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1.
Eur J Obstet Gynecol Reprod Biol ; 259: 95-99, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33636621

RESUMO

OBJECTIVE: During the 2020 COVID-19 pandemic there was a decrease in emergency room arrivals. There is limited evidence about the effect of this change in behavior on women's health. We aimed to evaluate the impact of the COVID-19 pandemic on the diagnosis, treatment and complications of women presenting with a tubal Ectopic Pregnancy (EP). STUDY DESIGN: This is a single centre retrospective cohort study. We compared the clinical presentation, treatment modalities and complications of all women presenting in our institution with a tubal EP during the COVID-19 pandemic between 15 March and 15 June 2020, with women who were treated in our institution with the same diagnosis in the corresponding period for the years 2018-2019. RESULTS: The study group included 19 cases of EP (N = 19) that were treated between the 15 March 2020 and 15 June 2020. The control group included 30 cases of EP (N = 30) that were admitted to in the corresponding period during 2018 and 2019. Maternal age, parity, gravity and mode of conception (natural vs. assisted) were similar between the two groups. There was no difference in the mean gestational age (GA) according to the last menstrual period. In the study group more women presented with sonographic evaluation of high fluid volume in the abdomen than in the control group (53 % vs 17 %, P value 0.01). This finding is correlated with a more advanced disease status. In the study group there was a highly statistically significant 3-fold increase in rupture among cases (P < 0.005) and a 4-fold larger volume of blood in the entrance to the abdomen (P < 0.002). We found that there were no cases of ruptured EP in the group of women who were pregnant after assisted reproduction. CONCLUSION: We found a higher rate of ruptured ectopic pregnancies in our institution during the COVID-19 pandemic. Health care providers should be alerted to this collateral damage in the non-infected population during the COVID-19 pandemic.


Assuntos
Gravidez Tubária/epidemiologia , Dor Abdominal/fisiopatologia , Abortivos não Esteroides/uso terapêutico , Adulto , Gonadotropina Coriônica Humana Subunidade beta/sangue , Estudos de Coortes , Diagnóstico Tardio , Feminino , Humanos , Israel/epidemiologia , Laparoscopia , Metotrexato/uso terapêutico , Gravidez , Gravidez Tubária/diagnóstico , Gravidez Tubária/fisiopatologia , Gravidez Tubária/terapia , Técnicas de Reprodução Assistida , Estudos Retrospectivos , Ruptura Espontânea/epidemiologia , Salpingectomia , Ultrassonografia Pré-Natal , Hemorragia Uterina/fisiopatologia
3.
BMC Womens Health ; 20(1): 142, 2020 07 07.
Artigo em Inglês | MEDLINE | ID: mdl-32635921

RESUMO

BACKGROUND: A wide range of drugs have been studied for first trimester medical abortion. Studies evaluating different regimens, including combination mifepristone and misoprostol and misoprostol alone regimens, show varying results related to safety, efficacy and other outcomes. Thus, the objectives of this systematic review were to compare the safety, effectiveness and acceptability of medical abortion and to compare medical with surgical methods of abortion ≤63 days of gestation. METHODS: Pubmed and EMBASE were systematically searched from database inception through January 2019 using a combination of MeSH, keywords and text words. Randomized controlled trials on induced abortion at ≤63 days that compared different regimens of medical abortion using mifepristone and/or misoprostol and trials that compared medical with surgical methods of abortion were included. We extracted data into a pre-designed form, calculated effect estimates, and performed meta-analyses where possible. The primary outcomes were ongoing pregnancy and successful abortion. RESULTS: Thirty-three studies composed of 22,275 participants were included in this review. Combined regimens using mifepristone and misoprostol had lower rates of ongoing pregnancy, higher rates of successful abortion and satisfaction compared to misoprostol only regimens. In combined regimens, misoprostol 800 µg was more effective than 400 µg. There was no significant difference in dosing intervals between mifepristone and misoprostol and routes of misoprostol administration in combination or misoprostol alone regimens. The rate of serious adverse events was generally low. CONCLUSION: In this systematic review, we find that medical methods of abortion utilizing combination mifepristone and misoprostol or misoprostol alone are effective, safe and acceptable. More robust studies evaluating both the different combination and misoprostol alone regimens are needed to strengthen existing evidence as well as assess patient perspectives towards a particular regimen.


