Early pregnancy failure--current management concepts

Telemedicine Follow-up After Medication Management of Early Pregnancy Loss

Objective: Our objective was to evaluate the feasibility of a new protocol for telemedicine follow-up after medication management of early pregnancy loss. Study Design: The study was designed to assess the feasibility of planned telemedicine follow-up after medication management of early pregnancy loss. We compared these follow-up rates with those after planned in-person follow-up of medication management of early pregnancy loss and planned telemedicine follow-up after medication abortion. We conducted a retrospective cohort study, including patients initiating medication management of early pregnancy loss <13w0d gestation and medication abortion ≤10w0d with a combination of mifepristone and misoprostol between April 1, 2020, and March 28, 2021. As part of a new clinical protocol, patients could opt for telemedicine follow-up one week after treatment and a home urine pregnancy test 4 weeks after treatment. Our primary outcome was completed follow-up as per clinical protocol. We also examined outcomes related to complications across telemedicine and in-person follow-up groups. Results: Of patients reviewed, 181 were eligible for inclusion; 75 had medication management of early pregnancy loss, and 106 had medication abortion. Thirty-six out of 75 patients elected for telemedicine follow-up after early pregnancy loss. Of patients scheduled for telemedicine follow-up, 29/36 (81%, 95% CI: 64-92) with early pregnancy loss and 64/69 (93%, 95% CI: 84-98) undergoing medication abortion completed follow-up as per protocol (p = 0.06). Completed follow-up was also similar among patients undergoing medication management of early pregnancy loss who planned for in-person follow-up (p = 0.135). Complications were rare and did not differ across early pregnancy loss and medication abortion groups. Conclusions: Telemedicine follow-up is a feasible alternative to in-person assessment after medication management of early pregnancy loss.

HLA-G Expression/Secretion and T-Cell Cytotoxicity in Missed Abortion in Comparison to Normal Pregnancy

The main role of HLA-G is to protect the semi-allogeneic embryo from immune rejection by proper interaction with its cognate receptors on the maternal immune cells. Spontaneous abortion is the most common adverse pregnancy outcome, with an incidence rate between 10% and 15%, with immunologic dysregulation being thought to play a role in some of the cases. In this study, we aimed to detect the membrane and soluble HLA-G molecule at the maternal-fetal interface (MFI) and in the serum of women experiencing missed abortion (asymptomatic early pregnancy loss) in comparison to the women experiencing normal early pregnancy. In addition, the proportion of T cells and their cytotoxic profile was evaluated. We observed no difference in the spatial expression of HLA-G at the MFI and in its serum levels between the women with missed abortions and those with normal early pregnancy. In addition, comparable numbers of peripheral blood and decidual total T and γδT cells were found. In addition, as novel data we showed that missed abortion is not associated with altered extravilous invasion into uterine blood vessels and increased cytotoxicity of γδT cells. A strong signal for HLA-G on non-migrating extravilous trophoblast in the full-term normal placental bed was detected. In conclusion, HLA-G production at the MFI or in the blood of the women could not be used as a marker for normal pregnancy or missed abortions.

Early pregnancy loss medical management in clinical practice

OBJECTIVES

This study aimed to review clinical practice outcomes of early pregnancy loss (EPL) medical management using mifepristone and misoprostol outside of a clinical trial setting.

STUDY DESIGN

In this retrospective cohort study, we reviewed a deidentified database of patients who received mifepristone-misoprostol for EPL from May 2018 to May 2021 at our academic center-based clinic, which was a study site for a multicenter mifepristone-misoprostol EPL trial completed in March 2018. All patients received mifepristone 200 mg orally and misoprostol 800 mcg vaginally or buccally, with clinic follow-up typically scheduled within 1 week. The primary outcome was successful medical management, defined as management without the need for aspiration, and the secondary outcomes included additional interventions and indications, follow-up ultrasonography findings, and adverse events requiring treatment.

RESULTS

We treated 90 patients with a median ultrasound-measured gestational size of 49 (range 30-80) days and median time from mifepristone to misoprostol of 24 (range 8-66) hours. Follow-up was completed in clinic by 80 (88.9%), completed remotely by five (5.6%), and not completed by five (5.6%) patients. Overall, 76 (95% CI 82.9%-96.0%) of 85 patients (89.4%) with follow-up were successfully managed without uterine aspiration. Eighty patients had initial follow-up ultrasonography interpreted as gestational sac expulsion; seven (8.8%) of these ultimately underwent aspiration, including one patient who had a previously undiagnosed cesarean scar ectopic pregnancy. Two patients had significant safety outcomes: one pelvic infection and one blood transfusion during aspiration in the patient with a cesarean scar ectopic pregnancy.

CONCLUSIONS

Outside of a clinical trial setting, medical management of EPL with mifepristone and misoprostol remains effective and safe.

IMPLICATIONS

Medical management of EPL with mifepristone and misoprostol is effective and safe outside of a clinical trial setting. A standardized protocol based on the best available clinical trial evidence can be used in clinical practice for the medical management of EPL.

Epigenetic Factors in Eutopic Endometrium in Women with Endometriosis and Infertility

Eutopic endometrium in patients with endometriosis is characterized by aberrant expression of essential genes during the implantation window. It predisposes to disturbance of endometrial receptivity. The pathomechanism of implantation failures in women with endometriosis remains unclear. This paper aims to summarize the knowledge on epigenetic mechanisms in eutopic endometrium in the group of patients with both endometriosis and infertility. The impaired DNA methylation patterns of gene promoter regions in eutopic tissue was established. The global profile of histone acetylation and methylation and the analysis of selected histone modifications showed significant differences in the endometrium of women with endometriosis. Aberrant expression of the proposed candidate genes may promote an unfavorable embryonic implantation environment of the endometrium due to an immunological dysfunction, inflammatory reaction, and apoptotic response in women with endometriosis. The role of the newly discovered proteins regulating gene expression, i.e., TET proteins, in endometrial pathology is not yet completely known. The cells of the eutopic endometrium in women with endometriosis contain a stable, impaired methylation pattern and a histone code. Medication targeting critical genes responsible for the aberrant gene expression pattern in eutopic endometrium may help treat infertility in women with endometriosis.

Barriers and Enablers to Family Physicians' Provision of Early Pregnancy Loss Management in the United States

BACKGROUND

Early pregnancy loss (EPL) is a common experience. Treatment options include expectant management, medication, and uterine aspiration. Although family physicians can offer comprehensive EPL treatment in their office-based settings, few actually do. This study explored the postresidency provision of EPL management and factors that inhibit or enable providing this care among family physicians trained in early abortion during residency.

