Management of first trimester miscarriage; new insight in old dilemmas

In this thesis and the related thesis by Marike Lemmers ‘Outcomes of treatment for first trimester miscarriage’ we describe the short and long term effects of misoprostol and curettage in the treatment of first trimester miscarriage.
The first part describes current practice in miscarriage treatment. We provide an overview of the three treatment options: surgical, medical and expectant management. We conducted a systematic review (Cochrane) to investigate the most optimal regimen for medical treatment. Furthermore we describe the results of a nationwide survey on treatment of first trimester miscarriage. Although medical treatment is available in virtually all Dutch hospitals, there is still a large practice variation.
The second part provides an overview of incidences of acute complications after surgical treatment for miscarriage, and compares these complications to those of medical treatment and/or expectant management.
The third part describes the management of an incomplete evacuation of the uterus after misoprostol treatment for first trimester miscarriage. Although women with an incomplete evacuation are often relatively asymptomatic, a curettage is often performed. We conducted a randomized controlled trial, comparing curettage to expectant management. A cohort study was conducted alongside this trial following women who received treatment of their preference. These studies show, that although curettage is slightly more effective, expectant management is safe and effective in at least 5 out of 6 women. Patients had a strong preference for a specific treatment type. The most important factors on which they base their preference were probability of success and risk of reduced fertility.