Management of spontaneous miscarriage in the first trimester: an example of putting informed shared decision making into practice
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7298.1343 (Published 02 June 2001) Cite this as: BMJ 2001;322:1343All rapid responses
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We read the Clinical review article by Ankum et al1 with
interest. We would like to make certain comments. Summary point ‘Surgical
evacuation is unnecessary after a complete miscarriage with retained
product of conception and should be indicated by clinical rather than
ultrasonographical criteria’ Definition of complete miscarriage is
‘absence of retained products of conception’ and hence does not need
treatment.
We would like to take issue with another summary point- ‘Medical
management has no apparent benefits over expectant management, and it has
side effects’. Medical management cannot be entirely excluded from
treatment options, since we know from the North American experience-
Simonds et al2, medical management of therapeutic abortion, that majority
of women prefer the medical method to the surgical method. This would
indicate that if the expectant management is not acceptable then an
alternative to the surgical procedure should be available as a choice.
The significance of the results of the Nielsen and Hahlin3 study
remain questionable in this context. Even though they stated no difference
between expectant and surgical management, they unfortunately only
included women already in the process of miscarrying – excluding the large
group of non-viable pregnancies seen on scan – but not yet starting to
miscarry. This excluded group of women often requiring intervention and
expectant management can be hard for them to accept. It also has a higher
failure rate Ref If the purpose of the service is to offer a choice
and ‘shared decision’, then medical management surely has a place for the
woman; if they wish to avoid surgery.
The variation of success rates of studies on medical management of
miscarriage is complicated by the variability in regimens and agents used.
Further randomised controlled Trials are desired to determine optimum
agents and schedule and only then can these be compared to expectant and
surgical alternatives.
Pina Amin Gynaecologist
Department of Obstetrics and Gynaecology, University Hospital of Wales,
Cardiff, South Wales.
Janet Evans Consultant Gynaecologist
Department of Obstetrics and Gynaecology, Llandough Hospital, Penarth,
South Wales.
1 Ankum W M, Wieringa-de Waard M, Bindels P J E. Management of
spontaneous miscarriage in the first trimester: an example of putting
informed shared decision making into practice. BMJ 2001:322:1343-46.(2
June)
2 Simonds W, Ellertson C, Springer K, Winkoff B. Abortion Revised:
Participants in the U.S. clinical trials evaluate mifepristone Soc. Sci.
Med. 1998:46:1313-1323.
3 Nielsen S, Hahlin M. Expectant management of first-trimester
spontaneous abortion. Lancet 1995:345:84-86.
Competing interests: No competing interests
Dear Sir,
The recent review article on the management of spontaneous
miscarriage suggests that medical management is of little benefit in the
treatment of incomplete miscarriage[1] It may be however, that differences
in ultrasound use are responsible for the wide variation in reported
success rates.
The use of ultrasound for confirming retained products of conception
(RPOC) in those who are clinically incomplete will exclude about 30% of
women from treatment as they will be found to have empty uteri[2]. If
ultrasound is not used at this stage the success rate will be inflated by
the inclusion of women undergoing unnecessary treatment.
Conversely, the use of ultrasound after uterine evacuation for the
assessment of completeness may reduce the apparent success rates. The
finding of intrauterine tissue on ultrasound usually leads to an
assumption that the treatment has failed. The natural history of this
finding, however, is unknown and it is likely that the majority of these
women will complete spontaneously without further intervention.
Analysis of the available studies reveals a clear relationship
between the reported success rates and the time at which the post-
treatment ultrasound assessment was conducted (Figure 1). The findings
suggest that the low reported success rates in some studies may have
occurred as a result of an overreaction to ultrasound findings which are
of undetermined significance. It may be that the combination of initial
medical treatment followed by a time of expectant management is the key to
the effective management of incomplete miscarriages. These findings also
add weight to the arguments in favour of using expectant management alone.
These two regimens need to be compared.
The graph in Figure 1 may represent the natural history of incomplete
miscarriages, but this needs to be confirmed in a prospective ultrasound
study of women undergoing expectant management.
