Management of spontaneous abortion-medical or surgical.
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Abortifacient Agents, Nonsteroidal↗
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Is pathology examination useful after early surgical abortion?
OBJECTIVE: To study if the pathologist's examination of surgical abortion tissue offers more information than immediate fresh tissue examination by the surgeon. Immediate examination of the fresh tissue aspirate after surgical abortion helps reduce the risk of failed abortion and other complications. Regulations in some states also require a pathologist to analyze abortion specimens at added cost to providers. We conducted this study to evaluate the incremental clinical benefit of pathology examination after surgical abortion at less than 6 weeks' gestation. METHODS: As part of a prospective case series of women who had early surgical abortions at the Planned Parenthood League of Massachusetts during a 32-month period, we collected data on clinical outcomes and the results of postoperative tissue examinations. Using outcomes verified by in-person follow-up as the "gold standard," we calculated the validity of the tissue examinations by the surgeons and the outside pathologists. RESULTS: A total of 676 women had documented outcomes and complete tissue examination data. The sensitivity (ability of the examiner to detect an outcome other than complete abortion) was 57% (95% confidence interval [CI] 35, 76) for the surgeons' tissue inspections and 22% (95% CI 8, 44) for the pathologists' examinations. The predictive value of a positive (abnormal) tissue screen was 14% (95% CI 8, 24) and 7% (95% CI 3, 17) for the surgeons and pathologists, respectively. CONCLUSION: Routine pathology examination of the tissue aspirate after early surgical abortion confers no incremental clinical benefit. Although the surgeons' tissue inspections predicted abnormal outcomes poorly, the pathologists did no better. Our results challenge the rationale for state regulations requiring pathologic analysis of all surgical abortion specimens.
Abortion, Incomplete↗
Treatment of miscarriage: current practice and rationale.
OBJECTIVE: To describe health service use during miscarriage and medical treatment of miscarriage in Finland and the rationales behind them. METHODS: Description of the treatment practices was based on a survey sent to a nationally representative sample of 3000 Finnish women age 18-44 years in 1994, on national hospital care register data from 1988 and 1995, and on treatment recommendations in textbooks (from 1950-1994) for physicians, nurses, and midwives. Published, controlled studies that were identified through various systematic searches were reviewed for scientific evidence justifying the identified practices. RESULTS: According to the survey, 97% of the 326 women who had a miscarriage had visited a physician, and 74% were treated as inpatients. The hospital registers indicated that most (at least 84% in 1988, and 88% in 1995) women who had a miscarriage had their uteri evacuated operatively. According to the textbook recommendation, care by a physician, inpatient care, and routine uterine evacuations were seen as norms. No controlled studies providing empirical support for these practices were found. In general, studies were few and recent, and they placed emphasis on different evacuation methods. CONCLUSION: Current treatment of miscarriage is not based on controlled studies. All aspects of care, from best care provider to various interventions, urgently need further evaluation by trials.
Abortion, Incomplete↗
Induction of therapeutic abortion in early pregnancy with mifepristone in combination with prostaglandin pessary.
Therapeutic abortion was induced in 100 women in early pregnancy (less than 56 days' amenorrhoea) with a combination of the antigestagen mifepristone (RU 486) and a synthetic prostaglandin analogue, gemeprost. Mifepristone in oral doses of 400-600 mg was followed 48 h later by a gemeprost vaginal pessary (0.5-1.0 mg). Bleeding was induced in all women 22-70 h after the mifepristone dose and although bleeding continued for 4-43 days (median 12) the total measured blood-loss was only a median of 72.5 ml (range 15-398). Complete abortion occurred in 95 women. Surgical evacuation of the uterus for minimum debris was required in the remaining 5. Only 10 women had diarrhoea or pain that required opioid analgesia. The combination of mifepristone and gemeprost provides a safe and effective alternative to surgical evacuation of the uterus for therapeutic abortion in early pregnancy.
Abortifacient Agents↗
Pelvic ultrasound performed by emergency physicians for the detection of ectopic pregnancy in complicated first-trimester pregnancies.
