Cybermedlife - Therapeutic Actions Expectant Management (Birth/Miscarriage)

Expectant management of spontaneous first-trimester miscarriage: prospective validation of the '2-week rule'. 📎

Abstract Title: Expectant management of spontaneous first-trimester miscarriage: prospective validation of the '2-week rule'. Abstract Source: Ultrasound Obstet Gynecol. 2010 Feb;35(2):223-7. PMID: 20049981 Abstract Author(s): I Casikar, T Bignardi, J Riemke, D Alhamdan, G Condous Article Affiliation: Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Centre for Perinatal Care, Nepean Clinical School, University of Sydney, Nepean Hospital, Penrith, Sydney, Australia. i This email address is being protected from spambots. You need JavaScript enabled to view it. Abstract: OBJECTIVES: To assess uptake and success of expectant management of first-trimester miscarriage for a finite 14-day period, in order to evaluate our '2-week rule' of management. METHODS: This was a prospective observational study evaluating our proposed 2-week rule of expectant management, which is based on the finding that women managed expectantly are most likely to miscarry in the first 14 days and that to wait longer than 2 weeks without intervention does not confer a greater chance of successful resolution. Eligible women diagnosed with first-trimester miscarriage were offered a choice of expectant management or surgical evacuation under general anesthesia. Inclusion criteria for expectant management were: diagnosis of incomplete miscarriage (heterogeneous tissue, with or without a gestational sac, seen on ultrasound in the uterine cavity and distorting the endometrial midline echo), missed miscarriage (crown-rump length (CRL)>or= 6 mm with absent fetal heart activity) or empty sac (anembryonic pregnancy) based on transvaginal ultrasonography. Women with complete miscarriage, missed miscarriage at the nuchal translucency scan, molar pregnancy or miscarriage>or= 3 weeks in duration (missed miscarriage in which the CRL was>or= 3 weeks smaller than the gestational age based on last menstrual period), or with signs of infection or hemodynamic instability were excluded. Expectant management consisted of weekly ultrasonography for 2 weeks. If after 2 weeks resolution was not complete, surgery was advised. RESULTS: 1062 consecutive pregnant women underwent transvaginal ultrasound examination. Of these, 38.6% (410/1062) were diagnosed with miscarriage, of whom 241 (59%) were symptomatic at the time of presentation and 282 were eligible for the study. These were offered expectant management and 80% (227/282) took up this option. 11% (24/227) were lost to follow-up; therefore, complete data were available on 203 women. Overall spontaneous resolution of miscarriage at 2 weeks was observed in 61% (124/203) of women. Rates of spontaneous resolution at 2 weeks according to the type of miscarriage were 71% for incomplete miscarriage, 53% for empty sac and 35% for missed miscarriage. The incidence of unplanned emergency dilatation and curettage due to gynecological infection or hemorrhage was 2.5% (5/203). CONCLUSIONS: Expectant management based on the 2-week rule is a viable and safe option for women with first-trimester miscarriage. Women with an incomplete miscarriage are apparently the most suitable for expectant management. Article Published Date : Feb 01, 2010

Outcome of expectant management of spontaneous first trimester miscarriage: observational study. 📎

Abstract Title: Outcome of expectant management of spontaneous first trimester miscarriage: observational study. Abstract Source: Int J Cancer. 2009 Nov 15;125(10):2465-73. PMID: 11950733 Abstract Author(s): Ciro Luise, Karen Jermy, Caroline May, Gillian Costello, William P Collins, Thomas H Bourne Article Affiliation: Early Pregnancy, Gynaecological Ultrasound and Minimal Access Surgery Unit, St George's Hospital, London SW17 0RE. Abstract: OBJECTIVES: To evaluate the uptake and outcome of expectant management of spontaneous first trimester miscarriage in an early pregnancy assessment unit. PARTICIPANTS: 1096 consecutive patients with a diagnosis of spontaneous first trimester miscarriage. METHODS: Each miscarriage was classified as complete, incomplete, missed, or anembryonic on the basis of ultrasonography. Women who needed treatment were given the choice of expectant management or surgical evacuation of retained products of conception under general anaesthesia. Women undergoing expectant management were checked a few days after transvaginal bleeding had stopped, or they were monitored at weekly intervals for four weeks. MAIN OUTCOME MEASURES: A complete miscarriage (absence of transvaginal bleeding and endometrial thickness<15 mm), the number of women completing their miscarriage within each week of management, and complications (excessive pain or transvaginal bleeding necessitating hospital admission or clinical evidence of infection). RESULTS: Two patients with molar pregnancies were excluded, and 37% of the remainder (408/1094) were classified as having had a complete miscarriage. 70% (478/686) of women with retained products of conception chose expectant management; of these, 27 (6%) were lost to follow up. A successful outcome without surgical intervention was seen in 81% of cases (367/451). The rate of spontaneous completion was 91% (201/221) for those cases classified as incomplete miscarriage, 76% (105/138) for missed miscarriage, and 66% (61/92) for anembryonic pregnancy. 70% of women completed their miscarriage within 14 days of classification (84% for incomplete miscarriage and 52% for missed miscarriage and anembryonic pregnancy). CONCLUSIONS: Most women with retained products of conception chose expectant management. Ultrasonography can be used to advise patients on the likelihood that their miscarriage will complete spontaneously within a given time. Article Published Date : Nov 15, 2009

Expectant management of first-trimester miscarriage.