Assuntos
Abortivos não Esteroides/uso terapêutico , Abortivos Esteroides/uso terapêutico , Aborto Induzido/métodos , Mifepristona/uso terapêutico , Misoprostol/uso terapêutico , Feminino , Humanos , Gravidez , Primeiro Trimestre da Gravidez
4.
BMJ Sex Reprod Health ; 46(3): 172-176, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32665231

RESUMO

INTRODUCTION: This study aimed to explore patient experiences obtaining a medical abortion using an at-home telemedicine service operated by Marie Stopes Australia. METHODS: From July to October 2017, we conducted semistructured in-depth telephone interviews with a convenience sample of medical abortion patients from Marie Stopes Australia. We analysed interview data for themes relating to patient experiences prior to service initiation, during an at-home telemedicine medical abortion visit, and after completing the medical abortion. RESULTS: We interviewed 24 patients who obtained care via the at-home telemedicine medical abortion service. Patients selected at-home telemedicine due to convenience, ability to remain at home and manage personal responsibilities, and desires for privacy. A few telemedicine patients reported that a lack of general practitioner knowledge of abortion services impeded their access to care. Most telemedicine patients felt at-home telemedicine was of equal or superior privacy to in-person care and nearly all felt comfortable during the telemedicine visit. Most were satisfied with the home delivery of the abortion medications and would recommend the service. CONCLUSION: Patient reports suggest that an at-home telemedicine model for medical abortion is a convenient and acceptable mode of service delivery that may reduce patient travel and out-of-pocket costs. Additional provider education about this model may be necessary in order to improve continuity of patient care. Further study of the impacts of this model on patients is needed to inform patient care and determine whether such a model is appropriate for similar geographical and legal contexts.


Assuntos
Aborto Legal/psicologia , Misoprostol/uso terapêutico , Telemedicina/normas , Abortivos não Esteroides/administração & dosagem , Abortivos não Esteroides/uso terapêutico , Aborto Legal/métodos , Adulto , Austrália , Feminino , Acesso aos Serviços de Saúde/normas , Humanos , Entrevistas como Assunto/métodos , Pessoa de Meia-Idade , Misoprostol/administração & dosagem , Gravidez , Pesquisa Qualitativa , Telemedicina/instrumentação , Telemedicina/métodos
5.
Niger J Clin Pract ; 23(5): 638-646, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32367870

RESUMO

Background: Manual vacuum aspiration is a safe and effective technology for the treatment of incomplete miscarriage but it is not widely available and affordable in rural areas particularly in low-resource countries. Misoprostol is an alternative to manual vacuum aspiration for the treatment of incomplete miscarriage. Aim: To compare the effectiveness, client acceptability and satisfaction, and cost-effectiveness of misoprostol with manual vacuum aspiration for the treatment of the first-trimester incomplete miscarriage. Subjects and Methods: This study was conducted between February 1, 2018 and August 31, 2018 at Alex Ekwueme Federal University Teaching Hospital Abakaliki, Nigeria. 100 participants were randomized to treatment with either manual vacuum aspiration or 600 µg oral misoprostol. The main outcome measures assessed at 1-week follow-up were complete uterine evacuation, client acceptability and satisfaction, and cost-effectiveness. Data were analyzed using SPSS version 25. Sociodemographic characteristics, treatment outcomes and other variables were summarized by descriptive statistics. Chi-square test was used for comparison between groups as regard categorical data while Student's't' test was used for comparison between groups for continuous data. P value of <0.05 was regarded as statistically significant. Results: There was a higher failure rate in the misoprostol arm when compared with MVA. Although this difference in complete uterine evacuation rate did not reach statistical significance (81.3% versus 95.7%, RR = 4.3, 95% CI 0.98-18.9, P value = 0.05), more participants in the misoprostol arm would choose the method again when compared with women in the MVA group (47 versus 30, X[2] = 16.95, P < 0.001). The mean client satisfaction score was significantly higher among women in the misoprostol arm compared to MVA group (13.2 (2.1) versus 7.3 (4.6), P < 0.001). The mean cost of primary treatment was higher in the MVA group compared with misoprostol arm ($67.8 (8.9) versus 14.4 (4.0), P < 0.001). There was no significant difference in the mean cost of repeat uterine evacuation in both study arms (MVA, $64.9 (6.3) versus misoprostol, $65.76 (6.6), P = 0.86). Conclusion: Although medical treatment was associated with a higher failure rate, there was no statistically significant difference in the effectiveness of both treatment methods. However, medical treatment was associated with higher client acceptance and satisfaction and was more cost-effective than surgical treatment.


Assuntos
Abortivos não Esteroides/uso terapêutico , Aborto Incompleto/tratamento farmacológico , Aborto Incompleto/cirurgia , Misoprostol/uso terapêutico , Curetagem a Vácuo/métodos , Abortivos não Esteroides/administração & dosagem , Administração Oral , Adulto , Feminino , Humanos , Misoprostol/administração & dosagem , Nigéria , Satisfação do Paciente , Gravidez , Primeiro Trimestre da Gravidez , Resultado do Tratamento
7.
Acta Obstet Gynecol Scand ; 99(4): 488-493, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31784973

