A missed opportunity for excellence: the NICE guideline on the diagnosis and initial management of ectopic pregnancy and miscarriage

Hysteroembryoscopy and hysteroscopic uterine evacuation of early pregnancy loss: A feasible procedure in selected cases

Hysteroscopic uterine evacuation of early pregnancy loss using tissue removal devices seems to be a safe and feasible procedure in selected cases. The hysteroscopic approach allows the precise localisation of the gestational sac inside the uterine cavity. The endoscopic approach allows one to perform hysteroembryoscopy before uterine evacuation and this technique appears to be more accurate than dilatation & curettage for fetal chromosome karyotyping, with lower maternal cell contamination. This “under vision” procedure may reduce retained products of conception rates and risk of intrauterine adhesions formation.

An exploration of how women in the UK perceive the provision of care received in an early pregnancy assessment unit: an interpretive phenomenological analysis

OBJECTIVE

The objective of the study was to explore how women experience care within an early pregnancy assessment unit (EPAU) and how they are helped to understand, reconcile and make sense of their loss and make informed decisions about how their care will be managed following a first trimester miscarriage.

DESIGN

This was a single centre, prospective qualitative study. An interpretive phenomenological analysis approach was used to interpret the participants' meanings of their experiences. It is an ideographic approach that focuses in depth on a small set of cases to explore how individuals make sense of a similar experience.

SETTING

An EPAU in a large teaching hospital in the Midlands that provides care to women in their early pregnancy, including those experiencing pregnancy loss.

PARTICIPANTS

A purposive sample of 10 women were recruited to this study. All of the women were either miscarrying at the time of this study or had miscarried within the previous few weeks.

RESULTS

Six superordinate themes in relation to women's experiences of miscarriage were identified: (1) the waiting game, (2) searching for information, (3) management of miscarriage: no real choice, (4) the EPAU environment, (5) communication: some room for improvement and (6) moving on.

CONCLUSIONS

This study found that improvements are required to ensure women and their partners receive a streamlined, informative, supportive and continuous package of care from the point they first see their general practitioner or midwife for support to being discharged from the EPAU. The provision of individualised care, respect for women's opinions and appropriate clinical information is imperative to those experiencing miscarriage to help them gain a degree of agency within an unfamiliar situation and one in which they feel is out of their control.

Pregnancy of Unknown Location: A Survey-Based Evaluation of When and Why Physicians Intervene?

INTRODUCTION

Management of pregnancies of unknown location (PUL) is a complex challenging clinical situation with possibilities for pitfalls. Obstetricians and gynaecologists of varied levels of training and experience from Canada and the Nordic countries were questioned about their approach when faced with PUL.

METHOD

A 13-item web-based questionnaire was used to evaluate physicians' behaviors by surveying their management of a PUL encountered at different levels of human chorionic gonadotropin (hCG). They were queried regarding the level of hCG at which they would take management action in an asymptomatic PUL, in a given scenario.

RESULTS

Three hundred fifty three questionnaires were completed resulting in a response rate, representing completeness of the survey, of 78.6%. Three distinct hCG thresholds, at which intervention to interrupt a PUL would be considered, dominated the responses. Thirty seven percent of physicians would intervene at hCG levels between 1000-3000 IU, 22% selected the 4000-6000 IU range, and 13% would only intervene if the hCG level exceeded 10 000 IU. These ranges were similar across different levels of clinical experience. In addition to hCG values, a patient's desire to keep the pregnancy, the development of new symptoms, and the expected gestational age were the other principal factors influencing the decision to intervene.

CONCLUSION

There appears to be little consensus regarding the hCG threshold at which medical intervention should be initiated in an asymptomatic pregnancy of unknown location and further studies to justify earlier or later intervention are needed to determine the appropriate time for intervention.