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Misoprostol is a prostaglandin analog commonly used to induce termination of pregnancy. Clandestine home terminations complicate forensic fetal autopsy when a history of misoprostol use is withheld and the gross and histologic findings are sparse, as is often the case. One hundred thirty-two placentas with no vaginal misoprostol use, low-dose misoprostol use, and high-dose misoprostol use were reviewed for the presence, volume, and locations of microcrystalline cellulose and crospovidone, common tablet fillers in misoprostol tablets. Microcrystalline cellulose and/or crospovidone was identified in 0 (0%) of 88 cases with no vaginal administration or low-dose vaginal administration and 29 (66%) of 44 placentas with high-dose vaginal administration. When identified, microcrystalline cellulose and/or crospovidone is most commonly present on the maternal surfaces of the extraplacental membranes. The presence of microcrystalline cellulose and/or crospovidone was associated with smaller placental weight (Mann-Whitney U, P = 0.019). These fillers have a reasonable sensitivity for high-dose vaginal tablet use and are very specific. Although they are not diagnostic for misoprostol administration, they provide a finding that may prompt additional investigation into the nature of the vaginal tablet administered and the circumstances surrounding birth.

Background: Methotrexate (MTX) is widely used as an immunosuppressant, chemotherapeutic, and abortifacient agent. It is also a potent teratogen, and intentional or unintentional exposure during pregnancy is associated with heterogeneous birth anomalies. Methods: We retrospectively reviewed a cohort of patients who presented to our clinic with limb anomalies in the setting of MTX embryopathy. Results: In our case series, we describe 7 cases of patients who had limb anomalies with heterogeneous functionality, from severely debilitating to completely asymptomatic. Most of the upper extremity anomalies in our group were managed conservatively. Conclusions: Methotrexate embryopathy is a rare but clinically important entity with phenotypic and functional variability. This series underscores the need for proper counseling of patients and raises concern regarding using this medication for the purpose of abortion.

Cesarean scar ectopic pregnancy (CSEP) has a high rate of morbidity with nonspecific signs and symptoms making identification difficult. The criterion-standard treatment of CSEP has been subject to debate.This review defines CSEP, discusses pathogenesis and diagnosis, and compares treatment options and outcomes.A literature review was performed utilizing the termFive basic pathways have been identified in treatment of CSEP: expectant management, medical therapy, surgical intervention, uterine artery embolization, or a combination approach. Expectant management has the highest probability of morbid outcomes, including hemorrhage, uterine rupture, and preterm delivery. Medical management often requires further treatment with additional medication or surgery. Different surgical methods have been explored including uterine artery embolization; dilation and curettage; surgical removal via vaginal, laparoscopic, or laparotomic approach; and hysterectomy. Each method has various levels of success and depends on surgeon skill and patient presentation.Recent research supports any method that removes the pregnancy and scar to reduce morbidity and promote future fertility. Laparoscopic and transvaginal approaches are options for CSEP treatment, although continued research is required to identify the optimal approach.As cesarean delivery numbers rise, a subsequent increase in CSEPs can be anticipated. The ability to accurately diagnose and treat this morbid condition is vital to the practice of any specialist in general obstetrics and gynecology.

To examine rates of intrauterine device (IUD) insertion failure with and without prior misoprostol administration. Additional outcomes included difficulty of insertion, subjective pain, expulsion, and complications.Systematic searches were performed in PubMed MEDLINE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Cumulative Index to Nursing and Allied Health Literature for articles with the following keywords: "misoprostol," "intrauterine devices," and "IUDs."A total of 161 unique results were retrieved. Titles, abstracts, and full-text articles were independently screened twice by two reviewers for content and relevance. Quality assessment was performed using previously established criteria. After screening and quality assessment, nine randomized controlled trials (RCTs) were obtained for inclusion. Six articles were designated high quality and three were designated low quality.Six of six RCTs examining IUD insertion failure with misoprostol revealed no difference in this measure. Of nine RCTs examining difficulty of IUD insertion with misoprostol, seven revealed no difference in this measure and two revealed decreased difficulty of insertion with misoprostol administration. Of nine RCTs examining pain with IUD insertion, seven revealed no difference in pain measurement scores, one revealed increased pain with misoprostol administration, and one revealed decreased pain with misoprostol administration. Five studies examining rates of expulsion and two studies examining complications of IUD insertion revealed no difference in this measure.No data support routine administration of misoprostol before IUD insertion. Success of insertion is high even among nulliparous women, and good-quality data do not demonstrate that misoprostol use increases success. These data similarly reveal no differences in difficulty of insertion, pain with insertion, or expulsion with prior administration of misoprostol. However, data for several outcomes are limited by lack of power.

