Medical Management of First Trimester Miscarriage: Predictors of Efficacy and Assessment of Women’s Experience

Background: Miscarriage is common. Most women experience miscarriage as part of the normal course of reproductive life. Morbidity and mortality from miscarriage are significantly reduced with appropriate clinical care. There are significant gaps in the literature to guide best practice in the setting of first trimester miscarriage and women are often offered a choice of management strategies. Medical management, the management of miscarriage with the use of medicines aimed to expel the products of conception, is a commonly offered approach. However, there is currently limited evidence available on factors that influence the efficacy of medical management of miscarriage and this evidence is often contradictory. There is also a lack of research into the effects of the different treatment modalities on women’s experience, particularly in regards to their psychological and emotional impact (NICE, 2012). Aims: To address the gaps in knowledge in the medical management of first-trimester miscarriage by 1) investigating the outcomes and predictors of efficacy of medical management in the setting of an early pregnancy unit and 2) investigating women’s experience of medical management as compared to other types of miscarriage management. Methods: A systematic review was performed to gather the current and most up to date evidence on all potential predictors of successful medical management of first trimester miscarriage. A prospective cohort study explored the outcomes and predictors through univariate and multivariate analysis to develop a predictive model of treatment outcome. Women’s experiences of miscarriage management were explored through an online based survey emailed six weeks following miscarriage management. Women were recruited from an early pregnancy unit at a tertiary maternity hospital from October 2015 to April 2017 (18 months). Results: The systematic review identified 57 studies with potential predictors of successful medical miscarriage management, but data heterogeneity limited analysis. A novel framework for categorizing predictors (clinical, ultrasound, biochemical) was developed. The review identified potential predictors for medical management success, including lower gravidity and parity (clinical factors), embryonic pregnancies, smaller gestational sac size, and smaller crown-rump length (ultrasound factors), and potentially lower serum HCG and progesterone levels (biochemical factors. The prospective study of 186 women found 68.8% overall efficacy for medical management, with stricter ultrasound criteria initially lowering success rates (47.5%). Repeat medical management showed lower efficacy compared to expectant management, particularly with a visible gestational sac. Higher BMI was associated with higher rates of complete miscarriage (p .005). Gestational age by ultrasound measurement of CRL was also a significant predictor, with better outcomes when CRL was between 10-20mm, and HCG levels were less than 20,000 IU/l (efficacy approaching 90%). A total of 235 with different management choices (expectant, medical and surgical) completed the miscarriage experience survey. Women undergoing medical management reported lower satisfaction and higher depression scores compared to expectant or surgical options. Conclusions: This thesis has addressed on the multifaceted nature of first trimester miscarriage management in a real-world clinical setting in a novel way. By examining outcome predictors and exploring women's experiences, it paves the way for a more holistic approach to miscarriage care. It has developed a standardised framework for exploring predictors of efficacy in miscarriage management. Future care should involve individualised treatment plans that empower women to make informed decisions based on their specific circumstances, ultimately leading to better outcomes for their individual needs.

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