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Women's Health (London, England) 2023
Topics: Female; Humans; Pregnancy; Abortion, Induced; Japan; Mifepristone; Misoprostol; Abortifacient Agents, Nonsteroidal; Abortifacient Agents, Steroidal
PubMed: 38017657
DOI: 10.1177/17455057231216533 -
The Cochrane Database of Systematic... Nov 2023Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent... (Review)
Review
BACKGROUND
Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent complications of PPH with timely and appropriate detection and management. However, implementing the best methods of PPH prevention, detection and management can be challenging, particularly in low- and middle-income countries.
OBJECTIVES
Our overall objective was to explore the perceptions and experiences of women, community members, lay health workers, and skilled healthcare providers who have experience with PPH or with preventing, detecting, and managing PPH, in community or health facility settings.
SEARCH METHODS
We searched MEDLINE, CINAHL, Scopus, and grey literature on 13 November 2022 with no language restrictions. We then performed reference checking and forward citation searching of the included studies.
SELECTION CRITERIA
We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored perceptions and experiences of PPH prevention, detection, and management among women, community members, traditional birth attendants, healthcare providers, and managers.
DATA COLLECTION AND ANALYSIS
We used three-stage maximum variation sampling to ensure diversity in terms of relevance of the study to the review objectives, richness of data, and coverage of critical contextual elements: setting (region, country income level), perspective (type of participant), and topic (prevention, detection, management). We extracted data using a data extraction form designed for this review. We used thematic synthesis to analyse and synthesise the evidence, and we used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. To identify factors that may influence intervention implementation, we mapped each review finding to the Theoretical Domains Framework (TDF) and the Capability, Motivation, and Opportunity model of Behaviour change (COM-B). We used the Behaviour Change Wheel to explore implications for practice.
MAIN RESULTS
We included 67 studies and sampled 43 studies for our analysis. Most were from low- or middle-income countries (33 studies), and most included the perspectives of women and health workers. We downgraded our confidence in several findings from high confidence to moderate, low, or very-low confidence, mainly due to concerns about how the studies were conducted (methodological limitations) or concerns about missing important perspectives from some types of participants or in some settings (relevance). In many communities, bleeding during and after childbirth is considered "normal" and necessary to expel "impurities" and restore and cleanse the woman's body after pregnancy and birth (moderate confidence). In some communities, people have misconceptions about causes of PPH or believe that PPH is caused by supernatural powers or evil spirits that punish women for ignoring or disobeying social rules or for past mistakes (high confidence). For women who give birth at home or in the community, female family members or traditional birth attendants are the first to recognise excess bleeding after birth (high confidence). Family members typically take the decision of whether and when to seek care if PPH is suspected, and these family members are often influenced by trusted traditional birth attendants or community midwives (high confidence). If PPH is identified for women birthing at home or in the community, decision-making about the subsequent referral and care pathway can be multifaceted and complex (high confidence). First responders to PPH are not always skilled or trained healthcare providers (high confidence). In health facilities, midwives may consider it easy to implement visual estimation of blood loss with a kidney dish or under-pad, but difficult to accurately interpret the amount of blood loss (very low confidence). Quantifying (rather than estimating) blood loss may be a complex and contentious change of practice for health workers (low confidence). Women who gave birth in health facilities and experienced PPH described it as painful, embarrassing, and traumatic. Partners or other family members also found the experience stressful. While some women were dissatisfied with their level of involvement in decision-making for PPH management, others felt health workers were best placed to make decisions (moderate confidence). Inconsistent availability of resources (drugs, medical supplies, blood) causes delays in the timely management of PPH (high confidence). There is limited availability of misoprostol in the community owing to stockouts, poor supply systems, and the difficulty of navigating misoprostol procurement for community health workers (moderate confidence). Health workers described working on the maternity ward as stressful and intense due to short staffing, long shifts, and the unpredictability of emergencies. Exhausted and overwhelmed staff may be unable to appropriately monitor all women, particularly when multiple women are giving birth simultaneously or on the floor of the health facility; this could lead to delays in detecting PPH (moderate confidence). Inadequate staffing, high turnover of skilled health workers, and appointment of lower-level cadres of health workers are key challenges to the provision of quality PPH care (high confidence). Through team-based simulation training, health workers of different cadres (doctors, midwives, lay health workers) can develop a shared mental model to help them work quickly, efficiently, and amicably as a team when managing women with PPH (moderate confidence).
