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Fertility and Sterility Apr 2013To study the genetic association between methylenetetrahydrofolate reductase (MTHFR) A1298 polymorphism and recurrent pregnancy loss (RPL). (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To study the genetic association between methylenetetrahydrofolate reductase (MTHFR) A1298 polymorphism and recurrent pregnancy loss (RPL).
DESIGN
Prospective case-control study, systematic review, and meta-analysis using an electronic database up to July 27, 2012.
SETTING
Meta-analysis of four studies on RPL and three studies on spontaneously aborted embryos, including the present study.
PATIENT(S)
A total of 129 RPL patients and 202 healthy control women with successful pregnancy were analyzed including 40 spontaneously aborted embryos and 40 aborted embryos as control samples. For meta-analysis, 1,080 case and 709 control subjects were included of RPL and 375 case and 384 control samples of spontaneously aborted embryos.
INTERVENTION(S)
Blood was collected by peripheral venous punctures, and spontaneously aborted embryos were collected by curettage or manual vacuum aspiration. Meta-analysis was done on the basis of heterogeneity of the studies.
MAIN OUTCOME MEASURE(S)
Genotyping was done by polymerase chain reaction (PCR)-restriction-fragment-length polymorphism (RFLP). DNA sequencing was used to ascertain PCR-RFLP results. Age-adjusted odds ratios were calculated by logistic regression analysis. Meta-analysis on this polymorphism was conducted to support our findings.
RESULT(S)
We found that presence of rare allele "C" and heterozygous and rare homozygous genotypes significantly increased the risk of RPL. No significant change in the fetal MTHFR A1298C genotype frequency was observed, regardless of chromosomal integrity. Meta-analysis of A1298C polymorphism on both RPL and in spontaneously aborted embryos showed significantly increased risk in the carriers of AC and CC genotypes.
CONCLUSION(S)
The data of the present study clearly suggests that MTHFR A1298C polymorphism is a genetic risk factor for pregnancy loss.
Topics: Abortion, Habitual; Abortion, Spontaneous; Adult; Case-Control Studies; Female; Fetus; Genotype; Humans; Hyperhomocysteinemia; India; Methylenetetrahydrofolate Reductase (NADPH2); Polymorphism, Single Nucleotide; Pregnancy; Prospective Studies; Risk Factors
PubMed: 23357458
DOI: 10.1016/j.fertnstert.2012.12.027 -
The Practising Midwife 2012The aim of this bi-monthly column is to highlight Cochrane Systematic Reviews of relevance to pregnancy and childbirth and to stimulate discussion on the relevance and... (Review)
Review
The aim of this bi-monthly column is to highlight Cochrane Systematic Reviews of relevance to pregnancy and childbirth and to stimulate discussion on the relevance and implications of the review for practice. The Cochrane Collaboration is an international organisation that prepares and maintains high quality systematic reviews to help people make well-informed decisions about healthcare and health policy. A systematic review tries to search for, appraise and synthesise existing research to answer a specific research question. The Cochrane Database of Systematic Reviews (CDSR) is published monthly online. Residents in countries with a national license to The Cochrane Library, including the UK and Ireland, can access the Cochrane Library online free through www.thecochranelibrary.com.
Topics: Abortion, Incomplete; Abortion, Spontaneous; Adult; Bed Rest; Dilatation and Curettage; Evidence-Based Medicine; Female; Humans; Maternal Welfare; Pregnancy; Prenatal Care; Ultrasonography; Vacuum Curettage; Watchful Waiting; Young Adult
PubMed: 22908503
DOI: No ID Found -
The Cochrane Database of Systematic... Apr 2012An incomplete miscarriage occurs when all the products of conception are not expelled through the cervix. Curettage or vacuum aspiration have been used to remove... (Review)
Review
BACKGROUND
An incomplete miscarriage occurs when all the products of conception are not expelled through the cervix. Curettage or vacuum aspiration have been used to remove retained tissues. The anaesthetic techniques used to facilitate this procedure have not been systematically evaluated in order to determine which provide better outcomes to the patients.
