Feasibility of guidelines for the management of threatened miscarriage in general practice/family medicine.

Objective: to determine the feasiblity in daily practice of guidelines on threatened miscarriage for general practice. The guidelines on threatened miscarriage were issued in 1989 by the Dutch College of General Practitioners. Methods: prospective recording of appointments by 86 general practitioners (GPs) in the Netherlands, who agreed to adhere to the threatened miscarriage guidelines. Interviews with the GPs after the recording period of 12 months. Adherence to each recommendation and reasons for non-adherence were measured. Results: 75 GPs actually recorded 251 patients. The GPs adhered to most recommendations in the guidelines except as regards carrying out physical examinations at both first appointment and follow-ups. Reasons for non-adherence with the physical examinations were mainly based on the GP's criticism of these recommendations. Scarcely anyone adhered to the recommmendation on follow-up appointments after ten days and a counselling consultation after six weeks. The GP's criticism of these recommendations, and the patient's wishes were mentioned as reasons for non-adherence. In 9% of the cases, the GP's policy was overridden either by the patient arranging an ultra-sound scan via a locum or a midwife, or by the obstetrician taking control after the GP had requested an ultrasound scan. Conclusions: in daily practice, care providers may encounter obstacles in adherence to guidelines. As for the threatened miscarriage guidelines, the GP's criticism of the guidelines was an important reason for non-adherence, followed by the situation of the specific patient (such as medical history) and the patient's wishes. Furthermore, poor collaboration between GP's, midwives and obstetricians was another obstacle in adherence. Those recommendations that are most often not adhered to should be reviewed. Furthermore, to reduce conflicts about ultrasound scans and referals, agreement on policy on threatened miscarriage should be established between GPs, midwives and obstetricians. (aut.ref.