AUTHORS' CONCLUSIONS
Our findings highlight how improving PPH prevention, detection, and management is underpinned by a complex system of interacting roles and behaviours (community, women, health workers of different types and with different experiences). Multiple individual, sociocultural, and environmental factors influence the decisions and behaviours of women, families, communities, health workers, and managers. It is crucial to consider the broader health and social systems when designing and implementing PPH interventions to change or influence these behaviours. We have developed a set of prompts that may help programme managers, policymakers, researchers, and other key stakeholders to identify and address factors that affect implementation and scale-up of interventions to improve PPH prevention, detection, and management.
Topics: Pregnancy; Female; Humans; Postpartum Hemorrhage; Misoprostol; Health Personnel; Midwifery; Family
PubMed: 38009552
DOI: 10.1002/14651858.CD013795.pub2 -
The Journal of International Medical... Nov 2023Caesarean section is associated with higher blood loss than vaginal delivery. This study was performed to compare the safety and efficacy of preoperative versus... (Randomized Controlled Trial)
Randomized Controlled Trial
Preoperative versus postoperative misoprostol use for prevention of blood loss during caesarean section in pregnant women at term: a multi-centre randomised controlled trial.
OBJECTIVE
Caesarean section is associated with higher blood loss than vaginal delivery. This study was performed to compare the safety and efficacy of preoperative versus postoperative rectal and sublingual misoprostol use for prevention of blood loss in women undergoing elective caesarean delivery.
METHODS
Eligible patients in Southeast Nigeria were randomly classified into those that received 600 µg of preoperative rectal, postoperative rectal, preoperative sublingual, and postoperative sublingual misoprostol. All patients received 10 units of intravenous oxytocin immediately after delivery. Data were analysed with SPSS Version 23.
RESULTS
Preoperative sublingual misoprostol use caused the highest postoperative packed cell volume, least change in the packed cell volume, and lowest intraoperative blood loss. Preoperative sublingual and rectal misoprostol use was associated with better haematological indices and maternal outcomes than postoperative use by these routes. However, preoperative sublingual and rectal use caused more maternal side effects than postoperative use by these routes.
CONCLUSION
Preoperative sublingual misoprostol was associated with the most favourable haematological indices. Although preoperative sublingual and rectal misoprostol use caused more maternal side effects, these routes were associated with better haematological indices and maternal outcomes than postoperative sublingual and rectal misoprostol use.
Topics: Female; Humans; Pregnancy; Misoprostol; Oxytocics; Cesarean Section; Pregnant Women; Oxytocin
PubMed: 37994048
DOI: 10.1177/03000605231213242 -
International Journal of Innovative... Jul 2023Induction of labour has remained one of the most valuable interventions in obstetric practice. Over the years, the proportion of women undergoing induction of labour...
BACKGROUND
Induction of labour has remained one of the most valuable interventions in obstetric practice. Over the years, the proportion of women undergoing induction of labour (IOL) has been on a steady increase. The significance to obstetrics practice as well as its maternal and perinatal outcomes are sacrosanct, hence the need for its periodic review.
OBJECTIVE
To determine the obstetric outcomes of induction of labour.
