The impact of introducing medical management on conservative and surgical management for early pregnancy miscarriage.

BACKGROUND: Medical management of miscarriage allows women to avoid the risks associated with surgical intervention. In 2011 the early pregnancy assessment service (EPAS) at the Royal Prince Alfred Hospital (RPAH) in Sydney, Australia introduced medical management of miscarriage with single-dose 800 µg vaginal misoprostol. AIMS: We sought to investigate the impact of the introduction of medical management had on the proportion of women having surgery and conservative management and to examine the success and complication rates of medical management. MATERIALS AND METHODS: We undertook a retrospective cohort study that included all women diagnosed with a miscarriage from 12 months prior to and 18 months after the introduction of medical management. Successful management was defined as the absence of retained products of conception or endometrial thickness less than 15 mm on ultrasound at two weeks. The change in management choices over time, the success rates and complication rates were measured. RESULTS: Of 1102 women in the final analysis, 446 were in Group A (before medical management) and 656 in Group B (after medical management). Primary surgical procedures fell significantly for missed miscarriages from 68 to 48% (P < 0.001) and primary conservative management reduced for incomplete miscarriages (63-44%; P = 0.01). Overall 89 of 108 (82.4%) patients managed medically had a resolution within two weeks. One in ten presented with a complication. DISCUSSION: The introduction of medical management led to a statistically significant reduction in the proportion of women undergoing primary surgical management of missed miscarriage. Success and complication rates were similar to other studies.

Curettage after medical induced abortions in second trimester.

We evaluated the use of curettage in second trimester medical induced abortions retrospectively in 186 women at Herning Hospital, Denmark. Curettage was carried out in a total of 55% of the women. The incidence of curettage was associated with low gestational age (r = 0.32, p < 0.001) but not with age, parity, and BMI. The average incidence of curettage dropped from 62% to 25% at the time before 2007 compared with the time after 2007 (p < 0.001). The indications for abortion were not associated with subsequent use of curettage.

Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis.

OBJECTIVE: To quantify the relative benefits and harms of different management options for first-trimester miscarriage. DATA SOURCES: MEDLINE, EMBASE, and Cochrane Controlled Trials Register searches (1966 to July 2004), including references of retrieved articles. METHODS OF STUDY SELECTION: Randomized trials assigning women with first-trimester missed or incomplete miscarriage to surgical, medical, or expectant management were included. Primary outcomes were successful treatment and patient satisfaction. Secondary outcomes included moderate or severe bleeding, blood transfusion, emergency curettage, pelvic inflammatory disease, nausea, vomiting, and diarrhea. Comparisons used the risk difference. Between-study heterogeneity and random effects summary estimates were calculated. TABULATION, INTEGRATION, AND RESULTS: Complete evacuation of the uterus was significantly more common with surgical than medical management (risk difference 32.8%, number needed to treat 3, success rate of medical management 62%) and with medical than expectant management (risk difference 49.7%, number needed to treat 2). Success rate with expectant management was spuriously low (39%) in the latter comparison. Analysis of cases with incomplete miscarriage only showed that medical management still had two thirds the chance to induce complete evacuation compared with surgical management, but it was better than expectant management. Data from studies that evaluated outcome at 48 hours or more after allocation indicated again that medical management had a better success rate than expectant management but a worse success rate than surgical management; expectant management probably had much lower success rates than surgical evacuation, but data were very sparse. Patient satisfaction data were sparse. Moderate or severe bleeding was less common with medical than expectant management (risk difference 3.2%) and possibly surgical management (risk difference 2.1%). There was a considerable amount of missing information, in particular for secondary outcomes. CONCLUSION: One additional success can be achieved among 3 women treated surgically rather than medically. Expectant management has had remarkably variable success rates across these studies, depending probably on the type of miscarriage. Greater standardization of outcomes should be a goal of future research.

Abordaje del sangrado uterino anormal en el Hospital "Bertha Calderón Roque" junio- diciembre 2002 / Boarding of the bled uterine abnormal in the Hospital Bertha Calderon june-december 2002

