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Rapid Responses: Rapid Responses published:
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Miscarriage is as natural as childbirth
- Annie Thomas Ninan (13 April 2002)
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management of miscarriage requires a more holistic understanding
- Ajay George (18 April 2002)
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More dedicated miscarriage units are needed before expectant management becomes a viable option
- Susan Logan, Julie Browne, Siladitya Bhattacharya (8 May 2002)
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Which miscarriage, which management, which mental anguish, which unit?
- Martin J Cameron, Grant Cumming (Consultant obstetrician & Gymaecologist, Elgin) (22 May 2002)
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Women's experience of miscarriage treatment
- Anna Lane (19 September 2007)
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Annie Thomas Ninan, Senior Registrar Sultan Qaboos University Hospital PB No 35, Code 123, Sultanate of Oman
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It was interesting to read this article on conservative management of miscarriage. I have had the same experience in the southern region of the Sultanate of Oman, where women were managed conservatively, not for study purposes, but because they dislike D&C's and refuse vehemently to have an evacuation. I would like to know more details from the authors, regarding the decision for conservative management, was it by patients choice or did the physician advise this kind of treatment? Were there any criteria like the amount of retained products or size of the uterus, or size of the sac in a missed abortion were an evacuation was advised? What about the complications, the rate of infection (where the patients covered by antibiotics) or excessive bleeding? Did any of the patients need blood transfusion? |
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Ajay George, GP Sunderland, SR2 7BW
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While suggesting that conservative management of miscarriage is a safe option the study by Luise and colleagues fails to take into account the psychological ramifications of such a decision. There are many emotional aspects of miscarriage and a woman may decide on prompt surgical management in order to be able to regain control, start grieving and begin to cope with the loss of their child. If a woman is bleeding for up to 2 weeks (in 70%of women) or for over 7-8 weeks (in 19% of women)how then are they able to being to move on physically and emotionally? What is not clear from the paper is how the decision to opt for conservative management was reached and why the 30% of women that opted for surgical management chose that option. Were there more women in this group who had had a previous miscarriage? It is possible that some women in the study chose conservative management on the basis that they could change their mind at any time and had quick access to this service. This may not be the case in all areas and so the percentage of women choosing conservative management may be lower. What would be interesting to know is having had the experience of conservative management how many of those women would have chosen that option with the benefit of hindsight. |
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Susan Logan, specialist registrar Department of Obstetrics & Gynaecology, Aberdeen Maternity Hospital, Foresterhill, Aberdeen AB25 2ZD, Julie Browne, Siladitya Bhattacharya
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Editor- Luis et al1 report that the majority of women with miscarriage choose expectant management and that over 80% will require no surgical intervention. Their population was monitored for up to 46 days, with 60% of all miscarriages and 72% of missed/ anembryonic pregnancies requiring follow up for over one week. The authors conclude that as complications were minimal, patients should be encouraged to persevere with expectant management. While these results look promising, we feel that two important issues- the role of the dedicated miscarriage unit and infective morbidity, were overlooked. Expectant management is attractive. It gives the couple time to come to terms with their loss and avoids the risks of surgical evacuation. As 15% of pregnancies miscarry, a move towards community care has important health service implications. However, psychological support and preservation