The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes326
EMQ1462
SBA2091
Do you realy want to delete this discussion?
Forum >>

Essay 286 - Miscarriage

Essay 286 - Miscarriage Posted by PAUL A.
A healthy 25 year old woman attends for a dating scan and is found to have an 8 weeks size missed miscarriage. (a) What would you tell her about the benefits and disadvantages of expectant management? [7 marks] (b) what would you tell her about the benefits and disadvantages of medical management? [7 marks] (c) what would you tell her about the benefits and disadvantages of surgical management? [6 marks].
Posted by Farzana N.
a)Diagnosis should be explained to the woman .Sympathetic counseling forms an important part of her management.
Deatailed history is taken about any pain or bleeding.Medical history is taken about asthma and blood group and Rh factor.Examination should include general and pelvic examination to assess the cervix.In the absence of contraindications and closed cervix various options available to her include-
Expectant management avoids complications of medical treatment ,anesthetic and surgical complications . It is also associated with lower risk of pelvic infection,and no adverse effects on future fertility.Anti D immunoglobulin is not required in Rh neg woman.
Sheshould be explained that in the presense of intact sac and closed cervix , success rate of expectant management is low(25-30%).Resolution would take several weeks .She may have unpredictable bleeding and require emergency surgical evacuation.
Shesould be given 24hrs contact number and advised to return anytime if she has bleeding.

b)Advantages of medical management include avoidance of anesthetic and surgical complications,but the success rate is lower than in surgical management,especially with intact sac and closed cervix.
She should be explained that in case of medical management she would be given Prostaglandins along with anti progesterone-mefipristone.Prostaglandins can be given orally or vaginally.Evidence says that vaginal misoprostol is more effective than oral therapy and is associated with fewer side effects.She has a small risk of anaphylaxis associated with prostaglandins and they would be contraindicated if she is asthmatic.AntiD should be given I she is Rh negative.
c)Surgical management has the advantages that it is usually day case procedure,with prompt resolution .Suction curettage would be done under local or general anesthesia.
Disadvantages are that it is more expensive than medical treatment and requires theatre facilities .There is a small risk of uterine perforation,cervical trauma , infection , and bleeding.
To reduce the risk of infection she should be screened for chlamydial infections and adequate treatment given.Anti D prophylaxis is required
She should give her an informed consent and her wishes would be respected.
.She would be referred to support group.

Posted by H H.
TSH
I will tell her that expectant management has the benfit that no intervention is done and the pregnancy will come down by nature and this has a psychological effect on the patient and will comfort those with religious believes. I will tell her that there is the advantage that no medications are taken with their side effects . If she blood group rhesus negative (Rh-ve), there is no need for anti D immunoglobulins and this of advantage if she is afraid of blood products. However the disadvantages are, patient anxiety about retaining a dead fetus and that it might affect her, the danger that bleeding can take place any time and might be severe enough to require emergency action and blood transfusion , and the fact that this management might fail and the pregnancy retained and stuck and might be difficult to expell even if surgical methods needed.I would provide written information.


I would tell her that medical evacuation would be a shorter procedure than expectant management , associated with less intervention and infection than surgical procedures and might mimic nature in expelling her fetus.There is the advantage of avoiding a surgical procedure. However , it would take longer than a surgical procedure (2-3 days), include taking medications with their side effects (nausea vomiting asthma with prostaglandins) , discomfort and pain . There is always the risk of heavy vaginal bleeding and bleeding taking long periods of time and both might need surgical evacuation if persistant. With medical management anti D immunoglobulin given if Rh-ve.I will give written information.


I will tell her that surgical evacuation is a short procedure and so less patient anxiety regarding getting things done. It is also the ultimate route for failed other procedures. It is a day case so the patient will not stay in hospital and if done under general anaesthesia will not feel anything, but should expect some discomfort after awakening. Being a surgical procedure it has risks of any surgery including risks of anesthesia . I will tell her that there is risk that we might fail in dilating the neck of womb ,risk of injury to cervix or perforation of uterus in 4/1000 procedures, risk of bleeding and risk of incomplete evacuation of uterus. There is risk of infection in 1/100 procdures and antibiotic cover might be needed ( discuss drug allergy with patient) .Anti D will be given if Rh -ve.I will give written information.



Posted by dr neelangini G.
A healthy 25 year old woman attends for a dating scan and is found to have an 8 weeks size missed miscarriage. (a) What would you tell her about the benefits and disadvantages of expectant management? [7 marks] (b) what would you tell her about the benefits and disadvantages of medical management? [7 marks] (c) what would you tell her about the benefits and disadvantages of surgical management? [6 marks

a) The benefit of expectant management is possibility of spontaneous passage of products of conception out of the womb through vagina within few days or weeks, in this case there would be no hospital stay, no risk of general anaesthesia & associated complications , no surgical interference so less chance of perforation, postoperative infection & intrauterine adhesion formation, as no medical intervention, no untoward effects of abortifacients like prostaglandins, if she is Rh negative as no surgical intervention done, no need of giving anti D prophylaxis.
Disadvantages will be she has to be under supervision & follow up & support for entire duration of expectant management, if there will be incomplete abortion leading to retained products of conceptions, more blood loss, and pain associated with the processs , in that case emergency procedure of evacuation (S& E) to be undertaken which will be associated with more risk of infection & perforation. Chance of infection & although remote possibility of developing disseminated intravascular coagulation if products of conception remain in utero longer than approximately 4 -5 weeks, so she has to undertake investigations like weekly platelet count & if it shows marked reduction , she may require blood products & urgent surgical intervention. Also patient’s psychology towards this management to be taken in account as few women’s psychology would not allow them to carry day to days activities with dead embryo inside their womb.

b) Benefits of medical management would be again no hospital stay as management can be done at outpatient clinic. With success of medical management , the risk associated with surgical procedure i.e, anaesthetic complications, bleeding during or after surgery as retained products of conceptions, uterine perforation l& its complications , adhesion formation & infection can be avoided.
Risk associated with medical management would be related to drug effects , like associated with prostaglandin use e.g fever, vomiting, diarrhoea, abdominal cramps. Drugs like nonsteroidal anti-inflammatory agents can not be used with these abortifacients as NSAIDs reduce the efficacy of prostaglandins. With medical management , there is a possibility of failure of treatment and risk associated with having products of conception retained for long time causing infection, excessive bleeding & disseminated intravascular coagulation.

c) Benefits of surgical management is , it is a day care procedure & within short interval the products of conception will be out & in this case sample can be sent foe histopathology or for karyotyping & genetic study if desired. Because of short day care procedure , patient will not have to wait for long period as that of expectant management.
As suction & evacuation will be done under general anaesthesia , it will be associated with anaesthetic complications & surgical risk of injury to cervical os causing incompetence, uterine perforation - bowel or vessel damage & complication of associated major procedure like laparotomy, intraoperative bleeding & postoperative infection & bleeding related to retained products of conception or endometritis , rare but remote possibility of Adhesions causing Asherman’s syndrome
Posted by Manoj M.
A healthy 25 year old woman attends for a dating scan and is found to have an 8 weeks size missed miscarriage. (a) What would you tell her about the benefits and disadvantages of expectant management? [7 marks] (b) what would you tell her about the benefits and disadvantages of medical management? [7 marks] (c) what would you tell her about the benefits and disadvantages of surgical management? [6 marks].

A) Benefits of expectant management is that she can avoid hospital and related hospital acquired infections like MRSA and C.Difficile.
She can avoid medications and complications involved with medical and surgical management of missed miscarriage.
She can avoid risks of infections and haemorrhage associated with medical and surgical management.
She can avoid anaesthetic risk and surgical risks involved with surgical management of missed miscarriage.
Economical cheaper as may not need to come into hospital.
Does not require anti-D if rhesus negative with spontaneous complete miscarriage and blood loss is minimal
Disadvantage is unpredictability of completion of miscarriage and associated risk of unexpected increased bleeding or increased pain requiring acute hospital admission.
May require medical or surgical management for completion of pregnancy in immediate future.
Risk of infection is negligible but when associated may need medical or surgical intervention.
Emotional trauma may be longer with unpredictable events.

B)Benefits are approximate 85% of missed miscarriage is complete with medical management.
It is organised and planned management and so relatively predictable events and patient can recover sooner physically and emotionally from the events of miscarriage.
Medical management of missed miscarriage (MMM) avoids anaesthetic complications and surgical risks involved with surgical management.
Disadvantages are MMM is associated with risk of haemorrhage and may need surgical evacuation to stop bleeding and also may need blood transfusion.
Risk of infection and the need for prophylactic antibiotics.
MMM will need hospital admission for second part of treatment which is approximate 3-6 hours after prostaglandins administration or longer is associated with excess bleeding.
MMM may need further follow-up with scans if incomplete and may need either further medical/surgical management.
MMM is associated with antiprogesterone and prostaglandin and may cause pain and need for analgesics, also possible side effects of prostaglandins like pyrexia, diarrhoea.
In MMM antiD prophylaxis is recommended in rhesus negative women.

C)Benefits of surgical management is timely intervention and predicability.
Early recourse to normality of life both physically and emotionally.
95% success of completion of miscarriage with surgical management.
Disadvantages are risk of haemorrhage which may need blood transfusion.
Risk of infection and need for antibiotics.
If the procedure is done under general anaesthesia it is involved with the risk of general anaesthesia.
Surgical risk of perforation of uterus is approximate 1% with 0.1% risk of abdominal trauma to structures like bowel and bladder.
Risk of cervical trauma may cause long term problems with future pregnancy like miscarriage or preterm labour which is not fully aware.
AntiD prophylaxis is recommended for surgical management of missed miscarriage with rhesus negative patients.
Risk of needing further follow-up, scans and further medical/surgical intervention for incomplete procedures.

Posted by Manoj Babu  R.
(a) What would you tell her about the benefits and disadvantages of expectant management? [7 marks]

The women should be counseled about the management options including conservative management and she should be assisted to decide the management option. She should be told that conservative management is successful in 65-75 % of women over a period of 2-6 weeks without increasing complications. There is no risk of complications like uterine perforation, intrauterine adhesions and injury to adjacent structures which can rarely occur with surgical evacuation. She can remain at home also. It will not increase the risk of pelvic infections or any future fertility problems. This also gives time to some women who are not convinced about the diagnosis and gives time for the results of cervical swabs to be available before any possible surgical intervention.

The disadvantages include the risk excessive bleeding and pain which is maximum in the first 8 days. Duration of management may be prolonged and may go up to 6-8 weeks but it’s not harmful unless there are features of infection like fever, persistent abdominal pain or foul smelling discharge per vagina occurs. She may need regular repeat scans every 1-2 weeks and may need unplanned hospital admission, blood transfusion and surgical evacuation if there is excessive bleeding, infection or incomplete miscarriage. Another disadvantage is the difficulty in getting adequate tissue for histopathological examination.

(c) What would you tell her about the benefits and disadvantages of medical management?
She should be told that medical management is associated with shorter duration of treatment compared to expectant management. Usually time taken is 8 hours from induction and the bleeding stops by 8 days. It can be either prostaglandin like misoprostol alone or along with a progesterone antagonist, mifepristone and the success rates are 40-90% and 70-80 % respectively.

The disadvantages include the side effects like nausea, vomiting, fever and diarrhea which depends type, dose and mode of administration of drug. There increased pain and the need for analgesia compared to expectant management. Some patients may need readmission for excessive bleeding leading to blood transfusions and emergency surgical evacuation. She should also be told that misoprostol is not licensed at present for missed miscarriage but it is licensed for use in induced abortions.

c) what would you tell her about the benefits and disadvantages of surgical management? [6 marks].

She should be told that that surgical evacuation having the highest success rate of 95-100 %. It is not associated increased risk of infections, or any adverse effect on future conception rates and pregnancy outcome.

But in less than 5% cases there is need for repeat evacuations. It can be associated with complications like uterine perforation in 1% cases and there is risk of cervical trauma, and rarely damage to intra-abdominal contents like bowel. It can also cause bleeding and pain during the procedure as well as anesthetic complications. There is risk of pelvic infections if there is untreated cervical infection with organisms like Chlamydia. She should be reassured that screening will be done for detecting any infection before the procedure and prostaglandin may be used preoperatively to prevent trauma to the cervix.


Posted by Mark D.

mark d

a)
The benefit is she may feel in control of all that is happening and satisfied that natural way is chosen.Since there is no intervention involved there is no risk due to GA or instrumentation like perforation ,infection or cervical trauma.It is effective in 60-65% cases of missed miscarriage,it is cost effective as it avoids inpatient stay, repeated visits to hospital, and also separation from family.Although in most cases the sac may get reabsorbed ,it may take 6-8 weeks for complete resorption.She may occasionally experience unpredictable severe pain in abdomen or bleeding and in such situation or if there is foul smelling discharge,pain or fever she should report to the hospital.She may need surgical evacuation by suction (3-5% cases )if the bleeding is severe and continous or there is evidence of infection.she would be provided a 24 hour contact number and written information and her acces to hospital and transport ensured.

b)
I will tell her that medical option is faster than expectant with complete miscarriage occuring in 80-94% of cases and mean interval of abortion is about 1-6 days from dose of mifepristone.It can be done on outpatient basis and aviod separation from family and nosocomial inefctions.The infection rates are lower than surgical termination and no risk of GA and instrumentation.there is no effect on subsequent fertility. The patient satisfaction rates are high 85%.
The disadvantage is the bleeding may continue as heavy for 3-4 days and then lighter for next 14-21 days , she will have to use tampoon or pad till then. There are also side effects of prostaglandin tablets used like diarrhoea, hyperthermia and GI upset. She may need to come for follow up at 14-21 days to ensure completeness. she may ocasionally need a suction evacuation occasionally in case of heavy and continous bleeding.
I will provide 24 hr contact number and written information to backup the verbal information.


c)
it is done by suction evacuation under sedation or GA in single sitting after cervical ripening by a vaginal pessary( gameprost) before 3 hrs.
there is no pain during procedure and may experience mild bleeding for a week after it.there is no increased risk of placenta previa, infertlity ,ca breast. A Cut may be inserted at the same time if she wants.There is a small rise in preterm labour and miscarriage in next pregancy.preoperatively she will have to be screened for chalmydia and will receive prophylactic antbiotic like rectal metronidazole and oral doxycycline after surgery for 7 days.Like any other surgery there is a rare risk of anaphylaxis to drugs, risk of GA, and risks of instrumentation like perforation (2-8/1000), bleeding requiring transfusion (4/1000) cervical trauma,infection(14%) and retained pocs (1%) written information willl be given.

