Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis

Can we use a lower intravaginal dose of misoprostol in the medical management of miscarriage? A randomised controlled study

BACKGROUND

The optimal dose of misoprostol to be used in the medical management of miscarriage before 13 weeks has not been resolved.

AIM

To evaluate the effectiveness and side effect profile of two different dosages of misoprostol.

METHODS

A randomised controlled, equivalence study comparing 400 vs 800 μg misoprostol per vaginum (PV) on an outpatient basis. The allocated dose was repeated the next day if clinically the products of conception had not been passed. Complete miscarriage was evaluated using two methods: ultrasound criteria on Day 7 and the need for surgical management (clinical criteria). Equivalence was demonstrated if the 95% confidence interval [CI] of the observed risk difference between the two doses for complete miscarriage lay between -15.0 and 15.0%. Differences in side effects and patient satisfaction were evaluated using patient-completed questionnaires.

RESULTS

One hundred and fifty-eight women were allocated to receive 400 μg and 152 women to 800 μg misoprostol for the management of missed (91.3%) or incomplete (8.7%) miscarriage. The rate of induced complete miscarriage was equivalent using both ultrasound criteria (observed risk difference (ORD) -4.6%, 95% CI -12.8 to 3.7%; P = 0.313) and clinical criteria (ORD -5.6%, 95% CI -14.8 to 3.6%; P = 0.273). Following the 400 μg dose, the reported rate of fever/rigors was lower (ORD -15.6%, 95% CI -28.1 to -3.0%; P = 0.015), and more women reported their decision to undergo medical management as a good decision (ORD 15.2%, 95% CI 2.8 to 27.7%; P = 0.018).

CONCLUSION

Four hundred-microgram misoprostol PV can be recommended for the medical management of miscarriage on an outpatient basis.

Expectant care versus surgical treatment for miscarriage

BACKGROUND

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, hemorrhage, or infection.

OBJECTIVES

To compare the safety and effectiveness of expectant management versus surgical treatment for early pregnancy failure.

SEARCH METHODS

We 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.

SELECTION CRITERIA

Randomized trials comparing expectant care and surgical treatment (vacuum aspiration or dilation and curettage) for miscarriage were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial quality and extracted data. We contacted study authors for additional information. For dichotomous data, we calculated the Mantel-Haenszel risk ratio (RR) with 95% confidence interval (CI). For continuous data, we computed the mean difference (MD) and 95% CI. We entered additional data such as medians into 'Other data' tables.

MAIN RESULTS

We 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).

AUTHORS' CONCLUSIONS

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.

Immediate versus delayed medical treatment for first-trimester miscarriage: a randomized trial

OBJECTIVE

To compare immediate vs delayed medical treatment for first-trimester miscarriage.

STUDY DESIGN

Randomized open-label trial in a university hospital gynecologic emergency department. Between April 2003 and April 2006, 182 women diagnosed with spontaneous abortion before 14 weeks' gestation were assigned to immediate medical treatment (oral mifepristone, followed 48 hours later by vaginal misoprostol, n = 91) or sequential management (1 week of watchful waiting followed, if necessary, by the above-described medical treatment, n = 91). Vacuum aspiration was performed in case of treatment failure, hemorrhage, pain, infection, or patient request.

RESULTS

Compared with immediate medical treatment, sequential management resulted in twice as many vacuum aspirations overall (43.5% vs 19.1%; P < .001), 4 times as many emergent vacuum aspirations (20% vs 4.5%; P = .001), and twice as many unplanned visits to the emergency department (34.1% vs 16.9%; P = .009).

CONCLUSION

Delaying medical treatment of first-trimester miscarriage increases the rate of unplanned surgical uterine evacuation.

A cost-effectiveness analysis of surgical versus medical management of early pregnancy loss

OBJECTIVE

To determine the cost-effectiveness of medical and surgical management of early pregnancy loss.