To estimate the proportion of obstetrician-gynecologists (ob-gyns) who provided induced abortion in the prior year, disaggregated by surgical and medication methods, and document barriers to provision of medication abortion.In 2016-2017, we conducted a cross-sectional survey of a national sample of American College of Obstetricians and Gynecologists Fellows and Junior Fellows who were part of the Collaborative Ambulatory Research Network. We sent the survey by email, and mailed nonresponders paper surveys. We performed descriptive statistics, χ tests, and logistic regression analyses.Sixty-seven percent (655/980) of Collaborative Ambulatory Research Network members responded. Ninety-nine percent reported seeing patients of reproductive age, and 72% reported having a patient in the prior year who needed or wanted an abortion. Among those seeing patients of reproductive age, 23.8% (95% CI 20.5%-27.4%) reported performing an induced abortion in the prior year; 10.4% provided surgical and medication abortion, 9.4% surgical only, and 4.0% medication only. In multivariable analysis, physicians practicing in the Midwest (adjusted odds ratio [AOR] 0.31, 95% CI 0.16-0.60) or South (AOR 0.22, 95% CI 0.11-0.42) had lower odds of provision compared with those practicing in the Northeast, whereas those practicing in an urban inner city (AOR 2.71, 95% CI 1.31-5.60) or urban non-inner-city area (AOR 2.89, 95% CI 1.48-5.64 vs midsize towns, rural areas, or military settings) had higher odds of provision. The most common reasons for not providing medication abortion were personal beliefs (34%) and practice restrictions (19%). Among those not providing medication abortion, 28% said they would if they could write a prescription for mifepristone.Compared with the previous national survey in 2008-2009, abortion provision may be increasing among practicing ob-gyns, although important geographic disparities persist. Few provide medication abortion, but uptake might increase if mifepristone could be prescribed.

Chronic ectopic pregnancy (CEP) is a rare form of tubal pregnancy. It is characterised by chronic degeneration of an early trophoblastic tissue causing tubal destruction. CEP remains a diagnostical...

Medical abortion offers a well tolerated and effective method to terminate early pregnancy, but remains underutilized in the United States. Over the last decade, 'telemedicine' has been studied as an option for medical abortion to improve access when patients and providers are not together. A number of studies have explored various practice models and their feasibility as an alternative to in-person service provision.A direct-to-clinic model of telemedicine medical abortion has similar efficacy with no increased risk of significant adverse events when compared with in-person abortion. A direct-to-consumer model is currently being studied in the United States. International models of direct-to-consumer medical abortion have shown promising results.The introduction of telemedicine into abortion care has been met with early success. Currently, there are limitations to the reach of telemedicine because of specific restrictions on mifepristone in the United States as well as laws that specifically prohibit telemedicine for abortion. If these barriers are removed, telemedicine can potentially increase abortion access.

Cervical ectopic pregnancy can lead to catastrophic hemorrhage, and may be managed conservatively with intra-amniotic methotrexate (MTX), systemic MTX, or both; surgical evacuation with or without balloon tamponade; and uterine artery embolization. However, some patients require hysterectomy, which has traditionally been performed abdominally.A 39-year-old parous woman was diagnosed with cervical ectopic pregnancy at an estimated 7 1/7 weeks of gestation. Her β-hCG level remained at 29,433 milli-international units/mL, and the gestational sac persisted on ultrasonography after first intra-amniotic then multidose systemic MTX treatment. After a review of other fertility-sparing procedures, she chose definitive treatment with hysterectomy because she did not desire future childbearing. She underwent a successful vaginal hysterectomy, a novel approach for this condition.Vaginal hysterectomy can be performed successfully for treatment of cervical ectopic pregnancy in patients who have completed childbearing and for whom conservative treatment has failed.

