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The Cochrane Database of Systematic... Jun 2021Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime. An estimated 15% of pregnancies end in miscarriage. Miscarriage can lead to serious morbidity, including haemorrhage, infection, and even death, particularly in settings without adequate healthcare provision. Early miscarriages occur during the first 14 weeks of pregnancy, and can be managed expectantly, medically or surgically. However, there is uncertainty about the relative effectiveness and risks of each option.
OBJECTIVES
To estimate the relative effectiveness and safety profiles for the different management methods for early miscarriage, and to provide rankings of the available methods according to their effectiveness, safety, and side-effect profile using a network meta-analysis.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth's Trials Register (9 February 2021), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (12 February 2021), and reference lists of retrieved studies.
SELECTION CRITERIA
We included all randomised controlled trials assessing the effectiveness or safety of methods for miscarriage management. Early miscarriage was defined as less than or equal to 14 weeks of gestation, and included missed and incomplete miscarriage. Management of late miscarriages after 14 weeks of gestation (often referred to as intrauterine fetal deaths) was not eligible for inclusion in the review. Cluster- and quasi-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded non-randomised trials.
DATA COLLECTION AND ANALYSIS
At least three review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for the primary outcomes of complete miscarriage and composite outcome of death or serious complications. The certainty of evidence was assessed using GRADE. Relative effects for the primary outcomes are reported subgrouped by the type of miscarriage (incomplete and missed miscarriage). We also performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available methods.
MAIN RESULTS
Our network meta-analysis included 78 randomised trials involving 17,795 women from 37 countries. Most trials (71/78) were conducted in hospital settings and included women with missed or incomplete miscarriage. Across 158 trial arms, the following methods were used: 51 trial arms (33%) used misoprostol; 50 (32%) used suction aspiration; 26 (16%) used expectant management or placebo; 17 (11%) used dilatation and curettage; 11 (6%) used mifepristone plus misoprostol; and three (2%) used suction aspiration plus cervical preparation. Of these 78 studies, 71 (90%) contributed data in a usable form for meta-analysis. Complete miscarriage Based on the relative effects from the network meta-analysis of 59 trials (12,591 women), we found that five methods may be more effective than expectant management or placebo for achieving a complete miscarriage: · suction aspiration after cervical preparation (risk ratio (RR) 2.12, 95% confidence interval (CI) 1.41 to 3.20, low-certainty evidence), · dilatation and curettage (RR 1.49, 95% CI 1.26 to 1.75, low-certainty evidence), · suction aspiration (RR 1.44, 95% CI 1.29 to 1.62, low-certainty evidence), · mifepristone plus misoprostol (RR 1.42, 95% CI 1.22 to 1.66, moderate-certainty evidence), · misoprostol (RR 1.30, 95% CI 1.16 to 1.46, low-certainty evidence). The highest ranked surgical method was suction aspiration after cervical preparation. The highest ranked non-surgical treatment was mifepristone plus misoprostol. All surgical methods were ranked higher than medical methods, which in turn ranked above expectant management or placebo. Composite outcome of death and serious complications Based on the relative effects from the network meta-analysis of 35 trials (8161 women), we found that four methods with available data were compatible with a wide range of treatment effects compared with expectant management or placebo: · dilatation and curettage (RR 0.43, 95% CI 0.17 to 1.06, low-certainty evidence), · suction aspiration (RR 0.55, 95% CI 0.23 to 1.32, low-certainty evidence), · misoprostol (RR 0.50, 95% CI 0.22 to 1.15, low-certainty evidence), · mifepristone plus misoprostol (RR 0.76, 95% CI 0.31 to 1.84, low-certainty evidence). Importantly, no deaths were reported in these studies, thus this composite outcome was entirely composed of serious complications, including blood transfusions, uterine perforations, hysterectomies, and intensive care unit admissions. Expectant management and placebo ranked the lowest when compared with alternative treatment interventions. Subgroup analyses by type of miscarriage (missed or incomplete) agreed with the overall analysis in that surgical methods were the most effective treatment, followed by medical methods and then expectant management or placebo, but there are possible subgroup differences in the effectiveness of the available methods. AUTHORS' CONCLUSIONS: Based on relative effects from the network meta-analysis, all surgical and medical methods for managing a miscarriage may be more effective than expectant management or placebo. Surgical methods were ranked highest for managing a miscarriage, followed by medical methods, which in turn ranked above expectant management or placebo. Expectant management or placebo had the highest chance of serious complications, including the need for unplanned or emergency surgery. A subgroup analysis showed that surgical and medical methods may be more beneficial in women with missed miscarriage compared to women with incomplete miscarriage. Since type of miscarriage (missed and incomplete) appears to be a source of inconsistency and heterogeneity within these data, we acknowledge that the main network meta-analysis may be unreliable. However, we plan to explore this further in future updates and consider the primary analysis as separate networks for missed and incomplete miscarriage.