RESUMO

INTRODUCTION: It has been estimated that one out of every four women experience first-trimester miscarriage. Missed miscarriage is a common form of early miscarriage where the products of conception are not expelled from the uterus. It is diagnosed by ultrasound. The primary objective of this study was to evaluate the success rate of a combination treatment with mifepristone and misoprostol for missed miscarriage in clinical practice. The secondary objective was to identify significant factors influencing the rate of success. MATERIAL AND METHODS: A cohort of 941 consecutive women with an ICD-10 diagnosis of missed miscarriage who received treatment with 800 µg vaginal misoprostol and 2 repeat doses of 400 µg oral misoprostol after mifepristone pretreatment between 1 January 2012 and 31 December 2014 was analyzed. Women with a uterine size smaller than 12 weeks who were planned for medical treatment were included in the study. The exclusion criteria were primary surgical management or planned follow up outside the Stockholm County Council area. RESULTS: The success rate of medical treatment, defined as no need for surgical treatment, was 85.5% (805/941) in women with a uterine size of less than 12 weeks. However, for women with uterine size below 9 weeks the success rate was 88.9% (586/659). Indeed, uterine size of 9 gestational weeks or larger at time of treatment was identified as the only significant risk factor for surgical intervention. CONCLUSIONS: The medical regimen for missed miscarriage offered in this study appears to be safe and with high rates of success. Conclusions about which women to exclude from medical treatment could not be made. Medical treatment may therefore benefit all women with missed miscarriage who wish to avoid primary surgery.


Assuntos
Abortivos não Esteroides/uso terapêutico , Abortivos Esteroides/uso terapêutico , Aborto Retido/tratamento farmacológico , Mifepristona/uso terapêutico , Misoprostol/uso terapêutico , Útero/patologia , Aborto Retido/cirurgia , Adolescente , Adulto , Quimioterapia Combinada , Feminino , Humanos , Pessoa de Meia-Idade , Tamanho do Órgão , Gravidez , Trimestres da Gravidez , Resultado do Tratamento , Ultrassonografia , Útero/diagnóstico por imagem , Adulto Jovem
8.
Artigo em Inglês | MEDLINE | ID: mdl-31281014

RESUMO

Medical and surgical methods can both be recommended for second trimester abortion (after 12-weeks of gestational age). Induced abortion with a mifepristone and misoprostol regimen is the preferred approach; where mifepristone is not available, misoprostol alone for medical abortion is also effective. Dilation and evacuation (D&E) is the procedure of choice for surgical abortions, and adequate cervical preparation contributes significantly to safety. Availability of drugs and instruments, ability to provide pain control, provider skill and comfort, client preference, cultural considerations, and local legislation all influence the method of abortion likely to be performed in a given setting. Both surgical and modern medical methods are safe and effective when provided by a trained, experienced provider.


Assuntos
Abortivos não Esteroides/uso terapêutico , Aborto Induzido/métodos , Mifepristona/uso terapêutico , Misoprostol/uso terapêutico , Abortivos não Esteroides/administração & dosagem , Dilatação/métodos , Feminino , Humanos , Mifepristona/administração & dosagem , Misoprostol/administração & dosagem , Dor Pós-Operatória , Gravidez , Segundo Trimestre da Gravidez
9.
J Fam Pract ; 68(10): 668;569;572, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31860701

RESUMO

Yes. While medical management of early pregnancy loss with misoprostol frequently results in treatment failure, pretreating with mifepristone can increase efficacy.


Assuntos
Abortivos não Esteroides/uso terapêutico , Abortivos Esteroides/uso terapêutico , Aborto Espontâneo/prevenção & controle , Quimioterapia Combinada , Medicina de Família e Comunidade/normas , Mifepristona/uso terapêutico , Misoprostol/uso terapêutico , Administração Oral , Adulto , Feminino , Humanos , Guias de Prática Clínica como Assunto , Gravidez
10.
BMC Pregnancy Childbirth ; 19(1): 443, 2019 Nov 27.
Artigo em Inglês | MEDLINE | ID: mdl-31775677

