscarriage. Management of late miscarriages after 14 weeks of gestation (often referred to as intrauterine fetal deaths) was not eligible for inclusion in the review. Cluster- and quasi-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded non-randomised trials.

DATA COLLECTION AND ANALYSIS

At least three review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for the primary outcomes of complete miscarriage and composite outcome of death or serious complications. The certainty of evidence was assessed using GRADE. Relative effects for the primary outcomes are reported subgrouped by the type of miscarriage (incomplete and missed miscarriage). We also performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available methods.

MAIN RESULTS

Our network meta-analysis included 78 randomised trials involving 17,795 women from 37 countries. Most trials (71/78) were conducted in hospital settings and included women with missed or incomplete miscarriage. Across 158 trial arms, the following methods were used: 51 trial arms (33%) used misoprostol; 50 (32%) used suction aspiration; 26 (16%) used expectant management or placebo; 17 (11%) used dilatation and curettage; 11 (6%) used mifepristone plus misoprostol; and three (2%) used suction aspiration plus cervical preparation. Of these 78 studies, 71 (90%) contributed data in a usable form for meta-analysis. Complete miscarriage Based on the relative effects from the network meta-analysis of 59 trials (12,591 women), we found that five methods may be more effective than expectant management or placebo for achieving a complete miscarriage: · suction aspiration after cervical preparation (risk ratio (RR) 2.12, 95% confidence interval (CI) 1.41 to 3.20, low-certainty evidence), · dilatation and curettage (RR 1.49, 95% CI 1.26 to 1.75, low-certainty evidence), · suction aspiration (RR 1.44, 95% CI 1.29 to 1.62, low-certainty evidence), · mifepristone plus misoprostol (RR 1.42, 95% CI 1.22 to 1.66, moderate-certainty evidence), · misoprostol (RR 1.30, 95% CI 1.16 to 1.46, low-certainty evidence). The highest ranked surgical method was suction aspiration after cervical preparation. The highest ranked non-surgical treatment was mifepristone plus misoprostol. All surgical methods were ranked higher than medical methods, which in turn ranked above expectant management or placebo. Composite outcome of death and serious complications Based on the relative effects from the network meta-analysis of 35 trials (8161 women), we found that four methods with available data were compatible with a wide range of treatment effects compared with expectant management or placebo: · dilatation and curettage (RR 0.43, 95% CI 0.17 to 1.06, low-certainty evidence), · suction aspiration (RR 0.55, 95% CI 0.23 to 1.32, low-certainty evidence), · misoprostol (RR 0.50, 95% CI 0.22 to 1.15, low-certainty evidence), · mifepristone plus misoprostol (RR 0.76, 95% CI 0.31 to 1.84, low-certainty evidence). Importantly, no deaths were reported in these studies, thus this composite outcome was entirely composed of serious complications, including blood transfusions, uterine perforations, hysterectomies, and intensive care unit admissions. Expectant management and placebo ranked the lowest when compared with alternative treatment interventions. Subgroup analyses by type of miscarriage (missed or incomplete) agreed with the overall analysis in that surgical methods were the most effective treatment, followed by medical methods and then expectant management or placebo, but there are possible subgroup differences in the effectiveness of the available methods.  AUTHORS' CONCLUSIONS: Based on relative effects from the network meta-analysis, all surgical and medical methods for managing a miscarriage may be more effective than expectant management or placebo. Surgical methods were ranked highest for managing a miscarriage, followed by medical methods, which in turn ranked above expectant management or placebo. Expectant management or placebo had the highest chance of serious complications, including the need for unplanned or emergency surgery. A subgroup analysis showed that surgical and medical methods may be more beneficial in women with missed miscarriage compared to women with incomplete miscarriage. Since type of miscarriage (missed and incomplete) appears to be a source of inconsistency and heterogeneity within these data, we acknowledge that the main network meta-analysis may be unreliable. However, we plan to explore this further in future updates and consider the primary analysis as separate networks for missed and incomplete miscarriage.

Availability, accessibility and utilization of post-abortion care in Sub-Saharan Africa: A systematic review

At the 1994 ICPD, sub-Saharan African (SSA) states pledged, inter alia, to guarantee quality post-abortion care (PAC) services. We synthesized existing research on PAC services provision, utilization and access in SSA since the 1994 ICPD. Generally, evidence on PAC is only available in a few countries in the sub-region. The available evidence however suggests that PAC constitutes a significant financial burden on public health systems in SSA; that accessibility, utilization and availability of PAC services have expanded during the period; and that worrying inequities characterize PAC services. Manual and electrical vacuum aspiration and medication abortion drugs are increasingly common PAC methods in SSA, but poor-quality treatment methods persist in many contexts. Complex socio-economic, infrastructural, cultural and political factors mediate the availability, accessibility and utilization of PAC services in SSA. Interventions that have been implemented to improve different aspects of PAC in the sub-region have had variable levels of success. Underexplored themes in the existing literature include the individual and household level costs of PAC; the quality of PAC services; the provision of non-abortion reproductive health services in the context of PAC; and health care provider-community partnerships.

When political solutions for acute conflict in Yemen seem distant, demand for reproductive health services is immediate: a programme model for resilient family planning and post-abortion care services

The political situation in Yemen has been precarious since 2011 when popular protest broke out amid the Arab Spring, calling for President Saleh to step down. In March 2015, a Houthi insurgency took control of the capital, Sana’a and ignited a civil conflict that is now characterised by foreign political and military involvement. Since 2015, health facilities have been a primary target for airstrikes and bombing. Seaports have been blockaded barring the delivery of essential medicines and supplies, contributing to the near collapse of an already fragile health system. Since 2012, Save the Children (SC) has been implementing a Family Planning (FP) and Post-abortion Care (PAC) programme in two governorates heavily affected by the conflict. Despite the risks associated with the conflict, there remains a strong demand for SC's FP and PAC services. Ongoing programmatic support and capacity strengthening have allowed quality FP and PAC services to continue for Yemenis even when humanitarian access is impeded. Since the onset of conflict in March 2015, 16 facilities provided services to 43,218 new FP clients (with 23% accepting a long-acting method) and treated 3627 women with PAC. Over 93% of FP clients would recommend FP services at the facility to a friend or family member. Findings support growing evidence that women affected by conflict require family planning services, and that demand does not decline as long as quality services remain accessible. An adaptable reproductive health programme model that embraces innovative approaches is necessary for establishing services and maintaining quality during acute conflict.

Voluntary Contraceptive Uptake Among Postabortion Care Clients Treated With Misoprostol in Rwanda

INTRODUCTION

Unsafe abortion remains a problem in Rwanda, where abortion is highly restricted by law. To reduce mortality and morbidity from unsafe abortion, Rwanda implemented a national postabortion care (PAC) program in 2012, which included using misoprostol to treat incomplete abortion. Key components of PAC are offering and providing voluntary contraceptive methods and counseling on their use, but little is known about contraceptive uptake among PAC clients treated with misoprostol. The objectives of the current study were (1) to assess the contraceptive uptake of PAC clients treated with misoprostol, including whether extended bleeding hinders uptake; and (2) to assess providers' knowledge of contraception and their willingness to counsel PAC clients on contraception, provide methods, or refer for contraceptive services.

