Methods for the induction of labor: efficacy and safety.

This review assessed the efficacy and safety of pharmacologic agents (prostaglandins, oxytocin, mifepristone, hyaluronidase, and nitric oxide donors) and mechanical methods (single- and double-balloon catheters, laminaria, membrane stripping, and amniotomy) and those generally considered under the rubric of complementary medicine (castor oil, nipple stimulation, sexual intercourse, herbal medicine, and acupuncture). A substantial body of published reports, including 2 large network meta-analyses, support the safety and efficacy of misoprostol (PGE1) when used for cervical ripening and labor induction. Misoprostol administered vaginally at doses of 50 µg has the highest probability of achieving vaginal delivery within 24 hours. Regardless of dosing, route, and schedule of administration, when used for cervical ripening and labor induction, prostaglandin E2 seems to have similar efficacy in decreasing cesarean delivery rates. Globally, although oxytocin represents the most widely used pharmacologic agent for labor induction, its effectiveness is highly dependent on parity and cervical status. Oxytocin is more effective than expectant management in inducing labor, and the efficacy of oxytocin is enhanced when combined with amniotomy. However, prostaglandins administered vaginally or intracervically are more effective in inducing labor than oxytocin. A single 200-mg oral tablet of mifepristone seems to represent the lowest effective dose for cervical ripening. The bulk of the literature assessing relaxin suggests this agent has limited benefit when used for this indication. Although intracervical injection of hyaluronidase may cause cervical ripening, the need for intracervical administration has limited the use of this agent. Concerning the vaginal administration of nitric oxide donors, including isosorbide mononitrate, isosorbide, nitroglycerin, and sodium nitroprusside, the higher incidence of side effects with these agents has limited their use. A synthetic hygroscopic cervical dilator has been found to be effective for preinduction cervical ripening. Although a pharmacologic agent may be administered after the use of the synthetic hygroscopic dilator, in an attempt to reduce the interval to vaginal delivery, concomitant use of mechanical and pharmacologic methods is being explored. Combining the use of a single-balloon catheter with dinoprostone, misoprostol, or oxytocin enhances the efficacy of these pharmacologic agents in cervical ripening and labor induction. The efficacy of single- and double-balloon catheters in cervical ripening and labor induction seems similar. To date, the combination of misoprostol with an intracervical catheter seems to be the best approach when balancing delivery times with safety. Although complementary methods are occasionally used by patients, given the lack of data documenting their efficacy and safety, these methods are rarely used in hospital settings.

Investigating the prilling/vibration technique to produce gastric-directed drug delivery systems for misoprostol.

Prilling/vibration technique to produce oral microcapsules was explored to achieve local delivery of misoprostol (MIS), a prostaglandin E1 analogue indicated for the treatment of gastric-duodenal ulcers, at the gastric mucosa. To improve MIS chemical stability and reduce its associated systemic side effects, drug delivery systems were designed and developed as microcapsules consisting of a core of sunflower oil and MIS (Fs6 and Fs14) or a MIS complex with hydroxypropyl-beta-cyclodextrin (HP-ß-CD) (Fs18), confirmed by specific studies, and a polymeric shell. The produced microcapsules showed high encapsulation efficiencies for those with MIS solubilized in sunflower oil (>59.86 %) and for the microcapsules with MIS/HP-ß-CD (97.61 %). To demonstrate the ability of these systems to deliver MIS into the stomach, swelling and drug release experiments were also conducted in simulated gastric fluid. Among the three formulations, FS18 showed gastric release within 30 min and was the most advantageous formulation because the presence of the MIS/HP-ß-CD inclusion complex ensured a greater ability to stabilise MIS in the simulated gastric environment. In addition, these new systems have a small size (<540 µm), and good flow properties and the dose of the drug could be easily adapted using different amounts of microcapsules (flexibility), making them a passepartout for different age population groups.

Perceptions and experiences of the prevention, detection, and management of postpartum haemorrhage: a qualitative evidence synthesis.