Abortion “Reversal” Four states require abortion providers to tell their patients about treatment that may reverse the effect of mifepristone if they change their mind after starting a medication abortion. But abortion reversal treatment remains experimental and unproven.

Resumo O objetivo deste artigo é analisar narrativas sobre as experiências de abortar disponíveis em uma comunidade online, buscando discutir os métodos e estratégias aos quais as mulheres recorrem frente à impossibilidade legal de interrupção voluntária de gravidez e os efeitos da criminalização do aborto induzido. Como método, utilizou-se a etnografia virtual, com observação da plataforma Women on Web, coleta e análise de 18 narrativas, disponíveis publicamente e sem restrições, selecionadas entre novembro de 2016 e janeiro de 2017. As narrativas informam métodos mesclados para a realização de aborto, com prevalência de utilização do medicamento Cytotec. Em alguns casos, hospitais e consultórios médicos são incluídos nos itinerários, seja para realização de exames ou para atendimento de intercorrências. A internet se revela uma ferramenta de informação, negociação e mesmo aquisição de medicamento abortivo bastante comum, além de uma plataforma de troca de experiências. Conclui-se que as narrativas sinalizam as inseguranças, riscos e violências às quais estão submetidas as mulheres no contexto da clandestinidade, indicam a importância do debate sobre a descriminalização do aborto no Brasil, e também reforçam a existência de uma cultura compartilhada do aborto, já apontada em estudos anteriores.

Sera from 378 female Mijaheem camels of different age groups were collected from different parts of the country. All of them were simultaneously tested serologically for specific antibodies against brucellosis, chlamydiosis and coxiellosis while 368 of the same serum samples were also tested for toxoplasmosis and neosporosis, using indirect enzyme-linked immunosorbent assays. The results were statistically analyzed to determine the prevalence rate of each of these abortifacient agents and the association of the geographical location and age of the animal with the prevalence. The overall serological prevalence was 16.67% for brucellosis, 49.18% for toxoplasmosis, 13.32% for neosporosis, 10.05% for chlamydiosis and 42.36% for coxiellosis. Statistical analysis revealed significant associations between the serological prevalence of each of the studied abortifacient agents with the location of the animal, and there was also a significant association with age in the case of toxoplasmosis and chlamydiosis. The results indicate that the causative agents of brucellosis, toxoplasmosis, neosporosis, chlamydiosis and coxiellosis are widespread among indigenous Mijaheem camels in Saudi Arabia, and that their prevalence varied with region and age group. These different agents should therefore be considered in the differential diagnosis of infectious abortion in Saudi Arabian camels.

Access to abortion in the United States has eroded significantly. Accordingly, there is a growing movement to empower women to self-induce abortion. To date, physicians' roles and responsibilities in this changing environment have not been defined. Here, we consider a harm reduction approach to first-trimester abortion as a way for physicians to honor clinical and moral obligations to care for women, negotiate ever-increasing abortion restrictions, and support women who consider abortion self-induction. Harm reduction approaches to abortion have been successfully implemented in a range of countries around the world and typically take the form of teaching women how to use misoprostol. When women self-administer misoprostol, rather than resort to other means such as self-instrumentation or abdominal trauma, to end a pregnancy, maternal mortality falls. There are clinical and ethical benefits as well as limitations to a harm reduction approach to abortion in U.S. Settings Its legal implications for patients and physicians are unclear. Ultimately, we suggest that despite its limitations, a harm reduction approach may help both physicians and patients.

