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1.
J Am Board Fam Med ; 34(Suppl): S33-S36, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33622815

RESUMO

Despite first trimester abortion being common and safe, there are numerousrestrictions that lead to barriers to seeking abortion care. The COVID-19 pandemic hasonly exacerbated these barriers, as many state legislators push to limit abortion accesseven further. During this pandemic, family physicians across the country haveincorporated telemedicine into their practices to continue to meet patient needs.Medication abortion can be offered to patients by telemedicine in most states, andmultiple studies have shown that labs, imaging, and physical exam may not beessential in all cases. Family physicians are well-poised to incorporate medicationabortion into their practices using approaches that limit the spread of the coronavirus,ultimately increasing access to abortion in these unprecedented times.


Assuntos
Abortivos/administração & dosagem , Aborto Induzido/métodos , Medicina de Família e Comunidade/organização & administração , Acesso aos Serviços de Saúde/organização & administração , Papel do Médico , Telemedicina/organização & administração , /epidemiologia , Medicina de Família e Comunidade/métodos , Feminino , Humanos , Pandemias , Gravidez , Primeiro Trimestre da Gravidez , Autoadministração , Telemedicina/métodos , Estados Unidos/epidemiologia
2.
JAMA Netw Open ; 3(12): e2029245, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-33337493

RESUMO

Importance: Increasing evidence indicates that people are attempting their own abortions outside the formal health care system. However, population-based estimates of experience with self-managed abortion (SMA) are lacking. Objective: To estimate the prevalence of SMA attempts among the general US population. Design, Setting, and Participants: This cross-sectional survey study was fielded August 2 to 17, 2017 among English- and Spanish- speaking, self-identified female panel members from the GfK web-based KnowledgePanel. Women ages 18 to 49 years were approached to complete a 1-time survey. Data were analyzed from September 22, 2017, to March 26, 2020. Main Outcomes and Measures: SMA was defined as "some women may do something on their own to try to end a pregnancy without medical assistance. For example, they may get information from the internet, a friend, or family member about pills, medicine, or herbs they can take on their own, or they may do something else to try to end the pregnancy." SMA was assessed using the question, "Have you ever taken or used something on your own, without medical assistance, to try to end an unwanted pregnancy?" Participants reporting SMA were asked about methods used, reasons, and outcomes. Factors associated with SMA experience, including age, race/ethnicity, socioeconomic status, nativity, reproductive health history, and geography, were assessed. Projected lifetime SMA prevalence was estimated using discrete-time event history models, adjusting for abortion underreporting. Results: Among 14 151 participants invited to participate, 7022 women (49.6%) (mean [SE] age, 33.9 [9.0] years) agreed to participate. Among these, 57.4% (95% CI, 55.8%-59.0%) were non-Hispanic White, 20.2% (95% CI, 18.9%-21.5%) were Hispanic, and 13.3% (95% CI, 12.1%-14.5%) were non-Hispanic Black; and 15.1% (95% CI, 14.1%-16.3%) reported living at less than 100% federal poverty level (FPL). A total of 1.4% (95% CI, 1.0%-1.8%) of participants reported a history of attempting SMA while in the US. Projected lifetime prevalence of SMA adjusting for underreporting of abortion was 7.0% (95% CI, 5.5%-8.4%). In bivariable analyses, non-Hispanic Black (prevalence ratio [PR], 3.16; 95% CI, 1.48-6.75) and Hispanic women surveyed in English (PR, 3.74; 95% CI, 1.78-7.87) were more likely than non-Hispanic White women to have attempted SMA. Women living below 100% of the FPL were also more likely to have attempted SMA compared with those at 200% FPL or greater (PR, 3.43; 95% CI, 1.83-6.42). At most recent SMA attempt, 20.0% (95% CI, 10.9%-33.8%) of respondents used misoprostol, 29.2% (95% CI, 17.5%-44.5%) used another medication or drug, 38.4% (95% CI, 25.3%-53.4%) used herbs, and 19.8% (95% CI, 10.0%-35.5%) used physical methods. The most common reasons for SMA included that it seemed faster or easier (47.2% [95% CI, 33.0%-61.8%]) and the clinic was too expensive (25.2% [95% CI, 15.7%-37.7%]). Of all attempts, 27.8% (95% CI, 16.6%-42.7%) of respondents reported they were successful; the remainder reported they had subsequent facility-based abortions (33.6% [95% CI, 21.0%-49.0%]), continued the pregnancy (13.4% [95% CI, 7.4%-23.1%]), had a miscarriage (11.4% [95% CI, 4.2%-27.5%]), or were unsure (13.3% [95% CI, 6.8%-24.7%]). A total of 11.0% (95% CI, 5.5%-21.0%) of respondents reported a complication. Conclusions and Relevance: This cross-sectional study found that approximately 7% of US women reported having attempted SMA in their lifetime, commonly with ineffective methods. These findings suggest that surveys of SMA experience among patients at abortion clinics may capture only one-third of SMA attempts. People's reasons for attempting SMA indicate that as abortion becomes more restricted, SMA may become more common.