Yours truly,
Dr Andrew D Weeks MD MRCOG (corresponding author)
Lecturer in Obstetrics and Gynaecology,
Department of Obstetrics and Gynaecology,
Makerere University,
P.O. Box 7072,
Kampala,
Uganda
e-mail: aweeks@doctors.org.uk
Dr Godfrey Alia MB ChB
Senior House Officer in Obstetrics and Gynaecology
Mulago Hospital, Kampala
e-mail: godfreyalia@hotmail.com
References
1. Ankum WM, de Waard MW, Bindels PJE. Management of spontaneous
miscarriage in the first trimester: an example of putting informed shared
decision making into practice. BMJ 2001;322:1343-6.
2. Cheung T, Leung P, Cheung LP, Haines C, Chang AMZ. A medical approach
to management of spontaneous abortion using misoprostol. Acta Obstet
Gynecol Scand 1997;76:248-51.
3. De Jonge ETM, Makim JD, Manefeldt E, De Wet GH, Pattinson RC.
Randomised clinical trial of medical evacuation and surgical curettage for
incomplete miscarriage. BMJ 1995;311:662.
4. Cheung TKH, Lee DTS, Cheung LP, Haines CJ, Chang AMZ. Spontaneous
abortion: a randomized, controlled trial comparing surgical evacuation
with conservative management using misoprostol. Fertil Steril 1999;71:1054
-9.
5. Nielsen S, Hahlin M. Expectant management of first trimester
spontaneous abortion. Lancet 1995;345:84-6.
6. Nielsen S, Hahlin M, Platz CJ. Randomised trial comparing expectant
with medical management for first trimester miscarriages. Br J Obstet
Gynaecol 1999;106:804-7.
7. Chipchase J, James D. Randomised trial of expectant versus surgical
management of spontaneous miscarriage. Br J Obstet Gynaecol 1997;104:840-
1.
8. Henshaw RC, Cooper K, El-Rafaey H, Smith NC, Templeton AA. Medical
management of miscarriage: non-surgical uterine evacuation of incomplete
and inevitable spontaneous abortion. BMJ 1993;306:894-5.
9. Hinshaw K. Medical uterine evacuation in the management of first
trimester miscarriage. In: Clinical Management of Early Pregnancy Ed:
Prendiville W & Scott JR. Arnold, London. 1999:79-89.
Figure 1: Comparison of the reported success rates with the time at
which ultrasound assessment was conducted post-treatment. Filled
triangles are results of medical management from randomised trials and
open triangles are results of expectant management from randomised trials.
Stars represent the results from observational trials of medical
management. The numbers refer to references below.
Competing interests: No competing interests
Dear Sir,
The BMJ and Ankum et al [BMJ 2 June 2001] have made a most refreshing
contribution to a condition long neglected by the profession possibly
because it is self limiting and can be rapidly treated in hospital. The
need for immediate admission of incomplete and inevitable miscarriages has
been revolutionised by the widespread use of ultrasound which has allowed
logical actions to be followed and the abandonment of expectant bed rest.
However is immediate admission needed for all women who are miscarrying?
The answer is often no, and well over half early miscarriages never
reach hospital * but I believe many more women could be managed at home
with the help of midwives thus avoiding the distress of admission to a
strange hospital and that of leaving their family. This is a moment in
their life when they will be confused and upset and they need more say in
their treatment: admission is of course expensive.
A woman who has bleeding in early pregnancy will generally seek
advice from her General Practitioner. So in Alton Health Center we
acquired a mobile Ultra Sound machine in 1988 and developed a routine for
women who were threatening to miscarry, in a similar way to Hospital
Pregnancy Assessment Units. Once the diagnosis of uncomplicated
miscarriage was made the patient was generally offered a choice unless
admission was necessary as an emergency. Either they could go straight to
hospital or go home to their family for a few hours (even overnight) to
adjust to their tragic loss and to make domestic arrangements for
subsequent admission and possible surgical evacuation. For these early
miscarriages many women choose to delay admission as they disliked being
rushed in to hospital. Given support from their GP and or Midwife they
often completed the miscarriage at home without problem thus avoiding
hospitalisation. This routine worked but depended on good local medical
support from their General Practitioner, and the practice Community
Midwife on duty who was much more competent to support the patient.
