The association between abortion restrictions and patient-centered care for early pregnancy loss at US obstetrics-gynecology residency programs.

BACKGROUND: Early pregnancy loss is a common medical problem, and the recommended treatments overlap with those used for induced abortions. The American College of Obstetricians and Gynecologists recommends the incorporation of clinical and patient factors when applying conservative published imaging guidelines to determine the timing of intervention for early pregnancy loss. However, in places where abortion is heavily regulated, clinicians who manage early pregnancy loss may cautiously rely on the strictest criteria to differentiate between early pregnancy loss and a potentially viable pregnancy. The American College of Obstetricians and Gynecologists also notes that specific treatment modalities that are frequently used to induce abortion, including the use of mifepristone in medical therapy and surgical aspiration in an office setting, are cost-effective and beneficial for patients with early pregnancy loss. OBJECTIVE: This study aimed to determine how US-based obstetrics and gynecology residency training institutions adhere to the American College of Obstetricians and Gynecologists recommendations for early pregnancy loss management, including the timing and types of interventions, and to evaluate the relationship with institutional and state abortion restrictions. STUDY DESIGN: From November 2021 to January 2022, we conducted a cross-sectional study of all 296 US-based obstetrics and gynecology residency programs by emailing them and requesting that a faculty member complete a survey about early pregnancy loss practices at their institution. We asked about location of diagnosis, use of imaging guidelines before offering intervention, treatment options available at their institution, and program and personal characteristics. We used chi-square tests and logistic regressions to compare the availability of early pregnancy loss care based on institutional indication-based abortion restrictions and state legislative hostility to abortion care. RESULTS: Of the 149 programs that responded (50.3% response rate), 74 (49.7%) reported that they did not offer any intervention for suspected early pregnancy loss unless rigid imaging criteria were met, whereas the remaining 75 (50.3%) programs reported that they incorporated imaging guidelines with other factors. In an unadjusted analysis, programs were less likely to incorporate other factors with imaging criteria if they were in a state with legislative policies that were hostile toward abortion (33% vs 79%; P<.001) or if the institution restricted abortion by indication (27% vs 88%; P<.001). Mifepristone was used less often in programs located in hostile states (32% vs 75%; P<.001) or in institutions with abortion restrictions (25% vs 86%; P<.001). Similarly, office-based suction aspiration use was lower in hostile states (48% vs 68%; P=.014) and in institutions with restrictions (40% vs 81%; P<.001). After controlling for program characteristics, including state policies and affiliation with family planning training programs or religious entities, institutional abortion restrictions were the only significant predictor of rigid reliance on imaging guidelines (odds ratio, 12.3; 95% confidence interval, 3.2-47.9). CONCLUSION: In training institutions that restrict access to induced abortion based on indication for care, residency programs are less likely to holistically incorporate clinical evidence and patient priorities in determining when to intervene in early pregnancy loss as recommended by the American College of Obstetricians and Gynecologists. Programs in restrictive institutional and state environments are also less likely to offer the full range of early pregnancy loss treatment options. With state abortion bans proliferating nationwide, evidence-based education and patient-centered care for early pregnancy loss may also be hindered.

Evaluating interventions and adjuncts to optimize pregnancy outcomes in subfertile women: an overview review.

BACKGROUND: There is a wealth of information regarding interventions for treating subfertility. The majority of studies exploring interventions for improving conception rates also report on pregnancy outcomes. However, there is no efficient way for clinicians, researchers, funding organizations, decision-making bodies or women themselves to easily access and review the evidence for the effect of adjuvant therapies on key pregnancy outcomes in subfertile women. OBJECTIVE AND RATIONALE: The aim was to summarize all published systematic reviews (SRs) of randomized controlled trials (RCTs) of interventions in the subfertile population, specifically reporting on the pregnancy outcomes of miscarriage and live birth. Furthermore, we aimed to highlight promising interventions and areas that need high-quality evidence. SEARCH METHODS: We searched the Cochrane Database of Systematic Reviews and PubMed clinical queries SR filter (inception until July 2021) with a list of key words to capture all SRs specifying or reporting any miscarriage outcome. Studies were included if they were SRs of RCTs. The population was subfertile women (pregnant or trying to conceive) and any intervention (versus placebo or no treatment) was included. We adopted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) for determining the quality of the evidence. Exclusion criteria were overview reviews, reviews that exclusively reported on women conceiving via natural conception, reviews including non-randomized study designs or reviews where miscarriage or live birth outcomes were not specified or reported. OUTCOMES: The primary outcome was miscarriage, defined as pregnancy loss <24 weeks of gestation. Data were also extracted for live birth where available. We included 75 published SRs containing 121 251 participants. There were 14 classes of intervention identified: luteal phase, immunotherapy, anticoagulants, hCG, micronutrients, lifestyle, endocrine, surgical, pre-implantation genetic testing for aneuploidies (PGT-As), laboratory techniques, endometrial injury, ART protocols, other adjuncts/techniques in the ART process and complementary interventions. The interventions with at least moderate-quality evidence of benefit in reducing risk of miscarriage or improving the chance of a live birth are: intrauterine hCG at time of cleavage stage embryo transfer, but not blastocyst transfer, antioxidant therapy in males, dehydroepiandrosterone in women and embryo medium containing high hyaluronic acid. Interventions showing potential increased risk of miscarriage or reduced live birth rate are: embryo culture supernatant injection before embryo transfer in frozen cycles and PGT-A with the use of fluorescence in situ hybridization. WIDER IMPLICATIONS: This review provides an overview of key pregnancy outcomes from published SRs of RCTs in subfertile women. It provides access to concisely summarized information and will help clinicians and policy makers identify knowledge gaps in the field, whilst covering a broad range of topics, to help improve pregnancy outcomes for subfertile couples. Further research is required into the following promising interventions: the dose of progesterone for luteal phase support, peripheral blood mononuclear cells for women with recurrent implantation failure, glucocorticoids in women undergoing IVF, low-molecular-weight heparin for unexplained subfertility, intrauterine hCG at the time of cleavage stage embryo or blastocyst transfer and low oxygen concentrations in embryo culture. In addition, there is a need for high-quality, well-designed RCTs in the field of reproductive surgery. Finally, further research is needed to demonstrate the integrated effects of non-pharmacological lifestyle interventions.

