The Success of Mifepristone and Misoprostol in the Management of Early Pregnancy Loss at a Community Hospital: A Prospective Study.

OBJECTIVES: This prospective single-arm study was conducted to understand the expulsion rate of the gestational sac in the management of early pregnancy loss (EPL). METHODS: We recruited 441 participants; 188 met the eligibility criteria. Participants were 18 years of age and older who experienced a confirmed EPL (<12 weeks gestational age) defined by an intrauterine pregnancy with a non-viable embryonic or anembryonic gestational sac with no fetal heart activity. Participants were given 200 mg of mifepristone pre-treatment orally followed by 2 doses of misoprostol 800 µg vaginally after 24 and 48 hours. Participants were seen in follow-up on day 14 to confirm the absence of a gestational sac, classified as treatment success. For failed treatment (defined by retained gestational sac), we offered expectant management or a third dose of misoprostol and/or dilatation and curettage. We followed all participants for 30 days. We collected data on overtreatment for retained products of conception and hospital admissions for adverse events. RESULTS: Overall, 181 participants followed the protocol and 169 (93.3%) participants had a complete expulsion of the gestational sac by the second visit (day 14). Twelve (6.6%) failed the treatment and 1 had an adverse event of heavy vaginal bleeding requiring dilatation and curettage. Despite the expulsion of the gestational sac, 29 cases (17.1%) at subsequent follow-up were diagnosed as retained products of conception based on ultrasound assessment of thickened endometrium. CONCLUSIONS: Pretreatment with mifepristone followed by 2 doses of misoprostol with a 14-day follow-up resulted in a high expulsion rate and is a safe management option for EPL.

Large Submucosal Uterine Leiomyoma Prolapse Into the Vagina After Complicating a Pregnancy: A Case Report.

Uterine leiomyomas are the most common pelvic neoplasm in females. They are non-cancerous monoclonal tumors that develop from the fibroblasts and smooth muscle cells of the myometrium. They can develop in females of reproductive age and post-menopausal as well. When symptomatic, they frequently manifest as abnormal uterine bleeding and/or pelvic pain or pressure. Reproductive effects are also possible in fibroids such as infertility and poor pregnancy outcomes. In this report, we present a case of a 39-year-old woman, G9P4A4, GA 16 weeks who came to the ER with an incomplete abortion at home after which she had large multiple uterine submucosal fibroids prolapsing into the vagina. On ultrasound, the placenta was still inside, and a large submucosal anterior uterine fibroid and a posterior uterine fibroid were found with sizes 10x10 cm and 2x3, respectively. Evacuation and curettage (E&C) could not be completed because fibroids were obstructing and limiting the access. The patient was managed medically and then discharged, after which she came back with prolapsing uterine fibroids and part of the placenta. In the end, she was managed by hysteroscopic myomectomy.

Proceso de implementación de una iniciativa de atención a mujeres en postaborto en Chile, 2016-2020 / The implementation process of a post-abortion healthcare initiative in Chile, 2016-2020

Objetivo: Analizar el proceso de implementación de una iniciativa de calidad de atención en el postaborto en tres hospitales de Santiago de Chile para su posterior escalamiento al ámbito nacional. Método: Se efectuó un estudio cualitativo, con base en una revisión documental sustentada en documentos normativos emitidos por el Ministerio de Salud y 23 entrevistas semiestructuradas a tomadores de decisiones, profesionales de salud y usuarias. Se realizó un análisis de contenido usando el programa Atlas-ti 8. Resultados: A nivel normativo, se identificaron acciones relacionadas con la implementación de la iniciativa, y a nivel de proceso se identificaron los aciertos, las dificultades y las resistencias que experimentaron los equipos involucrados en el piloto durante su implementación. A pesar de que la implementación de la iniciativa no fue planificada, tuvo efectos positivos para el bienestar de las mujeres y el desempeño de los profesionales de atención implicados en el proceso. Conclusiones: Esta experiencia es un punto de partida para planear la implementación nacional con base en estrategias bien definidas. Los resultados aportan una experiencia documentada para quienes desean desarrollar iniciativas o programas de atención a mujeres en situación de postaborto.

Objective: To analyze the implementation process of a quality post-abortion care initiative in three hospitals in Santiago de Chile for its subsequent scale up at the national level. Method: A qualitative study was carried out, based on a documentary review supported by governmental normative documents issued by the Ministry of Health and 23 semi-structured interviews with decision-makers, health providers and users. Content analysis was performed using the Atlas-ti 8 software. Results: At the regulatory level, actions related to the implementation of the initiative were identified, and at the process level, the success, difficulties and resistance experienced by the teams involved in the pilot during its implementation were identified. Although the implementation of the initiative was not planned, it had positive effects on the well-being of the women and the performance of the care providers involved in the process. Conclusions: This experience is a starting point to plan implementation at the national level with well-defined strategies. Our results provide a documented experience for those who wish to develop post-abortion care initiatives or programs.

