to the editor: Thank you to Drs. Prine and MacNaughton for a well-written review of the management of early pregnancy loss. However, I felt their description of manual vacuum aspiration was incomplete. I regularly perform this office procedure, and it is a dilation and curettage, the same as any elective abortion, with the same risks and pain. It is not to be compared with an endometrial biopsy. In the accompanying patient information handout, the statement about the paracervical block numbing the pain inaccurately implies that the procedure is pain-free. The cervix is usually softened because of the loss, and the procedure usually takes less than five minutes; however, women who elect manual vacuum aspiration in an office setting should realize that this procedure may involve considerable discomfort, even when conscious sedation is being administered. Women who may be unable to tolerate the discomfort of a dilation and curettage should consider other options, including undergoing the same procedure in an operating room.

in reply: We appreciate Dr. Kaufman's concerns regarding the anticipatory guidance that women receive about the treatment for a miscarriage. Extensive literature exists on the pain associated with the first-trimester aspiration procedure.^1,2 Many authors conclude that the psychological state of the woman has the greatest influence on her perception of pain. As we point out in our article, patient preference about treatment choice is paramount. The article focuses on strategies that an office-based family physician can offer for management of miscarriage. However, after receiving accurate counseling regarding all aspects of the procedure (including logistics, timing, pain control, and cost), if the patient prefers a hospital-based procedure to expectant or medical management, or an office-based procedure, her preference should be honored.

We find that with this counseling nearly all women elect to stay within the family medicine office because this allows them to have a support person of their choosing with them throughout the procedure, and provides them the comfort and convenience of remaining in a familiar setting with a known physician. These benefits, in addition to other pain management modalities (including oral pain medications, the paracervical block, heat, music, and verbal anesthesia) allow women to cope exceptionally well with the discomfort of the procedure.

In the article, we noted that the procedure steps are similar to those of an endometrial biopsy, although a paracervical block is indicated and dilation of the cervix may be needed. This explanation of the required preparation and instruments is for physicians who may not perform the procedure.

During counseling, most women ask about the discomfort they will experience. The answer is that every option, including a procedure under general anesthesia, has its associated discomforts. Women should be counseled on all options and, ideally, be allowed to decide based on their preference rather than on availability of services.