Medical treatments for incomplete miscarriage
Editorial Group: Cochrane Pregnancy and Childbirth Group
Published Online: 28 MAR 2013
Assessed as up-to-date: 7 JAN 2013
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Neilson JP, Gyte GML, Hickey M, Vazquez JC, Dou L. Medical treatments for incomplete miscarriage. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD007223. DOI: 10.1002/14651858.CD007223.pub3.
- Publication Status: New search for studies and content updated (no change to conclusions)
- Published Online: 28 MAR 2013
Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable.
To assess the effectiveness, safety and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks).
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2012) and reference lists of retrieved papers.
Randomised controlled trials comparing medical treatment with expectant care or surgery or alternative methods of medical treatment. Quasi-randomised trials were excluded.
Data collection and analysis
Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked.
Twenty studies (4208 women) were included. There were no trials specifically of miscarriage treatment after 13 weeks' gestation.
Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no statistically significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women, random-effects), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women, random-effects). There were few data on ‘deaths or serious complications’.
Twelve studies involving 2894 women addressed the comparison of misoprostol (six studies used oral administration, four studies used vaginal, one study sub-lingual, one study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.97, 95% CI 0.95 to 0.99, 11 studies, 2493 women, random-effects) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.06, 95% CI 0.02 to 0.13; 11 studies, 2654 women, random-effects) but more unplanned procedures (average RR 5.82, 95% CI 2.93 to 11.56; nine studies, 2274 women, random-effects). There were few data on ‘deaths or serious complications’. Nausea was more common with misoprostol (average RR 2.41, 95% CI 1.44 to 4.03; nine studies, 2179 women, random-effects).
Five trials compared different routes of administration and/or doses of misoprostol. There was no clear evidence of one regimen being superior to another.
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.
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. Future studies should include long-term follow-up.
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 20 studies involving 4208 women and all these studies were of women at 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 real 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 an increase in the incidence of 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 and should include long-term follow-up. There is an urgent need for studies on women who miscarry when more than 13 weeks' gestation.