METHODS

Using an exploratory sequential mixed-methods design, we studied a sample of family physicians trained in early abortion during residency. We initially interviewed a subset trained in uterine aspiration during residency, then surveyed the entire sample. Interview transcripts were coded and analyzed using grounded theory; results informed survey development. On survey responses, we used Pearson χ² to examine the association between certain variables and provision of EPL care options.

RESULTS

Most of the 15 interview and 231 survey respondents provided expectant management of EPL. Of the survey respondents, 47.2% provided medication management and 11.4% manual vacuum aspiration. Key challenges and facilitators involved referral, training, ultrasound access, and managing systems-level issues. In bivariate analyses, providing prenatal care, offering abortion care, access to ultrasound, and competency were positively associated with providing EPL management options (p < .05).

CONCLUSIONS

Clinical training alone is insufficient to expand access to comprehensive EPL care in family medicine office-based settings. Supporting family physicians during and after residency with training and technical assistance to address barriers to care may strengthen their abilities to champion practice change and expand access to comprehensive EPL management options.

Gestational Age at Arrest of Development: An Alternative Approach for Assigning Time at Risk in Studies of Time-Varying Exposures and Miscarriage

The time between arrest of pregnancy development and miscarriage represents a window in which the pregnancy is nonviable and not developing. In effect, the pregnancy loss has already occurred, and additional exposure cannot influence its outcome. However, epidemiologic studies of miscarriage traditionally use gestational age at miscarriage (GAM) to assign time in survival analyses, which overestimates duration of exposure and time at risk. In Right From the Start, a pregnancy cohort study (2000-2012), we characterized the gap between estimated gestational age at arrest of development (GAAD) and miscarriage using transvaginal ultrasound in 500 women recruited from 3 states (North Carolina, Tennessee, and Texas). We compared effect estimates from models using GAAD with GAM to assign time at risk through a simulation study of several exposure patterns with varying effect sizes. The median gap between GAAD and miscarriage was 23 days (interquartile range, 15-32). Use of GAAD decreased the bias and variance of the estimated association for time-varying exposures, whereas half the time using GAM led to estimates that differed from the true effect by more than 20%. Using GAAD to assign time at risk should result in more accurate and consistent characterization of miscarriage risk associated with time-varying exposures.

Management of early pregnancy loss, with a focus on patient centered care

Early pregnancy loss is the most common complication in pregnancy. Management options for miscarriage include expectant management, medical intervention, or surgical aspiration. Non-surgical and surgical management are all safe and acceptable options for medically uncomplicated patients. Patient and provider preferences contribute profoundly to clinical decisions about miscarriage management. Shared-decision making and evidence based counseling have been shown to significantly improve patient satisfaction with early pregnancy loss care. This review article will discuss the epidemiology and risk factors of early pregnancy loss, current evidence and clinical practice guidelines around management options, and provider and patient preferences for early pregnancy loss management.

Fertility and obstetric outcomes after curettage versus expectant management in randomised and non-randomised women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage

OBJECTIVE

To assess fertility and obstetric outcomes in women treated with curettage or undergoing expectant management for an incomplete miscarriage after misoprostol treatment.

STUDY DESIGN

Between June 2012 and July 2014, we conducted a multicentre randomised clinical trial (RCT) with a parallel cohort study for non-randomised women, treated according to their preference. In the RCT 30 women were allocated curettage and 29 expectant management. In the cohort 197 women participated; 65 underwent curettage and 132 women underwent expectant management. Primary outcome was curation, defined as either an empty uterus on sonography at six weeks or an uneventful clinical follow-up. We used questionnaires to assess fertility and obstetric outcome of the first new pregnancy subsequent to study enrolment.

RESULTS

Curation was seen in 91/95 women treated with curettage (95.8%) versus 134/161 women managed expectantly (83.2%) (p=0.003). The response rate was 211/255 (82%). In 198 women pursuing a new pregnancy, conception rates were 92% (67/73) in the curettage group versus 96% (120/125) in the expectant management group (OR 0.96, 95% CI 0.89;1.03, p=0.34), with ongoing pregnancy rates of 87% (58/67) versus 78% (94/120), respectively (OR 1.12, 95% CI 0.99;1.28, p=0.226). Preterm birth rates were 1/46 in the curettage group versus 8/81 in the expectant management group (OR 0.22, 95% CI 0.03;1.71 P=0.15). Caesarean section rates were 23% and 24% for women in the curettage group and expectant management group respectively.

CONCLUSION

In women with an incomplete evacuation of the uterus after misoprostol treatment, curettage and expectant management does not lead to different fertility and pregnancy outcomes, as compared to expectant management.

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

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.

Cervical ripening before first trimester surgical evacuation for non-viable pregnancy

BACKGROUND

Medications or mechanical dilators are often used to soften and dilate the cervix prior to surgical evacuation of the uterus for non-viable pregnancy, or miscarriage. The majority of miscarriages occur in the first trimester. The aim of cervical ripening is to reduce the possibility of injury to the uterus and cervix and improve the surgical ease of the procedure. Cervical ripening agents can have adverse effects and it is uncertain as to whether these risks outweigh the benefits of their use.

OBJECTIVES

To systematically review the benefits and harms of using cervical ripening agents prior to surgical evacuation of non-viable pregnancy prior to 14 weeks' gestation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2015) and reference lists of retrieved papers.