DESIGN

Analyses of cost, effectiveness, and incremental cost-effectiveness ratios and utilities of a multicenter trial with 652 women with first-trimester pregnancy failure randomized to medical or surgical management.

SETTING

Analysis of data from a multicenter trial.

PATIENT(S)

Secondary analysis of a multicenter trial.

INTERVENTION(S)

Cost-effectiveness analysis.

MAIN OUTCOME MEASURE(S)

Cost and effectiveness of competing treatment strategies.

RESULT(S)

Cost analysis of treatment demonstrates an increased cost of US$336 for 13% increased efficacy of surgical management. This analysis was sensitive to the probability of an extra office visit, the cost of the visit, and the probability of success. When the surgical arm is divided into outpatient manual vacuum aspiration (MVA) versus inpatient electric vacuum aspiration (EVA), there is an increased cost of $745 for EVA but a decreased cost of $202 for MVA compared with medical management. In general, MVA was found to be more cost-effective than medical management. For treatment of incomplete or inevitable abortion, medical management was found to be less costly and more efficacious. Utilities studies demonstrated that a patient would need to prefer surgery 14% less than medication for its treatment efficacy to be outweighed by the desire to avoid surgery.

CONCLUSION(S)

Surgical or medical management of early pregnancy failure can be cost effective, depending on the circumstances. Surgery is cost effective and more efficacious when performed in an outpatient setting. For incomplete or inevitable abortion, medical management is cost effective and more efficacious.

Mifepristone and misoprostol for early pregnancy failure: a cohort analysis

OBJECTIVE

We sought to examine outcomes of mifepristone and misoprostol for early pregnancy failure (EPF) treatment in a nonresearch setting.

STUDY DESIGN

A protocol was developed for physicians to use mifepristone 200 mg orally and misoprostol 800 μg vaginally for EPF. Success rates were analyzed and an adjusted multivariable regression was used to identify factors predictive of success.

RESULTS

Treatment success occurred in 99 (80%; 95% confidence interval, 72-87%) of 123 patients after mifepristone and a single dose of misoprostol and 102 (83%; 95% confidence interval, 75-89%) patients overall. The odds of successful medical treatment were increased in women with a diagnosis of intrauterine embryonic/fetal demise (odds ratio, 3.80) and decreased in women who made additional emergency department visits (odds ratio, 0.12).

CONCLUSION

Patients and clinicians may be more likely to intervene surgically with an EPF when a strict study protocol is not being followed.

A randomized controlled trial of 400-μg sublingual misoprostol versus manual vacuum aspiration for the treatment of incomplete abortion in two Egyptian hospitals

OBJECTIVE

To compare the safety, efficacy, and acceptability of 400-μg sublingual misoprostol with that of manual vacuum aspiration (MVA) in 2 Egyptian hospitals.

METHODS

Participating women were randomized to either MVA or misoprostol treatment for incomplete abortion. The primary outcome, complete uterine evacuation, was determined 1 week later, as were adverse effects, change in hemoglobin, acceptability, and satisfaction.

RESULTS

Complete uterine evacuation was achieved in 98.3% of women who received misoprostol and 99.7% who underwent MVA (relative risk [RR] 0.99; 95% confidence interval [CI], 0.97-1.00). A decrease in hemoglobin of 2g/dL or more was comparably rare in the 2 groups (0.3% misoprostol vs 0.9% MVA; RR 0.34 [95% CI, 0.04-3.21]). Mean change in hemoglobin was also clinically similar (-0.5 g/dL misoprostol vs -0.4 g/dL MVA; P<0.01). Heavy bleeding was rare (2.4% misoprostol vs 1.6% MVA; RR 1.55 [95% CI, 0.51-4.68]) following treatment. Nearly all women (96.8% misoprostol vs 98.3% MVA) were satisfied with their treatment but those who received misoprostol were significantly more likely to prefer that method in the future (81.9% vs 62.8%; RR 1.30 [95% CI, 1.19-1.43]).

