OUTCOME
OF EXPECTANT MANAGEMENT OF SPONTANEOUS FIRST TRIMESTER MISCARRIAGE:
OBSERVATIONAL STUDY.
Luise
C, et al. BMJ 2002 Apr 13;324(7342):873-5.
OBJECTIVES:
To evaluate the uptake and outcome of expectant management of spontaneous first
trimester miscarriage in an early pregnancy assessment unit.
PARTICIPANTS:
1096 consecutive patients with a diagnosis of spontaneous first trimester
miscarriage.
METHODS:
Each miscarriage was classified as complete, incomplete, missed, or anembryonic
on the basis of ultrasonography. Women who needed treatment were given the
choice of expectant management or surgical evacuation of retained products of
conception under general anaesthesia. Women undergoing expectant management
were checked a few days after transvaginal bleeding had stopped, or they were
monitored at weekly intervals for four weeks.
MAIN
OUTCOME MEASURES: A complete miscarriage (absence of transvaginal bleeding and
endometrial thickness <15 mm), the number of women completing their
miscarriage within each week of management, and complications (excessive pain
or transvaginal bleeding necessitating hospital admission or clinical evidence
of infection).
RESULTS:
Two patients with molar pregnancies were excluded, and 37% of the remainder
(408/1094) were classified as having had a complete miscarriage. 70% (478/686)
of women with retained products of conception chose expectant management; of
these, 27 (6%) were lost to follow up. A successful outcome without surgical
intervention was seen in 81% of cases (367/451). The rate of spontaneous
completion was 91% (201/221) for those cases classified as incomplete
miscarriage, 76% (105/138) for missed miscarriage, and 66% (61/92) for
anembryonic pregnancy. 70% of women completed their miscarriage within 14 days
of classification (84% for incomplete miscarriage and 52% for missed miscarriage
and anembryonic pregnancy).
CONCLUSIONS:
Most women with retained products of conception chose expectant management.
Ultrasonography can be used to advise patients on the likelihood that their miscarriage
will complete spontaneously within a given time.
EXPECTANT,
MEDICAL, OR SURGICAL TREATMENT OF SPONTANEOUS ABORTION IN FIRST TRIMESTER OF
PREGNANCY? A POOLED QUANTITATIVE LITERATURE EVALUATION.
Geyman
JP, Oliver LM, Sullivan SD. J Am Board Fam Pract 1999 Jan-Feb;12(1):55-64
BACKGROUND:
Spontaneous abortion is a common problem in everyday clinical practice,
accounting for 15 to 20 percent of all recognized pregnancies. The traditional
treatment of this problem has been surgical, emptying the uterus by dilatation
and curettage (D&C). Recent therapeutic and laboratory advances call
surgical therapy into question for many patients. It is believed that this
pooled quantitative literature evaluation is the first with the goal to clarify
the roles of expectant, medical, and surgical treatment of this common problem.
METHODS:
The literature review was focused on published studies in the English language
of outcomes of therapy for spontaneous abortion in the first trimester. We
looked for both observational and randomized controlled trials. A successful
outcome of treatment required that three criteria be met: vaginal bleeding
stopped by 3 weeks, products of conception fully expelled by 2 weeks, and
absence of complications. Pooled weighted average success estimates and
standard errors were determined for each study; 95 percent confidence intervals
were calculated for each form of treatment. Sensitivity analysis compared
randomized controlled trials with observational studies for both expectant and
surgical treatment.
RESULTS:
Of the 31 studies retrieved, 18 met inclusion criteria, including 9 involving
expectant treatment (545 pooled patients), 3 for medical treatment
(prostaglandin or antiprogesterone agents) (198 pooled patients), and 10 for
surgical treatment (D&C) (1408 pooled patients). Successful outcomes were
found in 92.5 percent of patients receiving expectant treatment, in 93.6 percent
of those undergoing D&C, and in 51.5 percent of patients receiving medical
treatment.
CONCLUSIONS:
Expectant management of spontaneous abortion in the first trimester is safe and
effective for many afebrile patients whose blood pressure and heart rate are stable
and who have no excess bleeding or unacceptable pain. Transvaginal sonographic
studies might be useful in patient selection, and serial chorionic gonadotropin
monitoring should be considered while observing the initial course of expectant
treatment. Currently there is insufficient evidence to support medical therapy
of spontaneous abortion, and further research is needed to clarify the more
limited role of surgical treatment.