SELECTION CRITERIA

Randomised controlled trials (published in full-text form, or as abstracts only), which assessed the use of pharmacological or mechanical agents to ripen the cervix in women undergoing dilation and curettage or vacuum aspiration for non-viable pregnancy at less than 14 weeks' gestation were eligible for inclusion. Cluster-randomised controlled trials and trials using a cross-over design were not eligible for inclusion.Unpublished randomised controlled trials and quasi-randomised trials would have been eligible for inclusion but none were identified.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included nine trials with 469 women. A diverse set of medications and regimens were studied in these trials, making the comparisons available for meta-analysis limited. The comparisons draw data from six trials with 383 participants. All trials were relatively small and had several aspects of unclear risk of bias with few of this review's outcomes reported. Due to this, no data from three trials were able to be used despite them meeting inclusion criteria.We carried out four comparisons: isosorbide mononitrate or dinitrate compared with misoprostol; misoprostol compared with placebo; chemical dilation (use of medications) compared with mechanical dilation; and any cervical preparation compared with placebo.None of the included studies reported data on the review's primary outcome: cervical or uterine injury (perforation, laceration, creation of a false passage).No clear difference was shown between isosorbide compounds and misoprostol for the outcome need for manual cervical dilation (average risk ratio (RR) 0.76, 95% confidence interval (CI) 0.10 to 5.64; three trials, 150 women; Tau² = 2.11; I² = 69%), however the data were heterogenous. In terms of adverse effects, misoprostol was associated with more vomiting (RR 0.11, 95% CI 0.01 to 0.85; two trials, 120 women), however there were no clear differences between isosorbide compounds and misoprostol in relation to other reported adverse effects (headache, nausea or hypotension). The dosing regimens differed in terms of dose, number of administrations and route of administration in the different trials. Mechanical (Dilapan-S hygroscopic) dilators performed similarly to chemical dilators in a single trial (65 women) that measured difficulty in cervical dilation, excessive bleeding and adverse effects.Misoprostol was shown to be more effective than placebo for cervical ripening (reduced need for manual cervical dilation) (RR 0.14, 95% CI 0.08 to 0.26; one trial, 120 women), and surgical time was reduced when misoprostol was used (mean difference (MD) -3.15, 95% CI -3.59 to -2.70; one trial, 120 women). However, compared to placebo, misoprostol, was associated with more abdominal pain (RR 29.00, 95% CI 1.77 to 475.35; one trial, 120 women), although no clear differences in the risk of other adverse effects (nausea, vomiting, headache or fever) were observed between groups.There was no clear differences between chemical dilation and mechanical dilators for the outcomes: difficulty in cervical dilation, excessive bleeding or adverse effects.Compared with placebo, any cervical preparation reduced the need for manual cervical dilatation (average RR 0.25, 95% CI 0.07 to 0.89; two trials, 168 women; Tau² = 0.67; I² = 81%), and reduced surgical time (MD -2.55, 95% CI -3.67 to -1.43, two trials, 168 women; Tau² = 0.63; I² = 96%).None of the included trials reported on the review's other secondary outcomes, including: injury to bladder or bowel, miscarriage/preterm birth in a subsequent pregnancy, analgesia use after administration of ripening agent but before surgery, or analgesia use after surgery.

AUTHORS' CONCLUSIONS

This review found no evidence to evaluate cervical ripening prior to first trimester surgical evacuation for miscarriage for reducing the rate of cervical or uterine injury, however, this may be because these outcomes are very rare. Cervical preparation was shown to reduce the need for manual cervical dilatation compared with placebo.Misoprostol and isosorbide mononitrate and dinitrate were similarly effective in ripening the cervix, however there was more vomiting with misoprostol. Mechanical (Dilapan-S hygroscopic) dilators performed similarly to chemical dilators.The nine studies included in this review were small and the methodological quality of the trials was mixed, and for the most part, not well-described; thus any conclusions drawn from the data included in this review must be treated with caution. Consequently, large, high-quality trials are required to determine whether the benefits of this treatment outweigh the risks. Further research should be powered to assess the rate of cervical and uterine injury between interventions. Future research should also guide clinicians in deciding whether the benefits of reduced manual cervical dilatation outweigh the risks of adverse effects associated with these agents (nausea, vomiting, headache, fever, diarrhoea and pain). Women's satisfaction and outcomes of future pregnancies should also be assessed.

Barriers to and Facilitators of Moving Miscarriage Management Out of the Operating Room

CONTEXT

Miscarriage care can safely and effectively be offered in appropriately equipped offices and emergency departments. However, it is often treated in the operating room, which limits access to timely, cost-effective and high-quality care.

METHODS

Between May 2013 and January 2014, in-depth interviews were conducted with 30 staff holding diverse roles at 15 medical offices and emergency departments with the aim of exploring barriers to and facilitators of offering miscarriage care, and identifying methods for expanding care. On-site observations were also conducted at four facilities. All data were transcribed, iteratively coded and analyzed using qualitative techniques.

RESULTS

Similar barriers to and facilitators of providing miscarriage care were identified across facility types. Barriers were physician preference for providing care in the operating room, the similarity of miscarriage management and abortion procedures, the limited availability of support staff, difficulties integrating miscarriage management into patient scheduling and flow, and uncertainty about responding to women's emotional needs. Facilitators were a commitment to evidence-based medicine, insurance coverage of miscarriage, offering other procedures of similar complexity and the minimal resources needed for miscarriage care. Resources needed to expand miscarriage services included a medically trained "champion," best practices for implementing services, persistence and patience, training, clear protocols, and systems for tracking equipment and supplies.

CONCLUSIONS

Miscarriage care was viewed as neither resource-intensive nor technically complex to provide. Although it may be emotionally and politically challenging to offer, effective strategies are available for expanding the scope of miscarriage care offered in multiple settings.

Validation of ICD-9 Codes for Stable Miscarriage in the Emergency Department

Introduction

International Classification of Disease, Ninth Revision (ICD-9) diagnosis codes have not been validated for identifying cases of missed abortion where a pregnancy is no longer viable but the cervical os remains closed. Our goal was to assess whether ICD-9 code “632” for missed abortion has high sensitivity and positive predictive value (PPV) in identifying patients in the emergency department (ED) with cases of stable early pregnancy failure (EPF).

Methods

We studied females ages 13–50 years presenting to the ED of an urban academic medical center. We approached our analysis from two perspectives, evaluating both the sensitivity and PPV of ICD-9 code “632” in identifying patients with stable EPF. All patients with chief complaints “pregnant and bleeding” or “pregnant and cramping” over a 12-month period were identified. We randomly reviewed two months of patient visits and calculated the sensitivity of ICD-9 code “632” for true cases of stable miscarriage. To establish the PPV of ICD-9 code “632” for capturing missed abortions, we identified patients whose visits from the same time period were assigned ICD-9 code “632,” and identified those with actual cases of stable EPF.

Results

We reviewed 310 patient records (17.6% of 1,762 sampled). Thirteen of 31 patient records assigned ICD-9 code for missed abortion correctly identified cases of stable EPF (sensitivity=41.9%), and 140 of the 142 patients without EPF were not assigned the ICD-9 code “632”(specificity=98.6%). Of the 52 eligible patients identified by ICD-9 code “632,” 39 cases met the criteria for stable EPF (PPV=75.0%).

Conclusion

ICD-9 code “632” has low sensitivity for identifying stable EPF, but its high specificity and moderately high PPV are valuable for studying cases of stable EPF in epidemiologic studies using administrative data.

