Medical management of miscarriage

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Hughes and co-workers, who compared women treated medically and surgically, observed 7.1% infections in women managed medically compared to 13.2% in women managed surgically (P <0.001, %2).93 These studies may suggest that surgical evacuation of the uterine cavity in early pregnancy carries an increased risk of PID compared to non-surgical management.

Medical treatment for miscarriage with prostaglandins alone or in combination with the antiprogesterone mifepristone has been explored. There are a few randomized studies comparing expectant with medical management, the success rate varies probably due to different doses and inclusion criteria.86,94-96 It seems, however, that medical treatment is slightly more effective than expectant management alone. Treatment with misoprostol is potentially dangerous to a normal ongoing pregnancy, due to its abortifacient effect and teratogenicity. Careful assessment with an exact diagnosis is mandatory before treatment with misoprostol. This is not always available at an emergency room. In addition it seems that medical treatment is accompanied with more pain than expectant management. It would therefore seem reasonable to propose a strategy whereby misoprostol could be used as second line treatment after an initial attempt to manage things expectantly for at least a week.95 In this way intervention may be avoided in the majority of women where the miscarriage will resolve spontaneously.86,95,96 One should also bear in mind that most women with retained products of conception will probably chose expectant

Serum progesterone nmol/L

Figure 5.2 Relationship between sac volume and serum progesterone.

management. Furthermore, ultrasonography can be used to advise women on the likelihood that their miscarriage will complete spontaneously within a given time. Fifty-two per cent of incomplete miscarriages will resolve spontaneously by day 7 of management and 84% by day 14. Furthermore, the corresponding values for missed miscarriages and anembryonic pregnancies are 28% by day 7 and 56% by day 14.89 This means that most women who miscarry in the first trimester and choose expectant management will complete their miscarriage without intervention.

Ultrasonography provides a useful assessment of whether a miscarriage will complete without intervention within a given time. The first randomized study exploring expectant management for miscarriage78 excluded women with an antero-posterior diameter of retained products of conception in uterus of >50 mm and all studies since then have used similar cut-off values on the assumption that larger amounts of retained products of conception will be followed by more bleeding and pain. The relationship between volume and serum progesterone and diameter and the outcome of expectant management of 103 women managed expectantly is illustrated in Figure 5.2. Blue dots represent women who miscarried without intervention within three days of expectant management. Diameters in the antero-posterior view of retained products in uterus bellow 15 mm have been considered as being consistent with a complete miscarriage. This is also supported by an analysis of 118 women followed up after a complete miscarriage (diameter <15 mm) where none were admitted for surgical intervention after the first visit.98 As discussed in other chapters, the ultrasound findings are not sufficient to confirm a complete miscarriage, and serial hCG levels are needed to exclude an ectopic pregnancy in these women.

Available data show that expectant management for the majority of women with firsttrimester miscarriage is a safe procedure. Furthermore, available data today suggest that the complication rate, fertility,99 and the emotional and psychological short-term compli-cations100,101 do not differ significantly between different treatment modalities for miscarriage.

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