Experience of a Tertiary Service in the Treatment of Women with Cervical Pregnancy.

OBJECTIVE: Cervical pregnancy is challenging for the medical community, as it is potentially fatal. The treatment can be medical or surgical; however, there are no protocols that establish the best option for each case. The objective of the present study was to describe the cases of cervical pregnancy admitted to a tertiary university hospital over a period of 18 years. METHODS: A retrospective study based on a review of the medical records of all cervical pregnancies admitted to the Women's Hospital at Universidade Estadual de Campinas, Southeastern Brazil, from 2000 to 2018. RESULTS: We identified 13 cases of cervical pregnancy out of a total of 673 ectopic pregnancies; only 1 case was initially treated with surgery because of hemodynamic instability. Of the 12 cases treated conservatively, 7 were treated with single-dose intramuscular methotrexate, 1, with intravenous and intramuscular methotrexate, 1, with intravenous methotrexate, 1, with 2 doses of intramuscular methotrexate, and 2, with intra-amniotic methotrexate. Of these cases, one had a therapeutic failure that required a hysterectomy. Two women received blood transfusions. Four women required cervical tamponade with a Foley catheter balloon for hemostasis. There was no fatal outcome. CONCLUSION: Cervical pregnancy is a rare and challenging condition from diagnosis to treatment. Conservative treatment was the primary method of therapy used, with satisfactory results. In cases of increased bleeding, cervical curettage was the initial treatment, and it was associated with the use of a cervical balloon for hemostasis.

OBJETIVO: A gravidez ectópica cervical é um desafio para a comunidade médica, pois pode ser fatal. O tratamento pode ser clínico ou cirúrgico, mas não existem protocolos que estabeleçam a melhor opção para cada caso. O objetivo deste estudo foi descrever os casos de gravidez ectópica cervical internados em um hospital universitário terciário durante 18 anos. MéTODOS: Estudo retrospectivo com revisão de prontuários de todas as gestações ectópicas cervicais internadas no Hospital da Mulher da Universidade Estadual de Campinas de 2000 a 2018. RESULTADOS: Foram identificados treze casos de gestação ectópica cervical em um total de 673 gestações ectópicas; apenas 1 caso foi inicialmente tratado com cirurgia por causa de instabilidade hemodinâmica. Dos 12 casos tratados conservadoramente, 7 foram tratados com metotrexato por via intramuscular em dose única, 1, com metotrexato pelas vias intravenosa e intramuscular, 1, com metotrexato por via intravenosa, 1, com 2 doses de metotrexato por via intramuscular, e 2, com metotrexato por via intra-amniótica. Desses casos, um apresentou falha terapêutica, e realizou-se uma histerectomia. Duas mulheres receberam transfusões de sangue. Quatro mulheres necessitaram de tamponamento cervical com cateter balão de Foley para hemostasia. Não houve casos fatais. CONCLUSãO: A gravidez cervical é uma condição rara e desafiadora desde o diagnóstico até o tratamento. O tratamento conservador foi o principal método terapêutico utilizado, com resultados satisfatórios. Nos casos de sangramento aumentado, a curetagem cervical foi o tratamento inicial, e foi associada ao uso de balão cervical para hemostasia.

A Scary Complication: Single-center Study on Management and Outcome of Cesarean Scar Pregnancy.

A cesarean scar pregnancy (CSP) is a scary and life-threatening complication of cesarean section (CS). Nevertheless, the incidence of CS is constantly growing. The CSP incidence is 0,15% of pregnancies after CS which represents 6,1% of all ectopic pregnancies in women with condition after CS. Therefore, it should be more present in the clinical daily routine. From mild nonspecific symptoms to hypovolemic shock, diagnosis and therapy must be performed quickly. With the progressive growth of the scar pregnancy, a uterine rupture involves the risk of severe bleeding, and an emergency hysterectomy could be necessary. Prolongation of pregnancy has been successful only in a few cases. We report 11 cases from our hospital in the past 10 years. In the discussion, treatment options of this complication with an increasing incidence, which is associated with serious morbidity and mortality, are presented based on the current literature. Treatment options include drug therapy, but also surgical or combined procedures with radiological intervention.

