Management of first trimester miscarriage after implementation of a standardized protocol in a tertiary hospital in Cape Town, South Africa – an observational study

Breidenthal, Anne Guri (2017-12)

Thesis (MMed)--Stellenbosch University, 2017.

Thesis

Background Spontaneous first trimester miscarriage is common problem in primary care and emergency settings. Management options have changed over time and now include surgical, medical and expectant management options. Aim To assess the effectiveness and complications of these various choices for women with first trimester miscarriages who present to an acute and outpatient early pregnancy service, Tygerberg hospital, a tertiary level public hospital in Cape Town, South Africa. Prior to this the standard practice was surgical management of first trimester miscarriages Methods A protocol introducing the various management options of first trimester miscarriages was created and implemented, and an audit was carried out over six months to assess outcomes between January 2015 and June 2015. Data was captured and analyzed with SPSS software using Kaplan-Meier analysis and Pearson Chi-square test. Results Of the 157 women whose management of their miscarriage was assessed, 32% had surgical, 40% had medical and 28% had expectant management. Median days until complete miscarriage was 1 [1 -66 days] for surgical, 10 [1 – 105 days] for medical and 18 [1 – 66 days] for expectant management. All patients who chose initial surgical management completed the miscarriage in that category. Seventy-five percent of women who intended medical management and 18.4% who chose expectant management successfully completed the miscarriage as initially planned. The remainder completed their miscarriages in the medically or surgically. Complication rates included: 10.2% blood transfusions, 5.1% sepsis, 1.3% misoprostol side-effects, and 0.6% re-evacuations. Conclusion Surgical management is the quickest and most effective option followed by medical and expectant management. Complication rates were high, reflecting the inclusion of unstable patients requiring urgent surgical management. Medical and expectant management should only be offered to stable low risk women. Counselling should include the time taken to completed miscarriage and the possible need to change the management method. This allows women to choose a management option best suited to them.

Agtergrond Spontane miskrame in die eerste trimester van swangerskap is ‘n algemene probleem in primêre sorg klinieke en noodeenhede. Die verskillende opsies vir hantering het verander oor die afgelope jare en daar is nou chirurgiese, mediese and afwagtende opsies beskikbaar. Doel Die doel van hierdie studie was om die effektiwiteit van hierdie verskillende behandelings opsies te ondersoek asook om die komplikasies te beskryf in vrouens wat met eerste trimester miskrame by ‘n noodeenheid sowel as buitepasiënt kliniek by Tygerberg Hospitaal hanteer word. Tygerberg Hospitaal is ‘n sekondêre en tersiêre verwysingshospitaal in Kaapstad, Suid Afrika. Die roetine hantering voor hierdie studie was chirurgie. Metodes Die studie volg na die skryf en implementering van ‘n nuwe protokol wat al die verskillende hanteringsopsies aanbied. ‘n Oudit vir die eerste ses maande na implementering is uitgevoer. Dataverwerking is uitgevoer met behulp van die SPSS sagtewarepakket en Kaplan-Meier oorlewings analises sowel as die Pearson Chi-kwadraat toets is gebruik waar nodig. Resultate Daar was 157 pasiënte in die studie en van hulle het 32% chirurgiese hantering gehad, 40% het mediese behandeling ontvang en 28% afwagtende of konserwatiewe hantering. Die mediaan vir die aantal dae tot die miskraam volledig was, was 1 dag (1-66 dae) vir chirurgie; 10 dae (1-105 dae) vir die mediese groep en 18 dae (1-66 dae) vir die groep met afwagtende hantering. Die vrouens wat die chirurgiese opsie gekies het, het slegs hierdie behandeling benodig. Van die mediese behandeling groep het 75% en van die konserwatiewe groep het 18.4% slegs die aanvanklike metode benodig en die res het addisionele chirurgiese of mediese behandeling benodig. Die komplikasies sluit bloedoortapping (10.2%), sepsis (5.1%), neweeffekte van misoprostol (1.3%) en herhaal ledigings van die uterus (0.6%) in. Gevolgtrekking Die mees effektiewe metode is chirurgie en daarna is dit mediese en dan afwagtende hantering. Daar was ‘n redelike hoë voorkoms van komplikasies, meesal as gevolg van onstabiele pasiënte wat chirurgie benodig het. Mediese sowel as konserwatiewe hantering moet net aan lae risiko vrouens wat heeltemal stabiel is aangebied word. Tydens raadgewing moet vrouens ingelig word oor die tydsduur van die verskillende metodes en die moontlikheid dat ‘n tweede opsie nodig kan raak. Dit sal vrouens toelaat om ‘n keuse te maak oor die metode wat die beste vir hulle sal werk.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/102905
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