METHODS

We surveyed 68 PAC clients treated with misoprostol and 43 providers (84% nurses) in 17 health facilities across 3 districts in Rwanda where misoprostol for PAC had been introduced recently. PAC clients were recruited into the study prior to facility discharge and surveyed between 10 days and 1 month after discharge. We asked PAC clients and providers about demographic characteristics and attitudes toward contraception. We also asked PAC clients about contraceptive counseling received and postabortion contraceptive uptake or reasons for nonuse, and providers about their knowledge about return to fertility, pregnancy and contraceptive counseling, practices related to contraceptive method provision, and their knowledge and potential biases about PAC clients using contraception. We used descriptive statistics for analysis.

RESULTS

PAC clients were 19-46 years old, and most (69%) had at least 1 child. Almost all PAC clients (94%) reported being counseled on contraception, but only 47% reported choosing and receiving a method before being discharged from the facility. Nevertheless, by the time of the survey, 71% reported using a method. PAC clients' main reason for not using contraception was wanting to become pregnant. Only 1 woman reported nonuse because of bleeding. Among providers, more than half (56%) reported there are contraceptive methods PAC clients should never use and about a quarter (26%) reported incorrect information on when PAC clients' fertility could return.

CONCLUSION

We found no evidence that bleeding associated with misoprostol for PAC influenced women's contraceptive uptake. However, as PAC programs expand to include misoprostol as a treatment option, accurate and high-quality postabortion contraception counseling and method provision at both treatment and follow-up visits must be strengthened.

Medical treatment for early fetal death (less than 24 weeks)

BACKGROUND

In most pregnancies that miscarry, arrest of embryonic or fetal development occurs some time (often weeks) before the miscarriage occurs. Ultrasound examination can reveal abnormal findings during this phase by demonstrating anembryonic pregnancies or embryonic or fetal death. Treatment has traditionally been surgical but medical treatments may be effective, safe, and acceptable, as may be waiting for spontaneous miscarriage. This is an update of a review first published in 2006.

OBJECTIVES

To assess, from clinical trials, the effectiveness and safety of different medical treatments for the termination of non-viable pregnancies.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (24 October 2018) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials comparing medical treatment with another treatment (e.g. surgical evacuation), or placebo, or no treatment for early pregnancy failure. Quasi-randomised studies were excluded. Cluster-randomised trials were eligible for inclusion, as were studies reported in abstract form, if sufficient information was available to assess eligibility.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

Forty-three studies (4966 women) were included. The main interventions examined were vaginal, sublingual, oral and buccal misoprostol, mifepristone and vaginal gemeprost. These were compared with surgical management, expectant management, placebo, or different types of medical interventions were compared with each other. The review includes a wide variety of different interventions which have been analysed across 23 different comparisons. Many of the comparisons consist of single studies. We limited the grading of the quality of evidence to two main comparisons: vaginal misoprostol versus placebo and vaginal misoprostol versus surgical evacuation of the uterus. Risk of bias varied widely among the included trials. The quality of the evidence varied between the different comparisons, but was mainly found to be very-low or low quality.Vaginal misoprostol versus placeboVaginal misoprostol may hasten miscarriage when compared with placebo: e.g. complete miscarriage (5 trials, 305 women, risk ratio (RR) 4.23, 95% confidence interval (CI) 3.01 to 5.94; low-quality evidence). No trial reported on pelvic infection rate for this comparison. Vaginal misoprostol made little difference to rates of nausea (2 trials, 88 women, RR 1.38, 95% CI 0.43 to 4.40; low-quality evidence), diarrhoea (2 trials, 88 women, RR 2.21, 95% CI 0.35 to 14.06; low-quality evidence) or to whether women were satisfied with the acceptability of the method (1 trial, 32 women, RR 1.17, 95% CI 0.83 to 1.64; low-quality evidence). It is uncertain whether vaginal misoprostol reduces blood loss (haemoglobin difference > 10 g/L) (1 trial, 50 women, RR 1.25, 95% CI 0.38 to 4.12; very-low quality) or pain (opiate use) (1 trial, 84 women, RR 5.00, 95% CI 0.25 to 101.11; very-low quality), because the quality of the evidence for these outcomes was found to be very low.Vaginal misoprostol versus surgical evacuation Vaginal misoprostol may be less effective in accomplishing a complete miscarriage compared to surgical management (6 trials, 943 women, average RR 0.40, 95% CI 0.32 to 0.50; Heterogeneity: Tau² = 0.03, I² = 46%; low-quality evidence) and may be associated with more nausea (1 trial, 154 women, RR 21.85, 95% CI 1.31 to 364.37; low-quality evidence) and diarrhoea (1 trial, 154 women, RR 40.85, 95% CI 2.52 to 662.57; low-quality evidence). There may be little or no difference between vaginal misoprostol and surgical evacuation for pelvic infection (1 trial, 618 women, RR 0.73, 95% CI 0.39 to 1.37; low-quality evidence), blood loss (post-treatment haematocrit (%) (1 trial, 50 women, mean difference (MD) 1.40%, 95% CI -3.51 to 0.71; low-quality evidence), pain relief (1 trial, 154 women, RR 1.42, 95% CI 0.82 to 2.46; low-quality evidence) or women's satisfaction/acceptability of method (1 trial, 45 women, RR 0.67, 95% CI 0.40 to 1.11; low-quality evidence).Other comparisonsBased on findings from a single trial, vaginal misoprostol was more effective at accomplishing complete miscarriage than expectant management (614 women, RR 1.25, 95% CI 1.09 to 1.45). There was little difference between vaginal misoprostol and sublingual misoprostol (5 trials, 513 women, average RR 0.84, 95% CI 0.61 to 1.16; Heterogeneity: Tau² = 0.10, I² = 871%; or between oral and vaginal misoprostol in terms of complete miscarriage at less than 13 weeks (4 trials, 418 women), average RR 0.68, 95% CI 0.45 to 1.03; Heterogeneity: Tau² = 0.13, I² = 90%). However, there was less abdominal pain with vaginal misoprostol in comparison to sublingual (3 trials, 392 women, RR 0.58, 95% CI 0.46 to 0.74). A single study (46 women) found mifepristone to be more effective than placebo: miscarriage complete by day five after treatment (46 women, RR 9.50, 95% CI 2.49 to 36.19). However the quality of this evidence is very low: there is a very serious risk of bias with signs of incomplete data and no proper intention-to-treat analysis in the included study; and serious imprecision with wide confidence intervals. Mifepristone did not appear to further hasten miscarriage when added to a misoprostol regimen (3 trials, 447 women, RR 1.18, 95% CI 0.95 to 1.47).

AUTHORS' CONCLUSIONS

Available evidence from randomised trials suggests that medical treatment with vaginal misoprostol may be an acceptable alternative to surgical evacuation or expectant management. In general, side effects of medical treatment were minor, consisting mainly of nausea and diarrhoea. There were no major differences in effectiveness between different routes of administration. Treatment satisfaction was addressed in only a few studies, in which the majority of women were satisfied with the received intervention. Since the quality of evidence is low or very low for several comparisons, mainly because they included only one or two (small) trials; further research is necessary to assess the effectiveness, safety and side effects, optimal route of administration and dose of different medical treatments for early fetal death.