RESUMO

BACKGROUND: Early pregnancy failure (EPF) is a common complication of pregnancy. If women do not abort spontaneously, they will undergo medical or surgical treatment in order to remove the products of conception from the uterus. Curettage, although highly effective, is associated with a risk of complications; medical treatment with misoprostol is a safe and less expensive alternative. Unfortunately, after 1 week of expectant management in case of EPF, medical treatment with misoprostol has a complete evacuation rate of approximately 50%. Misoprostol treatment results may be improved by pre-treatment with mifepristone; its effectiveness has already been proven for other indications of pregnancy termination. This study will test the hypothesis that, in EPF, the sequential combination of mifepristone with misoprostol is superior to the use of misoprostol alone in terms of complete evacuation (primary outcome), patient satisfaction, complications, side effects and costs (secondary outcomes). METHODS: The trial will be performed multi-centred, prospectively, two-armed, randomised, double-blinded and placebo-controlled. Women with confirmed EPF by ultrasonography (6-14 weeks), managed expectantly for at least 1 week, can be included and randomised to pre-treatment with oral mifepristone (600 mg) or oral placebo (identical in appearance). Randomisation will take place after receiving written consent to participate. In both arms pre-treatment will be followed by oral misoprostol, which will start 36-48 h later consisting of two doses 400 µg (4 hrs apart), repeated after 24 h if no tissue is lost. Four hundred sixty-four women will be randomised in a 1:1 ratio, stratified by centre. Ultrasonography 2 weeks after treatment will determine short term treatment effect. When the gestational sac is expulsed, expectant management is advised until 6 weeks after treatment when the definitive primary endpoint, complete or incomplete evacuation, will be determined. A sonographic endometrial thickness < 15 mm using only the allocated therapy by randomisation is considered as successful treatment. Secondary outcome measures (patient satisfaction, complications, side effects and costs) will be registered using a case report form, patient diary and validated questionnaires (Short Form 36, EuroQol-VAS, Client Satisfaction Questionnaire, iMTA Productivity Cost Questionnaire). DISCUSSION: This trial will answer the question if, in case of EPF, after at least 1 week of expectant management, sequential treatment with mifepristone and misoprostol is more effective than misoprostol alone to achieve complete evacuation of the products of conception. TRIAL REGISTRATION: Clinicaltrials.gov (d.d. 02-07-2017): NCT03212352. Trialregister.nl (d.d. 03-07-2017): NTR6550. EudraCT number (d.d. 07-08-2017): 2017-002694-19. File number Commisie Mensgebonden Onderzoek (d.d. 07-08-2017): NL 62449.091.17.


Assuntos
Abortivos não Esteroides/uso terapêutico , Abortivos Esteroides/uso terapêutico , Aborto Incompleto/tratamento farmacológico , Mifepristona/uso terapêutico , Misoprostol/uso terapêutico , Abortivos não Esteroides/administração & dosagem , Abortivos Esteroides/administração & dosagem , Aborto Incompleto/diagnóstico por imagem , Adolescente , Adulto , Análise Custo-Benefício , Método Duplo-Cego , Quimioterapia Combinada/efeitos adversos , Feminino , Humanos , Mifepristona/administração & dosagem , Misoprostol/efeitos adversos , Estudos Multicêntricos como Assunto , Satisfação do Paciente , Gravidez , Primeiro Trimestre da Gravidez , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Ultrassonografia , Conduta Expectante , Adulto Jovem
11.
Medicine (Baltimore) ; 98(40): e17396, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31577749

RESUMO

Oral mifepristone combined with rivanol lactate (rivanol) is commonly used in second-trimester pregnancy termination. However, rivanol is not suitable to premature rupture of membranes and oligohydramnios because amniocentesis is difficult. Mifepristone combined with misoprostol is suitable for the patients with oligohydramnios. In accordance with the misoprostol dosing recommendations by the International Federation of Gynecology and Obstetrics (FIGO), the incidences of uterine rupture and cervical laceration are relatively high in Chinese pregnant women. The aim of our study was to optimize misoprostol dosing regimen in terms of efficacy and safety in Chinese pregnant women.We modified the Bishop Score, and then gave patients low-dose misoprostol according to the modified Bishop score. Based on the amniotic fluid volume (AFV) indicated by type-B ultrasonic instrument, the cases with AFV ≤2 cm receiving low-dose misoprostol combined with mifepristone and the cases with amniocentesis failure followed by receiving low-dose misoprostol combined with mifepristone were enrolled into study group, and the cases with AFV >2 cm receiving rivanol combined with mifepristone were enrolled into control group. The start time of uterine contractions, time of fetal expulsion, birth process, hospital day, successful induced labor rate, complete induced labor rate, and incomplete induced labor rate were observed and compared between the 2 groups.There were significant differences in the start time of uterine contractions, time of fetal expulsion, birth process, and hospital day between the control group and the study group (all P < .05). The successful induced labor rate, complete induced labor rate, and incomplete induced labor rate were also significantly different between the 2 groups (all P < .05).In the induced labor of 16 to 28 weeks pathological pregnancy, low-dose misoprostol can markedly improve the successful induced labor rate and complete induced labor rate, shorten the birth process and hospital day, and decrease uterine curettage rate and uterine rupture risk. Low-dose misoprostol combined with mifepristone is suitable to the induced labor of 16 to 28 weeks pathological pregnancy in Chinese women.