A scary complication: single-center study on management and outcome of cesarean scar pregnancy

Abstract A cesarean scar pregnancy (CSP) is a scary and life-threatening complication of cesarean section (CS). Nevertheless, the incidence of CS is constantly growing. The CSP incidence is 0,15% of pregnancies after CS which represents 6,1% of all ectopic pregnancies in women with condition after CS. Therefore, it should be more present in the clinical daily routine. From mild nonspecific symptoms to hypovolemic shock, diagnosis and therapy must be performed quickly. With the progressive growth of the scar pregnancy, a uterine rupture involves the risk of severe bleeding, and an emergency hysterectomy could be necessary. Prolongation of pregnancy has been successful only in a few cases.We report 11 cases from our hospital in the past 10 years. In the discussion, treatment options of this complication with an increasing incidence, which is associated with serious morbidity and mortality, are presented based on the current literature. Treatment options include drug therapy, but also surgical or combined procedures with radiological intervention.

Retrospective Evaluation of Patients Treated for Ectopic Pregnancy: Experience of a Tertiary Center.

OBJECTIVE: In recent years, there has been an increase in the incidence of ectopic pregnancies; therefore, it is important for tertiary centers to report their approaches and outcomes to expand and improve treatment modalities. The aim of the present study was to evaluate the general characteristics, treatment and outcomes of cases diagnosed with ectopic pregnancy. METHODS: In total, 432 patients treated for ectopic pregnancy between February 2016 and June 2019 were retrospectively evaluated. RESULTS: Overall, 370 patients had tubal pregnancy, 32 had cesarean scar pregnancy, 18 had pregnancy of unknown location, 6 had cervical pregnancy, and 6 had interstitial pregnancy. The most important risk factors were advanced age (> 35 years; prevalence: 31.2%) and smoking (prevalence: 27.1%). Thirty patients who did not have any symptoms of rupture and whose human chorionic gonadotropin (ß-hCG) levels were ≤ 200 mIU/ml were followed-up with expectant management, while 316 patients whose ß-hCG levels were between 1,500 mIU/ml and 5,000 mIU/ml did not have an intrauterine gestational sac on the transvaginal or abdominal ultrasound, did not demonstrate findings of rupture, and were treated with a systemic multi-dose methotrexate treatment protocol. In total, 24 patients who did not respond to the medical treatment, 20 patients whose ß-hCG levels were > 5,000 mIU/ml, 16 patients who had shown symptoms of rupture at the initial presentation, and 6 patients diagnosed with interstitial pregnancy underwent surgery. Patients with cervical and scar pregnancies underwent ultrasound-guided curettage, and no additional treatment was needed. CONCLUSION: The fertility status of the patients, the clinical and laboratory findings, and the levels of ß-hCG are the factors that must be considered in planning the appropriate treatment.

Retrospective evaluation of patients treated for ectopic pregnancy: Experience of a tertiary center

Abstract Objective In recent years, there has been an increase in the incidence of ectopic pregnancies; therefore, it is important for tertiary centers to report their approaches and outcomes to expand and improve treatment modalities. The aim of the present study was to evaluate the general characteristics, treatment and outcomes of cases diagnosed with ectopic pregnancy. Methods In total, 432 patients treated for ectopic pregnancy between February 2016 and June 2019 were retrospectively evaluated. Results Overall, 370 patients had tubal pregnancy, 32 had cesarean scar pregnancy, 18 had pregnancy of unknown location, 6 had cervical pregnancy, and 6 had interstitial pregnancy. The most important risk factors were advanced age (> 35 years; prevalence: 31.2%) and smoking (prevalence: 27.1%). Thirty patients who did not have any symptoms of rupture and whose human chorionic gonadotropin (β-hCG) levels were ≤ 200 mIU/ml were followed-up with expectant management, while 316 patients whose β-hCG levels were between 1,500 mIU/ml and 5,000 mIU/ml did not have an intrauterine gestational sac on the transvaginal or abdominal ultrasound, did not demonstrate findings of rupture, and were treated with a systemic multi-dose methotrexate treatment protocol. In total, 24 patients who did not respond to the medical treatment, 20 patients whose β-hCG levels were > 5,000 mIU/ml, 16 patients who had shown symptoms of rupture at the initial presentation, and 6 patients diagnosed with interstitial pregnancy underwent surgery. Patients with cervical and scar pregnancies underwent ultrasound-guided curettage, and no additional treatment was needed. Conclusion The fertility status of the patients, the clinical and laboratory findings, and the levels of β-hCG are the factors that must be considered in planning the appropriate treatment.

