Therapeutic Actions Expectant Management (Birth/Miscarriage)

NCBI pubmed

Risks of miscarriage or preterm delivery in trichorionic and dichorionic triplet pregnancies with embryo reduction versus expectant management: a systematic review and meta-analysis.

Related Articles Risks of miscarriage or preterm delivery in trichorionic and dichorionic triplet pregnancies with embryo reduction versus expectant management: a systematic review and meta-analysis. Hum Reprod. 2017 Apr 21;:1-9 Authors: Anthoulakis C, Dagklis T, Mamopoulos A, Athanasiadis A Abstract STUDY QUESTION: Is pregnancy outcome in triplet pregnancies improved with embryo reduction (ER) to twins compared to expectant management? SUMMARY ANSWER: In trichorionic triplet pregnancies, ER to twins reduces the risk of preterm birth (<34 weeks) without significantly increasing the risk of miscarriage (<24 weeks), whereas in dichorionic triplet pregnancies, the results are inconclusive. WHAT IS KNOWN ALREADY: Triplet pregnancies are associated with a high risk of miscarriage and preterm birth. ER can ameliorate these conditions in higher order multiple gestations but is still controversial in triplets. STUDY DESIGN, SIZE, DURATION: This study aimed to conduct a systematic review, following the PRISMA guidelines, and critically appraise ER at 8-14 weeks of gestation in both trichorionic triamniotic (TCTA) and dichorionic triamniotic (DCTA) pregnancies. Selective ER to twins was compared with expectant management, focusing on the risks of miscarriage and preterm birth. The computerized database search was performed on 8 January 2017. Overall, from 25 citations of relevance, eight studies with a total of 249 DCTA and 1167 TCTA pregnancies fulfilled the inclusion criteria. PARTICIPANTS/MATERIALS, SETTING, METHODS: A comprehensive computerized systematic literature search of all English language studies between 2000 and 2016 was performed in PubMed, EMBASE, Scopus, Evidence Based Medicine Reviews (Cochrane Database and Cochrane Central Register of Controlled Trials) and Google Scholar. Relevant article reference lists were hand searched. The management options were compared for rates of miscarriage <24 weeks and preterm birth <34 weeks. Only studies with both expectant management and ER to twins were included in the analysis. The quality of each individual article was critically appraised and appropriate statistical methods were used to extract results. MAIN RESULTS AND THE ROLE OF CHANCE: In TCTA pregnancies managed expectantly (n = 501), the rates of miscarriage and preterm birth were 7.4 and 50.2%, respectively. Meta-analysis demonstrated that ER to twins in TCTA pregnancies (n = 666) was associated with a lower risk (17.3 versus 50.2%) of preterm birth (RR = 0.36, 95% CI: 0.28-0.48), whereas the risk of miscarriage (8.1% versus 7.4%) did not significantly increase (RR = 1.08, 95% CI: 0.58-1.98). In DCTA triplets managed expectantly (n = 200), the rates of miscarriage and preterm birth were 8.5 and 51.9%, respectively. Although the meta-analysis was inconclusive, it suggested that ER to twins in DCTA triplets, either of the foetus with a separate placenta (n = 15) or one of the monochorionic pair (n = 34), was neither significantly associated with an increased risk of miscarriage (8.5 versus 13.3%, P = 0.628 and RR = 1.22, 95% CI: 0.38-3.95, respectively) nor with a lower risk of preterm birth (51.9 versus 46.2%, P = 0.778 and RR = 0.5, 95% CI: 0.04-5.7, respectively). LIMITATIONS, REASONS FOR CAUTION: No randomized controlled trials of ER versus expectant management in TCTA or DCTA pregnancies were identified from our literature search. We were able to include only a handful of papers with small sample sizes and suffering from bias, and non-English publications were missed. Irrespective of the strict inclusion and exclusion criteria, publication bias was evident. WIDER IMPLICATIONS OF THE FINDINGS: The greatest strength of our systematic review is that, contrary to the existing literature, it only included studies with both the intervention and expectant arm. Our results are in agreement with current literature. In TCTA pregnancies, ER to twins is associated with a lower risk of preterm birth but is not associated with a higher risk of miscarriage. In the absence of a randomized trial, the data from systematic reviews appear to be the best existing evidence for counselling in the first trimester on the different options available. Finally, in DCTA pregnancies, indications exist that ER (of one of the MC pair) to twins could possibly reduce the risk of preterm birth without increasing the risk of miscarriage. STUDY FUNDING/COMPETING INTEREST(S): None to declare. REGISTRATION NUMBER: N/A. PMID: 28444191 [PubMed - as supplied by publisher]

Fertility and obstetric outcomes after curettage versus expectant management in randomised and non-randomised women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage.

Related Articles Fertility and obstetric outcomes after curettage versus expectant management in randomised and non-randomised women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage. Eur J Obstet Gynecol Reprod Biol. 2017 Apr;211:78-82 Authors: Lemmers M, Verschoor MA, Overwater K, Bossuyt PM, Hendriks D, Hemelaar M, Schutte JM, Adriaanse AH, Ankum WM, Huirne JA, Mol BW Abstract OBJECTIVE: To assess fertility and obstetric outcomes in women treated with curettage or undergoing expectant management for an incomplete miscarriage after misoprostol treatment. STUDY DESIGN: Between June 2012 and July 2014, we conducted a multicentre randomised clinical trial (RCT) with a parallel cohort study for non-randomised women, treated according to their preference. In the RCT 30 women were allocated curettage and 29 expectant management. In the cohort 197 women participated; 65 underwent curettage and 132 women underwent expectant management. Primary outcome was curation, defined as either an empty uterus on sonography at six weeks or an uneventful clinical follow-up. We used questionnaires to assess fertility and obstetric outcome of the first new pregnancy subsequent to study enrolment. RESULTS: Curation was seen in 91/95 women treated with curettage (95.8%) versus 134/161 women managed expectantly (83.2%) (p=0.003). The response rate was 211/255 (82%). In 198 women pursuing a new pregnancy, conception rates were 92% (67/73) in the curettage group versus 96% (120/125) in the expectant management group (OR 0.96, 95% CI 0.89;1.03, p=0.34), with ongoing pregnancy rates of 87% (58/67) versus 78% (94/120), respectively (OR 1.12, 95% CI 0.99;1.28, p=0.226). Preterm birth rates were 1/46 in the curettage group versus 8/81 in the expectant management group (OR 0.22, 95% CI 0.03;1.71 P=0.15). Caesarean section rates were 23% and 24% for women in the curettage group and expectant management group respectively. CONCLUSION: In women with an incomplete evacuation of the uterus after misoprostol treatment, curettage and expectant management does not lead to different fertility and pregnancy outcomes, as compared to expectant management. PMID: 28199872 [PubMed - in process]

Expectant management versus multifetal pregnancy reduction in higher order multiple pregnancies containing a monochorionic pair and a review of the literature.

