54 Explore management options other than expectant management if:
the woman is at increased risk of haemorrhage (for example, she is in the late first trimester), or
she has previous adverse and/or traumatic experience associated with pregnancy such as previous miscarriage or antepartum haemorrhage, or she is at increased risk from the effects of haemorrhage.
55 If the resolution of bleeding and pain indicate that the miscarriage has completed during 7–14 days of expectant management, advise the woman to take a urine pregnancy test after 3 weeks, and to return if it is positive for individualised management.
56 Offer a repeat scan if after the period of expectant management the bleeding and pain:
have not started (suggesting that the process of miscarriage has not begun) or
are persisting and/or increasing (suggesting incomplete miscarriage). Discuss all treatment options with the woman to allow her to make an informed choice.
57 Review the condition of a woman who opts for continued expectant management at a minimum of 14 days after the first follow-up appointment.
1
2
Number
Research recommendation
RR 6 In women with confirmed miscarriage, does the type of intervention (expectant, medical and surgical) impact on women’s experience, including psychological and emotional outcomes?
Why this is important
The management of miscarriage in the UK has changed in many ways over the past two decades, particularly in the shift from inpatient to outpatient or day case care and the introduction of medical and expectant management as alternatives to surgery.
Despite these changes there is a lack of research into the effects of these different approaches from the patient’s perspective, in particular their psychological and emotional impact. Miscarriage is distressing for most women, and the type of management itself might affect women’s need for counselling, with a resulting cost to the NHS. Because of this it is an important area for research.
The deficiency in the literature could be addressed by a comparative study of women having the different treatments (expectant, medical or surgical) and in a variety of clinical settings (for example, early pregnancy assessment unit, gynaecological ward, or gynaecological emergency unit). The data collected could be both quantitative (using validated psychological health questionnaires) and qualitative (focusing particularly on women’s experience of the particular type and setting of care).
7.5
Misoprostol
and
mifepristone
for
managing
1
miscarriage
2
Review question
3
What is the most appropriate dose of misoprostol and mifepristone to provide for managing
4
miscarriage?
5
Introduction
6
Medical management of miscarriage has been offered to women suffering miscarriage for a number
7
of years with varying doses, timing and routes of administration of drugs being used. The reviews
8
carried out for the purposes of this guideline aimed to ascertain the most appropriate and efficacious
9
dose. The GDG considered the data for two groups of women: those having a missed miscarriage
10
and those having an incomplete miscarriage, as some of the clinicians on the GDG reported a
11
difference in treatment outcomes for these groups of women.
12
Description of included studies
13
Twenty one studies were included in this review (Ayudhaya et al., 2006; Bagratee et al., 2004;
14
Blanchard et al., 2004; Blohm et al., 2005; Creinin et al., 1997; Kovavisarach & Jamnansiri, 2005;
15
Kovavisarach & Sathapanachai, 2002; Kushwah & Singh, 2009; Lelaidier et al., 1993; Lister et al.,
16
2005; Ngoc et al., 2004; Ngoc et al., 2005; Pang et al., 2001; Paritakul & Phupong, 2011; Rita et al.,
17
2006; Shah et al., 2010; Stockheim et al., 2006; Tang et al., 2003; Tang et al., 2006; Tanha et al.,
18
2010; Wood & Brain, 2002).
19
All of the included studies were randomised controlled trials, and were conducted in the UK (Bagratee
20
et al., 2004), USA (Creinin et al., 1997; Lister et al., 2005), Canada (Wood & Brain, 2002), France
21
(Lelaidier et al., 1993), Sweden (Blohm et al., 2005), Israel (Stockheim et al., 2006), Hong Kong
22
(Pang et al., 2001; Tang et al., 2003; Tang et al., 2006), Thailand (Ayudhaya et al., 2006;
23
Kovavisarach & Jamnansiri, 2005; Kovavisarach & Sathapanachai, 2002; Paritakul & Phupong,
24
2011), Vietnam (Blanchard et al., 2004; Ngoc et al., 2004; Ngoc et al., 2005), India (Kushwah &
25
Singh, 2009; Rita et al., 2006), Pakistan (Shah et al., 2010), and Iran (Tanha et al., 2010).
26
The GDG decided that, for this review question, studies should only be included if they treated women
27
with incomplete miscarriages and women with missed miscarriages as separate populations. Four
28
studies only included women with incomplete miscarriages (Blanchard et al., 2004; Ngoc et al., 2005;
29
Pang et al., 2001; Paritakul & Phupong, 2011), and two studies included women with both incomplete
30
miscarriages and missed miscarriage, but reported at least one outcome separately for the two
31
populations (Bagatree et al., 2004; Blohm et al., 2005). The remainder of the studies only included
32
women with missed miscarriage.
33
All of the included studies evaluated the use of misoprostol (Ms) and/or mifepristone (Mf) for the
34
management of first trimester miscarriage. One study compared the efficacy of misoprostol alone to a
35
combined regimen of mifepristone and misoprostol (Stockheim et al., 2006). Four studies compared
36
different dosages of misoprostol using the same route of administration, of which one evaluated
37
vaginal misoprostol (Kovavisarach & Jamnansiri, 2005), one evaluated sublingual misoprostol (Tang
38
et al., 2006), and two evaluated oral misoprostol (Blanchard et al., 2004; Ngoc et al., 2005). Nine
39
studies compared misoprostol administered via different routes, of which three compared oral and
40
sublingual administration (Ayudhaya et al., 2006; Kushwah & Singh, 2009; Paritakul & Phupong,
41
2011), three compared sublingual and vaginal administration (Shah et al., 2010; Tang et al., 2003;
42
Tanha et al., 2010), and four compared oral and vaginal administration (Creinin et al., 1997; Ngoc et
43
al., 2004; Pang et al., 2001; Rita et al., 2006). Six trials were placebo controlled, of which five
44
evaluated misoprostol (Bagratee et al., 2004; Blohm et al., 2005; Kovavisarach & Sathapanachai,
45
2002; Lister et al., 2005; Wood & Brain, 2002), and one evaluated mifepristone (Lelaidier et al., 1993).
46
Evidence profile
47
The treatment regimens described in the GRADE tables and evidence statements detail the maximum
48
number of doses that women could receive; some women did not receive repeat doses if expulsion