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Toutain T, Philip CA, Bollon L, Cros M, Fraissenon A, Dupont C, Gaucher L, Haesebaert J, Nohuz E, Cortet M. Surgical management of a loss of pregnancy in the first trimester: Patient experience and influencing factors, a prospective observational study. J Gynecol Obstet Hum Reprod 2023; 52:102602. [PMID: 37187317 DOI: 10.1016/j.jogoh.2023.102602] [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: 08/08/2022] [Revised: 04/30/2023] [Accepted: 05/07/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE Describe the "patient experience" regarding care provided during the surgical management of a loss of pregnancy in the first trimester and identify the factors influencing this experience. MATERIAL AND METHODS It is an observational prospective study conducted in two type III, academic, maternity wards in Lyon, France, carrying out 8,500 deliveries per year. Adult female patients, having undergone a suction curettage for a loss of pregnancy in the first trimester from 24 December 2020 to 13 June 2021 were inculded. The "patient experience" was assessed using the 15 questions of the Picker Patient Experience (PPE-15) questionnaire, and research was conducted on factors influencing the patient experience. The main outcome was the percentage of patients reporting a problem in response to at least one of the PPE-15 questions. RESULTS 58 out of 79 patients (73% CI [62-83]) reported at least one problem with their care. The largest proportion of problems was raised in question about "Opportunity for family/loved ones to talk to the doctor" (76% CI [61-87]). The lowest proportion of problems was raised in question about "Treated with respect and dignity" (8% CI [3-16]). No factors influencing the patient experience were identified. DISCUSSION Almost three out of four patients reported a problem in the experience as a patient. The main areas of improvement reported by patients were the participation of their family/relatives and the emotional support provided by the healthcare team. TWEETABLE ABSTRACT Better communication with patient families and emotional support could improve patient experience during the surgical management of a loss of pregnancy in the first trimester.
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Affiliation(s)
- T Toutain
- Department of Obstetrics and Gynaecology, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon 69004, France
| | - C-A Philip
- Department of Obstetrics and Gynaecology, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon 69004, France; LabTAU INSERM U1032, Université Lyon1, Lyon 69003, France
| | - L Bollon
- Faculty of Maieutic, Lyon, France
| | - M Cros
- Faculty of Maieutic, Lyon, France
| | - A Fraissenon
- Mother and Child Radiology Department, North University Hospital, Saint Etienne 42000, France; Paediatric Imaging Department, Woman-Mother-Child University Hospital, Hospices Civils de Lyon, Bron 69500, France
| | - C Dupont
- Research on Healthcare Performance (RESHAPE) INSERM U1290, Lyon 69003, France; AURORE Perinatal Network, Lyon 69004, France
| | - L Gaucher
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Midwifery Department, Geneva, Switzerland; Hospices Civils de Lyon, Public Healthcare Centre, Lyon F-69008, France
| | - J Haesebaert
- Research on Healthcare Performance (RESHAPE) INSERM U1290, Lyon 69003, France; Hospices Civils de Lyon, Public Healthcare Centre, Lyon F-69008, France
| | - E Nohuz
- Department of Obstetrics and Gynaecology, Woman-Mother-Child University Hospital, Hospices Civils de Lyon, Bron 69500, France
| | - M Cortet
- Department of Obstetrics and Gynaecology, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon 69004, France; LabTAU INSERM U1032, Université Lyon1, Lyon 69003, France.
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Devall A, Chu J, Beeson L, Hardy P, Cheed V, Sun Y, Roberts T, Ogwulu CO, Williams E, Jones L, Papadopoulos JLF, Bender-Atik R, Brewin J, Hinshaw K, Choudhary M, Ahmed A, Naftalin J, Nunes N, Oliver A, Izzat F, Bhatia K, Hassan I, Jeve Y, Hamilton J, Deb S, Bottomley C, Ross J, Watkins L, Underwood M, Cheong Y, Kumar C, Gupta P, Small R, Pringle S, Hodge F, Shahid A, Gallos I, Horne A, Quenby S, Coomarasamy A. Mifepristone and misoprostol versus placebo and misoprostol for resolution of miscarriage in women diagnosed with missed miscarriage: the MifeMiso RCT. Health Technol Assess 2021; 25:1-114. [PMID: 34821547 DOI: 10.3310/hta25680] [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: 11/22/2022] Open
Abstract
TRIAL DESIGN A randomised, parallel-group, double-blind, placebo-controlled multicentre study with health economic and nested qualitative studies to determine if mifepristone (Mifegyne®, Exelgyn, Paris, France) plus misoprostol is superior to misoprostol alone for the resolution of missed miscarriage. METHODS Women diagnosed with missed miscarriage in the first 14 weeks of pregnancy were randomly assigned (1 : 1 ratio) to receive 200 mg of oral mifepristone or matched placebo, followed by 800 μg of misoprostol 2 days later. A web-based randomisation system allocated the women to the two groups, with minimisation for age, body mass index, parity, gestational age, amount of bleeding and randomising centre. The primary outcome was failure to pass the gestational sac within 7 days after randomisation. The prespecified key secondary outcome was requirement for surgery to resolve the miscarriage. A within-trial cost-effectiveness study and a nested qualitative study were also conducted. Women who completed the trial protocol were purposively approached to take part in an interview to explore their satisfaction with and the acceptability of medical management of missed miscarriage. RESULTS A total of 711 women, from 28 hospitals in the UK, were randomised to receive either mifepristone plus misoprostol (357 women) or placebo plus misoprostol (354 women). The follow-up rate for the primary outcome was 98% (696 out of 711 women). The risk of failure to pass the gestational sac within 7 days was 17% (59 out of 348 women) in the mifepristone plus misoprostol group, compared with 24% (82 out of 348 women) in the placebo plus misoprostol group (risk ratio 0.73, 95% confidence interval 0.54 to 0.98; p = 0.04). Surgical intervention to resolve the miscarriage was needed in 17% (62 out of 355 women) in the mifepristone plus misoprostol group, compared with 25% (87 out of 353 women) in the placebo plus misoprostol group (risk ratio 0.70, 95% confidence interval 0.52 to 0.94; p = 0.02). There was no evidence of a difference in the incidence of adverse events between the two groups. A total of 42 women, 19 in the mifepristone plus misoprostol group and 23 in the placebo plus misoprostol group, took part in an interview. Women appeared to have a preference for active management of their miscarriage. Overall, when women experienced care that supported their psychological well-being throughout the care pathway, and information was delivered in a skilled and sensitive manner such that women felt informed and in control, they were more likely to express satisfaction with medical management. The use of mifepristone and misoprostol showed an absolute effect difference of 6.6% (95% confidence interval 0.7% to 12.5%). The average cost per woman was lower in the mifepristone plus misoprostol group, with a cost saving of £182 (95% confidence interval £26 to £338). Therefore, the use of mifepristone and misoprostol for the medical management of a missed miscarriage dominated the use of misoprostol alone. LIMITATIONS The results from this trial are not generalisable to women diagnosed with incomplete miscarriage and the study does not allow for a comparison with expectant or surgical management of miscarriage. FUTURE WORK Future work should use existing data to assess and rank the relative clinical effectiveness and safety profiles for all methods of management of miscarriage. CONCLUSIONS Our trial showed that pre-treatment with mifepristone followed by misoprostol resulted in a higher rate of resolution of missed miscarriage than misoprostol treatment alone. Women were largely satisfied with medical management of missed miscarriage and would choose it again. The mifepristone and misoprostol intervention was shown to be cost-effective in comparison to misoprostol alone. TRIAL REGISTRATION Current Controlled Trials ISRCTN17405024. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 68. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Adam Devall
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Justin Chu
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Leanne Beeson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Versha Cheed