OBJECTIVES
To assess the effects of general anaesthesia, sedation or analgesia, regional or paracervical block anaesthetic techniques, or differing regimens of these, for surgical evacuation of incomplete miscarriage.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 January 2012), CENTRAL (The Cochrane Library 2012, Issue 1), PubMed (1966 to 23 January 2012), EMBASE (1974 to 23 January 2012), CINAHL (1982 to 23 January 2012), LILACS (1982 to 23 January 2012) and reference lists of retrieved studies.
SELECTION CRITERIA
All published and unpublished randomised controlled trials (RCTs) or cluster-RCTs comparing the use of any anaesthetic technique (defined by authors as general anaesthesia, sedation/analgesia, regional or paracervical local block (PCB) procedures) to perform surgical evacuation of an incomplete miscarriage. We excluded quasi-randomised trials and studies that were only available as abstracts.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed studies for inclusion and assessed risk of bias. Data were independently extracted and checked for accuracy.
MAIN RESULTS
We included seven trials involving 800 women. The comparisons revealed a very high clinical heterogeneity. As a result of the heterogeneity in the randomisation unit, we did not combine trials but reported the individual trial results in the 'Data and analysis' section and in the text. Half of trials have unclear or high risk of bias in several domains.We did not find any trial reporting data about maternal mortality. In terms of postoperative pain, PCB does not improve the control of postoperative pain when it is compared against sedation/analgesia or versus no anaesthesia/no analgesia. In the comparison of PCB with lidocaine versus PCB with saline solution, significant differences favouring the group with lidocaine were found in one trial (moderate or severe postoperative pain) (risk ratio (RR) 0.32; 95% confidence interval (CI) 0.18 to 0.59).When opioids were used, postoperative nausea and vomiting was more frequent in two trials comparing those versus PCB. In terms of requirement of blood transfusion, two trials showed conflicting results.
AUTHORS' CONCLUSIONS
Particular considerations that influence the choice of anaesthesia for this procedure such as availability, effectiveness, safety, side effects, practitioner's choice, costs and woman's preferences of each technique should continue to be used until more evidence supporting the use of one technique or another.
Topics: Abortion, Incomplete; Anesthesia, General; Anesthesia, Obstetrical; Dilatation and Curettage; Female; Humans; Hypnotics and Sedatives; Pain, Postoperative; Patient Satisfaction; Postoperative Nausea and Vomiting; Pregnancy
PubMed: 22513963
DOI: 10.1002/14651858.CD008681.pub2 -
The Cochrane Database of Systematic... Mar 2012Miscarriage is a common complication of early pregnancy that can have both medical and psychological consequences such as depression and anxiety. The need for routine... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Miscarriage is a common complication of early pregnancy that can have both medical and psychological consequences such as depression and anxiety. The need for routine surgical evacuation with miscarriage has been questioned because of potential complications such as cervical trauma, uterine perforation, hemorrhage, or infection.
OBJECTIVES
To compare the safety and effectiveness of expectant management versus surgical treatment for early pregnancy failure.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 February 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 4 of 4), PubMed (2005 to 11 January 2012), POPLINE (inception to 11 January 2012), LILACS (2005 to 11 January 2012) and reference lists of retrieved studies.
SELECTION CRITERIA
Randomized trials comparing expectant care and surgical treatment (vacuum aspiration or dilation and curettage) for miscarriage were eligible for inclusion.
DATA COLLECTION AND ANALYSIS
Two review authors assessed trial quality and extracted data. We contacted study authors for additional information. For dichotomous data, we calculated the Mantel-Haenszel risk ratio (RR) with 95% confidence interval (CI). For continuous data, we computed the mean difference (MD) and 95% CI. We entered additional data such as medians into 'Other data' tables.
