Incomplete Miscarriages: Are Medical Treatments Safe, Effective?

Medical treatment and expectant care are acceptable alternatives to routine surgery after a miscarriage, concluded an intervention review conducted by the Cochrane Pregnancy and Childbirth Group.¹
   
Miscarriages occur in approximately 10% to 15% of all pregnancies and are the most common cause of a pregnancy loss. Most miscarriages occur during the first trimester, or before the 13th week of pregnancy, but any pregnancy loss that occurs before the fetus is viable, usually before 24 weeks’ gestation, is a miscarriage. Approximately 50% of all miscarriages are complete-when the body naturally expels all tissues related to the fetus and placenta. Complete miscarriages generally occur before 10 weeks’ gestation. Incomplete miscarriages typically require dilation and curettage (D&C), a surgical procedure involving the scraping or suctioning of the uterine wall with either a curette instrument or vacuum aspiration. The main treatment goal for a miscarriage is prevention of hemorrhage and infection.
   
It has been suggested that medical treatment, usually involving misoprostol, or expectant care may be just as effective as a D&C and carry less risk of infection. To evaluate this assertion, researchers analyzed randomized and quasi-randomized controlled trials that compared medical treatment with expectant care or surgery or alternative methods of medical treatment.
   
A total of 20 studies involving 4208 women were evaluated. The researchers found that none of the studies specifically assessed miscarriage treatment after 13 weeks’ gestation, which limits the generalizability of the results to all miscarriages. When vaginal administration of misoprostol was compared with expectant care, there were no significant differences in the rates of complete miscarriages or in the need for surgical evacuation. When misoprostol was compared with surgical evacuation, the women in the misoprostol group had slightly lower rates of complete miscarriage, but the success rates for both treatment methods were high. In general, misoprostol was associated with fewer surgical evacuations but more unplanned D&Cs.
   
In this review, the success rates when comparing misoprostol with surgery and when comparing misoprostol with expectant management were similar and ranged from 80% to 99%. Women reportedly were satisfied with whatever treatment they received. However, there were serious limitations that affect the generalizability of these results, specifically the heterogeneity of the study populations and the limited data on death and other serious complications, such as sepsis and hemorrhage. The review authors suggest that the overall evidence indicates that given the availability of health care services, both medical treatment with misoprostol and expectant management are acceptable alternatives to routine D&Cs.

Pertinent Points:
- No real differences in the success of misoprostol and waiting for spontaneous miscarriage or between misoprostol and surgery were found.
- Women who experience a miscarriage should always be informed of all available treatment options. Some women may find that the psychological effects of certain options hinder their ability to begin the healing process.
- There is a need for more studies evaluating the treatment of miscarriage after 13 weeks’ gestation.

 

References:

1. Neilson JP, Gyte GM, Hickey M, et al. Medical treatments for incomplete miscarriage. Cochrane Database Syst Rev. 2013;3:CD007223.