Conservative management of spontaneous miscarriage

Abstract

Surgical evacuation of retained products of conception has for many years remained the standard management of spontaneous miscarriage. It is estimated that 80 000 evacuations are performed each year in the United Kingdom for women with early miscarriages (missed abortion and incomplete miscarriages). During the past decade preliminary reports of alternative non-surgical options demonstrated the safety of these options in relation to surgical uterine evacuation. There is still, however, some reluctance among clinicians in offering these alternative options to women. The work in this thesis is mainly focused on the role of conservative management of women with retained products of conception following a spontaneous miscarriage in the first trimester in comparison to the 'gold standard' surgical evacuation of the uterine cavity under general anaesthesia.An extensive review of the literature relevant to the management of these clinical conditions was carried out in the first chapter. It was very clear following the literature review that the lack of randomised trials of appropriate size, power and design has resulted in reluctance from the clinicians' side in adopting these options into routine daily practice.The second chapter in this thesis presents the results of a large randomised trial comparing the safety and efficacy of an expectant approach against those of surgical intervention using suction evacuation under general anaesthetic. This chapter has iv confirmed the safety and the relative effectiveness of conservative management when compared to surgical evacuation.A self-administered questionnaire based study was conducted to investigate the impact of seeing and handling the products of conception on the incidence of psychological adverse reactions in women managed conservatively as compared to the control group (women managed by surgical uterine evacuation). Women managed conservatively seemed to recover psychologically quicker than women managed by surgical evacuation.The impact of conservative management on the reproductive potential of women with retained products of conception was assessed in the fourth chapter. The first part of the fourth chapter studied the return of ovulation in a subgroup of women (n = 30) randomised to conservative management as compared to women (n = 30) randomised to surgical evacuation. The return of normal ovulation was examined by assessing the daily urinary excretion of luteinizing hormone (LH), pregnanediol (P₄) and total urinary oestrogen (E₂), follicular and endometrial development using transvaginal ultrasound. The second part of this chapter concentrated on following up women who desired to become pregnant from the two management groups. Conservative management had similar outcomes to surgical evacuation in relation to the reproductive performance.Finally, a systematic assessment of the cost-effectiveness of conservative management was carried out in comparison with surgical evacuation in the last chapter of the thesis, which revealed a potential for substantial cost savings in NHS resources with the widespread use of conservative management.