Posted by Neelam A.
a)Benefits of expectant management include no surgical or anaesthetic risks and no side effects of any medications and patient feels under control. No hospital admission is required. There is never heavy bleeding as products undergo resorption. However, it takes longer and there are high failure rate especially in cases of missed miscarriage. Higher efficiency is seen in cases of incomplete miscarriage and smaller gestation sac. It is associated with low incidence of infection. She requires further follow-up and she might need medical or surgical management in cases of failure.
b)She should be counselled for medical management and her wishes should be taken in consideration. Unit protocols should be followed for medical management which includes priming with antiprogesterone ie mifepristone followed by oral or vaginal treatment with prostaglandin analogue ie misoprostal. Success rate depends on type of miscarriage, size of gestation sac and dose and route of prostaglandin and priming with mifepristone and type of follow up. Success rate with medical management varies from 13-96%. Higher success rate is seen with incomplete miscarriage or smaller gestation sac. About one third have bleeding or miscarriage after priming with antiprogesterone. She should be also counselled for pain and heavy bleeding. She should be given the contact number and facility should be available to provide advice and admission in cases of heavy bleeding and pain. Bleeding normally continues for 3-4 weeks. No risk of surgical or anaesthetic complications. Low risk of infection and low cost to NHS compared to surgical management. It can be managed as out-patient.
c)Surgical management involves risk of anaesthetic and surgical complications. Surgical risks are cervical trauma, bleeding, infection, uterine perforation adhesions and retained products. Pelvic infection rate can be reduced either by screening before attempting instrumentation of uterine cavity or offering prophylactic antibiotics. Vaccum aspiration is associated low incidence of bleeding compared to dilatation and curettage. Use of syntocinon reduces further amount of blood loss. Cervical priming with misoprostol or gameprost is recommended to reduce extra force to dilate cervix and reduce uterine perforation complications. Anaesthetic risks can be reduced by performing this procedure under sedation, but this is not the usual practice in UK. It cost more compared to medical or expectant management. Efficiency is 96% is expected in experienced hands.
Women’s wish should be considered in decision making for therapeutic intervention. Information leaflets should be provided. Support and counselling should be offered. Rhesus negative women undergoing medical or surgical management would need Anti D. Products of conception should be send for histological examination to rule out ectopic or gestational trophoblastic neoplasia. Follow up appointment should be arranged either in form of clinical or ultrasound.
Posted by S M.
SM reply.
a)
The benefit of expectant management is that hospital admission can be avoided . When successful, side-effects of medications , anaesthesia and surgery can be completely avoided . It is less expensive to the NHS. The risks of pelvic infections are lesser than when surgical methods are used. This method has no adverse effect on future fertility. Anti-D injection, which is a blood product, can be avoided.
The disadvantage of expectant management of missed miscarriage is that success rate with intact sac and closed os is less than 50%. The pregnancy may require weeks to resolve completely. Bleeding per vagina can be sudden, unpredictable and profuse. She may need surgical evacuation finally. Hence, she will need quick access to a hospital round the clock.

b)
The benefit of medical management of missed miscarriage is that the woman feels more in control. She can avoid risks of surgery and anaesthesia if this method is successful. Hospital admission is not required. This method is more cost – effective to the NHS. Risk of pelvic infection is less.
The disadvantage is that she may end up needing a surgical evacuation. She needs Anti-D injection if she is Rh negative. Success is lower with this method if there is an intact sac and closed cervix . This method can take upto 2 days to complete.

c)
The benefit of surgical management is that it is a planned procedure. It can be done under GA or local anaesthesia. She can go home the same day, usually. Sexually transmitted infection screen will be offered to her.
The disadvantage is that she will need hospital admission. Complication of anaesthesia can occur like aspiration .Complications of surgery like uterine perforation, trauma to bowel/bladder and hemorrhage needing blood transfusion can occur. Pelvic infections are more likely to occur after a surgical procedure. She will need Anti –D injection after the procedure. Prophylactic antibiotics may be required. This is a more expensive option for the NHS.

The woman’s wishes must be respected. Written information will be offered. Emotional trauma is comparable with all three options of management. Counselling and support must be offerd.
Posted by Arun J.
a -I would tell her that she does not have to get admitted and does not have to take medications ,so cost effective.It doesnt cause much of pain as is in medical management.Avoids anaesthetic(anaphylaxis to drugs) and surgical complications such as perforation cervical tear and haemorrhage .Anti -d prophylaxis if the patient is Rh negative is not required.The disadvantages are, that of patient anxiety of waiting for long period as it may take 2 weeks also. It should be adviced only to patients with 24 hr telephone and hospital admission acces .The chance of successful resorption is less with missed misscarriage.( when compared to incomplete misscarriage).Tissue for HPE not got with expectant management.
Posted by Arun J.
b -The benefits of medical management are that it has more patient acceptability.It needs only short hospital stay. It avoids anaesthetic and surgical complications of surgical termination. It has decreased incidence of pelvic infection and no adverse effects on fertility.The disadvantages are that of pain, so requires analgesics.It causes bleeding also. It creates a feeling of medicalisation of the whole process in the patients mind.Failed treatment requires surgical evacuation at a later date.Anti -d needs to be given if she is Rh negative.This treatment should be advised only if 24 hr telephone and hospital access is available to the patient.
c -The benefits of surgical treatment are that HPE is available for diagnosis.The satisfaction rates may be more .The disadvantages are that the need for hospital admission and its cost.Outcome is dependent on the surgical expertise of the surgeon and the cause. The success of surgical treatment in early 1 st trimester is less( ie failed evacuation).There are complications such as risk of uterine perforation(1-4/1000 procedures),haemorrhage(0.88/1000 procedures), cervical tear though less in this gestation when compared to 2 nd trimester surgical evacuation, infection, and acute medical complications such as cardiac arrest during dilatation of cervix, and effects on future fertility such as preterm labour and misscarriage.Anti-d needs to be given if the patient is Rh negative.
Posted by Sowmithya B.
A. Benefits of expectant management include minimal bleeding as the pregnancy resolves by complete resorption and avoidance of surgical and anaesthetic complications like perforation and cervical trauma associated with surgical evacuation. Better quality of life been documented as women feel that they are more in control with the procedure. There is reduction in clinical pelvic infection and does not have any adverse effect on future fertility. It is cost effective. Serum progesterone less than 20nmol/L can predict the successful outcome of expectant management with sensitivity of 93% and specificity of 94%
The efficacy of the expectant management varies between 25-100% depending on the type of miscarriage, sac size and whether follow up is based on clinical examination or ultrasound. For missed miscarriage success rate is lower and patient might need surgical evacuation at a later date to complete the process. Histological examination of the products of conception may not be available. Repeated follow up may be required to assess the outcome. In one third of patients severe bleeding per vaginum can occur requiring emergency hospital admission and surgical evacuation.

B. Medical management can be provided as outpatient treatment and it is cost effective. The efficacy varies from 13-96% and it depends on type of miscarriage, sac size, follow up (whether based on clinical examination or ultrasound) dose and duration of prostaglandin and route of administration. For missed miscarriage cervical priming with mifipristone is required before prostaglandins for successful outcome. No surgical intervention involved and hence no surgical or anaesthetic complications. Reduced incidence of clinical pelvic infection and has no adverse effect on future fertility.
Disadvantages include increased pain and bleeding especially with tissue passage. Patient can have bleeding everyday from 14 to 21 days following the procedure. In case of severe bleeding or retained products of conception she will require surgical evacuation

C. At least 35% of women show strong preference for surgical evacuation. It is performed as day case procedure. Specimen would be available for histopathological evaluation. Usually performed under systemic analgesia or patient controlled anaesthesia and hence patient will not experience pain. Usually screening for chlamydia , bacterial vaginosis and gonococcal infection would be done and hence reducing the risk of pelvic inflammatory disease. Suction evacuation is associated with lesser pain, bleeding and lesser operating hours. Use of prostaglandins preoperatively will reduce the force required to diale the cervix and reduce the risk of perforation and cervical trauma. Use of oxytocin will reduce bleeding.
Disadvantages include cervical trauma, uterine perforation, intra abdominal injury haemorrhage, and intrauterine adhesions because of overzealous curettage. Anaesthetic complications are also involved. It is not cost effective. Patient should be offered these options in sensitive way and encouraging her to make informed decision. Involvement of women in decision making has better quality of life on objective assessment. Information about disposal of fetal parts should be given and her views should be recorded in case sheet. Written information should be provided. Support groups should be identified to her.
Posted by Priti T.
prt

a]I would like to tell the patient that expectant management of missed miscarriage involves waiting for the natural resorption of the products of conception.It can be successful in 74% of the cases and 25% may require surgical evacuation.It is cheaper and cost effective.Patient stays at home and avoids varoius complications associated with medical/surgical methods.
The disadvantage of the expectant Mx is the unpredictability and the long course compared to other methods.It may take upto 6-8 weeks to resorb completely and patient needs frequent followups in early pregnancy unit and USG to monitor.Patient should be given the contact numbers and the written appointments.In case patient is in a hurry then she needs to choose other methods.
We should tell the patient that in all these three methods,there is no particular benefit of one method over the other.

b]Patient is told that the medical Mx involves the use of drugs for the termination of pregnancy.It is successful in 85-90% of the cases,but 10% may require surgical evacuation for excessive bleeding or retained products of conception.She is told that she would be given Mifepristone200-600mg followed by gemeprost 1mg/misoprostol after 36-48 hours.She can be managed in out patient department and does not need admission unless she bleeds excessively.
The disadvantage of the medical Mx are the gastrointestinal adverse effects like nausea,vomitting in 50% of the cases.These can be reduced by reducing the dose of mifepristone to 200mg.She should be given the hospital contact numbers for the emergency contact in case of excessive bleeding.There is risk of infection so she would need prophylactic antibiotics.To avoid pain ,the analgesia should be prescribed also.She needs Anti D prophylaxis in case Rh negative unlike expectant Mx.She should be told that she can bleed from 10-14 days in medical Mx.