What does informal access to misoprostol in Colombia look like? A mystery client methodology in Bogotá and the Coffee Axis.

INTRODUCTION: In 2006, abortion was decriminalised in Colombia under certain circumstances. Yet, women avail themselves of ways to terminate pregnancy outside of the formal health system. This study explored how drug sellers engage with women who attempt to purchase misoprostol from them. METHODS: A mapping exercise was undertaken to list small-chain and independent drug stores in two regions in Colombia. A sample (n=558) of drug stores was selected from this list and visited by mystery clients between November and December 2017. Mystery clients sought to obtain a medication to bring back a delayed period, and described the experience, the information obtained and the medications proffered in exit interviews. RESULTS: Misoprostol was offered for purchase in 15% of the visits; in half of visits, only information about misoprostol was shared, while no information about misoprostol was provided on the remaining visits. Over half of sellers who refused to sell any medication provided referrals, most commonly to an abortion provider. Among visits which included discussion of misoprostol, two out of five sellers provided dosage instructions with most recommending the minimum adequate dosage. Mystery clients received little information on the physical effects to expect with the use of misoprostol and possible complications. CONCLUSIONS: As misoprostol is being obtained from some drug sellers without a prescription, capacitating this cadre with at least a minimum of standardised information on dosage, routes of administration and expected effects and outcomes have the potential to improve reproductive health outcomes for women who choose to terminate pregnancies this way in Colombia.

Experiencia y manejo del embarazo ectópico cervical: revisión del tema / Experience and management of cervical ectopic pregnancy: topic review

Introducción y Objetivos: El Embarazo Cervical (EC) corresponde a una patología de muy baja frecuencia y tasa de sospecha. En la literatura actual se han propuestos diferentes tratamientos, pero se recomienda el manejo médico con Metotrexato como primera línea. Los objetivos de este estudio son describir las características relevantes de los casos de EC en el servicio de Ginecología del Hospital Dr. Sótero del Río y realizar una revisión actualizada del tema. Métodos: Estudio Retrospectivo de todas las pacientes hospitalizadas en la unidad de Ginecología entre 2004 y 2020. Análisis descriptivo de las pacientes con diagnóstico de Embarazo Cervical. Resultados: Se revisaron 33740 pacientes. 1910 presentaron diagnóstico de Embarazo ectópico, de las cuales 6 corresponden a embarazo cervical, 5 casos se sospecharon desde el ingreso y sólo 1 caso ingresó con el diagnóstico de aborto en evolución. La mayoría fue manejada con Metrotrexato, con buenos resultados y sin complicaciones. Conclusiones: El Embarazo cervical es una patología poco frecuente. El manejo médico con Metrotrexato es la opción de primera línea en pacientes hemodinámicamente estable posibilitando la fertilidad posterior.

Introduction and Objectives: Cervical Pregnancy is known as a pathology of very low frequency and suspicion rate. Different treatments have been proposed in the current literature, but medical management with Methotrexate is recommended as the first line. The objectives of this study are to describe the relevant characteristics of cervical pregnancy cases in the Gynecology Department of the Dr. Sotero del Rio Hospital and to carry out an updated review of the subject. Methods: Retrospective study of all hospitalized patients in the Gynecology unit between 2004 and 2020. Descriptive analysis of patients diagnosed with Cervical Pregnancy. Results: 33740 patients were reviewed. 1910 presented a diagnosis of ectopic pregnancy, of which 6 correspond to cervical pregnancy, 5 cases were suspected from admission and only 1 case entered with the diagnosis of abortion in progress. Most were managed with Methotrexate, with good results and without complications. Conclusion: Cervical pregnancy is a rare disease. Medical management with Methotrexate is the first line option in hemodynamically stable patients enabling subsequent fertility.

Methotrexate Therapy for Ectopic Pregnancies: A Tertiary Center Experience.