BACKGROUND: Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent complications of PPH with timely and appropriate detection and management. However, implementing the best methods of PPH prevention, detection and management can be challenging, particularly in low- and middle-income countries. OBJECTIVES: Our overall objective was to explore the perceptions and experiences of women, community members, lay health workers, and skilled healthcare providers who have experience with PPH or with preventing, detecting, and managing PPH, in community or health facility settings. SEARCH METHODS: We searched MEDLINE, CINAHL, Scopus, and grey literature on 13 November 2022 with no language restrictions. We then performed reference checking and forward citation searching of the included studies. SELECTION CRITERIA: We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored perceptions and experiences of PPH prevention, detection, and management among women, community members, traditional birth attendants, healthcare providers, and managers. DATA COLLECTION AND ANALYSIS: We used three-stage maximum variation sampling to ensure diversity in terms of relevance of the study to the review objectives, richness of data, and coverage of critical contextual elements: setting (region, country income level), perspective (type of participant), and topic (prevention, detection, management). We extracted data using a data extraction form designed for this review. We used thematic synthesis to analyse and synthesise the evidence, and we used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. To identify factors that may influence intervention implementation, we mapped each review finding to the Theoretical Domains Framework (TDF) and the Capability, Motivation, and Opportunity model of Behaviour change (COM-B). We used the Behaviour Change Wheel to explore implications for practice. MAIN RESULTS: We included 67 studies and sampled 43 studies for our analysis. Most were from low- or middle-income countries (33 studies), and most included the perspectives of women and health workers. We downgraded our confidence in several findings from high confidence to moderate, low, or very-low confidence, mainly due to concerns about how the studies were conducted (methodological limitations) or concerns about missing important perspectives from some types of participants or in some settings (relevance). In many communities, bleeding during and after childbirth is considered "normal" and necessary to expel "impurities" and restore and cleanse the woman's body after pregnancy and birth (moderate confidence). In some communities, people have misconceptions about causes of PPH or believe that PPH is caused by supernatural powers or evil spirits that punish women for ignoring or disobeying social rules or for past mistakes (high confidence). For women who give birth at home or in the community, female family members or traditional birth attendants are the first to recognise excess bleeding after birth (high confidence). Family members typically take the decision of whether and when to seek care if PPH is suspected, and these family members are often influenced by trusted traditional birth attendants or community midwives (high confidence). If PPH is identified for women birthing at home or in the community, decision-making about the subsequent referral and care pathway can be multifaceted and complex (high confidence). First responders to PPH are not always skilled or trained healthcare providers (high confidence). In health facilities, midwives may consider it easy to implement visual estimation of blood loss with a kidney dish or under-pad, but difficult to accurately interpret the amount of blood loss (very low confidence). Quantifying (rather than estimating) blood loss may be a complex and contentious change of practice for health workers (low confidence). Women who gave birth in health facilities and experienced PPH described it as painful, embarrassing, and traumatic. Partners or other family members also found the experience stressful. While some women were dissatisfied with their level of involvement in decision-making for PPH management, others felt health workers were best placed to make decisions (moderate confidence). Inconsistent availability of resources (drugs, medical supplies, blood) causes delays in the timely management of PPH (high confidence). There is limited availability of misoprostol in the community owing to stockouts, poor supply systems, and the difficulty of navigating misoprostol procurement for community health workers (moderate confidence). Health workers described working on the maternity ward as stressful and intense due to short staffing, long shifts, and the unpredictability of emergencies. Exhausted and overwhelmed staff may be unable to appropriately monitor all women, particularly when multiple women are giving birth simultaneously or on the floor of the health facility; this could lead to delays in detecting PPH (moderate confidence). Inadequate staffing, high turnover of skilled health workers, and appointment of lower-level cadres of health workers are key challenges to the provision of quality PPH care (high confidence). Through team-based simulation training, health workers of different cadres (doctors, midwives, lay health workers) can develop a shared mental model to help them work quickly, efficiently, and amicably as a team when managing women with PPH (moderate confidence). AUTHORS' CONCLUSIONS: Our findings highlight how improving PPH prevention, detection, and management is underpinned by a complex system of interacting roles and behaviours (community, women, health workers of different types and with different experiences). Multiple individual, sociocultural, and environmental factors influence the decisions and behaviours of women, families, communities, health workers, and managers. It is crucial to consider the broader health and social systems when designing and implementing PPH interventions to change or influence these behaviours. We have developed a set of prompts that may help programme managers, policymakers, researchers, and other key stakeholders to identify and address factors that affect implementation and scale-up of interventions to improve PPH prevention, detection, and management.

Toxicities of herbal abortifacients.

BACKGROUND: In the post-Roe era, barriers to facility-based abortions may lead to an increased incidence of self-managed abortions. While misoprostol-based medication abortions have significant literature supporting its safety profile, there is a knowledge deficit within the medical community regarding the toxicities of commonly used herbal abortifacients. METHODS: This is a narrative review, based on a MEDLINE and HOLLIS database search, of self-managed abortion methods with herbal abortifacients and their associated toxicities. RESULTS: Common herbal abortifacients with significant morbidity and mortality implications include pennyroyal, blue cohosh, rue, and quinine. Other commonly reported abortifacients considered to be less toxic also are discussed in brief. Special considerations for hepatic, cardiac, renal, and hematologic toxicities are important in patients with significant exposures to these herbal substances. CONCLUSION: There is an anticipated increase in the utility of herbal xenobiotics for self-managed abortions with post-Roe restrictions to standard mifepristone-misoprostol protocols. Frontline providers should be aware of the associated toxicities and have special considerations when treating a poisoned patient in this population.

In-country availability of medical abortion medicines: a description of the framework and methodology of the WHO landscape assessments.

BACKGROUND: Availability of quality-assured medical abortion medicines plays a crucial role in providing comprehensive abortion care. However, access to these medicines is still restricted for many abortion seekers. Increasing availability of affordable, quality-assured mifepristone and misoprostol is important to improve access to safe medical abortion services. Driven by the outcomes of a global consultation hosted by the World Health Organization and the Swedish International Development Cooperation Agency in 2018, we decided to holistically examine access to medical abortion medicines from supply to demand. The overarching principle of the national landscape assessments was to generate evidence to support policy dialog and policymaking that is contextual to the needs of the country. This paper aims to describe the framework and methodological approach used in the World Health Organization landscape assessments of medical abortion medicines at country-level. METHODS: A country assessment protocol was developed to guide the methodology of the World Health Organization landscape assessments. The assessment protocol included adaptation of an existing availability framework, an online desk review and literature review for existing data available for the country of interest, country-level key informant interviews, and analysis of the data to identify barriers and opportunities to improve medical abortion availability. CONCLUSION: The availability framework and methodology will allow the identification of key barriers that limit readiness of medical abortion medicines, and the development of opportunities to overcome those barriers. The national landscape assessments will provide directions for future investments and offer guidance for policy and programming on medical abortion care.

