Editor—Ankum et al's regular review on the management of spontaneous miscarriage suggests that medical management is of little benefit in the treatment of incomplete miscarriage.1 The wide variation in reported success rates might, however, be responsible for differences in the use of ultrasonography.
The use of ultrasonography to determine whether there are retained products of conception will exclude about 30% of women from treatment as they will be found to have an empty uterus.2 If ultrasonography is not used at this stage the success rate will be inflated by the inclusion of women having unnecessary treatment. Conversely, the use of ultrasonography to assess completeness after uterine evacuation may reduce the apparent success rates: the finding of intrauterine tissue usually leads to an assumption that the treatment has failed. The clinical course of this finding, however, is unknown, and most of these women will probably complete the spontaneous miscarriage without further intervention.
Analysis of the available studies shows a clear relation between the reported success rates and the time at which the ultrasonography was carried out after treatment (figure). The analysis suggests that the low reported success rates in some studies occurred as a result of an over-reaction to ultrasonographic findings that are of undetermined relevance. Initial medical treatment followed by expectant management may be the key to the effective management of incomplete miscarriages. These findings also add weight to the arguments in favour of using expectant management alone. These two regimens need to be compared.
The figure may represent the natural course of incomplete miscarriages, but this needs to be confirmed in a prospective ultrasonographic study of women having expectant management.
Figure.
Comparison of reported success rates with time at which ultrasonography was carried out after treatment. Numbers refer to references
References
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