Related Articles Expectant management versus multifetal pregnancy reduction in higher order multiple pregnancies containing a monochorionic pair and a review of the literature. Arch Gynecol Obstet. 2016 Nov;294(6):1167-1173 Authors: Abel JS, Flöck A, Berg C, Gembruch U, Geipel A Abstract PURPOSE: To compare the perinatal outcome in multifetal pregnancies containing a monochorionic twin pair, managed either expectantly or by fetal reduction (MFPR). METHODS: This was a retrospective analysis of prospectively collected data on 47 triplet and 10 quadruplet pregnancies recruited between 10 and 14 weeks. Main outcome measures were miscarriage <24 weeks, preterm birth, fetal growth restriction, birth weight and survival rates. RESULTS: For triplets the miscarriage rates <24 weeks were 6.3 % after reduction and 20.0 % for expectant management and MFPR, respectively. While we recorded no case of severe preterm delivery <30 weeks in the reduction group, it was 25 % in those with expectant management. Mean gestational age and birth weight were significantly higher after fetal reduction than for the conservative approach (37.7 ± 1.6 weeks vs. 30.9 ± 3.2 weeks, p < 0.01 and 2676 ± 705 g vs. 1429 ± 542 g, p < 0.01). Expectantly managed triplets were complicated by twin-twin transfusion syndrome in 18.8 % and intrauterine fetal death in 8.3 %. Survival rates were 85.4 % for those managed expectantly and 80.0 % after fetal reduction. Mean gestational age of ongoing quadruplets was 26.9 ± 2.0 weeks vs. 34.5 ± 4.3 weeks for those with reduction of the monochorionic pair (p < 0.05). Survival rates were 100 % in the reduction group and 58.3 % in the expectant management group (p < 0.05). There was an inverse correlation between the final number of fetuses and the birth weight. CONCLUSION: Fetal reduction in triplets and quadruplets including a monochorionic pair is associated with decreased early prematurity. While in quadruplets the overall survival is higher after reduction, there was no difference for dichorionic triplets with reduction or conservative management. Complications owing to monochorionicity are frequently observed. PMID: 27380181 [PubMed - in process]

Intent to treat analysis of in vitro fertilization and preimplantation genetic screening versus expectant management in patients with recurrent pregnancy loss.

Related Articles Intent to treat analysis of in vitro fertilization and preimplantation genetic screening versus expectant management in patients with recurrent pregnancy loss. Hum Reprod. 2016 Aug;31(8):1668-74 Authors: Murugappan G, Shahine LK, Perfetto CO, Hickok LR, Lathi RB Abstract STUDY QUESTION: In an intent to treat analysis, are clinical outcomes improved in recurrent pregnancy loss (RPL) patients undergoing IVF and preimplantation genetic screening (PGS) compared with patients who are expectantly managed (EM)? SUMMARY ANSWER: Among all attempts at PGS or EM among RPL patients, clinical outcomes including pregnancy rate, live birth (LB) rate and clinical miscarriage (CM) rate were similar. WHAT IS KNOWN ALREADY: The standard of care for management of patients with RPL is EM. Due to the prevalence of aneuploidy in CM, PGS has been proposed as an alternate strategy for reducing CM rates and improving LB rates. STUDY DESIGN, SIZE, DURATION: Retrospective cohort study of 300 RPL patients treated between 2009 and 2014. PARTICIPANTS/MATERIALS, SETTING, METHODS: Among two academic fertility centers, 112 RPL patients desired PGS and 188 patients chose EM. Main outcomes measured were pregnancy rate and LB per attempt and CM rate per pregnancy. One attempt was defined as an IVF cycle followed by a fresh embryo transfer or a frozen embryo transfer (PGS group) and 6 months trying to conceive (EM group). MAIN RESULTS AND THE ROLE OF CHANCE: In the IVF group, 168 retrievals were performed and 38 cycles canceled their planned PGS. Cycles in which PGS was intended but cancelled had a significantly lower LB rate (15 versus 36%, P = 0.01) and higher CM rate (50 versus 14%, P < 0.01) compared with cycles that completed PGS despite similar maternal ages. Of the 130 completed PGS cycles, 74% (n = 96) yielded at least one euploid embryo. Clinical pregnancy rate per euploid embryo transfer was 72% and LB rate per euploid embryo transfer was 57%. Among all attempts at PGS or EM, clinical outcomes were similar. Median time to pregnancy was 6.5 months in the PGS group and 3.0 months in the EM group. LIMITATIONS, REASONS FOR CAUTION: The largest limitation is the retrospective study design, in which patients who elected for IVF/PGS may have had different clinical prognoses than patients who elected for expectant management. In addition, the definition of one attempt at conception for PGS and EM groups was different between the groups and can introduce potential confounders. For example, it was not confirmed that patients in the EM group were trying to conceive for each month of the 6-month period. WIDER IMPLICATIONS OF THE FINDING: Success rates with PGS are limited by the high incidence of cycles that intend but cancel PGS or cycles that do not reach transfer. Counseling RPL patients on their treatment options should include not only success rates with PGS per euploid embryo transferred, but also LB rate per initiated PGS cycle. Furthermore, patients who express an urgency to conceive should be counseled that PGS may not accelerate time to conception. STUDY FUNDING/COMPETING INTERESTS: None. TRIAL REGISTRATION NUMBER: N/A. TRIAL REGISTRATION DATE: N/A. DATE OF FIRST PATIENT'S ENROLLMENT: N/A. PMID: 27278003 [PubMed - in process]

Assisted reproductive technologies for male subfertility.