c]Patient can be told that the benefits of surgical evacuation are that its a one stage procedure .She can be admitted for a day in day care surgery and discharged same day.She can be screened in the same sitting for STI like chlamydia and gonorrhea and treated with drugs for the same.In case she is keen for the contraception she can be fitted with IUCD also.
Varoius disadvantages of the surgical procedure should be told and consent for the same and general anasthesia is taken.She should be told about the risk of uterine perforation 2-8/1000,risk of haemorrhage ,infection and blood transfusion.There is 1% risk of Retained /incomplete products of conception.The complications can be reduced by cervical priming by prostaglandins 3 hours before the operation.She should be reassured that these are rare complications.She should be given the name and contact numbers of the support groups like Miscarriage Association for the psychological counselling.
Posted by Osman A.
a. She should be informed that the success rate of expectant management varies from 25-75%. The patient should be informed that it may require follow up till several weeks (4-6 weeks). The benefit of expectant management is cost effective as compared to medical/surgical intervention. It is associated with less separation from their family in expectant management as compared to surgical intervention. However, expectant management is associated with increased risk of incomplete miscarriage. This group of patient will experience heavier and longer duration of pervaginal bleeding. It is also associated with increased anxiety rate among women who subjected to expectant management. The risk of unexpected surgical intervention is highest in expectant management (10-44%) as compared to surgical (2-5%) or medical management (10-36%). Written information should be given to patient. There is no different in risk of infection/endometritis.
b. The success rate of medical management is about 60-95%, but the outcome varies depend on the duration and dosage of prostaglandin used for medical intervention. She should be told that the success rate is increased if combined medicine is used (prostaglandin and mifepristone). The procedure can be done as out patient, thus reduce the admission rate. But it is associated with abdominal pain and heavy bleeding. The requirement of analgesia is also increased. There is no different in rate of infection and outcome of future pregnancy. Written information should be given to the patient.
c. Surgical intervention is associated with high success rate (95-100%) and associated with lower rate of unexpected surgical intervention. The patient should be informed the best choice of surgical intervention will be in a form of suction and curettage. It is a treatment of choice in a patient with recurrent and heavy bleeding, haemodynamicly unstable patient and infected retained product of conception. It requires day care procedure and requires either sedation or general anesthesia. It carries higher risk to develop intrauterine adhesion. It is also associated with complication of surgical intervention like uterine perforation and cervical injury. Written information should be given to the patient.
Posted by J P.
a.The benefit of expectant management is that it is natural way of termination and avoids other operative procedures.Infection risk is not increased and there is no adverse effect on fertility.Anti-D not required in rhesus negative individuals.The disadvantages are bleeding may be unpredictable and prolonged,severe bleeding may necessitate blood transfusion or emergency evacuation.Success rate in closed cervix with intact sac is low-25-43%.
b.Benefits of medical management are the avoidance of surgical and anaesthetic management.The medications can be taken orally or vaginally and the patients feel more in control of the process.Infection risk is less and more cost effective than surgical termination.Success rate is 80-85%.The disadvantage may be due to the effect of medication like pain,cramps,nausea.Bleeding may be heavy and necessitate transfusion in 1-5 % of cases.Emergency surgical evauation may be needed for retained products of conception in 4-15/1000 cases.Anti D required in Rh negative individuals.
c.Benefits ofsurgical treatment include that it is a defintive management with success rate of 90-95%.Failure rate is rare in experienced hand of 1-2/1000 cases.It is done as a day care procedure, though usually done under GA can be done under local anaesthesia.
Disadvantages are it may need prior piming ,complications like infection,bleeding,blood transfusion,cervical trauma ,uterine injury,anaesthetic risks.Anti-d required in Rh negative women.Information leaflets will be provided with the information and patient wishes respected.
Posted by J P.
a.The benefit of expectant management is that it is natural way of termination and avoids other operative procedures.Infection risk is not increased and there is no adverse effect on fertility.Anti-D not required in rhesus negative individuals.The disadvantages are bleeding may be unpredictable and prolonged,severe bleeding may necessitate blood transfusion or emergency evacuation.Success rate in closed cervix with intact sac is low-25-43%.
b.Benefits of medical management are the avoidance of surgical and anaesthetic management.The medications can be taken orally or vaginally and the patients feel more in control of the process.Infection risk is less and more cost effective than surgical termination.Success rate is 80-85%.The disadvantage may be due to the effect of medication like pain,cramps,nausea.Bleeding may be heavy and necessitate transfusion in 1-5 % of cases.Emergency surgical evauation may be needed for retained products of conception in 4-15/1000 cases.Anti D required in Rh negative individuals.
c.Benefits ofsurgical treatment include that it is a defintive management with success rate of 90-95%.Failure rate is rare in experienced hand of 1-2/1000 cases.It is done as a day care procedure, though usually done under GA can be done under local anaesthesia.
Disadvantages are it may need prior piming ,complications like infection,bleeding,blood transfusion,cervical trauma ,uterine injury,anaesthetic risks.Anti-d required in Rh negative women.Information leaflets will be provided with the information and patient wishes respected.
Posted by Kp K.
A healthy 25 year old woman attends for a dating scan and is found to have an 8 weeks size missed miscarriage. (a) What would you tell her about the benefits and disadvantages of expectant management? [7 marks] (b) what would you tell her about the benefits and disadvantages of medical management? [7 marks] (c) what would you tell her about the benefits and disadvantages of surgical management? [6 marks].


I would tell the patient that expectant management is safe and acceptable method. There are no side effects of the drugs as in medical and no risk of anesthetia complications and procedural risks as involved in surgical method. It is an outpatient management. It involves less blood loss as resorption of fetal tissue takes place overtime. There is reduction of clinical pelvic infection and no effects on future fertility.

Disadvantages of this method are it takes weeks to completely misscary(2-6weeks oppr). Has a lower efficacy rate as compared to other methods. Increase psychological impact and anxiety. Remote risk of coagulopathy as a dead fetus in uterine cavity. Follow up is required in early preganacy unit on a regular basis till complete miscarriage confirmed.

b) Medical method is the effective method for the first trimester miscarriage and has higher efficacy rate than expectant management. Efficacy rate is increase with high dose of prostaglandins, intravaginal use and the sac size. Can be offered as an outpatient procedure and admission is neded in only less than 1% of cases if heavy bleeding occur.
Mefipristone will be given as a single dose and she needs to follow up in 36-48 hrs time for misoprostol 800ug given intravaginal as single dose. She should be informed that these drugs are not licensed in UK for this procedure but are highly effective and has been used for many years for management of miscarriage with no long term adverse effects. It is the most cost effective method.
Drugs have minor side effects of nausea, vomiting and diahroia. She may experience more pain than expectant and surgical method and may require analgesic . Failure of the procedure may lead to repeat procedure or she can wish surgical method. Surgical method of evacuation may require in less than 1% case if she experience very heavy bleeding.

c) surgical method is the very quick method of evacuation of uterus. It is the most effective method with efficacy rate as high as 99%. It is done a s day case procedure and hence can be discharged on the same day. Less painful procedure as done under anaesthesia. Products of the conception can be obtained for hisopatholgy examination to rule out gestational trophoblastic disease and for investigations for recuurent miscarriage.
This procedure carries risk of anaesthesia. There is a risk of cervical trauma (1-14/1000) but can be reduced by prior use of prostaglandins intavaginaally. 1-4/1000 risk of perforation of the uterus in which case laparotomy may be inicated if large perforation. Increase risk of bleeding, infection and intrauterine adhesions should be informed.

Patient should be given written information and clinicians should encourage informed decisions and support their decisions as it is associated with positive quality of life outcomes.
Posted by Dr Dyslexia V.
X

a. I would inform her that expectant management includes natural course of the miscarriage in which awaiting for sponataneous uterine evacuation or resorption of the product of conceptus. The advantages include that it is and outpatient basis and does not require admission. She will be able have emergency admission or telephone assistance from the early pregnancy assessment unit if she is aborting. The risk of infection is relatively lower than surgical evacuation. It is also associated with higher return to fertility. And it is cost effective, if it is successful in 60 to 80% of the time. It is also associated with less bleeding as some degree of resorption takes place. But unfortunately it is has higher chance of failure than the other methods. It is also associated with more pain. It could require higher chance of having emergency ERPC. It sometimes require a long duration before the miscarriage resolves.


b. Medical management of miscarriage includes antprogesterone priming such as mifepristone and usage if prostaglandin such gameprost or misoprostol. This mode also carries a smaller risk of infection compared to surgical evacuaton. It is also faster to resolve the miscarriage compared to expectant. This treatment also could be done as outpatient. This method is more effective than the expectant management. The return to fertility is also comparable to expectant management. But emergency surgical evacuation is a drawback to this method. It is also associate with increased pain and higher blood loss.

c. Surgical management is still a popular approach as the women has more control to the miscarriage and success rate is about 99%. It could be done as an elective basis and the woman could sort out her affairs before the procedure. The pain would be very minimal compared to the other methods as analgesia is given. Opportunistic screening for Chlamydia and bacterial vaginosis could also be done during procedure. But it is associated with anesthesia risk such as infection and aspiration. The risk of endometritis is relatively higher compared to the other methods. The surgical risk as cervical trauma, and uterine perforation is a also a disadvantage. Risk of Ashermans’s syndrome upon overzealous curettage also predisposes to subfertility and decrease in return to fertility. It also ruquire hospital admission
Posted by Maayka ..
nellie

a) Expectant management involves her awaiting products of conception (POC) to be expelled or resorption to occur. The chance of success is reduced with an intact sac as compared to having an incomplete miscarriage. She has more control of what occurs by choosing this method. There may be up to 3 weeks of pv bleeding and follow up should be by a transvaginal scan (TVS) to ensure the POC have been expelled. There is no risks like from surgical intervention, from the surgery itself as well as the aneasthetic complications. It is done as an outpatient procedure. There is reduced chance of infection as compared to surgical management because there is no introduction of organisms into the genital tract, into the uterus and tubes. The chance of success though may be smaller as compared to that obtained via medical or surgical management.The disadvantages are that the expected time for resolution is uncertain and so having follow up may have the patient anxious about the probability of POC left inside. The theoretical probability of infection still exists but the risks seems less vs. surgical management. There is no need for administration of Anti- D Ig if non-sensitized and pv bleeding not heavy. The patient must be able to have choice of converting to option of medical or surgical management at any time though.

b) Medical management involves the use of drugs given orally, per vaginam or a combination of Mifepristone and prostaglandins to aid in expediting the process of removal of POC. The drugs used like Misoprostol are associated with side effects like diarrhea, abdominal pain, nausea and vomiting, abnormal vaginal bleeding. She needs to be aware of such and should have access to an emergency department 24 hrs, even for telephone contact to be advised on symptoms which are excessive. It will involve in some settings in hospital administration of some tablets with instructions for at home dosing thereafter. There is still the probability of surgical management if the pv bleeding is excessive. The Rhesus status must be known because Anti- D will have to be given to a non – sensitized Rh negative patient. The advantages are there is quicker resolution and removal of POC and the patient may feel reassured. One more disadvantage – follow up is required.

c) Surgical management has the advantage of being quick with little follow up required i.e. having a repeat TVS. The patient is still in control of her decision and there is less anxiety associated with probable remnants of POC when the surgery is completed. The disadvantages of ERPC are there are anaesthetic complications if general anaesthesia especially used or local. The other surgical risks are of uterine perforation- and if it is possible, she may need to remain in hospital for a period of observation with the possibility of laparotomy. There is a chance of cervical tears, infection risk increased, and haemorrhage. This has to be done in hospital so she would need to be admitted to hospital, likely only a day case if uneventful. Anti- D must be given if non- sensitized Rh-negative patient
Posted by PAUL A.
a)Diagnosis should be explained to the woman .Sympathetic counseling forms an important part of her management you were not asked about management .
Deatailed history you were not asked to take a Hx is taken about any pain or bleeding.Medical history is taken about asthma and blood group and Rh factor.Examination should include general and pelvic examination to assess the cervix.In the absence of contraindications and closed cervix various options available to her include- this is a complete waste of your time and space. JUST ANSWER THE QUESTION ASKED
Expectant management avoids it does not avoid these complications but reduces the risk complications of medical treatment ,anesthetic and surgical complications . It is also associated with lower risk of pelvic infection (1) ,and no adverse effects on future fertility.Anti D immunoglobulin is not required in Rh neg woman.
Sheshould be explained that in the presense of intact sac and closed cervix , success rate of expectant management is low(25-30%).Resolution would take several weeks (1) .She may have unpredictable bleeding and require emergency surgical evacuation (1) .
Shesould be given 24hrs contact number and advised to return anytime if she has bleeding.

b)Advantages of medical management include avoidance of anesthetic and surgical complications,but the success rate is lower than in surgical management,especially with intact sac and closed cervix (1) .
She should be explained that in case of medical management she would be given Prostaglandins along with anti progesterone-mefipristone.Prostaglandins can be given orally or vaginally.Evidence says that vaginal misoprostol is more effective than oral therapy and is associated with fewer side effects are these advantages / disadvantages? . She has a small risk of anaphylaxis associated with prostaglandins anaphylaxis??? and they would be contraindicated if she is asthmatic is misoprostol contraindicated?? .AntiD should be given I she is Rh negative. WHERE ARE THE DISADVANTAGES???
c)Surgical management has the advantages that it is usually day case procedure,with prompt resolution (1) .Suction curettage would be done under local or general anesthesia.
Disadvantages are that it is more expensive than medical treatment and requires theatre facilities .There is a small risk of uterine perforation,cervical trauma , infection , and bleeding (1) IS THE RISK OF INFECTION HIGHER THN WITH EXPECTANT OR MEDICAL MANAGEMENT?.
To reduce the risk of infection she should be screened for chlamydial infections and adequate treatment given is this an advantage or disadvantage? If neither, you are wasting your time .Anti D prophylaxis is required
She should give her an informed consent and her wishes would be respected.
.She would be referred to support group.
? written information
Posted by PAUL A.
TSH
I will tell her that expectant management has the benfit that no intervention is done and the pregnancy will come down by nature and this has a psychological effect on the patient ? evidence and will comfort those with religious believes why should it? You are not terminating her pregnancy. Religious beliefs should never appear in your answer unless specifically stated in the question, for instance, with respect to blood transfusion . I will tell her that there is the advantage that no medications are taken with their side effects . If she blood group rhesus negative (Rh-ve), there is no need for anti D immunoglobulins and this of advantage if she is afraid of blood products (1) . However the disadvantages are, patient anxiety about retaining a dead fetus and that it might affect her, the danger that bleeding can take place any time and might be severe enough to require emergency action and blood transfusion (1) , and the fact that this management might fail and the pregnancy retained and stuck and might be difficult to expell even if surgical methods needed why should expectant management make surgical evacuation more difficut? .I would provide written information. woman retains control, lower risk of infection; lower surgical and anaesthetic risks. Disadvantages – tissue not available for histology, more pain, only possible in units where 24h emergency admission is possible


I would tell her that medical evacuation would be a shorter procedure than expectant management , associated with less intervention and infection (1) than surgical procedures and might mimic nature in expelling her fetus.There is the advantage of avoiding a surgical procedure. However , it would take longer than a surgical procedure (2-3 days) is this an advantage or disadvantage? , include taking medications with their side effects (nausea vomiting asthma with prostaglandins) , discomfort and pain (1) are these advantages or disadvantages??. There is always the risk of heavy vaginal bleeding and bleeding taking long periods of time and both might need surgical evacuation if persistant. With medical management anti D immunoglobulin given if Rh-ve.I will give written information. the examiner has been systematic and asked you about advantages then disadvantages. You need to make crystal clear what you are presenting as advantages and what are disadvantages


I will tell her that surgical evacuation is a short procedure (1) and so less patient anxiety regarding getting things done not true . It is also the ultimate route for failed other procedures. It is a day case so the patient will not stay in hospital and if done under general anaesthesia will not feel anything, but should expect some discomfort after awakening is this an advantage or disadvantage? . Being a surgical procedure it has risks of any surgery including risks of anesthesia . I will tell her that there is risk that we might fail in dilating the neck of womb ,risk of injury to cervix or perforation of uterus in 4/1000 procedures, risk of bleeding and risk of incomplete evacuation of uterus (1) . There is risk of infection in 1/100 procdures and antibiotic cover might be needed ( discuss drug allergy with patient) .Anti D will be given if Rh -ve.I will give written information (1)

