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1.
BMJ Case Rep ; 14(2)2021 Feb 04.
Artigo em Inglês | MEDLINE | ID: mdl-33542016

RESUMO

The differential diagnosis for ulcerating small bowel strictures is extensive and includes exposure to non-steroidal anti-inflammatory drugs (NSAIDs), Crohn's disease, infections, gastrointestinal lymphoma and vasculopathy. It also encompasses the exceptionally rare and poorly understood diagnosis of cryptogenic multifocal ulcerative stenosing enterocolitis (CMUSE), often a diagnosis of exclusion and considerable difficulty. We present a case of persistent proximal jejunal ulcerating stenoses in a 75-year-old Caucasian man, which continued despite cessation of NSAIDs. After extensive clinical, radiographic, laboratory and ultimately surgical pathological appraisal-as well as failure to improve with both misoprostol and budesonide-he was diagnosed with CMUSE and managed with limited small bowel resection. In the presentation of this case, we aim to underscore the diagnostic challenges that clinicians face in differentiating CMUSE from other more common diagnoses, particularly NSAIDs-induced enteropathy.


Assuntos
Enterite/diagnóstico , Obstrução Intestinal/diagnóstico , Intestino Delgado/patologia , Úlcera/diagnóstico , Dor Abdominal/etiologia , Idoso , Anti-Inflamatórios não Esteroides , Antiulcerosos/uso terapêutico , Constrição Patológica , Diagnóstico Diferencial , Humanos , Masculino , Misoprostol/uso terapêutico , Tomografia Computadorizada por Raios X
3.
San Salvador; MINSAL; sept.16, 2020. 12 p. ilus, graf.
Não convencional em Espanhol | LILACS, BIGG - guias GRADE, BISSAL | ID: biblio-1121036

RESUMO

La presente guía se elaboró siguiendo los lineamientos del Manual para la elaboración de guías de la Organización Mundial de la Salud. De forma general, se creó un grupo desarrollador multidisciplinario, compuesto por expertos temáticos, epidemiólogos, metodólogos y pacientes. Con base en la evidencia proveniente de la guía para el uso de uterotónicos para la prevención de hemorragia posparto, se desarrolló una adaptación para el contexto del Sistema Nacional Integrado de Salud de El Salvador. Se incluyó de evidencia local y la contextualización de sus recomendaciones. Las recomendaciones fueron graduadas en un panel de expertos conformado por profesionales en estadística, enfermería, materno infantil y médicos generales y especialistas en las siguientes áreas: ginecología y obstetricia, perinatología, anestesiología, medicina familiar, economía de la salud, epidemiología, además se incluyó la participación de pacientes siguiendo el enfoque Grading of Recommendations, Assessment, Development and Evaluation (GRADE)


This guide was prepared following the guidelines of the Manual for the preparation of guidelines of the World Health Organization. In general, a multidisciplinary development group was created, composed of thematic experts, epidemiologists, methodologists, and patients. Based on the evidence from the guide for the use of uterotonics for the prevention of postpartum hemorrhage, an adaptation was developed for the context of the National Integrated Health System of El Salvador. Local evidence and the contextualization of their recommendations were included. The recommendations were graded by a panel of experts made up of professionals in statistics, nursing, maternal and child health, and general practitioners and specialists in the following areas: gynecology and obstetrics, perinatology, anesthesiology, family medicine, health economics, epidemiology, and it was also included patient participation following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE)


Assuntos
Gravidez , Ocitócicos/uso terapêutico , Hemorragia Pós-Parto/prevenção & controle , Hemorragia Pós-Parto/tratamento farmacológico , Hemorragia Pós-Parto/terapia , Ocitocina/uso terapêutico , Misoprostol/uso terapêutico
4.
Lancet ; 396(10253): 770-778, 2020 09 12.
Artigo em Inglês | MEDLINE | ID: mdl-32853559