METHODS
A five-year retrospective study of all cases of induction of labour at the maternity unit of Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, Nigeria between January 1st 2017 and 31st December 2021. The labour ward's records were assessed to determine the total number of women who had induction of labour during the study period. Women whose case files could be not retrieved were excluded. The folder numbers of the patients were extracted and their case files retrieved from the medical records department of the hospital. The primary outcomes measures were the indications and the methods of induction of labour, while the secondary outcome measures were the mode of delivery, cause of failed induction, and the perinatal outcome. Data were obtained using proformas and analysed using statistical packages for social sciences (SPSS) version 26.0 IBM corporation.
RESULT
A total of 3,638 deliveries were taken during the period under review and 168 patients had induction of labour giving an overall prevalence of 4.6% (46/1000 deliveries). Induction of labour was successful in 71.2% of cases. Misoprostol was used in 90.4% of cases as an induction agent. The commonest indication for induction of labour was postdate pregnancy (53.8%). Failed induction was due to fetal distress, poor progress of labour from cephalopelvic disproportion/malposition and failed cervical ripening. In about 72% of deliveries, there was good perinatal outcome, 10.3% of babies had moderate to severe asphyxia while 1.3% had neonatal death.
CONCLUSION
Induction of labour is a safe and beneficial procedure in obstetrics. However, it can be associated with adverse obstetric outcomes.
PubMed: 37987020
DOI: 10.23958/ijirms/vol08-i07/1706 -
Cureus Oct 2023Medical termination of pregnancy, also known as medication abortion, is a safe and effective method of terminating pregnancies in the early stages. It involves using... (Review)
Review
Medical termination of pregnancy, also known as medication abortion, is a safe and effective method of terminating pregnancies in the early stages. It involves using medications, such as mifepristone and prostaglandin, to induce a miscarriage. The success rates of medical abortion vary depending on factors such as gestational age and the specific medications used. For pregnancies that are 49 days or less, the success rates range from 92% to 98%. The choice between misoprostol and gemeprost, both prostaglandins, does not significantly impact the outcomes. It is important to note that various factors, including study design, definitions of success, and prior experience with medical abortion may influence success rates. Strict criteria for success and limited familiarity with the procedure may result in lower reported success rates. Medical termination of pregnancy should be carried out under the guidance and supervision of healthcare professionals. It is crucial to consult a healthcare provider to receive accurate information, personalized guidance, and appropriate support throughout the process. Each situation is unique, and decisions regarding medical termination of pregnancy should be made in collaboration with a trusted healthcare provider.
PubMed: 37927767
DOI: 10.7759/cureus.46444 -
PloS One 2023Approximately one in four women will experience a miscarriage in their lifetime. Ultrasound-guided manual vacuum aspiration (USG-MVA) is an ideal outpatient surgical...
BACKGROUND AND AIM
Approximately one in four women will experience a miscarriage in their lifetime. Ultrasound-guided manual vacuum aspiration (USG-MVA) is an ideal outpatient surgical treatment alternative to traditional surgical evacuation. We aimed to examine the cost-effectiveness of US-MVA with cervical preparation for treatment of early pregnancy loss from the perspective of public healthcare provider of Hong Kong.
METHODS
A decision-analytic model was designed to simulate outcomes in a hypothetical cohort of patients with early pregnancy loss on four interventions: (1) US-MVA, (2) misoprostol, (3) surgical evacuation of uterus by dilation and curettage (surgical evacuation), and (4) expectant care. Model inputs were retrieved from published literature and public data. Model outcome measures were total direct medical cost and disutility-adjusted life-year (DALY). Base-case model results were examined by sensitivity analysis.
RESULTS
The expected DALYs (0.00141) and total direct medical cost (USD736) of US-MVA were the lowest of all interventions in base-case analysis, and US-MVA was the preferred cost-effective option. One-way sensitivity analysis showed that the misoprostol group became less costly than the US-MVA group if the evacuation rate of misoprostol (base-case value 0.832) exceeded 0.920. In probabilistic sensitivity analysis, At the willingness-to-pay (WTP) threshold of 49630 USD/DALY averted (1x gross domestic product per capita of Hong Kong), the US-MVA was cost-effective in 72.9% of the time.