OBJECTIVE: Our aim is to demonstrate the importance of methotrexate (MTX) therapy for the treatment of ectopic pregnancy (EP). METHODS: This retrospective study consisted of 99 patients (72 tubal EPs, 20 pregnancies of unknown location (PUL), 4 cesarean section (CS) scar EPs and 3 cervical EPs) treated with MTX. RESULTS: Methotrexate therapy was successful in 68.5% of EPs. There were statistically significant differences between the MTX success and failure groups based on ultrasonographic findings, patient complaints, gestational week and serum human chorionic gonadotropin (hCG) values. The MTX success rates in PUL and tubal pregnancies were 95% and 61.1%, respectively. The MTX success rates in single-dose, two-dose and multi-dose protocol groups were 86.9%, 28.6% and 40%, respectively. All cervical and CS scar ectopic pregnancies were treated successfully with MTX therapy. CONCLUSION: Methotrexate might be the first-line treatment option for EPs under certain conditions. Physicians must be more cautious in cases with higher hCG values, the presence of abdominal-pelvic pain, the presence of fetal cardiac activity, larger gestational sac (GS) diameters, and more advanced gestational weeks according to the last menstrual period.

Methotrexate therapy for ectopic pregnancies: A tertiary center experience

Abstract Objective Our aim is to demonstrate the importance of methotrexate (MTX) therapy for the treatment of ectopic pregnancy (EP). Methods This retrospective study consisted of 99 patients (72 tubal EPs, 20 pregnancies of unknown location (PUL), 4 cesarean section (CS) scar EPs and 3 cervical EPs) treated with MTX. Results Methotrexate therapy was successful in 68.5% of EPs. There were statistically significant differences between the MTX success and failure groups based on ultrasonographic findings, patient complaints, gestational week and serum human chorionic gonadotropin (hCG) values. The MTX success rates in PUL and tubal pregnancies were 95% and 61.1%, respectively. The MTX success rates in single-dose, two-dose and multi-dose protocol groups were 86.9%, 28.6% and 40%, respectively. All cervical and CS scar ectopic pregnancies were treated successfully with MTX therapy. Conclusion Methotrexate might be the first-line treatment option for EPs under certain conditions. Physicians must be more cautious in cases with higher hCG values, the presence of abdominal-pelvic pain, the presence of fetal cardiac activity, larger gestational sac (GS) diameters, and more advanced gestational weeks according to the last menstrual period.

Tratamiento médico del embarazo ectópico no complicado; experiencia del hospital regional de Talca / Medical treatment of uncomplicated ectopic pregnancy: regional hospital of Talca experience

El tratamiento médico del embarazo ectópico (EE) no complicado es una alternativa para el manejo de esta patología. Existen distintos criterios para su uso y las tasas de éxito publicadas son variadas. Realizamos una revisión de 34 casos de pacientes con diagnóstico de EE no complicado en el Hospital Regional de Talca, reportándose una tasa de éxito con dosis única de metotrexato de 65%. Un 20,5% de las pacientes requirieron una dosis adicional de metotrexato. La tasa total de éxito con tratamiento médico alcanzó un 73.5%. El manejo médico es una alternativa efectiva a la cirugía en pacientes bien seleccionadas. Se debe evaluar de manera local los criterios de inclusión para el tratamiento médico del EE no complicado.

Medical treatment of non complicated ectopic pregnancy is an alternative for the management of this pathology. There are different criteria for it's use, and published success rates are heterogeneous. We reviewed 34 cases of patients with diagnosis of no complicated ectopic pregnancy in Hospital Regional de Talca, and we reported a success rate of 65% with a single dose of methotrexate. 20,5% of patients needed an additional dose of medication. The global success rate of medical treatment was 73,5%. No surgical management is an effective alternative for well-selected patients. The criteria for medical treatment of no complicated EE must be evaluated locally.

Safe abortion information hotlines: An effective strategy for increasing women's access to safe abortions in Latin America.

This paper describes the implementation of five Safe Abortion Information Hotlines (SAIH), a strategy developed by feminist collectives in a growing number of countries where abortion is legally restricted and unsafe. These hotlines have a range of goals and take different forms, but they all offer information by telephone to women about how to terminate a pregnancy using misoprostol. The paper is based on a qualitative study carried out in 2012-2014 of the structure, goals and experiences of hotlines in five Latin American countries: Argentina, Chile, Ecuador, Peru and Venezuela. The methodology included participatory observation of activities of the SAIH, and in-depth interviews with feminist activists who offer these services and with 14 women who used information provided by these hotlines to induce their own abortions. The findings are also based on a review of materials obtained from the five hotline collectives involved: documents and reports, social media posts, and details of public demonstrations and statements. These hotlines have had a positive impact on access to safe abortions for women whom they help. Providing these services requires knowledge and information skills, but little infrastructure. They have the potential to reduce the risk to women's health and lives of unsafe abortion, and should be promoted as part of public health policy, not only in Latin America but also other countries. Additionally, they promote women's autonomy and right to decide whether to continue or terminate a pregnancy.

