Miscarriage care is inconsistent and complex, and a new system is necessary to ensure that affected women receive adequate physical and mental healthcare, according to a series of reports from England.
A redefinition of miscarriage care is needed, and accurate testing, treatments for prevention, and management rooted in patient preferences are critical to provide comprehensive care, according to Siobhan Quenby, MD, of the University of Warwick, Arri Coomarasamy, MD, of the University of Birmingham, and colleagues.
There is good evidence for the administration of vaginal micronized progesterone to women at a high risk of miscarriage. But when this prevention method does not work, expectant management, management with misoprostol and mifepristone, or surgical options should all be considered based on patient preferences, they stated in The Lancet.
Additionally, psychological effects of miscarriage are poorly understood, and mental health support should be provided for both affected women and their partners, the researchers said.
"Miscarriage causes devastation to large numbers of couples in every country," they wrote. "There is silence around miscarriage from women and their partners, healthcare providers, policy makers, and funders."
"Urgent research is needed into methods to prevent and predict women at high risk of physical and psychological morbidity associated with miscarriage, and to screen for mental health issues after pregnancy loss," the researchers stated.
In an accompanying editorial, editors at The Lancet wrote that the series calls for "a complete rethink of the narrative around miscarriage and a comprehensive overhaul of medical care and advice offered to women who have miscarriages."
"For too long miscarriage has been minimised and often dismissed," they stated. "The lack of medical progress should be shocking. Instead, there is a pervasive acceptance."
In addition to guidelines for vaginal micronized progesterone for prevention and management methods, the editorialists explained that the series provides a nuanced look at long-term issues associated with miscarriage, including future adverse obstetric outcomes, cardiovascular disease, venous thromboembolism, and mental health complications. A graded model of care, in which women who endure a miscarriage receive guidance and testing based on their individual risk, should replace the current, fragmented care system, they added.
"This Series should catalyse a major focus on miscarriage for the medical research community, for service providers, and for policy makers. The era of telling women to 'just try again' is over," according to the editorial.
Globally, more than 23 million miscarriages occur each year, with the pooled risk totaling 15% worldwide, noted Quenby's group. Couples with increasing maternal or paternal age (older than 35 and 40, respectively), women who have a high BMI, and Black women all have an increased miscarriage risk. Environmental risk factors for miscarriage include air pollution, pesticides, alcohol, smoking, persistent stress, and night shift work.
Quenby, Coomarasamy, and colleagues stated that "accurate diagnosis of miscarriage is the foundation of an effective early pregnancy service," and involves high-quality ultrasonography.
For prevention of miscarriage in women who have early pregnancy vaginal bleeding or a history of loss, the researchers recommended vaginal micronized progesterone. All evidence included in the series showed that the use of progestogens (including micronised vaginal progesterone and dydrogesterone) in patients with early pregnancy bleeding was associated with a decrease in risk of miscarriage (RR 0.80, 95% CI 0.66-0.97), and an increased chance of live birth or ongoing pregnancy (RR 1.05, 95% CI 1.01-1.08).
Regarding treatments, the researchers stated that women can choose to have an expectant, medical, or surgical management of miscarriage. Suction aspiration with cervical preparation was the most effective treatment for miscarriage completion compared to expectant management (RR 2.12, 95% CI 1.41-2.20), followed by dilation and curettage (RR 1.49, 95% CI 1.26-1.75), suction aspiration alone (RR 1.44, 95% CI 1.29-1.62), and mifepristone and misoprostol combination (RR 1.42, 95% 1.22-1.66).
The researchers proposed a graded model of care for patients who endure a miscarriage, and specifically those who experience recurrent loss. In this model, after one miscarriage, women should receive a health evaluation and preconceptual advice for future pregnancies. If they have a second miscarriage, they should be offered a nurse or midwifery-led service with continuity of care, appropriate investigations, and ultrasound scanning for reassurance in future pregnancies. After a third miscarriage, women should be offered a consultant-led service as well as a full panel of investigations for future miscarriage.
The authors also called for more research and resources in low- and middle-income countries, where most miscarriages occur.
Quenby, Coomarasamy, and colleagues said that while this series aimed to compile the best available evidence, they were limited by both the quantity and quality of data. The group used consensus among experts when necessary.
Disclosures
The series was funded by Tommy's charity/Tommy's National Centre for Miscarriage Research.
Quenby, Coomarasamy, and co-authors disclosed no relevant relationships with industry.
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