Topics: Abortion, Incomplete; Abortion, Missed; Abortion, Spontaneous; Drug Therapy, Combination; Female; Humans; Mifepristone; Misoprostol; Network Meta-Analysis; Oxytocics; Placebos; Pregnancy; Pregnancy Trimester, First; Randomized Controlled Trials as Topic; Suction; Vacuum Curettage; Watchful Waiting
PubMed: 34061352
DOI: 10.1002/14651858.CD012602.pub2 -
JAMA Apr 2023Vacuum aspiration is commonly used to remove retained products of conception in patients with incomplete spontaneous abortion. Scarring of the uterine cavity may occur,...
IMPORTANCE
Vacuum aspiration is commonly used to remove retained products of conception in patients with incomplete spontaneous abortion. Scarring of the uterine cavity may occur, potentially impairing future fertility. A procedural alternative, operative hysteroscopy, has gained popularity with a presumption of better future fertility.
OBJECTIVE
To assess the superiority of hysteroscopy to vacuum aspiration for subsequent pregnancy in patients with incomplete spontaneous abortion who intend to have future pregnancy.
DESIGN, SETTING, AND PARTICIPANTS
The HY-PER randomized, controlled, single-blind trial included 574 patients between November 6, 2014, and May 3, 2017, with a 2-year duration of follow-up. This multicenter trial recruited patients in 15 French hospitals. Individuals aged 18 to 44 years and planned for surgery for an incomplete spontaneous abortion with plans to subsequently conceive were randomized in a 1:1 ratio.
INTERVENTIONS
Surgical treatment by hysteroscopy (n = 288) or vacuum aspiration (n = 286).
MAIN OUTCOMES AND MEASURES
The primary outcome was a pregnancy of at least 22 weeks' duration during 2-year follow-up.
RESULTS
The intention-to-treat analyses included 563 women (mean [SD] age, 32.6 [5.4] years). All aspiration procedures were completed. The hysteroscopic procedure could not be completed for 19 patients (7%), 18 of which were converted to vacuum aspiration (8 with inability to completely resect, 7 with insufficient visualization, 2 with anesthetic complications that required a shortened procedure, 1 with equipment failure). One hysteroscopy failed due to a false passage during cervical dilatation. During the 2-year follow-up, 177 patients (62.8%) in the hysteroscopy group and 190 (67.6%) in the vacuum aspiration (control) group achieved the primary outcome (difference, -4.8% [95% CI, -13% to 3.0%]; P = .23). The time-to-event analyses showed no statistically significant difference between groups for the primary outcome (hazard ratio, 0.87 [95% CI, 0.71 to 1.07]). Duration of surgery and hospitalization were significantly longer for hysteroscopy. Rates of new miscarriages, ectopic pregnancies, Clavien-Dindo surgical complications of grade 3 or above (requiring surgical, endoscopic, or radiological intervention or life-threatening event or death), and reinterventions to remove remaining products of conception did not differ between groups.
CONCLUSIONS AND RELEVANCE
Surgical management by hysteroscopy of incomplete spontaneous abortions in patients intending to conceive again was not associated with more subsequent births or a better safety profile than vacuum aspiration. Moreover, operative hysteroscopy was not feasible in all cases.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT02201732.
Topics: Pregnancy; Humans; Female; Adult; Abortion, Spontaneous; Vacuum Curettage; Single-Blind Method; Pregnancy, Ectopic; Hysteroscopy
PubMed: 37039805
DOI: 10.1001/jama.2023.3415 -
American Journal of Obstetrics and... May 2020Cesarean scar pregnancy is a complication in which an early pregnancy implants in the scar from a prior cesarean delivery. This condition presents a substantial risk for...