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yongzhong Sun
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Tracy Roberts
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Chidubem Okeke Ogwulu
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Eleanor Williams
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Laura Jones
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | | | | | - Kim Hinshaw
- Sunderland Royal Hospital, South Tyneside & Sunderland NHS Foundation Trust, Sunderland, UK
| | - Meenakshi Choudhary
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Amna Ahmed
- Sunderland Royal Hospital, South Tyneside & Sunderland NHS Foundation Trust, Sunderland, UK
| | - Joel Naftalin
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Natalie Nunes
- West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Isleworth, UK
| | - Abigail Oliver
- St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Feras Izzat
- University Hospital Coventry, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Kalsang Bhatia
- Burnley General Hospital, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - Ismail Hassan
- Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Yadava Jeve
- Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Judith Hamilton
- Guy's and St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Shilpa Deb
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Cecilia Bottomley
- Chelsea and Westminster Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Jackie Ross
- King's College Hospital, King's College Hospital NHS Foundation Trust, London, UK
| | - Linda Watkins
- Liverpool Women's Hospital, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Martyn Underwood
- Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
| | - Ying Cheong
- Department of Reproductive Medicine, University of Southampton, Southampton, UK
| | - Chitra Kumar
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Pratima Gupta
- Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rachel Small
- Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stewart Pringle
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Frances Hodge
- Singleton Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Anupama Shahid
- Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Ioannis Gallos
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Andrew Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Siobhan Quenby
- Biomedical Research Unit in Reproductive Health, University of Warwick, Coventry, UK
| | - Arri Coomarasamy
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Fernlund A, Jokubkiene L, Sladkevicius P, Valentin L, Sjöström K. Psychological impact of early miscarriage and client satisfaction with treatment: comparison between expectant management and misoprostol treatment in a randomized controlled trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:757-765. [PMID: 33798287 DOI: 10.1002/uog.23641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/14/2021] [Accepted: 03/18/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To compare the short- and long-term emotional distress (grief, anxiety and depressive symptoms) after early miscarriage and satisfaction with treatment between women randomized to expectant management vs vaginal misoprostol treatment. METHODS This was a preplanned analysis of data collected during a randomized controlled trial comparing expectant management with misoprostol treatment in women with early anembryonic or embryonic miscarriage and vaginal bleeding. If the miscarriage was not complete on day 31 after inclusion, surgical evacuation was recommended. The main outcomes were levels of anxiety and grief, depressive symptoms and client satisfaction with the treatment, which were assessed using the following validated psychometric self-assessment instruments: Spielberger State-Trait Anxiety Inventory (STAI, Form Y), Perinatal Grief Scale (PGS), Montgomery-Åsberg Depression Rating Scale (MADRS-S; self-reported version) and Client Satisfaction Questionnaire (CSQ-8). All women were assessed at four timepoints: on the day of randomization, on the day when the miscarriage was judged to be complete, and at 3 months and 14 months after complete miscarriage. The psychometric and client satisfaction scores were compared between the misoprostol group and the expectant-management group at each assessment. Analysis was performed by the intention-to-treat principle. RESULTS Ninety women were randomized to expectant management and 94 to misoprostol treatment. The psychometric and client satisfaction scores were similar in the two treatment groups at all assessment timepoints. At inclusion, 41% (35/86) of the women managed expectantly and 37% (34/92) of those treated with misoprostol had a STAI-state score of > 46 ('high level of anxiety'), and 9% (8/86) and 10% (9/91), respectively, had symptoms of moderate or severe depression (MADRS-S score ≥ 20). In both treatment groups, symptom scores for anxiety and depression were significantly higher at inclusion than after treatment and remained low until 14 months after complete miscarriage. Grief reactions were mild in both groups, with a median PGS score of 40.0 at 3 months and 37.0 at 14 months after complete miscarriage in both treatment groups. Four women treated with misoprostol and two women managed expectantly had a PGS score of > 90 (indicating deep grief) 3 months after complete miscarriage, while one woman managed expectantly had a PGS score of > 90 14 months after complete miscarriage. Women in both treatment groups were satisfied with their management, as indicated by a median CSQ-8 score of > 25 at each assessment. More than 85% of participants in each of the two groups reported that they would recommend the treatment they received to a friend. CONCLUSIONS The psychological response to and recovery after early miscarriage did not differ between women treated with misoprostol and those managed expectantly. Satisfaction with treatment was high in both treatment groups. Our findings support patient involvement when deciding on the management of early miscarriage. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Fernlund
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - L Jokubkiene
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - P Sladkevicius
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - L Valentin
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - K Sjöström
- Department of Care Sciences, Malmö University, Malmö, Sweden
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Enzelsberger SH, Wetzlmair D, Hermann P, Wagner H, Shebl O, Oppelt P, Trautner PS. Bleeding pattern after medical management of early pregnancy loss with mifepristone–misoprostol and its prognostic value: a prospective observational cohort study. Arch Gynecol Obstet 2021; 306:349-355. [PMID: 34694431 PMCID: PMC9349076 DOI: 10.1007/s00404-021-06291-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 10/13/2021] [Indexed: 10/26/2022]
Abstract
Abstract
Purpose
To improve counseling of women by reporting bleeding characteristics at home after medical management of an early pregnancy loss (EPL) with mifepristone and misoprostol, and to evaluate occurring bleeding patterns as a prognostic tool.
Methods
This prospective two-center observational cohort study enrolled 197 women who presented with an EPL (embryonic or anembryonic miscarriage) from December 2017 to April 2019 and chose a home-based medical management with 200 mg mifepristone and 800 mcg misoprostol. From the day of mifepristone intake, the strength of vaginal bleeding was recorded daily for 2 weeks by the patient herself using a diary sheet. Treatment success was defined as no histologically confirmed retained products of conception (RPOC) within 3 months. After considering all drop-out criteria, 154 women were included in the analysis.
Results
40.0% of patients (95% CI 30.4–49.6) already reported bleeding onset in the time period between the intake of mifepristone and misoprostol. The median duration of vaginal bleeding including spotting was 13 days. The chance of RPOC was about sixfold (OR 6.06, 95% CI 2.15–17.10) in the group of persistent bleeding after 2 weeks compared to the group with a terminated bleeding at that time. Exploratory regression analysis indicated association of higher serum levels of leukocytes at treatment start with RPOC (p = 0.013).
Conclusions
Terminated bleeding after 2 weeks is a useful indicator for successful medical induction of EPL. Women undergoing medical treatment with mifepristone must be informed about the high frequency of bleeding onset before misoprostol intake.
