Expectant care versus surgical treatment for miscarriage: Cochrane systematic review

Abstract

Assessed as up to date: 2012/02/10

Background

Miscarriage is a common complication of early pregnancy that can have both medical and psychological consequences such as depression and anxiety. The need for routine surgical evacuation with miscarriage has been questioned because of potential complications such as cervical trauma, uterine perforation, hemorrhage, or infection.

Objectives

To compare the safety and effectiveness of expectant management versus surgical treatment for early pregnancy failure.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 February 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 4 of 4), PubMed (2005 to 11 January 2012), POPLINE (inception to 11 January 2012), LILACS (2005 to 11 January 2012) and reference lists of retrieved studies.

Selection criteria

Randomized trials comparing expectant care and surgical treatment (vacuum aspiration or dilation and curettage) for miscarriage were eligible for inclusion.

Data collection and analysis

Two review authors assessed trial quality and extracted data. We contacted study authors for additional information. For dichotomous data, we calculated the Mantel-Haenszel risk ratio (RR) with 95% confidence interval (CI). For continuous data, we computed the mean difference (MD) and 95% CI. We entered additional data such as medians into 'Other data' tables.

Main results

We included seven trials with 1521 participants in this review. The expectant-care group was more likely to have an incomplete miscarriage by two weeks (RR 3.98; 95% CI 2.94 to 5.38) or by six to eight weeks (RR 2.56; 95% CI 1.15 to 5.69). The need for unplanned surgical treatment was greater for the expectant-care group (RR 7.35; 95% CI 5.04 to 10.72). The mean percentage needing surgical management in the expectant-care group was 28%, while 4% of the surgical-treatment group needed additional surgery. The expectant-care group had more days of bleeding (MD 1.59; 95% CI 0.74 to 2.45). Further, more of the expectant-care group needed transfusion (RR 6.45; 95% CI 1.21 to 34.42). The mean percentage needing blood transfusion was 1.4% for expectant care compared with none for surgical management. Results were mixed for pain. Diagnosis of infection was similar for the two groups (RR 0.63; 95% CI 0.36 to 1.12), as were results for various psychological outcomes. Pregnancy data were limited. Costs were lower for the expectant-care group (MD -499.10; 95% CI -613.04 to -385.16; in UK pounds sterling).

Authors' conclusions

Expectant management led to a higher risk of incomplete miscarriage, need for unplanned (or additional) surgical emptying of the uterus, bleeding and need for transfusion. Risk of infection and psychological outcomes were similar for both groups. Costs were lower for expectant management. Given the lack of clear superiority of either approach, the woman's preference should be important in decision making. Pharmacological ('medical') management has added choices for women and their clinicians and has been examined in other reviews.

Author(s)

Nanda Kavita, Lopez Laureen M, Grimes David A, Peloggia Alessandra, Nanda Geeta

Summary

Expectant care (waiting) versus surgical treatment for miscarriage

Miscarriage is pregnancy failure before 14 weeks, which is common in early pregnancy. Such a loss in early pregnancy can affect a woman’s physical and mental health. Doctors often suggest surgery such as dilation and curettage (D and C) or vacuum aspiration to complete the process. Surgery might cause problems such as trauma, heavy bleeding, or infection. Expectant management means waiting for the miscarriage to finish on its own, and may involve bed rest, examination by ultrasound, and antibiotics. This review looked at whether expectant management works as well as surgery for miscarriage.

We searched for randomized trials that compared waiting versus surgery for miscarriage. In addition, we looked at reference lists to find trials. We also wrote to researchers to find more studies. Seven trials with 1521 women looked at waiting versus surgery for miscarriage. More women who waited for the miscarriage to complete on its own had tissue left in the womb. This was studied at two weeks and at six to eight weeks. More of these women needed surgery to complete the process. These women also had more days of bleeding. Some needed to be given blood, compared with none in the surgery group. Both groups had about the same numbers of infections. Results were mixed for pain. Mental health also seemed about the same for both treatment groups. Costs were lower for waiting than for surgery. Overall, no strong medical results argue for either approach. Information was limited on future pregnancy. One trial was large, while the others had small numbers of women. What the woman prefers should be the major concern. Drug treatment (such as with misoprostol and mifepristone) has added choices for women and their clinicians, and has been studied in other reviews.

Reviewer's Conclusions

Implications for practice

The existing evidence does not indicate the superiority of either expectant care or surgical treatment. If women can accept a higher rate of incomplete miscarriage, need for later surgical evacuation, and need for blood transfusion, watchful waiting is a reasonable course of action. The policy of routine uterine evacuation lacks scientific support. Infection rates did not differ, although transfusion rates did. Costs were higher for surgical management. Given the evidence, women's preferences should play a large role in management plans.

Implications for research

One large trial of good quality compared expectant care with surgical management. Medical management was also examined in that trial and in another smaller one, but was not reviewed here. Several studies were underpowered. Studies evaluating expectant management without ultrasound examination would also be of interest. Lastly, studies need to separate outcomes for pregnancies found to be non-viable by ultrasound examination (without bleeding or pain).

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TY - ELEC T1 - Expectant care versus surgical treatment for miscarriage: Cochrane systematic review ID - 433819 BT - Cochrane Abstracts UR - https://evidence.unboundmedicine.com/evidence/view/Cochrane/433819/all/Expectant_care_versus_surgical_treatment_for_miscarriage:_Cochrane_systematic_review DB - Evidence Central DP - Unbound Medicine ER -