Monday, April 7, 2014

Supporting women with incomplete miscarriages

- Jennifer Middleton, MD, MPH

All family physicians, even those not providing full obstetric (OB) care, can have a role in helping women and their partners through the heartbreak of an incomplete miscarriage. Last week's AFP examined a recent Cochrane review titled "Medical Treatments for Incomplete Miscarriage." While we may not all be making this diagnosis and prescribing treatment, understanding the treatment options and recognizing the prevalence of grief and depression after treatment can allow us to provide much-needed caring and support to these women and their families.

An algorithm can help physicians determine if an incomplete miscarriage has taken place; the options for women and their partners, then, fall into three categories: expectant management (waiting for the miscarriage to happen naturally), surgical evacuation, or medical treatment with misoprostol. The AFP reviewers state that most women don't want surgery but also don't want to wait up to 14 days for a natural miscarriage. Medical treatment with misoprostol can offer women and their partners closure while avoiding a surgical procedure.

The Cochrane reviewers looked at 20 studies and found that misoprostol is almost as good as surgical evacuation regarding successful completion of miscarriage. Misoprostol was safe and helped women avoid the need for surgery 95% of the time, though it did result in an average of 2 more days of bleeding compared with surgery and expectant management. Misoprostol is available in several dosing preparations, though the AFP reviewers note that the vaginal route has fewer gastrointestinal side effects compared with oral routes.

The completion of a miscarriage is rarely the end of the story for patients and their loved ones, though. Grief following a miscarriage can be as profound for women and their partners as the loss of a close friend or family member. A study published in JAMA in the late 1990s shows that women are at increased risk of depression following any type of pregnancy loss; more recent studies in the OB/GYN literature and psychiatry literature found similar results. A thoughtful review in an OB nursing journal a few years ago describes several websites that provide excellent support following miscarriage, providing some concrete ways to help these women and their partners.

Although many family physicians do provide full spectrum OB care and are in an excellent position to care for women after a miscarriage, even those family physicians who don't provide OB care have much to offer these grieving women within the context of the doctor-patient relationship. There's an AFP By Topic on prenatal care, with a section on pregnancy loss, if you'd like to read more.

How do you and your office care for women after a miscarriage?