| Spontaneous abortion (miscarriage) is a common gynaecological problem which affects an estimated 1 in 4 women in their reproductive years. Treating this condition consumes substantial resources, yet accepted management has changed little over the last 60-70 years. Clinical assessment, with or without sonographic investigation, is usually followed by surgical evacuation of retained products of conception (ERPC). However, the signs and symptoms of threatened abortion on which most clinical assessments are based, do not appear to allow clinicians to reach a confident diagnosis of whether the pregnancy was viable or not in the majority of cases. Furthermore, ERPC may not be necessary in all cases because spontaneous abortion may already be complete at presentation.;This thesis challenges accepted practice by suggesting and testing the performance of a structured and systematic approach to clinical assessment of a woman presenting with a threatened abortion. A computer prediction model, based on logistic regression using information obtained from this structured approach to clinical assessment is presented. This thesis also challenges the accepted wisdom that all cases of spontaneous abortion should be treated with ERPC by testing a less invasive management protocol based on routine transvaginal sonography (TVS), conservative or medical (non surgical) therapeutic intervention initially, followed as a last resort, where necessary, by ERPC.;Summary of results. A structured and prescribed clinical assessment and the computer prediction model derived from it did not perform any better than normal clinical judgement. TVS was able to define a group of women who had emptied their uteruses at presentation and did not require further treatment. In women with confirmed retained POCs, the prostaglandin analogues, gemeprost and misoprostol, were able to empty the uterus in 50% of women studied. The women so treated did not suffer from increased medical morbidity when compared to those who were managed by routine, universal ERPC. |