Assuntos
Aborto Induzido , Gravidez não Desejada/psicologia , Autogestão , Aborto Induzido/métodos , Aborto Induzido/estatística & dados numéricos , Adulto , Estudos Transversais , Tomada de Decisões , Grupos Étnicos , Feminino , Humanos , Gravidez , Prevalência , História Reprodutiva , Autogestão/métodos , Autogestão/psicologia , Autogestão/estatística & dados numéricos , Fatores Socioeconômicos , Estados Unidos/epidemiologia
3.
Taiwan J Obstet Gynecol ; 59(6): 808-811, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33218393

RESUMO

Many routine and elective services have already been postponed or suspended by both Government and private setups in most parts of the world because of the unprecedented pandemic of COVID-19. Healthcare systems everywhere in the world are under pressure. Being a component of essential health services, family planning and abortion services should continue to cater the population in order to prevent the complications arising from unintended pregnancies and sudden rise in STIs. Due to airborne nature of transmission of the virus, it is advisable for all consultations relating to family planning services to be done remotely unless and until visit is absolutely necessary. Contraception initiation and continuation can be done by telemedicine in most individuals. Post partum contraception can be advised before discharge from hospital. In an individual planning for pregnancy, currently it is not advisable to discontinue contraceptive and plan for pregnancy as not much is known about the effect of the virus on foetal development. Also, pregnancy requires routine antenatal and peripartum care and complications arising from pregnancy may necessitate frequent hospital visits, exposing the individual to the risk of infection. Abortion services are time sensitive therefore should not be denied or delayed beyond legal limit. We need to change from real to virtual consultation to prevent the rise in unplanned pregnancies, sexually transmitted infections and unsafe abortions.


Assuntos
Aborto Induzido/métodos , Infecções por Coronavirus/prevenção & controle , Serviços de Planejamento Familiar/métodos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Complicações Infecciosas na Gravidez/prevenção & controle , Telemedicina/métodos , Betacoronavirus , Anticoncepção/métodos , Feminino , Humanos , Cuidado Pré-Concepcional/métodos , Gravidez , Complicações Infecciosas na Gravidez/virologia
5.
Obstet Gynecol ; 136(4): 855-858, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32976374

RESUMO

Medication abortion, also referred to as medical abortion, is a safe and effective method of providing abortion. Medication abortion involves the use of medicines rather than uterine aspiration to induce an abortion. The U.S. Food and Drug Administration (FDA)-approved medication abortion regimen includes mifepristone and misoprostol. The purpose of this document is to provide updated evidence-based guidance on the provision of medication abortion up to 70 days (or 10 weeks) of gestation. Information about medication abortion after 70 days of gestation is provided in other ACOG publications ().


Assuntos
Aborto Induzido , Mifepristona/farmacologia , Misoprostol/farmacologia , Abortivos/farmacologia , Aborto Induzido/métodos , Aborto Induzido/normas , Protocolos Clínicos , Feminino , Idade Gestacional , Humanos , Guias de Prática Clínica como Assunto , Gravidez , Primeiro Trimestre da Gravidez/efeitos dos fármacos , Estados Unidos
7.
Obstet Gynecol ; 136(4): 774-781, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925621