RESUMO

BACKGROUND: The anti-progesterone drug mifepristone and the prostaglandin misoprostol can be used to treat missed miscarriage. However, it is unclear whether a combination of mifepristone and misoprostol is more effective than administering misoprostol alone. We investigated whether treatment with mifepristone plus misoprostol would result in a higher rate of completion of missed miscarriage compared with misoprostol alone. METHODS: MifeMiso was a multicentre, double-blind, placebo-controlled, randomised trial in 28 UK hospitals. Women were eligible for enrolment if they were aged 16 years and older, diagnosed with a missed miscarriage by pelvic ultrasound scan in the first 14 weeks of pregnancy, chose to have medical management of miscarriage, and were willing and able to give informed consent. Participants were randomly assigned (1:1) to a single dose of oral mifepristone 200 mg or an oral placebo tablet, both followed by a single dose of vaginal, oral, or sublingual misoprostol 800 µg 2 days later. Randomisation was managed via a secure web-based randomisation program, with minimisation to balance study group assignments according to maternal age (<30 years vs ≥30 years), body-mass index (<35 kg/m2vs ≥35 kg/m2), previous parity (nulliparous women vs parous women), gestational age (<70 days vs ≥70 days), amount of bleeding (Pictorial Blood Assessment Chart score; ≤2 vs ≥3), and randomising centre. Participants, clinicians, pharmacists, trial nurses, and midwives were masked to study group assignment throughout the trial. The primary outcome was failure to spontaneously pass the gestational sac within 7 days after random assignment. Primary analyses were done according to intention-to-treat principles. The trial is registered with the ISRCTN registry, ISRCTN17405024. FINDINGS: Between Oct 3, 2017, and July 22, 2019, 2595 women were identified as being eligible for the MifeMiso trial. 711 women were randomly assigned to receive either mifepristone and misoprostol (357 women) or placebo and misoprostol (354 women). 696 (98%) of 711 women had available data for the primary outcome. 59 (17%) of 348 women in the mifepristone plus misoprostol group did not pass the gestational sac spontaneously within 7 days versus 82 (24%) of 348 women in the placebo plus misoprostol group (risk ratio [RR] 0·73, 95% CI 0·54-0·99; p=0·043). 62 (17%) of 355 women in the mifepristone plus misoprostol group required surgical intervention to complete the miscarriage versus 87 (25%) of 353 women in the placebo plus misoprostol group (0·71, 0·53-0·95; p=0·021). We found no difference in incidence of adverse events between the study groups. INTERPRETATION: Treatment with mifepristone plus misoprostol was more effective than misoprostol alone in the management of missed miscarriage. Women with missed miscarriage should be offered mifepristone pretreatment before misoprostol to increase the chance of successful miscarriage management, while reducing the need for miscarriage surgery. FUNDING: UK National Institute for Health Research Health Technology Assessment Programme.


Assuntos
Aborto Retido/tratamento farmacológico , Mifepristona/uso terapêutico , Misoprostol/uso terapêutico , Ocitócicos/uso terapêutico , Adulto , Método Duplo-Cego , Quimioterapia Combinada , Humanos , Resultado do Tratamento
5.
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
6.
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
7.
J Ayub Med Coll Abbottabad ; 32(2): 198-203, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32583994

RESUMO

BACKGROUND: Uterine myomas are most common non-cancerous tumours in reproductive period. The fertility preserving surgery, i.e., myomectomy as compared to hysterectomy, is associated with massive blood loss due to dissection of huge fibroids making it technically difficult procedure. Misoprostol (a uterotonic) is an effective option amongst different interventions used to reduce intraoperative blood loss during myomectomy. This randomized control trial investigated effectiveness of single dose of rectal misoprostol given preoperatively in reducing intraoperative blood loss during abdominal myomectomy.. METHODS: Fifty Patients undergoing abdominal myomectomy were selected for the study. Twenty-five patients were given 800 micrograms misoprostol per rectally half an hour before surgery while rest received placebo, i.e., control group. Number and weight of surgical packs were recorded both Pre and post operatively to assess blood loss. Preoperative and 24 hrs postoperative haemoglobin was also recorded. Data analysed by SPSS-20. RESULTS: Mean of age, parity and myoma size were not statistically different between the two groups. However intraoperative blood loss (as measured by weighing and counting number of swabs used) and postoperative haemoglobin after 24 hours were significantly different between two groups with p-value <0.01. CONCLUSIONS: Single dose of misoprostol given preoperatively via rectal route is effective in reducing intraoperative blood loss during abdominal myomectomy. Misoprostol must be used in different doses and routes in order to investigate its effectiveness in reducing intraoperative blood loss.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Misoprostol/uso terapêutico , Ocitócicos/uso terapêutico , Miomectomia Uterina/efeitos adversos , Feminino , Humanos , Histerectomia/efeitos adversos , Misoprostol/administração & dosagem , Ocitócicos/administração & dosagem
8.
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
9.
Am J Obstet Gynecol ; 223(4): 551.e1-551.e7, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32305259