MAIN RESULTS
We included seven trials with 1521 participants in this review. The expectant-care group was more likely to have an incomplete miscarriage by two weeks (RR 3.98; 95% CI 2.94 to 5.38) or by six to eight weeks (RR 2.56; 95% CI 1.15 to 5.69). The need for unplanned surgical treatment was greater for the expectant-care group (RR 7.35; 95% CI 5.04 to 10.72). The mean percentage needing surgical management in the expectant-care group was 28%, while 4% of the surgical-treatment group needed additional surgery. The expectant-care group had more days of bleeding (MD 1.59; 95% CI 0.74 to 2.45). Further, more of the expectant-care group needed transfusion (RR 6.45; 95% CI 1.21 to 34.42). The mean percentage needing blood transfusion was 1.4% for expectant care compared with none for surgical management. Results were mixed for pain. Diagnosis of infection was similar for the two groups (RR 0.63; 95% CI 0.36 to 1.12), as were results for various psychological outcomes. Pregnancy data were limited. Costs were lower for the expectant-care group (MD -499.10; 95% CI -613.04 to -385.16; in UK pounds sterling).
AUTHORS' CONCLUSIONS
Expectant management led to a higher risk of incomplete miscarriage, need for unplanned (or additional) surgical emptying of the uterus, bleeding and need for transfusion. Risk of infection and psychological outcomes were similar for both groups. Costs were lower for expectant management. Given the lack of clear superiority of either approach, the woman's preference should be important in decision making. Pharmacological ('medical') management has added choices for women and their clinicians and has been examined in other reviews.
Topics: Abortion, Incomplete; Abortion, Spontaneous; Anti-Bacterial Agents; Bed Rest; Dilatation and Curettage; Female; Humans; Pregnancy; Pregnancy Trimester, First; Randomized Controlled Trials as Topic; Ultrasonography; Vacuum Curettage; Watchful Waiting
PubMed: 22419288
DOI: 10.1002/14651858.CD003518.pub3 -
The Cochrane Database of Systematic... Nov 2011Surgical abortion by vacuum aspiration or dilatation and curettage has been the method of choice for early pregnancy termination since the 1960s. Medical abortion became... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Surgical abortion by vacuum aspiration or dilatation and curettage has been the method of choice for early pregnancy termination since the 1960s. Medical abortion became an alternative method of first trimester pregnancy termination with the availability of prostaglandins in the early 1970s and anti-progesterones in the 1980s. The most widely researched drugs are prostaglandins (PGs) alone, mifepristone alone, methotrexate alone, mifepristone with prostaglandins and methotrexate with prostaglandins.
OBJECTIVES
To compare different medical methods for first trimester abortion.
SEARCH METHODS
The Cochrane Controlled Trials Register, MEDLINE and Popline were systematically searched. Reference lists of retrieved papers were also searched. Experts in WHO/HRP were contacted.
SELECTION CRITERIA
Types of studies Randomised controlled trials comparing different medical methods for abortion during first trimester (e.g. single drug, combination) were considered. Trials were assessed and included if they had adequate concealment of allocation, randomisation procedure and follow-up. Women, pregnant during the first trimester, undergoing medical abortion were the participants. The outcomes were mortality, failure to achieve complete abortion, surgical evacuation, ongoing pregnancy at follow-up, time until passing of conceptus, blood transfusion, side effects and women's dissatisfaction with the procedure.
DATA COLLECTION AND ANALYSIS
Two reviewers independently selected trials for inclusion from the results of the search strategy described previously.The selection of trials for inclusion in the review was performed independently by two reviewers after employing the search strategy described previously. Trials under consideration were evaluated for appropriateness for inclusion and methodological quality without consideration of their results. Data were processed using Revman software.