Related Articles Assisted reproductive technologies for male subfertility. Cochrane Database Syst Rev. 2016 Feb 26;2:CD000360 Authors: Cissen M, Bensdorp A, Cohlen BJ, Repping S, de Bruin JP, van Wely M Abstract BACKGROUND: Intra-uterine insemination (IUI), in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) are frequently used fertility treatments for couples with male subfertility. The use of these treatments has been subject of discussion. Knowledge on the effectiveness of fertility treatments for male subfertility with different grades of severity is limited. Possibly, couples are exposed to unnecessary or ineffective treatments on a large scale. OBJECTIVES: To evaluate the effectiveness and safety of different fertility treatments (expectant management, timed intercourse (TI), IUI, IVF and ICSI) for couples whose subfertility appears to be due to abnormal sperm parameters. SEARCH METHODS: We searched for all publications that described randomised controlled trials (RCTs) of the treatment for male subfertility. We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO and the National Research Register from inception to 14 April 2015, and web-based trial registers from January 1985 to April 2015. We applied no language restrictions. We checked all references in the identified trials and background papers and contacted authors to identify relevant published and unpublished data. SELECTION CRITERIA: We included RCTs comparing different treatment options for male subfertility. These were expectant management, TI (with or without ovarian hyperstimulation (OH)), IUI (with or without OH), IVF and ICSI. We included only couples with abnormal sperm parameters. DATA COLLECTION AND ANALYSIS: Two review authors independently selected the studies, extracted data and assessed risk of bias. They resolved disagreements by discussion with the rest of the review authors. We performed statistical analyses in accordance with the guidelines for statistical analysis developed by The Cochrane Collaboration. The quality of the evidence was rated using the GRADE methods. Primary outcomes were live birth and ovarian hyperstimulation syndrome (OHSS) per couple randomised. MAIN RESULTS: The review included 10 RCTs (757 couples). The quality of the evidence was low or very low for all comparisons. The main limitations in the evidence were failure to describe study methods, serious imprecision and inconsistency. IUI versus TI (five RCTs)Two RCTs compared IUI with TI in natural cycles. There were no data on live birth or OHSS. We found no evidence of a difference in pregnancy rates (2 RCTs, 62 couples: odds ratio (OR) 4.57, 95% confidence interval (CI) 0.21 to 102, very low quality evidence; there were no events in one of the studies).Three RCTs compared IUI with TI both in cycles with OH. We found no evidence of a difference in live birth rates (1 RCT, 81 couples: OR 0.89, 95% CI 0.30 to 2.59; low quality evidence) or pregnancy rates (3 RCTs, 202 couples: OR 1.51, 95% CI 0.74 to 3.07; I(2) = 11%, very low quality evidence). One RCT reported data on OHSS. None of the 62 women had OHSS.One RCT compared IUI in cycles with OH with TI in natural cycles. We found no evidence of a difference in live birth rates (1 RCT, 44 couples: OR 3.14, 95% CI 0.12 to 81.35; very low quality evidence). Data on OHSS were not available. IUI in cycles with OH versus IUI in natural cycles (five RCTs)We found no evidence of a difference in live birth rates (3 RCTs, 346 couples: OR 1.34, 95% CI 0.77 to 2.33; I(2) = 0%, very low quality evidence) and pregnancy rates (4 RCTs, 399 couples: OR 1.68, 95% CI 1.00 to 2.82; I(2) = 0%, very low quality evidence). There were no data on OHSS. IVF versus IUI in natural cycles or cycles with OH (two RCTs)We found no evidence of a difference in live birth rates between IVF versus IUI in natural cycles (1 RCT, 53 couples: OR 0.77, 95% CI 0.25 to 2.35; low quality evidence) or IVF versus IUI in cycles with OH (2 RCTs, 86 couples: OR 1.03, 95% CI 0.43 to 2.45; I(2) = 0%, very low quality evidence). One RCT reported data on OHSS. None of the women had OHSS.Overall, we found no evidence of a difference between any of the groups in rates of live birth, pregnancy or adverse events (multiple pregnancy, miscarriage). However, most of the evidence was very low quality.There were no studies on IUI in natural cycles versus TI in stimulated cycles, IVF versus TI, ICSI versus TI, ICSI versus IUI (with OH) or ICSI versus IVF. AUTHORS' CONCLUSIONS: We found insufficient evidence to determine whether there was any difference in safety and effectiveness between different treatments for male subfertility. More research is needed. PMID: 26915339 [PubMed - indexed for MEDLINE]

In vitro fertilisation for unexplained subfertility.

Related Articles In vitro fertilisation for unexplained subfertility. Cochrane Database Syst Rev. 2015 Nov 19;(11):CD003357 Authors: Pandian Z, Gibreel A, Bhattacharya S Abstract BACKGROUND: One-third of subfertile couples have no identifiable cause for their inability to conceive. In vitro fertilisation (IVF) is a widely accepted treatment for this condition; however, this treatment is invasive and expensive and is associated with risks. OBJECTIVES: To evaluate the effectiveness and safety of IVF compared with expectant management, unstimulated intrauterine insemination (IUI) or intrauterine insemination along with ovarian stimulation with gonadotropins (IUI + gonadotropins) or clomiphene (IUI + CC) or letrozole (IUI + letrozole) in improving pregnancy outcomes. SEARCH METHODS: This review has drawn on the search strategy developed by the Cochrane Menstrual Disorders and Subfertility Group. We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched May 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, first quarter), MEDLINE (1946 to May 2015), EMBASE (1985 to May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (May 2015) and reference lists of articles. We searched the following trial registries: clinicaltrials.gov (http://www.clinicaltrials.gov) and the World Health Organization International Trials Registry Platform search portal (http://www.who.int/trialsearch/Default.aspx). We searched the Web of Science (http://wokinfo.com/) as another source of trials and conference abstracts, OpenGrey (http://www.opengrey.eu/) for unpublished literature from Europe and the Latin American Caribbean Health Sciences Literature (LILACS) database (http://regional.bvsalud.org/php/index.php?lang=en). Moreover, we handsearched relevant conference proceedings and contacted study authors to ask about additional publications.Two review authors independently assessed trial eligibility, extracted data and assessed risk of bias. The primary review outcome was cumulative live birth rate. Multiple pregnancy and other adverse effects were secondary outcomes. We combined data to calculate pooled risk ratios (RRs) and 95% confidence intervals (CIs). We assessed statistical heterogeneity by using the I(2) statistic. We assessed the overall quality of evidence for the main comparisons using Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in which the effectiveness of IVF in couples with unexplained subfertility was compared with that of other treatments, including expectant management, unstimulated IUI and stimulated IUI using gonadotropins or clomiphene or letrozole.Live birth rate (LBR) per woman was the primary outcome. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the eligibility and quality of trials and evaluated the quality of the evidence by using GRADE criteria. MAIN RESULTS: IVF versus expectant management (two RCTs):Live birth rate per woman was higher with IVF than with expectant management (odds ratio (OR) 22.00, 95% confidence interval (CI) 2.56 to 189.37, one RCT, 51 women, very low quality evidence). Multiple pregnancy rates (MPRs), ovarian hyperstimulation syndrome (OHSS) and miscarriage were not reported. IVF versus unstimulated IUI (two RCTs):Live birth rate was higher with IVF than with unstimulated IUI (OR 2.47, 95% CI 1.19 to 5.12, two RCTs, 156 women, I(2) = 60%, low quality evidence). There was no evidence of a difference between the groups in multiple pregnancy rates (OR 1.03, 95% CI 0.04 to 27.29, one RCT, 43 women, very low quality evidence) IVF versus IUI + ovarian stimulation with gonadotropins (three RCTs) or clomiphene (one RCT) or letrozole (no RCTs):Data from these trials could not be pooled because of high statistical heterogeneity (I(2) = 93.3%). Heterogeneity was eliminated when studies were stratified by pretreatment status.In trials comparing IVF versus IUI + gonadotropins among treatment-naive women, there was no conclusive evidence of a difference between the groups in live birth rates (OR 1.27, 95% CI 0.94 to 1.73, four RCTs, 745 women, I(2) = 8.0%, moderate-quality evidence). In women pretreated with IUI + clomiphene, a higher live birth rate was reported among those who underwent IVF than those given IUI + gonadotropins (OR 3.90, 95% CI 2.32 to 6.57, one RCT, 280 women, moderate-quality evidence).There was no conclusive evidence of a difference in live birth rates between IVF and IUI + CC in treatment-naive women (OR 2.51, 95% CI 0.96 to 6.55, one RCT, 103 women, low quality evidence).In treatment-naive women, there was no evidence of a difference in rates of multiple pregnancy between women who underwent IVF and those who received IUI + gonadotropins (OR 0.79, 95% CI 0.45 to 1.39, four RCTs, 745 women, I(2) = 0%, moderate quality evidence). There was no evidence of a difference in MPRs between women who underwent IVF compared with those given IUI + CC (OR 1.02, 95% CI 0.20 to 5.31, one RCT, 103 women, low-quality evidence).There was no evidence of a difference in ovarian hyperstimulation syndrome rate between treatment-naive women who underwent IVF and those given IUI + gonadotropins (OR 1.23, 95% CI 0.36 to 4.14, two RCTs, 221 women, low quality evidence). There was no evidence of a difference in OHSS rates between groups receiving IVF versus those receiving IUI + CC (OR 1.02, 95% CI 0.20 to 5.31, one RCT, 103 women, low-quality evidence).In treatment naive women, there was no evidence of a difference in miscarriage rates between IVF and IUI + CC (OR 1.16, 95% CI 0.44 to 3.02, one RCT, 103 women, low-quality evidence), nor between women treated with IVF versus those receiving IUI+ gonadotropins (OR 1.16, 95% CI 0.44 to 3.02, one RCT, 103 women).No studies compared IVF with IUI + letrozole.The quality of the evidence ranged from very low to moderate. The main limitation was serious imprecision resulting from small study numbers and low event rates. AUTHORS' CONCLUSIONS: IVF may be associated with higher live birth rates than expectant management, but there is insufficient evidence to draw firm conclusions. IVF may also be associated with higher live birth rates than unstimulated IUI. In women pretreated with clomiphene + IUI, IVF appears to be associated with higher birth rates than IUI + gonadotropins. However in women who are treatment-naive there is no conclusive evidence of a difference in live birth rates between IVF and IUI + gonadotropins or between IVF and IUI + clomiphene. Adverse events associated with these interventions could not be adequately assessed owing to lack of evidence. PMID: 26583517 [PubMed - indexed for MEDLINE]