Your answer plan should have a list of advantages then disadvantages. You should present your answer with advantages first and make it very clear which points are advantages. If you are simply describing the procedure, you are not answering the question.
.
Posted by PAUL A.
A healthy 25 year old woman attends for a dating scan and is found to have an 8 weeks size missed miscarriage. (a) What would you tell her about the benefits and disadvantages of expectant management? [7 marks] (b) what would you tell her about the benefits and disadvantages of medical management? [7 marks] (c) what would you tell her about the benefits and disadvantages of surgical management? [6 marks

a) The benefit of expectant management is possibility of spontaneous passage of products of conception out of the womb through vagina within few days or weeks, in this case there would be no hospital stay, no risk of general anaesthesia & associated complications , no surgical interference so less chance of perforation, postoperative infection & intrauterine adhesion formation (1) , as no medical intervention, no untoward effects of abortifacients like prostaglandins, if she is Rh negative as no surgical intervention done, no need of giving anti D prophylaxis (1) this is a single sentence! Any sentence that is this long will be very difficult to comprehend .
Disadvantages will be she has to be under supervision & follow up & support for entire duration of expectant management, if there will be incomplete abortion miscarriage leading to retained products of conceptions, more blood loss, and pain (1) associated with the processs , in that case emergency procedure of evacuation (S& E) to be undertaken which will be associated with more risk of infection & perforation sentence is too long . Chance of infection & although remote possibility of developing disseminated intravascular coagulation if products of conception remain in utero longer than approximately 4 -5 weeks, so she has to undertake investigations like weekly platelet count not necessary & if it shows marked reduction , she may require blood products & urgent surgical intervention. Also patient’s psychology towards this management to be taken in account as few women’s psychology would not allow them to carry day to days activities with dead embryo inside their womb. a good answer will address every individual point in a separate sentence

b) Benefits of medical management would be again no hospital stay as management can be done at outpatient clinic (1) . With success of medical management , the risk associated with surgical procedure i.e, anaesthetic complications, bleeding during or after surgery as retained products of conceptions, uterine perforation l& its complications , adhesion formation & infection can be avoided (1) .
Risk associated with medical management would be related to drug effects , like associated with prostaglandin use e.g fever, vomiting, diarrhoea, abdominal cramps (1) . Drugs like nonsteroidal anti-inflammatory agents can not be used with these abortifacients as NSAIDs reduce the efficacy of prostaglandins. With medical management , there is a possibility of failure of treatment and risk associated with having products of conception retained for long time causing infection, excessive bleeding & disseminated intravascular coagulation.

c) Benefits of surgical management is , it is a day care procedure & within short interval the products of conception will be out & in this case sample can be sent foe histopathology or for karyotyping & genetic study if desired (1) . Because of short day care procedure , patient will not have to wait for long period as that of expectant management.
As suction & evacuation will be done under general anaesthesia , it will be associated with anaesthetic complications & surgical risk of injury to cervical os causing incompetence, uterine perforation - bowel or vessel damage & complication of associated major procedure like laparotomy, intraoperative bleeding & postoperative infection & bleeding related to retained products of conception or endometritis , rare but remote possibility of Adhesions causing Asherman’s syndrome (1) Your answer is almost impossible to mark as every sentence is too long and has to be read several times. If the examiner has to do this, you will not get the mark
Posted by PAUL A.
A healthy 25 year old woman attends for a dating scan and is found to have an 8 weeks size missed miscarriage. (a) What would you tell her about the benefits and disadvantages of expectant management? [7 marks] (b) what would you tell her about the benefits and disadvantages of medical management? [7 marks] (c) what would you tell her about the benefits and disadvantages of surgical management? [6 marks].

A) Benefits of expectant management is that she can avoid hospital and related hospital acquired infections like MRSA and C.Difficile.
She can avoid medications and complications involved with medical and surgical management of missed miscarriage (1) .
She can avoid risks of infections and haemorrhage associated with medical and surgical management.
She can avoid anaesthetic risk and surgical risks are surgical risks different from complications mentioned above? Is the risk reduced or avoided? involved with surgical management of missed miscarriage.
Economical cheaper as may not need to come into hospital.
Does not require anti-D if rhesus negative with spontaneous complete miscarriage (1) and blood loss is minimal
Disadvantage is unpredictability (1) of completion of miscarriage and associated risk of unexpected increased bleeding or increased pain requiring acute hospital admission.
May require medical or surgical management (1) for completion of pregnancy in immediate future.
Risk of infection is negligible but when associated may need medical or surgical intervention.
Emotional trauma may be longer with unpredictable events.

B)Benefits are approximate 85% of missed miscarriage is complete with medical management (1) .
It is organised and planned management and so relatively predictable events and patient can recover sooner physically and emotionally from the events of miscarriage ? evidence for emotional recovery .
Medical management of missed miscarriage (MMM) avoids anaesthetic complications and surgical risks involved with surgical management not avoided but reduced as surgery may still be needed .
Disadvantages are MMM is associated with risk of haemorrhage and may need surgical evacuation to stop bleeding (1) and also may need blood transfusion.
Risk of infection and the need for prophylactic antibiotics why? Is the risk higher or lower when compared to surgical or expectant Mx? .
MMM will need hospital admission for second part of treatment which is approximate 3-6 hours after prostaglandins administration or longer is associated with excess bleeding ? meaning?? Second part will be 24-36h after mifepristone .
MMM may need further follow-up with scans if incomplete and may need either further medical/surgical management.
MMM is associated with antiprogesterone and prostaglandin and may cause pain and need for analgesics you get pain with expectant, medical and surgical Mx. The issue will be whether a particular approach is more or less painful than the others , also possible side effects of prostaglandins like pyrexia, diarrhoea (1) .
In MMM antiD prophylaxis is recommended in rhesus negative women.

C)Benefits of surgical management is timely intervention and predictability (1) .
Early recourse to normality of life both physically and emotionally ? evidence?? .
95% success of completion of miscarriage with surgical management.
Disadvantages are risk of haemorrhage which may need blood transfusion there is a risk of haemorrhage with all approaches. Is the risk with surgical Mx higher or lower when compared to expectant or medical Mx? If you do not make this clear, how will the woman be able to decide which is best? .
Risk of infection and need for antibiotics.
If the procedure is done under general anaesthesia it is involved with the risk of general anaesthesia.
Surgical risk of perforation of uterus is approximate 1% with 0.1% risk of abdominal trauma to structures like bowel and bladder (1) .
Risk of cervical trauma may cause long term problems with future pregnancy like miscarriage or preterm labour which is not fully aware ? meaning?? .
AntiD prophylaxis is recommended for surgical management of missed miscarriage with rhesus negative patients.
Risk of needing further follow-up, scans and further medical/surgical intervention for incomplete procedures surely this applies to all methods. Is the risk higher or lower with surgical management? When indicating whether something is an advantage or disadvantage (for instance, infection), you should state whether the risk is higher or lower with surgical Mx compared to the others. If you simply say there is a risk of bleeding, infection, incomplete evacuation… in all 3 methods, how will anyone know which method is better for them? .
Posted by PAUL A.
(a) What would you tell her about the benefits and disadvantages of expectant management? [7 marks]

The women should be counseled about the management options including conservative management and she should be assisted to decide the management option. She should be told that conservative management is successful in 65-75 % of women over a period of 2-6 weeks without increasing complications (1) . There is no risk of complications like uterine perforation, intrauterine adhesions and injury to adjacent structures which can rarely occur with surgical evacuation how can this be true when expectant Mx is unsuccessful in 25-35% of cases?? . She can remain at home also. It will not increase the risk of pelvic infections (1) is the risk reduced compared to medical or surgical Mx?? or any future fertility problems. This also gives time to some women who are not convinced about the diagnosis and gives time for the results of cervical swabs to be available before any possible surgical intervention.

The disadvantages include the risk excessive bleeding and pain which is maximum in the first 8 days. Duration of management may be prolonged and may go up to 6-8 weeks (1) but it’s not harmful unless there are features of infection like fever, persistent abdominal pain or foul smelling discharge per vagina occurs. She may need regular repeat scans every 1-2 weeks and may need unplanned hospital admission, blood transfusion and surgical evacuation if there is excessive bleeding, infection or incomplete miscarriage (1) . Another disadvantage is the difficulty in getting adequate tissue for histopathological examination (1) .

(c) What would you tell her about the benefits and disadvantages of medical management?
She should be told that medical management is associated with shorter duration of treatment compared to expectant management. Usually time taken is 8 hours from induction and the bleeding stops by 8 days. It can be either prostaglandin like misoprostol alone or along with a progesterone antagonist, mifepristone and the success rates are 40-90% and 70-80 % respectively (1) lower risk of infection compared to surgical Mx, lower risk of surgical and anaesthetic complications, woman has some degree of control, may be more cost effective compared to surgical Mx.

The disadvantages include the side effects like nausea, vomiting, fever and diarrhea which depends type, dose and mode of administration of drug. There increased pain and the need for analgesia compared to expectant management (1) . Some patients may need readmission for excessive bleeding leading to blood transfusions and emergency surgical evacuation (1) . She should also be told that misoprostol is not licensed at present for missed miscarriage but it is licensed for use in induced abortions .

c) what would you tell her about the benefits and disadvantages of surgical management? [6 marks].

She should be told that that surgical evacuation having the highest success rate of 95-100 %. It is not associated increased risk of infections, or any adverse effect on future conception rates and pregnancy outcome incorrect. What do you tell women when you consent them for ERPC? Do you mention risk of infection, uterine perforation… .

But in less than 5% cases there is need for repeat evacuations. It can be associated with complications like uterine perforation in 1% cases and there is risk of cervical trauma and these have no effect on future pregnancy outcomes??/ , and rarely damage to intra-abdominal contents like bowel. It can also cause bleeding and pain during the procedure as well as anesthetic complications is blood loss or pain greater in surgical Mx compared to expectant or medical Mx?? . There is risk of pelvic infections if there is untreated cervical infection with organisms like Chlamydia. She should be reassured that screening will be done for detecting any infection before the procedure and prostaglandin may be used preoperatively to prevent trauma to the cervix.
Posted by PAUL A.
mark d

a)
The benefit is she may feel in control (1) of all that is happening and satisfied that natural way is chosen.Since there is no intervention involved there is no risk due to GA or instrumentation like perforation ,infection or cervical trauma.It is effective in 60-65% cases of missed miscarriage how do these statements tally? Expectant Mx is successful in 60-65% of cases yet there is NO risk of complications associated with intervention. So what do with the 35% unsuccessful cases? ,it is cost effective (1) as it avoids inpatient stay, repeated visits to hospital, and also separation from family. Although in most cases the sac may get reabsorbed , it may take 6-8 weeks for complete resorption is this a benefit? . She may occasionally experience unpredictable severe pain in abdomen or bleeding and in such situation or if there is foul smelling discharge,pain or fever she should report to the hospital.She may need surgical evacuation by suction (3-5% cases )if the bleeding is severe and continous or there is evidence of infection.she would be provided a 24 hour contact number and written information and her acces to hospital and transport ensured are these benefits or disadvantages? You were asked about benefits and disadvantages and you began with ‘the benefit is… Where is your answer on disadvantages??? .

b)
I will tell her that medical option is faster than expectant with complete miscarriage occuring in 80-94% of cases and mean interval of abortion is about 1-6 days from dose of mifepristone (1) .It can be done on outpatient basis and aviod separation from family and nosocomial infections.The infection rates are lower than surgical termination you are not terminating the pregnancy and no risk of GA and instrumentation.there is no effect on subsequent fertility how can this be true when it is successful in 80-94%? Presumably you will do surgical evacuation in the failures . The patient satisfaction rates are high (1) 85%.
The disadvantage is IF YOU CAN DO THIS HERE, WHY DID YOU NOT DO IT IN (a)?? the bleeding may continue as heavy for 3-4 days and then lighter for next 14-21 days (1) , she will have to use tampoon will you recommend use of tampons?? or pad till then. There are also side effects of prostaglandin tablets used like diarrhoea, hyperthermia and GI upset. She may need to come for follow up at 14-21 days to ensure completeness. she may ocasionally need a suction evacuation (1) occasionally in case of heavy and continous bleeding.
I will provide 24 hr contact number and written information to backup the verbal information.