MAIN RESULTS
Fifty-eight trials were included in the review. The effectiveness outcomes below refer to 'failure to achieve complete abortion' with the intended method unless otherwise stated. 1) Combined regimen mifepristone/prostaglandin: Mifepristone 600 mg compared to 200 mg shows similar effectiveness in achieving complete abortion (4 trials, RR 1.07, 95% CI 0.87 to 1.32). Misoprostol administered orally is less effective (more failures) than the vaginal route (RR 3.00, 95% CI 1.44 to 6.24) and may be associated with more frequent side effects such as nausea and diarrhoea. Sublingual and buccal routes were similarly effective compared to the vaginal route, but had higher rates of side effects. 2) Mifepristone alone is less effective when compared to the combined regimen mifepristone/prostaglandin (RR 3.76 95% CI 2.30 to 6.15). 3) Five trials compared prostaglandin alone to the combined regimen (mifepristone/prostaglandin). All but one reported higher effectiveness with the combined regimen. The results of these studies could not be combined but the RR of failure with prostaglandin alone is reportedly between 1.4 to 3.75 with the 95% confidence intervals indicating statistical significance. 4) In one trial comparing gemeprost 0.5 mg with misoprostol 800 mcg, misoprostol was more effective (failure with gemeprost: RR 2.86, 95% CI 1.14 to 7.18). 5) There was no difference in effectiveness with use of a divided dose compared to a single dose of prostaglandin. 6) Combined regimen methotrexate/prostaglandin demonstrates similar rates of failure to complete abortion when comparing intramuscular to oral methotrexate administration (RR 2.04, 95% CI 0.51 to 8.07). Similarly, day 3 vs. day 5 administration of prostaglandin following methotrexate administration showed no significant differences (RR 0.72, 95% CI 0.36 to 1.43). One trial compared the effect of tamoxifen vs. methotrexate and no statistically significant differences were observed in effectiveness between the groups.
AUTHORS' CONCLUSIONS
Safe and effective medical abortion methods are available. Combined regimens are more effective than single agents. In the combined regimen, the dose of mifepristone can be lowered to 200 mg without significantly decreasing the method effectiveness. Vaginal misoprostol is more effective than oral administration, and has less side effects than sublingual or buccal. Some results are limited by the small numbers of participants on which they are based. Almost all trials were conducted in settings with good access to emergency services, which may limit the generalizability of these results.
Topics: Abortifacient Agents; Abortion, Incomplete; Abortion, Induced; Drug Therapy, Combination; Female; Humans; Methotrexate; Mifepristone; Misoprostol; Pregnancy; Pregnancy Trimester, First; Prostaglandins; Randomized Controlled Trials as Topic; Tamoxifen
PubMed: 22071804
DOI: 10.1002/14651858.CD002855.pub4 -
The Cochrane Database of Systematic... Sep 2010Incomplete miscarriage is a major problem that should be effectively managed with safe and appropriate procedures. Surgical evacuation of the uterus for management of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Incomplete miscarriage is a major problem that should be effectively managed with safe and appropriate procedures. Surgical evacuation of the uterus for management of incomplete miscarriage usually involves vacuum aspiration or sharp curettage.
OBJECTIVES
To compare the safety and effectiveness of surgical uterine evacuation methods for management of incomplete miscarriage.
SEARCH STRATEGY
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2010).
SELECTION CRITERIA
Randomized trials where different surgical methods were used to manage incomplete miscarriage were eligible for inclusion.
DATA COLLECTION AND ANALYSIS
We extracted population characteristics, settings, and exclusion criteria, in addition to outcomes such as complications of the procedure, duration, need for re-evacuation, blood transfusion, and analgesia/anesthesia.
