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Sporadic Miscarriage: Evidence to Provide Effective Care

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Sporadic Miscarriage: Evidence to Provide Effective Care Series Miscarriage 2 Sporadic miscarriage: evidence to provide effective care Arri Coomarasamy, Ioannis D Gallos, Argyro Papadopoulou, Rima K Dhillon-Smith, Maya Al-Memar, Jane Brewin, Ole B Christiansen, Mary D Stephenson, Olufemi T Oladapo, Chandrika N Wijeyaratne, Rachel Small, Phillip R Bennett, Lesley Regan, Mariëtte Goddijn, Adam J Devall, Tom Bourne, Jan J Brosens, Siobhan Quenby Lancet 2021; 397: 1668–74 The physical and psychological effect of miscarriage is commonly underappreciated. The journey from diagnosis of Published Online miscarriage, through clinical management, to supportive aftercare can be challenging for women, their partners, and April 26, 2021 caregivers. Diagnostic challenges can lead to delayed or ineffective care and increased anxiety. Inaccurate diagnosis of https://doi.org/10.1016/ a miscarriage can result in the unintended termination of a wanted pregnancy. Uncertainty about the therapeutic S0140-6736(21)00683-8 effects of interventions can lead to suboptimal care, with variations across facilities and countries. For this Series See Editorial page 1597 paper, we have developed recommendations for practice from a literature review, appraisal of guidelines, and expert This is the second in a Series of three papers about miscarriage group discussions. The recommendations are grouped into three categories: (1) diagnosis of miscarriage, Tommy’s National Centre for (2) prevention of miscarriage in women with early pregnancy bleeding, and (3) management of miscarriage. We Miscarriage Research, Institute recommend that every country reports annual aggregate miscarriage data, similarly to the reporting of stillbirth. Early of Metabolism and Systems pregnancy services need to focus on providing an effective ultrasound service, as it is central to the diagnosis of Research, University of miscarriage, and be able to provide expectant management of miscarriage, medical management with mifepristone Birmingham, Birmingham, UK (Prof A Coomarasamy MD, and misoprostol, and surgical management with manual vacuum aspiration. Women with the dual risk factors of I D Gallos MD, early pregnancy bleeding and a history of previous miscarriage can be recommended vaginal micronised progesterone A Papadopoulou MBChB, to improve the prospects of livebirth. We urge health-care funders and providers to invest in early pregnancy care, R K Dhillon-Smith PhD, with specific focus on training for clinical nurse specialists and doctors to provide comprehensive miscarriage care A J Devall PhD); Tommy’s National Centre for Miscarriage within the setting of dedicated early pregnancy units. Research, Imperial College London, London, UK Introduction care might be provided by generalists or specialists, and (M Al-Memar PhD, There are uncertainties about the best approaches to be offered in emergency care departments or dedicated Prof P R Bennett PhD, Prof L Regan MD, diagnose a miscarriage, prevent a miscarriage in women early pregnancy units. Uncertainties exist about the Prof T Bourne PhD); Tommy’s with early pregnancy bleeding, provide care needed for optimal ways to organise and provide care. Charity, Laurence Pountney women with a confirmed miscarriage, and optimally To facilitate evidence-based care, we have developed Hill, London, UK (J Brewin BSc); organise and provide emergency miscarriage care. recommendations for practice from a literature review, Centre for Recurrent Pregnancy Loss of Western Pain and bleeding in early pregnancy are distressing appraisal of existing guidelines, and expert group Denmark, Department of to women. Those who have had these symptoms are discussions. The recommendations are grouped into Obstetrics and Gynaecology, anxious about the fate of their pregnancy and want to three categories: (1) diagnosis of miscarriage; (2) preven- Aalborg University Hospital, know the risk of a miscarriage at that moment, and the tion of miscarriage in women with early pregnancy Aalborg, Denmark (Prof O B Christiansen PhD); availability of any treatment that can be offered to reduce bleeding; and (3) clinical management of a confirmed University of Illinois Recurrent their risk. A miscarriage can also occur without any pain miscarriage. We conclude with a proposal for organising Pregnancy Loss Program, or bleeding. Such a loss, called a missed miscarriage, is and providing emergency miscarriage care and a call to Department of Obstetrics and diagnosed by ultrasonography.1 action for improved care and high-quality research in Gynecology, University of Illinois at Chicago, Chicago, IL, Health-care providers strive to avoid diagnostic errors specific areas. USA (Prof M D