BAKGRUNN I Norge utfores abort kun i offentlige sykehus. I 2010 besluttet Helse- og omsorgsdepartementet a iverksette et toarig proveprosjekt som ga avtalespesialister i fodselshjelp og kvinnesykdommer adgang til a tilby medikamentell abort for utgangen av 9. svangerskapsuke. Proveprosjektet ble igangsatt 1.3.2015 og varte til 31.3.2017. I denne artikkelen presenterer vi de forste erfaringene, herunder hvordan behandlingstilbudet ble mottatt av kvinnene. MATERIALE OG METODE Gravide med en svangerskapsvarighet < 63 dager ultrasonografisk vurdert, som oppsokte avtalespesialist for medikamentell abort, ble fortlopende inkludert i prosjektet (n = 476). Kvinnene inntok 200 mg mifepriston peroralt pa legekontoret, 36-48 timer senere satte de selv 800 µg misoprostol vaginalt hjemme. Informasjon ble innhentet ved sporreskjema pa den forste konsultasjonen, under aborten og ved etterkontrollen 2-4 uker etter aborten. RESULTATER Under aborten rapporterte 66 % (296/450) moderat eller sterk smerte og 79 % (358/451) moderat eller sterk blodning. De fleste opplevde det som trygt a vaere hjemme. 96 % (390/406) ville valgt medikamentell abort hos avtalespesialist ved en eventuell senere abort, og 97 % (392/405) ville anbefalt behandlingstilbudet til andre i samme situasjon. FORTOLKNING Kvinnene i studien opplevde abortbehandling hos avtalespesialist som trygt. Tilbudet gir storre valgfrihet til gravide som onsker abort, og pasientene er tilfredse.

OBJECTIVE: To compare the treatment success and failure rates, as well as side effects and surgery rates between methotrexate protocols. DATA SOURCES: PubMed, Embase and the Cochrane library searched up till July 2018. STUDY ELIGIBILITY CRITERIA: RCTs that compared women with ectopic pregnancies receiving the single dose, two dose or multi-dose methotrexate protocols. STUDY APPRAISAL AND SYNTHESIS METHODS: Odds of treatment success, treatment failure, side effects and surgery for tubal rupture as well as length of follow-up until treatment success compared using random and fixed effects meta-analysis. Sensitivity analyses compared treatment success in high hCG and large adnexal mass groups, as defined by individual studies. Cochrane’s collaboration tool used to assess risk of bias. RESULTS: The two dose protocol was associated with higher treatment success compared to single dose protocol (OR: 1.84, 95% CI: 1.13, 3.00). The two dose protocol was more successful in women with high hCG (OR: 3.23, 95% CI: 1.53, 6.84) and in women with a large adnexal mass (OR: 2.93 95% CI: 1.23, 6.9). The odds of surgery for tubal rupture were lower in the two dose protocol (OR: 0.65, 95%CI: 0.26, 1.63), but not statistically significant. The length of follow up was 7.9 days shorter for the two dose protocol (95% CI: −12.2, −3.5). Odds of side effects were higher in the two dose protocol (OR: 1.53, 95% CI: 1.01, 2.30). Compared to the single dose protocol the multi-dose protocol is associated with a nonsignificant reduction in treatment failure (OR: 0.56, 95% CI: 0.28, 1.13) and a higher chance of side effects (OR: 2.10, 95% CI: 1.24, 3.54). Odds of surgery for tubal rupture (OR: 1.62, 95% CI: 0.41, 6.49) and time to follow-up (−1.3, 95% CI: −5.4, 2.7) were similar. CONCLUSION: The two dose methotrexate protocol is superior to the single dose protocol for the treatment of ectopic pregnancy in terms of treatment success and time to success. Importantly, these findings hold true in patients thought to be at a lower likelihood of responding to medical management, such as those with higher hCGs and large adnexal mass.

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This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: Our primary objective is to assess the effectiveness and safety of medical versus surgical abortion among women living with HIV. Our secondary objectives are to: (1) assess abortion outcomes for both methods between women living with HIV and HIV-negative women and (2) assess abortion outcomes among women living with HIV.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 43 - N° 2 - p. 103-106

To describe the human chorionic gonadotropin (hCG) elimination rate in patients with intentionally retained placenta percreta.Medical records for cases of placenta percreta with intentional retention of the placenta were reviewed. The natural log of the hCG levels were plotted versus time and then the elimination rate equations were derived.The hCG elimination rate equations were log-linear in three cases individually (R (2) = 0.96-0.99) and in aggregate R (2) = 0.92). The mean half-life of hCG elimination was 146.3 h (6.1 days).The elimination of hCG in patients with intentionally retained placenta percreta is consistent with a two-compartment elimination model. The hCG elimination in retained placenta percreta is predictable in a log-linear manner that is similar to other reports of retained abnormally adherent placentae treated with or without methotrexate.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 42 - N° 2 - p. 137-142

Pregnancy of unknown location (PUL) is a common diagnostic challenge. The primary diagnostic goal is to ensure that the PUL is nonviable prior to proceeding with any invasive procedures. In nonviable PUL, there are several diagnostic and treatment strategies, which are generally quite safe. However, the management option that provides the most definite diagnosis is uterine curettage. We advocate use of uterine curettage in all cases of nonviable PUL because it limits exposure to a chemotherapeutic agent to only those who need it and it allows for the most accurate information for counseling the patient on prognosis of future pregnancies.