CONCLUSIONS
US-MVA appeared to be cost-saving and effective for treatment of early pregnancy loss from the perspective of public healthcare provider of Hong Kong.
Topics: Pregnancy; Female; Humans; Abortion, Spontaneous; Misoprostol; Vacuum Curettage; Cost-Effectiveness Analysis; Pregnancy Trimester, First; Ultrasonography, Interventional; Cost-Benefit Analysis
PubMed: 37922290
DOI: 10.1371/journal.pone.0294058 -
Minerva Medica Oct 2023
PubMed: 37906205
DOI: 10.23736/S0026-4806.23.08732-3 -
What do healthcare providers think of the quality of uterotonics? A mixed-methods systematic review.BMJ Open Oct 2023To synthesise evidence on the perceptions of healthcare providers (HCPs) about the quality of oxytocin and misoprostol available in their settings, and their actions as...
OBJECTIVES
To synthesise evidence on the perceptions of healthcare providers (HCPs) about the quality of oxytocin and misoprostol available in their settings, and their actions as a result of these perceptions.
DESIGN
Mixed-methods systematic review.
ELIGIBILITY CRITERIA
We included quantitative and qualitative studies reporting HCPs' perceptions about oxytocin or misoprostol quality.
DATA SOURCES
We searched CINAHL, Cochrane Library, Ebscohost, Embase, PubMed, Global Index Medicus, Portal regional BVS, PsycNET, Scopus and Web of Science from inception to 31 March 2022 and grey literature.
RISK OF BIAS
We used the Center for Evidence-Based Management critical appraisal tool for surveys. For qualitative studies, we used the Critical Appraisal Skills Programme tool.
DATA EXTRACTION AND SYNTHESIS
Two independent reviewers performed study selection, data extraction and quality assessment. We conducted separate quantitative and qualitative syntheses and integrated the evidence into a narrative synthesis (convergent segregated review design).
RESULTS
We included five (three quantitative and two qualitative) studies, of moderate or high quality, conducted in low-income and middle-income countries (LMICs). In the three quantitative studies (N=7065 participants), 8.2-21.3% of HCPs had experienced problems due to known/suspected low-quality oxytocin and 3.3% due to low-quality misoprostol. In the two qualitative studies, perception of oxytocin quality varied. In quantitative studies, when confronted with suspected/known low-quality oxytocin, 29-78% of HCPs would inform a supervisor, 62% would document this in writing, 45-54% would change to another drug and 5-37% would double the dose of oxytocin. Qualitative evidence suggests that many HCPs do not formally report suspected low-quality oxytocin or misoprostol, and use higher doses or additional uterotonics.
CONCLUSIONS
A proportion of HCPs from LMICs perceive oxytocin to be of low quality. There is very limited evidence on their perceptions about misoprostol. Many HCPs do not report suspected low-quality uterotonics but change to another medicine or double the dose of oxytocin.
PROSPERO REGISTRATION NUMBER
CRD42022323812.
Topics: Female; Humans; Oxytocin; Misoprostol; Postpartum Hemorrhage; Health Personnel
PubMed: 37899165
DOI: 10.1136/bmjopen-2022-068442 -
JAMA Network Open Oct 2023Misoprostol-alone regimens for abortion may be more effective than previously thought. (Observational Study)
Observational Study
IMPORTANCE
Misoprostol-alone regimens for abortion may be more effective than previously thought.
OBJECTIVE
To estimate the effectiveness of medication abortion with misoprostol alone among individuals self-managing their abortion.
DESIGN, SETTING, AND PARTICIPANTS
For this prospective observational cohort study of callers to safe abortion hotlines and accompaniment groups in Argentina, Nigeria, and Southeast Asia, participants were recruited between July 31, 2019, and October 1, 2020, prior to starting their medication abortion. Eligible participants were 13 years or older, had no contraindications to medication abortion, and were not currently bleeding. Participants completed a baseline and 2 follow-up surveys. The analysis was restricted to participants who reported using misoprostol alone and was performed between January 6, 2022 and September 8, 2023.