Assuntos
Abortivos não Esteroides/uso terapêutico , Aborto Induzido/métodos , Mifepristona/uso terapêutico , Misoprostol/uso terapêutico , Complicações na Gravidez/terapia , Segundo Trimestre da Gravidez , Abortivos não Esteroides/administração & dosagem , Abortivos não Esteroides/efeitos adversos , Aborto Induzido/efeitos adversos , Adulto , Grupo com Ancestrais do Continente Asiático , China , Relação Dose-Resposta a Droga , Quimioterapia Combinada , Feminino , Humanos , Mifepristona/administração & dosagem , Mifepristona/efeitos adversos , Misoprostol/administração & dosagem , Misoprostol/efeitos adversos , Oligo-Hidrâmnio/terapia , Gravidez , Fatores de Tempo , Ruptura Uterina/prevenção & controle
12.
Int Perspect Sex Reprod Health ; 45: 45-54, 2019 10 21.
Artigo em Inglês | MEDLINE | ID: mdl-31639080

RESUMO

CONTEXT: In Bangladesh, prior to the availability of the approved combination regimen of mifepristone and misoprostol for menstrual regulation (MR), drug seller provision of misoprostol-only regimens for MR without a prescription was widespread but service quality was poor. Examining provider practices relating to misoprostol-only provision in Bangladesh may increase understanding of misoprostol use and provision in other low-resource, legally restrictive settings. METHODS: In 2013-2014, a countrywide cross-sectional knowledge, attitudes and practice survey was conducted among 777 randomly selected drug sellers; data were analyzed descriptively. Logistic regression was used to test the associations between exposure to three interventions designed to improve drug seller practice (nongovernmental organization [NGO]-led training, a call center and in-shop training from pharmaceutical company representatives) and correct knowledge of the misoprostol-only MR regimen. RESULTS: Almost all (97%) of the drug sellers reported providing medications intended for MR; misoprostol-only was more commonly sold than the combination regimen (96% vs. 26%). Nine percent had received NGO-led training, 62% had received in-shop training from a pharmaceutical company representative and 27% had used the call center. Overall, 19% of drug sellers knew the correct misoprostol-only MR regimen, and 74% wanted more information about this regimen. Correct regimen knowledge was positively associated with receipt of NGO training and call center utilization (odds ratios, 2.0 and 1.9, respectively). CONCLUSIONS: NGO-led training and call centers should be considered in other settings in which misoprostol alone is provided off-label for pregnancy termination.


Assuntos
Abortivos não Esteroides/uso terapêutico , Indutores da Menstruação/uso terapêutico , Mifepristona/uso terapêutico , Misoprostol/uso terapêutico , Assistência Farmacêutica/organização & administração , Adulto , Atitude do Pessoal de Saúde , Bangladesh , Estudos Transversais , Feminino , Humanos , Avaliação de Resultados em Cuidados de Saúde , Farmácias
13.
Sex Reprod Health Matters ; 27(1): 1571311, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31533561

RESUMO

In the setting of increasing restrictions to legal abortion in the United States, reports have emerged of self-induced termination of pregnancies with misoprostol, obtained without a prescription or provider. This study seeks to describe the prevalence of women seeking or employing misoprostol for self-induced abortion, and how they access information. In a cross-sectional study of women immediately following their abortion at three reproductive health clinics in the Midwestern United States, an anonymous survey queried gestational age, barriers, online investigation about self-induction and opinions concerning the availability of medical abortion. From June to September 2016, 276 women participated out of 437 presenting to the clinics during the study period. One hundred and ninety-one (74.6%) women had investigated abortion options online, and of those, 58 (30.9%) investigated misoprostol online, for home use. Women who investigated online options were less likely to have had a prior abortion than those who did not investigate online (29.3% vs. 63.1%, p < .01). They were also more likely to report prior home attempts to end this pregnancy (8.6% vs. 0%, p = .05). Overall, four (1.6%) of the respondents purchased misoprostol and three (1.2%) used it. A majority of women seeking an abortion sought online information prior to their clinic appointment, and almost a third of those had investigated misoprostol for home use. Women are accessing information regarding misoprostol for self-induction of abortion on the Internet. As barriers to legal abortion increase, women may be more likely to self-induce abortion.


Assuntos
Abortivos não Esteroides/uso terapêutico , Aborto Induzido/métodos , Aborto Induzido/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Misoprostol/uso terapêutico , Aborto Induzido/estatística & dados numéricos , Adulto , Estudos Transversais , Uso de Medicamentos , Feminino , Acesso aos Serviços de Saúde , Humanos , Comportamento de Busca de Informação , Serviços de Saúde Materna , Meio-Oeste dos Estados Unidos , Gravidez , Saúde Reprodutiva , Automedicação , Inquéritos e Questionários , Adulto Jovem
14.
Ginekol Pol ; 90(8): 438-443, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31482546

