Can we use a lower intravaginal dose of misoprostol in the medical management of miscarriage? A randomised controlled study.

BACKGROUND: The optimal dose of misoprostol to be used in the medical management of miscarriage before 13 weeks has not been resolved. AIM: To evaluate the effectiveness and side effect profile of two different dosages of misoprostol. METHODS: A randomised controlled, equivalence study comparing 400 vs 800 µg misoprostol per vaginum (PV) on an outpatient basis. The allocated dose was repeated the next day if clinically the products of conception had not been passed. Complete miscarriage was evaluated using two methods: ultrasound criteria on Day 7 and the need for surgical management (clinical criteria). Equivalence was demonstrated if the 95% confidence interval [CI] of the observed risk difference between the two doses for complete miscarriage lay between -15.0 and 15.0%. Differences in side effects and patient satisfaction were evaluated using patient-completed questionnaires. RESULTS: One hundred and fifty-eight women were allocated to receive 400 µg and 152 women to 800 µg misoprostol for the management of missed (91.3%) or incomplete (8.7%) miscarriage. The rate of induced complete miscarriage was equivalent using both ultrasound criteria (observed risk difference (ORD) -4.6%, 95% CI -12.8 to 3.7%; P = 0.313) and clinical criteria (ORD -5.6%, 95% CI -14.8 to 3.6%; P = 0.273). Following the 400 µg dose, the reported rate of fever/rigors was lower (ORD -15.6%, 95% CI -28.1 to -3.0%; P = 0.015), and more women reported their decision to undergo medical management as a good decision (ORD 15.2%, 95% CI 2.8 to 27.7%; P = 0.018). CONCLUSION: Four hundred-microgram misoprostol PV can be recommended for the medical management of miscarriage on an outpatient basis.

A survey of policies for the monitoring of fetal growth in Australian and New Zealand hospitals.

BACKGROUND: Fetal growth restriction is associated with increased perinatal mortality and morbidity and adverse developmental outcome. However, evidence is lacking on optimal approaches to antenatal screening of fetal size and growth. AIMS: To determine the current policies and practices for assessment of fetal size and monitoring fetal growth with a view to informing future research in this area. METHODS: Web-based survey of Directors of Obstetrics and Gynaecology in maternity hospitals with over 1000 births per annum in Australia and New Zealand (ANZ). The survey focussed on the existence and details of guidelines for the clinical assessment of fetal size and growth in low- and high-risk pregnancies, techniques utilised for clinical assessment of fetal size and growth and the use of birthweight charts. RESULTS: Completed surveys were received from 49 (66%) of the 74 hospitals surveyed. Forty-four percent of hospitals have a fetal growth screening guideline, with abdominal palpation and symphysis fundal height (SFH) measurement the most common screening tools. Seventy-nine percent indicated that obstetric or birthweight charts were in use; 39% were unsure which chart/s were in use, and use differed by region. There was reasonable agreement regarding decision to take action following discrepancies between gestational age and SFH. Sixty-five percent of participants are interested in participating in a randomised controlled trial in this area. CONCLUSIONS: The survey revealed that while there is some agreement with respect to methods used in the clinical assessment of fetal size and growth, there is interest in ANZ hospitals to pursue this area of research further.

Implementation of a clinical practice guideline for smoking cessation in a public antenatal care setting.

BACKGROUND: Despite high level evidence showing that antenatal smoking cessation programs are effective in reducing the number of women who smoke during pregnancy and the number of low birthweight and preterm births, few Australian hospitals have adopted a systematic approach to assist pregnant women to stop smoking. AIMS: The aim of this study was to assess the effectiveness of a smoking cessation guideline, developed specifically for clinicians providing antenatal care in public maternity hospitals, combined with an implementation program on the uptake of evidence-based practice. METHODS: A clinical practice guideline was developed and an implementation strategy was tested, using a prospective before-and-after study design, at the Mater Mothers' Hospital in Brisbane. Women were surveyed in late pregnancy, pre- and post-implementation. The primary outcome measures were women's report of appropriate smoking cessation support received, specifically, information brochures and referral to Quitline. Secondary outcome measures included women's report of smoking status in late pregnancy and relapse rates. RESULTS: Post-implementation, more women reported receiving written materials on smoking cessation (76% vs 35%; relative risk (RR) 3.4; 95% confidence interval (CI) 2.7, 4.2) and referral to Quitline (67% vs 14%; RR 4.9; 95% CI 3.0, 8.0). While not statistically significant, fewer women post-implementation reported smoking in late pregnancy (19.5% vs 16.7%) and fewer reported smoking > 10 cigarettes per day (38% vs 25%). CONCLUSIONS: Clinical practice guidelines specifically designed for a public maternity care setting combined with an implementation program resulted in an increase in evidence-based practice with some indication of improved smoking behaviour for women.