[Male factors and countermeasures for recurrent spontaneous abortion].

Recurrent spontaneous abortion (RSA) has a very complicated pathogenesis and male factors for this condition should not to be ignored, which are mainly related to genetics, immunology, infection, sperm quality, and others. In case of RSA, an etiological screening ought to be performed for the husband, which involves general, genetic and immunological examinations and infection detection. According to specific etiological factors, such measures as genetic consultation, immunotherapy, and traditional Chinese medication can be taken, which may contribute to the outcome of pregnancy.

Intrauterine administration of autologous peripheral blood mononuclear cells (PBMCs) activated by HCG improves the implantation and pregnancy rates in patients with repeated implantation failure: a prospective randomized study.

PROBLEM: Intrauterine administration of autologous peripheral blood mononuclear cells (PBMCs) activated by HCG in vitro was reported to improve implantation rates in patients with repeated failure of IVF-ET (in vitro fertilization-embryo transfer). In this article, the value of intrauterine administration of PBMCs before embryo transfer and its optimal cell culture method will be investigated. METHOD OF STUDY: Patients who had not experienced successful pregnancy despite three or more IVF-ET sessions were enrolled in this study (n=240, 240 cycles). PBMCs were obtained from patients themselves and were cultured with HCG for 24 hours. Twenty-four hours later, PBMCs were then administered to the intrauterine cavity of that patient from the study group (n=93, 93 cycles). The control group (n=105, 105 cycles) underwent ET without intrauterine administration. RESULTS: Clinical pregnancy rate, implantation rate, and miscarriage rate in the PBMC-treated group (46.24% and 23.66%, n=43 and 22, respectively) were significantly higher than those in the non-treated group (20.95% and 11.43%, P<.05; n=22 and 12, respectively). CONCLUSION: These findings indicate that intrauterine administration of autologous PBMC activated by HCG in vitro effectively improves embryo implantation in patients with three or more IVF failures.

Influence of acupuncture on the outcomes of in vitro fertilisation when embryo implantation has failed: a prospective randomised controlled clinical trial.

OBJECTIVE: To evaluate the effectiveness of acupuncture and moxibustion as an adjuvant treatment in women undergoing in vitro fertilisation (IVF) when embryo implantation has failed. METHODS: A prospective, randomised controlled clinical trial was conducted with 84 infertile patients who had had at least two unsuccessful attempts of IVF. The patients were randomised in three groups: control (n=28), sham (n=28) and acupuncture (n=28). The sample size was calculated by assuming a pregnancy rate of 10% when embryo implantation had failed. The pregnancy rates of the current IVF cycle were evaluated by measurement of blood ß human chorionic gonadotrophin (ßhCG) and subsequent transvaginal ultrasound. Acupuncture was performed on the first and seventh day of ovulation induction, on the day before ovarian puncture and on the day after embryo transfer. In the acupuncture group, patients were treated with moxibustion at nine acupuncture points (BL18, BL22, BL23, BL52, CV3, CV4, CV5, CV7, GV4) and needling at 12 points. In the sham group needles were inserted in eight areas that did not correspond to known acupuncture points. RESULTS: The clinical pregnancy rate in the acupuncture group was significantly higher than that in the control and sham groups (35.7% vs 7.1% vs 10.7%; p=0.0169). CONCLUSIONS: In this study, acupuncture and moxibustion increased pregnancy rates when used as an adjuvant treatment in women undergoing IVF, when embryo implantation had failed.

The family medicine residency training initiative in miscarriage management: impact on practice in Washington State.

