Management of pregnancy loss in the first trimester: a retrospective audit

Abstract

Background: Early pregnancy loss occurs in 10% of all clinically recognised pregnancies. 80% of pregnancy losses occur in the first trimester. Offering choice and participation in the management decisions is essential to patient-centred care. The aim of this study was to assess the management of first trimester pregnancy loss at the Emirati Hospital in Rafah, Gaza Strip.

Methods: In this retrospective audit, we compared the management of first trimester pregnancy loss at Emirati Hospital using the American College of Obstetricians and Gynecologists guidelines (ACOG, No. 150, May 2015). Data were obtained from patients' medical records.

Findings: 50 cases were identified in November and December, 2015. 32 (64%) cases were missed miscarriages (an ultrasound finding of a non-viable pregnancy in an asymptomatic patient), 13 (26%) were incomplete miscarriages, and five (10%) were complete miscarriages. All cases were haemodynamically stable. Only seven (14%) cases were managed medically (200 μg misoprostol four times sublingually without repetition). 43 (86%) cases were treated surgically. Of these, two (4%) cases were treated without prior medical management because of acute presentation with bleeding, and 41 (82%) cases were treated after failure of medical management, when expulsion of conception products did not occur after the full dose of medical management regimen. 43 (86%) women received antibiotic prophylaxis after surgery without specific indication, which is not recommended. Seven (14%) women received no antibiotics, whereas others received a variety of different antibiotic regimens. Expectant management did not require admission, and these cases were not recorded in this audit.

Interpretation: This audit showed a high percentage of failure in the medical management regimen and poor adherence to antibiotic prophylaxis guidelines in surgical management. Furthermore, all patients not presenting with acute bleeding were treated with medical management first, without an opportunity to choose surgical management. To improve outcomes of medical management and offer patients a real choice of management methods, clear local guidelines need to be developed with an evidence-based medical management regimen (the ACOG regimen reports an expulsion rate of up to 84%). Regular audit and team feedback could further improve guideline adherence also in the use of antibiotic prophylaxis.

Funding: None.