15 June 2012
USA: Expectant care versus surgical treatment for miscarriage
The authors concluded that 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. From Cochrane Database of Systematic Reviews.
The authors note that 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, haemorrhage, or infection.
The study’s objective was to compare the safety and effectiveness of expectant management versus surgical treatment for early pregnancy failure.
The authors 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. Randomised trials comparing expectant care and surgical treatment (vacuum aspiration or dilation and curettage) for miscarriage were eligible for inclusion.
Two review authors assessed trial quality and extracted data. The authors contacted study authors for additional information. For dichotomous data, they calculated the Mantel-Haenszel risk ratio (RR) with 95% confidence interval (CI). For continuous data, they computed the mean difference (MD) and 95% CI. The authors entered additional data such as medians into ‘Other data’ tables.
The authors 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).
The authors concluded that 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.
Expectant care versus surgical treatment for miscarriage. Nanda K, Lopez LM, Grimes DA, Peloggia A, Nanda G. Cochrane Database of Systematic Reviews. 2012 Mar 14;3:CD003518.