BACKGROUND AND OBJECTIVES: Non-complicated spontaneous abortion cases should be counseled about the full range of management approaches, including uterine evacuation using manual vacuum aspiration (MVA). The Residency Training Initiative in Miscarriage Management (RTI-MM) is an intensive, multidimensional intervention designed to facilitate implementation of office-based management of spontaneous abortion using MVA in family medicine residency settings. The purpose of this study was to test the impact of the RTI-MM on self-reported use of MVA for management of spontaneous abortion. METHODS: We used a pretest/posttest one group study design and a web-based, anonymous survey to collect data on knowledge, attitudes, perceived barriers, and practice of office-based management of spontaneous abortion. We used multivariable models to estimate incident relative risks and accounted for data clustering at the residency site level. RESULTS: Our sample included 441 residents and faculty from 10 family medicine residency sites. Our findings show a positive association between the RTI-MM and self-reported use of MVA for management of spontaneous abortion (adjusted RR=9.11 [CI=4.20--19.78]) and were robust to model specification. Male gender, doing any type of management of spontaneous abortion (eg, expectant, medication), other on-site reproductive health training interventions, and support staff knowledge scores were also significant correlates of physician practice of MVA. CONCLUSIONS: Our findings suggest that the RTI-MM was successful in influencing the practice of management of spontaneous abortion using MVA in this population and that support staff knowledge may impact physician practice. Integrating MVA into family medicine settings would potentially improve access to evidence-based, comprehensive care for women.

A collaborative framework for managing pregnancy loss in the emergency department.

The purpose of this article is to examine how nurses can improve comprehensive care for women who suffer an early pregnancy loss in the emergency department and highlight the integral role of obstetric and emergency department nurses within a new holistic framework of collaborative care. These nurses are integral in the proposed collaborative "fetal loss framework," which provides an innovative approach for holistic care for this population.

Morphological criteria for normalization of menstrual function in women with spontaneous abortion.

Normalization of the menstrual function in women with spontaneous abortion receiving sorbent and bioresonance (extremely high-frequency) therapy was evaluated by morphological criteria (correspondence of structural changes in the endometrium to the phase of the menstrual cycle). The absence of microvilli and cilia on the apical surface of surface and glandular epitheliocytes, presence of intranuclear tubules and giant mitochondria in the cytoplasm, and signs of apocrine secretion in epitheliocytes attested to the luteal phase of the cycle.

Metodologia e tratamento do abortamento infectado / Methodology and treatment of infected abortion

Visa este estudo mostrar a metodologia empregada por 143 pacientes que provocaram o abortamento e que foram atendidas na Maternidade da Encruzilhada, Recife, de 1 de janeiro a 30 de junho de 1994. Todas as pacientes com abortamento atendidas no período referido eram submetidas a uma anamnese acurada quando se investigava se o abortamento fora provocado ou espontâneo. Nos casos de abortamento provocado, investigava-se o método utilizado. Nos casos simples sem infecçao, o tratamento de escolha era a curetagem uterina. Na presença de infecçao ou manuseio por sonda ou gotas cáusticas, associava-se um ou mais antibióticos, conforme a gravidade do caso. Os métodos mais utilizados pelas pacientes para provocar o abortamento foram: misoprostol 77 por cento, sonda só ou associada a gotas 17 por cento, chás diversos 11 por cento e injetáveis 5 por cento. Os seguintes métodos terapêuticos foram realizados: curetagem uterina 70 por cento, curetagem uterina e um antibiótico 16 por cento, curetagem uterina e dois antibióticos 7 por cento e curetagem uterina e três antibióticos 7 por cento. Nao houve complicaçoes sérias a registrar e o misoprostol foi o método mais freqüentemente utilizado para provocar o abortamento. Em 70 por cento das vezes, a curetagem uterina foi o tratamento único e em 30 por cento das oportunidades foi acrescido o antibiótico. Enfatiza-se, por fim, a grande importância do planejamento familiar como soluçao definitiva para o problema do abortamento provocado.

Care for the imminent miscarriage by midwives and GPs.

A postal questionnaire was sent to a random sample of 495 Dutch general practitioners (GPs) and 278 midwives to evaluate the use of the 'imminent miscarriage' standard used by the Dutch College of General Practitioners. The response rates were 63 and 87% respectively. The first questions asked related to the respondents' routine management of an imminent miscarriage. The second part of the questionnaire addressed the respondents' attitude to the 17 most important guidelines in the standard. Finally, the respondents were invited to describe problems arising in adhering to the standard. Midwives and GPs differed in their management of an imminent miscarriage. Midwives used more 'technology' such as ultrasound scans or a doptone to trace complications or see if the fetus was still viable, whereas the GPs more often carried out vaginal and speculum examinations. Midwives also paid more attention to care following a miscarriage. The guidelines that many respondents did not adhere to involved the period of 10 days for the follow-up appointment and counselling after 6 weeks. Guidelines restricting ultrasound scans and the decision only to refer the patients to an obstetrician after three consecutive miscarriages were also not accepted by all respondents. Respondents mentioned several practical problems or obstacles in adhering to the standard, including women's requests for ultrasound scans or referrals and also the attitude of obstetricians who sometimes simply assumed control. The results will serve as a starting point for updating the standard.