RESUMO

OBJECTIVE: To assess whether mifepristone pretreatment adversely affects the cost of medical management of miscarriage. METHODS: Decision tree analyses were constructed, and Monte Carlo simulations were run comparing costs of combination therapy (mifepristone and misoprostol) with monotherapy (misoprostol alone) for medical management of miscarriage in multiple scenarios weighing clinical practice, patient income, and surgical evacuation modalities for failed medical management. Rates of completed medical evacuation for each were obtained from a recent randomized controlled trial. RESULTS: In every scenario, combination therapy offered a significant cost advantage over monotherapy. Using a Monte Carlo analysis, cost differences favoring combination therapy ranged from 6.3% to 19.5% in patients making federal minimum wage. The cost savings associated with combination therapy were greatest in scenarios using a staged approach to misoprostol administration and in scenarios using in-operating room dilation and curettage as the only modality for uterine evacuation, a savings of $190.20 (99% CI 189.35-191.07) and $217.85 (99% CI 217.19-218.50) per patient in a low-income wage group, respectively. A smaller difference was seen in scenarios using in-office manual vacuum aspiration to complete medical management failures. As patients' wages increased, the difference in cost between combination therapy and monotherapy increased. CONCLUSION: Mifepristone combined with misoprostol is, overall, more cost effective than monotherapy, and therefore cost should not be a deterrent to its adoption in the management of miscarriage.


Assuntos
Aborto Incompleto , Aborto Induzido , Quimioterapia Combinada , Mifepristona , Misoprostol , Abortivos/administração & dosagem , Abortivos/economia , Aborto Incompleto/induzido quimicamente , Aborto Incompleto/economia , Aborto Incompleto/cirurgia , Aborto Induzido/efeitos adversos , Aborto Induzido/economia , Aborto Induzido/métodos , Análise Custo-Benefício , Dilatação e Curetagem/economia , Dilatação e Curetagem/métodos , Quimioterapia Combinada/economia , Quimioterapia Combinada/métodos , Feminino , Humanos , Mifepristona/administração & dosagem , Mifepristona/economia , Misoprostol/administração & dosagem , Misoprostol/economia , Método de Monte Carlo , Padrões de Prática Médica , Gravidez
8.
Obstet Gynecol ; 136(4): e31-e47, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32804884

RESUMO

Medication abortion, also referred to as medical abortion, is a safe and effective method of providing abortion. Medication abortion involves the use of medicines rather than uterine aspiration to induce an abortion. The U.S. Food and Drug Administration (FDA)-approved medication abortion regimen includes mifepristone and misoprostol. The purpose of this document is to provide updated evidence-based guidance on the provision of medication abortion up to 70 days (or 10 weeks) of gestation. Information about medication abortion after 70 days of gestation is provided in other ACOG publications ().


Assuntos
Aborto Induzido , Mifepristona/farmacologia , Misoprostol/farmacologia , Abortivos/farmacologia , Aborto Induzido/métodos , Aborto Induzido/normas , Protocolos Clínicos , Feminino , Idade Gestacional , Humanos , Gravidez , Primeiro Trimestre da Gravidez/efeitos dos fármacos , Estados Unidos
10.
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
11.
BMC Womens Health ; 20(1): 96, 2020 05 06.
Artigo em Inglês | MEDLINE | ID: mdl-32375746

RESUMO

BACKGROUND: Madagascar has restrictive abortion laws with no explicit exception to preserve the woman's life. This study aimed to estimate the incidence of abortion in the country and examine the methods, consequences, and risk factors of these abortions. METHODS: We interviewed 3179 women between September 2015 and April 2016. Women were selected from rural and urban areas of ten districts via a multistage, stratified cluster sampling survey and asked about any induced abortions within the previous 10 years. Analyses used survey weighted estimation procedures. Quasi-Poisson regression was used to estimate the incidence rate of abortions. Logistic regression models with random effects to account for the clustered sampling design were used to estimate the risk of abortion complications by abortion method, provider, and month of pregnancy, and to describe risk factors of induced abortion. RESULTS: For 2005-2016, we estimated an incidence rate of 18.2 abortions (95% CI 14.4-23.0) per 1000 person-years among sexually active women (aged 18-49 at the time of interview). Applying a multiplier of two as used by the World Health Organization for abortion surveys suggests a true rate of 36.4 per 1000 person-year of exposure. The majority of abortions involved invasive methods such as manual or sharp curettage or insertion of objects into the genital tract. Signs of potential infection followed 29.1% (21.8-37.7%) of abortions. However, the odds of potential infection and of seeking care after abortion did not differ significantly between women who used misoprostol alone and those who used other methods. The odds of experiencing abortion were significantly higher among women who had ever used contraceptive methods compared to those who had not. However, the proportion of women with a history of abortion was significantly lower in rural districts where contraception was available from community health workers than where it was not. CONCLUSIONS: Incidence estimates from Madagascar are lower than those from other African settings, but similar to continent-wide estimates when accounting for underreporting. The finding that the majority of abortions involved invasive procedures suggests a need for strengthening information, education and communications programs on preventing or managing unintended pregnancies.


