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Spontaneous abortion occurs in 15% to 20% of all human pregnancies. Since the late 1800s, the management of incomplete spontaneous abortion has focused on using curettage to empty the uterus as quickly as possible. This practice began to reduce blood loss and infection and has been unquestioned for 4 decades. In today's medical climate, few spontaneous abortions are the resuslt of illegal manipulation, given the availability of legal pregnancy termination. Antibiotics and transfusions are available, should complications arise in conservatively managed cases. Two prospective randomized trials suggest that conservative management may be advantageous for women who have stable vital signs without evidence of infection. They will have fewer perforations and, possibly, fewer infections and uterine synechiae with expectant or medical management. Larger trials should be undertaken to critically assess surgical evacuation compared to medical management, factoring in the psychologic impact of treatment. We believe that medical management will prove to be the most appropriate treatment for uncomplicated spontaneous incomplete abortion in the 21st century.

Transvaginal sonography (TVS) was used to assess uterine contents in 100 consecutive subjects presenting with a diagnosis of spontaneous abortion. TVS assessments were correlated with findings at subsequent evacuation of retained products of conception (ERPC). There was a strong correlation between the weight of the surgical specimen at ERPC with both the sagittal (r = 0.76; p < 0.05) and transverse (r = 0.73; p < 0.05) plane area measurements of the uterine cavity. Combining the 2 sonographic measurements increased the correlation to r = 0.81 (p < 0.05). Fifteen of 25 subjects who had been categorised to have an 'empty' uterus had less than 5 g of tissue removed and the other 10 subjects less than 10 g of tissue. In 20 of these 25 cases, the surgeon described the amount of curettings as 'small or non-significant'. TVS can accurately identify those women who do not have a significant amount of residual uterine tissue following spontaneous abortion.

Early pregnancy loss is a profound adverse life event for many women, and increased psychiatric morbidity has been shown to occur after spontaneous abortion. Dilatation and curettage (D&C) has been the cornerstone in the treatment of first trimester spontaneous abortion over the last few decades. During recent years the possibility of conservative management has, however, been increasingly discussed. In a prospective randomized trial, we compared psychological reactions and morbidity, after either expectant management or D&C, for miscarriages of < 13 weeks gestation in which a transvaginal ultrasound examination showed intrauterine tissue and/or blood clots with an antero-posterior diameter of between 15 and 50 mm. Of the 86 patients included, 58 were randomized to expectant management and 28 to primary D&C. In patients randomized to expectant management, pregnancy products shown by transvaginal ultrasound disappeared within 3 days in 43 cases (74%), whereas 15 patients (26%) underwent D&C owing to retained products of conception after 3 days. At 2 weeks after inclusion, all patients answered self-administered questionnaires, including visual analogue scales, concerning their experience of the pregnancy loss, the present situation and concerns about the future. A brief anxiety status inventory was included. This study showed no increase in anxiety or depressive reactions 2 weeks after a first trimester spontaneous abortion when these patients were compared with non-pregnant healthy working females 19-39 years of age. Moreover, there were no significant differences in psychological reactions between patients managed either expectantly or by D&C.

We describe a normal pregnancy that was conceived less than 3 weeks following curettage for a blighted ovum. A delay between curettage and subsequent pregnancy is often recommended. Evidence supporting such a delay is examined.

We report our experience concerning the laparoscopic treatment of ectopic pregnancy (EP). One-hundred and nine women with EP were treated in our department over a 4 year period, between February 1988 (date of our first laparoscopic surgery for EP) and December 1991. Twenty-two of these women underwent laparotomy and the remaining 87 laparoscopic surgery alone. Four therapeutic failures were noted in women treated by laparoscopy. Our results are compared with those of other series and the indications, as well as the modalities of laparoscopic treatment are detailed. It is concluded that laparoscopic surgery of EP is a reliable method which must always be considered, except for a few rare indications.

We conducted a prospective study to assess the need for curettage after spontaneous expulsion of the placenta in midtrimester termination of pregnancy. The rate of early complications (9.4%) was consistent with previously reported data. A higher incidence of intrauterine adhesions, detected on hysteroscopy, was observed in patients who underwent curettage (38.5% vs. 7.7%, P = .0727). In order to prevent intrauterine adhesions, curettage should be restricted to cases in which retained products of conception are suspected. It should not be performed routinely in every case of midtrimester termination of pregnancy after spontaneous expulsion of the placenta.

Among 114 women with early spontaneous abortions, low beta-human chorionic gonadotropin levels and no ultrasonographically demonstrable residual tissue in the uterine cavity, 68 underwent uterine curettage, and 46 were managed conservatively. No complications, such as bleeding or infection, were observed in either group, and the probability of conception, outcome of subsequent pregnancies and rate of subsequent abortions were similar. Curettage offers no advantage over conservative management in selected patients with early abortions.