MAIN RESULTS
Two trials (involving 550 women) were included. Vacuum aspiration was associated with statistically significantly decreased blood loss (mean difference (MD) -17.10 ml, 95% confidence interval (CI) -24.05 to -10.15 ml), less pain during the procedure (risk ratio (RR) 0.74, 95% CI 0.61 to 0.90), and shorter duration of the procedure (MD -1.20 minutes, 95% CI -1.53 to -0.87 minutes), than sharp metal curettage, in the single study that evaluated these outcomes in 357 women. Serious complications such as uterine perforation and other morbidity were rare and the sample sizes of the trials were not large enough to evaluate small or moderate differences.
AUTHORS' CONCLUSIONS
Although the review indicates that vacuum aspiration is safe, quick to perform, and less painful than sharp curettage, and should be recommended for use in the management of incomplete miscarriage, the results are based on data from only one study. Analgesia and sedation should be provided as necessary for the procedure.
Topics: Abortion, Incomplete; Dilatation and Curettage; Female; Humans; Pregnancy; Treatment Outcome; Vacuum Curettage
PubMed: 20824830
DOI: 10.1002/14651858.CD001993.pub2 -
BJOG : An International Journal of... Jan 2008As an alternative to electric vacuum aspirations (EVA), there is an increasing interest in using manual vacuum aspiration (MVA). (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
As an alternative to electric vacuum aspirations (EVA), there is an increasing interest in using manual vacuum aspiration (MVA).
OBJECTIVE
To compare the safety, efficacy and acceptability of MVA with those of EVA for first-trimester abortion.
SEARCH STRATEGY
We searched MEDLINE, EMBASE, Cochrane Library and Chinese Biomedical Database in all language, together with reference lists of retrieved papers.
SELECTION CRITERIA
Randomised controlled trials comparing MVA with EVA for first-trimester abortion were included. The outcomes are complete abortion rate, uterine perforation rate, blood loss, pain perception and acceptability.
DATA COLLECTION AND ANALYSIS
Two reviewers independently extracted the data. Results from the trials were combined to calculate relative risks (RRs) or risk differences for dichotomous outcomes and weighted mean differences (WMDs) for continuous outcomes, together with 95% CIs.
MAIN RESULTS
Ten trials were included, involving 1660 women. Generally, the methodological quality was poor. There were no statistically significant differences, comparing MVA with EVA, in complete abortion rate (RR 1.00; 95% CI 0.99-1.02) and participants' satisfaction (RR 1.02; 95% CI 0.87-1.20). In participants with less than 50 days of gestational age, less blood loss (WMD -1.84; 95% CI -2.45 to -1.23) and less severe pain perception (RR 0.04; 95% CI 0.01-0.12) were reported during the MVA procedure, whereas the operation time was shorter (WMD 0.32; 95% CI 0.02-0.63) in the EVA procedure.
AUTHOR'S CONCLUSIONS
There is some evidence that MVA is as effective and acceptable as EVA and might be safer than EVA.
Topics: Abortion, Induced; Female; Humans; Pain; Patient Satisfaction; Postpartum Hemorrhage; Pregnancy; Pregnancy Trimester, First; Randomized Controlled Trials as Topic; Vacuum Curettage; Vacuum Extraction, Obstetrical
PubMed: 18053098
DOI: 10.1111/j.1471-0528.2007.01572.x -
The Cochrane Database of Systematic... Apr 2006Miscarriage is a common complication of early pregnancy that can have both medical and psychological consequences like depression and anxiety. The need for routine... (Review)
Review
BACKGROUND
Miscarriage is a common complication of early pregnancy that can have both medical and psychological consequences like depression and anxiety. The need for routine surgical evacuation with miscarriage has been questioned because of potential complications such as cervical trauma, uterine perforation, hemorrhage, or infection.
OBJECTIVES
To compare the safety and effectiveness of expectant management versus surgical treatment for early pregnancy loss.
SEARCH STRATEGY
We searched the Cochrane Pregnancy and Childbirth Group Trials Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2004, Issue 3), PubMed (1966 to March 2005), POPLINE (inception to March 2005), and LILACS (1982 to March 2005) and reference lists of reviews.