Assuntos
Aborto Incompleto/epidemiologia , Aborto Induzido/efeitos adversos , Aborto Induzido/estatística & dados numéricos , Serviços de Planejamento Familiar/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Aborto Induzido/métodos , Adolescente , Adulto , Estudos Transversais , Feminino , Humanos , Incidência , Madagáscar/epidemiologia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Gravidez , Gravidez não Planejada , Gravidez não Desejada , Saúde Reprodutiva , Fatores de Risco , População Rural , Inquéritos e Questionários , População Urbana , Adulto Jovem
13.
Gene ; 741: 144533, 2020 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-32145327

RESUMO

BACKGROUND: Syncytin-1 and syncytin-2 which are endogenous retroviral genes products play a great role in syncytialization during trophoblast differentiation in normal placental tissues. In aneuploidic placentas due to the low level of pregnancy-induced hormones an alteration was occurred in the syncytialization process, while in the presence of cytogenetically abnormal karyotype the effect of syncytin gene expression levels on syncytialization process and in occured to spontaneous abortions is not clear. To reveal this, we investigated in syncytin-1 and syncytin-2 genes expression levels of chromosomally abnormal and normal trophophoblastic tissues and we also discussed the effect of the syncytin gene expression levels to the occurense of the spontaneous abortion. MATERIAL AND METHODS: To each one of the trophoblastic cells; cultivation, harvesting, banding, and analysis were performed and the chromosomes were classified according to the presence of abnormality and normal XY constitution. To exclude the maternal decidual cell contamination, female karyotyped abortion materials were omitted in control group. The patient group consisted of thirty six placental tissues including trisomy 16 (n = 10), triploidy (n = 9), monosomy X (n = 9), trisomy 21 (n = 5) and trisomy 7 (n = 3). The control group was consisting twenty placental tissues with XY karyotypes. The some part of the dissected frozen trophoblastic cells were used for RNA isolation and were proceeded to the determination of the expression levels of syncytin-1 and syncytin-2 genes by single-step Real Time PCR. The cDNAs were obtained by probes used in the same PCR stages. The sequence analysis of the syncytin-1 and syncytin-2 genes were performed, and read by the usage of the FinchTV 1.4.0 program. RESULTS: Between the expression levels of syncytin-1 and syncytin-2 genes were statistically difference in the patients and controls. There was a difference (p < 0.0001) between trisomy 7 and other patient groups and controls, regarding to the expression of syncytin-1 gene. Numerous mutations in the syncytin-1 and syncytin-2 genes (on the expression sites) were detected, and the mutation rate was higher in the syncytin-1 gene compared to the syncytin-2 gene in the patient and in the control groups (p < 0.001). CONCLUSION: The results of the study indicate that the expression of the syncytin-2 genes could be altered in the presence of chromosomally abnormal trophoblastic tissues, and these could lead to the loss of pregnancy due to the insufficient syncytialization. In sum, the current research has value for the further studies covering the mechanisms of trophoblast cell fusion, and syncytiotrophoblast regeneration, and thus the pathophysiology of human placental development in the presence of genomic anomaly.


Assuntos
Cariótipo Anormal , Aborto Espontâneo/genética , Produtos do Gene env/economia , Proteínas da Gravidez/economia , Proteínas da Gravidez/genética , Feto Abortado/patologia , Aborto Induzido/métodos , Aborto Espontâneo/patologia , Adulto , Diferenciação Celular/genética , Feminino , Regulação da Expressão Gênica no Desenvolvimento/genética , Humanos , Cariótipo , Placenta/metabolismo , Gravidez , Trissomia/genética , Trissomia/patologia , Trofoblastos/patologia , Síndrome de Turner/genética , Síndrome de Turner/patologia , Adulto Jovem
14.
BJOG ; 127(11): 1348-1357, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32162427