STUDY OBJECTIVE: To determine the accuracy and application of pelvic ultrasound performed by emergency physicians in detecting ectopic pregnancy (EP) in complicated first-trimester pregnancies. METHODS: We studied consecutive pelvic ultrasounds performed in all women who presented with abdominal pain or vaginal bleeding during the first trimester of pregnancy over a 6-month period. Patients with clinical evidence of incomplete abortion were not included. We compared ultrasound results with subsequent ultrasound findings by the radiology department and correlated them with follow-up diagnoses and outcomes. RESULTS: Of the 136 eligible patients, a final diagnosis was rendered in 125; 11 were lost to follow-up. These ED ultrasound findings were recorded: established intrauterine pregnancy (IUP) with embryonic structures, 87 (70%); indeterminate scan revealing no distinct evidence of IUP or EP, 15 (12%); early intrauterine gestational sac of less than 6 weeks without embryonic structures, 12 (10%); EP, 8 (6%); blighted ovum, 2 (2%); and molar pregnancy, 1 (1%). The initial ED ultrasound determination was consistent with radiology department findings, final outcome, or both in 121 (96%) (95% confidence interval [CI], 91% to 97%). ED ultrasound accurately identified 87 pregnancies with intrauterine embryonic structures, including 5 patients with fetal demise (95% Cl, 97% to 100%). Diagnosis of pregnancy location in these 87 patients effectively ruled out EP, with a negative predictive value of 100%. The sensitivity and specificity of ED ultrasound in the detection of EP were 90% and 88%, respectively. CONCLUSION: Pelvic ultrasonography performed by emergency physicians can be used to rule out EP and make an accurate diagnosis in most patients with complicated first-trimester pregnancies during the initial ED visit. The remaining patients at risk can be identified and a diagnosis made by means of follow-up ultrasound and serial hCG determinations.
Adult↗
Prognostic value of repeated serum CA 125 measurements in first trimester pregnancy.
OBJECTIVE: To assess the diagnostic value of maternal CA 125 in patients with symptomatic first trimester pregnancy and to evaluate the prognostic significance of CA 125 versus beta-hCG in early pregnancies with intact fetal heartbeat, complicated by vaginal bleeding. STUDY DESIGN: Two prospective open-label studies with longitudinal follow-up in the second trial. SETTING: Academic Department of Obstetrics and Gynecology, University of Cologne. PATIENTS: Study 1: 168 patients presenting between gestational weeks 6 and 12 with: extrauterine pregnancy, 29; missed abortion, 50; incomplete spontaneous abortion, 38; imminent abortion, 33; and normal pregnancy (no history of endometriosis or ovarian mass), 18. Study 2: Fifty consecutive patients with vaginal bleeding during gestational weeks 6-12 all of whom having demostrable fetal heartbeat. Eighteen patients finally aborted whereas the remainder had normally continuing pregnancy until term. MAIN OUTCOME MEASURE: Study 1: Single serum determinations of CA 125 and beta-hCG were correlated with the different disorders observed. Study 2: Two sequential measurements of serum CA 125 and beta-hCG performed within a 5-7 days interval were related to the outcome of pregnancy as indicated by changes of the ultrasound presentation, miscarriage, future hospitalization, or delivery. RESULTS: Study 1: Patients with vaginal bleeding generally had higher median CA 125 values (38 IU/ml; range 1.3-540) compared to non-bleeding patients (17.8 IU/ml; range 1.0-157). No statistically significant differences in regard to median serum CA 125 levels between symptomatic and normal pregnancies occurred: normal pregnancy, 25.5 IU/ml (range 3.2-97); ectopic pregnancy, 26 IU/ml (range 1.3-157); missed abortion, 19.1IU/ml (range 1-242); threatened abortion, 48 IU/ml (range 5.2-540); spontaneous abortion, 40 IU/ml (range 5.4-442). Study 2: Initial CA 125 levels did not differ significantly between both groups of patients with 27/32 non-aborters and 13/18 aborters showing concentrations below 65 IU/ml. After 5-7 days, CA 125 in all patients who eventually aborted remained high or increased whereas non-aborters all had constantly low or steeply declining CA 125 measures. beta-hCG increased in all non-aborters but also in 13/18 aborters during the 5-7 day interval. CONCLUSION: Single serum measurements of CA 125 in symptomatic first trimester pregnant patients failed to discriminate spontaneous abortion, ectopic or normal pregnancies. However, sequential determinations of maternal CA 125 measurements appear to be a highly sensitive prognostic marker in patients with viable pregnancy at risk for abortion.
Abortion, Spontaneous↗
Complications of abortion performed under local anesthesia.