Clinical trial registration
DRKS—German Clinical Trials Register, ID: DRKS00013515, registration date 05.12.2017. http://www.drks.de/DRKS00013515.
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Ghosh J, Papadopoulou A, Devall AJ, Jeffery HC, Beeson LE, Do V, Price MJ, Tobias A, Tunçalp Ö, Lavelanet A, Gülmezoglu AM, Coomarasamy A, Gallos ID. Methods for managing miscarriage: a network meta-analysis. Cochrane Database Syst Rev 2021; 6:CD012602. [PMID: 34061352 PMCID: PMC8168449 DOI: 10.1002/14651858.cd012602.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime. An estimated 15% of pregnancies end in miscarriage. Miscarriage can lead to serious morbidity, including haemorrhage, infection, and even death, particularly in settings without adequate healthcare provision. Early miscarriages occur during the first 14 weeks of pregnancy, and can be managed expectantly, medically or surgically. However, there is uncertainty about the relative effectiveness and risks of each option. OBJECTIVES To estimate the relative effectiveness and safety profiles for the different management methods for early miscarriage, and to provide rankings of the available methods according to their effectiveness, safety, and side-effect profile using a network meta-analysis. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth's Trials Register (9 February 2021), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (12 February 2021), and reference lists of retrieved studies. SELECTION CRITERIA We included all randomised controlled trials assessing the effectiveness or safety of methods for miscarriage management. Early miscarriage was defined as less than or equal to 14 weeks of gestation, and included missed and incomplete miscarriage. Management of late miscarriages after 14 weeks of gestation (often referred to as intrauterine fetal deaths) was not eligible for inclusion in the review. Cluster- and quasi-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded non-randomised trials. DATA COLLECTION AND ANALYSIS At least three review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for the primary outcomes of complete miscarriage and composite outcome of death or serious complications. The certainty of evidence was assessed using GRADE. Relative effects for the primary outcomes are reported subgrouped by the type of miscarriage (incomplete and missed miscarriage). We also performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available methods. MAIN RESULTS Our network meta-analysis included 78 randomised trials involving 17,795 women from 37 countries. Most trials (71/78) were conducted in hospital settings and included women with missed or incomplete miscarriage. Across 158 trial arms, the following methods were used: 51 trial arms (33%) used misoprostol; 50 (32%) used suction aspiration; 26 (16%) used expectant management or placebo; 17 (11%) used dilatation and curettage; 11 (6%) used mifepristone plus misoprostol; and three (2%) used suction aspiration plus cervical preparation. Of these 78 studies, 71 (90%) contributed data in a usable form for meta-analysis. Complete miscarriage Based on the relative effects from the network meta-analysis of 59 trials (12,591 women), we found that five methods may be more effective than expectant management or placebo for achieving a complete miscarriage: · suction aspiration after cervical preparation (risk ratio (RR) 2.12, 95% confidence interval (CI) 1.41 to 3.20, low-certainty evidence), · dilatation and curettage (RR 1.49, 95% CI 1.26 to 1.75, low-certainty evidence), · suction aspiration (RR 1.44, 95% CI 1.29 to 1.62, low-certainty evidence), · mifepristone plus misoprostol (RR 1.42, 95% CI 1.22 to 1.66, moderate-certainty evidence), · misoprostol (RR 1.30, 95% CI 1.16 to 1.46, low-certainty evidence). The highest ranked surgical method was suction aspiration after cervical preparation. The highest ranked non-surgical treatment was mifepristone plus misoprostol. All surgical methods were ranked higher than medical methods, which in turn ranked above expectant management or placebo. Composite outcome of death and serious complications Based on the relative effects from the network meta-analysis of 35 trials (8161 women), we found that four methods with available data were compatible with a wide range of treatment effects compared with expectant management or placebo: · dilatation and curettage (RR 0.43, 95% CI 0.17 to 1.06, low-certainty evidence), · suction aspiration (RR 0.55, 95% CI 0.23 to 1.32, low-certainty evidence), · misoprostol (RR 0.50, 95% CI 0.22 to 1.15, low-certainty evidence), · mifepristone plus misoprostol (RR 0.76, 95% CI 0.31 to 1.84, low-certainty evidence). Importantly, no deaths were reported in these studies, thus this composite outcome was entirely composed of serious complications, including blood transfusions, uterine perforations, hysterectomies, and intensive care unit admissions. Expectant management and placebo ranked the lowest when compared with alternative treatment interventions. Subgroup analyses by type of miscarriage (missed or incomplete) agreed with the overall analysis in that surgical methods were the most effective treatment, followed by medical methods and then expectant management or placebo, but there are possible subgroup differences in the effectiveness of the available methods. AUTHORS' CONCLUSIONS: Based on relative effects from the network meta-analysis, all surgical and medical methods for managing a miscarriage may be more effective than expectant management or placebo. Surgical methods were ranked highest for managing a miscarriage, followed by medical methods, which in turn ranked above expectant management or placebo. Expectant management or placebo had the highest chance of serious complications, including the need for unplanned or emergency surgery. A subgroup analysis showed that surgical and medical methods may be more beneficial in women with missed miscarriage compared to women with incomplete miscarriage. Since type of miscarriage (missed and incomplete) appears to be a source of inconsistency and heterogeneity within these data, we acknowledge that the main network meta-analysis may be unreliable. However, we plan to explore this further in future updates and consider the primary analysis as separate networks for missed and incomplete miscarriage.
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Affiliation(s)
- Jay Ghosh
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Argyro Papadopoulou
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Adam J Devall
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Hannah C Jeffery
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Leanne E Beeson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Vivian Do
- University of Birmingham, Birmingham, UK
| | - Malcolm J Price
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Aurelio Tobias
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Antonella Lavelanet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
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Smith PP, Dhillon-Smith RK, O'Toole E, Cooper N, Coomarasamy A, Clark TJ. Outcomes in prevention and management of miscarriage trials: a systematic review. BJOG 2019; 126:176-189. [PMID: 30461160 DOI: 10.1111/1471-0528.15528] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2018] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- P P Smith
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - R K Dhillon-Smith
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - E O'Toole
- Women's Voices Involvement Panel, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Nam Cooper
- Barts and the London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - A Coomarasamy
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - T J Clark
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
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7
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San Lazaro Campillo I, Meaney S, McNamara K, O'Donoghue K. Psychological and support interventions to reduce levels of stress, anxiety or depression on women's subsequent pregnancy with a history of miscarriage: an empty systematic review. BMJ Open 2017; 7:e017802. [PMID: 28882928 PMCID: PMC5595175 DOI: 10.1136/bmjopen-2017-017802] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE The aim of this systematic review was to assess the effect of interventions to reduce stress in pregnant women with a history of miscarriage. DESIGN A systematic review of randomised controlled trials (RCTs). DATA SOURCE A total of 13 medical, psychological and social electronic databases were searched from January 1995 to April 2016 including PUBMED, CENTRAL, Web of Science and EMBASE. ELIGIBILITY CRITERIA This review focused on women in their subsequent pregnancy following miscarriage. All published RCTs which assessed the effect of non-medical interventions such as counselling or support interventions on psychological and mental health outcomes such as stress, anxiety or depression when compared with a control group were included. Stress, anxiety or depression had to be measured at least preintervention and postintervention. RESULTS This systematic review found no RCT which met our initial inclusion criteria. Of the 4140 titles screened, 17 RCTs were identified. All of them were excluded. One RCT, which implemented a caring-based intervention, included pregnant women in their subsequent pregnancy; however, miscarriage was analysed as a composite variable among other pregnancy losses such as stillbirth and neonatal death. Levels of perceived stress were measured by four RCTs. Different types of non-medical interventions, time of follow-up and small sample sizes were found. CONCLUSION Cohort studies and RCTs in non-pregnant women suggest that support and psychological interventions may improve pregnant women's psychological well-being after miscarriage. This improvement may reduce adverse pregnancy-related outcomes in subsequent pregnancies. However, this review found no RCTs which met our criteria. There is a need for targeted RCTs that can provide reliable and conclusive results to determine effective interventions for this vulnerable group.