Randomised Trial of Oral Misoprostol Versus Manual Vacuum Aspiration for the Treatment of Incomplete Abortion at a Nigerian Tertiary Hospital

Objectives

This study aimed to compare the efficacy of oral misoprostol with manual vacuum aspiration (MVA) in first trimester incomplete abortions.

Methods

This randomised controlled trial study was conducted at the University of Ilorin Teaching Hospital, Ilorin, Nigeria between April 2014 and November 2015. Pregnant women who presented with clinical features of incomplete abortion at a gestational age of 13 weeks or less were included. Patients who had profuse vaginal bleeding, an intrauterine device in situ, signs of pelvic infections or who were younger than 18 years old and had no accompanying adults to give informed consent were excluded. A total of 200 participants were randomly and equally allocated to either the MVA or misoprostol treatment group. The treatment group were given 600 μg of misoprostol orally. The primary outcome measure was complete uterine evacuation, while secondary outcome measures included the need for additional surgical evacuation for failed treatment, adverse effects/complications, acceptability of and satisfaction with the treatment.

Results

Both misoprostol and MVA had high complete evacuation rates, yet MVA was significantly higher (99% versus 83%, relative risk [RR]: 0.84, confidence interval [CI]: 0.766–0.918; P <0.001). Significantly more women in the misoprostol group required additional MVA for failed treatment than in the MVA treatment group (17% versus 1%, RR: 16.67, CI: 2.260–12.279; P <0.001). No significant difference was found between the misoprostol and MVA treatment groups in terms of satisfaction (92.7% versus 89.8%, RR: 1.04, CI: 0.946–1.127; P = 0.473).

Conclusion

Treatments with misoprostol and MVA had high complete uterine evacuation rates, as well as high rates of acceptability and satisfaction. However, MVA had a significantly higher complete evacuation rate than misoprostol.

Outcomes in prevention and management of miscarriage trials: a systematic review

BACKGROUND

There is a substantial body of research evaluating ways to prevent and manage miscarriage, but all studies do not report on the same outcomes.

OBJECTIVE

To review systematically, outcomes reported in existing miscarriage trials.

SEARCH STRATEGY

MEDLINE, Embase, CINAHL, and Cochrane were searched from inception until January 2017.

SELECTION CRITERIA

Randomised controlled trials (RCTs) reporting prevention or management of miscarriage. Miscarriage was defined as a pregnancy loss in the first trimester.

DATA COLLECTION AND ANALYSIS

Data about the study characteristics, primary, and secondary outcomes were extracted.

MAIN RESULTS

We retrieved 1553 titles and abstracts, from which 208 RCTs were included. For prevention of miscarriage, the most commonly reported primary outcome was live birth and the top four reported outcomes were pregnancy loss/stillbirth (n = 112), gestation of birth (n = 68), birth dimensions (n = 65), and live birth (n = 49). For these four outcomes, 58 specific measures were used for evaluation. For management of miscarriage, the most commonly reported primary outcome was efficacy of treatment. The top four reported outcomes were bleeding (n = 186), efficacy of miscarriage treatment (n = 105), infection (n = 97), and quality of life (n = 90). For these outcomes, 130 specific measures were used for evaluation.

CONCLUSIONS

Our review found considerable variation in the reporting of primary and secondary outcomes along with the measures used to assess them. There is a need for standardised patient-centred clinical outcomes through the development of a core outcome set; the work from this systematic review will form the foundation of the core outcome set for miscarriage.

TWEETABLE ABSTRACT

There is disparity in the reporting of outcomes and the measures used to assess them in miscarriage trials.

Induced abortion

Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in the period 2010-2014 was 35 abortions per 1000 women (aged 15-44 years), five points less than the rate of 40 for the period 1990-1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy.

Medical treatments for incomplete miscarriage

BACKGROUND

Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe, and acceptable.

OBJECTIVES

To assess the effectiveness, safety, and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks).

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (13 May 2016) and reference lists of retrieved papers.

SELECTION CRITERIA

We included randomised controlled trials comparing medical treatment with expectant care or surgery, or alternative methods of medical treatment. We excluded quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion, assessed risk of bias, and carried out data extraction. Data entry was checked. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 24 studies (5577 women). There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; 2 studies, 150 women, random-effects; very low-quality evidence), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. For unplanned surgical intervention, we did not identify any difference between misoprostol and expectant care (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence).Sixteen trials involving 4044 women addressed the comparison of misoprostol (7 studies used oral administration, 6 studies used vaginal, 2 studies sublingual, 1 study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.96, 95% CI 0.94 to 0.98; 15 studies, 3862 women, random-effects; very low-quality evidence) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.05, 95% CI 0.02 to 0.11; 13 studies, 3070 women, random-effects; very low-quality evidence) but more unplanned procedures (average RR 5.03, 95% CI 2.71 to 9.35; 11 studies, 2690 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.50, 95% CI 1.53 to 4.09; 11 studies, 3015 women, random-effects; low-quality evidence). We did not identify any difference in women's satisfaction between misoprostol and surgery (average RR 1.00, 95% CI 0.99 to 1.00; 9 studies, 3349 women, random-effects; moderate-quality evidence). More women had vomiting and diarrhoea with misoprostol compared with surgery (vomiting: average RR 1.97, 95% CI 1.36 to 2.85; 10 studies, 2977 women, random-effects; moderate-quality evidence; diarrhoea: average RR 4.82, 95% CI 1.09 to 21.32; 4 studies, 757 women, random-effects; moderate-quality evidence).Five trials compared different routes of administration, or doses, or both, of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches.

AUTHORS' CONCLUSIONS

The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Further studies, including long-term follow-up, are clearly needed to confirm these findings. There is an urgent need for studies on women who miscarry at more than 13 weeks' gestation.

Postabortion Care: 20 Years of Strong Evidence on Emergency Treatment, Family Planning, and Other Programming Components

Worldwide 75 million women need postabortion care (PAC) services each year following safe or unsafe induced abortions and miscarriages. We reviewed more than 550 studies on PAC published between 1994 and 2013 in the peer-reviewed and gray literature, covering emergency treatment, postabortion family planning, organization of services, and related topics that impact practices and health outcomes, particularly in the Global South. In this article, we present findings from studies with strong evidence that have major implications for programs and practice. For example, vacuum aspiration reduced morbidity, costs, and time in comparison to sharp curettage. Misoprostol 400 mcg sublingually or 600 mcg orally achieved 89% to 99% complete evacuation rates within 2 weeks in multiple studies and was comparable in effectiveness, safety, and acceptability to manual vacuum aspiration. Misoprostol was safely introduced in several PAC programs through mid-level providers, extending services to secondary hospitals and primary health centers. In multiple studies, postabortion family planning uptake before discharge increased by 30-70 percentage points within 1-3 years of strengthening postabortion family planning services; in some cases, increases up to 60 percentage points in 4 months were achieved. Immediate postabortion contraceptive acceptance increased on average from 32% before the interventions to 69% post-intervention. Several studies found that women receiving immediate postabortion intrauterine devices and implants had fewer unintended pregnancies and repeat abortions than those who were offered delayed insertions. Postabortion family planning is endorsed by the professional organizations of obstetricians/gynecologists, midwives, and nurses as a standard of practice; major donors agree, and governments should be encouraged to provide universal access to postabortion family planning. Important program recommendations include offering all postabortion women family planning counseling and services before leaving the facility, especially because fertility returns rapidly (within 2 to 3 weeks); postabortion family planning services can be quickly replicated to multiple sites with high acceptance rates. Voluntary family planning uptake by method should always be monitored to document program and provider performance. In addition, vacuum aspiration and misoprostol should replace sharp curettage to treat incomplete abortion for women who meet eligibility criteria.

