MATERNAL AND EARLY CHILD HEALTH

Health Evidence Bulletins - Wales

Date of Completion: 9.1.98

The contents of this bulletin are likely to be valid for approximately one year, by which time significantly new research evidence may become available


1. Haemorrhage in early pregnancy - Miscarriage and ectopic pregnancy

(Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation)

The Statements The Evidence
1a. Transvaginal ultrasound examination provides rapid confirmation of whether a fetus is alive or dead and if a pregnancy is likely to continue after threatened miscarriage(i).
(Health gain notation - 2 "likely to be beneficial")
It is essential that, in cases of doubt, the examination is repeated within 3-5 days (ii)
i. Jauniaux E, Gavriil P, Nicholaides KH. Ultrasonographic assessment of early pregnancy complications. Chapter 5 in Jurkovic D, Jauniaux E (eds.) Ultrasound and early pregnancy. Progress in Obstetrical and Gynaecological Sonography Series. London: Parthenon, 1996. p.58
(Type IV evidence - observational studies);
ii. Royal College of Obstetricians & Gynaecologists. Royal College of Radiologists. Guidance on ultrasound procedures in early pregnancy, London: Royal College of Radiologists, Royal College of Obstetricians and Gynaecologists,1995(Type V evidence - expert opinion);
1b. The management of threatened miscarriage must include ultrasound confirmation of ongoing pregnancy(i).
(Health gain notation - 2 "likely to be beneficial")
It follows that trials involved with the management of miscarriage should include only those women where ultrasonography has confirmed that her fetus is still alive.
i. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 p. 620
(Type V evidence - expert opinion. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p.88)
1c. The diagnosis and management of miscarriage and ectopic pregnancy should be improved utilising appropriately staffed day assessment units and by recognition of early signs(i,ii,iii).

(Health gain notation - 2 "likely to be beneficial")

i. Royal College of Obstetricians & Gynaecologists. Royal College of Radiologists. Guidance on ultrasound procedures in early pregnancy.   London: Royal College of Radiologists, Royal College of Obstetricians and Gynaecologists, 1995(Type V evidence - expert opinion);
ii.Department of Health et al. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1991-1993. London: HMSO, 1996 p.73 (Type V evidence - expert opinion);
iii. Mascarenhas, L. Ectopic pregnancy. PACE Review 97/07. London: Royal College of Obstetricians and Gynaecologists, 1997.
(Type V evidence - expert opinion)

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1d. There is no evidence of benefit from bed rest for threatened miscarriage(i).


(Health gain notation - 5 "unlikely to be beneficial"

i. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 624-625
(Type II evidence - single controlled study - now out of date. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp 87-88)
1e. Hormone administration (Progestogens or HCG) should be used only within controlled clinical trials until the ratio of benefits to hazards has been more clearly established(i,ii)

(Health gain notation - 4 "unknown")

i. Prendiville W. Human chorionic gonadotrophin (HCG) for recurrent miscarriage. Cochrane Database of Systematic Reviews. Cochrane Library, 1997 Issue 4
(Type I evidence - systematic review);
ii. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 615-619
(Type I evidence - systematic review. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp.86-87)
1f. Diethylstilboestrol in pregnancy either for miscarriage or any other indication is both ineffective and contraindicated because of the risk of cancer and other side effects(i)

(Health gain notation - 6 "likely to be harmful")

i. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 613-615
(Type I evidence - systematic review. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995 pp. 85-86)
1g. In the investigation of recurrent miscarriage (defined as 3 or more miscarriages), the following should be considered(i):
(Health gain notation - 2 " likely to be beneficial")
  • parental chromosome abnormality (3.5%)
  • thromophilic defect (15%)
  • polycystic ovaries
i. Rai R, Regan L. Recurrent miscarriage. PACE review No. 96/08. London: Royal College of Obstetricians and Gynaecologists, 1996

(Type V evidence - expert opinion)

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1h. Leucocyte therapy or trophoblast membrane infusion for recurrent miscarriage do not appear to be effective in the prevention of recurrent spontaneous abortion(i,ii).
Odds Ratio = 1.3 ii.

(Health gain notation - 5 "unlikely to be beneficial")

i. Scott JR. Recurrent miscarriage: Immunotherapy. Cochrane Database of Systematic Reviews. Cochrane Library, 1997 Issue 4
(Type I evidence - systematic review)
ii. Fraser EJ, Grimes DA, Schulz KF. Immunization as therapy for recurrent spontaneous abortion: a review and meta-analysis. Obstetrics and Gynecology 1993;82:854-9
(Type I evidence - meta-analysis, 302 women in total)
1i. For the small subgroup of women with recurrent miscarriage associated with phospholipid antibodies, prophylactic aspirin and heparin rather than aspirin alone (71% vs 42% live births) has been shown to be of value(i).

(Health gain notation - 2 "likely to be beneficial")

i. Rai R, Cohen H, Dave M, Regan L. Randomised controlled trial of aspirin and aspirin plus heparin in pregnant women with recurrent miscarriage associated with phospholipid antibodies (or antiphospholipid antibodies). British Medical Journal. 1997; 314:253-257
(Type II evidence - randomised controlled trial of 90 women)

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk