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Rapid Responses: Rapid Responses published:
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More involved than efficiency
- Jo Ann Rosenfeld (2 June 2001)
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Miscarriage terminology
- David J R Hutchon (3 June 2001)
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Miscarriage not spontaneous abortion
- David J R Hutchon (4 June 2001)
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First trimester miscarriage management
- Lindsay F P Smith (10 July 2001)
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Jo Ann Rosenfeld, ASst Professor Medicine (Family Medicine) Johns Hopkins
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The article by Ankum et al is a very good evidenced based report on treatment of spontaneous abortion. Although all practitioners need to know which methods are more efficacious and have fewer side effects, there is an additional level of complexity - the psychosocial effects; these were just alluded to in one article that examined bereavement and grief in various methods - surgical or medical or expectant. The woman on whom these treatments are practice must be involved in the decision, even if she is guided by the "best" advice. Spontaneous abortions are not menorrhagia, moles to be removed, or bleeding to be "cleaned up from." The woman may be alert, realistic and rational, or depressed, guilty and hysterical ("If only I hadn't...". She is the patient, the victim, and at times, she may consider herself the "perpetrator." The pregnancy may be wanted or special and grieved or unwanted. Many women, even with wanted or planned pregnancies, are ambivalent about the pregnant state in the first trimester and may have had wishes about ending it, and now feel guilty that it is gone. She may want it over as soon as possible (surgery) or not be ready to come to term with the reality that the wanted pregnancy is no longer viable. These wishes must be taken into account when planning method of treatment. Certainly, the physician needs to know the most effective method, but a review or study without dealing with the psychosocial effects of the woman is incomplete. |
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David J R Hutchon, Consultant Obstetrician and Gynaecologist Memorial Hospital, Darlington
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Sir, We welcome the use of miscarriage terminology throughout this (1) and the review article in the same issue. (2). (except in the references) While it may seem nit-picking, the use of the word spontaneous in front of miscarriage is unnecessary. Miscarriage is spontaneous, a spontaneous response of the woman's body to this particular pregnancy. Descriptive terms such as complete miscarriage can then be used for the clinical presentation. Adding the word spontaneous suggests the miscarriage can sometimes not be spontaneous. The somewhat cumbersome term missed miscarriage probably slowed down the discontinuance of abortion terminology for miscarriage. (3) Missed miscarriage however has been used in a leading journal more recently. (4) Although the Royal College of Obstetricians and Gynaecologists study group's recommendation of early fetal demise, this term is not favoured by the Miscarriage Association. (5) It may be a slightly more accurate description of the clinical problem but destroys the consistency of miscarriage terminology. Health professionals need to be able to use the same terms when speaking to patients as they use in the clinical notes.
David J R Hutchon Consultant Obstetrician and Gynaecologist
References 1.Cahill D J. Managing spontaneous first trimester miscarriage. BMJ 2001;322:1315-6. 2. Ankum W M, Wieringa-de Waand M, Bindels P J E. Management of spontaneous miscarriage in the first trimester: an example of putting informed shared decision making into practice. BMJ 2001;322:1343-6. 3. Hutchon D J. Missed abortion versus delayed miscarriage. Br J Obstet Gynaecol 1997;104:753 4. Jurovic D, Ross J A, Nicolaides K H. Expectant management of missed miscarriage. Br J Obstet Gynaecol 1998;105:670-1 5.Hutchon D J R, Cooper S. Terminology for early pregnancy loss must be changed. BMJ 1998:317:1081 |
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David J R Hutchon, Consultant Obstetrician and Gynaecologist Memorial Hospital, Darlington
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I agree entirely with the sentiment of the letter from Rosenfeld. The use of spontaneous abortion terminology in the letter by the author, despite the obvious appreciation of the sensitivity of this outcome of pregnancy by the author, is unfortunate. If someone with this level of insight can still use the inappropriate words in a pre-medicated letter to an international journal, how much easier is it for the average medical student, nurse or doctor to find themselves using abortion terminology when counselling women with miscarriage. Can we please use miscarriage as the general term for early pregnancy loss and qualify the term with the appropriate adjective such as complete, incomplete, missed etc? David J R Hutchon |
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Lindsay F P Smith, General Practitioner Somerset
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Dear Sir or Madam Re: First trimester miscarriage management We read with interest the editorial1 and the review article2 on this topic. We thought it might be helpful to update your readers that new information should be available to assist them in their decisions about management within twelve months. The editorial mentioned the MIST trial. This multicentre randomised controlled trial is comparing expectant, medical and surgical management of first trimester miscarriage diagnosed following scan in early pregnancy clinics. Women are followed up following randomisation at 10-14 days with clinical and scan assessments and again at six weeks to assess clinical, psychological, and social outcomes. The trial is also assessing health economic differences of the three management options. At present it has recruited over 1100 women and recruitment will finish at the end of this year. We hope results will be available in spring or early summer 2002. The primary outcome measure is gynaecological infection at fourteen days after randomisation. There is also a linked qualitative study exploring the personal and social dimensions of the management methods which is being led by the Department of Sociology in the University of Bristol. This is interviewing 80 women who have suffered a miscarriage, sixty of whom have been randomised to one of the three treatment arms in the trial and twenty who were eligible but who declined to take part. Sixty of the eighty interviews have been completed to date. Again the results of this qualitative study should be available within the next twelve months. At that stage we should be in an excellent position to offer new information to women and their carers on clinical, psycho-social, economic and qualitative outcomes of the three management options for first trimester miscarriage. This will enable and encourage women to make informed decisions in their care. Yours sincerely Lindsay F P Smith MD FRCGP
Jo Trinder MRCOG
Harriet Bradley PhD
Ruth Bender Atik
1: BMJ 2001; 322: 1315-6 2. BMJ 2001; 322: 1343-6 |
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