A Comparative Study to Evaluate the Efficacy of Vaginal vs Oral Prostaglandin E1 Analogue (Misoprostol) in Management of First Trimester Missed Abortion

INTRODUCTION

Missed miscarriages, occurring in upto 15% of all clinically recognized pregnancies are a cause of concern for the patients. Though many researchers in the past have compared the surgical and medical approaches in management of such patients, only a few have executed an appraisal of two routes of misoprostol at equal dosages in treatment of first trimester missed miscarriages.

AIM

To compare the efficacy of misoprostol by vaginal and oral route, for the management of first trimester missed abortion; and to recognize the utility of misoprostol for cervical dilation prior to any surgical termination of pregnancy.

MATERIALS AND METHODS

A randomized prospective trial, comparing the efficacy of misoprostol, by vaginal and oral routes, for termination of first trimester missed abortion was conducted in the Department of Obstetrics and Gynecology, Government Multi-Specialty Hospital, Chandigarh over one year. Hundred subjects satisfying the inclusion criteria from 213 consecutive women presenting to the institute with first trimester missed abortion were hospitalized. The study participants were randomly assigned to one of the two treatment groups, using sequentially numbered envelopes, to receive 400mcg misoprostol vaginally or orally to a maximum of three doses six hours apart, and outcome documented. Patients were followed up on Day 14 and 6 weeks after discharge. Primary outcome evaluated was drug-induced complete expulsion of Products of Conception (POCs). Secondary outcomes measured were induction expulsion interval, number of doses required, classification of failures, cervical canal permeability in women requiring surgical evacuation, side effects, hemoglobin drop, duration and amount of post-abortal bleeding, time of resumption of menses, experience with side effects, patient satisfaction and acceptability to treatment.

RESULTS

Both routes were highly effective (vaginal=92%, oral= 74%, p=0.032), safe and acceptable with tolerable side effects. The mean time to expulsion was longer (13.24hrs) in the oral than vaginal group (10.87hrs). All 4 unsuccessful cases in vaginal group and 12 of 13 in oral group had permeable cervices prior to surgical evacuation. Most women labeled the side effects as tolerable in both the groups. Overall acceptance rate to treatment was high in both the groups A and B (76% and 70%).

CONCLUSION

Vaginal misoprostol is more effective than oral misoprostol for first trimester missed abortion.

Hospital admission following induced abortion in Eastern Highlands Province, Papua New Guinea--a descriptive study

Background

In Papua New Guinea abortion is restricted under the Criminal Code Act. While safe abortions should available in certain situations, frequently they are not available to the majority of women. Sepsis from unsafe abortion is a leading cause of maternal mortality. Our findings form part of a wider, mixed methods study designed to identify complications requiring hospital treatment for post abortion care and to explore the circumstances surrounding unsafe abortion.

Methods

Through a six month prospective study we identified all women presenting to the Eastern Highlands Provincial Hospital following spontaneous and induced abortions. We undertook semi-structured interviews with women and reviewed individual case notes, extracting demographic and clinical information.

Findings

Case notes were reviewed for 56% (67/119) of women presenting for post abortion care. At least 24% (28/119) of these admissions were due to induced abortion. Women presenting following induced abortions were significantly more likely to be younger, single, in education at the time of the abortion and report that the baby was unplanned and unwanted, compared to those reporting spontaneous abortion. Obtained illegally, misoprostol was the method most frequently used to end the pregnancy. Physical and mechanical means and traditional herbs were also widely reported.

Conclusion

In a country with a low contraceptive prevalence rate and high unmet need for family planning, all reproductive age women need access to contraceptive information and services to avoid, postpone or space pregnancies. In the absence of this, women are resorting to unsafe means to end an unwanted pregnancy, putting their lives at risk and putting an increased strain on an already struggling health system. Women in this setting need access to safe, effective means of abortion.

Decrease in use of manual vacuum aspiration in postabortion care in Malawi: a cross-sectional study from three public hospitals, 2008-2012

OBJECTIVES

To investigate the use of manual vacuum aspiration in postabortion care in Malawi between 2008-2012.

METHODS

A retrospective cross-sectional study was done at the referral hospital Queen Elisabeth Central Hospital, and the two district hospitals of Chiradzulu and Mangochi. The data were collected simultaneously at the three sites from Feb-March 2013. All records available for women admitted to the gynaecological ward from 2008-2012 were reviewed. Women who had undergone surgical uterine evacuation after incomplete abortion were included and the use of manual vacuum aspiration versus sharp curettage was analysed.

RESULTS

Altogether, 5121 women were included. One third (34.2%) of first trimester abortions were treated with manual vacuum aspiration, while all others were treated with sharp curettage. There were significant differences between the hospitals and between years. Overall there was an increase in the use of manual vacuum aspiration from 2008 (19.7%) to 2009 (31.0%), with a rapid decline after 2010 (28.5%) ending at only 4.9% in 2012. Conversely there was an increase in use of sharp curettage in all hospitals from 2010 to 2012.

CONCLUSION

Use of manual vacuum aspiration as part of the postabortion care in Malawi is rather low, and decreased from 2010 to 2012, while the use of sharp curettage became more frequent. This is in contrast with current international guidelines.

An approach to evaluate the efficacy of vaginal misoprostol administered for a rapid management of first trimester spontaneous onset incomplete abortion, in comparison to surgical curettage

PURPOSE

The purpose of this study is to evaluate the efficacy and safety of the medical method in the management of first trimester spontaneous onset incomplete abortion, by using misoprostol vaginal tablets, in comparison to surgical evacuation, with an intention of completing the procedure within 24 h.

METHODS

In this prospective, randomised study of 100 women admitted with features suggestive of incomplete abortion, 50 women received misoprostol vaginal tablets, while another 50 underwent suction curettage of products of conceptus. They were followed up after 24 h of last dosage of misoprostol or surgical intervention. Statistical analysis was done with respect to efficacy, safety and procedure-related side effects.

RESULTS

In this study, when analysed after 24 h of treatment allocation, the efficacy of misoprostol was 91.3%, and the efficacy of the surgical method was 96%, with the statistical difference being insignificant. Procedure-related blood loss and pain perception between the two groups were statistically insignificant. However, the incidence of fever in the misoprostol group statistically appeared higher.

CONCLUSIONS

Misoprostol could be a safe and easily accessible alternative to surgical evacuation, in cases of first trimester spontaneous onset incomplete miscarriage, and could be administered by the patient herself at home.

Results from a study using misoprostol for management of incomplete abortion in Vietnamese hospitals: implications for task shifting

Background

Complications following spontaneous or induced abortion are a major cause of maternal morbidity. To manage these complications, post-abortion care (PAC) services should be readily available and easy to access. Standard PAC treatment includes surgical interventions that are highly effective but require surgical providers and medical centers that have the necessary space and equipment. Misoprostol has been shown to be an effective alternative to surgical evacuation and can be offered by lower level clinicians. This study sought to assess whether 400 mcg sublingual misoprostol could effectively evacuate the uterus after incomplete abortion and to confirm its applicability for use at lower level settings.

Methods

All women presenting with incomplete abortion at one of three hospitals in Vietnam were enrolled. Providers were not asked to record if the abortion was spontaneous or induced. It is likely that all were spontaneous given the legal status and easy access to abortion services in Vietnam. Participants were given 400 mcg sublingual misoprostol and instructed to hold the pills under their tongue for 30 minutes and then swallow any remaining fragments. They were then asked to return one week later to confirm their clinical status. Study clinicians were instructed to confirm a complete expulsion clinically. All women were asked to complete a questionnaire regarding satisfaction with the treatment.

Results

Three hundred and two women were enrolled between September 2009 and May 2010. Almost all participants (96.3%) had successful completions using a single dose of 400 mcg misoprostol. The majority of women (87.2%) found the side effects to be tolerable or easily tolerable. Most women (84.3%) were satisfied or very satisfied with the treatment they received; only one was dissatisfied (0.3%). Nine out of ten women would select this method again and recommend it to a friend (91.0% and 90.0%, respectively).

Conclusions

This study confirms that 400 mcg sublingual misoprostol effectively evacuates the uterus for most women experiencing incomplete abortion. The high levels of satisfaction and side effect tolerability also attest to the ease of use of this method. From these data and given the international consensus around the effectiveness of misoprostol for incomplete abortion care, it seems timely that use of the drug for this indication be widely expanded both throughout Vietnam and wherever access to abortion care is limited.

Trial registration

ClinicalTrials.gov, NCT00670761

Implementation of misoprostol for postabortion care in Kenya and Uganda: a qualitative evaluation

Objective

Evaluate implementation of misoprostol for postabortion care (MPAC) in two African countries.

Design

Qualitative, program evaluation.

Setting

Twenty-five public and private health facilities in Rift Valley Province, Kenya, and Kampala Province, Uganda.

Sample

Forty-five MPAC providers, health facility managers, Ministry of Health officials, and non-governmental (NGO) staff involved in program implementation.

Methods and main outcome measures

In both countries, the Ministry of Health, local health centers and hospitals, and NGO staff developed evidence-based service delivery protocols to introduce MPAC in selected facilities; implementation extended from January 2009 to October 2010. Semi-structured, in-depth interviews evaluated the implementation process, identified supportive and inhibitive policies for implementation, elicited lessons learned during the process, and assessed provider satisfaction and providers’ impressions of client satisfaction with MPAC. Project reports were also reviewed.

Results

In both countries, MPAC was easy to use, and freed up provider time and health facility resources traditionally necessary for provision of PAC with uterine aspiration. On-going support of providers following training ensured high quality of care. Providers perceived that many women preferred MPAC, as they avoided instrumentation of the uterus, hospital admission, cost, and stigma associated with abortion. Appropriate registration of misoprostol for use in the pilot, and maintaining supplies of misoprostol, were significant challenges to service provision. Support from the Ministry of Health was necessary for successful implementation; lack of country-based standards and guidelines for MPAC created challenges.

Conclusions

MPAC is simple, cost-effective and can be readily implemented in settings with high rates of abortion-related mortality.

Medical treatments for incomplete miscarriage

BACKGROUND

Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable.

OBJECTIVES

To assess the effectiveness, safety and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2012) and reference lists of retrieved papers.

SELECTION CRITERIA

Randomised controlled trials comparing medical treatment with expectant care or surgery or alternative methods of medical treatment. Quasi-randomised trials were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked.

MAIN RESULTS

Twenty studies (4208 women) were included. There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no statistically significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women, random-effects), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women, random-effects). There were few data on 'deaths or serious complications'.Twelve studies involving 2894 women addressed the comparison of misoprostol (six studies used oral administration, four studies used vaginal, one study sub-lingual, one study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.97, 95% CI 0.95 to 0.99, 11 studies, 2493 women, random-effects) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.06, 95% CI 0.02 to 0.13; 11 studies, 2654 women, random-effects) but more unplanned procedures (average RR 5.82, 95% CI 2.93 to 11.56; nine studies, 2274 women, random-effects). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.41, 95% CI 1.44 to 4.03; nine studies, 2179 women, random-effects).Five trials compared different routes of administration and/or doses of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches.

AUTHORS' CONCLUSIONS

The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice. Future studies should include long-term follow-up.

Public hospital costs of treatment of abortion complications in Nigeria

Unsafe abortion is a significant contributor to maternal mortality in Nigeria, and treatment of postabortion complications drains public healthcare resources. Provider estimates of medications, supplies, and staff time spent in 17 public hospitals were used to estimate the per-case and annual costs of postabortion care (PAC) provision in Ogun and Lagos states and the Federal Capital Territory. PAC with treatment of moderate complications (US $112) cost 60% more per case than simple PAC (US $70). In cases needing simple PAC, treatment with dilation and curettage (D&C, US $80) cost 18% more per case than manual vacuum aspiration (US $68). Annually, all public hospitals in these 3 states spend US $807 442 on PAC. This cost could be reduced by shifting service provision to an outpatient basis, allowing service provision by midwives, and abandoning the use of D&C. Availability of safe, legal abortion would further decrease cost and reduce preventable deaths from unsafe abortion.

Comprehensive abortion care: evidence of improvements in hospital-level indicators in Tigray, Ethiopia

OBJECTIVE

Approximately 18% of maternal deaths in East Africa is attributable to unsafe abortion. Availability of comprehensive abortion care (CAC) services at all levels of the healthcare system, including medical abortion, has the potential to increase access to safe abortion thereby reducing the burden of unsafe abortion. This study sought to assess trends in abortion-related morbidity indicators in referral hospitals.

DESIGN

Researchers conducted a secondary data analysis on retrospectively collected data.

METHODS

Data analysed were collected from four hospitals in the Tigray region of Ethiopia that took part in a CAC pilot project. Providers were trained in mid-2009 to provide abortion services using all available technologies. Data records from hospitals were collected in 2012 for the years 2006 through 2012; 2006/2007 data were too sparse to include in the analyses.

RESULTS

Trends in abortion-related services show a significant decrease in treatment of incomplete abortion, inverting the relationship between safe terminations and treatment of incompletes as a percentage of total abortions. Medication abortion was nearly non-existent in 2008, but increased steadily, representing 80% of total procedures in 2012. The inclusion of medication abortion and availability of CAC also contributed to a decline in inpatient procedures and prevalence of complications.

CONCLUSIONS

The trends observed in the data demonstrate how increased availability of CAC services at all levels of the healthcare system, among other factors, can contribute to reductions in the burden of unsafe abortion at referral hospitals.

Sublingual misoprostol versus standard surgical care for treatment of incomplete abortion in five sub-Saharan African countries

Background

In low-resource settings, where abortion is highly restricted and self-induced abortions are common, access to post-abortion care (PAC) services, especially treatment of incomplete terminations, is a priority. Standard post-abortion care has involved surgical intervention but can be hard to access in these areas. Misoprostol provides an alternative to surgical intervention that could increase access to abortion care. We sought to gather additional evidence regarding the efficacy of 400 mcg of sublingual misoprostol vs. standard surgical care for treatment of incomplete abortion in the environments where need for economical non-surgical treatments may be most useful.

