Latest papers on Abortion, Threatened, prevention & control
Mt Sinai J Med. ;78 (2):291-302 21425272
Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal Fetal Medicine, Mount Sinai School of Medicine, New York, NY, USA.
The use of bed rest in medicine dates back to Hippocrates, who first recommended bed rest as a restorative measure for pain. With the formalization of prenatal care in the early 1900s, maternal bed rest became a standard of care, especially toward the end of pregnancy. Antepartum bed rest is a common obstetric management tool, with up to 95% of obstetricians utilizing maternal activity restriction in some way in their practice. Bed rest is prescribed for a variety of complications of pregnancy, from threatened abortion and multiple gestations to preeclampsia and preterm labor. Although the use of bed rest is pervasive, there is a paucity of data to support its use. Additionally, many well-documented adverse physical, psychological, familial, societal, and financial effects have been discussed in the literature. There have been no complications of pregnancy for which the literature consistently demonstrates a benefit to antepartum bed rest. Given the well-documented adverse effects of bed rest, disruption of social relationships, and financial implications of this intervention, there is a real need for scientific investigation to establish whether this is an appropriate therapeutic modality. Well-designed randomized, controlled trials of bed rest versus normal activity for various complications of pregnancy are required to lay this debate to rest once and for all.
Uterolytic effect of Hypoxis hemerocallidea Fisch.& C.A. Mey.(Hypoxidaceae) corm [;African Potato'] aqueous extract.
Department of Pharmacology, School of Pharmacy & Pharmacology, Faculty of Health Sciences, University of KwaZulu-Natal, South Africa.
Extracts of Hypoxis hemerocallidea corm (African potato) are commonly used by some traditional health practitioners in KwaZulu-Natal Province of South Africa as natural antenatal remedy to prevent threatening or premature abortion and miscarriage, and to ensure successful confinement. In this study, we investigated the uterolytic activity of H. hemerocallidea corm aqueous extract on spontaneous, rhythmic contractions of uterine horns taken from pregnant rats and guinea-pigs, as well as on spasmogen-provoked contractions of stilboesterol-primed, oestrogen-dominated, non-pregnant rat and guinea-pig isolated uterine horns. Relatively low to high concentrations of H. hemerocallidea corm aqueous extract (APE, 25-400 mg/ml) inhibited the amplitude of the spontaneous, rhythmic contractions of, and relaxed, uterine horns isolated from pregnant rats and guinea-pigs in a concentration-related manner. Furthermore, relatively low to high concentrations of APE (25-400 mg/ml) relaxed basal tones of uterine horns taken from non-pregnant, oestrogen-dominated rats and guinea-pigs in a concentration-dependent manner. The same moderately low to high concentrations of APE (25-400 mg/ml) inhibited acetylcholine-, oxytocin-, bradykinin-, and potassium chloride (K(+))-induced contractions of oestrogen-dominated rat and guinea-pig isolated uterine horns in a concentration-related manner. Although the mechanism of uterolytic action of APE could not be established, the results of the present study lend pharmacological credence to the folkloric, ethnomedical uses of APE as a natural antenatal remedy for threatening or premature abortion, and suggest that the uterolytic action of the corm's extract is unlikely to be mediated via beta(2)-adrenoceptor stimulation, but probably mediated through a non-specific spasmolytic mechanism.
Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597.
Many surgical and non-surgical interventions are used in the management of threatened and recurrent miscarriages. Evidence-based management of recurrent miscarriages requires investigations into the underlying aetiology. When a specific cause is identified, directed treatment may reduce miscarriage rates. Combined aspirin and heparin for antiphospholipid syndrome, and screening and treatment of bacterial vaginosis between ten and 22 weeks of pregnancy with clindamycin, are the only interventions proven to be useful in randomised controlled trials (RCTs). The use of periconceptional metformin for polycystic ovarian (PCO) syndrome is promising, though data from RCTs are still required. The use of heparin in inherited thrombophilias, bromocriptine in hyperprolactinaemia and luteinising hormone suppression in fertile patients with PCO syndrome are more controversial. In threatened miscarriages, or when no cause is found, treatment becomes empirical. Supportive care may reduce miscarriage rates. Dydrogesterone, a progesterone derivative, may further reduce miscarriage rates. Bed rest and avoidance of sexual intercourse, though commonly advised, are of no proven benefit. Use of uterine relaxing agents, human chorionic gonadotrophin, immunotherapy and vitamins remain controversial in idiopathic recurrent miscarriages.