Objetivo: conocer el abordaje diagnóstico y terapéutico del sangrado uterino anormal. Material y método: Se hizo un estudio de corte transversal, de junio a diciembre de 2002. La población de estudio fueron 102 pacientes con sangrado uterino anormal. Resultados: el 57 porciento de las pacientes eran perimenopáusicas. El 25 porciento recibió terapia hormonal previa. En el 61 porciento, el criterio de ingreso fue la duración del sangrado. Los trastornos hemodinámicos se presentaron en el 13 porciento y la anemia severa en el 20 porciento. La ecografía pélvica se hizó en el 69 porciento y el legrado uterino en el 96 porciento. La miomatosis uterina se detectó por ecografía en el 38 porciento. El 62 porciento de las perimenopáusicas tenían miomatosis uterina. El 59 porciento de los hallazgos histopalógicos fueron la alteraciones estructurales endometriales por trastorno hormonal. El 95 porciento tuvo enfermedades ginecológicas asociadas, siendo la miomatosis uterina y las alteraciones estructurales endometriales, las más comunes. El adenocarcinoma se detectó sólo en tres pacientes. El tratamiento prescrito al egreso más frecuentemente fueron analgésicos- antinflamatorios no esteroides..

Gestational trophoblastic disease: a study of mode of evacuation and subsequent need for treatment with chemotherapy.

OBJECTIVES: The aim of this study was to assess whether there was a change in the mode of evacuation of GTD over two time periods and to assess whether mode of evacuation influenced the subsequent need for chemotherapy. METHODS: A retrospective case note study of 4257 cases between 1986 and 1996, at a screening and treatment center managing GTD, was performed. RESULTS: Between the time periods 1986-1989 and 1990-1996 there was significant change in the mode of evacuation to suction curettage. The mode of evacuation was significant in determining the need for chemotherapy. The highest rate of chemotherapy was associated with medical methods of evacuation. CONCLUSIONS: Suction curettage is a safe method of uterine evacuation in GTD and its usage has increased with time. Medical methods of uterine evacuation are associated with higher rates of chemotherapy. This is probably due to a higher rate of incomplete evacuation. Medical methods of evacuation should not be used in cases of complete hydatiform mole.

Diagnostic dilatation and curettage: is it used appropriately?

OBJECTIVE: To determine patterns of use of dilatation and curettage in Britain as compared with those in the United States; to examine variations in utilisation rates within one regional health authority. DESIGN: Analysis of routinely collected hospital inpatient statistics. SETTING: Statistics for England, Scotland, and the United States; local statistics for Oxford region. SUBJECTS: All inpatient episodes in which dilatation and curettage was performed but excluding those related to pregnancy. RESULTS: Dilatation and curettage rates remained stable in Britain between 1977 and 1990, whereas in the United States they declined dramatically. In 1989-90 the rate was 71.1 per 10,000 women in England as compared with only 10.8 per 10,000 in America. In 1989, 6936 women underwent diagnostic dilatation and curettage in the Oxford region, making it the most common elective operation. A total of 2726 (39%) of these women were under 40. There was a more than twofold variation in usage of the procedure among district health authorities within the region and even greater variation in rates in women under 40. The proportion of patients treated as day cases in the district general hospitals ranged from 22% to 82%. CONCLUSIONS: Dilatation and curettage may frequently be used inappropriately. The considerable variations in usage of dilatation and curettage internationally and nationally indicate differences in clinical perception of its appropriateness. This makes it suitable for audit. In developing guidelines it will be important to agree on the most appropriate patients and the relative merits of alternative methods of endometrial sampling. Probably this could result in considerable cost savings at no risk and possibly some benefit to patients.

Trends in uterine curettage among women under 30 with abnormal uterine bleeding at Ramathibodi Hospital.

This study represents the follow-up on number and trends of uterine curettage in women aged under 30 with menstrual disturbances in this institution. The total number of patients under 30 seen at the gynecological outpatient service with AUB decreased over the year studied, from January 1, 1987 to December 31, 1990. The trends in uterine curettage among this group of patients have also decreased, 125 (16.6%) cases in 1987, 101 (17.2%) cases in 1988, 75 (14.2%) cases in 1989 and 72 (14.1%) cases in 1990. The majority of patients had no significant pathology on the curetting tissues. Endometrial hyperplasia was found in 8 cases (4.6%). There was no case of endometrial carcinoma.

Current dilatation and curettage practice: a need for revision.

A ten-year retrospective review of 1383 diagnostic dilatation and curettages (D&C) was done at a university hospital. It was found that the detection or diagnosis of uterine cancer did not significantly increase until after the age of 50. No significant pathologic findings were detected in 60% or more of the women until the age of 70. Premalignant or other than benign tissue was observed to increase from 4% in the age 29 or less group to a peak of 16% in the age 45 to 49 group. The authors conclude that the current practice of routine D&C for abnormal uterine bleeding provides a low yield of cancer diagnoses, and that the indications for this procedure should be sharply reduced or replaced by simpler methods.