of future fertility need to be at the forefront of those caring for women with miscarriage. The majority of Luis et al’s patients still had retained products a week after diagnosis. Only a dedicated unit could provide the continuity of care, input, and counselling skills required to support these patients. Furthermore, while no infectious complications were reported, miscarriage populations have prevalence rates for Chlamydia trachomatis infection of 4%, with rates of 6% in women under 25 years.2 Expectant management still carries a risk of pelvic inflammatory disease (PID),3 with its recognised sequelae of ectopic pregnancy, tubal factor infertility, and chronic pelvic pain. As most chlamydial infections and Chlamydia-associated PID are asymptomatic,4 the authors cannot conclude that their patients came to no harm. We performed a questionnaire-based survey of miscarriage services in all consultant led gynaecology/ obstetric units in Scotland. The response rate was 96%. Only 32% had a designated miscarriage unit. Table 1 shows where women are presently admitted. As a result of this fragmentation, there were marked variations in clinical practice with 40% of units taking no special precautions against potential C. trachomatis infection. Studies promoting expectant management have been published since the 1930s, yet it has not been adopted in routine clinical practice. The lack of dedicated units may be a reason. Women presenting with miscarriage are ideally placed for opportunistic chlamydial screening. Dedicated units facilitate innovation, research, and the implementation of protocols,5 such as those that reduce infective morbidity. More dedicated units taking a holistic approach to women’s care during miscarriage are needed before expectant management can become a viable option. Susan Logan Julie Browne Siladitya Bhattacharya 1. Luis C, Jermy K, May C, Costello G, Collins WP, Bourne TH. Outcome of expectant management of spontaneous first trimester miscarriage: observational study. BMJ 2002; 324: 873-5. 2. Macmillan S, McKenzie H, Flett G, Templeton A. Which women should be tested for Chlamydia trachomatis? BJOG 2000; 107: 1088-1093. 3. Nielsen S, Hahlin M. Expectant management of first trimester spontaneous abortion. Lancet 1995; 345: 84-86. 4. Paavonen J, Eggert-Kruse W. Chlamydia trachomatis: impact on human reproduction. Human Reproduction Update 1999; 5(5): 433-447. 5. Royal College of Obstetricians and Gynaecologists. The management of early pregnancy loss. RCOG Guidelines No 7, 2000. Table 1. Admission policy in women presenting with miscarriage in Scotland (n=25) Type of ward admitting women with miscarriage Hospital Units (%) Gynaecology ward 9 (36) Designated miscarriage unit 8 (32) Both gynaecology and maternity wards 5 (20) Maternity ward 1 (4) Gynaecology ward/acute surgical unit 1 (4) Day surgery unit 1 (4) |
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Martin J Cameron, Research Fellow to the Scottish Programme for Clinical Effectiveness in Reproductive Health Center for Reproductive Biology, Chalmers St, Edinburgh. EH3 9ER, Grant Cumming (Consultant obstetrician & Gymaecologist, Elgin)
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Editor-we read with interest the papter by Luise et al (1). We commend them in their use of ultrasound to classify miscarriage into complete, incomplete, missed miscarriage or anembryonic pregnancy. By using such a classification, clinicians can counsel women about the likely outcome and time scale of therapeutic options. This study agrees with previous observational studies, in that 4 out of 5 women with incomplete miscarriage are likely to complete their miscarriage within 14 days with no intervention (2). It also highlights that only 1 woman in 2 with a missed miscarriage or anembryonic pregnancy will complete their miscarriage within 14 days if no active management is offered. However, we feel that their management of miscarriage is limited with respect to therapeutic interventions for a 2002 publication by not offering medical management. The Royal College of Obstetricians and Gynaecologists(RCOG)has produced a clinical guideline that states quite clearly that there is a grade A evidence for the use of either medical or expectant management (3). Published data on the efficacy of emptying the uterus using medical management is summarised in Table 1. In most of these seventeen studies, the use of medical management would suggest an efficacy rate of between 80 to 90%. Luise et al are right to offer