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Affiliation(s)
- Indra San Lazaro Campillo
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork - National University of Ireland, Cork, Ireland
| | - Sarah Meaney
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork - National University of Ireland, Cork, Ireland
- National Perinatal Epidemiology Centre (NPEC), University College Cork - National University of Ireland, Cork, Ireland
| | - Karen McNamara
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork - National University of Ireland, Cork, Ireland
| | - Keelin O'Donoghue
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork - National University of Ireland, Cork, Ireland
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork - National University of Ireland, Cork, Ireland
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MisoREST: Surgical versus expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage: A cohort study. Eur J Obstet Gynecol Reprod Biol 2017; 211:83-89. [DOI: 10.1016/j.ejogrb.2017.01.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/09/2017] [Accepted: 01/15/2017] [Indexed: 11/20/2022]
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Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe, and acceptable. OBJECTIVES To assess the effectiveness, safety, and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (13 May 2016) and reference lists of retrieved papers. SELECTION CRITERIA We included randomised controlled trials comparing medical treatment with expectant care or surgery, or alternative methods of medical treatment. We excluded quasi-randomised trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias, and carried out data extraction. Data entry was checked. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included 24 studies (5577 women). There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; 2 studies, 150 women, random-effects; very low-quality evidence), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. For unplanned surgical intervention, we did not identify any difference between misoprostol and expectant care (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence).Sixteen trials involving 4044 women addressed the comparison of misoprostol (7 studies used oral administration, 6 studies used vaginal, 2 studies sublingual, 1 study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.96, 95% CI 0.94 to 0.98; 15 studies, 3862 women, random-effects; very low-quality evidence) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.05, 95% CI 0.02 to 0.11; 13 studies, 3070 women, random-effects; very low-quality evidence) but more unplanned procedures (average RR 5.03, 95% CI 2.71 to 9.35; 11 studies, 2690 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.50, 95% CI 1.53 to 4.09; 11 studies, 3015 women, random-effects; low-quality evidence). We did not identify any difference in women's satisfaction between misoprostol and surgery (average RR 1.00, 95% CI 0.99 to 1.00; 9 studies, 3349 women, random-effects; moderate-quality evidence). More women had vomiting and diarrhoea with misoprostol compared with surgery (vomiting: average RR 1.97, 95% CI 1.36 to 2.85; 10 studies, 2977 women, random-effects; moderate-quality evidence; diarrhoea: average RR 4.82, 95% CI 1.09 to 21.32; 4 studies, 757 women, random-effects; moderate-quality evidence).Five trials compared different routes of administration, or doses, or both, of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Further studies, including long-term follow-up, are clearly needed to confirm these findings. There is an urgent need for studies on women who miscarry at more than 13 weeks' gestation.
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Affiliation(s)
- Caron Kim
- WHODepartment of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | | | | | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
| | - Juan C Vazquez
- Instituto Nacional de Endocrinologia (INEN)Departamento de Salud ReproductivaZapata y DVedadoHabanaCuba10 400
| | - Lixia Dou
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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10
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Lemmers M, Verschoor M, Oude Rengerink K, Naaktgeboren C, Opmeer B, Bossuyt P, Huirne J, Janssen C, Radder C, Klinkert E, Langenveld J, Catshoek R, Van der Voet L, Siemens F, Geomini P, Van Hooff M, Van der Ploeg J, Coppus S, Ankum W, Mol B. MisoREST: surgical versus expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage: a randomized controlled trial. Hum Reprod 2016; 31:2421-2427. [DOI: 10.1093/humrep/dew221] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 05/25/2016] [Accepted: 06/14/2016] [Indexed: 11/12/2022] Open
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Colleselli V, Nell T, Bartosik T, Brunner C, Ciresa-Koenig A, Wildt L, Marth C, Seeber B. Marked improvement in the success rate of medical management of early pregnancy failure following the implementation of a novel institutional protocol and treatment guidelines: a follow-up study. Arch Gynecol Obstet 2016; 294:1265-1272. [PMID: 27554492 PMCID: PMC5071363 DOI: 10.1007/s00404-016-4179-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 08/09/2016] [Indexed: 11/30/2022]
Abstract
Purpose To analyze the success rate, time to passage of tissue and subjective patient experience of a newly implemented protocol for medical management of early pregnancy failure (EPF) over a 2-year period. Methods A retrospective chart review of all patients with early pregnancy failure primarily opting for medical management was performed. 200 mg mifepristone were administered orally, followed by a single vaginal dose of 800 mcg misoprostol after 36–48 h. We followed-up with our patients using a written questionnaire. Results 167 women were included in the present study. We observed an overall success rate of 92 %, defined as no need for surgical management after medication administration. We could not identify predictive values for success in a multivariate regression analysis. Most patients (84 %) passed tissue within 6 h after misoprostol administration. The protocol was well tolerated with a low incidence of side effects. Pain was managed well with sufficient analgesics. Responders to the questionnaire felt adequately informed prior to treatment and rated their overall experience as positive. Conclusion The adaption of the institutional medical protocol resulted in a marked improvement of success rate when compared to the previously used protocol (92 vs. 61 %). We credit this increase to the adjusted medication schema as well as to targeted physician education on the expected course and interpretation of outcome measures. Our results underscore that the medical management of EPF is a safe and effective alternative to surgical evacuation in the clinical setting.