To compare outcomes with simultaneous administration of mifepristone and misoprostol with a regimen in which the drugs are administered at a 24-hour interval for second-trimester abortion.In this placebo-controlled, double-blind trial, participants were randomized to receive mifepristone either 24 hours before or at the same time as misoprostol. Participants were hospitalized to receive 400 micrograms buccal misoprostol at 3-hour intervals up to 48 hours or until uterine expulsion. The primary outcome was the proportion of women who experienced uterine expulsion within 24 hours after the first misoprostol dose and this required 504 women to examine our hypothesis that this rate would be 85% in the 24-hour interval arm compared with 70% in the simultaneous arm. Secondary outcomes included total abortion time from mifepristone and misoprostol.From February 2013 to April 2014, 509 women were enrolled. Women in the 24-hour interval arm were more likely to abort within 24 hours (94.4% compared with 85.0%, relative risk 1.11, 95% confidence interval [CI] 1.05-1.18). At 48 hours, the rate was similar in the two arms (96.8% [24-hour interval] and 95.7% [simultaneous], relative risk 1.01, 95% CI 0.97-1.04). Median misoprostol dosing time was shorter in the 24-hour interval arm (7.7 compared with 13 hours; P.001) and consistent with the median misoprostol doses required (three compared with five; P.001). Median time from mifepristone to uterine expulsion was longer in the 24-hour interval arm (32.3 compared with 13 hours; P.001). Both regimens had high acceptability rates and reported similar side effects and pain scores.Administering mifepristone and misoprostol simultaneously results in lower expulsion rates within 24 hours of taking misoprostol, longer median misoprostol treatment times, and requires more misoprostol doses. At 48 hours, both regimens work equally well. Simultaneous dosing results in less total time from the first clinical contact to complete abortion.ClinicalTrials.gov, https://clinicaltrials.gov, NCT01768299.

The aim of this study was to present the implications of the use of herbs during pregnancy, pointing out those that should be avoided during this condition because of their abortifacient and/or teratogenic potential. We carried out searches in the databases ScienceDirect, Scielo and Google Scholar, adopting as criteria for inclusion: book chapters and/or complete articles (with abstract), available in English, Portuguese or Spanish, published from 1996 to in 2011. After a pre-selection of 83 articles, 49 bibliographies were used in the manufacturing end of the article, where 25 were from the Scielo database, 18 from ScienceDirect and 6 from Google Scholar. From the articles studied, we identified the four most commonly used plants as emmenagogue/abortifacient agents by patients of the Department of Prenatal SUS: senne, arruda, boldo and buchinha-do-norte or cabacinha. Thus, we conclude that people often adhere to the maxim "if it's natural, it does no harm" in their rational use of natural products, without the right guidance, believing that these products are safe to use. This usage is even more worrisome among the elderly, pregnant women and children. Regarding the safety of these products, some information and reliable data are scarce or contradictory.Este trabalho busca as implicações atuais sobre o uso de plantas medicinais durante a gravidez, alertando sobre aquelas que devem ser evitadas nesse período por serem potencialmente abortivas e/ou teratogênicas. Para tanto, foram realizadas buscas nas bases de dados Sciencedirect, Scielo e Google scholar, adotando-se como critérios de inclusão capítulos de livros e/ou artigos completos (com abstract) e disponíveis, em português, inglês ou espanhol, publicados de 1996 a 2011. Após uma pré-seleção de 83 artigos, 49 bibliografias foram utilizadas na confecção final do artigo, sendo 25 provenientes da base de dados Scielo, 18 do Sciencedirect e 06 do Google scholar. A partir dos artigos estudados, identificaram-se as quatro plantas mais utilizadas como emenagogas/abortivas por pacientes do Serviço de Pré-Natal do SUS: senne, arruda, boldo e buchinha-do-norte ou cabacinha. Assim, é possível concluir que, muitas vezes, a população se utiliza da máxima "se é natural, não faz mal" para fazer uso irracional de produtos naturais, sem a correta orientação, acreditando que esses produtos sejam incapazes de provocar qualquer dano. Esse uso é ainda mais preocupante quando realizado por idosos, gestantes e crianças. Em relação à segurança do uso desses produtos, algumas informações e dados confiáveis ainda são escassos ou contraditórios.