Manejo conservador de retención de productos de la concepción con anticonceptivos orales combinados / Conservative Management of Retained Products of Conception with Combined Oral Contraceptives. Case Report

Objetivo: presentar el caso de una paciente con retención de productos de la concepción (RPC) después de aborto médico, tratada con anticonceptivos orales combinados (ACOC), y efectuar revisión de la literatura. Caso Clínico: paciente de 37 años, con sangrado genital escaso y leve dolor pélvico, quien tuvo aborto provocado con misoprostol cuatro días antes, acude sin signos de infección, con endometrio mixto de 18,5 mm. Durante seis semanas de seguimiento persiste sangrado y endometrio mixto engrosado, con disminución lenta de la gonadotrofina corionica humana (GCH); se sospecha RPC, se suministra ciclo de ACOC y al terminarlos expulsa completamente el tejido retenido. Metodología: búsqueda bibliográfica en bases de datos Google Scholar, Science Direct, RIMA, PubMed. Revisión de literatura: la RPC se presenta después de parto o aborto (más frecuente). Criterios diagnósticos: sangrado persistente, hallazgos ecográficos y medición de GCH. Diagnóstico diferencial: enfermedad trofoblastica gestacional y malformaciones arteriovenosas uterinas. Es factible el manejo conservador, con bajas tasas de infección o procedimientos quirúrgicos. Ante la evolución prolongada, presencia de signos de infección o hemorragia importante, se impone la evacuación quirúrgica, tradicionalmente con dilatación y legrado, y más recientemente resección histeroscópica. La bibliografía reciente sugiere el uso de ACOC como manejo médico. En nuestro caso, la paciente tomó un ciclo de ACOC y al terminarlos presentó expulsión de los restos retenidos. Conclusiones: el manejo conservador de la RPC con ACOC surge como una opción en casos seleccionados; son necesarios estudios controlados para definir su utilidad..Au

Objective: to report the case of a patient with retained products of conception (RPC) after a medical abortion, successfully treated with combined oral contraceptives (COCs), and to review the literature. Clinical case: a 37-year-old patient, with little genital bleeding and slight pelvic pain, who had had a misoprostol-induced abortion four days before consulting, she attended without signs of infection, with a thikened 18.5 mm mixed endometrium. After six weeks follow-up genital bleeding and thickened mixed endometrium persist, with a slow decrease in human chorionic gonadotropin (HCG), RPC is suspected, and a COC cycle is administered, when finished, she completely expelled the retained tissue. Methodology: Google Scholar, Science Direct, RIMA and PubMed databases were searched. Literature review: RPC occurs after delivery or abortion (more frequent), diagnostic criteria: persistent bleeding, ultrasound findings and HCG measurement; the differential diagnosis includes gestational trophoblastic disease and uterine arteriovenous malformations. Conservative management is feasible, with low rates of infection or surgical procedures, however, in case of prolonged evolution, evident signs of infection or significant bleeding, surgical evacuation is required, traditionally with dilation and curettage, and more recently hysteroscopic resection. Novel bibliography suggests the use of ACOC as medical management. In our case, the patient took a cycle of COC and at the end she expelled the retained remains. Conclusions: conservative management of RPC with COC arises as an option in selected cases, controlled trails are needed to define its usefulness..Au

Controversias en el tratamiento del aborto incompleto: AMEU versus tratamiento médico con misoprostol

El aborto incompleto no complicado es una de las emergencias obstétricas más frecuentes que llegan a nuestros establecimientos de salud, ocasionando altos costos en su atención. Existen en la actualidad dos métodos modernos para su manejo: la aspiración manual endouterina (AMEU) y el tratamiento médico con misoprostol, ambos hacen posible el manejo ambulatorio del aborto incompleto, la reducción de los costos para el sistema de salud, y además se brindan dentro de un respeto a los derechos de las mujeres. Se analizan las controversias entre ambas tecnologías y se concluye que tanto el AMEU como el tratamiento con misoprostol son tecnologías modernas que tienen su aplicación dentro de los servicios de ginecología y obstetricia de nuestro país, con la misma seguridad y efectividad por la evidencia que muchos estudios realizados a la fecha nos presentan. Ambas tecnologías deben manejarse dentro de un modelo de atención basado en el respeto a los derechos de las mujeres.

Non-complicated incomplete abortion is one of the most frequent obstetric emergencies in our health facilities, causing high care costs. There are two current modern methods for its attention: manual vacuum aspiration (MVA) and medical treatment with misoprostol, both with the possibility of outpatient management, reducing costs to the health system. Controversies between the two technologies are analyzed and it is concluded that both MVA and misoprostol treatments are modern technologies applicable in gynecology and obstetrics services in our country, with same safety and effectiveness by evidence of many studies conducted.

