Applying reflective multicriteria decision analysis to understand the value of therapeutic alternatives in the management of gestational and peripartum anaemia in Spain.

BACKGROUND: The objective of the FeminFER project was to assess the value of ferric carboxymaltose following a multicriteria decision analysis in obstetrics and gynaecology in Spain. METHODS: Ferric carboxymaltose (FCM) and ferrous sulphate were evaluated using the EVIDEM framework. Ten stakeholders participated to collect different perspectives. The framework was adapted considering evidence retrieved with a PICO-S search strategy and grey literature. Criteria/subcriteria were weighted by level of relevance and an evidence-based decision-making exercise was developed in each criterion; weights and scores were combined to obtain the value of intervention relative to each criterion/subcriterion, that were further combined into the Modulated Relative Benefit-Risk Balance (MRBRB). RESULTS: The most important criterion favouring FCM was Compared Efficacy/Effectiveness (0.183 ± 0.07), followed by Patient Preferences (0.059 ± 0.10). Only Direct medical costs criterion favoured FS (-0.003 ± 0.03). MRBRB favoured FCM; 0.45 ± 0.19; in a scale from -1 to + 1. CONCLUSIONS: In conclusion, considering the several criteria involved in the decision-making process, participants agreed with the use of FCM according to its MRBRB.

Vaginal misoprostol and cervical ripening balloon for induction of labor in late-term pregnancies.

AIM: The aim of this study was to compare vaginal misoprostol with the Cook cervical ripening balloon (CCRB) for induction of labor in late-term nulliparous women. METHODS: This open, quasi-experimental, prospective study included 109 nulliparous women with late-term pregnancies and Bishop scores < 7. Fifty-five women were allocated to receive vaginal misoprostol 25 mcg and 54 received the CCRB to induce labor. The primary outcome was the time until delivery. Secondary outcomes included time to the onset of labor and obstetric and perinatal outcomes. RESULTS: Women in the misoprostol group experienced shorter time until delivery (25.41 h vs 31.26 h; P < 0.01) and in a greater percentage gave birth within the first 24 h. Time to active stage of labor was 19.5 h and 23.8 h (P < 0.01) for misoprostol and the CCRB, respectively. There were no differences in the rates of cesarean section or post-partum anemia. Additionally, there were no differences in rates of tachysystolia, intrapartum fever, or meconium. Perinatal outcomes, post-partum pH, Apgar scores, and neonatal admissions were similar in the two groups. CONCLUSION: Misoprostol 25 mcg reduces labor induction time compared with the CCRB with similar safety in late-term pregnancies.

What can we do to reduce the associated costs in induction of labour of intrauterine growth restriction foetuses at term? A cost-analysis study.

OBJECTIVE: To evaluate the costs associated with induction of labour in intrauterine growth restriction fetuses comparing different procedures. STUDY DESIGN: 150 pregnancies at term diagnosed with intrauterine growth restriction and indication for induction of labour were included. 24 were ripened with misoprostol 25 µg tablets, 24 with dinoprostone 10 mg vaginal insert, and 77 with Cook® cervical ripening balloon. To determine the costs of induction of labour, method of induction, intrapartum medication, epidural analgesia, type of delivery, and maternal and neonatal admissions were considered. Statistical analysis was performed using the G-Stat 2.0 free statistical software. ANOVA test was used for comparisons between quantitative parametric variables. Chi-squared test or Fisher test was used for qualitative variables. A value of p < 0.05 was considered statistically significant. RESULTS: Up to 70.83% women in dinoprostone group gave birth within the first 24 h compared to 42.66% in misoprostol group and 36.36% in CG (p < 0.01). Misoprostol tablets were cheaper (9.45 ± 1.52 US dollars) than dinoprostone or Cook® balloon (41.67 ± 0 and 59.85 ± 0 54.45 ± 0 US dollars, respectively) (p < 0.01). Costs related to maternal admissions were higher in CG (475.13 ± 146.95$) than dinoprostone group (475.13 ± 146.95$) or MG (427.97 ± 112.65$) (p = 0.03). Total costs in misoprostol group (2765.18 ± 495.38$) were lower than in the dinoprostone group (3075.774 ± 896.14$) or Cook® balloon group (3228.02 ± 902.06$) groups. CONCLUSIONS: Misoprostol for induction of labour had lower related costs than dinoprostone or Cook® balloon, with similar obstetrical and perinatal outcomes.

Efficacy and safety of misoprostol, dinoprostone and Cook's balloon for labour induction in women with foetal growth restriction at term.