OBJECTIVE: To assess the incidence of complications of abortion performed under local anesthesia. DESIGN: Prospective study. SETTING: A family planning center in the Paris area. POPULATION: Eight hundred and fifty-eight women admitted for abortion under local anesthesia. MAIN OUTCOME MEASURES: Incidence of immediate (the day of vacuum aspiration) and delayed complications (at the follow-up visit 2 weeks after the procedure). RESULTS: Among the 858 women who underwent vacuum aspiration, 683 (80%) attended the follow-up visit 2 weeks after the procedure. Fifty-nine percent of the 858 women had not had a previous abortion, 25% had had one, and 16% had had two or more. The average duration of amenorrhea was 8.6 weeks (19% at 6 or 7 weeks, 67% between 8 and 10 weeks, and 14% after 10 weeks). The overall complication rate was 3.4% (23/683) (95% CI=2.0-4.8%). The incidence of immediate complications was 1.7% (15/858) (0.8-2.6%) and that of delayed complications 1.2% (8/683) (0.4-2.0%). CONCLUSION: This study confirms the safety and efficacy of abortion by vacuum aspiration under local anesthesia.
Abortion, Incomplete↗
Intrauterine adhesions after conservative and surgical management of spontaneous abortion.
STUDY OBJECTIVE: To determine the frequency of intrauterine adhesions (IUA) after conservative management, medical evacuation, and surgical evacuation for spontaneous abortion. DESIGN: Prospective follow-up study (Canadian Task Force classification II-2). SETTING: Gynecology unit in a teaching hospital. PATIENTS: Eighty-two women who had been treated with conservative management, medical evacuation, or surgical evacuation of retained products of conception after spontaneous abortions in a randomized, controlled trial. MEASUREMENTS AND MAIN RESULTS: Hysteroscopic diagnosis of IUA 6 months after initial treatment was the primary outcome measure. No cases of IUA were found in patients managed conservatively or by medical evacuation, whereas two cases (7.7%) of filmy IUA were detected in those managed by surgical evacuation. There was no statistical significant difference in the rate of self-reported reduced menstrual flow 6 months after initial treatment by any method. CONCLUSION: The prevalence of IUA was low after each modality of treatment for spontaneous abortion. Conservative management and medical evacuation are both acceptable alternatives to standard surgical evacuation.
Abortion, Incomplete↗
Cervical Ectopic Pregnancy
A 26-year-old, gravida 2, para 0 woman with a 12-week pregnancy complicated by incomplete abortion was referred for evacuation of retained products of conception. Suction evacuation was carried out under general anesthesia, but heavy vaginal bleeding continued. Intravenous oxytocin and ergonovine maleate, intramyometrial injection of prostaglandin F2alpha, local pressure to the cervix, uterine massage, and temporary ligation of internal iliac arteries failed to stop the bleeding. The patient received 12 units of blood. The bleeding was finally stopped after inserting a Foley catheter into the cervical canal, inflating its balloon, and applying two cerclage sutures to the cervix above and below the balloon. The woman's postoperative course was complicated by left lung pneumonia, which was treated successfully with antibiotics, and she was discharged home 1 week after admission.
Journal Article↗
Feasibility of an ultrasound service on district health care level in Botswana.
OBJECTIVE: To assess the clinical benefit and financial feasibility of an ultrasound service in a district hospital in Botswana. METHOD: An ultrasound service was established in the study hospital. Clinical and ultrasound-aided diagnoses were compared in patients who met eligibility criteria laid down in an indication list. RESULTS: We enrolled 2309 patients over 18 months. The most frequent indications for ultrasound were pregnancy-related diagnoses followed by gynaecological and hepato-biliary disorders. Ultrasound assistance improved case management in 696 cases (30%) and led to an immediate change in management in 151 patients. Ultrasound diagnosis was used as gold standard to assess the accuracy of the clinical diagnosis of incomplete abortion (sensitivity 24%; positive predictive value, PPV 66%), pelvic mass (sensitivity 53%; PPV 69%), ectopic pregnancy (sensitivity 75%; PPV 28%), and gall bladder stones (sensitivity 30%; PPV 32%). CONCLUSIONS: Ultrasound improved case management for a wide diversity of clinical problems encountered on district health care level. The service proved to be affordable for the Botswana health care system.
Biliary Tract Diseases↗
The reliability of transvaginal ultrasonography to detect retained tissue after spontaneous first-trimester abortion, clinically thought to be complete.