RESUMO

OBJECTIVES: To assess the clinical value and treatment outcomes of postoperative methotrexate (MTX) therapy in themanagement of early abdominal pregnancy. MATERIAL AND METHODS: We retrospectively analyzed ten (10) cases of early abdominal pregnancy at our hospital between7th August, 2006 and 20th April, 2017. RESULTS: Out of the ten (10) cases identified, six (6) patients and four (4) patients underwent surgery (laparotomy or laparoscopy)only and surgery (laparotomy or laparoscopy) plus IM 50 mg/m2 methotrexate (MTX) within 24 hours of surgeryrespectively. The gestation age and serum ß-HcG levels were significantly lower (p < 0.05, 6.0 ± 1.82 and 8073.2 ± 9561.0)in the surgery plus MTX group in comparison to (7.33 ± 3.61 and 15625 ± 21275.2) for the surgery only group. Ultrasoundimaging findings reported extra uterine pregnancy in all cases and diagnostic surgery was necessary to locate precise siteof implantation to plan further treatment. Days of hospitalization were shorter in the surgery + MTX group than in thesurgery only group (3.00 ± 0.816 versus 5.66 ± 2.80). CONCLUSIONS: Earliness in diagnosis coupled with the appropriate (methotrexate) MTX regime could help prevent unwantedcomplications that could arise from delayed or misdiagnosis.


Assuntos
Abortivos não Esteroides/uso terapêutico , Gonadotropina Coriônica Humana Subunidade beta/sangue , Laparoscopia/métodos , Laparotomia/métodos , Metotrexato/uso terapêutico , Gravidez Abdominal/tratamento farmacológico , Gravidez Abdominal/cirurgia , Adolescente , Adulto , China , Diagnóstico Precoce , Feminino , Humanos , Período Pós-Operatório , Gravidez , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
15.
Reprod Biomed Online ; 39(5): 827-834, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31530445

RESUMO

RESEARCH QUESTION: Caesarean scar pregnancy (CSP) is an increasing concern in modern obstetrics. Early diagnosis and management are of utmost importance. The optimal management approach for CSP is not well established, with various treatment modalities reported. The role of conservative management of CSP has been previously reported, with conflicting results. This study aimed to further evaluate its role and better delineate the subsequent reproductive outcomes. DESIGN: A retrospective cohort study including all patients diagnosed with a CSP and treated by intention of conservative management with systemic methotrexate (MTX). Maternal and gestation characteristics were compared between treatment success and failure groups. RESULTS: Thirty-six cases of CSP were encountered. Overall, 29/36 (80.6%) were treated by systemic injection of MTX while the other 19.4% had combined systemic and local (i.e. intra-sac) MTX treatment. Invasive intervention was needed in five (13.9%) cases (failure group). Among those successfully treated with MTX, the median time to resolution was 22 (interquartile range 13-37) days. Cases who were converted to surgical treatment had a higher number of previous Caesarean deliveries (median 4 versus 2, P = 0.002). In logistic regression modelling, the number of previous Caesarean deliveries was the only factor independently associated with conversion to surgical management (odds ratio 2.02, 95% confidence interval 1.03-3.94). The majority of future pregnancies ended at term pregnancy with only one preterm delivery due to severe intrauterine growth restriction. CONCLUSIONS: Systemic MTX therapy is a safe and effective strategy for the treatment of CSP, with favourable subsequent reproductive results and a low conversion rate to surgical management.


Assuntos
Cesárea/efeitos adversos , Cicatriz , Metotrexato/uso terapêutico , Gravidez Ectópica/tratamento farmacológico , Abortivos não Esteroides/uso terapêutico , Adulto , Gonadotropina Coriônica/metabolismo , Tratamento Conservador , Feminino , Humanos , Análise Multivariada , Gravidez , Estudos Prospectivos , Análise de Regressão , Estudos Retrospectivos , Resultado do Tratamento
16.
Glob Health Sci Pract ; 7(Suppl 2): S231-S246, 2019 08 22.
Artigo em Inglês | MEDLINE | ID: mdl-31455621

RESUMO

BACKGROUND: Unsafe abortion contributes to maternal mortality worldwide and disproportionately affects the most disadvantaged women and girls; thus, improving the treatment of complications of abortion is essential. Shifting PAC treatment from sharp dilation and curettage (D&C) to the use of aspiration techniques, notably manual vacuum aspiration (MVA), and medical treatment with misoprostol improves health outcomes. Equally critical is ensuring that women have access to voluntary contraception after an abortion to prevent future unintended pregnancies. In humanitarian settings, access to voluntary family planning to disrupt the cycle of unsafe abortion is even more critical because access to quality services cannot be guaranteed due to security risks, migration, and devastation of infrastructure. Save the Children applied a multipronged postabortion care (PAC) approach in the Democratic Republic of the Congo (DRC), Somalia, and Yemen that focused on capacity building; assurance of supplies and infrastructure; community collaboration and mobilization; and monitoring and evaluation. METHODS: Program-level data were extracted for each of the 3 countries from the inception of their program through 2017. The sources of information included monthly service delivery reports that tracked key PAC indicators as well as qualitative data from evaluations of community mobilization activities. RESULTS: The number of PAC clients increased in all countries. In the DRC in 2012, 19% of PAC clients requiring treatment received D&C; in 2017 the percentage was reduced to 3%. In 2013, 25% of all PAC clients in Yemen were treated with D&C; this percentage was reduced to 3% in 2017. The proportion of women choosing contraception after an abortion increased. In 2012, only 42% of all PAC clients in the DRC chose a contraceptive method; by 2017, the proportion had increased to 70%. Somalia had substantial increases in PAC demand, with the percentage of all PAC clients electing contraception increasing from 64% in 2012 to 82% in 2017. In Yemen, where the health system has been constrained due to severe conflict, the percentage of PAC clients choosing voluntary contraception rose from 17% in 2013 to 38% in 2017. Uptake and demand for PAC was mobilized through targeted community outreach in each context. CONCLUSION: These data demonstrate that providers can effectively shift away from D&C as treatment for PAC and that contraceptive uptake by PAC clients can increase substantially, even in settings where the use of contraception after abortion is often stigmatized.