Interventional radiology and endovascular surgery in the treatment of ectopic pregnancies.

The advent of interventional radiology enabled remarkable advances in diagnosis and treatment of several situations in obstetrics and gynecology. In the field of obstetrics, these advances include temporary occlusion of the iliac arteries to the management of placenta accreta and/or prior, arteriovenous fistulas after embolization of uterine curettage and management of ectopic uterine and extra-uterine pregnancies. The non-tubal ectopic pregnancy, either cervical, abdominal, ovarian or in a cesarean scar, often represents major therapeutic challenge, especially when exists a desire to maintain fertility. Despite the systemic methotrexate therapy and surgical resection of the ectopic gestational sac be the most used therapeutic options, the interventionist approach of non-tubal ectopic pregnancies, direct injection of methotrexate in the gestational sac and intra-arterial chemoembolization of uterine arteries constitute in the currently literature viable, safe, effective modalities with low morbidity, shorter hospital stay, and rapid clinical recovery. Because of little variety of materials used, and the increase in training of specialists in the area, the radiological intervention as a treatment option in ectopic pregnancies is financially viable and present considerable accessibility in the world and at most of Brazilian medical centers.

Interventional radiology and endovascular surgery in the treatment of ectopic pregnancies / Radiologia intervencionista e cirurgia endovascular no tratamento das prenhezes ectópicas

The advent of interventional radiology enabled remarkable advances in diagnosis and treatment of several situations in obstetrics and gynecology. In the field of obstetrics, these advances include temporary occlusion of the iliac arteries to the management of placenta accreta and/or prior, arteriovenous fistulas after embolization of uterine curettage and management of ectopic uterine and extra-uterine pregnancies. The non-tubal ectopic pregnancy, either cervical, abdominal, ovarian or in a cesarean scar, often represents major therapeutic challenge, especially when exists a desire to maintain fertility. Despite the systemic methotrexate therapy and surgical resection of the ectopic gestational sac be the most used therapeutic options, the interventionist approach of non-tubal ectopic pregnancies, direct injection of methotrexate in the gestational sac and intra-arterial chemoembolization of uterine arteries constitute in the currently literature viable, safe, effective modalities with low morbidity, shorter hospital stay, and rapid clinical recovery. Because of little variety of materials used, and the increase in training of specialists in the area, the radiological intervention as a treatment option in ectopic pregnancies is financially viable and present considerable accessibility in the world and at most of Brazilian medical centers.

O advento da radiologia intervencionista tornou possível avanços notáveis no diagnóstico e no tratamento de diversas situações, na área de ginecologia e obstetrícia. No campo da obstetrícia, esses avanços incluem oclusão temporária das artérias hipogástricas para o manejo de placenta acreta e/ou prévia, embolização de fístulas arteriovenosas após curetagem uterina e manejo de prenhezes ectópicas uterinas e extrauterinas. A gravidez ectópica não tubária, seja cervical, abdominal, ovariana ou na cicatriz de cesárea, muitas vezes representa grande desafio terapêutico, principalmente quando há desejo de manutenção da fertilidade. As opções terapêuticas mais utilizadas para o tratamento de prenhez ectópica não tubária, são: terapia sistêmica com metotrexato e ressecção cirúrgica do saco gestacional ectópico; porém a abordagem intervencionista com injeção direta de metotrexato no saco gestacional ou quimiembolização intra-arterial das artérias uterinas, apresentam-se na literatura recente, como modalidades terapêuticas viáveis, seguras, eficazes, com baixa morbidade, menor tempo de internação e rápida recuperação clínica. Devido ao diminuto arsenal de materiais utilizados e à crescente formação de especialistas na área, a intervenção radiológica, como opção de tratamento nas prenhezes ectópicas, é financeiramente viável e apresenta acessibilidade considerável no mundo e na maioria do centros médicos brasileiros.