Beyond usual care: the economic consequences of expanding treatment options in early pregnancy loss

OBJECTIVE

The objective of this study was to estimate the economic consequences of expanding options for early pregnancy loss (EPL) treatment beyond expectant management and operating room surgical evacuation (usual care).

STUDY DESIGN

We constructed a decision model using a hypothetical cohort of women undergoing EPL management within a 30 day horizon. Treatment options under the usual care arm include expectant management and surgical uterine evacuation in an operating room (OR). Treatment options under the expanded care arm included all evidence-based safe and effective treatment options for EPL: expectant management, misoprostol treatment, surgical uterine evacuation in an office setting, and surgical uterine evacuation in an OR. Probabilities of entering various treatment pathways were based on previously published observational studies.

RESULTS

The cost per case was US $241.29 lower for women undergoing treatment in the expanded care model as compared with the usual care model (US $1033.29 per case vs US $1274.58 per case, expanded care and usual care, respectively). The model was the most sensitive to the failure rate of the expectant management arm, the cost of the OR surgical procedure, the proportion of women undergoing an OR surgical procedure under usual care, and the additional cost per patient associated with implementing and using the expanded care model.

CONCLUSION

This study demonstrates that expanding women's treatment options for EPL beyond what is typically available can result in lower direct medical expenditures.

Traumatic injuries in pregnant women: a case of motor vehicle accident for "Ground Round" discussion

The main objective for introducing this case study is to create a platform from which the importance of road traffic related injuries and traumas can be emphasized and discussed within and across various fields of investigation. The long term goal is to entice public campaign around unmet needs for higher road safety measures to reduce primary, secondary, and tertiary risks of injuries and traumas.

Treatment of early pregnancy failure: does induced abortion training affect later practices?

OBJECTIVE

The objective of the study was to examine the relationship between induced abortion training and views toward, and use of, office uterine evacuation and misoprostol in early pregnancy failure (EPF) care.

STUDY DESIGN

We surveyed 308 obstetrician-gynecologists on their knowledge and attitudes toward treatment options for EPF and previous training in office-based uterine evacuation.

RESULTS

Sixty-seven percent of respondents reported training in office uterine evacuation, and 20.3% reported induced abortion training. Induced abortion training was associated with strongly positive views toward both office-based uterine evacuation and misoprostol as treatment for EPF compared with those with office uterine evacuation training in other settings (odds ratio [OR], 2.64; P < .004 and OR, 3.22; P < .003, respectively). Furthermore, induced abortion training was associated with the use of office uterine evacuation for EPF treatment compared with those with office evacuation training in other settings (OR, 2.90; P = .004).

CONCLUSION

Training experiences, especially induced abortion training, are associated with the use of office uterine evacuation for EPF.

Association between gestational age and induction-to-abortion interval in mid-trimester pregnancy termination using misoprostol

OBJECTIVE

The study was aimed to evaluate the effectiveness, outcome, and pain intensity of the vaginal administration of misoprostol for the induction of abortion between 13 and 24 gestational weeks.

STUDY DESIGN

A retrospective study was conducted at our tertiary medical center from January 2006 to December 2009 on 122 consecutive women who underwent termination of pregnancy (TOP) in the mid-trimester. They were given 400 mcg of vaginal misoprostol every 6h, up to four doses. The induction-to-abortion interval and the level of pain experienced during the process were assessed. Success was defined by the fetus being expelled within 48 h.

RESULTS

Vaginal misoprostol was effective in 84% (98/122) of patients. The median duration of the induction-to-abortion interval was 16 (5-48)h. The induction-to-abortion interval was correlated with gestational age, while inversely correlated with parity. A correlation was also found between gestational age and pain intensity at 12h from induction.

CONCLUSION

Misoprostol is safe and effective in mid-trimester abortion induction. The induction-to-abortion interval is shorter and abortion less painful with lower gestational age. Higher parity is also associated with shorter induction to abortion interval.

Provider knowledge, attitudes, and treatment preferences for early pregnancy failure

OBJECTIVE

We sought to describe health care provider knowledge, attitudes, and treatment preferences for early pregnancy failure (EPF).

STUDY DESIGN

We surveyed 976 obstetrician/gynecologists, midwives, and family medicine practitioners on their knowledge and attitudes toward treatment options for EPF, and barriers to adopting misoprostol and office uterine evacuations. We used descriptive statistics to compare practices by provider specialty and logistic regression to identify associations between provider factors and treatment practices.

RESULTS

Seventy percent of providers have not used misoprostol and 91% have not used an office uterine evacuation to treat EPF in the past 6 months. Beliefs about safety and patient preferences, and prior induced abortion training were significantly associated with use of both of these treatments.

CONCLUSION

Increasing education and training on the use of misoprostol and office uterine evacuation, and clarifying patient treatment preferences may increase the willingness of providers to adopt new practices for EPF treatment.

Management of anembryonic pregnancy loss: an observational study

BACKGROUND

This study was undertaken to determine if expectant management with a longer waiting period is an effective and safe option for women with anembryonic pregnancy.

METHODS

Women with an ultrasound diagnosis of anembryonic pregnancy were offered the option of expectant management with a 3-week waiting period or surgical evacuation according to their preference.

RESULTS

A total of 121 women with anembryonic pregnancies participated in the study; 45 of them elected expectant management. The overall success rate was 83.3% in the expectant group and 97.3% in the surgical group. No significant complications were noted in either group.

CONCLUSION

Expectant management with a 3-week waiting period is an efficacious and safe option with a low risk of infection and hemorrhage. However, it is difficult to predict the exact time period before spontaneous abortion.

Oral misoprostol reduces vaginal bleeding following surgical evacuation for first trimester spontaneous abortion

OBJECTIVE

To assess the effectiveness and tolerability of misoprostol to reduce the amount and duration of vaginal bleeding following surgical evacuation for first trimester spontaneous abortion.

METHODS

A total of 160 patients who underwent surgical evacuation for first trimester spontaneous abortion between 8 and 12 weeks of pregnancy were randomized into 2 groups to receive either 200 microg of oral misoprostol immediately after evacuation followed every 6 hours for 48 hours or no misoprostol. Pain scores, duration and amount of bleeding, and endometrial thickness were assessed over 10 days.

RESULTS

Women who received misoprostol had significantly fewer bleeding days after evacuation (4.11+/-2.69 vs 5.89+/-3.06; P<0.001), fewer patients reported vaginal bleeding lasting 10 days or more (3.8% vs 15.0%; P=0.014), and endometrial thickness 10 days after evacuation was less (6.25+/-2.38 vs 7.23+/-1.94; P=0.05). Pain scores were comparable in both groups (1.54+/-0.65 vs 1.63+/-0.83; P=0.40) after 10 days.