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Affiliation(s)
- V Colleselli
- Department of Gynecology and Obstetrics, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - T Nell
- Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - T Bartosik
- Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - C Brunner
- Department of Gynecology and Obstetrics, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - A Ciresa-Koenig
- Department of Gynecology and Obstetrics, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - L Wildt
- Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - C Marth
- Department of Gynecology and Obstetrics, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - B Seeber
- Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Lemmers M, Verschoor M, Hooker A, Opmeer B, Limpens J, Huirne J, Ankum W, Mol B. Dilatation and curettage increases the risk of subsequent preterm birth: a systematic review and meta-analysis. Hum Reprod 2015; 31:34-45. [DOI: 10.1093/humrep/dev274] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 10/08/2015] [Indexed: 12/29/2022] Open
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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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14
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Mayi-Tsonga S, Minkobame U, Mbila A, Assoumou P, Diop A, Winikoff B. [First experience of the use of misoprostol as post-abortion care in Libreville, Gabon]. Pan Afr Med J 2014; 18:301. [PMID: 25469194 PMCID: PMC4247897 DOI: 10.11604/pamj.2014.18.301.4309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 07/27/2014] [Indexed: 11/11/2022] Open
Abstract
Introduction Une étude a été menée afin de déterminer le taux d'acceptabilité de 400µg de misoprostol par voie sublinguale comme traitement de première intention de l'avortement incomplet et de préciser le taux d'avortement complet ou vacuité utérine. Méthodes Les femmes éligibles avaient un diagnostic clinique d'avortement incomplet avec une taille utérine inférieure à celle d'un utérus de 12 semaines d'aménorrhées (SA). Chacune a reçu 400µg de misoprostol par voie sublinguale. Les femmes ont été revues après une semaine. A J7, celles qui n'avaient pas complètement expulsé ont eu le choix entre une nouvelle consultation de suivi à J14 et la pratique d'une évacuation chirurgicale immédiate. Résultats 145 patientes ont été éligibles et ont toutes accepté la méthode (100%). L’âge moyen était de 25,9 ± 6 ans. A J7, 120 patientes étaient guéries (85,7%). A J14, le taux de réussitea été de 95,7% soit 134 patientes guéries. Les patientes guéries ont déclaré être très satisfaites (57,5%), satisfaites (41,8%) et insatisfaite (0,7%). Au total,128 femmes (95,5%) ont dit être prêtes à utiliser de nouveau le misoprostol comme méthode d’évacuation utérine en cas d'avortement incomplet. Conclusion L’étude démontre que le 400µg misoprostol par voie sublinguale nous permet de prendre en charge d'une manière adéquate l'avortement incomplet surtout dans les pays à faible ressource et notamment dans les structures sanitaires de première ligne ou éloignées.
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Affiliation(s)
- Sosthène Mayi-Tsonga
- Université des Sciences de la Santé de Libreville, Libreville, Gabon ; Projet FIGO pour la lutte contre les avortements à risque au Gabon
| | - Ulysse Minkobame
- Service de Gynécologie Obstétrique du Centre Hospitalier Universitaire de Libreville, Libreville, Gabon
| | - Arielle Mbila
- Service de Gynécologie Obstétrique du Centre Hospitalier Universitaire de Libreville, Libreville, Gabon
| | - Pamphile Assoumou
- Service de Gynécologie Obstétrique du Centre Hospitalier Universitaire de Libreville, Libreville, Gabon
| | - Ayisha Diop
- Gynuity Health Projects, New York City, New York, USA
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15
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Cheung CS, Chan CH, Ng EH. Stress and anxiety-depression levels following first-trimester miscarriage: a comparison between women who conceived naturally and women who conceived with assisted reproduction. BJOG 2013; 120:1090-7. [DOI: 10.1111/1471-0528.12251] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2013] [Indexed: 11/27/2022]
Affiliation(s)
- CS Cheung
- Department of Obstetrics and Gynaecology; the University of Hong Kong; Queen Mary Hospital
| | - CH Chan
- Department of Social Work and Social Administration; the University of Hong Kong; Hong Kong SAR; China
| | - EH Ng
- Department of Obstetrics and Gynaecology; the University of Hong Kong; Queen Mary Hospital
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16
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Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable. OBJECTIVES To assess the effectiveness, safety and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2012) and reference lists of retrieved papers. SELECTION CRITERIA Randomised controlled trials comparing medical treatment with expectant care or surgery or alternative methods of medical treatment. Quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. MAIN RESULTS Twenty studies (4208 women) were included. There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no statistically significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women, random-effects), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women, random-effects). There were few data on 'deaths or serious complications'.Twelve studies involving 2894 women addressed the comparison of misoprostol (six studies used oral administration, four studies used vaginal, one study sub-lingual, one study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.97, 95% CI 0.95 to 0.99, 11 studies, 2493 women, random-effects) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.06, 95% CI 0.02 to 0.13; 11 studies, 2654 women, random-effects) but more unplanned procedures (average RR 5.82, 95% CI 2.93 to 11.56; nine studies, 2274 women, random-effects). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.41, 95% CI 1.44 to 4.03; nine studies, 2179 women, random-effects).Five trials compared different routes of administration and/or doses of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice. Future studies should include long-term follow-up.
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Affiliation(s)
- James P Neilson
- Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK.
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Kong GWS, Lok IH, Yiu AKW, Hui ASY, Lai BPY, Chung TKH. Clinical and psychological impact after surgical, medical or expectant management of first-trimester miscarriage - a randomised controlled trial. Aust N Z J Obstet Gynaecol 2013; 53:170-7. [PMID: 23488984 DOI: 10.1111/ajo.12064] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 01/23/2013] [Indexed: 01/17/2023]
Affiliation(s)
- Grace Wing Shan Kong
- Department of Obstetrics and Gynaecology; The Chinese University of Hong Kong; Prince of Wales Hospital; Shatin; Hong Kong; China
| | - Ingrid Hung Lok
- Department of Obstetrics and Gynaecology; The Chinese University of Hong Kong; Prince of Wales Hospital; Shatin; Hong Kong; China
| | - Alice Ka Wah Yiu
- Department of Obstetrics and Gynaecology; The Chinese University of Hong Kong; Prince of Wales Hospital; Shatin; Hong Kong; China
| | - Annie Shuk Yi Hui
- Department of Obstetrics and Gynaecology; The Chinese University of Hong Kong; Prince of Wales Hospital; Shatin; Hong Kong; China
| | - Beatrice Pui Yee Lai
- Division of Social Science; The Hong Kong University of Science and Technology; Hong Kong; China
| | - Tony Kwok Hung Chung
- Department of Obstetrics and Gynaecology; The Chinese University of Hong Kong; Prince of Wales Hospital; Shatin; Hong Kong; China
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18
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Shuaib AA, Alharazi AH. Medical versus surgical termination of the first trimester missed miscarriage. ALEXANDRIA JOURNAL OF MEDICINE 2013. [DOI: 10.1016/j.ajme.2012.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Alia A. Shuaib
- Sana'a University, Faculty of Medicine, Obstetrics and Gynecology Department, Sanaa, Yemen
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Wallace RR, Goodman S, Freedman LR, Dalton VK, Harris LH. Counseling women with early pregnancy failure: utilizing evidence, preserving preference. PATIENT EDUCATION AND COUNSELING 2010; 81:454-461. [PMID: 21093193 DOI: 10.1016/j.pec.2010.10.031] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Revised: 10/29/2010] [Accepted: 10/30/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVES To apply principles of shared decision-making to EPF management counseling. To present a patient treatment priority checklist developed from review of available literature on patient priorities for EPF management. METHODS Review of evidence for patient preferences; personal, emotional, physical and clinical factors that may influence patient priorities for EPF management; and the clinical factors, resources, and provider bias that may influence current practice. RESULTS Women have strong and diverse preferences for EPF management and report higher satisfaction when treated according to these preferences. However, estimates of actual treatment patterns suggest that current practice does not reflect the evidence for safety and acceptability of all options, or patient preferences. Multiple practice barriers and biases exist that may be influencing provider counseling about options for EPF management. CONCLUSION Choosing management for EPF is a preference-sensitive decision. A patient-centered approach to EPF management should incorporate counseling about all treatment options. PRACTICE IMPLICATIONS Providers can integrate a counseling model into EPF management practice that utilizes principles of shared decision-making and an organized method for eliciting patient preferences, priorities, and concerns about treatment options.
