Management of spontaneous miscarriage in the first trimester: an example of putting informed shared decision making into practice

Editorial by Cahill

In many parts of the Western world there is a strong preference among gynaecologists to rely on surgical evacuation for the management of miscarriages in the first trimester. Why so many specialists have adopted surgery as the standard procedure seems determined by custom and habit and rooted in history rather than being an evidence based choice. During the first half of the 20th century the high rate of infections from retained products of conception with ensuing mortality from septicaemia—often complications from criminal attempts to terminate a pregnancy—resulted in the policy of immediate surgical evacuation whenever a diagnosis of inevitable abortion was made.1 Today these complications are rare, and their role in the justification of a universal tendency to perform surgery has therefore expired.2

Expectant management finds its main protagonists in general practice, where the process of spontaneous miscarriage is acknowledged more readily as being a well regulated natural process in human reproduction.

Relatively new is the medical approach to spontaneous miscarriages.3 The combination of the antiprogestogen mifepristone and the prostaglandin analogue misoprostol is being used successfully for the termination of pregnancies on a large scale. The use of these substances has also been tried in the management of spontaneous miscarriage.

Doctors and patients are confronted with a situation where opinions about the proper management of spontaneous miscarriage differ widely. That the available options are so diverse makes it even more complex. This paper aims to increase the awareness of various management options and explores the available evidence.