Assuntos
Assistência ao Convalescente , Fortalecimento Institucional , Participação da Comunidade , Equipamentos e Provisões/provisão & distribução , Abortivos não Esteroides/uso terapêutico , Aborto Induzido , República Democrática do Congo , Dilatação e Curetagem , Emergências , Serviços de Planejamento Familiar , Feminino , Acesso aos Serviços de Saúde , Humanos , Misoprostol/uso terapêutico , Gravidez , Melhoria de Qualidade , Qualidade da Assistência à Saúde , Socorro em Desastres , Somália , Curetagem a Vácuo , Iêmen
17.
Glob Health Sci Pract ; 7(Suppl 2): S247-S257, 2019 08 22.
Artigo em Inglês | MEDLINE | ID: mdl-31455622

RESUMO

INTRODUCTION: Unsafe abortion remains a problem in Rwanda, where abortion is highly restricted by law. To reduce mortality and morbidity from unsafe abortion, Rwanda implemented a national postabortion care (PAC) program in 2012, which included using misoprostol to treat incomplete abortion. Key components of PAC are offering and providing voluntary contraceptive methods and counseling on their use, but little is known about contraceptive uptake among PAC clients treated with misoprostol. The objectives of the current study were (1) to assess the contraceptive uptake of PAC clients treated with misoprostol, including whether extended bleeding hinders uptake; and (2) to assess providers' knowledge of contraception and their willingness to counsel PAC clients on contraception, provide methods, or refer for contraceptive services. METHODS: We surveyed 68 PAC clients treated with misoprostol and 43 providers (84% nurses) in 17 health facilities across 3 districts in Rwanda where misoprostol for PAC had been introduced recently. PAC clients were recruited into the study prior to facility discharge and surveyed between 10 days and 1 month after discharge. We asked PAC clients and providers about demographic characteristics and attitudes toward contraception. We also asked PAC clients about contraceptive counseling received and postabortion contraceptive uptake or reasons for nonuse, and providers about their knowledge about return to fertility, pregnancy and contraceptive counseling, practices related to contraceptive method provision, and their knowledge and potential biases about PAC clients using contraception. We used descriptive statistics for analysis. RESULTS: PAC clients were 19-46 years old, and most (69%) had at least 1 child. Almost all PAC clients (94%) reported being counseled on contraception, but only 47% reported choosing and receiving a method before being discharged from the facility. Nevertheless, by the time of the survey, 71% reported using a method. PAC clients' main reason for not using contraception was wanting to become pregnant. Only 1 woman reported nonuse because of bleeding. Among providers, more than half (56%) reported there are contraceptive methods PAC clients should never use and about a quarter (26%) reported incorrect information on when PAC clients' fertility could return. CONCLUSION: We found no evidence that bleeding associated with misoprostol for PAC influenced women's contraceptive uptake. However, as PAC programs expand to include misoprostol as a treatment option, accurate and high-quality postabortion contraception counseling and method provision at both treatment and follow-up visits must be strengthened.


Assuntos
Abortivos não Esteroides/uso terapêutico , Aborto Incompleto/tratamento farmacológico , Aborto Induzido , Aborto Espontâneo/tratamento farmacológico , Assistência ao Convalescente , Anticoncepção/estatística & dados numéricos , Misoprostol/uso terapêutico , Adulto , Anticoncepcionais/uso terapêutico , Feminino , Humanos , Pessoa de Meia-Idade , Enfermeiras e Enfermeiros , Gravidez , Ruanda , Adulto Jovem
18.
Glob Health Sci Pract ; 7(Suppl 2): S315-S326, 2019 08 22.
Artigo em Inglês | MEDLINE | ID: mdl-31455627

