Medical treatments for incomplete miscarriage

  • Review
  • Intervention

Authors


Abstract

Background

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.

Objectives

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

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2012) and reference lists of retrieved papers.

Selection criteria

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.

Main results

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.

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. 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.

Laički sažetak

Što je bolje kod nepotpunog pobačaja: davanje lijekova, čekanje da tijelo to samo riješi ili kirurški zahvat za čišćenje maternice?

Pobačaj nastaje kad trudnica izgubi dijete prije nego se smatra da dijete može preživjeti izvan maternice, odnosno prije 24. tjedna trudnoće. Spontani pobačaj događa se u oko 10-15% trudnoća i obično su znakovi pobačaja krvarenje uz bol u trbuhu i grčeve. Uzrok pobačaja obično je nepoznat, ali najvjerojatnije uglavnom nastaje zbog poremećaja u kromosomima djeteta. Žene koje dožive pobačaj mogu biti vrlo potresene i preplavljene osjećajima praznine, krivnje i neuspjeha. Očevi također mogu biti emocionalno pogođeni. Tradicionalno se za uklanjanje bilo kakvog ostatnog tkiva za nepotpuni pobačaj koriste različiti kirurški postupci (kiretaža maternice ili aspiracija pomoću vakuuma). To su brzi zahvati. Pretpostavlja se da bi terapija lijekovima (obično je to misoprostol) mogla biti jednako djelotvorna kao kirurški zahvat i da bi mogla imati manji rizik od infekcija. Ovaj Cochrane sustavni pregled je usporedio liječenje lijekovima s kirurškim zahvatom i nikakvom terapijom (čekanjem) u žena koje su imale nepotpuni spontani pobačaj. Sustavnim pregledom literature pronađeno je 20 studija u kojima je sudjelovalo ukupno 4208 žena. Sve te studije provedene su na ženama koje su bile trudne manje od 13 tjedana. Lijekovi su davani na različite načine i za svaku usporedbu pronađen je malen broj podataka.

Kad su analizirani svi rezultati, pokazalo se da nema stvarne razlike u uspjehu između misoprostola ili čekanja da se dogodi spontani pobačaj, ili između misoprostola i kirurškog zahvata. Ukupan uspjeh terapije bio je 80%, a ponekad i 99%, a jedna studija nije utvrdila razliku u naknadnoj plodnosti u žena koje su primale različite vrste terapije. Vaginalni misoprostol uspoređen je s davanjem misoprostola na usta u jednoj studiji koja nije utvrdila razliku u uspjehu te dvije terapije, ali je zabilježena povećana stopa proljeva nakon uzimanja misoprostola na usta.  Međutim, činilo se da su žene zadovoljne sa skrbi koju su dobile, bez obzira na terapiju koja je primijenjena.

Ovaj Cochrane sustavni pregled ukazuje da su davanje misoprostola ili čekanje da dijelovi pobačenog tkiva sami izađu važne druge mogućnosti u odnosu na kirurški zahvat. Ženama bi trebalo opisati sve te tri mogućnosti i dopustiti im da same izaberu kako postupiti dalje. Daljnje studije bi trebale potvrditi te rezultate i provesti dulje praćenje žena. Hitno su potrebne studije na ovu temu među ženama koje dožive pobačaj nakon 13. tjedna trudnoće.

Bilješke prijevoda

Hrvatski Cochrane
Prevela: Livia Puljak
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr 

Ancillary