Clinica de Obstetrica-Ginecologie, Filantropia University Hospital, Bucharest, Romania. email@example.com
The objective of the study was to evaluate the efficacy of progestogenic therapy for the prevention of spontaneous abortions in patients with subchorionic hemorrhage. One hundred pregnant women with bleeding and ultrasonographic evidence of subchorionic hematoma were treated with oral dydrogesterone 40 mg/day. Only cases in which the embryo was viable were included. The follow-up included ultrasonography and intravaginal examination. Of the 100 pregnancies, 93 had a favorable evolution with maintenance of pregnancy. The abortion rate was therefore 7%. This compares with an abortion rate of 18.7% obtained in a previous study in women with subchorionic hematoma treated with micronized progesterone. The abortion rate was therefore reduced by up to 37% with dydrogesterone, as most cases had large-volume hematomas at the first visit and thus a poor prognosis. In conclusion, the marked immunomodulatory effect of dydrogesterone in maintaining a T helper-2 cytokine balance means that it is a good choice for preventing abortion in women suffering from subchorionic hemorrhage.
Chao-Hua Chuang, Wu-Shiun Hsieh, Yueliang Leon Guo, Yih-Jian Tsai, Pei-Jen Chang, Shio-Jean Lin, Pau-Chung Chen
Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan.
PURPOSE To explore the use (prevalence and related factors) of Chinese herbal medicines used by pregnant women. METHODS We used multistage stratified systematic sampling to recruit 2048 postpartum women from the Taiwan national birth register between November and December 2003. Subjects underwent a home interview 6 months after their deliveries. A structured questionnaire was successfully applied to 87% of the sampled population. RESULTS At least one Chinese herbal medicine was used during pregnancy by 24.1% of the interviewed subjects. Pregnant women with threatened abortion appeared to use more Chinese herbal medicines than other pregnant women. CONCLUSION Chinese herbal medicines are frequently used by pregnant women in Taiwan and are very frequently used by those with a threatened abortion.
The impact of dydrogesterone supplementation on serum cytokine profile in women with threatened abortion.
Department of Perinatology, I Division of Gynecology and Obstetrics, Medical University of Lodz, Poland. firstname.lastname@example.org
PROBLEM The role of increased Th1 cytokine expression in pregnancy failure has been questioned recently. The therapeutic value of progestogens in threatened abortion (TA) is still debated. The aim of this prospective study was to compare serum cytokine [tumor necrosis factor (TNF)-alpha, interleukin (IL)-12 and IL-10] concentrations in women with TA to those in women with normal pregnancy and to evaluate the impact of dydrogesterone supplementation in the former group on cytokine concentration. METHODS OF STUDY Twenty-seven threatened aborters were treated for 10 days with dydrogesterone (30-40 mg/day). Sixteen healthy pregnant controls received no treatment. Serum cytokine concentrations were measured twice in both groups by enzyme-linked immunosorbent assay. RESULTS Mean serum concentrations of Th1- and Th2-type cytokines in women with TA did not differ from those in women with normal pregnancy at first and second sampling. After dydrogesterone supplementation, mean TNF-alpha/IL-10 ratio changed from 1.08 to 1.75 while IL-12/IL-10 ratio remained almost the same (0.56-0.61) in the threatened aborters group and did not differ from those in healthy women. CONCLUSIONS The results of this study indicate that peripheral cytokine production in threatened aborters does not differ from that observed among healthy pregnant women. The protective effect of dydrogesterone supplementation in threatened aborters is manifested via restoring progesterone-induced blocking factor concentration rather than controlling cytokine production.
Physiology should be supported with evidence in progesterone administration for threatened miscarriage -- authors' reply.
Department of Obstetrics and Gynaecology, University Kebangsaan, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. email@example.com
OBJECTIVE To determine whether therapy with dydrogesterone in threatened abortion during the first trimester of pregnancy will improve pregnancy outcome. DESIGN Prospective open study. SUBJECTS Pregnant women presenting to the obstetric and gynaecology clinic admitting center with vaginal bleeding before 13 weeks gestation were evaluated for entry into the study. Women were excluded if they had a history of recurrent miscarriage. METHOD Eligible subjects were randomized to receive either dydrogesterone 40 mg stat dose followed by 10 mg twice a day for one week or conservative therapy. RESULTS One hundred and 54 women were recruited. There was no statistically significant differences between the two groups with regard to pre-treatment status. The continuing pregnancy success rate was significantly (p=0.037) higher in women treated with dydrogesterone (95.9%) compared with women who received conservative treatment (86.3%). The odds ratio of the success rate between dydrogesterone treatment and non-treatment was 3.773 (95% confidence interval: 1.009-14.108). CONCLUSION Corpus luteal support with dydrogesterone has been shown to reduce the incidence of pregnancy loss in threatened abortion during the first trimester in women without a history of recurrent abortion.
First trimester threatened miscarriage treatment with human chorionic gonadotrophins: a randomised controlled trial.