Methods

A total of 860 women received either sublingual misoprostol or standard surgical care for treatment of incomplete abortion in a multi-site randomized trial. Women with confirmed incomplete abortion, defined as past or present history of vaginal bleeding during pregnancy and an open cervical os, were eligible to participate. Participants returned for follow-up one week later to confirm clinical status. If abortion was incomplete at that time, women were offered an additional follow-up visit or immediate surgical evacuation.

Results

Both misoprostol and surgical evacuation are highly effective treatments for incomplete abortion (misoprostol: 94.4%, surgical: 100.0%). Misoprostol treatment resulted in a somewhat lower chance of success than standard surgical practice (RR = 0.90; 95% CI: 0.89-0.92). Both tolerability of side effects and women’s satisfaction were similar in the two study arms.

Conclusion

Misoprostol, much easier to provide than surgery in low-resource environments, can be used safely, successfully, and satisfactorily for treatment of incomplete abortion. Focus should shift to program implementation, including task-shifting the provision of post-abortion care to mid- and low- level providers, training and assurance of drug availability.

Trial registration

This study has been registered at clinicaltrials.gov as NCT00466999 and NCT01539408

Can we use a lower intravaginal dose of misoprostol in the medical management of miscarriage? A randomised controlled study

BACKGROUND

The optimal dose of misoprostol to be used in the medical management of miscarriage before 13 weeks has not been resolved.

AIM

To evaluate the effectiveness and side effect profile of two different dosages of misoprostol.

METHODS

A randomised controlled, equivalence study comparing 400 vs 800 μg misoprostol per vaginum (PV) on an outpatient basis. The allocated dose was repeated the next day if clinically the products of conception had not been passed. Complete miscarriage was evaluated using two methods: ultrasound criteria on Day 7 and the need for surgical management (clinical criteria). Equivalence was demonstrated if the 95% confidence interval [CI] of the observed risk difference between the two doses for complete miscarriage lay between -15.0 and 15.0%. Differences in side effects and patient satisfaction were evaluated using patient-completed questionnaires.

RESULTS

One hundred and fifty-eight women were allocated to receive 400 μg and 152 women to 800 μg misoprostol for the management of missed (91.3%) or incomplete (8.7%) miscarriage. The rate of induced complete miscarriage was equivalent using both ultrasound criteria (observed risk difference (ORD) -4.6%, 95% CI -12.8 to 3.7%; P = 0.313) and clinical criteria (ORD -5.6%, 95% CI -14.8 to 3.6%; P = 0.273). Following the 400 μg dose, the reported rate of fever/rigors was lower (ORD -15.6%, 95% CI -28.1 to -3.0%; P = 0.015), and more women reported their decision to undergo medical management as a good decision (ORD 15.2%, 95% CI 2.8 to 27.7%; P = 0.018).

CONCLUSION

Four hundred-microgram misoprostol PV can be recommended for the medical management of miscarriage on an outpatient basis.

Sublingual [corrected] misoprostol as first-line care for incomplete abortion in Burkina Faso

OBJECTIVE

To explore 400-μg sublingual misoprostol as primary treatment in lower-level facilities with no previous experience providing postabortion care.

METHODS

Women presenting with incomplete abortion were offered a single dose of 400-μg sublingual misoprostol. Incomplete abortion was defined as uterine size consistent with fewer than 12 weeks of gestation, open cervical os, and reports of past or present history of vaginal bleeding. Women returned to the clinic 1 week after misoprostol administration for follow-up. At that time, they were discharged if the uterine evacuation was a success or were offered a second follow-up visit or surgical completion if still incomplete.

RESULTS

One-hundred women received misoprostol; outcome data were unavailable for 1 woman. Complete uterine evacuation was achieved for 97 (98.0%) women. Satisfaction was high, with nearly all women indicating that they were "satisfied" (n=57 [57.6%]) or "very satisfied" (n=41 [41.4%]) with their experience. Adverse effects were considered "tolerable" by 72 of 97 (74.2%) women. Ninety-seven of 99 (98.0%) participants indicated that they would choose misoprostol for incomplete abortion care in the future and 95 of 97 (97.9%) stated that they would recommend it to a friend.

CONCLUSION

Misoprostol is a viable option for treatment of incomplete abortion at mid-level facilities.

Misoprostol as first-line treatment for incomplete abortion at a secondary-level health facility in Nigeria

OBJECTIVE

To determine the feasibility of introducing misoprostol as first-line treatment for incomplete abortion at a secondary-level health facility.

METHODS

An open-label prospective study was conducted in a secondary-level health facility in Nigeria. Eligible women diagnosed with incomplete abortion received 400-μg sublingual misoprostol as first-line treatment. Nurse-midwives took the lead in diagnosis, counseling, treatment, and assessment of final outcome. The primary outcome was the proportion of women who completed the abortion process.

RESULTS

Complete evacuation was achieved in 83 of 90 (92.2%) eligible women. The most common adverse effects were abdominal pain/cramps (58 [64.4%]), heavy bleeding (21 [23.3%]), spotting (15 [16.7%]), and fever/chills (11 [12.2%]). More than 90% of women reported that the procedure was satisfactory, that pain and adverse effects were tolerable, and that bleeding was acceptable. Eighty-four (93.3%) and 86 (95.6%) women, respectively, would use the method in the future and recommend it to friends.

CONCLUSION

Misoprostol is an effective, safe, and acceptable method for treating incomplete abortion. It can be successfully used as first-line treatment by nurse-midwives. Success rates over 90% are consistent with findings from previous studies in which drug administration was controlled solely by physicians.

Comparison of efficacy of modified electric vacuum aspiration with sharp curettage for the treatment of incomplete abortion: randomized controlled trial

AIM

The aim of this study was to compare the efficacy of modified electric vacuum aspiration (mEVA) and sharp curettage (SC) for treatment of incomplete abortion.

MATERIAL AND METHODS

A randomized controlled trial was conducted between 1 March 2005 and 15 December 2009. Ninety-four women with incomplete abortion were randomly allocated into two groups, group A (n = 47) underwent mEVA and group B (n=47) underwent SC. The procedures were performed using the paracervical block with 20 mL of lidocaine. Successful management and complication were assessed. Successful management was defined as complete uterine evacuation with no need for the second surgical procedure.

RESULTS

There were differences in women characteristics between groups. The successful rate of management was 100% for both groups. However, the operative time and estimated blood loss were less in the mEVA group than in the SC group. Severe pain was significantly less prevalent in group A than group B. Suspected endometritis was found in two (4.3%) patients in each group.

CONCLUSIONS

The efficacy of mEVA was the same as that of SC in successful management of incomplete abortion, but pain was experienced more often in the SC group.

Oral misoprostol for the management of incomplete abortion in Ecuador

OBJECTIVE

To assess the feasibility of introducing misoprostol for the treatment of incomplete abortion in Quito, Ecuador.

METHODS

In a randomized prospective study conducted at a large tertiary-level maternity hospital and a private secondary-level clinic between November 2006 and November 2007, women with incomplete abortion were treated with either 600 μg of oral misoprostol (n=122) or manual vacuum aspiration (MVA) (n=120). All participants were requested to return for follow-up care on day 7 to determine the success of the treatment and to document their satisfaction with the method and the adverse effects experienced.

