Treatment Of Miscarriage Research Articles

Reply: Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage

Reply: Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage

Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage

Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage

Management of Miscarriage: Expectant, Medical, or Surgical? Results of Randomised Controlled Trial (Miscarriage Treatment [MIST] Trial)

Management of Miscarriage: Expectant, Medical, or Surgical? Results of Randomised Controlled Trial (Miscarriage Treatment [MIST] Trial)

A randomized study comparing efficacy and patient satisfaction in medical or surgical treatment of miscarriage

To compare the efficacy of the medical treatment to surgical uterine evacuation and patient satisfaction in each group. A randomized, controlled study. An outpatient clinic in the Department of Gynecology and Obstetrics in Oulu University Hospital, Oulu, Finland. Ninety-eight eligible women who had had miscarriages. 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. The complete abortion rate with the primary treatment (primary outcome) and the patient satisfaction (secondary outcome). 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. 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.

Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage

Recurrent miscarriage (RM; > or =3 consecutive early pregnancy losses) affects around 1% of fertile couples. Parental chromosomal anomalies, maternal thrombophilic disorders and structural uterine anomalies have been directly associated with recurrent miscarriage; however, in the vast majority of cases the pathophysiology remains unknown. We have updated the ESHRE Special Interest Group for Early Pregnancy (SIGEP) protocol for the investigation and medical management of RM. Based on the data of recently published large randomized controlled trials (RCTs) and meta-analyses, we recommend that basic investigations of a couple presenting with recurrent miscarriage should include obstetric and family history, age, BMI and exposure to toxins, full blood count, antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibodies), parental karyotype, pelvic ultrasound and/or hysterosalpingogram. Other investigations should be limited to particular cases and/or used within research programmes. Tender loving care and health advice are the only interventions that do not require more RCTs. All other proposed therapies, which require more investigations, are of no proven benefit or are associated with more harm than good.

Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial)

Objective To ascertain whether a clinically important difference exists in the incidence of gynaecological infection between surgical management and expectant or medical management of miscarriage.Design Randomised controlled trial comparing medical...

1140918593 Altered expression of cell surface CD200 tolerance‐signaling molecule on human PBL stored at 4°C or 37°C correlates with reduced or increased efficacy in controlled trials of treatment of recurrent miscarriages

Problem: The CD200 molecule is required for prevention of abortions in mice by allogeneic lymphomyeloid cells bearing paternal antigen, and storage of at 4°C overnight causes loss of cell‐surface CD200 and loss of efficacy. Human PBL stored at 4°C overnight also lose CD200 and were ineffective in a randomized controlled trial RCT, odds ratio for live birth with stored cells = 0.55 (95% CI 0.27–1.14) versus 1.68 (95% CI 1.04–2.70) with freshly isolated PBL. A recent published RCT utilizing paternal PBL stored at 37°C overnight reported a dramatic reduction in abortion rate, odds ratio for live birth with treatment = 10.2 (95% CI 3.97–26.08). Does storage at 37°C increase expression of cell‐surface CD200?Methods: Hypaque‐ficoll‐purified human PBL were analysed by flow cytometry using PE‐anti‐huCD200 before and after storage in PBS for 18 hr at 4°C, 22°C, or 37°C.Results: Purified PBL stored at 4°C showed reduced expression of CD200, whereas at 37°C, CD200 expression was dramatically increased.Conclusions: The protective effect of paternal PBL against recurrent spontaneous abortion may be altered by storage conditions, and level of expression of cell‐surface CD200 appears to be a key correlate of efficacy.

First trimester threatened miscarriage treatment with human chorionic gonadotrophins: a randomised controlled trial

To determine whether administration of exogenous human chorionic gonadotrophin (hCG) treatment improve the pregnancy outcome in first trimester threatened miscarriages. A prospective, double blind, randomised, placebo-controlled trial. The Early Pregnancy Assessment Unit, Royal Bolton Hospital, Bolton, United Kingdom. One hundred and eighty-three women with vaginal bleeding and a viable fetus seen on ultrasound scan (USS) in the first 12 weeks of pregnancy. The patients were randomised to receive either hCG or placebo treatment until 14 weeks of gestation. The primary objective of the trial was to determine the miscarriage rate in the hCG arm compared from the placebo arm. Of the 183 cases, 87 were randomised to treatment with hCG while 96 were randomised to receive a placebo. Forty-seven (25%) did not comply with the study protocol. The mean [SD] gestational age at presentation was 7 [1.33] weeks. The mean [SD] age of women in study was 27 [5] years in the placebo and 28 [5] in the hCG group. The mean body mass index (kg/m(2)) was 25 [5] in the study. The number of patients actively bleeding per vaginum at presentation was 85 (93%) in placebo group and 79 (96%) in the hCG group. The median number of hCG or placebo injections for both groups was 7. Ten women (11%) in the placebo group proceeded to have a complete miscarriage, as did 10 women (12%) in the hCG group, relative risk (RR) [95% confidence interval (CI)] of 1.1 (0.63-1.6). Our study showed no evidence of a difference in the outcome of threatened miscarriages when treated with hCG in the first trimester, this may be because our study sample size was small and follow up was suboptimal. A large, randomised, multicentre trial is still needed to establish the usefulness of hCG treatment in cases of threatened miscarriage.

