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How do you manage a missed abortion?

Q What is the best management of missed abortion? Are there any significant risks attached to awaiting events?

A Miscarriage ends up to 25 per cent of pregnancies. Missed miscarriage is the term used to describe a failed intrauterine pregnancy which has not manifested clinically with the passage of products, heavy bleeding or pain.

There is currently no established 'best' management for missed miscarriage, so patients should get the option of surgical or non-surgical management.

Recent evidence suggests surgical evacuation is not always indicated.

Surgery has the advantage of immediate resolution of the failed pregnancy, but carries the small risks of cervical damage, uterine perforation, infection and retained products of conception as well as those of general anaesthetic.

Risks of cervical damage during dilatation may be reduced by the use of misoprostol.

Medical management with misoprostol has demonstrated complete expulsion of products in missed miscarriage within a week in the majority of women and reduces the need for surgery.

Given the option, about half those with missed miscarriage will opt for medical management.

The risks attached to 'awaiting events' include those of heavy bleeding, and the need for subsequent surgical evacuation ­ which may be necessary in up to 50 per cent of cases.

Patients should be advised complete expulsion may take up to four weeks. There is no basis for offering antibiotics in these circumstances. Indeed, there is surprisingly little evidence that retained products do become infected in the absence of uterine instrumentation.

Martha Hickey is associate professor at the University of Western Australia School of Women's and Infants' Health, King Edward Memorial Hospital

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