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EDITORIALS: Andrew Weeks and Kristina Gemzell Danielsson Spontaneous miscarriage in the first trimester BMJ 2006; 332: 1223-1224 [Full text]

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Success of medical management of miscarriage is better assessed 2 weeks post-treatment

Arabinda Saha, Scartho Road, Grimsby, DN33 2BA   (26 August 2006)

Success of medical management of miscarriage is better assessed 2 weeks post-treatment 26 August 2006
Arabinda Saha, Consultant in Obstetrics & Gynaecology Diana, Princess of Wales Hospital, Scartho Road, Grimsby, DN33 2BA Send response to journal: Re: Success of medical management of miscarriage is better assessed 2 weeks post-treatment	Weeks and Danielsson1 concluded in their editorial that the high failure rate of medical management of first trimester miscarriage in the MIST trial2 was due to too early assessment of success after administration of misoprostol. Participants were assessed 8 hours after misoprostol was administered in this trial and the failure rate for early fetal loss was 38%. In our unit, for early fetal loss up to 9 weeks gestation, women receive 200mg of mifepristone and return to the unit 36-48 hours later for a single vaginal administration of 800 microgram of misoprostol. All women at this visit also receive prophylactic antibiotics (1 gm azithromycin and 1 gm metronidazole single dose). Women are counselled what to expect subsequently, are given the contact details of the unit and are allowed home. They are reviewed 2 weeks later in the unit. For fetal loss of >9 weeks, an extended regime of misoprostol is used and such women are kept in till the fetal tissues are expelled or a maximum of four doses of misoprostol have been given. I f the fetal tissues are not expelled after 4 doses of misoprostol, they are allowed home and reviewed 2 weeks later. Over a 2-year period we had 34 cases of early fetal/embryonic loss. Women diagnosed as having retained product of conception or incomplete miscarriage at the first assessment were not included in this cohort. 23 of these 34 were up to 9 weeks gestation and the remaining 11 10-19 weeks. Surgical evacuation was required in 2 - one in each category. Hence, failure rate of the medical management in our women up to 9 weeks was 4.3% and above 9 weeks was 9.1%. We had one woman of 12 weeks gestation who was admitted with heavy bleeding and was managed conservatively. There was no documented case of gynaecological infection or transfusion within 2 weeks of misoprostol administration. Based on our experience, we believe that review of the success of the medical management of early fetal/embryonic loss can safely be deferred to the 2 weeks follow-up. When counselling women on the management options of early fetal/embryonic loss in our unit, based on the above data we quote a success rate of 90% with the medical management. 1 Weeks A, Danielsson KG. Spontaneous miscarriage in the first trimester. BMJ 2006;332: 1223-4. 2 Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial). BMJ 2006;332: 1235- 8. Competing interests: None declared