In order to assess the reliability of transvaginal ultrasonography for the detection of trophoblastic tissue retained after spontaneous first-trimester abortion and clinically thought to be complete, the clinical, sonographic and pathological data of 33 women were retrospectively analyzed. The patients' mean age was 34 years (range 24-48). The mean gestational age at presentation of symptoms was 8 weeks (range 5.1-11.1). Transvaginal sonography showed that in 18 cases retained tissue was absent, and that in 15 patients, retained trophoblastic tissue was suspected. Pathological reports (following dilatation and curettage) confirmed the absence of retained tissue in 17 cases and demonstrated its presence in 16 patients (13 in whom retained tissue was suspected by sonography and three in whom retained tissue was not suspected). Sensitivity, specificity, positive predictive value and negative predictive value in our series were 81%, 94%, 93% and 83%, respectively for the detection of retained trophoblastic tissue. We conclude that transvaginal ultrasonography is a reliable method to detect the presence of retained trophoblastic tissue following spontaneous first-trimester abortion, clinically thought to be complete.
Abortion, Incomplete↗
Modern management of miscarriage: is there a place for non-surgical treatment?
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Abortifacient Agents, Nonsteroidal↗
[Ultrasonographic diagnosis in disturbances of early pregnancy (author's transl)].
Ultrasonography using high-magnification, modern ultrasonographs enables information on intactness of pregnancy in early disturbed pregnancy. The ultrasound findings can be correlated with the clinical diagnoses, such as incomplete abortion. A final diagnosis, such as missed abortion, can frequently only be made after exact ultrasonographic investigation. The failure rate depends on the equipment and the experience of the investigator. Exact knowledge of the gestational age clearly influences the accuracy of an ultrasonographic diagnosis in early pregnancy. A gestational age earlier than the calculated one may be mistaken for a pregnancy that is no longer intact.
Abortion, Missed↗
Hormone analytical and carrier protein alternations following administration of mifepristone (RU 486) for termination of early pregnancy.
Outpatient terminations were performed on 50 biochemically confirmed pregnancies of 33 to 43 days amenorrhea with a single oral dose of 600 mg of mifepristone (RU 486). 37 women were randomly assigned to an additional endocrine investigation, comprising serum levels of beta hCG, progesterone (P), estradiol (E2), cortisol (C), sexual hormone binding globulin (SHBG), and cortisol binding globulin (CBG) on days 0 and 7 prior to and following the drug administration. Of these 37 patients, 30 experienced a complete expulsion of the uterine contents, 28 until day 7, 2 subjects on day 9 and 10, respectively. The remaining 7 women either showed an unaffected pregnancy or the symptoms of incomplete abortion, which made a surgical intervention necessary. In the successfully treated cases the levels of beta hCG, P and E2 decreased significantly, the nonresponders showed unchanged or even increasing hormone values. No significant changes of cortisol concentrations were found in the group of nonresponders, while the successful cases exhibited a slight elevation probably due to the abortion-associated processes. No considerable therapy-dependent differences were observed in the levels of SHBG. A small but significant decrease in the mean CBG value could be calculated in the group of responders.
Abortion, Spontaneous↗
Misoprostol and pregnancy.
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Abortifacient Agents, Nonsteroidal↗
Abortion: U.S.A. style.
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Abortion, Incomplete↗
The potential consequence of early recognition and treatment of retained fetal bony fragments.
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Abortion, Incomplete↗
Immunohistochemical demonstration of placental hormones in the diagnosis of uterine versus ectopic pregnancy.
The authors find that immunohistochemical demonstration of placental hormones in endometrium is useful in the identification of trophoblast independent of the presence of chorionic villi. Human chorionic gonadotropin (HCG) and human placental lactogen (HPL) are markers for trophoblastic cells. The markers were studied in 21 cases of gestational endometrium without villi in which the clinical differential diagnosis was ectopic pregnancy versus missed or incomplete uterine abortion. Trophoblastic cells were identified in four cases by routine microscopy and in an additional seven cases using the markers. In none of these cases was there a subsequent demonstration of ectopic pregnancy. In six of the ten negative cases, ectopic pregnancies subsequently were removed. Thus, the use of these hormone markers in endometrial specimens increases precision in the diagnosis of uterine versus ectopic pregnancy.
Abortion, Incomplete↗