RESULTS

Sixteen percent of women (39/242) did not return for their follow-up visit and their outcomes are unknown. Among those who did return, 94% (100/106) of women showed successful completion of abortion after treatment with misoprostol, as compared with 100% (97/97) of women treated with MVA. Most women described their adverse effects after treatment as tolerable (misoprostol, 95%; MVA, 91%). Nearly all women reported being satisfied with their treatment (196/203); there were no differences among the women's reports of satisfaction according to treatment received.

CONCLUSION

An oral dose of 600 μg of misoprostol was found to be an acceptable and effective non-surgical option for treating incomplete abortion. Clinical trials.gov NCT00674232.

Unsafe abortion and postabortion care - an overview

Forty per cent of the world's women are living in countries with restrictive abortion laws, which prohibit abortion or only allow abortion to protect a woman's life or her physical or mental health. In countries where abortion is restricted, women have to resort to clandestine interventions to have an unwanted pregnancy terminated. As a consequence, high rates of unsafe abortion are seen, such as in Sub-Saharan Africa where unsafe abortion occurs at rates of 18-39 per 1 000 women. The circumstances under which women obtain unsafe abortion vary and depend on traditional methods known and types of providers present. Health professionals are prone to use instrumental procedures to induce the abortion, whereas traditional providers often make a brew of herbs to be drunk in one or more doses. In countries with restrictive abortion laws, high rates of maternal death must be expected, and globally an estimated 66 500 women die every year as a result of unsafe abortions. In addition, a far larger number of women experience short- and long-term health consequences. To address the harmful health consequences of unsafe abortion, a postabortion care model has been developed and implemented with success in many countries where women do not have legal access to abortion. Postabortion care focuses on treatment of incomplete abortion and provision of postabortion contraceptive services. To enhance women's access to postabortion care, focus is increasingly being placed on upgrading midlevel providers to provide emergency treatment as well as implementing misoprostol as a treatment strategy for complications after unsafe abortion.

A randomized controlled trial of 400-μg sublingual misoprostol versus manual vacuum aspiration for the treatment of incomplete abortion in two Egyptian hospitals

OBJECTIVE

To compare the safety, efficacy, and acceptability of 400-μg sublingual misoprostol with that of manual vacuum aspiration (MVA) in 2 Egyptian hospitals.

METHODS

Participating women were randomized to either MVA or misoprostol treatment for incomplete abortion. The primary outcome, complete uterine evacuation, was determined 1 week later, as were adverse effects, change in hemoglobin, acceptability, and satisfaction.

RESULTS

Complete uterine evacuation was achieved in 98.3% of women who received misoprostol and 99.7% who underwent MVA (relative risk [RR] 0.99; 95% confidence interval [CI], 0.97-1.00). A decrease in hemoglobin of 2g/dL or more was comparably rare in the 2 groups (0.3% misoprostol vs 0.9% MVA; RR 0.34 [95% CI, 0.04-3.21]). Mean change in hemoglobin was also clinically similar (-0.5 g/dL misoprostol vs -0.4 g/dL MVA; P<0.01). Heavy bleeding was rare (2.4% misoprostol vs 1.6% MVA; RR 1.55 [95% CI, 0.51-4.68]) following treatment. Nearly all women (96.8% misoprostol vs 98.3% MVA) were satisfied with their treatment but those who received misoprostol were significantly more likely to prefer that method in the future (81.9% vs 62.8%; RR 1.30 [95% CI, 1.19-1.43]).

CONCLUSION

The high efficacy, safety, and acceptability of 400-μg sublingual misoprostol indicate that it is analogous to surgery as a first-line treatment for incomplete abortion. Misoprostol might improve post-abortion care when resources are limited and surgical treatment is unavailable.

Oral misoprostol as an alternative to surgical management for incomplete abortion in Ghana

OBJECTIVE

To investigate whether 600-μg oral misoprostol is an effective alternative to manual vacuum aspiration (MVA) for the treatment of incomplete abortion.

METHODS

From June 16, 2004, to July 20, 2005, 230 women of reproductive age presenting with incomplete abortion were randomized in an open-label trial to either 600-μg oral misoprostol or MVA for the treatment of incomplete abortion.

RESULTS

Regardless of the assigned method, more than 98% of participants experienced complete uterine evacuation following initial treatment. Efficacy, acceptability, and satisfaction ratings were similar and high for both methods.

CONCLUSION

600-μg oral misoprostol is a safe, effective, and acceptable alternative to MVA for the treatment of incomplete abortion.

Comparative study between oral and sublingual 600 µg misoprostol for the treatment of incomplete abortion

AIM

To evaluate and compare effectiveness, side effects and patient acceptability between oral and sublingual 600 µg misoprostol for the treatment of incomplete abortion.

METHODS

A randomized controlled trial was conducted. Pregnant women of less than 14 weeks gestation, diagnosed with incomplete abortion, were randomly assigned to receive 600 µg misoprostol orally or sublingually. The patients were evaluated at 48 h after drug administration for complete abortion.

RESULTS

A total of 64 women were recruited to the study (32 in the oral group and 32 in the sublingual group). The complete abortion rate was not statistically different between oral and sublingual groups (87.5% versus 84.4%, P > 0.05). There was no statistical difference in side effects and satisfaction rate. Fever/chills were the most common side effects.

CONCLUSION

Both sublingual and oral 600 µg misoprostol are useful for the management of incomplete abortion. Side effects and satisfaction rates are not different. Thus, these methods may be used as alternative treatments of incomplete abortion.

Choosing early pregnancy termination methods in Urban Mozambique

Little is known about who chooses medication abortion with misoprostol and why. Women seeking early abortion in 5 public hospitals in Maputo, Mozambique were recruited in 2005 and 2006 to explore decision-making strategies, method preferences and experiences with misoprostol and vacuum aspiration for early abortion. Client screenings (n=1799), structured clinical surveys (n=837), in-depth exit interviews (n=70), and nurse focus groups (n=2) were conducted. Triangulation of qualitative and quantitative data revealed seemingly contradictory findings. Choice of method reflected women's heightened concerns about privacy, pain, quality of home support, HIV infection risk, sexuality, and safety of research participation. Urban Mozambican women are highly motivated to find early pregnancy termination techniques that they deem socially and clinically low-risk. Although 42% found vaginal misoprostol self-administration challenging and 25% delayed care for over a week to amass funds for user fees, almost all (96%) reported adequate preparation and comfort with home management. Women reported satisfaction with all methods and quality of care, even if the initial method failed or pain management or postabortion contraception were not offered. A more nuanced understanding of what women value most can yield service delivery models that are responsive and effective in reducing maternal death and disability from unsafe abortion.

Medical treatments for incomplete miscarriage (less than 24 weeks)

BACKGROUND

Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining pregnancy tissues in the uterus. However, it has been suggested that drug-based medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable.

OBJECTIVES

To assess the effectiveness, safety and acceptability of any medical treatment for early incomplete miscarriage (before 24 weeks).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009).

SELECTION CRITERIA

Randomised controlled trials comparing medical treatment with expectant care or surgery. Quasi-randomised trials were excluded.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked.