CONCLUSION

The high efficacy, safety, and acceptability of 400-μg sublingual misoprostol indicate that it is analogous to surgery as a first-line treatment for incomplete abortion. Misoprostol might improve post-abortion care when resources are limited and surgical treatment is unavailable.

Counseling women with early pregnancy failure: utilizing evidence, preserving preference

OBJECTIVES

To apply principles of shared decision-making to EPF management counseling. To present a patient treatment priority checklist developed from review of available literature on patient priorities for EPF management.

METHODS

Review of evidence for patient preferences; personal, emotional, physical and clinical factors that may influence patient priorities for EPF management; and the clinical factors, resources, and provider bias that may influence current practice.

RESULTS

Women have strong and diverse preferences for EPF management and report higher satisfaction when treated according to these preferences. However, estimates of actual treatment patterns suggest that current practice does not reflect the evidence for safety and acceptability of all options, or patient preferences. Multiple practice barriers and biases exist that may be influencing provider counseling about options for EPF management.

CONCLUSION

Choosing management for EPF is a preference-sensitive decision. A patient-centered approach to EPF management should incorporate counseling about all treatment options.

PRACTICE IMPLICATIONS

Providers can integrate a counseling model into EPF management practice that utilizes principles of shared decision-making and an organized method for eliciting patient preferences, priorities, and concerns about treatment options.

Comparative study between oral and sublingual 600 µg misoprostol for the treatment of incomplete abortion

AIM

To evaluate and compare effectiveness, side effects and patient acceptability between oral and sublingual 600 µg misoprostol for the treatment of incomplete abortion.

METHODS

A randomized controlled trial was conducted. Pregnant women of less than 14 weeks gestation, diagnosed with incomplete abortion, were randomly assigned to receive 600 µg misoprostol orally or sublingually. The patients were evaluated at 48 h after drug administration for complete abortion.

RESULTS

A total of 64 women were recruited to the study (32 in the oral group and 32 in the sublingual group). The complete abortion rate was not statistically different between oral and sublingual groups (87.5% versus 84.4%, P > 0.05). There was no statistical difference in side effects and satisfaction rate. Fever/chills were the most common side effects.

CONCLUSION

Both sublingual and oral 600 µg misoprostol are useful for the management of incomplete abortion. Side effects and satisfaction rates are not different. Thus, these methods may be used as alternative treatments of incomplete abortion.

Assessment and management of bleeding in the first trimester of pregnancy

Vaginal bleeding occurs in 15% to 25% of early pregnancies. While 50% of women who have vaginal bleeding in the first trimester of pregnancy will continue to have a viable pregnancy, the event creates significant anxiety for the woman and can be managed in a multitude of ways. The 3 main differential diagnoses associated with vaginal bleeding are spontaneous abortion, ectopic pregnancy, and gestational trophoblastic disease. This article reviews early pregnancy development, etiologies of vaginal bleeding in the first trimester, strategies for evaluation, and recognition and management of the main diagnostic considerations. Case study examples illustrating the complexity of the assessment and management of vaginal bleeding in early pregnancy are presented.

Sublingual misoprostol after surgical management of early termination of pregnancy

OBJECTIVE

To assess the efficacy of sublingual misoprostol after surgical management of early termination of pregnancy (ETP) regarding duration and amount of bleeding, presence of retained products of conception (RPOC), and endometrial thickness.

DESIGN

Prospective, randomized clinical trial.

SETTING

University hospital.

PATIENT(S)

One hundred five patients admitted for possible management of early pregnancy failure and unwanted pregnancy.

INTERVENTION(S)

Manual vacuum aspiration (control and study groups) plus 400 microg sublingual misoprostol (study group) at pregnancy termination, and transvaginal ultrasonography (both groups) 10 days after the procedure.

MAIN OUTCOME MEASURE(S)

Duration and amount of bleeding and presence of RPOC and endometrial thickness 10 days after the procedure.