SELECTION CRITERIA
Randomized trials comparing expectant care and surgical treatment (vacuum aspiration or dilation and curettage (D & C)) for miscarriage were eligible for inclusion.
DATA COLLECTION AND ANALYSIS
Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information.
MAIN RESULTS
Five trials were included in this review with 689 total participants. The expectant-care group was more likely to have an incomplete miscarriage (RR 5.37; 95% CI 2.57 to 11.22). However, the time frames for declaring the process incomplete varied across the studies. The need for unplanned surgical treatment (such as vacuum aspiration or D&C) was greater for the expectant-care group (RR 4.78; 95% CI 1.99 to 11.48). The expectant-care group had more days of bleeding (WMD 1.59; 95% CI 0.74 to 2.45) and a greater amount of bleeding (WMD 1.00; 95% CI 0.60 to 1.40). Post-procedure diagnosis of infection was lower in the expectant-care group (RR 0.29; 95% CI 0.09 to 0.87). Information on psychological outcomes and pregnancy was too limited to draw conclusions.
AUTHORS' CONCLUSIONS
Expectant management led to a higher risk of incomplete miscarriage, need for surgical emptying of the uterus, and bleeding. None of these were serious. In contrast, surgical evacuation was associated with a significantly higher risk of infection. Given the lack of clear superiority of either approach, the woman's preference should play a dominant role in decision making. Medical management has added choices for women and their clinicians, but these were not reviewed here.
Topics: Abortion, Incomplete; Abortion, Spontaneous; Anti-Bacterial Agents; Bed Rest; Dilatation and Curettage; Female; Humans; Pregnancy; Pregnancy Trimester, First; Randomized Controlled Trials as Topic; Ultrasonography; Vacuum Curettage
PubMed: 16625583
DOI: 10.1002/14651858.CD003518.pub2 -
The Cochrane Database of Systematic... 2004Surgical abortion up to 63 days by vacuum aspiration or dilatation and curettage has been the method of choice since the 1960s. Medical abortion became an alternative... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Surgical abortion up to 63 days by vacuum aspiration or dilatation and curettage has been the method of choice since the 1960s. Medical abortion became an alternative method of first trimester pregnancy termination with the availability of prostaglandins in the early 1970s and anti-progesterones in the 1980s. The most widely researched drugs are prostaglandins (PGs) alone, mifepristone alone, methotrexate alone, mifepristone with prostaglandins and methotrexate with prostaglandins.
OBJECTIVES
To compare different medical methods for first trimester abortion.
SEARCH STRATEGY
The Cochrane Controlled Trials Register, MEDLINE and Popline were systematically searched. Reference lists of retrieved papers were also searched. Experts in WHO/HRP were contacted.
SELECTION CRITERIA
Types of studies. Randomised controlled trials comparing different medical methods (e.g. single drug, combination), ways of application, or different dose regimens, single or combined, for medical abortion, were considered. Trials were assessed and included if they had adequate concealment of allocation, randomisation procedure and follow-up. Women, pregnant in the first trimester, undergoing medical abortion were the participants. Different medical methods used for first trimester abortion, compared with each other or placebo were included. The outcomes sought include mortality, failure to achieve complete abortion, surgical evacuation (as emergency procedure, non-emergency procedure, or undefined), ongoing pregnancy at follow-up, time until passing of conceptus (> 3-6 hours), blood transfusion, blood loss (measured or clinically relevant drop in haemoglobin), days of bleeding, pain resulting from the procedure (reported by the women or measured by use of analgesics), additional uterotonics used, women's dissatisfaction with the procedure, nausea, vomiting, diarrhoea.
DATA COLLECTION AND ANALYSIS
Two reviewers independently selected trials for inclusion from the results of the search strategy described previously. The selection of trials for inclusion in the review was performed independently by two reviewers after employing the search strategy described previously. Trials under consideration were evaluated for appropriateness for inclusion and methodological quality without consideration of their results. A form was designed to facilitate the data extraction. Data were processed using Revman software.