CONCLUSION

Oral misoprostol is effective in reducing the prevalence and amount of vaginal bleeding after surgical evacuation for first trimester spontaneous abortion.

Pregnancy losses in young Australian women: findings from the Australian Longitudinal Study on Women's Health

INTRODUCTION

Little research has examined recognized pregnancy losses in a general population. Data from an Australian cohort study provide an opportunity to quantify this aspect of fecundity at a population level.

METHOD

Participants in the Australian Longitudinal Study on Women's Health who were aged 28-33 years in 2006 (n = 9,145) completed up to 4 mailed surveys over 10 years. Participants were categorized according to the recognized outcome of their pregnancies, including live birth, miscarriage/stillbirth, termination/ectopic, or no pregnancy.

RESULTS

At age 18-23, more women reported terminations (7%) than miscarriages (4%). By 28-33 years, the cumulative frequency of miscarriage (15%) was as common as termination (16%). For women aged 28-33 years who had ever been pregnant (n = 5,343), pregnancy outcomes were as follows: birth only (50%); loss only (18%); and birth and loss (32%), of which half (16%) were birth and miscarriage. A comparison between first miscarriage and first birth (no miscarriage) showed that most first miscarriages occurred in women aged 18-23 years who also reported a first birth at the same survey (15%). Half (51%) of all first births and first miscarriages in women aged 18-19 ended in miscarriage. Early childbearers (<28 years) often had miscarriages around the same time period as their first live birth, suggesting proactive family formation. Delayed childbearers (32-33 years) had more first births than first miscarriages.

CONCLUSION

Recognized pregnancy losses are an important measure of fecundity in the general population because they indicate successful conception and maintenance of pregnancy to varying reproductive endpoints.

Sublingual misoprostol after surgical management of early termination of pregnancy

OBJECTIVE

To assess the efficacy of sublingual misoprostol after surgical management of early termination of pregnancy (ETP) regarding duration and amount of bleeding, presence of retained products of conception (RPOC), and endometrial thickness.

DESIGN

Prospective, randomized clinical trial.

SETTING

University hospital.

PATIENT(S)

One hundred five patients admitted for possible management of early pregnancy failure and unwanted pregnancy.

INTERVENTION(S)

Manual vacuum aspiration (control and study groups) plus 400 microg sublingual misoprostol (study group) at pregnancy termination, and transvaginal ultrasonography (both groups) 10 days after the procedure.

MAIN OUTCOME MEASURE(S)

Duration and amount of bleeding and presence of RPOC and endometrial thickness 10 days after the procedure.

RESULT(S)

Bleeding lasted 3.2 and 5.1 days in the study and control groups. Severe vaginal bleeding occurred in two patients in the study group and in six patients in the control group. Mean endometrial thickness was 5.5 mm in the study group and 6.9 mm in the control group. These differences were statistically significant. No cases of RPOC occurred in the study group; two cases occurred in the control group.

CONCLUSION(S)

In countries in which surgical management of ETP is still done, using sublingual misoprostol postoperatively may reduce the duration and amount of bleeding.

Quality of life and acceptability of medical versus surgical management of early pregnancy failure

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.

Stepping back to gain perspective: pregnancy loss history, depression, and parenting capacity in the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B)

Previous empirical studies of pregnancy loss have predominantly focused on complex grief response and emergent problems associated with future parenting in self-selected samples of bereaved women. This article presents findings from a retrospective secondary data analysis conducted with a racially and ethnically diverse sample of currently parenting women in the United States (N = 10,688) that examined the relationships among pregnancy loss history, current maternal depressive symptoms, and mother-infant interaction with the enrolled child. Study findings underscore a racial-ethnic disparity in pregnancy loss history for African American women, whereas current maternal depressive symptoms remain fairly constant across racial-ethnic groups. Multiple loss history is associated with a slight elevation in overall symptoms of depression, but there is no relationship between pregnancy loss history and current mother-infant interaction in the study sample. An important limitation in this study is that the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B) data does not allow for inferences specific to the type of loss, gestational age of fetus, time since loss, or whether the loss was spontaneous or induced. However, study findings highlight areas of incongruity between clinical and population-based research that deserve further investigation. Ultimately, the findings from this population-based research contribute to a wider perspective regarding maternal response to reproductive loss that can inform future research and targeted bereavement support.

Rectal Misoprostol Versus Oxytocin in the Management of the Third Stage of Labour

OBJECTIVE

To compare the effect of rectal misoprostol with intramuscular oxytocin in the routine management of the third stage in a rural developing country.

METHODS

A randomized controlled trial was performed at two district hospitals in Ghana, West Africa. Four hundred fifty women in advanced labour were enrolled. The only exclusion criterion was a known medical contraindication to prostaglandin administration. Women were randomized to receive rectal misoprostol 800 microg or intramuscular oxytocin 10 IU with delivery of the anterior shoulder. The main outcome measure was change in hemoglobin concentration from before to after delivery. Secondary outcomes included the need for additional uterotonics, estimated blood loss, transfusion, and medication side effects.

RESULTS

Demographic characteristics were similar in each treatment group. There was no significant difference between treatment groups in change in hemoglobin (misoprostol 1.19 g/dL and oxytocin 1.16 g/dL; relative difference 2.6%; 95% confidence intervals [CI]-16.8% to 19.4%; P = 0.80). The only significant secondary outcome was shivering, which was more common in the misoprostol group (misoprostol 7.5% vs. oxytocin 0.9%; relative risk 8.0; 95% CI 1.86-34.36; P = 0.001).

CONCLUSION

Rectal misoprostol 800 microg is as effective as 10 IU intramuscular oxytocin in minimizing blood loss in the third stage of labour. Rectal misoprostol has a lower incidence of side effects than the equivalent oral dose. This confirms the utility of misoprostol as a safe and effective uterotonic for use in the rural and remote areas of developing nations where other pharmacologic agents may be less feasible.

Clinical indicators for success of misoprostol treatment after early pregnancy failure

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.