Dilatation and curettage increases the risk of subsequent preterm birth: a systematic review and meta-analysis.

Related Articles Dilatation and curettage increases the risk of subsequent preterm birth: a systematic review and meta-analysis. Hum Reprod. 2016 Jan;31(1):34-45 Authors: Lemmers M, Verschoor MA, Hooker AB, Opmeer BC, Limpens J, Huirne JA, Ankum WM, Mol BW Abstract STUDY QUESTION: Could dilatation and curettage (D&C), used in the treatment of miscarriage and termination of pregnancy, increase the risk of subsequent preterm birth? SUMMARY ANSWER: A history of curettage in women is associated with an increased risk of preterm birth in a subsequent pregnancy compared with women without such history. WHAT IS KNOWN ALREADY: D&C is one of the most frequently performed procedures in obstetrics and gynaecology. Apart from the acknowledged but relatively rare adverse effects, such as cervical tears, bleeding, infection, perforation of the uterus, bowel or bladder, or Asherman syndrome, D&C has been suggested to also lead to an increased risk of preterm birth in the subsequent pregnancy. STUDY DESIGN, SIZE, DURATION: In the absence of randomized data, we conducted a systematic review and meta-analysis of cohort and case-control studies. PARTICIPANTS/MATERIALS, SETTING, METHODS: We searched OVID MEDLINE and OVID EMBASE form inception until 21 May 2014. We selected cohort and case-control studies comparing subsequent preterm birth in women who had a D&C for first trimester miscarriage or termination of pregnancy and a control group of women without a history of D&C. MAIN RESULTS AND THE ROLE OF CHANCE: We included 21 studies reporting on 1 853 017 women. In women with a history of D&C compared with those with no such history, the odds ratio (OR) for preterm birth <37 weeks was 1.29 (95% CI 1.17; 1.42), while for very preterm birth the ORs were 1.69 (95% CI 1.20; 2.38) for <32 weeks and 1.68 (95% CI 1.47; 1.92) for <28 weeks. The risk remained increased when the control group was limited to women with a medically managed miscarriage or induced abortion (OR 1.19, 95% CI 1.10; 1.28). For women with a history of multiple D&Cs compared with those with no D&C, the OR for preterm birth (<37 weeks) was 1.74 (95% CI 1.10; 2.76). For spontaneous preterm birth, the OR was 1.44 (95% CI 1.22; 1.69) for a history of D&C compared with no such history. LIMITATIONS, REASONS FOR CAUTION: There were no randomized controlled trials comparing women with and without a history of D&C and subsequent preterm birth. As a consequence, confounding may be present since the included studies were either cohort or case-control studies, not all of which corrected the results for possible confounding factors. WIDER IMPLICATIONS OF THE FINDINGS: This meta-analysis shows that D&C is associated with an increased risk of subsequent preterm birth. The increased risk in association with multiple D&Cs indicates a causal relationship. Despite the fact that confounding cannot be excluded, these data warrant caution in the use of D&C for miscarriage and termination of pregnancy, the more so since less invasive options are available. STUDY FUNDING/COMPETING INTERESTS: This study was funded by ZonMw, a Dutch organization for Health Research and Development, project number 80-82310-97-12066. PMID: 26534897 [PubMed - indexed for MEDLINE]

Long-term complications and reproductive outcome after the management of retained products of conception: a systematic review.

Related Articles Long-term complications and reproductive outcome after the management of retained products of conception: a systematic review. Fertil Steril. 2016 Jan;105(1):156-64.e1-2 Authors: Hooker AB, Aydin H, Brölmann HA, Huirne JA Abstract OBJECTIVE: To examine the long-term complications and reproductive outcomes after the management of retained products of conception (RPOC). DESIGN: Systematic review. SETTING: Not applicable. PATIENT(S): Women suspected of RPOC who were subjected to medical therapy with misoprostol or surgical treatment. INTERVENTION(S): An electronic literature search was conducted in June 2015 using MEDLINE, EMBASE, and the Cochrane library. We included clinical trials in which women were consecutively included, independent of their symptoms. MAIN OUTCOME MEASURE(S): The prevalence of intrauterine adhesions (IUAs) and reproductive outcomes. RESULT(S): No studies reporting on IUAs or reproductive indicators after medical management with misoprostol were found. We included 10 cohort studies with poor to average methodological quality. Five cohort studies (n = 339) reported IUAs in 22.4% (95% confidence interval, 18.3%-27%) of women hysteroscopically evaluated. Significantly more IUAs were encountered after dilation and curettage (D&C) compared with after hysteroscopic resection (HR): 30% vs. 13%. Incomplete evacuation was encountered in, respectively, 29% and 1% of the D&C and HR cases. Similar conception, ongoing pregnancy, live-birth, and miscarriage rates were reported after D&C and HR in six cohort studies (n = 380), and there was a tendency toward earlier conception after HR. The reproductive outcomes were not reported in relation to IUAs. CONCLUSION(S): HR may be a preferable surgical treatment in women suspected of RPOC; fewer IUAs and incomplete evacuations are encountered, while similar reproductive outcomes were reported compared with D&C. Confirmation of the observed effects is required, and trials evaluating medical treatment with misoprostol as well as expectant management are urgently needed. PMID: 26453977 [PubMed - indexed for MEDLINE]

Physical Examination-Indicated Cerclage: A Systematic Review and Meta-analysis.