patients a choice of treatment. However, in failing to offer medical treatment, their conclusion that most women with retained products of conception will choose expectant management in 2002 has to be challenged. If ecpectant management can be offered then medical management should also have been offered. Some women will choose surgical evacuation of retained products of conception because it results in the treatment being completed quickly thereby allowing the grieving process to begin. By choosing surgery, these women have to undergo the anxiety of a surgical procedure with their management being placed in the hands of others. For women choosing expectant management, although they may feel more empowered, this is at the expense of having to undergo a longer period of "treatment" with no definite guarantee of completion resulting in a possible prolongation of anxiety and distress. Medical management seems to offer a half way house. Compared with surgical management, medical management may give control back to women thereby allowing them greater patient empowerment. Furthermore it avoids the need of both a general anaesthetic and an invasive procedure with their possible adverse sequelae. Compared with expectant management a higher success rate for completing the miscarriage in women with missed or anembryonic pregnancies is obtained and usually in a quicker time scale. For incomplete miscarriage, expectant and medical management may have similiar success rates for emptying the uterus, although the time to completion of the miscarriage may be shortened with the use of medical treatment. There are few published studies that address the important area of the psychological impact of the treatment modalities. One study found no significant differences in psychological reactions between patients managed expectantly or by surgery (4). A recent study that compared the psychological impact of routine surgical evacuation with medical evacuation in a Chinese population showed no difference in any of the measured psychological outcomes (5). Further studies are needed to address this question of which treatment modality causes the least distress to women with miscarriage and the degree to which the patient is involved in the decision making process. We agree with the RCOG guidelines that expectant and medical management can only be offered in units where patients have access to 24- hour telephone advice and immediate admission can be arranged. Therefore, the individual setting of the Early Pregnancy Assessment Unit(EPAU) may be a factor on deciding which management options can be offered. Scotland has a varied geographical population with some patients having to travel over 100 miles to reach their nearest EPAU. Clearly, expectant or medical management may be less of an acceptable option for these women, if it will take several hours to reach their base EPAU if they experience problems. Decisions about what treatment option is best for patients must always be individualised taking into account the woman's wishes but must take into acount the woman's environment and the services available to her. Ideally all women should have access to a dedicated early pregnancy assessment service providing the full range of treatment options and aftercare that every woman deserves. Table 1:Studies of effectiveness of medical management. Study % reported effectiveness of medical management Ngai et al(6) 83.3 McCreath et al(7) 83(Non-compliance correction-94) Wagaarachchi et al(8) 84.1 Pandian et al(9) 84.8 Demetroulis et al(10) 82.5 Nielsen et al(11) 82 Nielsen et al(12) 52 Crenin et al(13) 88 Herabutya et al(14) 83.3 Hughes et al(15) 89.1 Chung et al(16) 70.6 Egarter et al(17) 76.7 de Jonge et al(18) 13 Chung et al(19) 45.4 Henshaw et al(20) 96 Lelaidier et al(21) 82 El-Refaey et al(22) 96 Reference list. 1. Luise C, Jermy K, May C, Costello G, Collins WP, Bourne TH. Outcome of ecpectant management of spontaneous first trimester miscarriage: observational study. BMJ 2002;324:873-875. 2. Nielsen S, Hahlin M. Expectant management of first-trimester spontaneous abortion. Lancet 1995;345:84-86. 3. Hinshaw K, and Fayyad A. The Management of Early Pregnancy Loss. 2000. RCOG Green Top Guidelines No 25 4. Nielsen S, Hahlin M, Moller A, Granberg S. Bereavement, grieving and psychological morbidity after first trimester spontaneous abortion: comparing expectant management with surgical evacuation. Human Reproduction 1996;11:1767-1770. 