Women's experiences with the use of medical abortion in a legally restricted context: the case of Argentina.

This article presents the findings of a qualitative study exploring the experiences of women living in Buenos Aires Metropolitan Area, Argentina, with the use of misoprostol for inducing an abortion. We asked women about the range of decisions they had to make, their emotions, the physical experience, strategies they needed to use, including seeking health care advice and in dealing with a clandestine medical abortion, and their overall evaluation of the experience. An in-depth interview schedule was used. The women had either used misoprostol and sought counselling or care at a public hospital (n=24) or had used misoprostol based on the advice of a local hotline, information from the internet or from other women (n=21). Four stages in the women's experiences were identified: how the decision to terminate the pregnancy was taken, how the medication was obtained, how the tablets were used, and reflections on the outcome whether or not they sought medical advice. Safety and privacy were key in deciding to use medical abortion. Access to the medication was the main obstacle, requiring a prescription or a friendly drugstore. Correct information about the number of pills to use and dosage intervals was the least easy to obtain and caused concerns. The possibility of choosing a time of privacy and having the company of a close one was highlighted as a unique advantage of medical abortion. Efforts to improve abortion law, policy and service provision in Argentina in order to ensure the best possible conditions for use of medical abortion by women should be redoubled.

Medical abortion and manual vacuum aspiration for legal abortion protect women's health and reduce costs to the health system: findings from Colombia.

The majority of abortions in Colombia continue to take place outside the formal health system under a range of conditions, with the majority of women obtaining misoprostol from a thriving black market for the drug and self-administering the medication. We conducted a cost analysis to compare the costs to the health system of three approaches to the provision of abortion care in Colombia: post-abortion care for complications of unsafe abortions, and for legal abortions in a health facility, misoprostol-only medical abortion and vacuum aspiration abortion. Hospital billing records from three institutions, two large maternity hospitals and one specialist reproductive health clinic, were analysed for procedure and complication rates, and costs by diagnosis. The majority of visits (94%) were to the two hospitals for post-abortion care; the other 6% were for legal abortions. Only one minor complication was found among the women having legal abortions, a complication rate of less than 1%. Among the women presenting for post-abortion care, 5% had complications during their treatment, mainly from infection or haemorrhage. Legal abortions were associated not only with far fewer complications for women, but also lower costs for the health system than for post-abortion care. We calculated based on our findings that for every 1,000 women receiving post-abortion care instead of a legal abortion within the health system, 16 women experienced avoidable complications, and the health system spent US $48,000 managing them. Increasing women's access to safe abortion care would not only reduce complications for women, but would also be a cost-saving strategy for the health system.

Effectiveness of expectant management versus methotrexate in tubal ectopic pregnancy: a double-blind randomized trial.

PURPOSE: To compare the effectiveness of expectant management versus methotrexate in selected cases of tubal ectopic pregnancy. METHODS: A double-blind randomized trial included 23 selected patients with a confirmed diagnosis of tubal pregnancy who met the inclusion criteria (hemodynamic stability, initial serum ß-hCG concentration <2,000 mIU/mL, declining titers of ß-hCG 48 h prior to treatment, visible tubal pregnancy on transvaginal ultrasound, a tubal mass <5.0 cm and fertility desire). The patients were divided into two groups: 10 patients in the methotrexate group (MTX 50 mg/m(2) administered as a single intramuscular dose) and 13 patients in the placebo group (saline solution administered in a single intramuscular dose). Quantitative variables were expressed as means ± standard deviations and compared by Student's t test or Mann-Whitney test. Dichotomous variables (success/treatment failure) were presented as proportions and compared by the Fisher exact test. RESULTS: Successful treatment with negative titers of ß-hCG occurred in 9 cases (90.0%) of the methotrexate group and in 12 (92.3%) of the placebo group (p > 0.999). The ß-hCG values became undetectable at 22 ± 15.4 days in the methotrexate group and 20.6 ± 8.4 days in the placebo group (p = 0.80). CONCLUSION: This study showed no statistically significant difference between the treatment with methotrexate and placebo, with similar success rates and similar time interval for ß-hCG to become undetectable.

Prostaglandins for management of retained placenta.