RESUMO

BACKGROUND: Early pregnancy loss is a common event in the first trimester, occurring in 15%-20% of confirmed pregnancies. A common evidence-based medical regimen for early pregnancy loss uses misoprostol, a prostaglandin E1 analog, with a dosage of 800 µg, self-administered vaginally. The clinical utility of this regimen is limited by suboptimal effectiveness in patients with a closed cervical os, with 29% of patients experiencing early pregnancy loss requiring a second dose after 3 days and 16% of patients eventually requiring a uterine aspiration procedure. OBJECTIVE: This study aimed to evaluate clinical predictors associated with treatment success in patients receiving medical management with mifepristone-misoprostol or misoprostol alone for early pregnancy loss. STUDY DESIGN: We performed a planned secondary analysis of a randomized trial comparing mifepristone-misoprostol with misoprostol alone for management of early pregnancy loss. The published prediction model for treatment success of single-dose misoprostol administered vaginally included the following variables: active bleeding, type of early pregnancy loss (anembryonic pregnancy or embryonic and/or fetal demise), parity, gestational age, and treatment site; previous significant predictors were vaginal bleeding within the past 24 hours and parity of 0 or 1 vs >1. To determine if these characteristics predicted differential proportions of patients with treatment success or failure, we performed bivariate analyses; given the small proportion of treatment failures in the combined treatment arm, both arms were combined for analysis. Thereafter, we performed a logistic regression analysis to assess the effect of these predictors collectively in each of the 2 treatment groups separately as well as in the full cohort as a proxy for the combined treatment arm. Finally, by using receiver operating characteristic curves, we tested the ability of these predictors in association with misoprostol treatment success to discriminate between treatment success and treatment failure. To quantify the ability of the score to discriminate between treatment success and treatment failure in each treatment arm as well as in the entire cohort, we calculated the area under the curve. Using multivariable logistic regression, we then assessed our study population for other predictors of treatment success in both treatment groups, with and without mifepristone pretreatment. RESULTS: Overall, 297 evaluable participants were included in the primary study, with 148 in the mifepristone-misoprostol combined treatment group and 149 in the misoprostol-alone treatment group. Among patients who had vaginal bleeding at the time of treatment, 15 of 17 (88%) in the mifepristone-misoprostol combined treatment group and 12 of 17 (71%) in the misoprostol-alone treatment group experienced expulsion of pregnancy tissue. Among patients with a parity of 0 or 1, 94 of 108 (87%) in the mifepristone-misoprostol treatment group and 66 of 95 (69%) in the misoprostol-alone treatment group experienced expulsion of pregnancy tissue. These clinical characteristics did not predict treatment success in the combined cohort alone (area under the curve=0.56; 95% confidence interval, 0.48-0.64). No other baseline clinical factors predicted treatment success in the misoprostol-alone treatment arm or mifepristone pretreatment arm. In the full cohort, the significant predictors of treatment success were pretreatment with mifepristone (adjusted odds ratio=2.51; 95% confidence interval, 1.43-4.43) and smoking (adjusted odds ratio=2.15; 95% confidence interval, 1.03-4.49). CONCLUSION: No baseline clinical factors predicted treatment success in women receiving medical management with misoprostol for early pregnancy loss. Adding mifepristone to the medical management regimen of early pregnancy loss improved treatment success; thus, mifepristone treatment should be considered for management of early pregnancy loss regardless of baseline clinical factors.