Related Articles Physical Examination-Indicated Cerclage: A Systematic Review and Meta-analysis. Obstet Gynecol. 2015 Jul;126(1):125-35 Authors: Ehsanipoor RM, Seligman NS, Saccone G, Szymanski LM, Wissinger C, Werner EF, Berghella V Abstract OBJECTIVE: To estimate the effectiveness of physical examination-indicated cerclage in the setting of second-trimester cervical dilatation by systematic review and meta-analysis of published studies. DATA SOURCES: We searched MEDLINE, EMBASE, Scopus, ClinicalTrials.gov, Web of Science, and the Cochrane Library for studies published between 1966 and 2014 that evaluated cervical cerclage for the treatment of cervical insufficiency. METHODS OF STUDY SELECTION: The search yielded 6,314 citations. We included cohort studies and randomized controlled trials comparing cerclage placement with expectant management of women with cervical dilatation between 14 and 27 weeks of gestation. Two investigators independently reviewed each citation for inclusion or exclusion and discordant decisions were arbitrated by a third reviewer. Summary estimates were reported as the mean difference and 95% confidence interval (CI) for continuous variables or relative risk and with 95% CI for dichotomous outcomes. Fixed- and random-effects meta-analysis was used, depending on heterogeneity. TABULATION, INTEGRATION, AND RESULTS: Ten studies met inclusion criteria and were included in the final analysis. One was a randomized controlled trial, two were prospective cohort studies, and the remaining seven were retrospective cohort studies. Of the 757 women, 485 (64%) underwent physical examination-indicated cerclage placement and 272 (36%) were expectantly managed. Cerclage was associated with increased neonatal survival (71% compared with 43%; relative risk 1.65, 95% CI 1.19-2.28) and prolongation of pregnancy (mean difference 33.98 days, 95% CI 17.88-50.08). CONCLUSION: Physical examination-indicated cerclage is associated with a significant increase in neonatal survival and prolongation of pregnancy of approximately 1 month when compared with no such cerclage. The strength of this conclusion is limited by the potential for bias in the included studies. PMID: 26241265 [PubMed - indexed for MEDLINE]

Pessary versus cerclage versus expectant management for cervical dilation with visible membranes in the second trimester.

Related Articles Pessary versus cerclage versus expectant management for cervical dilation with visible membranes in the second trimester. J Matern Fetal Neonatal Med. 2016;29(9):1363-6 Authors: Gimovsky AC, Suhag A, Roman A, Rochelson BL, Berghella V Abstract OBJECTIVE: We evaluated pessary for dilated cervix and exposed membranes for prolonging pregnancy compared to cerclage or expectant management. METHODS: Multicenter retrospective cohort study of women, 15-24 weeks, singleton pregnancies, dilated cervix ≥2 cm and exposed membranes. Women received pessary, cerclage or expectant management. Primary outcome was gestational age (GA) at delivery. Secondary outcomes were time until delivery, preterm premature rupture of membranes (PPROM) and neonatal survival. RESULTS: About 112 women met study criteria; 9 - pessary, 85 - cerclage and 18 - expectant management. Mean GA at delivery was 22.9 ± 4.5 weeks with pessary, 29.2 ± 7.5 weeks with cerclage and 25.6 ± 6.7 weeks with expectant management (p = 0.015). Time until delivery was 16.1 ± 18.9 days in the pessary group, 61.7 ± 48.2 days in the cerclage group and 26.8 ± 33.4 days in the expectant group (p < 0.001). PPROM occurred less frequently and neonatal survival increased in women with cerclage. There was a significant difference in all the perinatal outcomes with cerclage compared with either pessary or expectant management. CONCLUSIONS: Perinatal outcomes with pessary were not superior to expectant management in women with dilated cervix with exposed membranes in the second trimester in this small retrospective cohort. PMID: 26067268 [PubMed - indexed for MEDLINE]

Dichorionic triplet pregnancies: risk of miscarriage and severe preterm delivery with fetal reduction versus expectant management. Outcomes of a cohort study and systematic review.

Related Articles Dichorionic triplet pregnancies: risk of miscarriage and severe preterm delivery with fetal reduction versus expectant management. Outcomes of a cohort study and systematic review. BJOG. 2015 Jul;122(8):1053-60 Authors: Morlando M, Ferrara L, D'Antonio F, Lawin-O'Brien A, Sankaran S, Pasupathy D, Khalil A, Papageorghiou A, Kyle P, Lees C, Thilaganathan B, Bhide A Abstract BACKGROUND: In trichorionic pregnancies, fetal reduction from three to two lowers the risk of severe preterm delivery, but provides no advantage in survival. Similar data for dichorionic triamniotic (DCTA) triplets is not readily available. OBJECTIVES: To document the natural history of DCTA triplets and the effect of reduction on the risk of miscarriage and severe preterm delivery, compared with expectant management. SEARCH STRATEGY: Systematic search on MEDLINE, EMBASE, and the Cochrane Library. SELECTION CRITERIA: DCTA triplets with three live fetuses at 8-14 weeks of gestation, outcome data with expectant management and/or reduction, miscarriage before 24 weeks of gestation and/or severe preterm delivery before 32-33 weeks of gestation. DATA COLLECTION AND ANALYSIS: Five studies were included. Data from these were combined with data from three centres. MAIN RESULTS: There were 331 DCTA triplets. The miscarriage rate was 8.9% (95% CI 5.8-13.3%) and the severe preterm delivery rate was 33.3% (95% CI 27.5-39.7%), with expectant management. The miscarriage rate was 14.5% (95% CI 7.6-26.2%) with a reduction of the monochorionic pair, 8.8% (95% CI 3.0-23.0%) with a reduction of one fetus of the monochorionic pair, and 23.5% (9.6-47.3%) with a reduction of the fetus with a separate placenta. Severe preterm delivery rates were 5.5% (95% CI 1.9-14-9%), 11.8% (95% CI 4.7-26.6%), and 17.6% (95% CI 6.2-41.0%), respectively. CONCLUSIONS: In DCTA triplets, expectant management is a reasonable choice when the top priority is a liveborn infant. Where the priority is to minimise severe preterm delivery, the most advisable option is fetal reduction. Further studies are needed to clarify which particular technique is advisable to optimise the outcome. PMID: 25851612 [PubMed - indexed for MEDLINE]

Prior ultrasound-indicated cerclage: how should we manage the next pregnancy?