BACKGROUND AND OBJECTIVES: To compare effectiveness and safety of dinoprostone, misoprostol and Cook's balloon as labour-inducing agents in women with intrauterine growth restriction (IUGR) at term. METHODS: Retrospective cohort chart review of women diagnosed with foetal growth restriction at term in Reina Sofia Hospital, Cordoba, Spain from January 2014 to December 2015. Registration of baseline characteristics and method of induction was made. The main outcome was time from induction to delivery. Obstetric and perinatal outcomes were also collected. RESULTS: A total of 99 women were diagnosed with IUGR in the mentioned period. Of them, 21 women were induced with dinoprostone [dinoprostone group (DG)], 20 with misoprostol (MG) and in 58 with Cook's balloon (CG). Groups were homogeneous regarding pre-induction Bishop score and parity. The CG required more time (24.36 vs. 19.23 h; p = 0.02) and more oxytocin dose for conduction of labour from induction to delivery (6.75 vs. 1.24 mUI; p < 0.01) than DG. Moreover, the CG also needed more oxytocin than MG, 6.75 vs. 2.37 mUI (p < 0.001). Caesarean rate was 5, 14.9 and 17.3% in MG, DG and CG, respectively. No differences were observed in rates of uterine tachysystole, non-reassuring foetal status and neonatal adverse events. INTERPRETATION AND CONCLUSIONS: Prostaglandins were more effective than Cook's balloon to induce labour and achieve vaginal birth in this sample of women with IUGR at term, with a similar safety profile.

Essure a novel option for the treatment of hydrosalpinx: a case series and literature review.

OBJECTIVE: The aim of this study is to evaluate the use of hysteroscopic Essure device placement for the treatment of hydrosalpinx (HS)-related infertility in patients with laparoscopic contraindications and compared their pregnancy outcomes following IVF-ICSI treatment with those patients having had laparoscopic tubal occlusion (LTO). PATIENTS: From 2008 to 2014 a total of 50 patients were diagnosed with unilateral or bilateral hydrosalpinges: 29 patients had laparoscopic contraindications and were treated hysteroscopically and 21 patients were treated with laparoscopical salpingectomy. RESULTS: Of the 29 patients who underwent treatment with Essure(®), 21 began a cycle of in vitro fertilization (IVF), and 13 finished in embryo transfer that resulted in seven clinical pregnancies. Furthermore, in the group of women treated with salpingectomy, 17 started an IVF cycle that resulted in 12 clinical pregnancies. The clinical pregnancy rate per patient with an IVF cycle started was 33.3% and 70.6%, the live-birth rate per patient was 14.3% and 52.9%, the miscarriage rate was 57.1% and 18.2%, and the implantation rate was 16.3% and 34.1% for hysteroscopy and laparoscopy, respectively. CONCLUSION: Essure(®) placement is an alternative method for occlusion of hydrosalpinges before IVF. Monitoring the live-birth rate confirms that this option may be considered when laparoscopy is impossible or contraindicated.

Luteal phase support with progesterone in intrauterine insemination: a prospective randomized study.

OBJECTIVE: To determine the effect of vaginal progesterone as luteal support on pregnancy outcomes in infertile patients who undergo ovulation induction with gonadotropins and intrauterine insemination (IUI). DESIGN: Prospective randomized trial. SETTING: Tertiary referral center. PATIENT(S): About 398 patients with primary infertility were treated during 893 ovarian stimulation and IUI cycles from February 2010 to September 2012. METHODS: All patients underwent ovarian stimulation with gonadotropins combined with IUI. Patients in the supported group received vaginal micronized progesterone capsules 200 mg once daily from the day after insemination until next menstruation or continuing for up to 8 weeks of pregnancy. Women allocated in the control group did not receive luteal phase support. MAIN OUTCOME MEASURE(S): Livebirth rate, clinical pregnancy rate and early miscarriage rate per cycle. RESULT(S): Of the 893 cycles, a total of 111 clinical pregnancies occurred. There were no significant differences between supported with progesterone and unsupported cycle in terms of livebirth rate (10.2% versus 8.3%, respectively, with a p value = 0.874) and clinical pregnancy rate (13.8% compared with 11.0% in unsupported cycle with a p value = 0.248). An early miscarriage rate of 3.6% was observed in the supported cycles and 2.7% in the unsupported cycles, with no significant differences between the groups (p value = 0.874). CONCLUSION(S): In infertile patients treated with mildly ovarian stimulation with recombinant gonadotropins and IUI, luteal phase support with vaginal progesterone is not associated with higher livebirth rate or clinical pregnancy rate compared with patients who did not receive any luteal phase support.

[Early diagnosis of cervix cancer: Correlation between cytology, colposcopy and biopsy]. / Diagnóstico precoz del cáncer de cérvix: correlación entre citología, colposcopia y biopsia.

OBJECTIVE: To determine the concordance between cytology, colposcopy and cervical biopsy in abnormal cytologies. MATERIAL AND METHODS: An observational cross-sectional, clinically based, single center study was performed. The selected population consisted of 416 women between the ages of 25 and 65 who had undergone colposcopy for abnormal cytologies at the Reina Sofía Hospital, Córdoba, between August 1st, 2014, and September 30th, 2016. Statistical analysis was performed using the Kappa index for the degree of concordance between cytology, colposcopy and biopsy. RESULTS: There was an insignificant concordance between cytology and colposcopy (k=0.16; 95% CI 0.09-0.22), a moderate concordance between colposcopy and biopsy (k=0.57; 95% CI 0.47-0.68) and an insignificant concordance between cytology and biopsy (k=0.21 (95% CI 0.08-0.34). CONCLUSIONS: Better concordance was found between colposcopy and biopsy than between either cytology and biopsy or cytology and colposcopy.