Surgical management of early pregnancy failure: history, politics, and safe, cost-effective care

Early pregnancy failure and induced abortion are often managed differently, even though safe uterine evacuation is the goal in both. Early pregnancy failure is commonly treated by curettage in operating room settings in anesthetized patients. Induced abortion is most commonly managed by office vacuum aspiration in awake or sedated patients. Medical evidence does not support routine operating room management of early pregnancy failure. This commentary reviews historical origins of these different care standards, explores political factors responsible for their perpetuation, and uses experience at University of Michigan to dramatize the ways in which history, politics, and biomedicine intersect to produce patient care. The University of Michigan initiated office uterine evacuations for early pregnancy failure treatment. Patients previously went to the operating room. These changes required faculty, staff, and resident education. Our efforts blurred the lines between spontaneous and induced abortion management, improved patient care and better utilized hospital resources.

The use of misoprostol for early pregnancy failure

PURPOSE OF REVIEW

This paper reviews the current management of early pregnancy failure with particular emphasis on the use of misoprostol.

RECENT FINDINGS

Medical management using misoprostol is effective for the management of miscarriages. The success rate ranged from 84 to 93% depending on the regimen of misoprostol, the duration of waiting period and the types of miscarriage.

SUMMARY

Miscarriages occur in 10 to 20% of all pregnancies. Surgical evacuation has been used to empty the uterus. Recently, medical treatment using misoprostol has been studied for the management of miscarriage. It avoids surgery and its associated complications. Compared to expectant management, the success rate is higher. Nonsurgical management takes a longer period to reach the endpoint and medical management is associated with side effect of medication. Studies have shown that medical management is safe and acceptable to women. The optimal regimen of medical management, however, is yet to be determined.

Prevalence and correlates of pregnancy loss history in a national sample of children and families

Public health prevalence data has consistently illustrated disparities in fetal mortality prevalence on a yearly basis, yet few studies have examined the prevalence and correlates of pregnancy loss history during the reproductive life span. Using nationally representative data from the Early Childhood Longitudinal Study, Birth Cohort, approximately 25% of childbearing women in the United States were found to have experienced one or more fetal deaths prior to the current live birth. An examination of the demographic correlates of singular and multiple loss history in age-controlled models reveals that a history of multiple loss was significantly related to African-American race, lower socioeconomic status, income below poverty, and lower maternal education. Singular loss history risk was relatively consistent across social and demographic groups with some increased risk noted only for African-American women. Predictive correlates of fetal mortality varied by racial-ethnic subpopulation in multivariate analysis. Findings from this study are discussed for their contribution to existing public health knowledge and the potential for future research focused on the experience of multiple loss and demographic groups at elevated risk.

Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure

OBJECTIVE

To examine patient treatment preferences and satisfaction with an office-based procedure for early pregnancy failure and to compare resource use and cost between office and operating room management of early pregnancy failure.

METHODS

This study was a prospective observational study of 165 women presenting for surgical management of early pregnancy failure. Participants completed a preoperative questionnaire addressing treatment preferences and expectations and a postoperative questionnaire measuring level of pain experienced and satisfaction with care. Resource use was determined by measuring the time patients spent at the health care facility and the actual procedure time. Cost was estimated using an institutional database.

RESULTS

One hundred fifteen women from the office and 50 from the operating room were enrolled. Patients selecting outpatient management scored "privacy," "avoiding going to sleep," and "previous experience" higher than the operating room group (P < .05). Patients who perceived that their physicians preferred one procedure over the other were more likely to select that procedure (P < .001). Satisfaction was high in both groups, and underestimating the procedure's discomfort was negatively associated with satisfaction (P < .002). Costs were greater than two-fold higher in the operating room group compared with the office group (P < .01). Complications were uncommon, but hemorrhage-related complications were four times more common in the operating room group than in the office group (P < .01).

CONCLUSION

Office-based surgical management of early pregnancy failure is an acceptable option for many women and offers substantial resource and cost savings.

LEVEL OF EVIDENCE

II-2.

Intrauterine adhesions after manual vacuum aspiration for early pregnancy failure

OBJECTIVE

To describe the occurrence of intrauterine adhesions after manual vacuum aspiration for early pregnancy failure.

DESIGN

Case series.

SETTING

Tertiary care center.

PATIENT(S)

Three women with intrauterine adhesions after manual vacuum aspiration for the treatment of early pregnancy failure.

INTERVENTION(S)

Chart review.

MAIN OUTCOME MEASURE(S)

Hysteroscopic diagnosis of intrauterine adhesions after manual vacuum aspiration.

RESULT(S)

Three cases of symptomatic intrauterine adhesions after manual vacuum aspiration.

CONCLUSION(S)

Intrauterine adhesion formation may follow manual vacuum aspiration for early pregnancy loss.

Factors related to successful misoprostol treatment for early pregnancy failure

OBJECTIVE

To identify potential predictors for treatment success in medical management with misoprostol for early pregnancy failure.

METHODS

We conducted a planned secondary analysis of data from a multicenter trial that compared medical and surgical management of early pregnancy failure. Medical management consisted of misoprostol 800 mug vaginally on study day 1, with a repeat dose if indicated on day 3. Women returned on days 3 and 15, and a telephone interview was conducted on day 30. Failure was defined as suction aspiration for any reason within 30 days. Demographic, historical, and outcome variables were included in univariable analyses of success. Multivariable analyses were conducted using clinical site, gestational age, and variables for which the univariable analysis resulted in a P < .1 to determine predictors of overall treatment success and first-dose success.

RESULTS

Of the 491 women who received misoprostol, 485 met the criteria for this secondary analysis. Lower abdominal pain or vaginal bleeding within the last 24 hours, Rh-negative blood type, and nulliparity were predictive of overall success. However, only vaginal bleeding within the last 24 hours and parity of 0 or 1 were predictive of first-dose success. Overall success exceeds 92% in women who have localized abdominal pain within the last 24 hours, Rh-negative blood type, or the combination of vaginal bleeding in the past 24 hours and nulliparity.

CONCLUSION

Misoprostol treatment for early pregnancy failure is highly successful in select women, primarily those with active bleeding and nulliparity. Clinicians and patients should be aware of these differences when considering misoprostol treatment.

LEVEL OF EVIDENCE

II-2.

Medical vs. surgical evacuation of first-trimester spontaneous abortion

OBJECTIVE

To determine whether management of incomplete first-trimester abortion with vaginal misoprostol in an under-resourced setting is a viable treatment option.

METHODS

A total of 94 women were randomized to 600 microg of misoprostol intravaginally or to surgical curettage. The women receiving misoprostol were administered a second dose if the abortion was incomplete; and if still not complete after a week, evacuation of retained products of conception was performed. All women had a follow-up visit 2 weeks following complete abortion.

