Non-surgical management of first-trimester miscarriage

Due to better diagnostic facilities during the last 5 decades, the diagnosis of miscarriage has doubled and it is today the outcome of approximately 15 % of all registered pregnancies. Surgical evacuation has remained the cornerstone of the management of miscarriages in industrialised nations during the last 5 decades. At the beginning of the 1990s, evacuations for miscarriage accounted for more than 50% of ìout of office timeî surgical interventions in gynaecological practice in the industrialised world. Surgical evacuation is, however, associated with risks and sequelae and has lately been questioned as first-line treatment for miscarriages. Medical treatment with prostaglandin analogues and antiprogesterone has been proposed as an alternative for the treatment of incomplete miscarriages and missed abortions. However, none of these treatment strategies has been evaluated against expectancy and little is known about the natural course of first trimester miscarriage. The aim of the present studies was to evaluate non-surgical management of first trimester miscarriages. In a prospective randomised trial, we compared the clinical results and psychological outcome after surgical evacuation and expectancy in 155 patients with first trimester miscarriage. Seventy-nine per cent of the miscarriages resolved without intervention within three days of expectancy. Neither the clinical outcome nor psychological consequences differed between patients randomised to expectancy and surgical evacuation. Using a logistic model on clinical and biochemical characteristics, the probability of a complete miscarriage within 3 days of expectancy could be calculated. The logistic model identified 5 items with diagnostic power, namely the intrauterine diameter in the longitudinal view with transvaginal ultrasound, the daily change in serum of human chorionic gonadotrophin and the serum levels at inclusion of progesterone, alpha-fetoprotein and carcinoembryonal antigen.In another prospective randomised trial, we compared the clinical result after either expectant management or outpatient pharmacological treatment with a combination of 400 mg mifepristone and 400 (g misoprostol in 122 patients with first trimester miscarriage. Seventy-six per cent of the patients randomised to expectancy and 82% of the patients randomised to pharmacological treatment had a complete miscarriage within 5 days. The short-term clinical outcome was the same for both groups. The results do not support outpatient pharmacological treatment of first trimester miscarriages.With the advent of ultrasound, many miscarriages are today diagnosed as missed abortions. In a prospective trial, mifepristone 400 mg and misoprostol 400 (g were evaluated for outpatient pharmacological treatment in 31 patients with missed abortion. The result showed that only 51% of the patients had a complete miscarriage within 6 days.In conclusion, expectant management of first trimester incomplete or inevitable miscarriage is a safe procedure that reduces the need for surgery and hospitalisation. Furthermore, it was possible to calculate the probability of a complete miscarriage within 3 days of expectancy, and thus to identify women with first trimester miscarriage who were suitable for expectant management. Outpatient pharmacological treatment with mifepristone 400 mg and misoprostol 400 (g did not significantly decrease the need for surgery in first trimester miscarriages and was not effective enough to be recommended as treatment for missed abortions