MAIN RESULTS
Thirty-nine trials were included in the review. The effectiveness outcomes below refer to 'failure to achieve complete abortion' with the intended method unless otherwise stated. 1) Combined regimen mifepristone/prostaglandin: Mifepristone 600 mg compared to 200 mg shows similar effectiveness in achieving complete abortion (4 trials, RR 1.07, 95% CI 0.87 to 1.32). Misoprostol administered orally is less effective (more failures) than the vaginal route (RR 3.00, 95% CI 1.44 to 6.24) and may be associated with more frequent side effects such as nausea and diarrhoea. 2) Mifepristone alone is less effective compared to the combined regimen mifepristone/prostaglandin (RR 3.76 95% CI 2.30 to 6.15). 3) Similarly, the 5 trials included in the comparison of prostaglandin compared to the combined regimen reported in all but one higher effectiveness with the combined regime compared to prostaglandin. The results of these studies were not pooled but the RR of failure with prostaglandin alone is between 1.4 to 3.75 and the 95% confidence intervals indicate statistical significance. 4) In one trial comparing gemeprost 0.5 mg with misoprostol 800 mcg, misoprostol was more effective (failure with gemeprost: RR 2.86, 95% CI 1.14 to 7.18). 5) There was no difference when using split dose compared to single dose of prostaglandin. 6) Combined regimen methotrexate/prostaglandin: there was no statistically significant difference in failure to achieve complete abortion comparing methotrexate administered intramuscular to oral (RR 2.04, 95% CI 0.51 to 8.07). Similarly, early (day 3) vs late (day 5) administration of prostaglandin showed no significant of prostaglandin showed no significant difference (RR 0.72, 95% CI 0.36 to 1.43). One trial compared the effect of tamoxifen vs methotrexate and no statistically significant differences were observed in effectiveness between the groups.
REVIEWERS' CONCLUSIONS
Safe and effective medical abortion methods are available. Combined regimens are more effective than single agents. In the combined regimen, the dose of mifepristone can be lowered to 200 mg without significantly decreasing the method effectiveness. Misoprostol vaginally is more effective than orally. Some of the results are based on small studies only and therefore carry some uncertainty. Almost all trials were conducted in hospital settings with good access to support and emergency services. It is therefore not clear if the results are readily applicable to under-resourced settings where such services are lacking even if the agents used are available.
Topics: Abortifacient Agents; Abortion, Incomplete; Abortion, Induced; Drug Therapy, Combination; Female; Humans; Methotrexate; Mifepristone; Misoprostol; Pregnancy; Pregnancy Trimester, First; Prostaglandins; Randomized Controlled Trials as Topic; Tamoxifen
PubMed: 15106180
DOI: 10.1002/14651858.CD002855.pub3 -
The Cochrane Database of Systematic... 2004Surgical abortion up to 63 days by vacuum aspiration or dilatation and curettage has been the method of choice since the 1960s. Medical abortion became an alternative... (Review)
Review
BACKGROUND
Surgical abortion up to 63 days by vacuum aspiration or dilatation and curettage has been the method of choice since the 1960s. Medical abortion became an alternative method of first trimester pregnancy termination with the availability of prostaglandins in the early 1970s and anti-progesterones in the 1980s. The most widely researched drugs are prostaglandins (PGs) alone, mifepristone alone, methotrexate alone, mifepristone with prostaglandins and methotrexate with prostaglandins.
OBJECTIVES
To compare different medical methods for first trimester abortion.
SEARCH STRATEGY
The Cochrane Controlled Trials Register, MEDLINE and Popline were systematically searched. Reference lists of retrieved papers were also searched. Experts in WHO/HRP were contacted.