Cesarean scar pregnancy is a complication in which an early pregnancy implants in the scar from a prior cesarean delivery. This condition presents a substantial risk for severe maternal morbidity because of challenges in securing a prompt diagnosis, as well as uncertainty regarding optimal treatment once identified. Ultrasound is the primary imaging modality for cesarean scar pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar pregnancy management, but the optimal treatment is not known. Women who decline treatment of a cesarean scar pregnancy should be counseled regarding the risk for severe morbidity. The following are Society for Maternal-Fetal Medicine recommendations: We recommend against expectant management of cesarean scar pregnancy (GRADE 1B); we suggest operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided vacuum aspiration be considered for surgical management of cesarean scar pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for medical treatment of cesarean scar pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar pregnancy (GRADE 1C); in women who choose expectant management and continuation of a cesarean scar pregnancy, we recommend repeat cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that women with a cesarean scar pregnancy be advised of the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception (GRADE 1C).
Topics: Abortifacient Agents, Nonsteroidal; Cesarean Section; Cicatrix; Disease Management; Female; Gestational Age; Gestational Sac; Humans; Injections; Methotrexate; Obstetric Surgical Procedures; Postoperative Complications; Pregnancy; Pregnancy, Ectopic; Surgery, Computer-Assisted; Ultrasonography, Prenatal; Vacuum Curettage; Watchful Waiting
PubMed: 31972162
DOI: 10.1016/j.ajog.2020.01.030 -
Ugeskrift For Laeger Aug 2023Morel-Lavallée lesion (MLL) is a closed degloving injury caused by traumatic sheering of subcutaneous tissue from the underlying fascia. MLL can be classified as acute... (Review)
Review
Morel-Lavallée lesion (MLL) is a closed degloving injury caused by traumatic sheering of subcutaneous tissue from the underlying fascia. MLL can be classified as acute (less-than 3 months) or chronic (greater-than 3 months or if a capsule has formed). Acute lesions are treated with compression, percutaneous aspiration, sclerodesis, suction-curettage or open surgery depending on vitality of the overlying skin, if fractures are present next to the lesion or if infection has occurred. Chronic lesions are treated with sclerodesis, suction-curettage or open surgery. Drain and vacuum-assisted closure placement should be used post-operatively, as argued in this review.
Topics: Humans; Fractures, Bone; Negative-Pressure Wound Therapy; Skin; Subcutaneous Tissue; Suction
PubMed: 37615228
DOI: No ID Found -
Clinical Obstetrics and Gynecology Dec 2023First-trimester abortion is a common and safe procedure. A focused history and physical examination are essential for providing this care. Laboratory assessment can...
First-trimester abortion is a common and safe procedure. A focused history and physical examination are essential for providing this care. Laboratory assessment can include Rh typing, hemoglobin, and cervicitis testing as indicated by a patient's risk factors. Procedural abortion in the first trimester includes cervical dilation with or without cervical preparation, and uterine evacuation utilizing a manual vacuum aspirator or electric vacuum aspirator. Complications occur rarely and are often easily managed at the time of diagnosis.
Topics: Pregnancy; Female; Humans; Pregnancy Trimester, First; Vacuum Curettage; Abortion, Induced; Abortion, Spontaneous; Cervix Uteri; Pregnancy Trimester, Second
PubMed: 37750678
DOI: 10.1097/GRF.0000000000000808 -
Fertility and Sterility Dec 2023To study the comparison between hysteroscopic morcellation (HM) of retained products of conception (RPOC) with ultrasound (US)-guided electric vacuum aspiration in terms... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To study the comparison between hysteroscopic morcellation (HM) of retained products of conception (RPOC) with ultrasound (US)-guided electric vacuum aspiration in terms of intrauterine adhesion (IUA) formation, efficacy, and complications.
DESIGN
A randomized controlled, nonblinded trial.
SETTING
Three teaching hospitals and one university hospital from April 2015 to June 2022.
PATIENTS
A total of 133 women with RPOC on US, ranging from 1-4 cm, were randomized to receive either HM or electric vacuum aspiration.
INTERVENTION
Hysteroscopic morcellation was performed with the TruClear System (Medtronic, Minneapolis, MN, USA). Electric vacuum aspiration was performed using an 8- or 10-mm flexible plastic Karman cannula under US guidance. Women allocated to vacuum aspiration underwent the procedure as soon as possible.
MAIN OUTCOME MEASURES
In the HM group, an office diagnostic hysteroscopy was planned a minimum of 6 weeks after the end of pregnancy, followed by retained product of conception removal at least 8 weeks after the end of the pregnancy. Postoperatively, an office second-look hysteroscopy was scheduled to assess the primary outcome of IUAs.