Assuntos
Abortivos não Esteroides , Abortivos Esteroides , Aborto Espontâneo/tratamento farmacológico , Mifepristona/uso terapêutico , Misoprostol/uso terapêutico , Paridade , Hemorragia Uterina/epidemiologia , Adulto , Quimioterapia Combinada , Feminino , Humanos , Gravidez , Resultado do Tratamento
11.
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
12.
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
13.
Am J Obstet Gynecol ; 223(2): 236.e1-236.e8, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32109462

RESUMO

BACKGROUND: In 2013, the Texas legislature passed House Bill 2, restricting use of medication abortion to comply with Food and Drug Administration labeling from 2000. The Food and Drug Administration updated its labeling for medication abortion in 2016, alleviating some of the burdens imposed by House Bill 2. OBJECTIVE: Our objective was to identify the impact of House Bill 2 on medication abortion use by patient travel distance to an open clinic and income status. MATERIALS AND METHODS: In this retrospective study, we collected patient zip code, county of residence, type of abortion, family size, and income data on all patients who received an abortion (medication or aspiration) from 7 Texas abortion clinics in 3 time periods: pre-House Bill 2 (July 1, 2012-June 30, 2013), during House Bill 2 (April 1, 2015-March 30, 2016), and post-Food and Drug Administration labeling update (April 1, 2016-March 30, 2017). Patient driving distance to the clinic where care was obtained was categorized as 1-24, 25-49, 50-99, or 100+ miles. Patient county of residence was categorized by availability of a clinic during House Bill 2 (open clinic), county with a House Bill 2-related clinic closure (closed clinic), or no clinic any time period. Patient income was categorized as ≤110% federal poverty level (low-income) and >110% federal poverty level. Change in medication abortion use in the 3 time periods by patient driving distance, residence in a county with an open clinic, and income status were evaluated using χ2 tests and logistic regression. We used geospatial mapping to depict the spatial distribution of patients who obtained a medication abortion in each time period. RESULTS: Among 70,578 abortion procedures, medication abortion comprised 26%, 7%, and 29% of cases pre-House Bill 2, during House Bill 2, and post-Food and Drug Administration labeling update, respectively. During House Bill 2, patients traveling 100+ miles compared to 1- 24 miles were less likely to use medication abortion (odds ratio, 0.21; 95% confidence interval, 0.15, 0.30), as were low-income compared to higher-income patients (odds ratio, 0.76; 95% confidence interval, 0.68, 0.85), and low-income, distant patients (adjusted odds ratio, 0.14; 95% confidence interval, 0.08, 0.25). Similarly, post-Food and Drug Administration labeling update, rebound in medication abortion use was less pronounced for patients traveling 100+ miles compared to 1-24 miles (odds ratio, 0.82; 95% confidence interval, 0.74, 0.91), low-income compared to higher-income patients (odds ratio, 0.77; 95% confidence interval, 0.72, 0.81), and low-income, distant patients (adjusted odds ratio, 0.80; 95% confidence interval, 0.68, 0.94). Post-Food and Drug Administration labeling update, patients residing in counties with House Bill 2-related clinic closures were less likely to receive medication abortion as driving distance increased (52% traveling 25-49 miles, 41% traveling 50-99 miles, and 26% traveling 100+ miles, P < .05). Geospatial mapping demonstrated that patients traveled from all over the state to receive medication abortion pre-House Bill 2 and post-Food and Drug Administration labeling update, whereas during House Bill 2, only those living in or near a county with an open clinic obtained medication abortion. CONCLUSION: Texas state law drastically restricted access to medication abortion and had a disproportionate impact on low-income patients and those living farther from an open clinic. After the Food and Drug Administration labeling update, medication abortion use rebounded, but disparities in use remained.


Assuntos
Abortivos/uso terapêutico , Aborto Induzido/estatística & dados numéricos , Instituições de Assistência Ambulatorial/legislação & jurisprudência , Acesso aos Serviços de Saúde , Disparidades em Assistência à Saúde , Viagem/estatística & dados numéricos , Aborto Induzido/legislação & jurisprudência , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Rotulagem de Medicamentos , Feminino , Mapeamento Geográfico , Humanos , Mifepristona/uso terapêutico , Misoprostol/uso terapêutico , Pobreza , Gravidez , Estudos Retrospectivos , População Rural , Análise Espacial , Texas , Estados Unidos , United States Food and Drug Administration
14.
Einstein (Sao Paulo) ; 18: eAO5029, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31721897