BACKGROUND: Retained placenta affects 0.5% to 3% of women following delivery and it is a major cause of maternal death due to postpartum haemorrhage. Usually, retained placenta has been managed by manual removal or curettage under anaesthesia, which may be associated with haemorrhage, infection and uterine perforation. Medical management to facilitate the delivery of the retained placenta could be a safe alternative avoiding surgical intervention. OBJECTIVES: To assess the effectiveness and safety of prostaglandins for the management of retained placenta. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 December 2013), LILACS (1982 to 1 December 2013), SciELO (1998 to 1 December 2013), Web of Science (2001 to 1 December 2013), openSIGLE (1997 to 1 December 2013), World Health Organization International Clinical Trials Registry Platform (ICTRP) (1 December 2013) and the metaRegister of Controlled Trials (mRCT) (1 December 2013). We also contacted authors of included studies and reviewed the reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled clinical trials comparing the use of prostaglandins (or prostaglandin analogues) with placebo, expectant management, tocolytic drugs, any other prostaglandins or surgical interventions for the management of retained placenta after vaginal delivery of singleton live infants of 20 or more weeks of gestation. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. Any disagreements were resolved through consensus or consultation with a third review author when required. Authors of the included studies were contacted for additional information. MAIN RESULTS: We included three trials, involving 244 women. The studies were considered to be at high risk of bias.The prostaglandins used were PG E2 analogue (sulprostone) in 50 participants and PG E1 analogue (misoprostol) in 194 participants at a dose of 250 mcg and 800 mcg respectively. The prostaglandins compared with placebo, were not superior in reducing the rate of manual removal of placenta (average risk ratio (RR) 0.82; 95% confidence interval (CI) 0.54 to 1.27), severe postpartum haemorrhage (RR 0.80; 95% CI 0.55 to 1.15), need for blood transfusion (RR 0.72; 95% CI 0.43 to 1.22), mean blood loss (mean difference (MD) -205.26 mL; 95% CI -536.31 to 125.79, random-effects) and the mean time from injection to placental removal (MD -7.00 minutes; 95% CI -21.20 to 7.20). Side-effects were no different between groups (vomiting, headache, pain and nausea between injection and discharge from the labour ward), with the exception of shivering, which was more frequent in women receiving prostaglandins (RR 10.00; 95% CI 1.40 to 71.49). We did not obtain any data for the primary outcomes of maternal mortality and the need to add another therapeutic uterotonic. AUTHORS' CONCLUSIONS: Currently there is limited, very low-quality evidence relating to the effectiveness and the safety using prostaglandins for the management of retained placenta. Use of prostaglandins resulted in less need for manual removal of placenta, severe postpartum haemorrhage and blood transfusion but none of the differences reached statistical significance. Much larger, adequately powered studies are needed to confirm that these clinically important beneficial effects are not just chance findings.Similarly, no differences were detected between prostaglandins and placebo in mean blood loss or the mean time from injection to placental removal (minutes) or side-effects (vomiting, headache, pain and nausea between injection and discharge from the labour ward) except for 'shivering' which was more frequent in women who received prostaglandin. The included studies were of poor quality and there is little confidence in the effect estimates; the true effect is likely to be substantially different. We can not make any recommendations about changes to clinical practice. More high-quality research in this area is needed.

Abortion in Chile: the practice under a restrictive regime.

This article examines, from a human rights perspective, the experience of women, and the practices of health care providers regarding abortion in Chile. Most abortions, as high as 100,000 a year, are obtained surreptitiously and clandestinely, and income and connections play a key role. The illegality of abortion correlates strongly with vulnerability, feelings of guilt and loneliness, fear of prosecution, physical and psychological harm, and social ostracism. Moreover, the absolute legal ban on abortion has a chilling effect on health care providers and endangers women's lives and health. Although misoprostol use has significantly helped to prevent greater harm and enhance women's agency, a ban on sales created a black market. Against this backdrop, feminists have taken action in aid of women. For instance, a feminist collective opened a telephone hotline, Linea Aborto Libre (Free Abortion Line), which has been crucial in informing women of the correct and safe use of misoprostol. Chile is at a crossroads. For the first time in 24 years, abortion law reform seems plausible, at least when the woman's life or health is at risk and in cases of rape and fetal anomalies incompatible with life. The political scenario is unfolding as we write. Congressional approval does not mean automatic enactment of a new law; a constitutional challenge is highly likely and will have to be overcome.