RESULTS
Postoperative IUAs were seen in 14.3% (9/63) of patients in the HM group and 20.6% (13/64) of patients in the vacuum aspiration group (-6% [-19.1% to 7.1%]). Significantly more RPOC were removed completely by HM compared with vacuum aspiration (95.2% vs. 82.5% (-14% [-24.9% to -3.1%]), and additional operative hysteroscopy was less frequently necessary in the HM group (12.5%) compared with the vacuum aspiration group (31.3%) (-20.1% [-34.3% to -6%]). The median operating time was shorter for vacuum aspiration compared with HM (5.80 minutes vs. 7.15 minutes). No differences were observed between HM and vacuum aspiration for the occurrence of intraoperative or postoperative complications (5.5% vs. 5.0% and 2.7% vs. 1.3%, respectively).
CONCLUSION
In our randomized controlled trial, no significant differences were found in the occurrence of IUAs and complications. However, the RPOC were more often completely removed by HM than vacuum aspiration, and the HM group required fewer additional hysteroscopic treatments.
CLINICAL TRIAL REGISTRATION NUMBER
NTR4923 (https://trialsearch.who.int/Trial2.aspx?TrialID=NTR4923). Date of registration: November 23, 2014, date of initial participant enrollment: January 1, 2015.
Topics: Pregnancy; Humans; Female; Morcellation; Uterine Diseases; Hysteroscopy; Pregnancy Complications; Vacuum Curettage
PubMed: 37657600
DOI: 10.1016/j.fertnstert.2023.08.956 -
Taiwanese Journal of Obstetrics &... Sep 2019Suction curettage is recommended for molar evacuation rather than sharp curettage because of its safety. However, the superiority of suction curettage with respect to... (Observational Study)
Observational Study
OBJECTIVE
Suction curettage is recommended for molar evacuation rather than sharp curettage because of its safety. However, the superiority of suction curettage with respect to the incidence of gestational trophoblastic neoplasia (GTN) has not been reported. This study aimed to compare the efficacy and safety of two evacuation procedures, vacuum aspiration and forceps/blunt curettage, for complete hydatidiform moles (CHMs) to determine the differences between them.
MATERIALS AND METHODS
Patients with androgenetic CHM determined by multiplex short tandem repeat polymorphism analysis were included in this observational cohort study. Patients underwent evacuation with forceps and blunt curettage (forceps group) before March 2013 and with vacuum aspiration (vacuum group) thereafter. GTN was diagnosed based on the International Federation of Gynecology and Obstetrics 2000 criteria. The incidence of GTN and other clinical parameters were compared.
RESULTS
Ninety-two patients were diagnosed with androgenetic CHM. The number of patients in the forceps and vacuum groups was 41 and 51, respectively. The incidence of GTN was 12.2% (5/41) and 13.7% (7/51) in the forceps and vacuum groups, respectively, which was not significantly different (P = 1, Fisher's exact test). No major adverse events, such as uterine perforation and blood transfusion, were noted in either group. The median surgery time was shorter in the vacuum group (16 min) than in the forceps group (25 min) (P = 0.05, Mann-Whitney U test).
CONCLUSION
There were no differences in the incidence of GTN between the forceps and vacuum groups for androgenetic CHM. However, vacuum aspiration could have the advantage of a shorter surgery period. The use of vacuum aspiration for molar pregnancy seems to be safer. Therefore, we recommend suction curettage for the first evacuation of hydatidiform moles.
Topics: Adult; Cohort Studies; Curettage; Female; Gestational Trophoblastic Disease; Humans; Hydatidiform Mole; Incidence; Postoperative Complications; Pregnancy; Surgical Instruments; Treatment Outcome; Uterine Neoplasms; Vacuum Curettage
PubMed: 31542087
DOI: 10.1016/j.tjog.2019.07.012 -
BMC Health Services Research Mar 2022Despite the increasing trend of Postabortion Care (PAC) needs and provision, the evidence related to its cost is lacking. This study aims to review the costs of...
BACKGROUND
Despite the increasing trend of Postabortion Care (PAC) needs and provision, the evidence related to its cost is lacking. This study aims to review the costs of Postabortion Care (PAC) per patient at a national level.
METHODS
A systematic review of literature related to PAC cost published in 1994 - October 2020 was performed. Electronic databases such as PubMed, Medline, The Cochrane Library, CINAHL, and PsycINFO were used to search the literature. Following the title and abstract screening, reporting quality was appraised using the Consolidates Health Economic Evaluation (CHEERS) checklist. PAC costs were extrapolated into US dollars ($US) and international dollars ($I), both in 2019.