Increasing availability of affordable, safe, and effective medical abortion medicines is necessary to improve access to safe medical abortion services. Driven by the results of a meeting hosted by the World Health Organization and the Swedish International Development Cooperation Agency in 2018, we decided to examine access to medical abortion medicines from supply to demand in selected countries. The overarching goal of the national landscape assessments was to generate evidence to support advocacy efforts and policymaking that is appropriate to the needs of the country. This paper aims to describe the assessment protocol and the steps taken in the World Health Organization landscape assessments of medical abortion medicines at country-level. The assessment allows for a determination of the enabling environment surrounding the provision of medical abortion services. This in turn allows for the identification of key barriers that limit availability of abortion medicines, and the identification of opportunities to overcome those barriers. The availability framework includes both supply and demand sides of commodity availability, considering factors from product introduction to use. This approach can be used for future national assessments for any health commodity or service. The assessment findings will be informative to policymakers and programme managers in developing plans to safeguard availability of safe and effective medical abortion medicines.

Integrative transcriptomics and proteomics analyses to reveal the therapeutic effect and mechanism of Buxue Yimu Pills in medical-induced incomplete abortion rats.

ETHNOPHARMACOLOGICAL RELEVANCE: Medical abortions using mifepristone and misoprostol have been approved in many countries for early pregnancy loss. Despite its high success rate, this medication regimen can result in incomplete abortion, which is responsible for endometrial damage, prolonged uterine bleeding, abdominal pain, etc. Buxue Yimu Pills (BYP) is a famous Chinese medicine prescription that is widely used in the field of gynecology and obstetrics for treating patients with postpartum complications. However, the therapeutic effect and mechanism of BYP remain to be explored. AIM OF THE STUDY: This study aimed to clarify the therapeutic effect and mechanism of action of BYP in postpartum complications using mifepristone and misoprostol-induced incomplete abortion in rats. MATERIALS AND METHODS: Experimental medical-induced incomplete abortion model rats were constructed using mifepristone and misoprostol, and further treated with saline or BYP by intragastric administration. Detailed information regarding the changes in mRNA and protein levels in the uterine tissues of rats regulated by BYP was illustrated by RNA sequencing (RNA-seq) analysis and quantitative proteomics analysis. The differentially expressed genes and proteins were further subjected to Gene Ontology (GO) and pathway enrichment analyses and further verified using quantitative Real-time PCR (qRT-PCR) analysis and western blot assay. RESULTS: BYP administration markedly alleviated the increase in serum prostaglandin F2α (PGF2α) and expression of PGF2α receptor (PGF2αR) in uterine tissues and inhibited the decrease in serum chorionic gonadotrophin (CG). Compared with the model group, 674 genes were upregulated and 344 genes were downregulated by BYP administration; 108 proteins were upregulated and 48 proteins were downregulated by BYP administration. qRT-PCR analysis of the uterine tissues showed that BYP treatment reversed the variation tendency of genes, including Mmp7, Mmp14, Timp2, Col6a4, Jak2, Wnt7a, and Mylk compared with the model group. Western blot analysis showed that BYP administration affected PKCδ, Collagen VI, MMP7, TIMP2, MLCK, and p-MLC protein levels. CONCLUSION: BYP administration facilitated uterine recovery in medical-induced incomplete abortion rats, and this therapeutic effect involved various targets and biological processes, including the TIMP2/MMP7 and MLCK/p-MLC signaling pathways, etc.

Effect Of The Flavonoid 6-Aminoflavone In Aspirin Induced Gastric Ulcer In Sprague-Dawely Rats: A Histomorphological Study.

Background: The analgesic drugs are the main cause of gastric ulcer. The objective of this study was to determine the gastroprotective ability of flavonoid, 6-aminoflavone in a rat pyloric ligation model of aspirin associated gastro-ulcerogenesis. Methods: A laboratory based experimental study was conducted in the animal house and research laboratory at Khyber Medical College, Peshawar from July to November 2019. A total of 42 adult male Spargue-Dawely rats were divided into seven groups. Flavonoid, 6-aminoflavone was administered orally in doses of 10, 25 and 100 mg/kg with misoprostol, as standard at 50 µg/kg orally for 4 days. On the last day aspirin was given orally at 200 mg/kg and the pyloric ligation surgery was performed. After 4 hours all animals were killed by cervical dislocation. The gastric tissues were collected for histomorphological study. The obtained data were expressed as mean±SEM. Analysis was carried out by using ANOVA. p value ˂0.05 was considered significant. Results: The animals treated with the different doses of 6-aminoflavone showed a marked protective effect in the histological observations. The 10 mg/kg dose had a mild protective effect as occasional ulcerative changes were observed. However, doses of 25 and 100 mg/kg significantly caused the reduction in the ulcer score. These effects produced were equipotent to the gastroprotective effectiveness inherent in the misoprostol. . Conclusion: These findings conclude that 6-aminoflavone as like other flavonoids has a significant gastroprotective propensity with significant effect produced at doses of 25 and 100 mg/kg and can be used as a part of therapy management for the treatment of gastrointestinal disease particularly ulcerative condition.