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Affiliation(s)
- Robin R Wallace
- University of California, San Francisco, Department of Family and Community Medicine, 1001 Potrero Avenue, Ward 6D, San Francisco, CA 94110, USA.
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20
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Neilson JP, Gyte GML, Hickey M, Vazquez JC, Dou L. Medical treatments for incomplete miscarriage (less than 24 weeks). Cochrane Database Syst Rev 2010:CD007223. [PMID: 20091626 PMCID: PMC4042279 DOI: 10.1002/14651858.cd007223.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining pregnancy tissues in the uterus. However, it has been suggested that drug-based medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable. OBJECTIVES To assess the effectiveness, safety and acceptability of any medical treatment for early incomplete miscarriage (before 24 weeks). SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009). SELECTION CRITERIA Randomised controlled trials comparing medical treatment with expectant care or surgery. Quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. MAIN RESULTS Fifteen studies (2750 women) were included, there were no studies on women over 13 weeks' gestation. Studies addressed a number of comparisons and data are therefore limited.Three trials compared misoprostol treatment (all vaginally administered) with expectant care. There was no significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women). There were few data on 'deaths or serious complications'.Nine studies involving 1766 women addressed the comparison of misoprostol (four oral, four vaginal, one vaginal + oral) with surgical evacuation. There was no statistically significant difference in complete miscarriage (average RR 0.96, 95% CI 0.92 to 1.00, eight studies, 1377 women) with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.07, 95% CI 0.03 to 0.18; eight studies, 1538 women) but more unplanned procedures (average RR 6.32, 95% CI 2.90 to 13.77; six studies, 1158 women). There were few data on 'deaths or serious complications'. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice.
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Affiliation(s)
- James P Neilson
- Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
| | - Gillian ML Gyte
- Cochrane Pregnancy and Childbirth Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
| | - Martha Hickey
- The University of Melbourne, The Royal Women’s Hospital, Melbourne, Australia
| | - Juan C Vazquez
- Departamento de Salud Reproductiva, Instituto Nacional de Endocrinologia (INEN), Habana, Cuba
| | - Lixia Dou
- Cochrane Pregnancy and Childbirth Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
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Harwood B, Nansel T. Quality of life and acceptability of medical versus surgical management of early pregnancy failure. BJOG 2008; 115:501-8. [PMID: 18271887 DOI: 10.1111/j.1471-0528.2007.01632.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study compares quality of life (QOL) and acceptability of medical versus surgical treatment of early pregnancy failure (EPF). DESIGN A randomised clinical trial of treatment for EPF compared misoprostol vaginally versus vacuum aspiration (VA). SETTING A multisite trial at four US Urban University Hospitals. POPULATION A total of 652 women with an EPF were randomised to treatment. METHODS Participants completed a daily symptom diary and a questionnaire 2 weeks after treatment. MAIN OUTCOME MEASURES The questionnaire assessment included subscales of the Short Form-36 Health Survey Revised for QOL and measures of wellbeing, recovery difficulties, and treatment acceptability. RESULTS The two groups did not differ in mean scores for QOL except bodily pain; medical treatment was associated with higher levels of bodily pain than VA (P < 0.001). Success of treatment was not related to QOL, but acceptability of the procedure was decreased for medical therapy if unsuccessful (P = 0.003). Type of treatment was not associated with differences in recovery, and the two groups reported similar acceptability except for cramping (P = 0.02), bleeding (P < 0.001), and symptom duration (P = 0.03). CONCLUSIONS Despite reporting greater pain and lower acceptability of treatment-related symptoms, QOL and treatment acceptability were similar for medical and surgical treatment of EPF. Acceptability, but not QOL, was influenced by success or failure of medical management.
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Affiliation(s)
- B Harwood
- Department of Obstetrics and Gynecology, University of Illinois at Chicago College of Medicine, Chicago, IL 60612, USA.
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22
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Robledo C, Zhang J, Troendle J, Barnhart K, Creinin MD, Westhoff C, Huang X, Frederick M. Clinical indicators for success of misoprostol treatment after early pregnancy failure. Int J Gynaecol Obstet 2007; 99:46-51. [PMID: 17599843 PMCID: PMC2040341 DOI: 10.1016/j.ijgo.2007.04.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 04/26/2007] [Accepted: 04/27/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To identify clinical indicators for success of misoprostol treatment after early pregnancy failure. METHODS A total of 473 women with early pregnancy failure received 800 microg of vaginal misoprostol on treatment day 1. At the follow-up visit on day 3, a second dose was given if expulsion was incomplete. On day 8, vacuum aspiration was offered if expulsion had not occurred. Ultrasonography was used as gold standard for success. A Classification and Regression Tree analysis was undertaken to derive two decision trees for the success of misoprostol treatment on study days 3 and 8. RESULTS Heavy bleeding after the first dose and an open cervical os were identified as clinical indicators of treatment success on day 3. Treatment success occurred in 84% of women with either or both indicators. Reporting passage of tissue after a second misoprostol dose and old blood in the vagina were potential indicators of treatment success or failure on day 8. A woman with either of these indicators has a 65% chance of treatment success after the second dose. Conversely, a woman with neither indicator on day 8 has a 94% chance of treatment failure. CONCLUSION Standard clinical findings may be useful as indicators for success or failure of medical management of early pregnancy failure in settings with limited or no access to ultrasonography. More research to identify even better indicators is warranted.
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Affiliation(s)
- C Robledo
- National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
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23
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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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24
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Abstract
Emerging evidence has suggested that miscarriage could be associated with significant and possibly enduring psychological consequences. As many as 50% of miscarrying women suffer some form of psychological morbidity in the weeks and months after loss. About 40% of miscarrying women were found to be suffering from symptoms of grief shortly after miscarriage, and pathological grief can follow. Elevated anxiety and depressive symptoms are common, and major depressive disorder has been reported in 10-50% after miscarriage. Psychological symptoms could persist for 6 months to 1 year after miscarriage. The underlying risk factors predisposing a miscarrying woman to psychological morbidity include a history of psychiatric illness, childlessness, lack of social support or poor marital adjustment, prior pregnancy loss, and ambivalence toward the fetus. In addition, care-givers should be aware of the possible moderating effect of clinical practices such as surgical treatment and ultrasound findings on the psychological impact on a miscarrying woman. Unlike in postpartum depression, simple and effective screening measures of psychological morbidity in the context of miscarriage have not been well established. While studies have highlighted that psychological follow-up was highly desired by miscarrying women, and that psychological intervention was potentially beneficial, there is a substantial lack of randomized controlled intervention studies in this area.