Eighteen patients with poor reproductive histories and 2 patients with primary infertility underwent Tompkins metroplasty for a septate uterus. There were 19 pregnancies within 2 years of surgery, and 11 patients had at least 1 viable pregnancy, for an overall success rate of 55%. One of the infertile patients conceived and delivered. The average fecundability rate for the first 24 months was 0.078 (normal, 0.20). The cumulative pregnancy rate at 27 months was 94% by the life-table method. The group of patients (n = 14) with two or more losses and no other major risk factors for reproductive failure had higher fecundability and a better success rate (71%). The Tompkins metroplasty is a technically simple procedure with a success rate similar to that of the Jones procedure.

Suction curettage for inevitable and incomplete spontaneous abortion has been performed by emergency physicians in the emergency department of the Central Group Health Hospital in Seattle for more than seven years. The equipment and techniques used in our practice are described, and guidelines for treatment are presented. Also presented is an analysis of 111 consecutive patients treated with suction curettage during an 18-month period with a minimum follow up of six months. The complication rate was minimal (4.5%), and compares favorably with previously published results of inpatient treatment. Several significant advantages of treating incomplete and inevitable abortion with suction curettage in the emergency department are described.

One hundred and fifteen patients admitted to Duke University Medical Center from January 1, 1973, to December 31, 1974 inclusive, with the diagnosis of uncomplicated spontaneous incomplete or inevitable abortion were included in a randomized prospective study. All patients underwent suction curettage under either analgesia or general inhalation anesthesia. Patient response was adjudged regarding comfort and cooperativeness in the group receiving analgesia and postprocedure rehabilitation and discharge times in both groups. Fifteen of 59 patients receiving analgesia only were recorded unanimously as failures. Post-operative ambulation was no more rapid in patients receiving analgesia. Procedure-to-discharge intervals were unrelated to medication modality. There appears to be no advantage to analgesia as far as rehabilitation time, procedure-to-discharge time, and medical complications are concerned.

The half-life of hCG was measured retrospectively in paired blood samples from 108 pregnancies with falling hCG levels. hCG levels fell significantly more slowly in women who had an ectopic pregnancy (41 cases) than in women who had spontaneous abortions (67 cases). When the hCG half-life was greater than or equal to 7 days, 86% of cases had ectopic pregnancies, a third of which had ruptured. By contrast, when the hCG half-life was less than 1.4 days, only 7.6% (2/26) of cases had an ectopic pregnancy (both of which were unruptured), and villi were identified in only 10% of curettage specimens from (presumed) cases of spontaneous abortion. When the half-life of hCG was between 1.4 and 6.9 days, 34% of the cases had ectopic pregnancies, 14% of which had ruptured: chorionic villi were recovered from 76% of the women who had a curettage, and failure to detect villi was more than 80% predictive of an ectopic pregnancy.

A case of adenocarcinoma of the endometrium discovered during curettage of inevitable abortion is described and seven instances with the association of fundal cancer and intrauterine pregnancy are reviewed. In half of the eight patients including the present case, a complication of pregnancy led to the discovery of the tumor; in the remaining four instances, the gestation occurred incidentally in a patient known to have a fundal cancer. All the seven neoplasms previously reported were well-differentiated, minimally or noninvasive adenocarcinoma or adenoacanthoma, while the tumor of the present case was moderately differentiated adenocarcinoma which invaded into about one-half of the myometrium. Progesterone-induced histologic findings, such as secretory differentiation of glands, mitotic arrest, and decidual reaction of stromal cells, were not noted. Prognosis of the patients with this association seems to be good. Follow-up on five of the seven previously reported cases indicates that four are well more than 5 years. The present patient is also well more than 5 years after hysterectomy and pelvic irradiation therapy. There is only one patient who has died of recurrence 3 years after definitive therapy.

The Authors examined surgical case studies for the 20-year period from February 1968 to February 1988 concerning hysterectomies performed for obstetric reasons at the "La Sapienza" University of Rome, Obstetrics and Gynaecology Department; these numbered 35 out of 69,677 births. They also considered hysterectomies carried out during caesarean sections, during birth or the postpartum period, during the puerperium and after miscarriage. They also analyzed reasons for the action taken, the type of operation, the length of the gestation period, the mother's age, and transfusions given.

A case of opisthotonus following the use of the anaesthetic induction agent propofol is described. The patient was a woman with a known history of epilepsy. It is recommended that propofol should not be used in such patients.