Evaluating women's acceptability of treatment of incomplete second trimester abortion using misoprostol provided by midwives compared with physicians: a mixed methods study.

BACKGROUND: Studies evaluating task sharing in postabortion care have mainly focused on women in first trimester and many lack a qualitative component. We aimed to evaluate patient acceptability of treatment of incomplete second trimester abortion using misoprostol provided by midwives compared with physicians and also gained a deeper understanding of the patients' lived treatment experiences in Uganda. METHODS: Our mixed methods study combined 1140 structured interview data from a randomized controlled equivalence trial and in-depth interviews (n = 28) among women managed with misoprostol for second trimester incomplete abortion at 14 public health facilities in Uganda. Acceptability, our main outcome, was measured at the 14-day follow-up visit using a structured questionnaire as a composite variable of: 1) treatment experience (as expected/ better than expected/ worse than expected), and 2) satisfaction - if patient would recommend the treatment to a friend or choose the method again. We used generalized mixed effects models to obtain the risk difference in acceptable post abortion care between midwife and physician groups. We used inductive content analysis for qualitative data. RESULTS: From 14th August 2018 to 16th November 2021, we assessed 7190 women for eligibility and randomized 1191 (593 to midwife and 598 to physician). We successfully followed up 1140 women and 1071 (94%) found the treatment acceptable. The adjusted risk difference was 1.2% (95% CI, - 1.2 to 3.6%) between the two groups, and within our predefined equivalence range of - 5 to + 5%. Treatment success and feeling calm and safe after treatment enhanced acceptability while experience of side effects and worrying bleeding patterns reduced satisfaction. CONCLUSIONS: Misoprostol treatment of uncomplicated second trimester incomplete abortion was equally and highly acceptable to women when care was provided by midwives compared with physicians. In settings that lack adequate staffing levels of physicians or where midwives are available to provide misoprostol, task sharing second trimester medical PAC with midwives increases patient's access to postabortion care services. TRIAL REGISTRATION: ClinicalTrials.gov NCT03622073.

Approximately 9.6% of abortion-related deaths occur in Sub-Saharan Africa. These deaths can be prevented if unintended pregnancies are avoided, women can access safe abortions within the expectations of the country's laws, and post abortion care (PAC) services are provided equitably. Previous research shows that women with abortion complications in the first trimester of pregnancy can be treated with misoprostol by either midwives or physicians. This sharing of tasks between the midwives and physicians is safe, effective, and acceptable. However, there is a gap in evidence on task sharing in the second trimester. To check practicability of task sharing in second trimester, we aimed to evaluate patient acceptability of treatment of incomplete second trimester abortion using misoprostol provided by midwives compared with physicians and also gained a deeper understanding of the patients' lived treatment experiences. Our study therefore combined quantitative and qualitative approaches. Women's acceptability of misoprostol treatment for incomplete second trimester abortion was found to be equally acceptable when provided by midwives compared with physicians. Treatment success, feeling calm and safe after treatment increased acceptability, while experience of side effects and worrying bleeding patterns reduced satisfaction. Counselling of women may address some of these problems since it provides reassurance and reduces anxiety. In settings that lack adequate staffing levels of physicians or where midwives are available to provide misoprostol, task sharing second trimester medical PAC with midwives increases patient's access to PAC services.

[Simultaneous determination and pharmacokinetic study of five compounds from total extract of Clinopodium chinense in abnormal uterine bleeding rat plasma by UPLC-MS/MS].

Clinopodium chinense, a traditional folk medicinal herb, has been used to treat abnormal uterine bleeding(AUB) for many years. Saponins and flavonoids are the main active components in C. chinense. To study the pharmacokine-tics of multiple components from the total extract of C. chinense(TEC), we established a sensitive and rapid method of ultra-perfor-mance liquid chromatography coupled with tandem mass spectrometry(UPLC-MS/MS) for simultaneous determination of five compounds in the plasma of AUB rats. After validation, the AUB model was established with SD female rats which got pregnant on the same day by gavage with mifepristone(12.4 mg·kg~(-1)) and misoprostol(130 µg·kg~(-1)). The established method was applied to the detection of hesperidin, naringenin, apigenin, saikosaponin a, and buddlejasaponin Ⅳb in AUB rats after the administration of TEC. The pharmacokinetic parameters were calculated by DAS 2.0. The five compounds showed good linear relationship within the detection range. The specificity, accuracy, precision, recovery, matrix effect, and stability of the method all matched the requirements of biolo-gical sample detection. The above 5 compounds were detected in the plasma of AUB rats after the administration of TEC. The C_(max) va-lues of hesperidin, naringenin, apigenin, saikosaponin a, and clinoposide A were 701.6, 429.5, 860.7, 75.1, and 304.1 ng·mL~(-1), respectively. All the compounds owned short half-life and quick elimination rate in vivo, and the large apparent volume of distribution indicated that they were widely distributed in tissues. Being rapid, accurate, and sensitive, this method is suitable for the pharmacokinetic study of extracts of Chinese herbal medicines and provides a reference for the study of pharmacodynamic material basis of C. chinense in treating AUB.