RESUMO

BACKGROUND: High-quality care for termination of pregnancy (TOP) requires pain to be effectively managed; however, practices differ, and the available guidelines do not specify optimal strategies. OBJECTIVE: To guide providers in effective pain management for second-trimester medical and surgical TOP. SEARCH STRATEGY: We searched PubMed, Cochrane and Embase databases, and the US National Library of Medicine clinical trials registry, from inception to the end of June 2019, and hand-searched reference lists. SELECTION CRITERIA: Trials comparing pain management strategies with no treatment, placebo or active interventions during induced medical or surgical TOP, occurring between 13 and 24 weeks of gestation, and reporting direct or indirect measures of pain. DATA COLLECTION AND ANALYSIS: Both authors summarised and systematically assessed the evidence and risk of bias using standard tools. MAIN RESULTS: We included seven medical and four surgical TOP studies, with 453 and 349 participants, respectively. The heterogeneity of interventions and outcomes prevented pooled analyses. Medical TOP: women receiving routine or continuous epidural analgesia experienced mild pain. The prophylactic use of nonsteroidal anti-inflammatory drugs (NSAIDs) decreased pain (mean difference -0.5, P < 0.001) and additional opioid requirements (3.5 versus 7 mg, P = 0.04) compared with placebo/other treatment. Paracervical block was ineffective. No studies assessed intramuscular (IM)/intravenous (IV) opioid or nonpharmacological treatment. Surgical TOP: general anaesthesia/deep IV sedation alleviated pain. Nitrous oxide was ineffective. No studies assessed moderate IV sedation, IV/IM opioid, paracervical block without sedation, NSAID or nonpharmacological treatment. CONCLUSION: Based on limited data, regional analgesia and NSAIDs mitigated second-trimester medical TOP pain; general anaesthesia/deep IV sedation alleviated surgical TOP pain. TWEETABLE ABSTRACT: Although women experience intense pain during second-trimester termination of pregnancy, few data are available to inform their treatment.


Assuntos
Aborto Induzido/efeitos adversos , Dor Pós-Operatória/prevenção & controle , Dor/prevenção & controle , Aborto Induzido/métodos , Analgesia Epidural , Analgésicos Opioides/uso terapêutico , Anestesia Geral , Anestesia Intravenosa , Anestesia Obstétrica , Anti-Inflamatórios não Esteroides/uso terapêutico , Feminino , Humanos , Gravidez , Segundo Trimestre da Gravidez
15.
Am J Public Health ; 110(5): 677-684, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32191521

RESUMO

In the aftermath of the introduction of severe restrictions on abortion in several US states, some activists have argued that providing widespread access to an abortive drug, misoprostol, will transform an induced abortion into a fully private act and therefore will empower women. In Brazil, where abortion is criminalized, the majority of women who wish to terminate an unwanted pregnancy already use the illegal, but easily accessible, misoprostol. We examine the history of misoprostol as an abortifacient in Brazil from the late 1980s until today and the professional debates on the teratogenicity of this drug. The effects of a given pharmaceutical compound, we argue, are always articulated, elicited, and informed within dense networks of sociocultural, economic, legal, and political settings. In a conservative and repressive environment, the use of misoprostol for self-induced abortions, even when supported by formal or informal solidarity networks, is far from being a satisfactory solution to the curbing of women's reproductive rights.


Assuntos
Abortivos/uso terapêutico , Aborto Induzido/legislação & jurisprudência , Aborto Induzido/métodos , Empoderamento , Misoprostol/uso terapêutico , Abortivos/administração & dosagem , Abortivos/efeitos adversos , Aborto Induzido/psicologia , Brasil , Características Culturais , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Misoprostol/administração & dosagem , Misoprostol/efeitos adversos , Política , Direitos Sexuais e Reprodutivos , Direitos da Mulher
16.
BMJ Open Qual ; 9(1)2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32209594

RESUMO

BACKGROUND: Effective care dearth in USA healthcare systems can be augmented by patient engagement and shared decision-making (SDM). These effective care strategies can facilitate medical abortion follow-up care (ensuring patients are not experiencing a continuing pregnancy) and follow-up options access. LOCAL PROBLEM: The quality improvement project clinic had a state-mandated waiting period, requiring additional visits. This delayed care for all abortion patients, creating travel, and cost barriers. The clinic had some of the lowest medical abortion follow-up rates out of its entire national network. METHODS: Four 'Plan-Do-Study-Act' (PDSA) cycles built on clinical changes, implementing an Agency for Healthcare Research and Quality serum human chorionic gonadotropin guideline. Medical abortion patient cohort size doubled during each PDSA cycle. INTERVENTIONS: Through four interventions (team engagement, patient engagement, Beta follow-up and contraception SDM), standardised follow-up care was integrated into clinic workflow with contraception SDM tools and an Option Grid. RESULTS: Most intervention measures were successful, with staff offering follow-up options counselling to all medical abortion patients by the end of the project. The Beta follow-up rate (84%) was higher than the overall follow-up rate (52%-73%), but the goal of a 92% overall follow-up rate was not met. Contraception SDM streamlined counselling but long-acting reversible contraception insertion rates did not increase. CONCLUSIONS: Effective care enabled the majority of medical abortion patients to choose Beta follow-up as their preferred follow-up method, especially those with a travel barrier. Beta follow-up gives assurance to close the follow-up gap over time.