RESULT(S)

Bleeding lasted 3.2 and 5.1 days in the study and control groups. Severe vaginal bleeding occurred in two patients in the study group and in six patients in the control group. Mean endometrial thickness was 5.5 mm in the study group and 6.9 mm in the control group. These differences were statistically significant. No cases of RPOC occurred in the study group; two cases occurred in the control group.

CONCLUSION(S)

In countries in which surgical management of ETP is still done, using sublingual misoprostol postoperatively may reduce the duration and amount of bleeding.

Uterocutaneous fistula after surgical treatment of an incomplete abortion: methylene blue test to verify the diagnosis

INTRODUCTION

Uterocutaneous fistula is an extremely rare clinical condition that can be seen after pelvic or uterine surgery. It can also complicate some obstetric procedures.

CASE

We report of an unusual case of an uterocutaneous fistula that developed in a multiparous woman after surgical evacuation of an incomplete first trimester septic abortion. The fistula tract was depicted on computed tomography, and to verify the diagnosis methylene blue was given through a transcervically introduced uterine catheter, and blue dye flow out through the external opening of fistula was observed. At laparatomy fistula tract was completely excised along with the enclosing omentum. Postoperative recovery and follow-up were uneventful.

DISCUSSION

Possible mechanisms of development of such a rare condition, and diagnostic and treatment options are discussed.

Exploring heterogeneity in meta-analyses: needs, resources and challenges

The investigation of heterogeneity remains an essential but difficult issue in the conduct of meta-analysis. We reviewed standard and graphical methods used to explore heterogeneity in meta-analysis and publications from January 2005 to April 2007 regarding meta-analyses that focused on perinatal health topics. We assessed their approaches to the investigation of heterogeneity, including: (1) whether statistical testing for heterogeneity was performed and, if so, which test was used, (2) how a finding of statistically significant heterogeneity was handled, and (3) how the analyses were conducted in the presence of heterogeneity.

Is misoprostol a safe, effective and acceptable alternative to manual vacuum aspiration for postabortion care? Results from a randomised trial in Burkina Faso, West Africa

OBJECTIVES

Previous research has demonstrated the effectiveness of misoprostol for treatment of incomplete abortion; however, few studies have systematically compared misoprostol's effectiveness with that of standard surgical care. This study documents the effectiveness of a single 600 micrograms dose of oral misoprostol versus manual vacuum aspiration (MVA) for treatment of incomplete abortion in a developing country setting.

DESIGN

Open-label randomised controlled trial.

SETTING

Two university teaching hospitals in Burkina Faso, West Africa.

POPULATION

Women of reproductive age presenting with incomplete abortion.

METHODS

From April 2004 through October 2004, 447 consenting women with incomplete abortion were randomised to either a single dose of 600 micrograms oral misoprostol or MVA for treatment of their condition.

MAIN OUTCOME MEASURE

Completed abortion following initial treatment.

RESULTS

Regardless of treatment assigned, nearly all participants had a complete uterine evacuation (misoprostol = 94.5%, MVA = 99.1%; relative risk [RR] = 0.95 [95% CI 0.92-0.99]). Acceptability and satisfaction ratings were similar and high for both misoprostol and MVA, with three out of four women indicating that the treatment's adverse effects were tolerable (misoprostol = 72.9%, MVA = 75.8%; RR = 0.96 [95% CI 0.86-1.07]). The majority of women were 'satisfied' or 'very satisfied' with the method they received (misoprostol = 96.8%, MVA = 97.7%; RR = 0.99 [95% CI 0.96-1.02]), expressed a desire to choose that method again (misoprostol = 94.5%, MVA = 86.6%; RR = 1.09 [95% CI 1.03-1.16]) and to recommend it to a friend (misoprostol = 94.5%, MVA = 85.2%; RR = 1.11 [95% CI 1.04-1.18]).

