Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso trial.

OBJECTIVE: To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage. DESIGN: Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS). SETTING: Twenty-eight UK NHS early pregnancy units. SAMPLE: A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage. METHODS: Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets. MAIN OUTCOME MEASURES: Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs). RESULTS: For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management. CONCLUSIONS: The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage. TWEETABLE ABSTRACT: The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.

Donor oocyte conception and pregnancy complications: a systematic review and meta-analysis.

BACKGROUND: Observational studies showed that women with a donor oocyte (DO) pregnancy have an increased risk of pregnancy complications. OBJECTIVES: Systematic review and meta-analysis to compare pregnancy complications of DO pregnancy with autologous oocyte in vitro fertilisation (IVF), and whether DO pregnancy acts as an independent risk factor. SEARCH STRATEGY: Online searches of databases from 1 January 1980 to 31 January 2015 were performed using a set of relevant keywords. SELECTION CRITERIA: All studies comparing pregnancy complications of women with donor oocyte IVF and autologous oocyte IVF were included. DATA COLLECTION AND ANALYSIS: Data collected included demographics and pregnancy complications. Methodological quality assessment was performed using the Newcastle-Ottawa scale. Statistical analysis was performed using review manager 5.3 and stata 13.0. Meta-regression was performed for age. MAIN RESULTS: In total, 11 studies (n = 81 752) were included. Ten studies (n = 11 539) examined the primary outcome. The risk of developing hypertensive disorders in pregnancy was significantly higher for DO pregnancy (odds ratio, OR 3.92; 95% confidence interval, 95% CI 3.21-4.78). Further subgroup analysis for singleton and twin pregnancies showed that the risk was significantly higher for DO pregnancy in each group. Secondary outcomes including small for gestational age (OR 1.81), caesarean section (OR 2.71), and preterm delivery (OR 1.34) were significantly higher with DO pregnancy. Meta-regression for the covariate of age suggested that risk was independent of age. AUTHOR'S CONCLUSIONS: Donor oocyte pregnancy acts as an independent risk factor for pregnancy complications, including hypertensive disorders, small for gestational age, and preterm delivery. Women should be counselled carefully before undergoing DO-assisted conception. TWEETABLE ABSTRACT: Donor oocyte conception is an independent risk factor for obstetric complications.

Comparison of techniques used to deliver a deeply impacted fetal head at full dilation: a systematic review and meta-analysis.

BACKGROUND: Second-stage caesarean section with a deeply impacted fetal head is associated with maternal and neonatal complications. OBJECTIVES: Systematic review and meta-analysis to identify, appraise and synthesise existing evidence that evaluated various techniques of delivering a baby with a deeply impacted head at full-dilation caesarean section. The primary outcome was uterine extension and secondary outcomes were other maternal and neonatal morbidities. SEARCH STRATEGY: Online searches of MEDLINE (1946-January 2015), EMBASE (1950-January 2015), Web of Sciences (1950-2015), and the Cochrane Library databases were performed using a set of relevant keywords. SELECTION CRITERIA: All studies that compared the outcome of various techniques of delivering the baby's head at full-dilation caesarean section. DATA COLLECTION AND ANALYSIS: Methodological quality was assessed using the Newcastle-Ottawa scale. Data collected from each of the studies included variables on the participants, comparisons used, and feto-maternal outcomes. Meta-analysis was performed using review manager 5.3. MAIN RESULTS: In total, 12 studies were included. Six studies (n = 455) examined primary outcomes. Meta-analysis showed that the risks of uterine incision extension, infection, mean blood loss, and operative time were significantly higher with the push technique compared with the reverse breech extraction. The evidence to support the Patwardhan method and fetal pillow was inadequate. AUTHORS' CONCLUSIONS: Evidence gathered from observational studies suggests that reverse breech extraction is associated with significantly lower maternal risks compared with the push method. TWEETABLE ABSTRACT: Meta-analysis suggests reverse breech extraction during caesarean section to deliver impacted fetus is safer.

Accuracy of first-trimester ultrasound in the diagnosis of early embryonic demise: a systematic review.

OBJECTIVES: To evaluate, by systematic review of the literature, the accuracy of first-trimester ultrasound in diagnosing early embryonic demise. METHODS: We searched MEDLINE (1951-2011), Embase (1980-2011) and the Cochrane Library (2010) for relevant citations. The reference lists of all known primary and review articles were examined. Language restrictions were not applied. Studies which evaluated the accuracy of first-trimester ultrasonography in pregnant women for the diagnosis of early embryonic demise were selected in a two-stage process and their data extracted by two reviewers. Accuracy measures including sensitivity, specificity and likelihood ratios (LRs) for abnormal and normal test results were calculated for each study and for each test threshold. RESULTS: Eight primary articles with four test categories (18 2 × 2 tables), involving 872 women, evaluated the accuracy of ultrasound in diagnosing early embryonic demise. The lower limit of the 95% CI for specificity was > 0.95 in only two tests. These were an empty gestational sac with mean diameter of ≥ 25 mm and absent yolk sac with a mean gestational sac diameter of ≥ 20 mm (specificity, 1.00; 95% CI, 0.96-1.00 for both). CONCLUSIONS: There is a paucity of high-quality, prospective data on which to base guidelines for the accurate diagnosis of early pregnancy demise. The findings are limited by the small number of studies and patients, the age of the studies, inclusion of symptomatic and asymptomatic women and variable reference standards for diagnosis of early pregnancy demise. Before guidelines for the safe management of threatened miscarriage can be formulated, there is an urgent need for an appropriately powered, prospective study using current ultrasound technology and an agreed reference standard for pregnancy success or loss.