RESULTS

The overall success rate of medical management was 91.5%, with 15 of 47 successful cases after 1 dose of misoprostol; 8.5% of the 47 women required evacuation of retained products of conception after 1 week because of treatment failure. The success rate in the surgical arm was 100%. Patients in the medical arm had a longer duration of bleeding and a greater need for analgesia. There were no differences in hemoglobin levels, white blood cell count, adverse effects, pain score, and satisfaction with treatment at the follow-up visit. However, more women who received the medical treatment would recommend it or choose it in the future.

CONCLUSION

Medical management using 600 microg of misoprostol in 2 doses is effective to treat incomplete first-trimester abortions in an under-resourced setting when there is no evidence of uterine sepsis.

Oral Misoprostol Versus Oxytocin in the Management of the Third Stage of Labour

OBJECTIVE

To compare the effects of oral misoprostol 800 mug with intramuscular oxytocin 10 IU in routine management of the third stage of labour.

METHODS

This randomized controlled trial was performed in a rural district hospital in Ghana, West Africa, and enrolled women in labour with anticipated vaginal delivery and no known medical contraindication to prostaglandin administration. Women were randomized to receive oral misoprostol 800 mug or intramuscular oxytocin 10 IU. Blood samples were taken to determine hemoglobin concentration before delivery and at 12 hours post partum. Treatment was administered at delivery of the anterior shoulder. The primary outcome was the change in hemoglobin concentration from before to after delivery. Secondary outcomes included other measures of blood loss and presumed medication side effects.

RESULTS

In total, 450 women were enrolled in the study. Their baseline characteristics were similar. There was no significant difference between the groups in the change in hemoglobin concentration (misoprostol 1.07 g/dL and oxytocin 1.00 g/dL). The only significant secondary outcomes were shivering (80.7% with misoprostol vs. 3.6% with oxytocin) and pyrexia (11.4% with misoprostol, none with oxytocin).

CONCLUSION

Routine use of oral misoprostol 800 microg appears to be as effective as 10 IU parenteral oxytocin in minimizing blood loss during the third stage of labour, as determined by change in hemoglobin concentration. Misoprostol appears to be a safe, inexpensive, and effective uterotonic for use in rural and remote areas, where intravenous oxytocin may be unavailable.

Transvaginal ultrasound after first-trimester uterine evacuation reduces the incidence of retained products of conception

OBJECTIVE

To assess the incidence of retained products of conception (RPOC) in relation to transvaginal ultrasound performed after first-trimester uterine evacuation.

METHODS

This was a prospective randomized study involving 809 women undergoing first-trimester uterine evacuation. The study group included 404 women in whom transvaginal sonography was performed at the end of the surgical procedure and the control group contained 405 women who did not undergo ultrasound examination. Initially, in the study group, recurettage was immediately performed if the endometrium appeared irregular but latterly only if endometrial thickness was > or = 8 mm. The patients were followed up by gynecological and ultrasound examinations 5-8 days following the surgical procedure.

RESULTS

The total complication rate was 4.3%. RPOC presented in three women in the study group (0.7%) and in 15 women in the control group (3.7%, P < 0.05). Vaginal bleeding requiring hospitalization occurred in two women in the study group (0.5%) vs. seven in the control group (1.7%, P = 0.2). Endometritis was diagnosed in one woman in the study group (0.2%) vs. six in the control group (1.5%) and uterine perforation occurred in one woman in the control group vs. none in the study group. There were no cases of RPOC in women who had an endometrial thickness of < 8 mm as demonstrated by ultrasound at the end of the surgical procedure.

CONCLUSION

Transvaginal sonography immediately following first-trimester uterine evacuation may reduce the incidence of RPOC and the total complication rate. When the endometrial thickness is > or = 8 mm at the end of suction curettage, an attempt at re-evacuation of the uterine cavity is indicated.

A randomized trial of misoprostol compared with manual vacuum aspiration for incomplete abortion

OBJECTIVE

To compare the safety, efficacy, and acceptability of misoprostol and manual vacuum aspiration for the treatment of incomplete abortion in a hospital setting in Kampala, Uganda.

METHODS

Three hundred seventeen women with clinically diagnosed incomplete first-trimester abortions were randomized to treatment with either manual vacuum aspiration or 600 mug misoprostol orally to complete their abortions. All women received antibiotics posttreatment and were followed up 1-2 weeks later.

RESULTS

Regardless of treatment allocation, nearly all women in this study successfully completed their abortions with either oral misoprostol or manual vacuum aspiration (96.3% versus 91.5%, relative risk 1.05, 95% confidence interval 0.98-1.14). Complications were less frequent in those receiving misoprostol than those having manual vacuum aspiration (0.9% versus 9.8%, relative risk 0.1, 95% confidence interval 0.01-0.78). In the 6 hours after treatment, women using misoprostol reported heavier bleeding but lower levels of pain than those treated with manual vacuum aspiration. Rates of acceptability were similarly high among women in the 2 treatment groups, with 94.2% and 94.7% of women reporting that their treatment was satisfactory or very satisfactory in the misoprostol and manual vacuum aspiration groups, respectively.

CONCLUSION

For treatment of first-trimester uncomplicated incomplete abortion, both manual vacuum aspiration and 600 microg oral misoprostol are safe, effective, and acceptable treatments. Based on availability of each method and the wishes of individual women, either option may be presented to women for the treatment of incomplete abortion.

LEVEL OF EVIDENCE

I.

A comparison of medical management with misoprostol and surgical management for early pregnancy failure

BACKGROUND

Misoprostol is increasingly used to treat women who have a failed pregnancy in the first trimester. We assessed the efficacy, safety, and acceptability of this treatment in a large, randomized trial.

METHODS

A total of 652 women with a first-trimester pregnancy failure (anembryonic gestation, embryonic or fetal death, or incomplete or inevitable spontaneous abortion) were randomly assigned to receive 800 microg of misoprostol vaginally or to undergo vacuum aspiration (standard of care) in a 3:1 ratio. The misoprostol group received treatment on day 1, a second dose on day 3 if expulsion was incomplete, and vacuum aspiration on day 8 if expulsion was still incomplete. Surgical treatment (for the misoprostol group) or repeated aspiration (for the vacuum-aspiration group) within 30 days after the initial treatment constituted treatment failure.

RESULTS

Of the 491 women assigned to receive misoprostol, 71 percent had complete expulsion by day 3 and 84 percent by day 8 (95 percent confidence interval, 81 to 87 percent). Treatment failed in 16 percent of the misoprostol group and 3 percent of the surgical group (absolute difference, 12 percent; 95 percent confidence interval, 9 to 16 percent) by day 30. Hemorrhage or endometritis requiring hospitalization was rare (1 percent or less in each group), with no significant differences between the groups. In the misoprostol group, 78 percent of the women stated that they would use misoprostol again if the need arose and 83 percent stated that they would recommend it to others.