Pesquisa sobre o aborto no Brasil: avanços e desafios para o campo da saúde coletiva: [revisão] / Research on abortion in Brazil: gaps and challenges for the public health field: [review]

O texto apresenta um panorama dos estudos sobre aborto no país, no campo da Saúde Coletiva, apontando lacunas e desafios para a investigação. A maioria das pesquisas está concentrada em hospitais públicos, com mulheres admitidas para tratamento do aborto incompleto, restringindo-se portanto aos abortos que apresentaram complicações. Descrevem o perfil das mulheres, métodos e razões para o aborto e conseqüências imediatas para a saúde física. Entretanto, permanecem limites relacionados à necessidade de estudos para mensuração da incidência do aborto; para investigação das especificidades dos óbitos por aborto e casos de morbidade grave; para análise da relação do aborto com anticoncepção; para investigação das repercussões do aborto na saúde mental das mulheres e para incorporação da perspectiva masculina. É urgente o desenvolvimento de pesquisas de avaliação da atenção ao aborto nos serviços públicos. Os resultados dos estudos devem ser divulgados, contribuindo para superar a visão ideologizada da discussão do direito ao aborto no país.

This paper provides a review of abortion studies produced in the field of public health in Brazil, highlighting current research gaps and challenges. Most studies focus on women admitted to public hospitals for treatment of incomplete abortion, so their scope is limited to abortions presenting complications. Women's profiles, abortion methods, motives, and immediate consequences for women's physical health are also included. However, there remains a need for studies on the following aspects: measuring abortion incidence; investigating cases of post-abortion complications and death; analyzing the relationship between abortion and contraception; investigating the impact of abortion on women's mental health; and incorporating men's perspectives. There is an urgent need for evaluative research on abortion care in public services. Research results should be disseminated widely, so as to help overcome any ideological bias in the current debate on abortion rights in the country.

Prevalence of uterine synechia after abortion evacuation curettage

CONTEXT AND OBJECTIVE: Intrauterine adhesion (IUA) is a possible complication of uterine curettage following abortion. Because IUA is an important cause of infertility, some investigators have been advocating its inclusion in the routine investigational workup after every abortion curettage procedure. The aim of this study was to evaluate the uterine cavity of patients subjected to abortion curettage, in order to ascertain the prevalence of IUA and its association with social and clinical factors. DESIGN AND SETTING: This was a cross-sectional study at the Human Reproduction Unit, Department of Obstetrics and Gynecology, Universidade Estadual de Campinas (Unicamp). METHODS: A total of 109 women were enrolled. The investigators searched the records of Unicamp's hospital for patients who had been subjected to uterine curettage following abortion. The hysteroscopy was performed 3 to 12 months after the curettage. The correlations between patients' characteristics and the prevalence of IUA were assessed by means of chi-squared and Fisher's exact test calculations. RESULTS: The prevalence of IUA was 37.6 percent. The number of previous abortions and curettage procedures did not correlate with the presence of IUA. Most of the women (56.1 percent) presented IUA grade I. CONCLUSIONS: In the present study, 37.6 percent of the women subjected to curettage following abortion had IUA, which was mostly mucous and grade I. None of the demographic and clinic characteristics evaluated were found to be associated with IUA. From this study, there is no firm evidence to justify carrying out routine diagnostic hysteroscopy following abortion evacuation.

CONTEXTO E OBJETIVO: As sinéquias uterinas são complicações que podem ocorrer após curetagem uterina por aborto. Como se trata de causa importante de infertilidade, muitos autores têm indicado uma investigação rotineira após curetagens uterinas por aborto. O objetivo do estudo foi avaliar a cavidade uterina de pacientes submetidas a curetagem após aborto para detectar a prevalência das sinéquias e a possível associação com alguns fatores sociais e clínicos. TIPO DE ESTUDO E LOCAL: Estudo de corte transversal, realizado na Unidade de Reprodução Humana do Departamento de Ginecologia e Obstetrícia da Universidade Estadual de Campinas (Unicamp). MÉTODOS: 109 mulheres foram submetidas a histeroscopia diagnóstica ambulatorial 3 a 12 meses após curetagem por aborto. Dados clínicos foram obtidos dos prontuários médicos. As correlações entre as características clínicas e a prevalência de sinéquias uterinas foram testadas através do cálculo do qui-quadrado e do teste exato de Fisher. RESULTADOS: A prevalência de sinéquias foi de 37,6 por cento. O número de abortos anteriores e de curetagens não se correlacionou com a presença de sinéquias. A maioria das mulheres (56,1 por cento) apresentou sinéquias grau I. CONCLUSÕES: Neste estudo, 37,6 por cento das mulheres submetidas a curetagem por aborto apresentaram sinéquias, a maioria delas do tipo mucoso e de grau I. Nenhuma das características clínicas e demográficas avaliadas associou-se às sinéquias. Os resultados deste estudo não autorizam indicação rotineira de histeroscopia diagnóstica em pacientes submetidas a curetagem uterina por aborto.