Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Expectant management of early miscarriage
- Jai B Sharma (30 May 2006)
-
Management of miscarriage: medical management and gestational trophoblastic disease risk
- Neil J Sebire (5 June 2006)
-
Re: Concerns about MIST trial
- Ahmed El Daley Zaki (7 June 2006)
-
Medical treatment is still an option after failed expectant management of miscarriage.
- Jo Marsden-Williams, Caroline Overton, Demetrios Psaroudakis (26 August 2006)
|
|
|||
|
Jai B Sharma, Assistant Professor of Obstetrics and Gynaecology All India Institute of Medical Sciences , New Delhi
Send response to journal:
|
The results of MIST trial by Trinder et al are not very surprising.There was no significant difference in the incidence of infection rate in the three types of miscarriages that is expectant management, medical management or surgical management confirming once again the safety and efficacy of the three types of management. But the much higher rate of evacuations required for medical and expectant management can not be ignored.What is most important before venturing for medical or expectant management is proper counselling of the patient especially when the lady had a surgical evacuation in the past in which the procedure is completed under anaesthesia in one go without the lady seeing anything. On the other hand in medical or expectant management all the products are passed per via naturalis often associated with significant discomfort or pain making the the lady uncomfortable and worried. To avoid unnecessary tension in her and to avoid unnecessary phone calls from the patients at odd hours, one must counsel them fully explaining them that all the products will be passed from vagina appearing to be too much bleeding. They should also be given a prescription of tramodol for pain as antiprostaglandins are to be avoided as they interfere with the action of misoprostol in case of medical miscarriage. After honest and accurate information about the efficacy of different methods of miscarriage, it should be left to the the patient which method she desires for the management of her miscarriage. Competing interests: None declared |
|||
|
|
|||
|
Neil J Sebire, Consultant in Trophoblastic Disease Pathology Trophoblastic Disease Unit, Charing Cross Hospital, London
Send response to journal:
|
Sir, A recent article presented the results of a randomised controlled trial of the management of early miscarriage[1] and concluded that the frequency of infection following surgical, expectant and medical management is similar between the trial groups. It was further suggested that expectant management may be particularly appropriate for cases of incomplete miscarriage and as an alternative management in early fetal demise.[1] Whilst the study provides useful additional information for counselling patients on this topic, one aspect of the management of early pregnancy failure which was not discussed should be highlighted. Namely, one of the possible causes of first trimester miscarriage is hydatidiform molar pregnancy, which is associated with a significantly increased risk of subsequent development of persistent gestational trophoblastic disease. A recent large study reported that only around 40% of hydatidiform moles are detected as molar on pre-evacuation ultrasound examination, the vast majority appearing to be incomplete or missed miscarriages by sonography alone.[2] Furthermore,it is known that following termination of pregnancy, patients presenting with symptomatic persistent gestational trophoblastic disease, compared with those who have the diagnosis made histologically following evacuation, are significantly more likely to experience a life- threatening complications and to require additional surgical or chemotherapeutic interventions.[3] Since routine histopathological examination of evacuated products of conception following early pregnancy failure remains the gold standard for detecting molar pregnancy,it is therefore likely that with the increasing use of expectant or medical management of miscarriage, the proportion of cases in whom tissue is submitted for histopathological examination will fall. Consequently, in a minority of cases managed this way, the diagnosis of molar pregnancy will be missed and there is an increased risk of such patients presenting clinically with advanced persistent trophoblastic disease. Before the introduction of the widespread routine application of medical or expectant management of miscarriage, development of more accurate methods of assessing the patient's risk for possible molar pregnancy at presentation are required. It is plausible that a combination of ultrasound examination and serum human chorionic gonadotrophin (hCG) measurement at presentation may better risk stratify these patients, but no such data are currently available. At present, patients who opt to undergo medical or expectant rather than surgical management of early pregnancy failure should be made aware of this issue and the introduction of a routine check of hCG concentration following conservative management of miscarriage should be further considered in such cases. Dr NJ Sebire 1. Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of miscarriage: expectant, medical, or surgical? Results of a randomised controlled trial (miscarriage treatment (MIST) trial) Br Med J 2006 332: 1235-8. 2. Fowler DJ, Lindsay I, Seckl MJ, Sebire NJ. Routine pre-evacuation ultrasound diagnosis of hydatidiform mole: experience of more than 1000 cases from a regional referral center.Ultrasound Obstet Gynecol. 2006;27: 56-60. 3. Seckl MJ, Gillmore R, Foskett M, Sebire NJ, Rees H, Newlands ES. Routine terminations of pregnancy-should we screen for gestational trophoblastic neoplasia? Lancet 2004; 364: 705-7. Competing interests: None declared |