Long-term reproductive outcome subsequent to medical versus surgical treatment for miscarriage

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. 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. 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. 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.

Depression in women

Depression is the leading cause of disease-related disability in women. Epidemiological studies have shown that the lifetime prevalence of a major depressive disorder in women (21.3%) is almost twice that in men (12.7%). This ratio has been documented in different countries and ethnic groups. Sex differences relating to depression vary with age, with male and female children showing similar incidence rates. National comorbidity data reveal that sex differences in prevalence first appear around the age of 10 years and persist until midlife, after which they disappear. Therefore, women have the greatest risk for developing depressive disorders during their child-bearing years. Several biological processes are thought to be involved in the predisposition of women to depression, including genetically determined vulnerability, hormonal fluctuations related to various aspects of reproductive function, and an undue sensitivity to such hormonal fluctuations in brain systems that mediate depressive states. Psychosocial events such as role-stress, victimization, sex-specific socialization, internalization coping style, and disadvantaged social status have all been considered to be contributors to the increased vulnerability of women to depression. Women are more susceptible than men to stress-induced depression and to changes in photoperiod (more than 80% of individuals with seasonal affective disorder are women). Depression in women may develop during different phases of the reproductive cycle (premenstrual dysphoric disorder, depression during pregnancy, postpartum depressive conditions, and menopausal depression). Other reproductive events such as infertility, miscarriage, oral contraceptives, and hormone replacement treatment have been reported to cause depression in women.

Are national recommendations regarding examination and disposal of products of miscarriage being followed? A need for revised guidelines?

National guidance documents advise that tissue obtained from treatment of miscarriage should be submitted for histological examination to exclude trophoblastic disease and ectopic pregnancy, and require sensitive disposal of human tissue. The aim of this study was to determine the extent to which health professionals have adopted these recommendations. Fifteen Scottish Obstetric and Gynaecology services participated in an audit of early pregnancy loss care. Three audit tools were used. In a case note review, 484 women completed medical or surgical treatment for miscarriage. 71% of records contained evidence of histological examination of tissue. Documentation of discussion of disposal of tissue with the woman was found in 29% of records. In a patient survey, 648 women with threatened or confirmed miscarriage returned questionnaires. Active treatment occurred in 134 cases. Only 55%, 50.9% and 47.4% reported being 'informed', 'consented' and 'involved', respectively, with decisions about tissue disposal. In a staff survey, a postal questionnaire was administered to 224 gynaecologists, with 144 replies. Self reported practice as 'seldom' or 'occasional' for sending tissue for histological examination was 34% for surgical evacuation and 57% for medical management. Reporting of 'seldom' or 'occasional' discussion of disposal of tissue with the woman was 42% and 49% for surgical and medical treatment, respectively. National guidance on these issues was found to be contentious and implementation was variable. Wide consultation with stakeholders is needed prior to the publication of revised guidance.

Medicinal plant use in the practice of midwifery in rural Honduras

Midwives in rural communities across the globe play an important role as primary health care providers, but few studies have documented the medicinal plants employed in this age-old practice. Semi-structured interviews were conducted with 23 midwives in seven rural communities near La Ceiba, Honduras, regarding the plants they employ during the birthing process as well as their associated beliefs. Seventy-nine different plant species used to treat 15 conditions occurring during the pregnancy, birth and postpartum stages were recorded. Most plants and uses were reported by only one or two midwives, reflecting the fact that most midwives in this region had immigrated from different parts of the country. Almost all the midwives used or knew of plant remedies for treatment of miscarriages, postpartum abdominal pain and hemorrhages, retained placenta, and for speeding up contractions during labor. The most frequently cited plants as well as those for which there was greatest consensus tended to be widespread cultivated or weedy species. Although use of medicinal plants by midwives has decreased as a result of retraining programs by government health centers, midwives’ knowledge of medicinal plants may provide an important resource for improving maternal–infant health in Honduras and elsewhere. Suggestions for future ethnobotanical and ethnopharmacological studies on this topic are provided.

Diagnosis and Treatment of Recurrent Miscarriage Associated with Immunologic Disorders: Is Paternal Lymphocyte Immunization a Relic of the Past?

Miscarriage is the most common complication of human pregnancy. Although the causes of recurrent miscarriage (RM) are various, immunologic aberrations between mother and fetus might be one of the causes of miscarriage. Immune responses fall into two categories: autoimmune and alloimmune. Currently, no appropriate diagnostic method has been established to identify alloimmune causes. We observed that NK cell activity in women with RM was higher than that in women without a history of miscarriage. Functional or quantitative analysis of NK cells could be used to identify alloimmune causes. Paternal lymphocyte immunization has been the most widely used treatment for alloimmune-mediated miscarriages. However, the latest Cochrane review by Scott reached the current conclusion that lymphocyte immunization therapy provided no significant beneficial effect over placebo in preventing further miscarriage. Approximately 70% of Japanese university hospitals are still performing paternal lymphocyte immunization. Is paternal lymphocyte immunization a relic of the past? Randomized controlled trials based on adequate patient selection in Japan should provide an answer to this question.