Abstract Title: Expectant management of first-trimester miscarriage. Abstract Source: J Obstet Gynaecol. 2009 Nov;29(8):681-5. PMID: 19821656 Abstract Author(s): M M El-Sayed, S A Mohamed, M H Jones Article Affiliation: Department of Obstetrics and Gynaecology, Darent Valley Hospital, Dartford, UK. This email address is being protected from spambots. You need JavaScript enabled to view it. Abstract: Miscarriage is the most common complication of pregnancy, which creates a significant workload for health-care professionals. For decades, surgical evacuation of the uterus has remained the conventional treatment of first-trimester miscarriage. Recently, non surgical treatments have been introduced with increasing popularity. This review explores the evidence in support of expectant management of first-trimester miscarriage. It is safe, effective and well-tolerated by women. It enhances women's choice and control. It generates significant cost savings compared with the traditional surgical management. Accurate diagnosis, counselling, 24/7 telephone advice and follow-up are among the important aspects of expectant management. More studies are needed to develop methods for identifying miscarriages suitable for expectant management. Article Published Date : Nov 01, 2009

Expectant management of incomplete abortion in the first trimester.

Abstract Title: Expectant management of incomplete abortion in the first trimester. Abstract Source: Int J Gynaecol Obstet. 2009 Jul;106(1):35-8. Epub 2009 Mar 28. PMID: 19329115 Abstract Author(s): Joana R Pauleta, Nuno Clode, Luís M Graça Article Affiliation: Department of Obstetrics, Gynecology and Reproductive Medicine, Santa Maria University Hospital, Lisbon, Portugal. This email address is being protected from spambots. You need JavaScript enabled to view it. Abstract: OBJECTIVE: To evaluate the effectiveness and acceptability of expectant management of induced and spontaneous first trimester incomplete abortion. METHODS: A prospective observational trial, conducted between June 2006 and November 2007, of 2 groups of patients diagnosed with an incomplete abortion: 66 patients who had received misoprostol for an induced abortion (group 1) and 30 patients who had had a spontaneous abortion (group 2). Transvaginal ultrasound was performed weekly. The success rate (complete abortion without surgery), time to resolution, duration of bleeding and pelvic pain, rate of infection, number of unscheduled hospital visits, and level of satisfaction with expectant management were recorded. RESULTS: The incidence of complete abortion was 86.4% and 82.1% in groups 1 and 2 respectively at day 14 after diagnosis, and 100% in both groups at day 30 (two group 2 patients underwent curettage and were excluded from the analysis). Both groups reported 100% satisfaction with expectant management, although over 90% of the women reported feeling anxious. CONCLUSION: Expectant management for incomplete abortion in the first trimester after use of misoprostol or after spontaneous abortion may be practical and feasible, although it may increase anxiety associated with the impending abortion. Article Published Date : Jul 01, 2009

Expectant management of miscarriage--prediction of outcome using ultrasound and novel biochemical markers. 📎

Abstract Title: Expectant management of miscarriage--prediction of outcome using ultrasound and novel biochemical markers. Abstract Source: Hum Reprod. 2005 Aug;20(8):2330-3. Epub 2005 Apr 28. PMID: 15860494 Abstract Author(s): J Elson, A Tailor, R Salim, K Hillaby, T Dew, D Jurkovic Article Affiliation: Early Pregnancy and Gynaecology Assessment Unit, Department of Obstetrics and Gynaecology, King's College Hospital, London, UK. Abstract: BACKGROUND: The aim of this study was to examine the value of various ultrasound and biochemical parameters for the prediction of successful expectant management of miscarriage. METHODS: This was a prospective observational study. Clinically stable women with an ultrasound diagnosis of miscarriage were offered expectant management. In all cases, gestational age, size of retained products of conception, serum HCG, progesterone, 17-hydroxyprogesterone, insulin growth factor-binding protein 1 (IGFBP-1), inhibin A and inhibin pro alpha-C RI levels were recorded. Follow-up continued until resolution of the pregnancy. Clinical data, ultrasound findings and biochemical markers were analysed using univariate analysis and decision tree analysis. RESULTS: Fifty-four women underwent expectant management of miscarriage. Thirty-seven (69%) had successful expectant management and 17 (31%) required surgery. The size of retained products, serum HCG, progesterone, inhibin A and inhibin pro alpha-C RI were all significantly different in those pregnancies that resolved spontaneously (P<0.05). Serum inhibin A was the best predictor of a complete miscarriage. CONCLUSION: This study shows that novel biochemical markers may be used to predict the likelihood of successful expectant management of miscarriage. Article Published Date : Aug 01, 2005

Expectant management of first-trimester miscarriage in clinical practice.