RESULTS
Twelve studies met the inclusion criteria. All studies reported direct medical cost per patient in accessing PAC, but only three of them included indirect medical cost. All studies reported either average or range of cost. In terms of range, the highest direct cost of PAC with MVA (Medical Vacuum Aspiration) services can be found in Colombia, between $US50.58-212.47, while the lowest is in Malawi ($US15.2-139.19). The highest direct cost of PAC with D&C (Dilatation and Curettage), services is in El Salvador ($US65.22-240.75), while the lowest is in Bangladesh ($US15.71-103.85). Among two studies providing average indirect cost data, Uganda with $US105.04 has the highest average indirect medical cost, while Rwanda with $US51.44 has the lowest.
CONCLUSIONS
Our review shows variability in the cost of PAC across countries. This study depicts a clearer picture of how costly it is for women to access PAC services, although it is still seemingly underestimated. When a study compared the use of UE (Uterine Evacuation) method between MVA and D&C, it is confirmed that MVA treatments tend to have lower costs and potentially reduce a significant cost. Therefore, by looking at both clinical and economic perspectives, improving and strengthening the quality and accessibility of PAC with MVA is a priority.
Topics: Abortion, Induced; Aftercare; Cost-Benefit Analysis; Female; Humans; Malawi; Pregnancy; Vacuum Curettage
PubMed: 35337323
DOI: 10.1186/s12913-022-07765-1 -
Best Practice & Research. Clinical... Jan 2020FIGO established a Working Group on the Prevention of Unsafe Abortion in 2007 and a parallel program or "Initiative" with the same name. The initiative involved 46 FIGO... (Review)
Review
FIGO established a Working Group on the Prevention of Unsafe Abortion in 2007 and a parallel program or "Initiative" with the same name. The initiative involved 46 FIGO member societies from seven regions: South-Southeast Asia, Eastern-Central Europe and Central Asia, North Africa and Eastern Mediterranean, Eastern-Central-Southern Africa, Western-Central Africa, Central America and Caribbean, and South America. Each society working in collaboration with the corresponding Ministry of Health and other agencies conducted a situational analysis and prepared a plan of action based on the findings. Such plans of action are continuously monitored by annual evaluation of the progress in the implementation at regional workshops. A substantial progress has been achieved in providing legal and safe abortion services, replacing curettage for manual vacuum aspiration or misoprostol and introducing and expanding postabortion contraception with emphasis on long-acting methods, such as IUDs and contraceptive implants.
Topics: Abortion, Induced; Abortion, Legal; Aftercare; Contraception; Female; Health Services Accessibility; Humans; International Agencies; Pregnancy; Societies, Medical
PubMed: 31331743
DOI: 10.1016/j.bpobgyn.2019.05.016 -
The Cochrane Database of Systematic... Jul 2020Non-tubal ectopic pregnancy is the implantation of an embryo at a site lying outside the uterine cavity or fallopian tubes. Sites include a caesarean scar, the cornua... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Non-tubal ectopic pregnancy is the implantation of an embryo at a site lying outside the uterine cavity or fallopian tubes. Sites include a caesarean scar, the cornua uteri, the ovary, the cervix, and the abdomen. There has been an increasing trend in the occurrence of these rare conditions, especially caesarean scar pregnancy (CSP).
OBJECTIVES
To evaluate the clinical effectiveness and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy in terms of fertility outcomes and complications.
SEARCH METHODS
We searched the Cochrane Gynaecology and Fertility (CGF) Group Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization (WHO) search portal and nine other databases to 12 December 2019. We handsearched reference lists of articles retrieved and contacted experts in the field to obtain additional data.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) published in all languages that examined the effects and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy.
DATA COLLECTION AND ANALYSIS
We used Cochrane standard methodological procedures. Primary outcomes were treatment success and complications.