Assuntos
Abortivos/uso terapêutico , Aborto Induzido/métodos , Assistência ao Convalescente/normas , Tomada de Decisões , Abortivos/farmacologia , Aborto Induzido/tendências , Adulto , Assistência ao Convalescente/métodos , Assistência ao Convalescente/tendências , Feminino , Humanos , Participação do Paciente/psicologia , Gravidez , Melhoria de Qualidade , Estados Unidos
17.
JAMA Netw Open ; 3(3): e201594, 2020 03 02.
Artigo em Inglês | MEDLINE | ID: mdl-32215633

RESUMO

Importance: Early pregnancy loss (EPL) is the most common complication of pregnancy. A multicenter randomized clinical trial compared 2 strategies for medical management and found that mifepristone pretreatment is 25% more effective than the standard of care, misoprostol alone. The cost of mifepristone may be a barrier to implementation of the regimen. Objective: To assess the cost-effectiveness of medical management of EPL with mifepristone pretreatment plus misoprostol vs misoprostol alone in the United States. Design, Setting, and Participants: This preplanned. prospective economic evaluation was performed concurrently with a randomized clinical trial in 3 US sites from May 1, 2014, through April 30, 2017. Participants included 300 women with anembryonic gestation or embryonic or fetal demise. Cost-effectiveness was computed from the health care sector and societal perspectives, with a 30-day time horizon. Data were analyzed from July 1, 2018, to July 3, 2019. Interventions: Mifepristone pretreatment plus misoprostol administration vs misoprostol alone. Main Outcomes and Measures: Costs in 2018 US dollars, effectiveness in quality-adjusted life-years (QALYs), and treatment efficacy. Incremental cost-effectiveness ratios (ICERs) of mifepristone and misoprostol vs misoprostol alone were calculated, and cost-effectiveness acceptability curves were generated. Results: Among the 300 women included in the randomized clinical trial (mean [SD] age, 30.4 [6.2] years), mean costs were similar for groups receiving mifepristone pretreatment and misoprostol alone from the health care sector perspective ($696.75 [95% CI, $591.88-$801.62] vs $690.88 [95% CI, $562.38-$819.38]; P = .94) and the societal perspective ($3846.30 [95% CI, $2783.01-$4909.58] vs $4845.62 [95% CI, $3186.84-$6504.41]; P = .32). The mifepristone pretreatment group had higher QALYs (0.0820 [95% CI, 0.0815-0.0825] vs 0.0806 [95% CI, 0.0800-0.0812]; P = .001) and a higher completion rate after first treatment (83.8% vs 67.1%; P < .001) than the group receiving misoprostol alone. From the health care sector perspective, mifepristone pretreatment was cost-effective relative to misoprostol alone with an ICER of $4225.43 (95% CI, -$195 053.30 to $367 625.10) per QALY gained. From the societal perspective, mifepristone pretreatment dominated misoprostol alone (95% CI, -$5 111 629 to $1 801 384). The probabilities that mifepristone pretreatment was cost-effective compared with misoprostol alone at a willingness-to-pay of $150 000 per QALY gained from the health care sector and societal perspectives were approximately 90% and 80%, respectively. Conclusions and Relevance: This study found that medical management of EPL with mifepristone pretreatment was cost-effective when compared with misoprostol alone. Trial Registration: ClinicalTrials.gov Identifier: NCT02012491.


Assuntos
Abortivos Esteroides , Aborto Induzido , Mifepristona , Abortivos Esteroides/economia , Abortivos Esteroides/uso terapêutico , Aborto Induzido/economia , Aborto Induzido/métodos , Aborto Induzido/estatística & dados numéricos , Adulto , Análise Custo-Benefício , Perda do Embrião/terapia , Feminino , Humanos , Mifepristona/economia , Mifepristona/uso terapêutico , Misoprostol/economia , Misoprostol/uso terapêutico , Gravidez , Estudos Prospectivos
18.
Cochrane Database Syst Rev ; 3: CD013181, 2020 Mar 09.
Artigo em Inglês | MEDLINE | ID: mdl-32150279