EXPOSURE
Self-managed medication abortion using misoprostol alone.
MAIN OUTCOMES AND MEASURES
The primary outcome was effectiveness, defined as participant self-report of complete abortion without procedural intervention, measured at 1 week and 3 weeks after taking misoprostol. Secondary outcomes included method safety, measured by self-report of experiencing warning signs (eg, heavy bleeding, pain, fever, discharge) indicative of a potential complication and by medical treatment (eg, blood transfusion, intravenous fluids, overnight hospital stay) indicative of a potential adverse event. Additional outcomes included length of bleeding and cramping, time to expulsion, and experience of adverse effects.
RESULTS
Among 1352 enrolled participants, 637 used misoprostol-alone regimens for abortion and were included in the analysis (591 [92.8%] from Nigeria, 45 [7.1%] from Southeast Asia, and 1 [0.2%] from Argentina; 384 [60.2%] aged 20-29 years; 317 [49.8%] with pregnancy durations <7 weeks and 205 [32.2%] with pregnancy durations between 7 and <9 weeks). At last follow-up after taking medication (median, 22 days; IQR, 21-26 days), 625 participants (98.1%; 95% CI, 96.7%-98.9%) had a complete abortion without procedural intervention. Potential adverse events were reported by 6 participants (0.9%; 95% CI, 0.4%-2.1%). Most participants experienced bleeding for less than 1 week (median, 4 days; IQR, 3-6 days) and expelled their pregnancy within 24 hours of starting the abortion process (median, 12 hours; IQR, 9-15 hours). Common side effects included nausea (335 participants [52.6%]), fever (232 [36.4%]), and diarrhea (181 [28.4%]).
CONCLUSIONS AND RELEVANCE
The findings suggest that misoprostol alone is a highly effective method of pregnancy termination. Future research should explore strategies to maximize the effectiveness of misoprostol alone in clinical and nonclinical settings.
Topics: Pregnancy; Female; Humans; Misoprostol; Prospective Studies; Mifepristone; Abortion, Induced; Abortion, Spontaneous
PubMed: 37889485
DOI: 10.1001/jamanetworkopen.2023.40042 -
Toxics Sep 2023Prostaglandins have stimulative influence on the human uterus and therefore were introduced to medical treatment in reproductive healthcare as labor inductors or...
Prostaglandins have stimulative influence on the human uterus and therefore were introduced to medical treatment in reproductive healthcare as labor inductors or abortifacients. The UHPLC-ESI-QqQ-MS/MS method was developed for six prostaglandins: carboprost, cloprostenol, dinoprost (PGF2α), dinoprostone (PGE2), misoprostol and sulprostone (substances for pregnancy termination) in pharmaceutical samples and was applied for the toxicological examination of pills containing misoprostol (collected during gynecological examination). There were used two internal standards: misoprostol- and PGF2α-. The quantification of analytes was performed in the MRM mode. The linearity of method was in the range from 0.1 to 10 µg/mL, with a coefficient of determination above 0.997 () for each compound. The precision and accuracy values did not exceed ±5.0%. Analysis of the pills revealed the presence of two substances: misoprostol and diclofenac. Misoprostol and diclofenac dose per sample were as follows: 608.8 ng (sample 1), 708.4 ng (sample 2), 618.8 ng (sample 3) and 67.7 mg (sample 1), 65.3 mg (sample 2) 67.3 mg (sample 3), respectively. A simple, precise and reliable method can be applied for routine examinations in terms of clinical and forensic toxicology examinations as well as in quality control of drugs for pharmaceutical purposes (original drugs and counterfeit medications).
PubMed: 37888653
DOI: 10.3390/toxics11100802