Comparison of the effectiveness and safety of treatment of incomplete second trimester abortion with misoprostol provided by midwives and physicians: a randomised, controlled, equivalence trial in Uganda.

BACKGROUND: To address the knowledge gaps in the provision of post-abortion care by midwives for women in the second trimester, we investigated the effectiveness and safety of treatment for incomplete second trimester abortion with misoprostol, comparing care provision by midwives with that provided by physicians in Uganda. METHODS: Our multicentre, randomised, controlled, equivalence trial undertaken in 14 health facilities in Uganda recruited women with incomplete abortion of uterine size 13-18 weeks. We randomly assigned (1:1) women to clinical assessment and treatment by either midwife or physician. The randomisation sequence was computer generated, in blocks of four to 12, and stratified for study site. Participants received sublingual misoprostol (400 µg once every 3 h for up to five doses). The study was not concealed from the health-care providers and study participants. Primary outcome was complete abortion within 24 h that did not require surgical evacuation. Analysis was per-protocol and intention to treat; the intention-to-treat population consisted of women who were randomised, received at least one dose of misoprostol, and reported primary outcome data, and the per-protocol population excluded women with unexplained discontinuation of treatment. We used generalised mixed-effects models to obtain the risk difference. The predefined equivalence range was -5% to 5%. The trial was registered at ClinicalTrials.gov, NCT03622073. FINDINGS: Between Aug 14, 2018, and Nov 16, 2021, 1191 eligible women were randomly assigned to each group (593 women to the midwife group and 598 to the physician group). 1164 women were included in the per-protocol analysis, and 530 (92%) of 577 women in the midwife group and 553 (94%) of 587 women in the physician group had a complete abortion within 24 h. The model-based risk difference for the midwife versus physician group was -2·3% (95% CI -4·4 to -0·3), and within our predefined equivalence range (-5% to 5%). Two women in the midwife group received blood transfusion. INTERPRETATION: Clinical assessment and treatment of second trimester incomplete abortion with misoprostol provided by midwives was equally effective and safe as when provided by physicians. In low-income settings, inclusion of midwives in the medical management of uncomplicated second trimester incomplete abortion has potential to increase women's access to safe post-abortion care. FUNDING: Swedish Research Council and THRiVE-2.

Antisecretory and Spasmolytic Activities of Aqueous and Ethanolic Stem Bark Extracts of Nauclea diderrichii in Wistar Rats.

Background: Diarrheal diseases are a major cause of morbidity and mortality throughout the world and particularly in developing countries. Nauclea diderrichii is a plant used in traditional medicine in the treatment of anemia, fever, gastric ulcer, malaria, abdominal pain, skin infections, and diarrhea. The present work is aimed at evaluating the antisecretory and spasmolytic activities of aqueous and ethanolic stem bark extracts of Nauclea diderrichii in Wistar rats. Methods: The effect of aqueous and ethanolic extracts of Nauclea diderrichii was tested at doses of 100, 200, and 300 mg/kg on castor oil-induced secretory diarrhea, misoprostol-induced fluid accumulation, and the effect of pretreatment with yohimbine and glibenclamide. They were also tested on normal motility and castor oil- and carbachol-induced hypermotility. Results: The results showed that the aqueous and ethanolic extracts of Nauclea diderrichii significantly (p < 0.001) inhibited castor oil-induced secretory diarrhea at all the doses. Both extracts significantly (p < 0.001) inhibit fluid accumulation induced by misoprostol. The pretreatment with glibenclamide reduced the antidiarrheal activity of aqueous extract of Nauclea diderrichii. The pretreatment with yohimbine did not alter the effect of the aqueous extract of Nauclea diderrichii. On intestine transit as on castor oil- and carbachol-induced motility, the aqueous and ethanolic extracts at doses of 100 and 200 mg/kg reduced significantly (p < 0.05, p < 0.01, and p < 0.001) the travelled distance by charcoal and peristaltic index. Conclusions: The study demonstrated that the aqueous and ethanolic extracts of Nauclea diderrichii possess antisecretory and antispasmolytic properties hence its use in traditional medicine against diarrhea.

Analysis of the Clinical Efficacy of Conservative Treatment for an Unruptured Cornual Pregnancy.