CONCLUSIONS

Treatment of early pregnancy failure with 800 microg of misoprostol vaginally is a safe and acceptable approach, with a success rate of approximately 84 percent.

Quality of Life in Women Undergoing Medical Treatment for Early Pregnancy Failure

OBJECTIVES

To examine predictors of quality of life, depression, and stress in women undergoing medical management of early pregnancy failure with misoprostal and to assess the relationship of quality of life, depression, and stress to treatment acceptability.

DESIGN

Descriptive observational study of women undergoing medical management of early pregnancy failure with misoprostol conducted as part of a multicenter pilot study testing the efficacy of saline-moistened versus dry application of vaginal misoprostol. Data were collected prior to treatment through 15 days posttreatment.

SETTING

Four university-based hospitals.

PARTICIPANTS

Women (n = 80) < or = 1 weeks pregnant diagnosed with anembryonic gestation or fetal demise.

INTERVENTION

Vaginal misoprostol for medical evacuation.

MAIN OUTCOME MEASURES

Quality of life (physical role functioning, emotional role functioning, social functioning, vitality, and bodily pain), depression, stress, and treatment acceptability.

RESULTS

Women who received medical evacuation demonstrated poorer quality of life than same-age published population norms, scoring 0.25 to 0.78 of a standard deviation below the population mean for four of the five subscales.

CONCLUSIONS

Nurses should assist patients to minimize and manage physical symptoms during treatment for early pregnancy failure. Women with higher external demands and lower social/tangible support may need greater assistance.

Endometrial thickness after misoprostol use for early pregnancy failure

OBJECTIVES

To assess if there was any potential relationship between endometrial thickness and final treatment outcome in women successfully treated with misoprostol for a first trimester anembryonic gestation, embryonic demise or fetal demise.

METHODS

Eighty women were treated with up to two doses of misoprostol 800 microg vaginally for early pregnancy failure. Subjects were scheduled to return 2 (range 1-4), 7 (range 5-9) and 14 (range 12-17) days after treatment. Transvaginal ultrasonography was performed at each follow-up visit.

RESULTS

The median endometrial thickness at each of the follow-up visits for women who had expelled the gestational sac was 14 mm, 10 mm, and 7 mm, respectively. The endometrial thickness at the first follow-up visit exceeded 15 mm in 20 subjects (36%) and 30 mm in four subjects (7%). Only three women had a suction aspiration for bleeding after documented expulsion. The endometrial thickness for these women was 11, 13, and 14 mm at the first follow-up visit.

CONCLUSIONS

There is no obvious relationship between increasing endometrial thickness and the need for surgical intervention in women treated with misoprostol for early pregnancy failure.

How should success be defined when attempting medical resolution of first-trimester missed abortion?

OBJECTIVES

There is currently no consensus on how success should be defined after medical management of first-trimester missed abortion. The aim of this study was to determine the transvaginal ultrasound criterion associated with highest success rate and, at the same time, lowest long-term complications.

DESIGN

Prospective observational study of consecutively enrolled patients.

SETTING

A tertiary care university hospital in northern Portugal.

PARTICIPANTS

Forty-four women submitted to medical management of first-trimester missed abortion using a regimen of vaginal misoprostol, with histologically confirmed conception products passed vaginally. A transvaginal ultrasound scan was performed by an experienced sonographer in the morning after treatment, to characterise uterine content. Patients were provided with a chart for daily registration of axillary temperature, vaginal bleeding and lower abdominal pain. Transvaginal ultrasound was repeated 2-3 weeks later, and again after the following menses.

MAIN OUTCOME MEASURES

Success rates of medical management when post-treatment transvaginal ultrasound criteria for subsequent expectant management were: absence of intra-uterine sac, largest anteroposterior diameter of hyperechogenic content, and maximum area of hyperechogenic intra-uterine content in a sagittal view. Self-reported duration of vaginal bleeding and abdominal pain after medical treatment.

RESULTS

Success rate was 86% (38/44) when absence of gestational sac on the 12 h transvaginal ultrasound was used as the main criterion for subsequent expectant management and there was no need for further intervention. The success rate using the ultrasound criterion anteroposterior diameter < or = 15 mm was 51% (22/43), and with maximum sagittal plane area under 7.5 cm(2), 72% (31/43). Mean duration of vaginal haemorrhage was 9 days (minimum 2 days, maximum 14 days) and of lower abdominal pain 6 days (minimum 0 days, maximum 14 days). No patient recorded an axillary temperature exceeding 37 degrees C. No apparent relationship between the size of ultrasound-estimated intra-uterine content and duration of symptoms was observed.

CONCLUSIONS

Absence of gestational sac on transvaginal ultrasound should be the criterion used to document success after medical management of first-trimester missed abortion, as it is associated with the highest short and long-term success rates, as well as mild and self-limited symptoms in the days following treatment.

The International Confederation of Midwives' study of essential competencies of midwifery practice

OBJECTIVE

To delineate the knowledge, skills, and behaviours that would characterise the domain of competencies of the midwife who is educated according to the international definition of the profession.

DESIGN

Phase I: a qualitative Delphi study; Phase II: a descriptive survey research process.

PARTICIPANTS

A stratified random sample of member organisations of the International Confederation of Midwives (ICM) and regulatory representatives from these same countries.

FINDINGS

A list of basic (essential) and additional competencies for midwives who have been educated in keeping with the ICM/WHO/FIGO international definition of the midwife was developed through an interative Delphi process, and then affirmed, using a survey research method. The final list includes 214 individual task statements within six domains of midwifery practice.

IMPLICATIONS FOR PRACTICE

This list of competencies can serve as a basis for educational curriculum design, as a guideline for regulatory policy development, as a reference document for individual practitioners in an assessment of their initial and continued competency and by the ICM and its member associations as a resource for advocating for the role of midwifery within health-care systems world-wide.

Current challenges in the assessment and management of patients with bleeding in early pregnancy

Bleeding in early pregnancy occurs in approximately 20% of clinically diagnosed pregnancies. History and physical examination are unable to reliably determine the anatomical location of the pregnancy (ectopic or intrauterine) or whether or not the fetus is alive. Ultrasound is the best tool for assessing these clinical questions and it is increasingly being used in the ED. This article looks at some of the common ultrasound findings and discusses the management options for failed and ectopic pregnancies.