Related Articles Prior ultrasound-indicated cerclage: how should we manage the next pregnancy? Eur J Obstet Gynecol Reprod Biol. 2015 May;188:129-32 Authors: Vousden N, Hezelgrave N, Carter J, Seed PT, Shennan AH Abstract OBJECTIVE: To determine the subsequent need for cerclage and pregnancy outcome, in women with a prior ultrasound-indicated cerclage. STUDY DESIGN: Analysis of a prospectively collected database from November 2010 to July 2014 from 15 Preterm Surveillance clinics across the UK was performed. Women with an index and previous singleton pregnancy with an ultrasound-indicated cerclage were eligible for inclusion (n=55). Previous ultrasound-indicated cerclage was defined as cerclage inserted prior to 24 weeks' for cervical length <25 mm as detected by transvaginal ultrasound. Women were managed in their subsequent pregnancy with either history-indicated cerclage, transvaginal ultrasound surveillance of cervical length with cerclage if <25 mm or transabdominal cerclage at the discretion of the physician. Exact logistic regression was used to estimate the odds ratio on the chance of delivery before 34 weeks'. Adjustments were made for major risk factors for prematurity: previous spontaneous preterm birth, previous late miscarriage (16+0 to 23+6 weeks') and previous cervical surgery; both individually and in combination. RESULTS: Of the 55 eligible women, 23 underwent history-indicated cerclage, 23 underwent transvaginal ultrasound cervical length surveillance and 8 underwent abdominal cerclage in the index pregnancy. Of those that had ultrasound surveillance, 13 (57%) did not require cerclage and all delivered after 34 weeks'. Of those that had a history-indicated cerclage, six delivered before 34 weeks'. Therefore, women that received a history-indicated cerclage had greater risk of preterm birth compared to women that underwent ultrasound surveillance with cerclage insertion only if cervical shortening was detected (OR 0.09 95% CI 0.00-0.74, p=0.02). Adjustments for risk factors for preterm birth did not significantly affect this risk. CONCLUSION: In women with prior ultrasound-indicated cerclage, who undergo cervical surveillance in the next pregnancy, the majority will not require intervention for a short cervix. Those women receiving a history-indicated vaginal cerclage were more likely to deliver preterm; this cannot be explained by their risk status. All women receiving an abdominal elective cerclage had good outcomes. Ultrasound surveillance is appropriate in women with a prior ultrasound-indicated cerclage who do not require an abdominal cerclage. PMID: 25819012 [PubMed - indexed for MEDLINE]

Cost-effectiveness analysis of preimplantation genetic screening and in vitro fertilization versus expectant management in patients with unexplained recurrent pregnancy loss.

Related Articles Cost-effectiveness analysis of preimplantation genetic screening and in vitro fertilization versus expectant management in patients with unexplained recurrent pregnancy loss. Fertil Steril. 2015 May;103(5):1215-20 Authors: Murugappan G, Ohno MS, Lathi RB Abstract OBJECTIVE: To determine whether in vitro fertilization with preimplantation genetic screening (IVF/PGS) is cost effective compared with expectant management in achieving live birth for patients with unexplained recurrent pregnancy loss (RPL). DESIGN: Decision analytic model comparing costs and clinical outcomes. SETTING: Academic recurrent pregnancy loss programs. PATIENT(S): Women with unexplained RPL. INTERVENTION(S): IVF/PGS with 24-chromosome screening and expectant management. MAIN OUTCOMES MEASURE(S): Cost per live birth. RESULT(S): The IVF/PGS strategy had a live-birth rate of 53% and a clinical miscarriage rate of 7%. Expectant management had a live-birth rate of 67% and clinical miscarriage rate of 24%. The IVF/PGS strategy was 100-fold more expensive, costing $45,300 per live birth compared with $418 per live birth with expectant management. CONCLUSION(S): In this model, IVF/PGS was not a cost-effective strategy for increasing live birth. Furthermore, the live-birth rate with IVF/PGS needs to be 91% to be cost effective compared with expectant management. PMID: 25772770 [PubMed - indexed for MEDLINE]

[Treatment options for early miscarriage; new insights].

Related Articles [Treatment options for early miscarriage; new insights]. Ned Tijdschr Geneeskd. 2014;158:A7900 Authors: Verschoor MA, Lemmers M, Wekker MZ, Ankum WM, Mol BW, Goddijn M Abstract Miscarriage is the most common complication during the first trimester of pregnancy. Three treatment options are available for women who experience early miscarriage: expectant management, curettage, or medical treatment. Curettage has traditionally been the usual treatment, but both expectant management and medical management with misoprostol are more cost-effective. Curettage increases the risk of surgical complications and intra-uterine adhesions (Asherman syndrome), and is associated with preterm birth. After adequate counselling, the woman's preference is a decisive factor; the choice of treatment for early miscarriage lends itself ideally to shared decision making. The Netherlands lacks a multidisciplinary guideline on the treatment of women following miscarriage. PMID: 25406815 [PubMed - indexed for MEDLINE]

Heterotopic cesarean scar pregnancy: diagnosis, treatment, and prognosis.

Related Articles Heterotopic cesarean scar pregnancy: diagnosis, treatment, and prognosis. J Ultrasound Med. 2014 Sep;33(9):1533-7 Authors: OuYang Z, Yin Q, Xu Y, Ma Y, Zhang Q, Yu Y Abstract Heterotopic cesarean scar pregnancy is a rare, life-threatening form of ectopic pregnancy. To provide information regarding the clinical manifestations, diagnosis, management, and prognosis of this condition, we reviewed all cases reported in the English literature. All literature on heterotopic cesarean scar pregnancy was retrieved by searching the PubMed database and tracking references of the relevant literature. Full texts were reviewed, and clinical manifestations, diagnostic methods, and the relationship between the treatment and prognosis were summarized. A total of 14 patients with heterotopic cesarean scar pregnancies were identified, including 6 spontaneous pregnancies and 8 following in vitro fertilization-embryo transfer. Gestational ages at diagnosis ranged from 5 weeks to 8 weeks 4 days. Only 5 cases presented with vaginal bleeding, and the others were asymptomatic. All 14 cases were diagnosed by transvaginal sonography. One patient with no future fertility requirements underwent pregnancy termination by methotrexate. Of the remaining 13 patients who desired to preserve their intrauterine gestations, 10 were treated by sonographically guided selective embryo reduction in situ (by embryo aspiration, drug injection, or both); 2 underwent laparoscopic and hysteroscopic excision of the ectopic pregnancy masses; and 1 was treated by expectant management. All operations were successful and maintained a living intrauterine gestation. Twelve cases resulted in live births by cesarean delivery (3 at term and 9 preterm). One patient underwent pregnancy termination at 12 weeks because of a fetal malformation confirmed by sonography. The possibility of heterotopic cesarean scar pregnancy after cesarean delivery should be considered, especially when pregnancy follows assisted reproductive technology. Transvaginal sonography is an important tool for diagnosis and management. Despite the many options, the best treatment for this condition remains unclear. Selective embryo reduction in situ with sonographic guidance is the main treatment modality and can result in a successful intrauterine gestation, albeit at high risk. PMID: 25154932 [PubMed - indexed for MEDLINE]

Endometriosis: an overview of Cochrane Reviews.