Context: Early diagnosis and early treatment of cornual pregnancy are very important. Conservative treatment before rupture can greatly reduce the patient's trauma. It's very important to choose a treatment method for cornual pregnancy with a high level of effectiveness, few adverse reactions, and no effects on fertility. Objective: The study intended to compare the clinical efficacy of different treatments for unruptured cornual pregnancy to find a safe, effective, minimally invasive treatment for unruptured cornual pregnancy that has few side effects and doesn't affect fertility. Design: The research team retrospectively collected the clinical data of patients to analyze the benefits of treatments for cornual pregnancy. Setting: The study took place in the Department of Obstetrics and Gynecology at the Wuhan Third Hospital in Wuhan, Hubei Province, China. Participants: Participants were 61 patients with an unruptured cornual pregnancy who had been admitted to the hospital between September 2002 and May 2012. Intervention: Participants were divided into four groups according to the treatment they received: (1) 20 patients who had been orally administered mifepristone combined with misoprostol and received uterine curettage were included in the drug abortion + curettage group (D group); (2) 16 patients who had received ultrasound-guided uterine aspiration were included in the uterine aspiration group (U group); (3) 15 patients who had received methotrexate (MTX) chemotherapy were included in the chemotherapy group (C group); and (4) 10 patients who had received ultrasound-guided hysteroscope operation were included in the hysteroscope operation group (H group). Outcome Measures: Adverse reactions and the decrease in participants' blood ß-HCG were recorded in detail. The participants were followed up for two months. Results: Of the 61 participants, 12 underwent surgery after failed conservative treatment, one in the D group, four in the U group, three in the C group, and four in the H group. No significant difference existed in the baseline data among the four groups. The decline rates of ß-HCG at seven days after treatment and the treatment success rates of participants in the D group were significantly higher than those in the U group, the C group, and the H group (all P < .05). The time at which the ß-HCG turned negative and the average hospital stays weren't significantly different among the four groups. Conclusions: The current study found that oral administration of mifepristone, combined with misoprostol, plus uterine curettage was superior to the other three methods in treatment of unruptured cornual pregnancy. The drug abortion + curettage treatment was found to be a safe, effective, minimally invasive treatment for unruptured cornual pregnancy, which has few side effects and doesn't affect fertility.

A synthesis of clinical and health system bottlenecks to implementing new WHO postpartum hemorrhage recommendations: Secondary data analysis of the Kenya Confidential Enquiry into Maternal Deaths 2014-2017.

OBJECTIVE: To describe maternal deaths from postpartum hemorrhage (PPH) in Kenya by secondary analysis of the Kenya Confidential Enquiry into Maternal Deaths (CEMD) database and clinical audit of a sample of those deaths, and to identify the perceived challenges to implementing country-specific PPH guidelines. METHODS: A retrospective descriptive study using the Kenyan CEMD database and anonymized maternal death records from 2014-2017. Eight standards from the Kenya National Guidelines for Quality Obstetric and Perinatal Care were selected to perform clinical audit. The process of supporting eight Sub-Saharan African countries to develop country-specific PPH guidelines was described and perceived challenges implementing these were identified. RESULTS: In total, 725 women died from PPH. Most women attended at least one antenatal care visit (67.2%) and most did not receive iron and folate supplementation (35.7%). Only 39.0% of women received prophylactic uterotonics in the third stage of labor. Factors significantly associated with receiving prophylactic uterotonics were place of delivery (χ2  = 43.666, df = 4; P < 0.001), being reviewed by a medical doctor (χ2  = 16.905, df = 1; P < 0.001), and being reviewed by a specialist (χ2  = 49.244, df = 1; P < 0.001). Only three of eight standards had a greater percentage of met cases in comparison to unmet cases. Key concerns about implementation of the new WHO PPH guidance included use of misoprostol by unskilled health personnel, availability of misoprostol and tranexamic acid (TXA) at primary healthcare level, lack of availability of heat-stable carbetocin (HSC) due to cost, lack of awareness and education about HSC and TXA, and lack of systems to ensure quality oxytocin is available at point of care. CONCLUSION: There is a need for improved quality of care for women to minimize the risk of mortality from PPH, by implementing updated clinical guidelines combined with focused health system interventions.

Mentha pulegium L. (Pennyroyal, Lamiaceae) Extracts Impose Abortion or Fetal-Mediated Toxicity in Pregnant Rats; Evidenced by the Modulation of Pregnancy Hormones, MiR-520, MiR-146a, TIMP-1 and MMP-9 Protein Expressions, Inflammatory State, Certain Related Signaling Pathways, and Metabolite Profiling via UPLC-ESI-TOF-MS.

Pregnant women usually turn to natural products to relieve pregnancy-related ailments which might pose health risks. Mentha pulegium L. (MP, Lamiaceae) is a common insect repellent, and the present work validates its abortifacient capacity, targeting morphological anomalies, biological, and behavioral consequences, compared to misoprostol. The study also includes untargeted metabolite profiling of MP extract and fractions thereof viz. methylene chloride (MecH), ethyl acetate (EtOAc), butanol (But), and the remaining liquor (Rem. Aq.) by UPLC-ESI-MS-TOF, to unravel the constituents provoking abortion. Administration of MP extract/fractions, for three days starting from day 15th of gestation, affected fetal development by disrupting the uterine and placental tissues, or even caused pregnancy termination. These effects also entailed biochemical changes where they decreased progesterone and increased estradiol serum levels, modulated placental gene expressions of both MiR-(146a and 520), decreased uterine MMP-9, and up-regulated TIMP-1 protein expression, and empathized inflammatory responses (TNF-α, IL-1ß). In addition, these alterations affected the brain's GFAP, BDNF, and 5-HT content and some of the behavioral parameters escorted by the open field test. All these incidences were also perceived in the misoprostol-treated group. A total of 128 metabolites were identified in the alcoholic extract of MP, including hydroxycinnamates, flavonoid conjugates, quinones, iridoids, and terpenes. MP extract was successful in terminating the pregnancy with minimal behavioral abnormalities and low toxicity margins.

"I'll just deal with this on my own": a qualitative exploration of experiences with self-managed abortion in the United States.

