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Intervention Review

Medical treatments for incomplete miscarriage (less than 24 weeks)

  1. James P Neilson1,*,
  2. Gillian ML Gyte2,
  3. Martha Hickey3,
  4. Juan C Vazquez4,
  5. Lixia Dou2

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 20 JAN 2010

Assessed as up-to-date: 21 SEP 2009

DOI: 10.1002/14651858.CD007223.pub2


How to Cite

Neilson JP, Gyte GML, Hickey M, Vazquez JC, Dou L. Medical treatments for incomplete miscarriage (less than 24 weeks). Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007223. DOI: 10.1002/14651858.CD007223.pub2.

Author Information

  1. 1

    The University of Liverpool, Department of Women's and Children's Health, Liverpool, UK

  2. 2

    The University of Liverpool, Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, Liverpool, UK

  3. 3

    The Royal Women's Hospital, The University of Melbourne, Melbourne, Victoria, Australia

  4. 4

    Instituto Nacional de Endocrinologia (INEN), Departamento de Salud Reproductiva, Habana, Cuba

*James P Neilson, Department of Women's and Children's Health, The University of Liverpool, First Floor, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool, L8 7SS, UK. jneilson@liverpool.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 20 JAN 2010

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary

Background

Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining pregnancy tissues in the uterus. However, it has been suggested that drug-based medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable.

Objectives

To assess the effectiveness, safety and acceptability of any medical treatment for early incomplete miscarriage (before 24 weeks).

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009) and reference lists of retrieved papers. We updated this search on 23 July 2012 and added the results to the awaiting classification section of the review.

Selection criteria

Randomised controlled trials comparing medical treatment with expectant care or surgery. Quasi-randomised trials were excluded.

Data collection and analysis

Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked.

Main results

Fifteen studies (2750 women) were included, there were no studies on women over 13 weeks' gestation. Studies addressed a number of comparisons and data are therefore limited.

Three trials compared misoprostol treatment (all vaginally administered) with expectant care. There was no significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women). There were few data on ‘deaths or serious complications’.

Nine studies involving 1766 women addressed the comparison of misoprostol (four oral, four vaginal, one vaginal + oral) with surgical evacuation. There was no statistically significant difference in complete miscarriage (average RR 0.96, 95% CI 0.92 to 1.00, eight studies, 1377 women) with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.07, 95% CI 0.03 to 0.18; eight studies, 1538 women) but more unplanned procedures (average RR 6.32, 95% CI 2.90 to 13.77; six studies, 1158 women). There were few data on ‘deaths or serious complications’.  

Limited evidence suggests that women generally seem satisfied with their care. Long-term follow up from one included study identified no difference in subsequent fertility between the three approaches.

Authors' conclusions

The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice.

[Note: the 34 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary

Comparing medical treatments for miscarriage with waiting for nature to take its course or using surgery to empty the womb

Miscarriage is when a pregnant woman loses her baby before the baby would be considered able to survive outside the womb, i.e. before 24 weeks' gestation. Miscarriage occurs in about 10% to 15% of pregnancies and the signs are bleeding usually with some abdominal pain and cramping. The cause of miscarriage is often unknown, but most are likely to be due to abnormalities in the baby’s chromosomes. Women experiencing miscarriage may be quite distressed, and there can be feelings of emptiness, guilt and failure. Fathers can also be affected emotionally. Traditionally, surgery (curettage or vacuum aspiration) has been the treatment used to remove any retained tissue and it is quick to perform. It has now been suggested that medical treatments (usually misoprostol) may be as effective and may carry less risk of infection. This review was undertaken to compare medical treatments with surgery or with no treatment. The review identified 15 studies involving 2750 women and all these studies were of women less than 13 weeks' gestation. There were a number of different ways of giving the drugs and so there are limited data for each comparison. Overall, the review found no difference in the success between misoprostol and waiting for spontaneous miscarriage, nor between misoprostol and surgery. The overall success rate was over 80% and sometimes as high as 99%, and one study identified no difference in subsequent fertility between treatments. Vaginal misoprostol was compared with oral misoprostol in one study which found  no difference in success but there was more diarrhoea with oral misoprostol.  However, women on the whole seemed happy with their care whichever treatment they were given. The review suggests that misoprostol or waiting for spontaneous expulsion of fragments are important alternatives to surgery, but women should be offered an informed choice. Further studies are clearly needed to confirm these findings. There is an urgent need for studies on women who miscarry when more than 13 weeks' gestation.