MAIN RESULTS

Fifteen studies (2750 women) were included, there were no studies on women over 13 weeks' gestation. Studies addressed a number of comparisons and data are therefore limited.Three trials compared misoprostol treatment (all vaginally administered) with expectant care. There was no significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women). There were few data on 'deaths or serious complications'.Nine studies involving 1766 women addressed the comparison of misoprostol (four oral, four vaginal, one vaginal + oral) with surgical evacuation. There was no statistically significant difference in complete miscarriage (average RR 0.96, 95% CI 0.92 to 1.00, eight studies, 1377 women) with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.07, 95% CI 0.03 to 0.18; eight studies, 1538 women) but more unplanned procedures (average RR 6.32, 95% CI 2.90 to 13.77; six studies, 1158 women). There were few data on 'deaths or serious complications'. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow up from one included study identified no difference in subsequent fertility between the three approaches.

AUTHORS' CONCLUSIONS

The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice.

Two routes of administration for misoprostol in the treatment of incomplete abortion: a randomized clinical trial

BACKGROUND

This study was conducted to compare the safety, effectiveness and acceptability of 400 mcg sublingual misoprostol and 600 mcg oral misoprostol for treatment of incomplete abortion.

STUDY DESIGN

We used an open-label randomized controlled trial conducted from July 2005 to August 2006 in a large tertiary level maternity hospital in Antananarivo, Madagascar, and a large tertiary level hospital in Chisinau, Moldova. Three hundred consenting women seeking treatment for clinically diagnosed incomplete abortion with uterine size <or=12 weeks since last menstrual period were randomized to misoprostol either 600 mcg orally or 400 mcg sublingually. The primary outcome measure was the complete resolution of clinical signs and symptoms of incomplete abortion without need for surgical intervention. Women were seen for follow-up on Day 7 and, if necessary, on Day 14 to assess abortion status. The study was powered to detect a 7% difference in efficacy with a total of 142 women required in each arm.

RESULTS

Efficacy rates were 94.6% and 94.5%, for the oral and sublingual routes, respectively (RR: 1.00, 95% CI=0.95-1.06, p=.98). At 1 week follow-up, more than 80% of women had completed abortions (77.8% oral and 84.8% sublingual, p=.12). Mean pain scores were 2.95 and 3.04, respectively, for the oral and sublingual groups. Side effects included abdominal pain, bleeding, headaches and dizziness/weakness with no differences reported between the two groups. Acceptability and satisfaction were high for both routes and women indicated a preference for medical versus surgical treatment if ever needed in the future.

CONCLUSIONS

Both treatment regimens were very effective. Four hundred micrograms of sublingual misoprostol and 600 mcg oral misoprostol appear to have similar safety and effectiveness profiles when used for the treatment of incomplete abortion. A lower 400-mcg misoprostol dose may provide an alternative treatment option as well as have potential benefits in terms of cost.

Saving maternal lives in resource-poor settings: facing reality

OBJECTIVE

Evaluate safe-motherhood interventions suitable for resource-poor settings that can be implemented with current resources.

METHODS

Literature review to identify interventions that require minimal treatment/infrastructure and are not dependent on skilled providers. Simulations were run to assess the potential number of maternal lives that could be saved through intervention implementation according to potential program impact. Regional and country level estimates are provided as examples of settings that would most benefit from proposed interventions.

RESULTS

Three interventions were identified: (i) improve access to contraception; (ii) increase efforts to reduce deaths from unsafe abortion; and (iii) increase access to misoprostol to control postpartum hemorrhage (including for home births). The combined effect of postpartum hemorrhage and unsafe abortion prevention would result in the greatest gains in maternal deaths averted.

DISCUSSION/CONCLUSIONS

Bold new initiatives are needed to achieve the Millennium Development Goal of reducing maternal mortality by three-quarters. Ninety-nine percent of maternal deaths occur in developing countries and the majority of these women deliver alone, or with a traditional birth attendant. It is time for maternal health program planners to reprioritize interventions in the face of human and financial resource constraints. The three proposed interventions address the largest part of the maternal health burden.

Treatment of incomplete abortion and miscarriage with misoprostol

A literature review was conducted to determine whether misoprostol is an effective treatment for incomplete abortion and, if so, to recommend an appropriate regimen. All English language articles published before October 2007 using misoprostol in at least one of the study arms were reviewed to determine the efficacy of misoprostol when used to treat incomplete abortion in the first trimester. All available unpublished data previously presented at international scientific meetings were also reviewed. Sufficient evidence was found in support of misoprostol as a safe and effective means of non-surgical uterine evacuation. A single dose of misoprostol 600 microg oral is recommended for treatment of incomplete abortion in women presenting with a uterine size equivalent to 12 weeks gestation.

Medical treatment for early fetal death (less than 24 weeks)

BACKGROUND

In most pregnancies that miscarry, arrest of embryonic or fetal development occurs some time (often weeks) before the miscarriage occurs. Ultrasound examination can reveal abnormal findings during this phase by demonstrating anembryonic pregnancies or embryonic or fetal death. Treatment before 14 weeks has traditionally been surgical but medical treatments may be effective, safe, and acceptable, as may be waiting for spontaneous miscarriage.

OBJECTIVES

To assess the effectiveness, safety and acceptability of any medical treatment for early pregnancy failure (anembryonic pregnancies or embryonic and fetal deaths before 24 weeks).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 November 2005).

SELECTION CRITERIA

Randomised trials comparing medical treatment with another treatment (e.g. surgical evacuation), or placebo, or no treatment for early pregnancy failure. Quasi-random studies were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted unblinded.

MAIN RESULTS

Twenty four studies (1888 women) were included. Vaginal misoprostol hastens miscarriage (complete or incomplete) when compared with placebo: e.g. miscarriage less than 24 hours (two trials, 138 women, relative risk (RR) 4.73, 95% confidence interval (CI) 2.70 to 8.28), with less need for uterine curettage (two trials, 104 women, RR 0.40, 95% CI 0.26 to 0.60) and no significant increase in nausea or diarrhoea. Lower-dose regimens of vaginal misoprostol tend to be less effective in producing miscarriage (three trials, 247 women, RR 0.85, 95% CI 0.72 to 1.00) with similar incidence of nausea. There seems no clear advantage to administering a 'wet' preparation of vaginal misoprostol or of adding methotrexate, or of using laminaria tents after 14 weeks. Vaginal misoprostol is more effective than vaginal prostaglandin E in avoiding surgical evacuation. Oral misoprostol was less effective than vaginal misoprostol in producing complete miscarriage (two trials, 218 women, RR 0.90, 95% CI 0.82 to 0.99). Sublingual misoprostol had equivalent efficacy to vaginal misoprostol in inducing complete miscarriage but was associated with more frequent diarrhoea. The two trials of mifepristone treatment generated conflicting results. There was no statistically significant difference between vaginal misoprostol and gemeprost in the induction of miscarriage for fetal death after 13 weeks.

AUTHORS' CONCLUSIONS

Available evidence from randomised trials supports the use of vaginal misoprostol as a medical treatment to terminate non-viable pregnancies before 24 weeks. Further research is required to assess effectiveness and safety, optimal route of administration and dose. Conflicting findings about the value of mifepristone need to be resolved by additional study.