Abstract Title: Expectant management of first-trimester miscarriage in clinical practice. Abstract Source: Acta Obstet Gynecol Scand. 2003 Jul;82(7):654-8. PMID: 12790848 Abstract Author(s): Febe Blohm, Barbro Fridén, Jens-Jörgen Platz-Christensen, Ian Milsom, Sven Nielsen Article Affiliation: Departments of Obstetrics and Gynecology, Sahlgrenska University Hospital/East, SE-416 85 Gothenburg, Sweden. This email address is being protected from spambots. You need JavaScript enabled to view it. Abstract: BACKGROUND: The aim of this study was to evaluate treatment efficacy and patient compliance in women with an early miscarriage managed expectantly in routine clinical practice. METHODS: During 1995-98, 263 consecutive women who sought medical attention for an ongoing or incomplete miscarriage (gestational length<99 days), and who were circulatory stable and had a gestational residue measuring 15-50 mm (anterio-posterior, A-P diameter) on ultrasound examination were invited to participate in this study. Hemoglobin (Hb), C-reactive protein (CRP), human chorionic gonadotrophin (hCG), progesterone and Rh-factor were analyzed and a questionnaire regarding the pregnancy, duration of genital bleeding and number of days of absenteeism was completed on admission and after 1 and 4 weeks. RESULTS: Expectant management was considered to be complete (vaginal ultrasound, gestational residue<15 mm after 1 week) in 83%. The patients who were managed successfully by expectant management had a smaller gestational residue (p = 0.026) and a lower mean serum progesterone level (p = 0.025) on referral than in the group of women with failed expectant management. A gynecologic infection was diagnosed in seven cases (3%) and five of the infections were in the group of women who underwent dilatation and curettage. No patient required a blood transfusion. The mean number of days of absenteeism was 3.2 days. There were no differences in Hb levels before or after treatment, number of bleeding days or absenteeism between the groups. CONCLUSIONS: Expectant management of clinically stable patients with symptoms of early miscarriage is safe, efficient and well tolerated. Article Published Date : Jul 01, 2003

Expectant management of incomplete, spontaneous first-trimester miscarriage: outcome according to initial ultrasound criteria and value of follow-up visits. 📎

Abstract Title: Expectant management of incomplete, spontaneous first-trimester miscarriage: outcome according to initial ultrasound criteria and value of follow-up visits. Abstract Source: Ultrasound Obstet Gynecol. 2002 Jun;19(6):580-2. PMID: 12099260 Abstract Author(s): C Luise, K Jermy, W P Collons, T H Bourne Article Affiliation: Early Pregnancy, Gynaecological Ultrasound and Minimal Access Surgery Unit, St George's Hospital, London UK. Abstract: OBJECTIVES: To assess whether the presence of a gestational sac or the width of the endometrium, can be used to predict the outcome of expectant management for an incomplete, first-trimester miscarriage, and to determine an appropriate schedule for follow-up visits. SUBJECTS: Consecutive women with a spontaneous miscarriage, who were attending an early pregnancy assessment unit. METHODS: Transvaginal ultrasonography was used at the first visit to identify those women with an incomplete miscarriage--defined as the presence of heterogeneous products of conception within the uterus and distinguishable from a missed miscarriage or an anembryonic pregnancy. The sonographic end-points were the presence of a gestational sac or the thickness of the endometrium. All subjects were offered the choice of surgical evacuation of the uterus under general anesthesia or expectant management with a follow-up visit within a few days of the cessation of transvaginal bleeding, or weekly monitoring for 4-5 weeks. The main outcome measures were the number of women with a complete miscarriage (defined as the absence of transvaginal bleeding and an endometrial thickness of<15 mm without surgical intervention) and the proportion of women completing their miscarriage within each week of management. RESULTS: Of the 312 women who participated, 234 (75%) chose expectant management; of these 13 were lost to follow-up leaving data from 221 for analysis. Two-hundred and one (91%) completed their miscarriage without intervention; the mean time from diagnosis to completion was 9 (range, 1-32) days. By the end of week 2, 184 women (83%) had miscarried. There was no statistically significant relationship between the initial presence of a gestational sac or endometrial thickness, and the success rate of expectant management. The odds of a woman completing a miscarriage spontaneously were 1 : 1 for week 1, 2 : 1 for week 2, 1 : 2 for week 3, and 1 : 5 for week 4. Twenty women had surgical treatment (19 elective with no serious prior complications, one emergency who was admitted to the accident and emergency department on day 21 of management). There were eight elective operations during week 1, and 11 over the following 3 weeks. CONCLUSIONS: Most women with an incomplete, spontaneous miscarriage chose expectant management and had a successful outcome. Neither the presence of a gestational sac, nor the endometrial thickness at diagnosis can be used to predict the likelihood of management failure. The current schedule of regular routine follow-up visits could be safely reduced to one or two fortnightly visits as appropriate, provided that patients have ready access to clinical advice by telephone. Article Published Date : Jun 01, 2002
Therapeutic Actions Expectant Management (Birth/Miscarriage)

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