Department of Obstetrics and Gynaecology, Royal Gwent Hospital, Newport, UK.
OBJECTIVE To determine whether administration of exogenous human chorionic gonadotrophin (hCG) treatment improve the pregnancy outcome in first trimester threatened miscarriages. DESIGN A prospective, double blind, randomised, placebo-controlled trial. SETTING The Early Pregnancy Assessment Unit, Royal Bolton Hospital, Bolton, United Kingdom. POPULATION One hundred and eighty-three women with vaginal bleeding and a viable fetus seen on ultrasound scan (USS) in the first 12 weeks of pregnancy. METHODS The patients were randomised to receive either hCG or placebo treatment until 14 weeks of gestation. MAIN OUTCOME MEASURES The primary objective of the trial was to determine the miscarriage rate in the hCG arm compared from the placebo arm. RESULTS Of the 183 cases, 87 were randomised to treatment with hCG while 96 were randomised to receive a placebo. Forty-seven (25%) did not comply with the study protocol. The mean [SD] gestational age at presentation was 7 [1.33] weeks. The mean [SD] age of women in study was 27  years in the placebo and 28  in the hCG group. The mean body mass index (kg/m(2)) was 25  in the study. The number of patients actively bleeding per vaginum at presentation was 85 (93%) in placebo group and 79 (96%) in the hCG group. The median number of hCG or placebo injections for both groups was 7. Ten women (11%) in the placebo group proceeded to have a complete miscarriage, as did 10 women (12%) in the hCG group, relative risk (RR)[95% confidence interval (CI)] of 1.1 (0.63-1.6). CONCLUSION Our study showed no evidence of a difference in the outcome of threatened miscarriages when treated with hCG in the first trimester, this may be because our study sample size was small and follow up was suboptimal. A large, randomised, multicentre trial is still needed to establish the usefulness of hCG treatment in cases of threatened miscarriage.
Physiology should be supported with evidence in progesterone administration for threatened miscarriage.
BACKGROUND: Miscarriage is the spontaneous loss of a pregnancy before the fetus is viable. Uterine muscle relaxant drugs have been used for women at risk of miscarriage in the belief they relax uterine muscle, and hence reduce the risk of miscarriage. OBJECTIVES: To assess the effects for the woman and her baby of uterine muscle relaxant drugs when used for threatened miscarriage. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (4 May 2004), and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2004). SELECTION CRITERIA: Randomised trials were included, and quasi-randomised trials were excluded. The participants were women with a pregnancy of less than 20 weeks' gestation having a threatened miscarriage. The interventions were any uterine muscle relaxing drugs (including tocolytic and antispasmodic agents) compared with either placebo or no drug. Primary outcomes for the review were miscarriage: defined as spontaneous pregnancy loss before fetal viability, baby death (stillbirth or neonatal death) and maternal death. DATA COLLECTION AND ANALYSIS: Both review authors independently assessed studies for eligibility and trial quality, and extracted data. MAIN RESULTS: One poor quality trial (170 women) was included. This compared a beta-agonist with placebo. There was a lower risk of intrauterine death associated with the use of a beta-agonist (relative risk (RR) 0.25, 95% confidence interval (CI) 0.12 to 0.51). Preterm birth was the only other outcome reported (RR 1.67, 95% CI 0.63 to 4.38). AUTHORS' CONCLUSIONS: There is insufficient evidence to support the use of uterine muscle relaxant drugs for women with threatened miscarriage. Any such use should be restricted to the context of randomised trials.
[Summary of the practice guideline 'Miscarriage'(second revision) from the Dutch College of General Practitioners (NHG)].
Nederland Huisartsen Genootschap, afd. Richtlijnontwikkeling en Wetenschapsbeleid, Postbus 3231, 3502 GE Utrecht.
The NHG practice guideline 'Miscarriage' provides guidelines for the diagnosis and management of pregnant women with vaginal bleeding during the period up to and including the 16th week after the first day of the last menstruation. The guideline has been revised on the basis of the developments over the last few years. The most important modifications are: In case of an imminent miscarriage, more consideration than before is given to the patient's preference with regard to ultrasonography, expectant management and curettage. The GP should therefore discuss the advantages and disadvantages of these options with the patient. A midwife was involved in the formulation of the new guideline. Referral from a GP to a midwife for transvaginal ultrasonography is offered as one of the possibilities. The paragraph on 'information' has been expanded on the basis of the results of a patient focus group.