BACKGROUND: A growing body of evidence indicates that some people seek options to terminate a pregnancy without medical assistance, but experiences doing so have largely been documented only among people accessing a clinic-based abortion. We aim to describe self-managed abortion (SMA) experiences of people recruited outside of clinics, including their motivations for SMA, pregnancy confirmation and decision-making processes, method choices, and clinical outcomes. METHODS: In 2017, we conducted 14 in-depth interviews with self-identified females of reproductive age who recently reported in an online survey administered to Ipsos' KnowledgePanel that, since 2000, they had attempted SMA while living in the United States. We asked participants about their reproductive histories, experiences seeking reproductive health care, and SMA experiences. We used an iterative process to develop codes and analyzed transcripts using thematic content analysis methods. RESULTS: Motivations and perceptions of effectiveness varied by whether participants had confirmed the pregnancy prior to SMA. Participants who confirmed their pregnancies chose SMA because it was convenient, accessible, and private. Those who did not test for pregnancy were motivated by a preference for autonomy and felt empowered by the ability to try something on their own before seeking facility-based care. Participants prioritized methods that were safe and available, though not always effective. Most used herbs or over-the-counter medications; none used self-sourced abortion medications, mifepristone and/or misoprostol. Five participants obtained facility-based abortions and one participant decided to continue the pregnancy after attempting SMA. The remaining eight reported being no longer pregnant after SMA. None of the participants sought care for  SMA complications; one participant saw a provider to confirm abortion completion. CONCLUSIONS: There are many types of SMA experiences. In addition to those who pursue SMA as a last resort (after facing barriers to facility-based care) or as a first resort (because they prefer homeopathic remedies), our findings show that some individuals view SMA as a potential interim step worth trying after suspecting pregnancy and before accessing facility-based care. These people in particular would benefit from a medication abortion product available over the counter, online, or in the form of a missed-period pill.

Some people in the United States (US) attempt to end a pregnancy on their own without medical supervision. What we know about this experience comes from studies focused on people who go to clinics. In this study, we conducted 14 interviews with self-identified women ages 18­49 who recently reported attempting to end a pregnancy on their own and who were recruited outside of the clinic setting. We asked participants about their fertility histories, experiences seeking reproductive health care, and experiences ending a pregnancy without medical assistance. Those who took a pregnancy test and then chose to end the pregnancy on their own did so because it was convenient, accessible, and private. Those who did not test for pregnancy felt empowered by the ability to try something on their own before seeking facility-based care. All participants prioritized methods that were safe and available, though not always effective. After they attempted to end the pregnancy on their own, five participants accessed abortion care in facilities, one decided to continue the pregnancy, and eight were no longer pregnant. Our findings show that, in addition to people who end a pregnancy on their own as a last resort (after facing barriers to facility-based care) or as a first resort (because of preferences for homeopathic methods), a third group values having an interim step to try after suspecting pregnancy and before accessing facility-based care. These people would particularly benefit from a medication abortion product available over the counter, online, or in the form of a missed-period pill.

Heterogenous use of misoprostol for induction of labour: results of an online survey among midwives in German-speaking countries.

PURPOSE: This online survey looked at the experiences and general perceptions of midwives concerning induction of labour and the specific use of misoprostol. METHODS: We published an online questionnaire with 24 questions in German on midwives' experiences and perceptions of different methods of induction of labour. RESULTS: The online survey was answered by 412 midwives between February 2016 and February 2017. At least 20% of the 24 questions were answered in 333 questionnaires, which were included in this analysis. Oral misoprostol was the most common induction method for primipara and for women with a previous vaginal birth and an unfavourable cervix. Apart from alternative methods for induction of labour like castor oil and complementary/alternative methods, oral misoprostol was the preferred method of induction of labour by midwives. Midwives described a wide range of dosage schedules concerning application intervals, starting doses, and the maximum daily dose of misoprostol. Approximately 50% of the participants of this study described prescriptions of more than 200 µg misoprostol daily for induction of labour. CONCLUSION: Misoprostol is widely used in Germany and was one of the three preferred methods of induction of labour among midwives in our study next to castor oil and complementary/alternative methods. The preparation and dosage of misoprostol vary significantly among hospitals and do not adhere to international guidelines. Midwives voiced their concerns about inconsistent indications and heterogenous use of different methods and dosages of induction. They wished for more patience with late-term pregnancies and individualized shared decision-making between pregnant women and obstetricians.

Developing and validating the Caesarean risk assessment nomogram and comparing the effect of cervical ripening balloon, evening primrose oil and misoprostol on childbirth outcomes in term pregnancies: A study protocol.

AIM: To develop and validate the nomogram for risk estimation of Caesarean delivery and to compare the effect of cervical ripening balloon, evening primrose oil (EPO) and misoprostol on Bishop Score and duration of the first stage of labour. DESIGN: The first phase is a prospective study, and the second phase is a randomized controlled trial. METHODS: In the first phase, the nomogram will be developed and validated over 300 participants, and in the second phase, the 90 participants will be allocated to three groups: vaginal 25mcg misoprostol, vaginal 4000mg EPO and double-balloon catheter, through block randomization method. The Bishop score will be evaluated every 4 hr, and if required the same dose will be repeated. Maximum waiting time for balloon is 12 hr if not effective, the catheter will be removed, and other interventions will be done according to guidelines. DISCUSSION: The nomogram will help informed decision-making for women undergoing an induction with an unfavourable cervix and introducing effective low-complication methods of labour induction can improve the pregnancy outcomes.

