Diagnosis and management of first trimester miscarriage

Jurkovic and colleagues present a clinical review on the diagnosis and management of first trimester miscarriage [1]. Making diagnoses is one of the major components of clinical decision making; however making diagnoses is susceptible to cognitive bias [2]. Critical to clinical decision making is keeping in mind alternative possibilities (differential diagnoses) which helps reduce making diagnostic and subsequently treatment errors, which can be catastrophic.

Clinical reviews of an entity should therefore routinely provide a list of key differential diagnoses to encourage clinicians not to lose sight of the bigger picture so as to minimize clinical errors. For example, here is an illustrative but not exhaustive list of entities that could present as a first trimester miscarriage [3,4]:

Ectopic pregnancy/Heterotopic pregnancy
Gestational trophoblastic disease
Cervix or vagina (infection, polyp, trauma, malignancy)
Uterus - fibroid
Ovarian cyst accident (torsion, rupture, hemorrhage)
Pelvic inflammatory disease
Implantation bleeding
Urinary tract – Cystitis
Gastrointestinal tract – Appendicitis
Hematologic - von Willebrand disease

References
1. Jurkovic D, Overton C, Bender-Atik R. Diagnosis and management of first trimester miscarriage. BMJ. 2013; 346:f3676.
2. Croskerry P. From Mindless to Mindful Practice — Cognitive Bias and Clinical Decision Making. N Engl J Med. 2013; 368(26):2445-8.
3. Deutchman M, Tubay AT, Turok D. First trimester bleeding. Am Fam Physician. 2009; 79(11):985-94.
4. Sebire NJ. The diagnosis of gestational trophoblastic disease in early pregnancy: implications for screening, counseling and management. Ultrasound Obstet Gynecol. 2005; 25(5):421-4.