Utrogestan is a modern progesterone, which shows maximal effectiveness with minimal side effects. It is a natural progesterone in micronized form, which makes it suitable for oral administration and vaginal application with same effectiveness. The aim of our retrospective study was to evaluate the therapeutical effects of Utrogestan in women with threatened abortion in the first trimester. Our experience dated from about one year and a half. Sixty eight women were treated for threatened abortion with a daily dose of 400 mg Utrogestan. The treatment continued at least 14 days/average 21 days/. Utrogestan was administered orally twice daily. The main indications were first or consecutive threatened spontaneous abortion in first trimester. For the period of time no side effects and subjective complaints were established except particular cases of slight headache and dizziness after morning application. Sixty one of the sixty eight women were dehospitalised with healthy pregnancy with no side effects. In our experience we preferred to use the drug in women with lutein insufficiency before pregnancy. We conclude that Utrogestan can be widely applied in Obstetrics with the proper indications, such as threatened abortion in the first trimester. The prophylactic treatment in women with slighter complaints like dull pain and weight Utrogestan is applied one tablet twice daily. In graver cases the starting dosage is two tablets two or three times daily.
Department of Neurology, Cukurova University School of Medicine, Adana, Turkey. firstname.lastname@example.org
We report on the development of transient parkinsonism after progesterone injection in a pregnant patient with a risk of abortion. Etiological possibilities are discussed, including pregnancy itself, possible toxic effects of the dead fetus, and progesterone injection. Progesterone-induced parkinsonism seems the most likely diagnosis in this case.
The paper presents the results of the action of underwater exercises and adaptational respiratory exercise under the hypoventilation mode on health of pregnant women with threatened abortion at different terms of gestation and of their babies. The exercises led to physiological development of pregnancy, diminished intrauterine fetal hypoxia, less frequent hospitalizations of the pregnant women, good pregnancy outcomes, delivery of healthy babies. Moreover, maternal morbidity decreased 1.5-fold and perinatal morbidity 2-fold.
Chelsea and Westminster Hospital, London.
Non-evidence-based use of Rho(D) immune globulin for threatened abortion by family practice and obstetric faculty physicians.
Departments of Family Medicine, Preventive Medicine and Environmental Health and Obstetrics and Gynecology, University of Iowa, 200 Hawkins Drive, 01291-A PFP, Iowa City, IA 52242-1097, USA.
OBJECTIVE To examine the practice patterns and differences between faculty members in obstetrics and gynecology (OB/G) and family practice (FP) residency programs in administering Rho(D) immune globulin (RhIG) for threatened abortion. STUDY DESIGN A questionnaire was mailed to 50%(222) of all FP residencies and 100%(267) of OB/G programs in the United States. The obstetric curriculum coordinator at each FP residency and the director of obstetrics or maternal-fetal medicine at each OB/G residency were asked to respond. A total of 156 (70%) FP questionnaires and 186 (70%) OB/G questionnaires were returned after two mailings. RESULTS Seventy-six percent of FP faculty and 85% of OB/G faculty reported giving RhIG in threatened abortion. Physicians with advanced training were more likely to recommend giving RhIG. CONCLUSION Most FP and OB/G residency faculty report using RhIG in threatened abortion. The practice has become part of the medical culture despite the lack of supporting evidence and should be revaluated in that light.
[Tocolytic treatment of pregnant women with threatened abortions and preterm labor in the second and third trimesters of pregnancy with magne B6 (a preliminary communication)].
The authors check the effect of the substitutional treatment of the pregnant patients with the uterine paints and contractions in the second and third months periods of the pregnancy with "Magne B6"--Sanofi. In the group of the examined patients the Mg deficiency that is the cause for these suffering has been established. After the substitutional treatment with "Magne B6" the described suffering disappeared and clinical-lab values of Mg in the serum and urine normalized.
III Clinica Ostetrica e Ginecologica, Policlinico Umberto I, Università degli Studi di Roma La Sapienza, Rome, Italy.
BACKGROUND: The aim of this study was to evaluate the efficacy of bed-rest in the treatment of threatened abortion. This is based on the extensive use made today of this practice, although there are no studies that suggest or prove its therapeutic success, and on the contrary many of them demonstrate its possible risks. METHODS: The efficacy of bed-rest is evaluated by comparing the abortion rate in patients treated with bed-rest those who received no treatment. A retrospective study was made on data obtained from interviews with 226 patients with previous threatened abortion hospitalised for pregnancy-related reasons at the Obstetrics and Gynecology Clinic of Policlinico Umberto I in Rome between October 1998 and June 1999. RESULTS: The following results were obtained: 84% of the 146 patients treated with bedrest continued pregnancy beyond week 20, whereas 16% aborted before week 20. Of the 80 patients who were not treated, 80% continued pregnancy beyond week 20 and 20% aborted before week 20. These results do not show statistically significant differences between the two groups (c2=0.4 p=NS). CONCLUSIONS: These results suggest that bed-rest does not improve the prognosis of threatened abortion.