[Treatment for non-viable pregnancy in primary care]. / Behandeling van niet-vitale zwangerschap in de eerste lijn.

OBJECTIVE: To explore the experiences of women and health care professionals with misoprostol as a first line treatment for non-viable pregnancy. Additionally, we investigated to what extent adding this treatment to primary care will prevent a referral to secondary care. DESIGN: Retrospective mixed methods study METHOD: Pregnant women with a non-viable pregnancy with a gestational age shorter than 12 weeks treated by community midwives in Nijmegen Lent as part of an on-going pilot project were included. Quantitative data regarding treatment outcomes and patient satisfaction were collected and analysed descriptively. In addition, semi structured interviews were performed with five patients and five primary care professionals on their experiences with this treatment. RESULTS: In total 24 women with 25 non-viable pregnancies were included. Of all women, 96% was satisfied about the treatment and 75% would choose primary care treatment again if they would have another non-viable pregnancy. Referral to a secondary care was prevented in 56% of the cases. Four main themes were found from the interviews: 1) Choice of health care, 2) Collaboration of the health care chain, 3) Competence of the midwives and the womens confidence in this, and 4) Disappointments. One overarching theme emerged that covered all other themes: Patient-centered care. CONCLUSION: Misoprostol as treatment for non-viable pregnancy in primary care is an acceptable alternative for women and health care professionals. Addition of misoprostol treatment in primary care prevents a referral to the secondary care in most cases treated with misoprostol.

Influence of nursing interventions in improving midwives' knowledge of misoprostol use in the management of postpartum haemorrhage at selected hospitals in Ondo State, Nigeria.

INTRODUCTION: despite large investments in maternal health services in the world, postpartum hemorrhage (PPH) remains a major cause of maternal mortality. Misoprostol is the most available, accessible, and affordable uterotonic agent in the management of the third stage of labor and has been found to be effective in PPH prevention in low-income countries. This study, therefore, assessed the influence of nursing interventions improving midwives´ awareness of misoprostol use in the management of PPH at selected health facilities. METHODS: we conducted a quasi-experimental study in two secondary health institutions in Ondo State. A total of 68 midwives, who consented to participate, were randomly distributed into experimental and control groups respectively. A questionnaire was administered for obtaining information about participants´ knowledge and use of misoprostol in the management of PPH. Midwives in the intervention group were trained using the adapted Pathfinder International Teaching Package on the use of misoprostol in the management of PPH. Data were analyzed using descriptive and inferential statistics. RESULTS: in the pre-intervention phase, the mean knowledge score of the control group was 7.55 ± 2.57 while that of the experimental group was 8.89 ± 2.57. There was a significant increase in the number of participants knowing the correct dose of misoprostol for the management of PPH after intervention (27.0% vs 81.1% p=0.01). After intervention, there was a significant increase (p=0.01) in knowledge of misoprostol use in the intervention group compared to the control group (14.73 ± 2.57 vs 8.89 ± 2.57). CONCLUSION: misoprostol educational intervention was effective in improving knowledge and use of misoprostol. Hence, continuing educational units in hospitals should include periodic training of midwives on the use of misoprostol in PPH prevention.

Transcutaneous Electrical Nerve Stimulation to Reduce Pain With Medication Abortion: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether high-frequency transcutaneous electrical nerve stimulation (hfTENS) reduces pain during medication abortion. METHODS: We conducted a randomized, placebo-controlled trial. Participants who were undergoing medication abortion with mifepristone and misoprostol through 70 days of gestation either received active 80 Hz hfTENS or sham to use for a minimum of 60 minutes within 8 hours of misoprostol. Maximum pain on an 11-point numerical rating scale at 8 hours after misoprostol was the primary outcome. We estimated 20 per group for 80% power to detect a 2-point difference and up to 10% attrition. Secondary outcomes included a maximum pain score at 24 hours, additional analgesia use, the difference in score before and after treatment, the experience of side effects, abortion outcomes, and acceptability. We collected data at baseline, time of misoprostol (0-hour), 8-hour and 24 hours using real-time electronic surveys, and at follow-up. RESULTS: Between June 2019 and March 2020, we screened 251 patients and randomized 40-20 each to hfTENS or sham-with one postrandomization exclusion and two patients lost to follow-up. Baseline characteristics were similar. Median maximum pain scores at 8 hours were 7.0 (interquartile range 3.0) and 10.0 (interquartile range 3.0) for hfTENS and sham, respectively. The distribution of these scores was lower among hfTENS users compared with sham (mean rank 15.17 vs 22.63, P=.036). High-frequency TENS users also experienced a significant reduction in posttreatment pain score (-2.0 [interquartile range 2.5] vs 0 [interquartile range 1.5], P=.008). We found no statistically significant differences in use of additional analgesia, distribution of maximum pain scores at 24 hours, side effects, or measures of acceptability. CONCLUSION: High-frequency TENS reduced maximum pain scores within 8 hours of misoprostol and reduced pain scores immediately after treatment compared with placebo. High-frequency TENS offers an effective nonpharmacologic option for pain management during medication abortion. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03925129.