Expectant Management Of Miscarriage

For many years there was a consensus that prevailed in the Western world concerning the approach to miscarriages and custom has dictated that inevitable and incomplete miscar riages must be completed, usually by curettage. Many physicians considered curettage mandatory to prove that a miscarriage is complete. Expectant management of first-trimester miscarriages had not been evaluated since Peckham stated in 1936 that women without profuse bleeding or signs of infection could avoid hospitalization.42 The justification for surgical evacuation as the correct management of first-trimester miscarriages was based on case reports and uncontrolled studies from a time when general health, parity, availability of health services, antibiotics and the incidence of criminal abortions differed greatly from now. The consensus has changed during the last decade and expectant management as well as different medical regimens for the conservative management of miscarriage have been evaluated.

In a randomized study between expectant management and surgical evacuation in 1995, of 103 women randomized to expectant management spontaneous resolution of the pregnancy products occurred within 3 days in 81 cases (79%). The remaining women underwent surgical evacuation.78

In another study 545 women with a diagnosis of early pregnancy failure were followed up; 298 with incomplete miscarriage and 247 with missed miscarriage or anembryonic pregnancies. A total of 305 of them opted for expectant management. The overall success rate was of 86%. The success rate for incomplete miscarriage (96%) was significantly better than that for missed miscarriage (62%).88 In 2002 Luise and co-workers presented a comparative study between expectant management and surgical evacuation. They found a resolution rate after 14 days of 84%; they also found that neither the presence of a gestational sac, nor the endome-trial thickness at diagnosis can be used to predict the likelihood of management failure.89 According to the data of Nielsen and Hahlin there is a significant correlation between levels of S-progesterone and hCG and the success rate of expectant management.90 In this study utilizing a stepwise logistic regression procedure, five diagnostic variables possessing prognostic power were identified: serum progesterone, daily serum hCG change, serum CA125, serum alpha fetoprotein and intrauterine diameter. The logistic regression analysis was also applied to three diagnostic variables chosen for routine clinical use: serum progesterone, serum hCG and intrauterine diameter. Using this algorithm, the probability of complete spontaneous miscarriage within 3 days of expectant management in each woman could be calculated. It was concluded that a logistic model to calculate the probability of complete spontaneous miscarriage within 3 days in women with first-trimester miscarriages is effective. Such information may be of clinical use in caring for women, as well as for the development of management guidelines for those with miscar-

riages.90

The complication rate, most commonly infection and haemorrhage, reported after surgical evacuation in cases of miscarriage and legal abortion varies between 4 and 13%.53,54,91,92 Infections after surgical evacuation are often easily treated but may lead to infertility, pelvic pain and an increased risk of future ectopic pregnancy.74,91 Dilatation of the cervical canal may interfere with the cervical protection against ascending infections, whilst curettage carries the risk of contaminating the uterine cavity.91 These risks of introducing an infection by surgical evacuation should be weighed against the possible hazards of leaving retained products of conception in the uterine cavity for long periods of time.

In a study by Nielsen and Hahlin only three infections were diagnosed among 103 women (3%) who underwent expectant management.78 In comparison, five infections and one case of postoperative anaemia were observed among 52 women (11%) randomized to surgical evacuation.78 In another study presented by the same group three infections were reported amongst 122 women primarily managed non-surgi-cally.86 Interestingly, infections in this study were only diagnosed among women who underwent surgery due to retained products of conception 5 days after inclusion.86 All women were followed up with serum samples and clinical examination 3 or 5 and 14 days after inclusion. It is possible that many infections which otherwise would have passed without intervention were discovered and treated because of the close follow-up in the study. On the other hand, 'sub-clinical' infections after a miscarriage may carry the risk of sequelae such as infertility and chronic pain.91 The mean time during which the women experienced vaginal bleeding was 1.3 days longer in the expectant management group compared to the group who underwent surgical evacuation.86 This is probably due to a quicker resolution of the retained products of conception for the women randomized to surgical evacuation.

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