c)
it is done by suction evacuation under sedation or GA in single sitting after cervical ripening by a vaginal pessary( gameprost) before 3 hrs is this a benefit? .
there is no pain during procedure will there be pain afterwards? and may experience mild bleeding for a week after it.there is no increased risk of placenta previa, infertlity ,ca breast ? relevance . A Cut you mean in incision? ?? relevance may be inserted at the same time if she wants.There is a small rise in preterm labour and miscarriage in next pregnancy ? evidence. IS THIS A BENEFIT OR DISADVANTAGE????? .preoperatively she will have to be screened for chalmydia and will receive prophylactic antbiotic like rectal metronidazole and oral doxycycline after surgery for 7 days.Like any other surgery there is a rare risk of anaphylaxis to drugs, risk of GA, and risks of instrumentation like perforation (2-8/1000), bleeding requiring transfusion (4/1000) cervical trauma,infection(14%) and retained pocs (1%) written information willl be given (1) .
You were specifically asked about benefits and disadvantages. In (a), you presented benefits but no disadvantages. In (b) you clearly presented benefits and disadvantages. In (c ), you presented neither. It is not clear why you were asked exactly the same question 3 times and approached it in 3 different ways.
Posted by PAUL A.
a)Benefits of expectant management include no surgical or anaesthetic risks and no side effects of any medications there is a possibility that she will require surgical management because of bleeding or incomplete evacuation. So how can you tell a woman who is about to embark on expectant management that there is no surgical risk? There is the potential for greater risk if she presents in the middle of the night with haemorrhage and undergoes an emergency procedure and patient feels under control (1) . No hospital admission is required. There is never heavy bleeding as products undergo resorption THIS IS INCORRECT – IS THERE ANY REASON WHY SHE SHOULD NOT EXPEL THE PRODUCTS WITH BLEEDING??? (-2) Your answer will fail on this alone . However, it takes longer and there are high failure rate especially in cases of missed miscarriage. Higher efficiency is seen in cases of incomplete miscarriage ? relevance to the question – SHE HAS A MISSED MISCARRIAGE. Is this a benefit or disadvantage? and smaller gestation sac. It is associated with low incidence of infection (1) lower. She requires further follow-up and she might need medical or surgical management in cases of failure is this a benefit or disadvantage? The examiner asked for benefits followed by disadvantages. So where are the disadvantages or are you expecting the examiner to decide which are disadvantages??? .
b) She should be counselled for medical management and her wishes should be taken in consideration. Unit protocols should be followed for medical management which includes priming with antiprogesterone ie mifepristone followed by oral or vaginal treatment with prostaglandin analogue ie misoprostal WHAT WILL YOU TELL HER ABOUT THE BENEFITS AND DISADVANTAGES? I will tell her the benefits are…… I will tell her the disadvantages are….. That is answering the question . Success rate depends on type of miscarriage, size of gestation sac you are given this information in the question and dose and route of prostaglandin and priming with mifepristone and type of follow up. Success rate with medical management varies from 13-96%. Higher success rate is seen with incomplete miscarriage or smaller gestation sac SHE HAS AN 8 WEEKS SIZE MISSED MISCARRIAGE . About one third have bleeding or miscarriage after priming with antiprogesterone. She should be also counselled for pain and heavy bleeding. She should be given the contact number and facility should be available to provide advice and admission in cases of heavy bleeding and pain. Bleeding normally continues for 3-4 weeks. No risk of surgical or anaesthetic complications but you have indicated that it is not always successful . Low risk of infection and low cost to NHS compared to surgical management. It can be managed as out-patient. Are you expecting the examiner to decide what are benefits and what are disadvantages from what you have written?
c)Surgical management involves risk of anaesthetic and surgical complications. Surgical risks are cervical trauma, bleeding, infection, uterine perforation adhesions and retained products (1) presume this is a disadvantage. You were asked about benefits first.. Pelvic infection rate can be reduced either by screening before attempting instrumentation of uterine cavity or offering prophylactic antibiotics. Vaccum aspiration is associated low incidence of bleeding compared to dilatation and curettage. Use of syntocinon reduces further amount of blood loss. Cervical priming with misoprostol or gameprost is recommended to reduce extra force to dilate cervix and reduce uterine perforation complications. Anaesthetic risks can be reduced by performing this procedure under sedation, but this is not the usual practice in UK. It cost more compared to medical or expectant management ? disadvantage . Efficiency is 96% is expected in experienced hands ? advantage .
Women’s wish should be considered in decision making for therapeutic intervention. Information leaflets should be provided. Support and counselling should be offered. Rhesus negative women undergoing medical or surgical management would need Anti D. Products of conception should be send for histological examination to rule out ectopic or gestational trophoblastic neoplasia. Follow up appointment should be arranged either in form of clinical or ultrasound. You have been asked a simple question but have not answered it. The answer should be:
a) The benefits of expectant management are….. The disadvantages are…..
b) The benefits of medical management are…… The disadvantages of medical management are….
c) The benefits of surgical management are….. The disadvantages of surgical management are ….
Posted by PAUL A.
a)Benefits of expectant management include no surgical or anaesthetic risks and no side effects of any medications there is a possibility that she will require surgical management because of bleeding or incomplete evacuation. So how can you tell a woman who is about to embark on expectant management that there is no surgical risk? There is the potential for greater risk if she presents in the middle of the night with haemorrhage and undergoes an emergency procedure and patient feels under control (1) . No hospital admission is required. There is never heavy bleeding as products undergo resorption THIS IS INCORRECT – IS THERE ANY REASON WHY SHE SHOULD NOT EXPEL THE PRODUCTS WITH BLEEDING??? (-2) Your answer will fail on this alone . However, it takes longer and there are high failure rate especially in cases of missed miscarriage. Higher efficiency is seen in cases of incomplete miscarriage ? relevance to the question – SHE HAS A MISSED MISCARRIAGE. Is this a benefit or disadvantage? and smaller gestation sac. It is associated with low incidence of infection (1) lower. She requires further follow-up and she might need medical or surgical management in cases of failure is this a benefit or disadvantage? The examiner asked for benefits followed by disadvantages. So where are the disadvantages or are you expecting the examiner to decide which are disadvantages??? .
b) She should be counselled for medical management and her wishes should be taken in consideration. Unit protocols should be followed for medical management which includes priming with antiprogesterone ie mifepristone followed by oral or vaginal treatment with prostaglandin analogue ie misoprostal WHAT WILL YOU TELL HER ABOUT THE BENEFITS AND DISADVANTAGES? I will tell her the benefits are…… I will tell her the disadvantages are….. That is answering the question . Success rate depends on type of miscarriage, size of gestation sac you are given this information in the question and dose and route of prostaglandin and priming with mifepristone and type of follow up. Success rate with medical management varies from 13-96%. Higher success rate is seen with incomplete miscarriage or smaller gestation sac SHE HAS AN 8 WEEKS SIZE MISSED MISCARRIAGE . About one third have bleeding or miscarriage after priming with antiprogesterone. She should be also counselled for pain and heavy bleeding. She should be given the contact number and facility should be available to provide advice and admission in cases of heavy bleeding and pain. Bleeding normally continues for 3-4 weeks. No risk of surgical or anaesthetic complications but you have indicated that it is not always successful . Low risk of infection and low cost to NHS compared to surgical management. It can be managed as out-patient. Are you expecting the examiner to decide what are benefits and what are disadvantages from what you have written?
c)Surgical management involves risk of anaesthetic and surgical complications. Surgical risks are cervical trauma, bleeding, infection, uterine perforation adhesions and retained products (1) presume this is a disadvantage. You were asked about benefits first.. Pelvic infection rate can be reduced either by screening before attempting instrumentation of uterine cavity or offering prophylactic antibiotics. Vaccum aspiration is associated low incidence of bleeding compared to dilatation and curettage. Use of syntocinon reduces further amount of blood loss. Cervical priming with misoprostol or gameprost is recommended to reduce extra force to dilate cervix and reduce uterine perforation complications. Anaesthetic risks can be reduced by performing this procedure under sedation, but this is not the usual practice in UK. It cost more compared to medical or expectant management ? disadvantage . Efficiency is 96% is expected in experienced hands ? advantage .
Women’s wish should be considered in decision making for therapeutic intervention. Information leaflets should be provided. Support and counselling should be offered. Rhesus negative women undergoing medical or surgical management would need Anti D. Products of conception should be send for histological examination to rule out ectopic or gestational trophoblastic neoplasia. Follow up appointment should be arranged either in form of clinical or ultrasound. You have been asked a simple question but have not answered it. The answer should be:
a) The benefits of expectant management are….. The disadvantages are…..
b) The benefits of medical management are…… The disadvantages of medical management are….
c) The benefits of surgical management are….. The disadvantages of surgical management are ….
Posted by PAUL A.
SM reply.
a)
The benefit of expectant management is that hospital admission can be avoided . When successful, side-effects of medications , anaesthesia and surgery can be completely avoided (1) . It is less expensive to the NHS. The risks of pelvic infections are lesser than when surgical methods are used (1) . This method has no adverse effect on future fertility. Anti-D injection, which is a blood product, can be avoided (1) .
The disadvantage of expectant management of missed miscarriage is that success rate with intact sac and closed os is less than 50%. The pregnancy may require weeks to resolve completely (1) . Bleeding per vagina can be sudden, unpredictable and profuse (1) . She may need surgical evacuation finally. Hence, she will need quick access to a hospital round the clock (1) .

b)
The benefit of medical management of missed miscarriage is that the woman feels more in control. She can avoid risks of surgery and anaesthesia if this method is successful (1) . Hospital admission is not required. This method is more cost – effective to the NHS (1) . Risk of pelvic infection is less (1) .
The disadvantage is that she may end up needing a surgical evacuation. She needs Anti-D injection if she is Rh negative. Success is lower with this method if there is an intact sac and closed cervix (1) . This method can take upto 2 days to complete.
more pain & bleeding compared to surgical Mx, tissue may not be available for histology
c)
The benefit of surgical management is that it is a planned procedure. It can be done under GA or local anaesthesia. She can go home the same day (1) , usually. Sexually transmitted infection screen will be offered to her. higher success rate, tissue available for histology, less pain & bleeding compared to medical Mx
The disadvantage is that she will need hospital admission. Complication of anaesthesia can occur like aspiration .Complications of surgery like uterine perforation, trauma to bowel/bladder (1) and hemorrhage needing blood transfusion can occur. Pelvic infections are more likely to occur after a surgical procedure (1) . She will need Anti –D injection after the procedure. Prophylactic antibiotics may be required. This is a more expensive option for the NHS.

The woman’s wishes must be respected. Written information will be offered. Emotional trauma is comparable with all three options of management. Counselling and support must be offerd.

GOOD ANSWER
Posted by PAUL A.
a -I would tell her that she does not have to get admitted and does not have to take medications ,so cost effective (1) .It doesnt cause much of pain as is in medical management. Avoids anaesthetic(anaphylaxis to drugs) and surgical complications such as perforation cervical tear and haemorrhage these are not avoided but the risks are lower .Anti -d prophylaxis if the patient is Rh negative is not required (1) .The disadvantages are, that of patient anxiety of waiting for long period as it may take 2 weeks also. It should be adviced only to patients with 24 hr telephone and hospital admission acces (1) .The chance of successful resorption does it always have to be resorbed? Can it not be expelled? is less with missed misscarriage.( when compared to incomplete misscarriage).Tissue for HPE not got with expectant management (1) .
b -The benefits of medical management are that it has more patient acceptability compared to what? Surgical or expectant Mx? .It needs only short hospital stay. It avoids these are not avoided anaesthetic and surgical complications of surgical termination THE PREGNANCY IS NOT BEING TERMINATED . It has decreased incidence of pelvic infection (1) and no adverse effects on fertility.The disadvantages are that of pain greater pain. Pain occurs with all options , so requires analgesics do you not need analgesia with expectant / surgical management .It causes bleeding also do you not get bleeding with expectant / surgical Mx? . It creates a feeling of medicalisation of the whole process in the patients mind.Failed treatment requires surgical evacuation at a later date.Anti -d needs to be given if she is Rh negative.This treatment should be advised only if 24 hr telephone and hospital access is available to the patient (1) .
c -The benefits of surgical treatment are that HPE what is this?? is available for diagnosis.The satisfaction rates may be more rapid resolution, less blood loss, higher success rate, high patient satisfaction… .The disadvantages are that the need for hospital admission and its cost (1) .Outcome is dependent on the surgical expertise of the surgeon and the cause ? meaning . The success of surgical treatment in early 1 st trimester is less less than with what? Medical / expectant management?? ( ie failed evacuation).There are complications such as risk of uterine perforation(1-4/1000 procedures),haemorrhage(0.88/1000 procedures), cervical tear (1) though less in this gestation when compared to 2 nd trimester ? relevance surgical evacuation, infection, and acute medical complications such as cardiac arrest during dilatation of cervix, and effects on future fertility such as preterm labour and misscarriage.Anti-d needs to be given if the patient is Rh negative.
Posted by Ahmad A.
The benefits of expectant management were discussed with the patient includes, that she is going to avoid hazards of anesthesia specially with general option. Also, she is going to avoids the side effects of surgical procedure like possibility of uterine perforation, cervical trauma, and uterine infection (endometritis). I would tell her that she may avoid the incidence of intrauterine adhesions (Ashermann) especially with repeated uterine curetting. She may have her daily work without significant interruption till significant bleeding or abdominal pain starts. She can avoid use of Anti-D in case Rh-ve patient. On the other side, I would tell her she may wait quite long time till spontaneous miscarriage (2-6 weeks) and this may have psychological side effects of keeping unhealthy, dead fetus. In case of failure either complete or incomplete, surgical procedure may carried out. Also, she may suffer from infection in case of retained products, in case she may need antibiotic cover.

The benefits of medical management are those involved in expectant management, specially with avoidance of the hazards of anesthesia and surgical procedure. The satisfaction rate is higher than expectant option and the complete abortion rate up to 90%. The period till the procedure completed may be shorter than the expectant option (2-7 days). The bleeding may become lower as using of potent uterotonic medication. However, there are some side of effects with use of prostaglandins, mifepristone including, gastrointestinal, diarrhoea, vomiting& cramps. Surgical evacuation may be used in case of incomplete miscarriage. Also, retained products may needs antibiotic cover to avoid possible infection.