Would Practice Community Midwives in general be happy to get more
involved in this early complication of pregnancy which I believe would be
interesting and not a great burden to them. We must also educate
miscarrying women that ‘’getting it all out’’ is often no longer the
treatment of choice and needing an emergency admission. It is time for us
to give women a proper choice in this condition and support them better,
so that in future their decision as to whether they would prefer expectant
or surgical treatment is merely based on our medical advice, rather than a
need to get them straight off to hospital.
Christopher Everett
* Everett CB. Incidence and outcome after bleeding prior to the 20th
week of pregnancy; a prospective study from general practice; Br Med J
1997:315:32-34
Competing interests: No competing interests
I suggest before there is a major shift to expectant management of
non viable first trimester pregnancy that some of the outstanding research
questions be addressed first. The RCTs on expectant management have been
small and not properly powered to answer the majority of relevant
questions. Criteria for identifying low risk cases have not been
adequately formulated and long term morbidity studies have not been done.
The problems of gastrointestinal side effects of misoprostol can largely
be avoided by vaginal route of administration. I agree there is a need to
move away from a predominately surgical approach to management, but this
should be based on better research data than is currently available.
Competing interests: No competing interests
Ultrasound for informed decision in managing miscarriage
Editor - We read with interest the review paper by Ankum et al.1 In
their concluding remarks Ankum et al. propose the use of clinical rather
than ultrasound criteria to assess the necessity for surgical evacuation.
Additionally, the authors suggest that management should be based on
informed, shared decision making between the patient and health worker.
We carried exactly such a study, where women with early pregnancy
loss were allowed to choose between expectant and surgical management,
after a detailed discussion about the risks and alternative management.2
Five hundred and forty five women were offered surgical or expectant
management after an ultrasound diagnosis of an early pregnancy loss. We
demonstrated an overall success rate of 86% for expectant management,
where the success rate with incomplete miscarriage was 96% and in missed
miscarriage was 62%. Given that other studies have shown an even lower
success rate for expectant management of missed miscarriage (25%), we
believe that this ultrasound finding justifies the offer of medical
options or surgical evacuation.3
Additional findings in our study were, that women's choice of
treatment was influenced by their parity, such that a significantly higher
number of multiparous women opted for expectant management. Also those who
had clinical symptoms of miscarriage were more likely to choose expectant
management than those who had a missed miscarriage or were asymptomatic.
Previous experience of childbirth and the symptoms of the natural process
of miscarriage therefore seem to be influential in the decision making
process. We as clinicians, should understand the value of ultrasound
criteria in helping women make appropriate decisions and to deliver safe
and effective health care.
Manjiri Khare,
Specialist Registrar Obstetrics & Gynaecolgy
Farnborough hospital,
Farnborough Common,
Orpington,
Kent
BR6 8ND
E-mail: mdkhare@cwcom.net
Shanthi Sairam,
Clinical Fellow
Basky Thilaganathan,
Senior Lecturer/Director
Fetal Medicine Unit,
St George's Hospital NHS Trust,
Blackshaw Rd,
London SW17 0QT
1. Ankum W, Wieringa-de Waard M, Bindels PJE. Management of
spontaneous miscarriage in the first trimester: an example of putting
informed shared decision making into practice. BMJ 2001; 322: 1343-6.
2. Sairam S, Khare M, Michailidis G, Thilaganathan B. The role of
ultrasound in the expectant management of early pregnancy loss. Ultrasound
Obstet Gyneccol 2001; 17: 506-509.
3. Jurkovic D, Ross JA, Nicolaides KH. Expectant management of missed
miscarriage. Br J Obstet Gynaecol 1998 ; 105: 670-1.
Competing interests: No competing interests