Related Articles Endometriosis: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2014 Mar 10;(3):CD009590 Authors: Brown J, Farquhar C Abstract BACKGROUND: This overview reports on interventions for pain relief and for subfertility in pre-menopausal women with clinically diagnosed endometriosis. OBJECTIVES: The objective of this overview was to summarise the evidence from Cochrane systematic reviews on treatment options for women with pain or subfertility associated with endometriosis. METHODS: Published Cochrane systematic reviews reporting pain or fertility outcomes in women with clinically diagnosed endometriosis were eligible for inclusion in the overview. We also identified Cochrane reviews in preparation (protocols and titles) for future inclusion. The reviews, protocols and titles were identified by searching the Cochrane Database of Systematic Reviews and Archie (the Cochrane information management system) in March 2014.Pain-related outcomes of the overview were pain relief, clinical improvement or resolution and pain recurrence. Fertility-related outcomes were live birth, clinical pregnancy, ongoing pregnancy, miscarriage and adverse events.Selection of systematic reviews, data extraction and quality assessment were undertaken in duplicate. Review quality was assessed using the AMSTAR tool. The quality of the evidence for each outcome was assessed using GRADE methods. Review findings were summarised in the text and the data for each outcome were reported in 'Additional tables'. MAIN RESULTS: Seventeen systematic reviews published in The Cochrane Library were included. All the reviews were high quality. The quality of the evidence for specific comparisons ranged from very low to moderate. Limitations in the evidence included risk of bias in the primary studies, inconsistency between the studies, and imprecision in effect estimates. Pain relief (14 reviews) Gonadotrophin-releasing hormone (GnRH) analogues One systematic review reported low quality evidence of an overall benefit for GnRH analogues compared with placebo or no treatment. Ovulation suppression Five systematic reviews reported on medical treatment using ovulation suppression. There was moderate quality evidence that the levonorgestrel-releasing intrauterine system (LNG-IUD) was more effective than expectant management, and very low quality evidence that danazol was more effective than placebo. There was no consistent evidence of a difference in effectiveness between oral contraceptives and goserelin, estrogen plus progestogen and placebo, or progestogens and placebo, though in all cases the relevant evidence was of low or very low quality. Non-steroidal anti-inflammatory drugs (NSAIDS)A review of NSAIDs reported inconclusive evidence of a benefit in symptom relief compared with placebo. Surgical interventions There were two reviews of surgical interventions. One reported moderate quality evidence of a benefit in pain relief following laparoscopic surgery compared to diagnostic laparoscopy only. The other reported very low quality evidence that recurrence rates of endometriomata were lower after excisional surgery than after ablative surgery. Post-surgical medical interventions Two reviews reported on post-surgical medical interventions. Neither found evidence of an effect on pain outcomes, though in both cases the evidence was of low or very low quality. Alternative medicine There were two systematic reviews of alternative medicine. One reported evidence of a benefit from auricular acupuncture compared to Chinese herbal medicine, and the other reported no evidence of a difference between Chinese herbal medicine and danazol. In both cases the evidence was of low or very low quality. Anti-TNF-α drugs One review found no evidence of a difference in effectiveness between anti-TNF-α drugs and placebo. However, the evidence was of low quality. Reviews reporting fertility outcomes (8 reviews) Medical interventions Four reviews reported on medical interventions for improving fertility in women with endometriosis. One compared three months of GnRH agonists with a control in women undergoing assisted reproduction and found very low quality evidence of an increase in clinical pregnancies in the treatment group. There was no evidence of a difference in effectiveness between the interventions in the other three reviews, which compared GnRH agonists versus antagonists, ovulation suppression versus placebo or no treatment, and pre-surgical medical therapy versus surgery alone. In all cases the evidence was of low or very low quality. Surgical interventions Three reviews reported on surgical interventions. There was moderate quality evidence that both live births or ongoing pregnancy rates and clinical pregnancy rates were higher after laparoscopic surgery than after diagnostic laparoscopy alone. There was low quality evidence of no difference in effectiveness between surgery and expectant management for endometrioma. One review found low quality evidence that excisional surgery resulted in higher clinical pregnancy rates than drainage or ablation of endometriomata. Post-surgical interventions Two reviews reported on post-surgical medical interventions. They found no evidence of an effect on clinical pregnancy rates. The evidence was of low or very low quality. Alternative medicine A review of Chinese herbal medicine in comparison with gestrinone found no evidence of a difference between the groups in clinical pregnancy rates. However, the evidence was of low quality. Adverse events Reviews of GnRH analogues and of danazol reported that the interventions were associated with higher rates of adverse effects than placebo; and depot progestagens were associated with higher rates of adverse events than other treatments. Chinese herbal medicine was associated with fewer side effects than gestrinone or danazol.Three reviews reported miscarriage as an outcome. No difference was found between surgical and diagnostic laparoscopy, between GnRH agonists and antagonists, or between aspiration of endometrioma and expectant management. However, in all cases the quality of the evidence was of low quality. AUTHORS' CONCLUSIONS: For women with pain and endometriosis, suppression of menstrual cycles with gonadotrophin-releasing hormone (GnRH) analogues, the levonorgestrel-releasing intrauterine system (LNG-IUD) and danazol were beneficial interventions. Laparoscopic treatment of endometriosis and excision of endometriomata were also associated with improvements in pain. The evidence on NSAIDs was inconclusive. There was no evidence of benefit with post-surgical medical treatment.In women with endometriosis undergoing assisted reproduction, three months of treatment with GnRH agonist improved pregnancy rates. Excisional surgery improved spontaneous pregnancy rates in the nine to 12 months after surgery compared to ablative surgery. Laparoscopic surgery improved live birth and pregnancy rates compared to diagnostic laparoscopy alone. There was no evidence that medical treatment improved clinical pregnancy rates.Evidence on harms was scanty, but GnRH analogues, danazol and depot progestagens were associated with higher rates than other interventions. PMID: 24610050 [PubMed - indexed for MEDLINE]

Embryo selection with preimplantation chromosomal screening in patients with recurrent pregnancy loss.