Stephenson MD); that could have serious consequences.2,3 A falsely positive UNDP/UNFPA/UNICEF/WHO/ diagnosis of miscarriage can result in the unintentional Diagnosis of miscarriage World Bank Special termination of a viable and wanted pregnancy. In 2012, The risk of miscarriage varies by the presenting clinical Programme of Research, Development and Research concerns about inaccuracies in miscarriage diagnosis symptoms and signs (appendix p 6). For example, the Training in Human resulted in urgent revisions to the UK National Institute presence of a small amount of bleeding in early Reproduction, Department of for Health and Care Excellence recommendations.4 In pregnancy is not associated with an increase in the risk Sexual and Reproductive an effort to tackle the diagnostic challenge, health-care of miscarriage, whereas heavy bleeding is associated Health and Research, WHO, Geneva, Switzerland providers often resort to arranging repeated visits and with a substantial risk of miscarriage (appendix p 6). (O T Oladapo MD); Department investigations for pregnant women. A clear diagnostic However, the presence of nausea and vomiting, which of Reproductive Medicine, pathway can help to reduce anxiety in women by reducing can be a marker of a healthy concentration of preg- University of Colombo, Colombo, Sri Lanka the period of uncertainty. It can also result in a more nancy hormones, is associated with a low risk of (Prof C N Wijeyaratne MD); effective and cost-efficient early pregnancy service. miscarriage (9·7%; appendix p 6). The probability of Birmingham Heartlands There are uncertainties about the most effective and miscarriage with particular ultrasound features is so Hospital, University Hospitals safe methods for managing a miscarriage. Each method high that these findings can be considered to have Birmingham NHS Foundation Trust, Birmingham, UK carries the potential for complications, such as unplanned sufficient accuracy to justify management as miscarriage surgery or blood transfusion. Emergency miscarriage (appendix p 6). Serum progesterone concentrations can 1668 www.thelancet.com Vol 397 May 1, 2021 Descargado para BINASSS Circulaci ([email protected]) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en mayo 06, 2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados. Series Search strategy and selection criteria Key messages The recommendations are based on a review of the current • Miscarriage diagnosis: accurate diagnosis of miscarriage relies on high-quality literature, appraisal of professional body guidelines, and ultrasound scanning and use of validated diagnostic algorithms; an empty gestation expert group discussions. For the literature reviews, sac with a mean sac diameter of 25 mm or more, or an embryo with a crown-rump we searched the Cochrane Database of Systematic Reviews length of 7 mm or more with no visible heart activity on transvaginal ultrasonography, and MEDLINE (from inception until Jan 9, 2020) for is considered to have sufficient accuracy for the diagnosis of miscarriage to justify systematic reviews specifying or reporting any miscarriage management as miscarriage outcome. Any review published before January, 2019, • Prevention of miscarriage in women with early pregnancy bleeding: there is was updated with a targeted literature search. Six reviews high-quality evidence that vaginal micronised progesterone increases livebirth rates in focused on the prevention of miscarriage in women with women with early pregnancy bleeding and a history of miscarriage; there is a bleeding and 12 on the management of miscarriage. 5% absolute rate increase in livebirths with progesterone, when compared with We reported results for miscarriage and livebirth separately. placebo, in women with bleeding and one or more previous miscarriages, and a For the review of professional body guidelines, we reviewed 15% absolute rate increase in livebirths in women with bleeding and three or more the latest international guidance on the diagnosis, previous miscarriages prevention, and management of miscarriage, including the • Miscarriage management: surgical management with vacuum suction aspiration after 2019 National Institute for Health and Care Excellence cervical preparation is ranked first among six competing strategies for completing a guideline on the management of ectopic pregnancy and missed miscarriage; among medical management strategies, a combination of miscarriage, the European Society of Human Reproduction mifepristone and misoprostol is more effective than misoprostol alone in completing a and Embryology guideline on the management of recurrent missed miscarriage; expectant management is an effective approach for women with pregnancy loss, and the American College of Obstetricians incomplete miscarriage; women
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