|||
|
|
|||
|
Ahmed El Daley Zaki, Senior Staff Grade Obstetrics & Gynaecology Harrogate & District NHS Foundation Trust. 16 Lancaster Park Road, Harrogate HG2 7SX
Send response to journal:
|
There is no doubt that MIST trial is a big randomized controlled trial. It was conducted in seven hospitals in UK and included 1200 women. However, I have some deep concerns about the trial that, I believe, make the results totally unreliable I found it very strange that a big trial addressing the subject of incidence of gynaecological infection was conducted without having a microbiologist among those who conducted the trial. The definition of gynaecological infection in the study was not accurate and never based on swaps or cultures. Infection was assumed and never proved. According to the methodology of the study, gynaecological infection was defined as two or more of the following: purulent vaginal discharge, pyrexia >38.0C, tenderness over the uterus on abdominal examination and a white cell count above 15. According to the RCOG green-topped guidelines, these symptoms lack sensitivity and specificity. They are suggestive but not diagnostic. Based on these clinical features, 15-30% of suspected cases have no laparoscopic evidence of acute infection. The word purulent vaginal discharge is vague and subjective. The presence of excess leucocytes on a wet mount vaginal smear may be associated with pelvic infection but is also found in women with isolated lower genital tract infection (Evidence level III) (1) Tenderness over the uterus on abdominal examination is also not sensitive or specific. Abdominally, the uterus is difficult to reach in women who had miscarriage at early gestations. Fever and increased white cell count can occur in all sorts of body infection. There is no evidence that these clinical findings mentioned in the trial can diagnose pelvic infection According to the definition of Gynaecological infection in the MIST trial, a lower urinary tract infection for example (present with fever, supra-pubic tenderness and increased white cell count) can be easily considered as gynaecological infection. This can cause lots of false positive results which make the results of the trial totally unreliable I will be grateful to Mr J.Trinder, if he brings any evidence to show that such criteria are diagnostic of gynaecological infection. I could not find any reference in the article to support his definition of infection. Thank you very much. Mr Ahmed Zaki
References: 1-Management of acute pelvic inflammatory disease. RCOG green-topped guidelines May 2003. Competing interests: None declared |
|||
|
|
|||
|
Jo Marsden-Williams, SpR Early Pregnancy Clinic, St Michael's Hospital, Bristol BS2 8EG, Caroline Overton, Demetrios Psaroudakis
Send response to journal:
|
To the Editor: We congratulate the author of the MIST study on scientifically dispelling the myth, that a surgical evacuation after miscarriage is necessary to prevent infection. We were disappointed that the default treatment for "failed" expectant, medical or surgical treatment was always a surgical evacuation of the uterus. In our small series, 18 women with "failed" expectant management of incomplete miscarriage had medical treatment as an outpatient with misoprostol 400 micrograms orally, five doses, three hours apart. Expectant management prior to medical treatment ranged from 7-63 days (mean 21.2 days. There were no emergency admissions with bleeding and treatment was well tolerated. Women were followed up within three weeks with an ultrasound scan. Three of the 18 women (16%) had surgical evacuation, all for persistent products of conception on ultrasound (mean diameter 14mm, 22mm, 19mm) rather than clinical symptoms. Our protocol has since changed and miscarriage would now be considered complete in these women. We suggest that if initial expectant treatment fails, that further management with medical treatment is a safe option, particularly when the woman chooses to avoid a surgical evacuation. Jo Marsden-Williams, SpR St Michael’s Hospital Early Pregnancy Clinic, Bristol. Jm4549@bristol.ac.uk Demetrios Psaroudakis SHO St Michael’s Hospital, Bristol. Caroline Overton, Consultant St Michael’s Hospital St Michael’s Hospital Early Pregnancy Clinic, Bristol. Caroline.Overton@ubht.swest.nhs.uk Competing interests: None declared |
|||