Medical management has become increasingly popular in the treatment of ectopic pregnancy. Given its convenience, for many it is used as a first-line treatment, however, this is not always the optimal choice for the patient. It is important to understand the options for medical treatment and when it is appropriate to treat a particular patient with medical management, or when one should opt for surgical management. This review outlines the different regimens for methotrexate administration and the associated risks and benefits to medical management.

This study evaluated the clinical efficacy, safety, and side effects of intramuscular administration of 15(S) methyl F2 alpha for midtrimester pregnancy termination. 25 healthy women, generally in the 14-6th weeks of pregnancy, were given repeated doses of 250 mcg of 15(S) followed by 300-600 mcg at 2-3 hour intervals, depending upon the uterine contractions and side effects. In addition, 15 women were given Lomotil tablets before prostaglandin administration to counteract gastrointestinal side effects. The mean required dosage of prostaglandin was 2.3 mg. The induction-abortion interval was 5-10 hours in 32%, 11-15 hours in 52%, 16-20 hours in 8%, and 21-25 hours in 8%, with a mean abortion time of 13.04 hours. 23 women (92%) has complete and spontaneous abortion. Women treated with Lomotil experienced fewer episodes of vomiting and diarrhea. Other side effects included nausea in 40% of cases, cough in 12%, and fever in 16%. These side effects were mild and well tolerated by the patients, however. It is concluded that serial intramuscular injection of prostaglandin 15(S) methyl F2 alpha is an effective method for midtrimester abortion. In view of the minimal blood loss and asepsis associated with this method, it is particularly suitable for centers where blood transfusion facilities are inadequate.

This study evaluated the effectiveness of extraovular .1% ethacridine lactate alone and edacridine lactate plus spartein sulfate in midtrimester pregnancy termination. In the 60 cases where ethacridine lactate alone was administered, 50 cases aborted within 48 hours of instillation (83.3% success rate). Of these 50, 25 aborted within 24 hours (41.7%). Abortion was complete in 45 cases. The time of onset of uterine contractions ranged from 1 hour to 16.5 hours, with a mean 21-1/4 hours. The mean time of membrane rupture in the series was 23 hours and the induction-abortion interval averaged 27-1/4 hours. Side effects included vomiting (18.3%), shivering (16.6%), fever (3.3%), cervical injuries (6.6%), and excessive blood loss (1.7%). Blood loss until expulsion of the fetus averaged 54.1 ml, and blood loss up to 4 hours after abortion averaged 115.1 ml in cases of complete abortion and 219 ml in cases of incomplete abortion. In the 90 cases where both ethacridine lactate and spartein sulfate were used, 76 aborted within 48 hours (success rate 84.6%) and 40 aborted within 24 hours (44.4%). Abortion was complete in 75% of cases. The abortion-induction interval ranged from 4 hours to 47-3/4 hours, with a mean of 28-1/2 hours. These results, which are comparable to those obtained in other studies, indicate that extraovular ethacridine lactate alone appears to be a safe, efficient, and relatively inexpensive method of midtrimester abortion. Although there were fewer reports of side effects in the group that received spartein sulfate, use of this compound does not reduce the induction-abortion interval. The relatively low incidence of side effects such as vomiting and diarrhea, the antiseptic properties of ethacridine lactate, and the absence of serious complications such as rupture of the uterus and cervicovaginal fistula are advantages of the ethacridine lactate method that nullify the disadvantage of its slightly prolonged induction-abortion interval.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 39 - N° 3S - p. F17-F24