With surgical management the patient\'s satisfaction rate is the highest between different option. With completed action till more than 95% of cases. It is a day case procedure and there are some precautions may be followed to avoid side effects. Like use of paracervical blocking as an alternative of genral anesthesia. Also, to use cervical preparation like misoprostol of mifepristone to avoid cervical trauma and uterine perforation. Use of screen and treat option to avoid possible infection secially with high risk patients and chlamydial infection. Use of suction curettage is a recommended option to avoid incomplete curetting and to reduce perforation rate. On the other hand, still there is significant side effects f general anaethesia. Also, hospital confinement and procedure may let the patient to be away from the work for sometime. There is still little increase in the rate of uterine perforation which needs more procedure to do (laparoscopy-Laparotomy) and she may need for blood transfusion in case of haemorrhage. Incomplet evacuation may need another set of procedure. Also, there is higher incidence of intrauterine synaechiae, Ashermann. In case of Rh-ve patient, she need for anti-D prophylaxis.

Patient\'s information leaflets should be provided with direct phone contacts in case of emergency need and provide suitable explanation for any queries during different methods of treatment.
Posted by A H.
ah

a) I would explain that expectant management entails waiting for spontaneous passage of products and resolution of symptoms. This is associated with less bleeding as much of the products of conception is resorbed. There will also be reduced risk of clinical pelvic infection and no adverse effect on future pregnancy.
The disadvantages are due firstly, to prolonged bleeding lasting several weeks, which may occur before the pregnancy is fully resolved. In a small minority of cases, passage of tissue is associated with heavy bleeding. Also, the efficacy is variable and can be as low as 25 percent. Significant patient anxiety may be engendered while awaiting resolution of the pregnancy.

b)I will explain that medical management involves the use of tablets either by the oral or vaginal route, to evacuate the uterus. This has the advantage of being more efficacious thn expectant care. Success depends on the size of the gestational sac and the dose of medication but is generally above 80 percent.The risk of pelvic infection is low and she can be managed as an outpatient with minimal risk to her family life.
The disadvantages are the possibilty of severe pain requiring parenteral analgesia and prolonged bleeding of up to three weeks after products are passed.In some cases bleeding may be heavy. Common side-effects of the drugs are mainly gastrointestinal, namely nausea, vomiting and ,if misoprostol is used, diarrhoea. If anaphylaxis which is rare, occurs, it may be fatal.

The advantages of surgical management includes termination of the pregnacy at a covenient time for the woman and her family,with less pain and bleeding.
The disadvantages are the risks associated with general anaesthesia, risk of pelvic inflammatory disease, and the need for hospitalisation for at least 6 to 8 hours.
Procedure related risks occur in less than 10% of cases and include trauma, namely cervical laceration, uterine perforation, and injury to bowel and bladder. Haemorrhage may be significant requiring blood transfusion or rarely, hysterectomy. Intrauterine adhesions may form contributing to future infertility. Cervical trauma can cause an incompetent cervix and future second trimester miscarriage. She will require prophylactic anti- RhD if she is Rhesus negative.
Posted by Ron C.
A.
Miscarriage is a distressing event which must be acknowledged. In expectant management about 60-70% of missed miscarriages will eventually abort spontaneously. Its main advantage is that it is a natural process, avoiding any medical or surgical intervention with their associated risks. The time required for this to happen will give the couple the opportunity to come to terms with the lost pregnancy. it may take 2-4 weeks though, and if so, time spent waiting may become emotionally taxing. There is a small potential for infection and heavy bleeding, especially in incomplete miscarriage. Surgical evacuation may have to be arranged after all as emergency procedure in such a case.

B.
Medical intervention uses oral or vaginal prostaglandins to obtain “spontaneous” evacuation of the failed pregnancy. Main advantage is reduction of interval between diagnosis and “evacuation” of the pregnancy, whilst still avoiding surgical intervention. This is particularly important in couples who emotionally can’t cope with a long interval from time of diagnosis. The medication may cause severe gastro-intestinal disturbance including vomiting & diarrhea. Infection and bleeding may still occur as well as incomplete miscarriage, again requiring surgical evacuation as emergency procedure.

C.
Surgical evacuation can be done as a planned daycase and involves dilating the cervix and evacuating the failed pregnancy, mostly by means of suction curettage as this reduces blood loss. Main advantage is a short interval from diagnosis to procedure with an almost certain outcome, though in rare cases the uterus is incompletely emptied and a 2nd procedure is required later on. Risk of bleeding and infection are still present, and additionally risk for damage/perforation of the uterus. The latter can mostly be managed conservatively, but if the instrument entered the abdominal cavity and suspicion for visceral damage is raised, laparoscopic inspection and if needed repair is necessary. There is a small risk for Ashermann Syndrome, which may compromise future fertility. As in any surgical procedure, anaesthetic complications may occur as well.
Posted by PAUL A.
A. Benefits of expectant management include minimal bleeding as the pregnancy resolves by complete resorption this is incorrect – is there any reason why the pregnancy should not be expelled with bleeding? and avoidance of surgical and anaesthetic complications NO – these are not avoided – there is the possibility that she presents with severe bleeding and requires an emergency ERPC with greater risks, or expectant management fails and she requires surgery like perforation and cervical trauma associated with surgical evacuation. Better quality of life been documented as women feel that they are more in control (1) with the procedure. There is reduction in clinical pelvic infection and does not have any adverse effect on future fertility incorrect – see earlier comment . It is cost effective. Serum progesterone less than 20nmol/L can predict the successful outcome of expectant management with sensitivity of 93% and specificity of 94%
The efficacy of the expectant management varies between 25-100% depending on the type of miscarriage, sac size the question tells you precisely the type of miscarriage and size of the sac. Is this a benefit or disadvantage? and whether follow up is based on clinical examination or ultrasound. For missed miscarriage success rate is lower and patient might need surgical evacuation at a later date to complete the process. Histological examination of the products of conception may not be available is this a benefit or disadvantage? . Repeated follow up may be required to assess the outcome. In one third of patients severe bleeding per vaginum can occur requiring emergency hospital admission and surgical evacuation (1) WHERE DO YOUR DISADVANTAGES BEGIN OR ARE YOU HOPING THE EXAMINER WILL DECIDE FOR YOU.

B. Medical management can be provided as outpatient treatment and it is cost effective. The efficacy varies from 13-96% and it depends on type of miscarriage, sac size, follow up you are given this in the question. Is a success rate of 13-96% a benefit or a disadvantage??? (whether based on clinical examination or ultrasound) dose and duration of prostaglandin and route of administration. For missed miscarriage cervical priming with mifipristone is required before prostaglandins for successful outcome. No surgical intervention involved how can this be true when the success rate is 13-96%? HOW CAN YOU TELL A WOMAN ABOUT TO EMBARK ON MEDICAL MANAGEMENT THAT THE SUCCESS RATE COULD BE AS LOW AS 13% YET NO SURGICAL INTERVENTION WILL BE REQUIRED????? and hence no surgical or anaesthetic complications. Reduced incidence of clinical pelvic infection and has no adverse effect on future fertility see earlier comment .
Disadvantages include increased pain and bleeding especially with tissue passage (1) . Patient can have bleeding everyday from 14 to 21 days following the procedure. In case of severe bleeding or retained products of conception she will require surgical evacuation yet you said NO SURGICAL INTERVENTION INVOLVED

C. At least 35% of women show strong preference for surgical evacuation is this a benefit or a disadvantage? If neither, you are wasting your time . It is performed as day case procedure. Specimen would be available for histopathological evaluation (1) . Usually performed under systemic analgesia or patient controlled anaesthesia All ERPCs in the UK are performed under general or regional anaesthesia except in very exceptional circumstances. What is patient controlled anaesthesia? How can a patient be in control of their own anaesthesia??? and hence patient will not experience pain will they not have pain after the operation? . Usually screening for chlamydia , bacterial vaginosis and gonococcal infection would be done and hence reducing the risk of pelvic inflammatory disease wrong – the risk of infection is higher with surgical compared to medical management . Suction evacuation is associated with lesser pain, bleeding and lesser operating hours compared to which other technique or procedure?? . Use of prostaglandins preoperatively will reduce the force required to diale the cervix and reduce the risk of perforation and cervical trauma. Use of oxytocin will reduce bleeding are these benefits or disadvantages?? .
Disadvantages include cervical trauma, uterine perforation, intra abdominal injury haemorrhage this cannot be a benefit as well as a disadvantage. Surgical management is associated with less bleeding compared to medical management , and intrauterine adhesions because of overzealous curettage. Anaesthetic complications are also involved. It is not cost effective (1) . Patient should be offered these options in sensitive way and encouraging her to make informed decision. Involvement of women in decision making has better quality of life on objective assessment. Information about disposal of fetal parts should be given and her views should be recorded in case sheet. Written information (1) should be provided. Support groups should be identified to her.
Posted by PAUL A.
prt

a]I would like to tell the patient that expectant management of missed miscarriage involves waiting for the natural resorption of the products of conception is there any reason why the products should not be expelled? . It can be successful in 74% of the cases and 25% may require surgical evacuation is this a benefit? .It is cheaper and cost effective.Patient stays at home and avoids varoius complications associated with medical/surgical methods (1) complications are not avoided.
The disadvantage of the expectant Mx is the unpredictability and the long course compared to other methods (1) .It may take upto 6-8 weeks to resorb completely and patient needs frequent followups in early pregnancy unit and USG to monitor.Patient should be given the contact numbers and the written appointments.In case patient is in a hurry then she needs to choose other methods.
We should tell the patient that in all these three methods,there is no particular benefit of one method over the other.

b]Patient is told that the medical Mx involves the use of drugs for the termination of pregnancy YOU ARE NOT TERMINATING HER PREGNANCY .It is successful in 85-90% of the cases,but 10% may require surgical evacuation for excessive bleeding or retained products of conception IS THIS A BENEFIT? .She is told that she would be given Mifepristone200-600mg followed by gemeprost 1mg/misoprostol after 36-48 hours IS THIS A BENEFIT OR A DISADVANTAGE? THIS IS WHAT YOU WERE ASKED ABOUT .She can be managed in out patient department and does not need admission unless she bleeds excessively.
The disadvantage of the medical Mx are the gastrointestinal adverse effects like nausea,vomitting in 50% of the cases.These can be reduced by reducing the dose of mifepristone to 200mg ARE THESE SIDE-EFFECTS DUE TO MIFEPRISTONE? .She should be given the hospital contact numbers for the emergency contact in case of excessive bleeding. There is risk of infection is this risk higher or lower compared to surgical Mx? so she would need prophylactic antibiotics.To avoid pain ,the analgesia should be prescribed also.She needs Anti D prophylaxis in case Rh negative unlike expectant Mx (1) .She should be told that she can bleed from 10-14 days in medical Mx.

c]Patient can be told that the benefits of surgical evacuation are that its a one stage procedure .She can be admitted for a day in day care surgery and discharged same day (1) .She can be screened in the same sitting for STI like chlamydia and gonorrhea and treated with drugs for the same.In case she is keen for the contraception she can be fitted with IUCD also.
Varoius disadvantages of the surgical procedure should be told and consent for the same and general anasthesia is taken.She should be told about the risk of uterine perforation 2-8/1000, risk of haemorrhage blood loss is lower with surgical Mx compared to medical Mx ,infection risk of infection is higher with surgical Mx compared to medical Mx and blood transfusion.There is 1% risk of Retained /incomplete products of conception.The complications can be reduced by cervical priming by prostaglandins 3 hours before the operation.She should be reassured that these are rare complications.She should be given the name and contact numbers of the support groups like Miscarriage Association for the psychological counselling.

For a woman to be able to chose between expectant, medical and surgical management, they need to know whether the risks of bleeding, infection… are higher or lower with a particular approach. Simply saying there is a risk of bleeding and infection with medical Mx, and a risk of bleeding, infection… with surgical Mx is totally unhelpful.
Posted by PAUL A.
a. She should be informed that the success rate of expectant management varies from 25-75% is this a benefit? . The patient should be informed that it may require follow up till several weeks (4-6 weeks) is this a benefit? . The benefit of expectant management is cost effective as compared to medical/surgical intervention (1) . It is associated with less separation from their family in expectant management as compared to surgical intervention. However, expectant management is associated with increased risk of incomplete miscarriage. This group of patient will experience heavier and longer duration of pervaginal bleeding (1) . It is also associated with increased anxiety rate ? evidence among women who subjected to expectant management. The risk of unexpected surgical intervention is highest in expectant management (10-44%) as compared to surgical (2-5%) or medical management (10-36%) (1) . Written information should be given to patient. There is no different in risk of infection/endometritis.
b. The success rate of medical management is about 60-95% is this a benefit? , but the outcome varies depend on the duration and dosage of prostaglandin used for medical intervention. She should be told that the success rate is increased if combined medicine is used (prostaglandin and mifepristone). The procedure can be done as out patient, thus reduce the admission rate. But it is associated with abdominal pain and heavy bleeding greater pain and heavier bleeding compared to surgical Mx . The requirement of analgesia is also increased (1) . There is no different in rate of infection incorrect and outcome of future pregnancy. Written information should be given to the patient.
c. Surgical intervention is associated with high success rate (95-100%) and associated with lower rate of unexpected surgical intervention (1) . The patient should be informed the best choice of surgical intervention will be in a form of suction and curettage. It is a treatment of choice in a patient with recurrent and heavy bleeding, haemodynamicly unstable patient and infected retained product of conception does any of this apply to the woman in question? . It requires day care procedure and requires either sedation or general anesthesia. It carries higher risk to develop intrauterine adhesion. It is also associated with complication of surgical intervention like uterine perforation and cervical injury. Written information should be given to the patient (1)