Medical treatment of miscarriage in a district general hospital is safe and effective up to 12 weeks’ gestation

SUMMARYThe findings are reported of a retrospective study of 207 women undergoing medical evacuation of the uterus for first trimester miscarriage, using mifepristone followed by a single dose of oral misoprostol. All women had the diagnosis confirmed by ultrasonography. Complete medical evacuation was achieved in 88% of cases. Thesuccess rate and incidence of complications was observed to be the same regardless of whether gestation was below or above 9 weeks. The number of cases in which antibiotic treatment for presumed pelvic infection was prescribed was 3%. The incidence of anaemia requiring blood transfusion was 3%.

A randomized prospective study of misoprostol alone or combined with mifepristone for treatment of first trimester spontaneous abortion

Objective: It has not been determined whether in women with spontaneous miscarriage treatment with the PGE1 analogue misoprostol is more effective when it follows ingestion of the antiprogesterone mifepristone (RU486). Our aim was to compare the outcome of medical abortions with misoprostol alone versus misoprostol combined with mifepristone pretreatment.

Saint Petersburg centre of the unbearing pregnancy prophylactics and treatment, results of the scietific and practical activity

The results of the twelve-year work of the St. Petersburg Center for the Prevention and Treatment of Miscarriage (NB) have been summed up. During this time, 6755 women, 2856 pregnant women and 3899 non-pregnant women were observed at the Center. Women suffering from misdiagnosis received a comprehensive comprehensive examination, on the basis of which the prevention and treatment of NB was carried out. This made it possible for women with 1OO% loss of pregnancies in the past to achieve a decrease in the frequency of spontaneous abortions in 2OO1 to 7.6% and premature births to 2.7%.

Low-dose aspirin is effective for treatment of recurrent miscarriage in patients with decreased coagulation factor XII

We found that a decrease in values for coagulation factor XII but not protein C, protein S, antithrombin III, or factor XIII predict subsequent early miscarriage in patients with a history of first trimester recurrent miscarriages, although it is well known that women with familial thrombophilia have an increased risk of miscarriage (1). Because the main clinical feature in patients with factor XII deficiency is thrombosis rather than bleeding, low-dose aspirin would be expected to prevent first-trimester miscarriage. We therefore analyzed the effect of low-dose aspirin, with respect to various parameters and antiphospholipid antibodies (APL), on subsequent live birth.

Antiaggregant and anticoagulant therapy in systemic lupus erythematosus and Hughes' syndrome.

Antiaggregant and anticoagulant drugs are essential in the management of the manifestations due to antiphospholipid syndrome (APS) in patients with primary Hughes' syndrome or systemic lupus erythematosus. Coumadin derivatives (warfarin and acenocumarol), heparin and aspirin are used for secondary thromboprophylaxis and treatment of recurrent miscarriage. The available evidence for each indication is reviewed in this paper. There is still debate regarding the optimal intensity of oral anticoagulation, the best drug combination for pregnancy failure in APS and the management of asymptomatic patients with antiphospholipid antibodies.

Depression among postnatal women in an urban Irish community

AbstractObjectives:To estimate the prevalence of postnatal depression in a community sample of women in a disadvantaged urban area in West Dublin, and to examine the factors which may be associated with it.Method: All women who had a live birth in the area over a one year period were identified (944) and the self-rated Edinburgh Postnatal Depression Scale (EPDS) was distributed to those who could be contacted by the public health nurses. Those scoring in the depressed range (> 12) were compared to non-depressed for age, marital status, employment, parity, presence of a confidant, mode of delivery, previous miscarriage and previous psychiatric history.Results: Contact was made with 596 women and 377 responded. Responders were older and more likely to be first time mothers, but there was no significant difference between responders and eligible population for marital status. One hundred and eight women (28.6%) scored in the depressed range. Ten sociodemographic and clinical variables were entered into a logistic regression. Scores over the threshold (> 12), suggesting clinical depression, were significantly associated with four variables, lower age, absence of a confidant, previous miscarriage and previous treatment for depression by a GP.Conclusions: A high prevalence of postnatal depression of 28.6% was reported, which may be associated with overall high levels of social disadvantage in this sample. There were implications for the targeting of resources into such areas. The associated factors are discussed.

The treatment of incomplete miscarriage with oral misoprostol.

In a retrospective study of 112 women, the effectiveness of three sequential oral doses of misoprostol was evaluated for the treatment of incomplete miscarriage. We report our experience with this regimen, which achieved a complete miscarriage rate of 85%. Surgical intervention was required in 17 women (15%). The regimen appears to be effective in terms of a high rate of complete miscarriage, and it is safe.