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Affiliation(s)
- Ingrid H Lok
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
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25
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Niinimäki M, Jouppila P, Martikainen H, Talvensaari-Mattila A. A randomized study comparing efficacy and patient satisfaction in medical or surgical treatment of miscarriage. Fertil Steril 2006; 86:367-72. [PMID: 16764872 DOI: 10.1016/j.fertnstert.2005.12.072] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2005] [Revised: 12/25/2005] [Accepted: 12/25/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To compare the efficacy of the medical treatment to surgical uterine evacuation and patient satisfaction in each group. DESIGN A randomized, controlled study. SETTING An outpatient clinic in the Department of Gynecology and Obstetrics in Oulu University Hospital, Oulu, Finland. PATIENT(S) Ninety-eight eligible women who had had miscarriages. INTERVENTION(S) Medical treatment of miscarriage (n = 49) with 200 mg of mifepristone and 0.8 mg of misoprostol 1-3 days after the event or surgical uterine evacuation (n = 49). Questionnaires to collect data of experienced pain and patient satisfaction. MAIN OUTCOME MEASURE(S) The complete abortion rate with the primary treatment (primary outcome) and the patient satisfaction (secondary outcome). RESULT(S) The success rate was equal (100% in surgical and 90% in medical group). More infections were diagnosed in the surgical group. Surgically treated patients were more satisfied with the treatment (100% vs. 88%). Medical treatment was considered more painful and fewer patients (70% vs. 91%) would choose the medical method in the future. CONCLUSION(S) Medical treatment is an effective alternative to surgical treatment and increases the choice available to women. Surgical treatment is associated with more infections. More medically treated patients experienced pain and dissatisfaction.
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Affiliation(s)
- Maarit Niinimäki
- Department of Gynecology and Obstetrics, Oulu University Hospital, Oulu, Finland.
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26
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Tam WH, Tsui MHY, Lok IH, Yip SK, Yuen PM, Chung TKH. Long-term reproductive outcome subsequent to medical versus surgical treatment for miscarriage. Hum Reprod 2005; 20:3355-9. [PMID: 16096322 DOI: 10.1093/humrep/dei257] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND When compared with the conventional surgical evacuation for the treatment of miscarriage, medical evacuation has been largely accepted as an effective and safe management. However, there is a lack of data on the long-term reproductive outcome of these two treatment modalities, which is crucial in patient counselling. The current study evaluates and compares the long-term fertility and pregnancy outcome following these two treatments. METHODS A cohort of 604 women enrolled in a previous randomized controlled trial comparing medical and surgical evacuation for miscarriage were followed up prospectively by telephone interview at a median of 6 (range 4-9) years using a structured questionnaire. RESULTS A total of 423 women were contacted and four declined to participate (response rate 69.4%). Of these, 261 women (131 medical and 130 surgical evacuations) had attempted to become pregnant since the miscarriage. There were no differences in their baseline characteristics including age, reproductive and contraceptive history. The natural conception rates were the same (97.7%, P = 0.99) and the cumulative pregnancy rates were similar between groups, being 60 and 80% at 12 and 24 months respectively. The median time-to-pregnancy was 8 months in both groups (P = 0.97) and the subsequent live birth rates (85.2 versus 88.2%, P = 0.72) resulting from the immediate pregnancy following previous treatment were similar. CONCLUSIONS The long-term conception rate and pregnancy outcome are not different following medical or surgical evacuation for miscarriage. Women should be reassured that their long-term fertility potential will not be compromised after medical treatment.
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Affiliation(s)
- Wing Hung Tam
- Department of Obstetrics and Gynaecology, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong.
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27
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Graziosi GC, Bruinse HW, Reuwer PJ, Mol BW. Women's preferences for misoprostol in case of early pregnancy failure. Eur J Obstet Gynecol Reprod Biol 2005; 124:184-6. [PMID: 16026923 DOI: 10.1016/j.ejogrb.2005.06.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2005] [Revised: 04/07/2005] [Accepted: 06/09/2005] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of this study was to assess the preference of women with early pregnancy failure for treatment with misoprostol as compared to curettage. STUDY DESIGN Women with early pregnancy failure were interviewed and asked whether they were motivated to trade a non-invasive but potentially less effective treatment with misoprostol at the virtually 100% guarantee of complete evacuation after curettage. All women had a structured interview, in which they were informed about both treatment options. The women were asked for a treatment preference in case the complete evacuation rate after misoprostol was set at 100%. In case the women preferred misoprostol, the complete evacuation rate was subsequently decreased to 10% using steps of 5%. RESULTS The study group consisted of 64 women with early pregnancy failure. Seven women (11%) did not opt for misoprostol at all, because of fear of pain or bleeding using misoprostol. Fifty percent of the women would prefer misoprostol if its complete evacuation rate exceeds 65%. CONCLUSION A majority of women would prefer misoprostol over curettage if its complete evacuation rate exceeds 65%.
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Affiliation(s)
- Giuseppe C Graziosi
- Department of Obstetrics and Gynecology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.
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Sotiriadis A, Makrydimas G, Papatheodorou S, Ioannidis JPA. Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis. Obstet Gynecol 2005; 105:1104-13. [PMID: 15863551 DOI: 10.1097/01.aog.0000158857.44046.a4] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To quantify the relative benefits and harms of different management options for first-trimester miscarriage. DATA SOURCES MEDLINE, EMBASE, and Cochrane Controlled Trials Register searches (1966 to July 2004), including references of retrieved articles. METHODS OF STUDY SELECTION Randomized trials assigning women with first-trimester missed or incomplete miscarriage to surgical, medical, or expectant management were included. Primary outcomes were successful treatment and patient satisfaction. Secondary outcomes included moderate or severe bleeding, blood transfusion, emergency curettage, pelvic inflammatory disease, nausea, vomiting, and diarrhea. Comparisons used the risk difference. Between-study heterogeneity and random effects summary estimates were calculated. TABULATION, INTEGRATION, AND RESULTS Complete evacuation of the uterus was significantly more common with surgical than medical management (risk difference 32.8%, number needed to treat 3, success rate of medical management 62%) and with medical than expectant management (risk difference 49.7%, number needed to treat 2). Success rate with expectant management was spuriously low (39%) in the latter comparison. Analysis of cases with incomplete miscarriage only showed that medical management still had two thirds the chance to induce complete evacuation compared with surgical management, but it was better than expectant management. Data from studies that evaluated outcome at 48 hours or more after allocation indicated again that medical management had a better success rate than expectant management but a worse success rate than surgical management; expectant management probably had much lower success rates than surgical evacuation, but data were very sparse. Patient satisfaction data were sparse. Moderate or severe bleeding was less common with medical than expectant management (risk difference 3.2%) and possibly surgical management (risk difference 2.1%). There was a considerable amount of missing information, in particular for secondary outcomes. CONCLUSION One additional success can be achieved among 3 women treated surgically rather than medically. Expectant management has had remarkably variable success rates across these studies, depending probably on the type of miscarriage. Greater standardization of outcomes should be a goal of future research.