5. Lee DT, Cheung LP, Haines CJ, Chan KP, Chung TK. A comparison of the psychologic impact and client satisfaction of surgical treatment with medical treatment of spontaneous abortion: a randomized controlled trial. American Journal of Obstetrtics & Gynecology 2001;185:953-958. 6. Ngai SW, Chang YM, Tang OS, Ho PC. Vaginal misoprostol as medical treatment for first trimester spontaneous miscarriage. Human Reproduction 2001;16:1493-1496. 7. McCreath WA, Kang J, Martin JR, Kiro M, Gilles JM. The efficacy of a 600-microgram misoprostol regimen for the evacuation of missed abortions. Obstetrics & Gynecology 2001;97:S67-S68. 8. Wagaarachchi PT, Ashok PW, Narvekar N, Smith NC, Templeton A. Medical management of early fetal demise using a combination of mifepristone and misoprostol. Human Reproduction 2001;16:1849-1853. 9. Pandian Z, Ashok P, Templeton A. The treatment of incomplete miscarriage with oral misoprostol. BJOG 2001;108:213-214. 10. Demetroulis C, Saridogan E, Kunde D, Naftalin AA. A prospective randomized control trial comparing medcial and surgical treatment for early pregnancy failure. Human Reproduction 2001;16:365-369. 11. Nielsen S, Hahlin M, Platz-Christensen J. Randomised trial comparing expectant with medical management for first trimester miscarriages. British Journal of Obstetrics & Gynaecology 1999;106:804-807. 12. Nielsen S, Hahlin M, Platz-Christensen JJ.Unsuccedssful treatment of missed abortion with a combination of an antiprogesterone and a prostaglandin E1 analogue. British Journal of Obstetrics & Gynaecology 1997;104:1094-1096. 13. Creinin MD, Moyer R, Guido R. Misoprostol for medical evacuation of early pregnancy failure. Obstetrics & Gynecology 1997;89:768-762. 14. Herabutya Y, Prasertsawat P. Misoprostol in the management of missed abortion. International Journal of Gynaecology & Obstetrics 1997;56:263-266. 15. Hughes J, Ryan M, Hinshaw K, Henshaw R, Rispin R, Templeton A. The costs of treating miscarriage a comparison of medical and surgical management. British Journal of Obstetrics & Gynaecology 1996;103:1217 -1221. 16. Chung T, Leung P, Cheung Lp, Haines C, Chang AM. A medical approach to management of spontaneous abortion using misoprostol. Extending misoprostol treatment to a maximum of 48 hours can further improve evacuation of retained products of conception in spontaneous abortion. Acta Obstetricia et Gynecologica Scandinavica 1997;76:248-251. 17. Egarter C, Lederhilger J Kurz C, Karas H, Reisenberger K. Gemeprost for first trimester missed abortion. Archiv es of Gynecology & Obstetrics 1995;256:29-32. 18. de Jonge ET, Makin JD, Manefeldt E, De Wet GH, Pattinson RC. Randomised clinical trial of medcial evacuation and surgical curettage for incomplete miscarriage. BMJ 1995;311:662. 19. Chung TKH, Cheung LP, Haines CJ, Chang AM, Lau WC. Spontaneous abortion: a medical approach to management Aust N.Z.J. Obstet Gynaecol 1994;34:432-436. 20. Henshaw RC, Cooper K, el-Refaey H, Smith NC, Templeton AA. Medical management of miscarriage: non-surgical uterine evacuation of incomplete and inevitable spontaneous abortion . BMJ 1993;306:894-895. 21. Lelaidier C, Baton SM, Fernandez H, Bourget P, Frydman R. Mifepristone (RU 486) induces embryo expulsion in first trimester non- developing pregnancies: a prospective randomized trial. Human Reproduction 1993;8:492-495. 22. el-Refaey H, Hinshaw K, Henshaw R, Smith N, Templeton A. Medical management of missed abortion and anembryonic pregnancy. BMJ 1992;305:1399. |
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Anna Lane, Medical journalist BMJ BestTreatments, BMA House, WC1H9JR
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I read with interest the report Outcome of expectant management of spontaneous first trimester miscarriage: observational study; especially as I was treated for an incomplete miscarriage earlier this year. I am surprised the authors did not seek the views of the women in the study, as the psychological and emotional impact of miscarriage is important. In my treatment, I was strongly advised to accept expectant management. Indeed I was not fully aware that I had another choice. My miscarriage completed without further treatment, but I endured more than a week of frightening bleeding and pain. There was no follow-up to check that the miscarriage had completed. I didn't feel empowered; just scared and miserable. I would have been interested to know how the women who underwent surgical treatment vs expectant management felt about their experiences. Competing interests: None declared |
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