SELECTION CRITERIA
Types of studies. Randomised controlled trials comparing different medical methods (e.g. single drug, combination), ways of application, or different dose regimens, single or combined, for medical abortion, were considered. Trials were assessed and included if they had adequate concealment of allocation, randomisation procedure and follow-up. Women, pregnant in the first trimester, undergoing medical abortion were the participants. Different medical methods used for first trimester abortion, compared with each other or placebo were included. The outcomes sought include mortality, failure to achieve complete abortion, surgical evacuation (as emergency procedure, non-emergency procedure, or undefined), ongoing pregnancy at follow-up, time until passing of conceptus (> 3-6 hours), blood transfusion, blood loss (measured or clinically relevant drop in haemoglobin), days of bleeding, pain resulting from the procedure (reported by the women or measured by use of analgesics), additional uterotonics used, women's dissatisfaction with the procedure, nausea, vomiting, diarrhoea.
DATA COLLECTION AND ANALYSIS
Two reviewers independently selected trials for inclusion from the results of the search strategy described previously. The selection of trials for inclusion in the review was performed independently by two reviewers after employing the search strategy described previously. Trials under consideration were evaluated for appropriateness for inclusion and methodological quality without consideration of their results. A form was designed to facilitate the data extraction. Data were processed using Revman software.
MAIN RESULTS
Thirty-nine trials were included in the review. The effectiveness outcomes below refer to 'failure to achieve complete abortion' with the intended method unless otherwise stated. 1) Combined regimen mifepristone/prostaglandin: Mifepristone 600 mg compared to 200 mg shows similar effectiveness in achieving complete abortion (4 trials, RR 1.07, 95% CI 0.87 to 1.32). Misoprostol administered orally is less effective (more failures) than the vaginal route (RR 3.00, 95% CI 1.44 to 6.24) and may be associated with more frequent side effects such as nausea and diarrhoea. 2) Mifepristone alone is less effective compared to the combined regimen mifepristone/prostaglandin (RR 3.76 95% CI 2.30 to 6.15). 3) Similarly, the 5 trials included in the comparison of prostaglandin compared to the combined regimen reported in all but one higher effectiveness with the combined regime compared to prostaglandin. The results of these studies were not pooled but the RR of failure with prostaglandin alone is between 1.4 to 3.75 and the 95% confidence intervals indicate statistical significance. 4) In one trial comparing gemeprost 0.5 mg with misoprostol 800 mcg, misoprostol was more effective (failure with gemeprost: RR 2.86, 95% CI 1.14 to 7.18). 5) There was no difference when using split dose compared to single dose of prostaglandin. 6) Combined regimen methotrexate/prostaglandin: there was no statistically significant difference in failure to achieve complete abortion comparing methotrexate administered intramuscular to oral (RR 2.04, 95% CI 0.51 to 8.07). Similarly, early (day 3) vs late (day 5) administration of prostaglandin showed no significant of prostaglandin showed no significant difference (RR 0.72, 95% CI 0.36 to 1.43). One trial compared the effect of tamoxifen vs methotrexate and no statistically significant differences were observed in effectiveness between the groups.
REVIEWER'S CONCLUSIONS
Safe and effective medical abortion methods are available. Combined regimens are more effective than single agents. In the combined regimen, the dose of mifepristone can be lowered to 200 mg without significantly decreasing the method effectiveness. Misoprostol vaginally is more effective than orally. Some of the results are based on small studies only and therefore carry some uncertainty. Almost all trials were conducted in hospital settings with good access to support and emergency services. It is therefore not clear if the results are readily applicable to under-resourced settings where such services are lacking even if the agents used are available.
Topics: Abortifacient Agents; Abortion, Incomplete; Abortion, Induced; Drug Therapy, Combination; Female; Humans; Methotrexate; Mifepristone; Misoprostol; Pregnancy; Pregnancy Trimester, First; Prostaglandins; Tamoxifen
PubMed: 14973995
DOI: 10.1002/14651858.CD002855.pub2