RESUMO

INTRODUCTION: In 2015, the government of Tanzania launched an effort to strengthen the quality of postabortion care (PAC), an integrated health service that includes treatment for abortion complications and provision of family planning counseling and voluntary services, in 25 facilities in mainland Tanzania and in Zanzibar. METHODS: To help guide the government's initiative, we conducted a mixed-method study in 2016 using health facility surveys and in-depth interviews with health care workers that offer PAC. Surveys of the 25 facilities assessed the current use of services and readiness to deliver them. Provider performance in PAC was assessed through direct observation of client-provider interactions. In-depth interviews (IDIs) with 30 staff from the facilities provided qualitative information on priorities for PAC quality improvement. RESULTS: In the 6 months preceding the study, 2,175 PAC clients sought care at the facilities. Of these PAC clients, 55% chose a family planning method, of whom 6% chose a voluntary long-acting reversible contraceptive. The median facility PAC readiness scores were 45% for health centers, 49% for district hospitals, and 61% for regional referral hospitals. Direct observations of manual vacuum aspiration provision for PAC revealed that providers implemented, on average, 69% of the critical clinical steps. For misoprostol provision, PAC providers implemented, on average, 42% of the critical steps. Multilevel influences affected PAC providers' work, often adversely, by shaping their confidence in their technical competency, confusing their role as health care workers and as clients' peers, and coloring their attitudes toward clientele. The PAC providers also felt that their ability to implement their responsibilities was shaped by lapses in essential support and functionality of the health care system, as well as by social and cultural norms. CONCLUSIONS: Technical assistance approaches that blend training, clinical quality improvement, systems strengthening, and social interventions that address demand-side barriers are needed to ensure providers achieve their potential and are able to deliver high-quality PAC.


Assuntos
Assistência ao Convalescente , Atitude do Pessoal de Saúde , Equipamentos e Provisões , Pessoal de Saúde , Qualidade da Assistência à Saúde , Abortivos não Esteroides/uso terapêutico , Fortalecimento Institucional , Feminino , Humanos , Contracepção Reversível de Longo Prazo , Misoprostol/uso terapêutico , Gravidez , Tanzânia , Curetagem a Vácuo , Recursos Humanos
19.
Afr J Reprod Health ; 23(2): 148-151, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31433602

RESUMO

After years of the worsening burden of unsafe abortion and attendant morbidities and mortalities in Nigeria, a National Guideline on the Safe termination of pregnancy for legal indications was enunciated. This report presents and discusses an illustrative case of a hydranencephaly that benefited from it. A 43-year old multipara was informed during routine ultrasonography at booking for antenatal care, at 16 weeks of gestation, of a major defect in her baby and advised to meet her physician. Following a repeat high- resolution ultrasonography and discussions between the Obstetricians, Neurosurgeon, and Ultrasonologist, the woman was counseled on the diagnosis. At her insistence and provision of written consent, medical abortion with Mifepristone and Misoprostol was successfully instituted.


Assuntos
Abortivos não Esteroides/uso terapêutico , Aborto Induzido/métodos , Hidranencefalia/diagnóstico por imagem , Mifepristona/uso terapêutico , Misoprostol/uso terapêutico , Abortivos não Esteroides/administração & dosagem , Abortivos Esteroides , Administração Oral , Adulto , Feminino , Humanos , Mifepristona/administração & dosagem , Misoprostol/administração & dosagem , Gravidez , Segundo Trimestre da Gravidez , Resultado do Tratamento
20.
Arch Gynecol Obstet ; 300(5): 1287-1293, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31422461

RESUMO

PURPOSE: We aimed to assess the role of repeat misoprostol administration in those with thickened endometrium in the management of early pregnancy failure (EPF). METHODS: A retrospective cohort study in two university hospitals among women receiving misoprostol treatment for EPF. Those with thickened endometrium at the first follow-up visit, who received a repeat 800 µg dose of vaginal misoprostol in institution B and no treatment in institution A, constituted the study group. The primary outcome was treatment success, defined as complete uterine evacuation without the need for any operative intervention RESULTS: Overall, 608 women with thickened endometrium as assessed by transvaginal ultrasonography 2 days following initial misoprostol administration for EPF were included. Of them, 427 did not receive repeat misoprostol dose, and 181 received repeat misoprostol dose. The rate of surgical intervention did not differ between those who received a repeat misoprostol dose (6.1%) and those who did not (4.3%) (P = 0.32). The median endometrial thickness was similar in those that did and did not require subsequent surgical intervention (P = 0.65), and was a poor predictor of treatment outcome. CONCLUSIONS: Repeat misoprostol administration among women with thickened endometrium following initial misoprostol administration for EPF was not associated with improved treatment success rates.


Assuntos
Abortivos não Esteroides/uso terapêutico , Aborto Induzido/métodos , Misoprostol/uso terapêutico , Abortivos não Esteroides/farmacologia , Administração Intravaginal , Adulto , Feminino , Humanos , Misoprostol/farmacologia , Gravidez , Estudos Retrospectivos , Resultado do Tratamento
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