OBJETIVOS: a tentativa de aborto mal sucedida com o uso do misoprostol (Cytotec®) sem indicação médica tem sido associada a malformações congênitas. Este estudo teve por objetivo identificar, em recém-nascidos malformados e controles normais, a frequência de exposição ao misoprostol e o espectro de malformações associadas. MÉTODOS: estudo de caso-controle desenvolvido em 2005 nas quatro principais maternidades públicas de Fortaleza (CE). Através de busca ativa diária, foram identificados recém-nascidos com diagnóstico de malformação fetal (caso) e controles saudáveis de mesmo sexo nascidos em seguida na mesma maternidade (pareamento 1:1). A amostra foi de 252 parturientes entrevistadas por equipe treinada utilizando questionário estruturado com base no Estudo Colaborativo Latino-Americano de Malformações Congênitas (ECLAMC). Além de abordar questões sociodemográficas e histórico familiar de malformação, o questionário objetivou identificar exposições diversas durante a gestação, incluindo o misoprostol. A análise bivariada com teste do χ2 comparou os grupos quanto às características e fatores associados à malformação e foi calculada a Odds Ratio para verificar a razão de chances de o Grupo Caso apresentar malformação em relação ao Grupo Controle com relação à exposição ao misoprostol. RESULTADOS: não houve diferenças significativas entre os grupos caso e controle quanto à maioria dos fatores de riscos investigados para malformações. O relato de tentativa de aborto foi de 6,8%, havendo uma maior exposição ao misoprostol durante a gestação em neonatos malformados comparados a saudáveis, Odds Ratio (OR)=3,65 (IC95%=0,74-17,91). O espectro de malformações encontradas entre os recém-nascidos expostos ao misoprostol foi compatível com a literatura, como os decorrentes de defeitos do tubo neural e disrupção vascular. CONCLUSÕES: os achados deste estudo, apesar de não apresentarem significância estatística, sugerem que os fetos expostos ao misoprostol apresentam uma tendência a maior risco de defeitos congênitos comparados aos não-expostos. Outras investigações devem ser incentivadas para que se identifique melhor o dano causado pela utilização indevida do misoprostol, principalmente em países onde o controle de medicamentos é ineficaz. PURPOSE: failed attempted abortions with the use of misoprostol (Cytotec®) without medical indication have been associated with the occurrence of congenital malformations. The objective of the present study was to identify, in newborns with malformations and in normal controls, the frequency of exposure to misoprostol and the spectrum of associated malformations. METHODS: this was a case-control study involving a daily survey at four public maternities in Fortaleza (CE) for the identification of newborns with malformations and paired controls (1:1) during the period from July to November 2005. The sample comprised 252 parturients interviewed by a trained team by means of a structured questionnaire based on the Latin American Collaborative Study of Congenital Malformations (Estudo Colaborativo Latino-Americano de Malformações Congênitas, ECLAMC). The questionnaire was used to obtain sociodemographic data and a family history of malformations, as well as to identify diverse forms of exposure during pregnancy, including misoprostol. Bivariate analysis and the chi-square test were used to compare cases and controls regarding their characteristics and factors associated with malformation, and the Odds Ratio was calculated to determine the chance of the Case Group to present malformations as compared to the Control Group after exposure to misoprostol. RESULTS: there were no significant differences between groups regarding most of the risk factors for malformations investigated. Attempted abortion was reported by 6.8% of the mothers, with a higher exposure to misoprostol during pregnancy resulting in a greater proportion of malformed newborns, Odds Ratio (OR)=3.65 (95%CI=0.74-17.91). The spectrum of congenital defects encountered with exposure to misoprostol included defects of the central nervous, musculoskeletal, urogenital and cardiovascular systems, in agreement with literature data. CONCLUSION: the findings of this study suggest that fetuses exposed to misoprostol tend to be at higher risk of developing congenital malformations in comparison to non-exposed fetuses. Other studies should be encouraged for a better identification of the damage caused by the improper use of misoprostol, especially in countries where the control of medication is inadequate.