RESUMO

OBJECTIVE: To characterize the use of the drug misoprostol for treatment of postpartum hemorrhage in pregnant women. METHODS: A descriptive observational study was carried out with secondary data from pregnant women who used misoprostol to treat postpartum hemorrhage in a reference public maternity, from July 2015 to June 2017. Clinical and sociodemographic profiles of pregnant women, how misoprostol was used and success rate in controling postpartum hemorrhage were characterized. RESULTS: A total of 717 prescriptions of misoprostol were identified. Of these, 10% were for treatment of postpartum hemorrhage. The majority of pregnant women were young adults, married, with complete high school education, white, residing in urban areas, multiparous (68.1%) and 25% had previous cesarean sections. The mean gestational age was 39 weeks and 51.4% had a cesarean section. There was prophylactic use of oxytocin in 47.2% of women. Treatment of postpartum hemorrhage was successful in 84.7% of women. Of these, 79.2% also used oxytocin and 54.2% methylergonovine. Only 13.5% of pregnant women had less than five prenatal visits, and the main cause of postpartum hemorrhage was uterine atony. There were 13 complications after hemorrhage, 15.3% required blood transfusion and there was one case of maternal death. CONCLUSION: Misoprostol showed to be effective and safe for treating postpartum hemorrhage.


Assuntos
Misoprostol/uso terapêutico , Ocitócicos/uso terapêutico , Hemorragia Pós-Parto/tratamento farmacológico , Adulto , Estudos Transversais , Feminino , Idade Gestacional , Humanos , Metilergonovina/uso terapêutico , Ocitocina/uso terapêutico , Gravidez , Adulto Jovem
15.
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
16.
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
17.
Am J Obstet Gynecol ; 222(6): 551-563.e13, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31715147

RESUMO

OBJECTIVE: To compare the effectiveness, safety, and acceptability of in-clinic and remote/self-assessment, as well as different remote/self-assessments, for confirming the success of medical abortion at ≤10+0 weeks' gestation. DATA SOURCES: Ovid Embase Classic and Embase; Ovid MEDLINE(R) and Epub Ahead-of-Print, In-Process & Other Non-Indexed Citations and Daily; and the Cochrane Library. We also consulted experts in this field for any ongoing or missed trials. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials published in English from 2000 onward, comparing in-clinic assessment with ultrasound to remote or self-assessment or comparing different remote or self-assessment strategies to confirm the success of medical abortion of pregnancies up to and including 10+0 weeks gestation, reporting any of the following outcomes: "missed ongoing pregnancy," "correct implementation of the follow-up strategy," patient satisfaction/preference, "adherence to follow-up strategy," "unscheduled visits/telephone calls to the abortion service," and surgical intervention. STUDY APPRAISAL AND SYNTHESIS METHODS: One author assessed the risk of bias in the studies using the Cochrane Collaboration checklist for randomized controlled trials. All outcomes were analyzed 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. RESULTS: Four randomized controlled trials (n = 5761) compared in-clinic to remote self-assessment and found no clinically significant differences apart from higher preference rates for remote follow-up, especially in the remote follow-up groups. The quality of this evidence was compromised by attrition, no blinding, inconsistency, indirectness, and low event rates. Two randomized controlled trials (n = 1125) compared different remote assessment strategies (using urine pregnancy tests) and also found no clinically significant differences apart from a clinically significantly lower rate of unscheduled visits to the abortion service in the remote follow-up group using a multilevel urine pregnancy test compared to remote follow-up using a high-sensitivity urine pregnancy test. The quality of this evidence was compromised by small event rates, lack of blinding, indirectness and high attrition rates. CONCLUSION: The published data support offering women who have had a medical abortion up to and including 10+0 weeks' gestation the choice of self-assessment, remote assessment, or clinic follow-up.