Related Articles Embryo selection with preimplantation chromosomal screening in patients with recurrent pregnancy loss. Semin Reprod Med. 2014 Mar;32(2):93-9 Authors: Shahine LK, Lathi RB Abstract Recurrent pregnancy loss (RPL) is a multifactorial disorder which is often challenging for both patients and providers. Guidelines for the evaluation and treatment of patients with RPL include screening for uterine abnormalities, parental chromosomes, and antiphospholipid antibodies, but approximately half of RPL patients remain unexplained. The current recommendation for patients with unexplained RPL is expectant management which offers most patients a 60 to 80% success rate over time. Genetic imbalances in the embryo, including inherited unbalanced translocations and de novo aneuploidy, are frequent causes of miscarriage. Preimplantation genetic screening (PGS) has been proposed as an effective method for selecting viable embryos for transfer that may result lower risk of miscarriage for patients with unexplained RPL and carriers of balanced translocations. The current evidence examining the use of in vitro fertilization with PGS in patients with RPL reveals variable results, due to differences in technologies used and variable patient populations. Newer approaches, which include blastocyst biopsy and the ability to screen for all 24 chromosomes, show the most promise in reducing miscarriage rates. Studies that identify which patients are most likely to benefit from PGS and include live birth rates per initiated cycles are needed before universally recommending this treatment to couples with RPL. PMID: 24515903 [PubMed - indexed for MEDLINE]

A search for hope and understanding: an analysis of threatened miscarriage internet forums.

Related Articles A search for hope and understanding: an analysis of threatened miscarriage internet forums. Midwifery. 2014 Jun;30(6):650-6 Authors: Betts D, Dahlen HG, Smith CA Abstract OBJECTIVE: threatened miscarriage is a common complication of early pregnancy, which increases the risk of miscarriage or pregnancy complications such as premature birth. Currently there is limited evidence to recommend beneficial medical treatments or lifestyle changes, resulting in a 'watchful waiting' approach. The aim of this study was to describe women's experiences of threatened miscarriage through examining postings to Internet discussion forums. DESIGN: a Goggle alert for threatened miscarriage was created with emails containing hyperlinks sent to the first author and collected over a seven month period (April to November 2011). Data was analysed using thematic analysis. FINDINGS: one hundred and twenty one discussion threads were collected. The overarching theme that emerged was one of 'a search for hope and understanding'. Within this there were four sub themes that illustrated this search. 'A reason for hope: stories and real life experiences' illustrated how women sought hope for a viable pregnancy through others. 'Becoming the expert,' captures how women gave advice from their own experiences. 'A safe place to share' and 'connecting to empathic support' illustrates how women used this medium for long distance support. KEY CONCLUSION: internet discussion forums were used by women to seek hope and support they were not receiving from their health professionals. Women urged each other to remain hopeful despite a negative medical prognosis. There was an acceptance of a lay expertise within the forums that was valid enough to challenge medical expertise. IMPLICATIONS FOR PRACTICE: health practitioners may need education that helps them balance their delivery of medical information with hope in order to increase feelings of trust. With women seeing the Internet as a useful form of support, it may be relevant for practitioners to consider recommending relevant Internet sites and discuss this with women. PMID: 24439850 [PubMed - indexed for MEDLINE]

Trichorionic and dichorionic triplet pregnancies at 10-14 weeks: outcome after embryo reduction compared to expectant management.

Related Articles Trichorionic and dichorionic triplet pregnancies at 10-14 weeks: outcome after embryo reduction compared to expectant management. Fetal Diagn Ther. 2013;34(4):199-205 Authors: Chaveeva P, Kosinski P, Puglia D, Poon LC, Nicolaides KH Abstract OBJECTIVE: To compare the outcome of trichorionic triplet (TCT) and dichorionic triplet (DCT) pregnancies managed expectantly and those with embryo reduction (ER) at 10-14 weeks to twins or singletons. METHODS: This was a retrospective study of triplet pregnancies with 3 live fetuses managed expectantly or by ER. Data were combined with the results of previous studies that used similar entry criteria and outcome measures. The management options were compared for rates of miscarriage and preterm birth <33 weeks. RESULTS: In TCTs managed expectantly (n = 358), the rates of miscarriage and preterm birth were 3.1 and 35.1%. Compared to the expectantly managed TCTs, the rate of miscarriage was higher and preterm birth lower in TCTs with ER to 2 fetuses (n = 833, 7.3 and 13.1%, respectively) and TCTs with ER to 1 fetus (n = 78, 11.5 and 8.7%). In DCTs managed expectantly (n = 136), the rates of miscarriage and preterm birth were 8.8 and 46.0%. In DCTs with ER to 2 fetuses (n = 15) or ER to 1 fetus (n = 42), there was a non-significant increase in miscarriage (13.3 and 16.7%, respectively) and decrease in preterm birth (23.1 and 8%, respectively). CONCLUSIONS: In TCT and DCT pregnancies, ER increases the rate of miscarriage but reduces the rate of preterm birth. PMID: 24192576 [PubMed - indexed for MEDLINE]

Emergency cerclage versus expectant management for prolapsed fetal membranes: a retrospective, comparative study.

Related Articles Emergency cerclage versus expectant management for prolapsed fetal membranes: a retrospective, comparative study. J Obstet Gynaecol Res. 2014 Feb;40(2):381-6 Authors: Aoki S, Ohnuma E, Kurasawa K, Okuda M, Takahashi T, Hirahara F Abstract AIM: To compare outcomes after emergency cerclage versus expectant management for prolapsed fetal membranes in women with cervical incompetency. METHODS: The January 2000-December 2012 hospital database was analyzed to identify women managed for prolapsed fetal membranes who did not have premature rupture of membranes, clinically discernible chorioamnionitis, or treatment-resistant uterine contractions from 15 to 26 weeks of gestation retrospectively. Durations of pregnancy prolongation and numbers of deliveries after 32 and 28 weeks were compared between women undergoing emergency cervical cerclage and those receiving expectant management. RESULTS: Fifteen of the 35 women underwent emergency cervical cerclage ('cerclage group'), while the other 20 were managed expectantly ('bedrest group'). In the cerclage group, median gestational ages at procedure and delivery times were 22.6 (15.9-26.1) and 32.4 (19.4-41.6) weeks, respectively. Median gestational ages on admission and at delivery in the bedrest group were 23.4 (21.1-26.4) and 26.0 (23.1-36.4) weeks, respectively. The median duration of pregnancy prolongation was 44 days (4-165) in the cerclage group and 12.5 days (2-93) in the bedrest group (P < 0.01). Numbers of deliveries after 28 and 32 weeks were both significantly higher in the cerclage than in the bedrest group (P < 0.05). CONCLUSION: In women with prolapsed fetal membranes but no signs of infection or painful uterine contractions, emergency cervical cerclage prolonged pregnancy duration as compared with expectant management. PMID: 24147884 [PubMed - indexed for MEDLINE]
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