Expectant, medical, or surgical management of first-trimester miscarriage

Literature Review Article

Sotiriadis A, Makrydimas G, Papatheodorou S, Ioannidis JP.  Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis.  Obstet Gynecol. 2005 May;105(5 Pt 1):1104-13. 

Review
Paul C. Lin, M.D., Seattle Reproductive Medicine

The purpose of this study was to assess the risks and benefits of various different management options for first trimester miscarriages. The authors looked at randomized trials whose subjects had either a first-trimester missed, anembryonic or incomplete miscarriages before the 14th week of gestation. With the primary endpoint being complete evacuation of the uterus as a successful treatment, 28 studies were part of the meta-analysis to evaluate the differences among medical management, surgical management and expectant management of miscarriages. When medical management was compared with expectant management, the overall success rate of expectant management across all studies was 39%. Medical management, which included varying doses of misoprostol and/or mifepristone, was more than twice (RR=2.8, 1.66-4.62)) as effective as expectant management in inducing complete evacuation. (P<0.001) When surgical management was compared with expectant management, the success rates were not significantly different (RR=1.22, 0.99-1.47). The number need to treat (NNT) was 6. In studies looking at surgical management compared with medical management, surgical intervention was more successful than medical management by 40% (RR=1.44, 1.15-1.80). Secondary outcomes between surgery and medical management such as bleeding, need for emergency curettage, PID, blood transfusion, nausea and vomiting were not statistically significant; however, such secondary outcomes were not looked at consistently among the studies.

Comments 
Daniel B. Williams, M.D., Cincinnati, OH

This meta-analysis demonstrates that expectant management is often not effective, requiring additional treatment. While D & C can still be viewed as the "gold standard", this study does suggest that medical management (misoprostol and/or mifepristone) is a viable non-surgical alternative to the management of these patients.

 

The above review and commentary on this article were written by SRS members. Publication of these summaries does not reflect endorsement of any particular procedure or treatment. Views expressed in these summaries do not necessarily reflect the views of SRS or ASRM.

  

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