Assuntos
Abortivos/uso terapêutico , Aborto Induzido/métodos , Autoavaliação Diagnóstica , Cooperação do Paciente , Satisfação do Paciente , Testes de Gravidez/métodos , Assistência Ambulatorial , Feminino , Humanos , Mifepristona/uso terapêutico , Misoprostol/uso terapêutico , Preferência do Paciente , Gravidez , Primeiro Trimestre da Gravidez , Inquéritos e Questionários , Telefone , Envio de Mensagens de Texto , Resultado do Tratamento , Ultrassonografia
18.
Gynecol Obstet Fertil Senol ; 48(1): 15-18, 2020 01.
Artigo em Francês | MEDLINE | ID: mdl-31669527

RESUMO

OBJECTIVE: To determine the management of patients with term prelabor rupture of membranes. METHODS: Synthesis of the literature from the PubMed and Cochrane databases and the recommendations of French and foreign societies and colleges. RESULTS: Term prelabor rupture of membranes is considered a physiological process up to 12hours of rupture (Professional consensus). In case of expectant management and with a low rate of antibiotic prophylaxis, home care compared to hospitalization could be associated with an increase in neonatal infections (LE3), especially in case of group B streptococcus colonization (LE3). Home care is therefore not recommended (Grade C). In the absence of spontaneous labor within 12hours of rupture, antibiotic prophylaxis could reduce the risk of maternal intrauterine infection but not of neonatal infection (LE3). Its use after 12hours of rupture in term prelabor rupture of the membranes is therefore recommended (Grade C). When antibiotic prophylaxis is indicated, intravenous beta-lactams are recommended (Grade C). Induction of labor with oxytocin (LE1), prostaglandin E2 (LE1) or misoprostol (LE1), is associated with shorter rupture of membranes to delivery intervals when compared to expectant management. Compared with expectant management, immediate induction of labor is not associated with lower rates of neonatal infection (LE1), even among women with a positive streptococcus B vaginal swab (LE2). Thus, expectant management can be offered without increasing the risk of neonatal infection (Grade B). Induction of labor is not associated with an increase or decrease in the cesarean delivery rate (LE2), whatever parity (LE2) or Bishop score at admission (LE3). Induction can thus be proposed without increasing the risk of cesarean delivery (Grade B). No induction method (oxytocin, dinoprostone, misoprostol or Foley® catheter) has demonstrated superiority over another, whether to reduce rate of intrauterine or neonatal infection, rate of cesarean delivery or to shorten rupture of membranes to delivery intervals regardless of Bishop's score and parity. CONCLUSION: Term prelabor rupture of membranes is a frequent event. A 12-hour delay without onset of spontaneous labor was chosen to differentiate a physiological condition from a potentially unsafe situation justifying an antibiotic prophylaxis. Expectant management or induction of labor can both be proposed, even in case of positive screening for streptococcus B, depending on the patient's wishes and maternity units' organization (Professional consensus).


Assuntos
Ruptura Prematura de Membranas Fetais/terapia , Antibioticoprofilaxia , Dinoprostona/uso terapêutico , Feminino , França , Humanos , Trabalho de Parto Induzido/métodos , Misoprostol/uso terapêutico , Ocitócicos/uso terapêutico , Ocitocina/uso terapêutico , Gravidez , Infecções Estreptocócicas/diagnóstico , Streptococcus agalactiae , beta-Lactamas/administração & dosagem
19.
Ginebra; WHO; 2020. 54 p.
Monografia em Inglês | BIGG - guias GRADE | ID: biblio-1151355