MAIN RESULTS
We included five RCTs with 303 women, all reporting Caesarean scar pregnancy. Two compared uterine arterial embolization (UAE) or uterine arterial chemoembolization (UACE) plus methotrexate (MTX) versus systemic MTX and subsequent dilation and suction curettage; one compared UACE plus MTX versus ultrasonography-guided local MTX injection; and two compared suction curettage under hysteroscopy versus suction curettage under ultrasonography after UAE/UACE. The quality of evidence ranged from moderate to very low. The main limitations were imprecision (small sample sizes and very wide confidence intervals (CI) for most analyses), multiple comparisons with a small number of trials, and insufficient data available to assess heterogeneity. UAE/UACE versus systemic MTX prior to suction curettage Two studies reported this comparison. One compared UAE with systemic MTX and one compared UACE plus MTX versus systemic MTX, in both cases followed by a suction curettage. We are uncertain whether UAE/UACE improved success rates after initial treatment (UAE: risk ratio (RR) 1.00, 95% CI 0.90 to 1.12; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.87, 95% CI 0.54 to 1.38; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced rates of complications (UAE: RR 0.47, 95% CI 0.13 to 1.75; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.62, 95% CI 0.26 to 1.48; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced adverse effects (UAE: RR 1.58, 95% CI 0.41 to 6.11; 1 RCT, 72 women; low-quality evidence; UACE: RR 1.16, 95% CI 0.32 to 4.24; 1 RCT, 28 women; low-quality evidence), and it was not obvious that the types of events had similar values to participants (e.g. fever versus vomiting). Blood loss was lower in UAE/UACE groups than systemic MTX groups (UAE: mean difference (MD) -378.70 mL, 95% CI -401.43 to -355.97; 1 RCT, 72 women; moderate-quality evidence; UACE: MD -879.00 mL, 95% CI -1135.23 to -622.77; 1 RCT, 28 women; moderate-quality evidence). Data were not available on time to normalize β-human chorionic gonadotropin (β-hCG). UACE plus MTX versus ultrasonography-guided local MTX injection We are uncertain whether UACE improved success rates after initial treatment (RR 0.95, 95% CI 0.56 to 1.60; 1 RCT, 45 women; very low-quality evidence). Adverse effects: the study reported the same number of failed treatments in each arm (RR 0.88, 95% CI 0.40 to 1.92; 1 RCT, 45 women). We are uncertain whether UACE shortened the time to normalize β-hCG (MD 1.50 days, 95% CI -3.16 to 6.16; 1 RCT, 45 women; very low-quality evidence). Data were not available for complications. Suction curettage under hysteroscopy versus under ultrasonography after UAE/UACE. Two studies reported this comparison. One compared suction curettage under hysteroscopy versus under ultrasonography after UAE, and one compared these interventions after UACE. We are uncertain whether suction curettage under hysteroscopy improved success rates after initial treatment (UAE: RR 0.91, 95% CI 0.81 to 1.03; 1 RCT, 66 women; very low-quality evidence; UACE: RR 1.02, 95% CI 0.96 to 1.09; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced rates of complications (UAE: RR 4.00, 95% CI 0.47 to 33.91; 1 RCT, 66 women; very low-quality evidence; UACE: RR 0.18, 95% CI 0.01 to 3.72; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced adverse effects (UAE: RR 3.09, 95% CI 0.12 to 78.70; 1 RCT, 66 women; very low-quality evidence; UACE: not estimable; 1 RCT, 92 women; very low-quality evidence). We are uncertain whether suction curettage under hysteroscopy shortened the time to normalize β-hCG (UAE: MD 4.03 days, 95% CI -1.79 to 9.85; 1 RCT, 66 women; very low-quality evidence; UACE: MD 0.84 days, 95% CI -1.90 to 3.58; 1 RCT, 92 women; low-quality evidence). Non-tubal ectopic pregnancy other than CSP No studies reported on non-tubal ectopic pregnancies in locations other than on a caesarean scar.
AUTHORS' CONCLUSIONS
For Caesarean scar pregnancies (CSP) it is uncertain whether there is a difference in success rates, complications, or adverse events between UAE/UACE and administration of systemic MTX before suction curettage (low-quality evidence). Blood loss was lower if suction curettage is conducted after UAE/UACE than after administration of systemic MTX (moderate-quality evidence). It is uncertain whether there is a difference in treatment success rates, complications, adverse effects or time to normalize β-hCG between suction curettage under hysteroscopy and under ultrasonography (very low-quality evidence). There are no studies of non-tubal ectopic pregnancy other than CSP and RCTs for these types of pregnancy are unlikely.
Topics: Abortifacient Agents, Nonsteroidal; Bias; Cesarean Section; Chemoembolization, Therapeutic; Cicatrix; Confidence Intervals; Dilatation and Curettage; Female; Humans; Hysteroscopy; Methotrexate; Pregnancy; Pregnancy, Ectopic; Randomized Controlled Trials as Topic; Sample Size; Ultrasonography, Interventional; Uterine Artery; Uterine Artery Embolization; Vacuum Curettage
PubMed: 32609376
DOI: 10.1002/14651858.CD011174.pub2