RESUMO

BACKGROUND: The advent of medical abortion has improved access to safe abortion procedures. Medical abortion procedures involve either administering mifepristone followed by misoprostol or a misoprostol-only regimen. The drugs are commonly administered in the presence of clinicians, which is known as provider-administered medical abortion. In self-administered medical abortion, drugs are administered by the woman herself without the supervision of a healthcare provider during at least one stage of the drug protocol. Self-administration of medical abortion has the potential to provide women with control over the abortion process. In settings where there is a shortage of healthcare providers, self-administration may reduce the burden on the health system. However, it remains unclear whether self-administration of medical abortion is effective and safe. It is important to understand whether women can safely and effectively terminate their own pregnancies when having access to accurate and adequate information, high-quality drugs, and facility-based care in case of complications. OBJECTIVES: To compare the effectiveness, safety, and acceptability of self-administered versus provider-administered medical abortion in any setting. SEARCH METHODS: We searched Cochrane Central Register of Controlled Trials, MEDLINE in process and other non-indexed citations, Embase, CINAHL, POPLINE, LILACS, ClinicalTrials.gov, WHO ICTRP, and Google Scholar from inception to 10 July 2019. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and prospective cohort studies with a concurrent comparison group, using study designs that compared medical abortion by self-administered versus provider-administered methods. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted the data, and we performed a meta-analysis where appropriate using Review Manager 5. Our primary outcome was successful abortion (effectiveness), defined as complete uterine evacuation without the need for surgical intervention. Ongoing pregnancy (the presence of an intact gestational sac) was our secondary outcome measuring success or effectiveness. We assessed statistical heterogeneity with Chi2 tests and I2 statistics using a cut-off point of P < 0.10 to indicate statistical heterogeneity. Quality assessment of the data used the GRADE approach. We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We identified 18 studies (two RCTs and 16 non-randomized studies (NRSs)) comprising 11,043 women undergoing early medical abortion (≤ 9 weeks gestation) in 10 countries. Sixteen studies took place in low-to-middle income resource settings and two studies were in high-resource settings. One NRS study received analgesics from a pharmaceutical company. Five NRSs and one RCT did not report on funding; nine NRSs received all or partial funding from an anonymous donor. Five NRSs and one RCT received funding from government agencies, private foundations, or non-profit bodies. The intervention in the evidence is predominantly from women taking mifepristone in the presence of a healthcare provider, and subsequently taking misoprostol without healthcare provider supervision (e.g. at home). There is no evidence of a difference in rates of successful abortions between self-administered and provider-administered groups: for two RCTs, risk ratio (RR) 0.99, 95% confidence interval (CI) 0.97 to 1.01; 919 participants; moderate certainty of evidence. There is very low certainty of evidence from 16 NRSs: RR 0.99, 95% CI 0.97 to 1.01; 10,124 participants. For the outcome of ongoing pregnancy there may be little or no difference between the two groups: for one RCT: RR 1.69, 95% CI 0.41 to 7.02; 735 participants; low certainty of evidence; and very low certainty evidence for 11 NRSs: RR 1.28, 95% CI 0.65 to 2.49; 6691 participants. We are uncertain whether there are any differences in complications requiring surgical intervention, since we found no RCTs and evidence from three NRSs was of very low certainty: for three NRSs: RR 2.14, 95% CI 0.80 to 5.71; 2452 participants. AUTHORS' CONCLUSIONS: This review shows that self-administering the second stage of early medical abortion procedures is as effective as provider-administered procedures for the outcome of abortion success. There may be no difference for the outcome of ongoing pregnancy, although the evidence for this is uncertain for this outcome. There is very low-certainty evidence for the risk of complications requiring surgical intervention. Data are limited by the scarcity of high-quality research study designs and the presence of risks of bias. This review provides insufficient evidence to determine the safety of self-administration when compared with administering medication in the presence of healthcare provider supervision. Future research should investigate the effectiveness and safety of self-administered medical abortion in the absence of healthcare provider supervision through the entirety of the medical abortion protocol (e.g. during administration of mifepristone or as part of a misoprostol-only regimen) and at later gestational ages (i.e. more than nine weeks). In the absence of any supervision from medical personnel, research is needed to understand how best to inform and support women who choose to self-administer, including when to seek clinical care.