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29
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You JHS, Chung TKH. Expectant, medical or surgical treatment for spontaneous abortion in first trimester of pregnancy: a cost analysis. Hum Reprod 2005; 20:2873-8. [PMID: 15979988 DOI: 10.1093/humrep/dei163] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Misoprostol and expectant care have been shown to be acceptable alternatives to routine surgical evacuation for treatment of spontaneous abortion in the first trimester of pregnancy. The objective of this study was to analyse the cost of expectant care, misoprostol therapy and surgical evacuation. METHODS A decision tree was designed to simulate the clinical outcome and health care resource utilization of surgical evacuation, misoprostol and expectant care for patients presenting with uncomplicated spontaneous abortion in the first trimester of pregnancy. Clinical inputs were estimated from literature and the cost analysis was conducted from the perspective of a public health care provider in Hong Kong. RESULTS The base-case analysis showed that the misoprostol group (1000 US dollars per patient) was the least costly alternative, followed by the expectant care (1172 US dollars per patient) and surgical evacuation (2007 US dollars per patient). Rates of complete abortion using misoprostol and expectant care were identified as influential factors. Monte Carlo simulation (10000 cohorts) showed that the misoprostol and the expectant care groups were less costly than the surgical evacuation group 100 and 88% of the time. The misoprostol group was less costly than the expectant group 100% of the time. CONCLUSIONS Misoprostol therapy appears to be the least costly approach for treatment of uncomplicated spontaneous abortion.
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Affiliation(s)
- Joyce H S You
- Centre for Pharmacoeconomics Research, School of Pharmacy, Department of Obstetrics & Gynaecology, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, NT.
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30
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Graziosi GCM, Mol BW, Ankum WM, Bruinse HW. Management of early pregnancy loss. Int J Gynaecol Obstet 2005; 86:337-46. [PMID: 15325850 DOI: 10.1016/j.ijgo.2004.04.038] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2003] [Revised: 04/20/2004] [Accepted: 04/28/2004] [Indexed: 11/28/2022]
Abstract
OBJECTIVES In order to assess the available evidence on the management of early pregnancy loss, we performed a meta-analysis on the subject. METHODS MEDLINE and EMBASE were searched for randomized studies reporting on the effectiveness of expectant management, misoprostol treatment or curettage. Outcomes considered were 'complete evacuation', complications, duration of bleeding, pain resulting from the procedure, side effects and women's satisfaction with the procedure. RESULTS Thirteen studies were identified. Combined data in women with missed abortion managed expectantly or treated with misoprostol showed complete evacuation rates of 28% (49/173) (range 14-47%) and 81% (242/298) (range 60-83%), respectively. In women with incomplete abortion, these rates were 94% (31/33) (range 80-100%) and 99% (75/76) (range 99-100%), respectively. CONCLUSION In the management of early pregnancy loss both expectant management and misoprostol treatment reduce the need for curettage, but misoprostol treatment seems to be more effective in women with missed abortion as compared to expectant management.
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Affiliation(s)
- G C M Graziosi
- Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein, The Netherlands.
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31
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Graziosi GCM, Bruinse HW, Reuwer PJH, van Kessel PH, Westerweel PE, Mol BW. Misoprostol versus curettage in women with early pregnancy failure: impact on women's health-related quality of life. A randomized controlled trial. Hum Reprod 2005; 20:2340-7. [PMID: 15831508 DOI: 10.1093/humrep/dei019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND We aimed to compare patients' health-related quality of life after a misoprostol strategy to a curettage in women with early pregnancy failure after failed expectant management. METHODS A multicentre randomized clinical trial was performed in The Netherlands. In all, 154 women with early pregnancy failure confirmed at ultrasonography who had been managed expectantly unsuccessfully for > or =1 week were randomly assigned to undergo either treatment with misoprostol (n=79) or curettage (n=75). The main outcome measures were health-related quality of life and satisfaction with treatment. RESULTS In the misoprostol strategy 47% of the women needed additional curettage, as compared to 4% after curettage. In both groups, health-related quality of life was impaired most severely 2 days after treatment. In the misoprostol group, health-related quality of life was more severely impaired; after 2 days this was due to more pain and after 2 and 6 weeks this was due to a worse general health perception. Health-related quality of life was temporarily significantly more impaired in women in whom misoprostol failed as compared to women in whom misoprostol treatment was successful. In both treatment groups, an equal percentage of women (58%) would choose the same treatment in the future. In women treated with misoprostol, however, this choice depended on the initial success of misoprostol: in cases where misoprostol had caused complete evacuation, 76% of the women would opt for the same treatment, whereas only 38% of women who needed curettage after unsuccessful misoprostol would do so (P<0.01). CONCLUSION Our study shows that, although both the misoprostol strategy and the curettage strategy resulted in complete evacuation in the end, women are willing to accept some disadvantages of misoprostol to avoid curettage. A treatment inconvenience using misoprostol is accepted as long as initial evacuation rate is high. This finding should be an integral part of counselling women when deciding upon management of early pregnancy failure.
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Affiliation(s)
- G C M Graziosi
- St Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, University Medical Centre, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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32
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Muffley PE, Stitely ML, Gherman RB. Early intrauterine pregnancy failure: a randomized trial of medical versus surgical treatment. Am J Obstet Gynecol 2002; 187:321-5; discussion 325-6. [PMID: 12193919 DOI: 10.1067/mob.2002.126205] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether medical treatment of early pregnancy failure represents a reasonable alternative to surgical therapy. STUDY DESIGN Patients who were diagnosed with pregnancy failure before 12 weeks of gestation were randomly assigned to receive either medical (intravaginal misoprostol) or surgical therapy (dilatation and curettage). In the medical arm of the study, 800 microg of misoprostol was placed within the posterior vaginal fornix. Patients subsequently were seen 24 and 48 hours after the initial dosing; intravaginal misoprostol was readministered only if ultrasound images revealed evidence of persistent pregnancy tissue. By 72 hours after initial study entry, if either a gestational sac or placental tissue was present, the medical treatment was considered a failure, and uterine curettage was performed. Statistical analysis was performed with the two-tailed unpaired t test, chi(2) analysis, Fisher exact test, and Mann-Whitney U test; a probability value of <.05 was considered statistically significant. RESULTS A total of 50 women were enrolled, with 2 patients in the surgical arm experiencing spontaneous pregnancy loss before their scheduled procedures. Twenty-five women received medical therapy; 25 women were randomized to surgical procedure. Fifteen patients in the medical group (60%; 95% CI, 0.41-0.79) had successful pregnancy termination and did not require curettage. There were no significant differences between the medical and surgical groups with respect to either posttreatment hematocrit level or the time needed to achieve negative human chorionic gonadotropin test results. CONCLUSION Intravaginal misoprostol is an effective agent for the treatment of early pregnancy failure. Medical treatment of early pregnancy failure represents a reasonable alternative to immediate surgical therapy.
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Affiliation(s)
- Patrick E Muffley
- Department of Obstetrics and Gynecology, Naval Medical Center Portsmouth, VA, USA
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