RESUMO

Postpartum haemorrhage (PPH) is commonly defined as a blood loss of 500 mL or more within 24 hours after birth and affects about 5% of all women giving birth around the world. Globally, nearly one quarter of all maternal deaths are associated with PPH and, in most low-income countries, it is the main cause of maternal mortality. Improving care during childbirth to prevent PPH is a necessary step towards the achievement of the health targets of the third Sustainable Development Goal (SDG 3), particularly target 3.1: reduce the global maternal mortality ratio to less than 70 per 100 000 live births by 2030. Efforts to prevent and reduce morbidity and mortality due to PPH can help to address the profound inequities in maternal and perinatal health globally. To achieve this, skilled health personnel, health managers, policy-makers and other stakeholders need up-to-date and evidence-informed recommendations to guide clinical policies and practices. In 2019, the Executive Guideline Steering Group (GSG) for World Health Organization (WHO) maternal and perinatal health recommendations prioritized updating of the existing WHO recommendations for advance misoprostol distribution to pregnant women for prevention of PPH in response to the availability of new evidence. The recommendation in this document thus supersedes the previous WHO recommendation for the prevention of PPH as published in the 2012 guideline, WHO recommendations for the prevention and treatment of postpartum haemorrhage. The primary audience for these recommendations includes health professionals who are responsible for developing national and local health-care guidelines and protocols (particularly those related to PPH prevention and treatment) and those involved in the provision of care to women and their newborns during labour and childbirth, including midwives, nurses, general medical practitioners and obstetricians, as well as managers of maternal and child health programmes, and relevant staff in ministries of health and training institutions, in all settings. The updating of these recommendations was guided by standardized operating procedures in accordance with the process described in the WHO handbook for guideline development. The recommendations were initially developed and updated using this process, namely: (i) identification of priority questions and outcomes; (ii) retrieval of evidence; (iii) assessment and synthesis of evidence; (iv) formulation of the recommendations; and (v) planning for the dissemination, implementation, impact evaluation and future updating of the recommendations. The scientific evidence supporting the recommendation was synthesized using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An updated systematic review was used to prepare the evidence profiles for the prioritized question. WHO convened a meeting on 11­12 March 2020 where the Guideline Development Group (GDG) members reviewed, deliberated and achieved consensus on the strength and direction of the recommendation presented herein. Through a structured process, the GDG reviewed the balance between the desirable and undesirable effects and the overall certainty of supporting evidence, values and preferences of stakeholders, resource requirements and cost-effectiveness, acceptability, feasibility and equity. The GDG reviewed the balance between the desirable and undesirable effects and the overall certainty of supporting evidence, values and preferences of stakeholders, resource requirements and cost-effectiveness, acceptability, feasibility and equity. The GDG issued the recommendation on a strategy of advance misoprostol distribution to pregnant women for the prevention of PPH, with remarks and implementation considerations. To ensure that the recommendation is correctly understood and applied in practice, guideline users may want to refer to the remarks, as well as to the evidence summary, including the considerations on implementation.


Assuntos
Humanos , Feminino , Gravidez , Hemorragia Pós-Parto/prevenção & controle , Hemorragia Pós-Parto/tratamento farmacológico , Misoprostol/uso terapêutico , Morte Materna/prevenção & controle
20.
San Salvador; Ministerio de Salud; 20200000. 1-83 p.
Monografia em Espanhol | LILACS, BIGG - guias GRADE | ID: biblio-1146852

RESUMO

Objetivo: Proveer recomendaciones para mejorar la calidad del cuidado y desenlaces para mujeres que reciben atención del parto, en relación a la prevención de la hemorragia posparto (HPP) por atonía uterina en El Salvador. Métodos: La presente guía fue desarrollada siguiendo los lineamientos del Manual para la elaboración de guías de la Organización Mundial de la Salud1. De forma general, se creó un grupo para la elaboración con enfoque multidisciplinario compuesto por expertos sobre el tema, epidemiólogos, metodólogos y pacientes. Con base en la evidencia proveniente de la guía para el uso de uterotónicos para la prevención de hemorragia posparto, se desarrolló una adaptación para el contexto del sistema de salud de El Salvador2. Se realizó inclusión de evidencia local y la contextualización de sus recomendaciones. Las recomendaciones fueron graduadas en un panel de expertos conformado por profesionales en estadística, enfermería, materno infantil, médicos generales y especialistas en ginecología y obstetricia, perinatología, anestesiología, medicina familiar, economía de la salud, epidemiología, además se incluyó la participación de pacientes siguiendo el enfoque GRADE. Adicionalmente, la guía fue evaluada por pares temáticos y metodológicos. Todos los participantes del panel y del grupo desarrollador firmaron un formato de conflicto de intereses que analizaron los coordinadores de la guía.


Assuntos
Gravidez , Ocitócicos/uso terapêutico , Hemorragia Pós-Parto/prevenção & controle , Hemorragia Pós-Parto/terapia , Misoprostol/uso terapêutico , Hemorragia Pós-Parto/tratamento farmacológico
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