You were asked about benefits first then disadvantages. You should therefore begin your answer with benefits and indicate unequivocally where you are presenting disadvantages
.
Posted by PAUL A.
a.The benefit of expectant management is that it is natural way of termination and avoids other operative procedures risk is reduced but not avoided .Infection risk is not increased does this mean it is reduced? and there is no adverse effect on fertility.Anti-D not required in rhesus negative individuals (1) .The disadvantages are bleeding may be unpredictable and prolonged,severe bleeding may necessitate blood transfusion or emergency evacuation (1) .Success rate in closed cervix with intact sac is low-25-43% (1) so how could you say operative procedures are avoided?.
b.Benefits of medical management are the avoidance of surgical and anaesthetic management see comment above .The medications can be taken orally or vaginally and the patients feel more in control (1) of the process.Infection risk is less and more cost effective (1) than surgical termination YOU ARE NOT TERMINATING HER PREGNANCY .Success rate is 80-85% is this a benefit? .The disadvantage may be due to the effect of medication like pain,cramps,nausea.Bleeding may be heavy (1) heavier blood loss compared to surgical Mx and necessitate transfusion in 1-5 % of cases.Emergency surgical evauation may be needed for retained products of conception (1) in 4-15/1000 cases.Anti D required in Rh negative individuals.
c.Benefits ofsurgical treatment include that it is a defintive management with success rate of 90-95% (1) .Failure rate is rare in experienced hand of 1-2/1000 cases.It is done as a day care (1) procedure, though usually done under GA can be done under local anaesthesia.
Disadvantages are it may need prior piming why is this a disadvantage?? ,complications like infection, bleeding,blood transfusion you said bleeding was higher with medical Mx ,cervical trauma ,uterine injury,anaesthetic risks.Anti-d required in Rh negative women.Information leaflets will be provided with the information (1) and patient wishes respected.
Posted by PAUL A.
A healthy 25 year old woman attends for a dating scan and is found to have an 8 weeks size missed miscarriage. (a) What would you tell her about the benefits and disadvantages of expectant management? [7 marks] (b) what would you tell her about the benefits and disadvantages of medical management? [7 marks] (c) what would you tell her about the benefits and disadvantages of surgical management? [6 marks].


I would tell the patient that expectant management is safe and acceptable method. incorrect. There is a risk of heavy bleeding requiring emergency surgery / failed treatment . It is an outpatient management. It involves less blood loss as resorption of fetal tissue takes place overtime why should the products not be expelled with bleeding which might be heavy? . There is reduction of clinical pelvic infection (1) and no effects on future fertility.

Disadvantages of this method are it takes weeks to completely misscary(2-6weeks oppr) (1) . Has a lower efficacy rate as compared to other methods what is low? 5%?? . Increase psychological impact and anxiety ? evidence . Remote risk of coagulopathy as a dead fetus in uterine cavity. Follow up is required in early preganacy unit on a regular basis till complete miscarriage confirmed.

b) Medical method is the effective method why is this THE EFFECTIVE method?? for the first trimester miscarriage and has higher efficacy rate than expectant management. Efficacy rate is increase with high dose of prostaglandins, intravaginal use and the sac size. Can be offered as an outpatient procedure and admission is neded in only less than 1% of cases if heavy bleeding occur.
Mefipristone will be given as a single dose and she needs to follow up in 36-48 hrs time for misoprostol 800ug given intravaginal as single dose. She should be informed that these drugs are not licensed in UK for this procedure but are highly effective and has been used for many years for management of miscarriage with no long term adverse effects ?? benefits??? . It is the most cost effective method (1) .
Drugs have minor side effects of nausea, vomiting and diahroia. She may experience more pain than expectant and surgical method and may require analgesic . Failure of the procedure may lead to repeat procedure or she can wish surgical method. Surgical method of evacuation may require in less than 1% case if she experience very heavy bleeding are these benefits? Are you expecting the examiner to decide what are disadvantages? .

c) surgical method is the very quick method of evacuation of uterus. It is the most effective method with efficacy rate as high as 99% (1) . It is done a s day case procedure and hence can be discharged on the same day. Less painful procedure as done under anaesthesia (1) . Products of the conception can be obtained for hisopatholgy examination (1) to rule out gestational trophoblastic disease and for investigations for recuurent miscarriage.
This procedure carries risk of anaesthesia. There is a risk of cervical trauma (1-14/1000) but can be reduced by prior use of prostaglandins intavaginaally. 1-4/1000 risk of perforation of the uterus in which case laparotomy may be inicated if large perforation. Increase risk of bleeding HOW CAN THE RISK OF BLEEDING BE INCREASED? Blood loss is lower than with medical management , infection and intrauterine adhesions should be informed.

Patient should be given written information (1) and clinicians should encourage informed decisions and support their decisions as it is associated with positive quality of life outcomes.
Posted by PAUL A.
X

a. I would inform her that expectant management includes natural course of the miscarriage in which awaiting for sponataneous uterine evacuation or resorption of the product of conceptus. The advantages include that it is and outpatient basis and does not require admission (1) . She will be able have emergency admission or telephone assistance from the early pregnancy assessment unit if she is aborting is this a benefit? . The risk of infection is relatively lower than surgical evacuation (1) . It is also associated with higher return to fertility. And it is cost effective, if it is successful in 60 to 80% of the time this is an inappropriate statement – it is like saying a drug is safe if you do not get side-effects . It is also associated with less bleeding as some degree of resorption takes place. But unfortunately it is has higher chance of failure than the other methods. It is also associated with more pain (1) . It could require higher chance of having emergency ERPC. It sometimes require a long duration before the miscarriage resolves (1) .


b. Medical management of miscarriage includes antprogesterone priming such as mifepristone and usage if prostaglandin such gameprost or misoprostol. This mode also carries a smaller risk of infection (1) compared to surgical evacuaton. It is also faster to resolve the miscarriage compared to expectant. This treatment also could be done as outpatient. This method is more effective (1) than the expectant management. The return to fertility is also comparable to expectant management. But emergency surgical evacuation is a drawback to this method. It is also associate with increased pain and higher blood loss (1) drug side-effects, tissue may not be available for histology; only suitable in centres able to provide 24h emergency surgery.

c. Surgical management is still a popular approach as the women has more control to the miscarriage and success rate is about 99% (1) . It could be done as an elective basis and the woman could sort out her affairs before the procedure. The pain would be very minimal compared to the other methods (1) as analgesia is given. Opportunistic screening for Chlamydia and bacterial vaginosis could also be done during procedure. tissue available for histology, But it is associated with anesthesia risk such as infection and aspiration. The risk of endometritis is relatively higher (1) compared to the other methods. The surgical risk as cervical trauma, and uterine perforation is a also a disadvantage (1) . Risk of Ashermans’s syndrome upon overzealous curettage also predisposes to subfertility and decrease in return to fertility. It also ruquire hospital admission
Posted by PAUL A.
nellie

a) Expectant management involves her awaiting products of conception (POC) to be expelled or resorption to occur. The chance of success is reduced with an intact sac as compared to having an incomplete miscarriage is this benefit of expectant management? You were asked about benefits first . She has more control of what occurs by choosing this method (1) . There may be up to 3 weeks of pv bleeding is this a benefit? and follow up should be by a transvaginal scan (TVS) to ensure the POC have been expelled. There is no risks like from surgical intervention, from the surgery itself as well as the aneasthetic complications So you have told the woman expectant management might not work but carries NO RISK of surgery? So what do you do if it does not work? . It is done as an outpatient procedure. There is reduced chance of infection (1) as compared to surgical management because there is no introduction of organisms into the genital tract, into the uterus and tubes. The chance of success though may be smaller as compared to that obtained via medical or surgical management.The disadvantages are that the expected time for resolution is uncertain and so having follow up may have the patient anxious about the probability of POC left inside. The theoretical probability of infection still exists but the risks seems less vs. surgical management make your mind up – is infection a benefit or disadvantage? It cannot be both . There is no need for administration of Anti- D Ig if non-sensitized and pv bleeding not heavy is this a disadvantage?? . The patient must be able to have choice of converting to option of medical or surgical management at any time though you clearly did not write an answer plan or if you did, you did not follow it. You have benefits mixed in with disadvantages and any patient given information in this way will be very confused .

b) Medical management involves the use of drugs given orally, per vaginam or a combination of Mifepristone and prostaglandins to aid in expediting the process of removal of POC. The drugs used like Misoprostol are associated with side effects like diarrhea, abdominal pain, nausea and vomiting, abnormal vaginal bleeding you were asked about benefits and disadvantages, NOT disadvantages and benefits . She needs to be aware of such and should have access to an emergency department 24 hrs, even for telephone contact to be advised on symptoms which are excessive. It will involve in some settings in hospital administration of some tablets with instructions for at home dosing thereafter. There is still the probability of surgical management if the pv bleeding is excessive. The Rhesus status must be known because Anti- D will have to be given to a non – sensitized Rh negative patient. The advantages BENEFITS and DISADVANTAGES – you will not answer part (b) of the question before part (a) are there is quicker resolution and removal of POC and the patient may feel reassured. One more disadvantage – follow up is required this will be unnecessary if you had written an answer plan and followed it .

c) Surgical management has the advantage why did the examiner ask for BENEFITS instead of ADVANTAGES?? of being quick with little follow up required i.e. having a repeat TVS. The patient is still in control of her decision and there is less anxiety associated ? evidence with probable remnants of POC when the surgery is completed. The disadvantages of ERPC are there are anaesthetic complications if general anaesthesia especially used or local. The other surgical risks (1) are of uterine perforation- and if it is possible, she may need to remain in hospital for a period of observation with the possibility of laparotomy. There is a chance of cervical tears, infection risk increased, and haemorrhage. This has to be done in hospital so she would need to be admitted to hospital, likely only a day case if uneventful. Anti- D must be given if non- sensitized Rh-negative patient
Posted by PAUL A.
The benefits of expectant management were discussed with the patient includes, that she is going to avoid hazards of anesthesia specially with general option. Also, she is going to avoids the side effects of surgical procedure like possibility of uterine perforation, cervical trauma, and uterine infection (endometritis) risk reduced but these are not avoided. Expectant Mx might fail or she presents with heavy bleeding requiring surgery . I would tell her that she may avoid the incidence poor English of intrauterine adhesions (Ashermann) especially with repeated uterine curetting. She may have her daily work without significant interruption do you think a woman in this position should go back to work and be expected to carry on as normal? till significant bleeding or abdominal pain starts. She can avoid use of Anti-D in case Rh-ve patient (1) . On the other side, I would tell her she may wait quite long time till spontaneous miscarriage (2-6 weeks) (1) and this may have psychological side effects ? evidence of keeping unhealthy what is unhealthy about the fetus? , dead fetus. In case of failure either complete or incomplete, surgical procedure may carried out. Also, she may suffer from infection in case of retained products, in case she may need antibiotic cover.

The benefits of medical management are those involved in expectant management there are 7 marks – do you expect marks for this statement?? , specially with avoidance of the hazards of anesthesia and surgical procedure NOT AVOIDED . The satisfaction rate is higher (1) than expectant option and the complete abortion rate up to 90% is this a benefit or a disadvantage? . The period till the procedure completed may be shorter than the expectant option (2-7 days). The bleeding may become lower as using of potent uterotonic medication. However, there are some side of effects with use of prostaglandins, mifepristone including, gastrointestinal, diarrhoea, vomiting& cramps (1) . Surgical evacuation may be used in case of incomplete miscarriage. Also, retained products may needs antibiotic cover to avoid possible infection.

With surgical management the patient\'s satisfaction rate (1) is the highest between different option. With completed action till more than 95% of cases ? meaning . It is a day case procedure and there are some precautions may be followed to avoid side effects. Like use of paracervical blocking as an alternative of genral anesthesia. Also, to use cervical preparation like misoprostol of mifepristone to avoid cervical trauma and uterine perforation are these benefits of surgical management or just the way the operation should be done? . Use of screen and treat option to avoid possible infection secially with high risk patients and chlamydial infection. Use of suction curettage is a recommended option to avoid incomplete curetting and to reduce perforation rate. On the other hand, still there is significant side effects f general anaethesia. Also, hospital confinement and procedure may let the patient to be away from the work for sometime. There is still little increase in the rate of uterine perforation (1) which needs more procedure to do (laparoscopy-Laparotomy) and she may need for blood transfusion in case of haemorrhage blood loss is higher with medical management . Incomplet evacuation may need another set of procedure. Also, there is higher incidence of intrauterine synaechiae, Ashermann. In case of Rh-ve patient, she need for anti-D prophylaxis.

Patient\'s information leaflets (1) should be provided with direct phone contacts in case of emergency need and provide suitable explanation for any queries during different methods of treatment.