Please cite this paper as: Moores K, Keriakos R, Anumba D, Connor M, Lashenb H. Management challenges of a live 12-week sub-hepatic intra-abdominal pregnancy.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 39 - N° 3S - p. F3-F10

Resume Objectif Comparer l'impact d'une politique de prise en charge conservatrice ou radicale du placenta accreta sur la morbidite maternelle. Methodes Il s'agit d'une revue retrospective des donnees medicales de toutes les patientes ayant accouche a la maternite Port-Royal avec un diagnostic de placenta accreta, increta ou percreta de janvier 1993 a octobre 2005. Nous avons compare deux periodes consecutives. Durant la periode A (janvier 1993 a juin 1997), le protocole de service comportait une tentative de delivrance complete du placenta pour toutes les patientes. Durant la periode B (Juillet 1997 a octobre 2005), une politique conservatrice a ete appliquee. Les criteres suivants ont ete etudies pour les deux periodes : taux d'hysterectomie et de transfusion, admission en reanimation, duree de sejour en reanimation, septicemie et coagulation intravasculaire disseminee, infection du post-partum. Resultats Cinquante et un cas de placenta accreta ont ete observes pour 40 281 accouchements (1,3/1000). L'incidence des hysterectomies (11/13 versus 10/38 ; p p p p = 0,22). Conclusion Une prise en charge conservatrice du placenta accreta pourrait permettre de reduire la morbidite maternelle et de preserver la fertilite.

The objectives of these studies were to evaluate the efficacy of a PGF(2alpha) (PGF) analog given through different routes on causing luteal regression in lactating dairy cows. In Experiment 1, lactating Holstein cows (n=118) at random stages of lactation were blocked by parity and days in milk (DIM) and, within each block, randomly assigned to receive PGF as an intra-muscular (IM) injection in the semimembranous/semitendinous muscle (CON), subcutaneous (SC) injection in the cervical area (SCN), or SC injection in the ischio-rectal fossa (IRF). Blood was sampled at 0, 12, 24, 36, and 48 h after treatment for assessment of progesterone concentration. In Experiment 2, a total of 379 lactating Holstein cows, 46+/-7 DIM, were blocked by DIM and, within each block, randomly assigned to receive treatment similar to CON or IRF groups from Experiment 1. Blood was sampled 0 and 48 h after treatment for assessment of progesterone concentration. Cows were classified as experiencing luteal regression when progesterone concentration was

To evaluate operative time after adjunctive misoprostol or mifepristone compared with overnight osmotic dilators alone for cervical preparation before dilation and evacuation at 16-23 6/7 weeks of gestation.This double-blind, three-arm, multicenter, randomized trial compared overnight osmotic dilators alone, dilators plus 400 micrograms buccal misoprostol 3 hours preoperatively, and dilators plus 200 mg oral mifepristone during dilator placement for dilation and evacuation. Our primary outcome was dilation and evacuation operative time within two cohorts: 16-18 6/7 weeks of gestation (N=150) and 19-23 6/7 weeks of gestation (N=150). Three hundred women were required for 80% power to detect a 2-minute difference in operative time. Secondary outcomes included initial cervical dilation, side effects, physician satisfaction by Likert scale, and complications.Between February 2013 and February 2014 we randomized 300 women evenly across treatment arms. Group demographics were similar. We found no difference in operative time in either gestational cohort (early cohort [minutes]: 5.11±3.0 dilators alone, 4.99±3.3 misoprostol, 4.33±2.0 mifepristone, P=.34; late cohort [minutes]: 7.50±3.7 dilators alone, 7.62±5.4 misoprostol, 6.74±3.2 mifepristone, P=.53). In the early cohort, initial dilation was greater with misoprostol than dilators alone (2.4 compared with 2.0 cm, P=.007). Patients given misoprostol had significantly more pain, fever, and chills. In the late cohort, dilation and evacuation procedures were less difficult after mifepristone (4.1%, 95% confidence interval [CI] 0.0-9.6) than misoprostol (18.8%, 95% CI 7.7-29.8) or dilators alone (18.8%, 95% CI 7.7-29.8; P=.04). We had inadequate power to infer differences in complications: dilators alone (10%, 95% CI 4.2-16.0) compared with misoprostol (2%, 95% CI 0-4.7) compared with mifepristone (2%, 95% CI 0-4.8).Despite no difference in operative time, adjunctive mifepristone facilitates later dilation and evacuation compared with osmotic dilators alone and is better tolerated than misoprostol.ClinicalTrials.gov, www.clinicaltrials.gov, NCT01751087.I.

Cornual ectopic pregnancies are a rare, but very challenging form of ectopic pregnancy to manage. They account for 2–4% of all ectopic pregnancies and the mortality rate remains 6–7 times higher th...