Assuntos
Abortivos/administração & dosagem , Aborto Induzido/métodos , Segurança do Paciente , Feminino , Humanos , Mifepristona/administração & dosagem , Misoprostol/administração & dosagem , Gravidez , Primeiro Trimestre da Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto
19.
Hum Reprod Update ; 26(2): 141-160, 2020 02 28.
Artigo em Inglês | MEDLINE | ID: mdl-32096862

RESUMO

BACKGROUND: Long-acting reversible contraceptives (LARCs) are safe, effective and convenient post-abortal methods. However, there is concern that some LARCs may reduce the effectiveness of abortifacient drugs or result in other adverse outcomes. OBJECTIVE AND RATIONALE: We undertook two systematic reviews to examine the early administration of LARCs in women undergoing medical abortion with mifepristone and misoprostol. (i) For women who are having a medical abortion and who plan to use a progestogen-only contraceptive implant or injectable, does administration of the contraception at the same time as mifepristone influence the efficacy of the abortion? (Implant/injectable review). (ii) For women who have had a medical abortion, how soon after expulsion of the products of conception is it safe to insert an intrauterine contraceptive device/system? (LNG-IUS/Cu-IUD review). SEARCH METHODS: On 19 November 2018, we searched Embase Classic, Embase; Ovid MEDLINE(R) including Daily and Epub Ahead-of-Print, In-Process and Other Non-Indexed Citations; the Cochrane Library; Cinahl Plus; and Web of Science Core Collection. Eligible studies were randomised controlled trials (RCTs), in English from 1985 (Implant/injectable review) or 2007 (LNG-IUS/Cu-IUD review) onwards, conducted in women undergoing medical abortion with mifepristone and misoprostol and studying either (i) simultaneous administration of mifepristone and a progestogen-only contraceptive implant or injectable compared to administration >24 h after mifepristone, or (ii) immediate insertion of intrauterine contraception after expulsion of the products of conception compared to early insertion (≤7 days) or to delayed insertion (>7 days) or early compared to delayed insertion. One author assessed the risk of bias in the studies using the Cochrane Collaboration checklist for RCTs. All the outcomes were analysed as risk ratios and meta-analysed in Review Manager 5.3 using the Mantel-Haenszel statistical method and a fixed-effect model. The overall quality of the evidence was assessed using GRADE. OUTCOMES: Two RCTs (n = 1027) showed lower 'subsequent unintended pregnancy' rates and higher 'patient satisfaction' rates, and no other differences, after simultaneous administration of mifepristone and the implant compared to delayed administration. One RCT (n = 461) showed higher 'patient satisfaction' rates after simultaneous administration than after delayed administration of mifepristone and the injectable, but no other differences between these interventions. Three RCTs (n = 536) found no differences other than higher copper IUC uptake after early compared to delayed insertion at ≤9 weeks of gestation and higher rates of IUC expulsion, continuation and uptake after immediate compared to delayed insertion at 9+1-12+0 weeks of gestation and higher IUC continuation rates after immediate compared to delayed insertion at 12+1-20+0 weeks of gestation. The quality of this evidence ranged from very low to high and was mainly compromised by low event rates, high attrition and no blinding. WIDER IMPLICATIONS: The contraceptive implant or injectable should be offered on the day of taking mifepristone. Intrauterine methods of contraception should be offered as soon as possible after expulsion of the pregnancy.


Assuntos
Aborto Induzido , Contracepção Reversível de Longo Prazo , Cuidados Pós-Operatórios/métodos , Aborto Induzido/métodos , Aborto Induzido/estatística & dados numéricos , Feminino , Humanos , Dispositivos Intrauterinos/efeitos adversos , Dispositivos Intrauterinos/estatística & dados numéricos , Contracepção Reversível de Longo Prazo/efeitos adversos , Contracepção Reversível de Longo Prazo/métodos , Contracepção Reversível de Longo Prazo/estatística & dados numéricos , Mifepristona/uso terapêutico , Cuidados Pós-Operatórios/efeitos adversos , Cuidados Pós-Operatórios/estatística & dados numéricos , Gravidez , Gravidez não Planejada , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento
20.
Artigo em Inglês | MEDLINE | ID: mdl-32029379

RESUMO

Abortion care is a fundamental part of women's reproductive health care. Surgical and medical abortion methods are safe and effective throughout the gestational age range wherein abortions are performed. Although risks increase with the gestational age of the pregnancy being terminated, rates of complications remain low and comparable between surgical and medical techniques. A high-quality abortion service should offer women a choice between abortion methods and provide the one they prefer.


Assuntos
Aborto Induzido/métodos , Aborto Induzido/tendências , Feminino , Idade Gestacional , Humanos , Gravidez , Saúde da Mulher
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