Your English needs to be improved
Posted by PAUL A.
ah

a) I would explain that expectant management entails waiting for spontaneous passage of products and resolution of symptoms. This is associated with less bleeding as much of the products of conception is resorbed ? evidence. What stops the products being expelled with bleeding? . There will also be reduced risk of clinical pelvic infection (1) and no adverse effect on future pregnancy. woman is in control, cost-effective, may not require anti-D
The disadvantages are due firstly, to prolonged bleeding lasting several weeks (1) , which may occur before the pregnancy is fully resolved. In a small minority of cases, passage of tissue is associated with heavy bleeding. Also, the efficacy is variable and can be as low as 25 percent (1) . Significant patient anxiety may be engendered while awaiting resolution of the pregnancy.

b)I will explain that medical management involves the use of tablets either by the oral or vaginal route, to evacuate the uterus. This has the advantage of being more efficacious thn expectant care. Success depends on the size of the gestational sac and the dose of medication but is generally above 80 percent.The risk of pelvic infection is low (1) lower than for surgical Mxand she can be managed as an outpatient with minimal risk to her family life cost effective; woman retains some control .
The disadvantages are the possibilty of severe pain more pain compared to surgical Mx requiring parenteral analgesia and prolonged bleeding of up to three weeks after products are passed (1) .In some cases bleeding may be heavy. Common side-effects of the drugs are mainly gastrointestinal, namely nausea, vomiting and ,if misoprostol is used, diarrhoea (1) . If anaphylaxis which is rare, occurs, it may be fatal. tissue may not be available for histology

The advantages of surgical management includes termination YOU ARE NOT TERMINATING HER PREGNANCY of the pregnacy at a covenient time for the woman and her family,with less pain and bleeding (1) .
The disadvantages are the risks associated with general anaesthesia, risk of pelvic inflammatory disease, and the need for hospitalisation for at least 6 to 8 hours.
Procedure related risks occur in less than 10% of cases and include trauma, namely cervical laceration, uterine perforation (1) , and injury to bowel and bladder. Haemorrhage less blood loss compared to medical Mx may be significant requiring blood transfusion or rarely, hysterectomy. Intrauterine adhesions may form contributing to future infertility. Cervical trauma can cause an incompetent cervix and future second trimester miscarriage. She will require prophylactic anti- RhD if she is Rhesus negative.
Posted by M M.
a)The benefits of expectant management for missed miscarriage is the avoidance of hospital admission. The woman may feel that waiting for spontaneous miscarriage is more natural. Expectant management is associated with less risk of infection compared to surgical intervention. If successful, it can also avoid risks associated with medication, anesthesia & surgical intervention. Rh negative woman can avoid risk associated with anti-D administration.The disadvantages of expectant management includes the unpredictability of the outcome. In may take upto few weeks before the woman spontaneously miscarry or resorption of products occur. In cases where the sac is intact & the cervix is closed, the success rate is less than 50%. It may be associated with pain and heavy bleeding that might require hospital admission or surgical intervention at the end. Tissue may not be available for histological examination.
b) Medical management has the benefit of avoiding hospital admission. It can also avoid risks associated with surgical management & anaesthesia. It carries less risk of pelvic infection compared to surgical evacuation. The disadvantages are pain & heavy pv bleeding that may require hospital admission and may also end up with needing an emergency surgical evacuation. Tissue may not be available for histology. Anti-D which is a blood product needs to be given to Rh negative woman.
c) Surgical management has the benefit of being a planned procedure. It can be done as a day case. It is associated with less pain and bleeding compared to medical management. Tissue will be available for histological examination. The disadvantages of surgical management are risks of anaesthesia, uterine perforation, bowel & bladder injury. It has higher risk of infection compared to medical management. Occasionally, evacuation is not complete and requires second evacuation. Anti-D will need to be administered to Rh negative woman.
Posted by R M.
(a)I would tell her that expectant management includes letting the nature take it’s course.There are many benefits .This method allows her to be at home.Avoids risks associated with anaesthaesia and surgery.This method is more cost effective to NHS if successful compared to medical and surgical management.No increased risk of infection compared to other methods..No need for Anti D injections if successful as no increased risk of Rh-sensitization.The disadvantages are : unable to estimate timescale compared to other two methods-may have to wait for a long duration which increases patient anxiety ;risk of prolonged bleeding leading to reduction in haemoglobin levels ;successful only in around 50% of cases-so may need medical or surgical methods later on ; risk of heavy bleeding and pain at home necessitating emergency hospital admission and evacuation of uterus ; products of conception may not be available for histopathological examination.I’ll provide her with written information and contact numbers.

(b)I would tell her that medical management using prostaglandins alone or along with mifepristone is successful in around 85% of cases.The benefits include :it avoids risks of anaesthesia ; avoids risks associated with instrumentation of uterus like cervical trauma, uterine perforation and risks of visceral injury consequently ;also less risks of introducing infection to uterus compared to surgical methods ; more predictable with regard to timing compared to expectant management .There are many disadvantages also.Though it speeds up time in hospital ,may miscarry at home before planned admission .Products of conception can’t be obtained many a times for histopathological examination.May be associated with increased pain and bleeding compared to other methods-due to the effect of prostaglandins.Prostaglandins also cause side effects like gastrointestinal discomfort, diarrhea and pyrexia.10-15% of cases may need surgical evacuation later on due to retained products and persistent bleeding.She will need Anti D injections as prostaglandin induced uterine contractions increases the risk of Rh –sensitisation.I’ll provide her with written information about medical management of miscarriage.

(c)I would tell her that surgical removal of products of conception is the most successful method of all-successful in more than 95% cases.It is quite predictable with regard to timing and outcome.Avoids going through the process of bleeding.Can go home on the same day.Provides the most rapid resolution of problems.But carries with it inherent risks of anaethesia.Risks related to instrumenting uterus like risk of cervical trauma , uterine perforation ,visceral injury and increased risk of infection compared to other methods.May need additional repair procedures and blood transfusion if any complication does arise.There remains a small risk of retained products even after surgical evacuation.She will need Anti-D injection.
I’ll provide her with written information to substantiate the discussion.I’ll also provide her with details of support groups like Miscarriage Association and hospital contact numbers.
(Details of discussion will be documented in her file)
Posted by PAUL A.
A.
Miscarriage is a distressing event which must be acknowledged. In expectant management about 60-70% of missed miscarriages will eventually abort spontaneously. Its main advantage is that it is a natural process, avoiding any medical or surgical intervention with their associated risks how is intervention AVOIDED if it is only successful in 60-70% of cases? . The time required for this to happen will give the couple the opportunity to come to terms with the lost pregnancy. it may take 2-4 weeks though, and if so, time spent waiting may become emotionally taxing is this a benefit? . There is a small potential for infection and heavy bleeding, especially in incomplete miscarriage. Surgical evacuation may have to be arranged after all as emergency procedure in such a case. you were asked to tell her about benefits and disadvantages. The word ‘benefit’ or ‘disadvantage’ does not appear in your answer.

B.
Medical intervention uses oral or vaginal prostaglandins to obtain “spontaneous” how can an intervention possibly lead to spontaneous evacuation??? evacuation of the failed pregnancy. Main advantage is reduction of interval between diagnosis and “evacuation” of the pregnancy (1) , whilst still avoiding surgical intervention. This is particularly important in couples who emotionally can’t cope with a long interval from time of diagnosis. The medication may cause severe gastro-intestinal disturbance including vomiting & diarrhea. Infection and bleeding may still occur as well as incomplete miscarriage, again requiring surgical evacuation as emergency procedure.
WHERE ARE THE DISADVANTAGES? IS THE EXAMINER SUPPOSED TO DECIDE WHAT ARE DISADVANTAGES??
C.
Surgical evacuation can be done as a planned daycase and involves dilating the cervix and evacuating the failed pregnancy, mostly by means of suction curettage as this reduces blood loss. Main advantage is a short interval from diagnosis to procedure with an almost certain outcome (1) , though in rare cases the uterus is incompletely emptied and a 2nd procedure is required later on. Risk of bleeding and infection are still present, and additionally risk for damage/perforation of the uterus. The latter can mostly be managed conservatively, but if the instrument entered the abdominal cavity and suspicion for visceral damage is raised, laparoscopic inspection and if needed repair is necessary. There is a small risk for Ashermann Syndrome, which may compromise future fertility. As in any surgical procedure, anaesthetic complications may occur as well WHERE ARE THE DISADVANTAGES??? .
Posted by PAUL A.
a)The benefits of expectant management for missed miscarriage is the avoidance of hospital admission admission is not avoided as the it might not be successful . The woman may feel that waiting for spontaneous miscarriage is more natural. Expectant management is associated with less risk of infection compared to surgical intervention (1) . If successful, it can also avoid risks associated with medication, anesthesia & surgical intervention (1) . Rh negative woman can avoid risk associated with anti-D administration (1) .The disadvantages of expectant management includes the unpredictability of the outcome. In may take upto few weeks (1) before the woman spontaneously miscarry or resorption of products occur. In cases where the sac is intact & the cervix is closed, the success rate is less than 50% (1) . It may be associated with pain and heavy bleeding that might require hospital admission or surgical intervention at the end. Tissue may not be available for histological examination (1) .
b) Medical management has the benefit of avoiding reduces need for admission but it is not avoided hospital admission. It can also avoid risks associated with surgical management & anaesthesia reduces risk . It carries less risk of pelvic infection (1) compared to surgical evacuation. The disadvantages are pain & heavy pv bleeding (1) more pain / bleeding – pain and bleeding occur with all aproaches that may require hospital admission and may also end up with needing an emergency surgical evacuation. Tissue may not be available for histology (1) . Anti-D which is a blood product needs to be given to Rh negative woman.
c) Surgical management has the benefit of being a planned procedure. It can be done as a day case (1) . It is associated with less pain and bleeding compared to medical management (1) . Tissue will be available for histological examination (1) . The disadvantages of surgical management are risks of anaesthesia, uterine perforation, bowel & bladder injury (1) . It has higher risk of infection (1) compared to medical management. Occasionally, evacuation is not complete and requires second evacuation. Anti-D will need to be administered to Rh negative woman.
GOOD ANSWER
Posted by PAUL A.
(a)I would tell her that expectant management includes letting the nature take it’s course.There are many benefits .This method allows her to be at home. Avoids risks associated with anaesthaesia and surgery risks are reduced but not avoided . This method is more cost effective to NHS if successful compared to medical and surgical management this is incorrect – you do not assess cost-effectiveness on condition that the treatment is successful. Otherwise a treatment with a 1% success rate may be ‘cost-effective if successful’ compared to a more expensive treatment with a 100% success rate!!! . No increased risk of infection compared to other methods is the risk of infection the same as for surgical?? ..No need for Anti D injections if successful (1) as no increased risk of Rh-sensitization.The disadvantages are : unable to estimate timescale compared to other two methods-may have to wait for a long duration (1) which increases patient anxiety ;risk of prolonged bleeding leading to reduction in haemoglobin levels ;successful only in around 50% (1) of cases-so may need medical or surgical methods later on ; risk of heavy bleeding and pain at home necessitating emergency hospital admission and evacuation of uterus ; products of conception may not be available for histopathological examination (1) .I’ll provide her with written information and contact numbers.

(b)I would tell her that medical management using prostaglandins alone or along with mifepristone is successful in around 85% of cases.The benefits include :it avoids risks reduces risk of anaesthesia ; avoids risks reduces risks associated with instrumentation of uterus like cervical trauma, uterine perforation and risks of visceral injury consequently ;also less risks of introducing infection to uterus (1) compared to surgical methods ; more predictable with regard to timing compared to expectant management (1) .There are many disadvantages also.Though it speeds up time in hospital ,may miscarry at home before planned admission .Products of conception can’t be obtained many a times for histopathological examination (1) .May be associated with increased pain and bleeding (1) compared to other methods-due to the effect of prostaglandins.Prostaglandins also cause side effects like gastrointestinal discomfort, diarrhea and pyrexia.10-15% of cases may need surgical evacuation later on due to retained products and persistent bleeding (1) .She will need Anti D injections as prostaglandin induced uterine contractions increases the risk of Rh –sensitisation.I’ll provide her with written information about medical management of miscarriage.

(c)I would tell her that surgical removal of products of conception is the most successful method of all-successful in more than 95% cases (1) .It is quite predictable with regard to timing and outcome.Avoids going through the process of bleeding.Can go home on the same day (1) .Provides the most rapid resolution of problems.But carries with it inherent risks of anaethesia.Risks related to instrumenting uterus like risk of cervical trauma , uterine perforation ,visceral injury (1) and increased risk of infection compared to other methods (1) .May need additional repair procedures and blood transfusion if any complication does arise.There remains a small risk of retained products even after surgical evacuation.She will need Anti-D injection.
I’ll provide her with written information (1) to substantiate the discussion.I’ll also provide her with details of support groups like Miscarriage Association and hospital contact numbers.
(Details of discussion will be documented in her file)
Posted by PAUL A.
A good candidate should
(a)
Expectant management – benefits (4)
• Reduced risk of GA and complications of surgery / side-effects of drugs
• Reduces need for anti-D if Rh negative
• Woman remains ‘in control’
• Lower risk of infection compared to surgical management
• May be more cost-effective compared to surgical management

Expectant management – disadvantages (3)
• Pregnancy may take several weeks to resolve
• Heavy bleeding may occur requiring emergency evacuation
• Only available in units where 24h telephone contact and emergency admission are possible
• Success rate variable 25-100%
• Tissue may not be available for histology
• Associated with more pain

(b)
Medical management – benefits (4)
• Reduced risk of GA and complications of surgery
• Woman retains a degree of control
• High levels of patient acceptability
• Lower risk of infection compared to surgical management
• More cost-effective compared to surgical management
• May be undertaken on an out-patient basis

Medical management – disadvantages (3)
• Bleeding may persist for up to 3 weeks
• Variable success rates – 13-96%
• Associated with more pain and bleeding compared to surgical management
• Heavy bleeding may necessitate emergency evacuation
• Tissue may not be available for histology
• Should only be undertaken in units where 24h telephone contact and emergency admission are possible

(c)
Surgical management – benefits (3)
• Offers prompt resolution of pregnancy with high success rate over 95%
• Tissue available for histology
• High levels of patient acceptability
• Less pain & bleeding


Surgical management – disadvantages (3)
• Associated with anaesthetic and surgical risks
• Higher risk of infection
• More expensive than medical management


• Outcome likely to be good irrespective of choice of management
• Provide written information
ad Posted by PAUL A.

ad