CONCLUSION

Six hundred micrograms of oral misoprostol is as safe and acceptable as MVA for the treatment of incomplete abortion. Operations research is needed to ascertain the role of misoprostol within postabortion care programmes worldwide.

Surgical management of early pregnancy failure: history, politics, and safe, cost-effective care

Early pregnancy failure and induced abortion are often managed differently, even though safe uterine evacuation is the goal in both. Early pregnancy failure is commonly treated by curettage in operating room settings in anesthetized patients. Induced abortion is most commonly managed by office vacuum aspiration in awake or sedated patients. Medical evidence does not support routine operating room management of early pregnancy failure. This commentary reviews historical origins of these different care standards, explores political factors responsible for their perpetuation, and uses experience at University of Michigan to dramatize the ways in which history, politics, and biomedicine intersect to produce patient care. The University of Michigan initiated office uterine evacuations for early pregnancy failure treatment. Patients previously went to the operating room. These changes required faculty, staff, and resident education. Our efforts blurred the lines between spontaneous and induced abortion management, improved patient care and better utilized hospital resources.

Psychological morbidity following miscarriage

Emerging evidence has suggested that miscarriage could be associated with significant and possibly enduring psychological consequences. As many as 50% of miscarrying women suffer some form of psychological morbidity in the weeks and months after loss. About 40% of miscarrying women were found to be suffering from symptoms of grief shortly after miscarriage, and pathological grief can follow. Elevated anxiety and depressive symptoms are common, and major depressive disorder has been reported in 10-50% after miscarriage. Psychological symptoms could persist for 6 months to 1 year after miscarriage. The underlying risk factors predisposing a miscarrying woman to psychological morbidity include a history of psychiatric illness, childlessness, lack of social support or poor marital adjustment, prior pregnancy loss, and ambivalence toward the fetus. In addition, care-givers should be aware of the possible moderating effect of clinical practices such as surgical treatment and ultrasound findings on the psychological impact on a miscarrying woman. Unlike in postpartum depression, simple and effective screening measures of psychological morbidity in the context of miscarriage have not been well established. While studies have highlighted that psychological follow-up was highly desired by miscarrying women, and that psychological intervention was potentially beneficial, there is a substantial lack of randomized controlled intervention studies in this area.

The use of misoprostol for early pregnancy failure

PURPOSE OF REVIEW

This paper reviews the current management of early pregnancy failure with particular emphasis on the use of misoprostol.

RECENT FINDINGS

Medical management using misoprostol is effective for the management of miscarriages. The success rate ranged from 84 to 93% depending on the regimen of misoprostol, the duration of waiting period and the types of miscarriage.

SUMMARY

Miscarriages occur in 10 to 20% of all pregnancies. Surgical evacuation has been used to empty the uterus. Recently, medical treatment using misoprostol has been studied for the management of miscarriage. It avoids surgery and its associated complications. Compared to expectant management, the success rate is higher. Nonsurgical management takes a longer period to reach the endpoint and medical management is associated with side effect of medication. Studies have shown that medical management is safe and acceptable to women. The optimal regimen of medical management, however, is yet to be determined.

Common problems and emergencies in the obstetric patient

Physicians not used to caring for pregnant patients may feel uncomfortable dealing with the many routine problems that can occur during a pregnancy. Other than true obstetric emergencies, which are usually cared for by obstetricians and family physicians, and the common problems of pregnancy can often be cared for by any primary care physician. Given the litigious nature of our society, especially in the realm of obstetrics, it does behoove the physician caring for pregnant women to be aware of the standards of care. When in doubt, it would be prudent to consult with a physician that routinely provides care to pregnant women.

Gestational sac aspiration: a novel alternative to dilation and evacuation for management of early pregnancy failure

STUDY OBJECTIVE

To explore the effectiveness (success, safety, and complications) of a novel technique of gestational sac aspiration in the management of early pregnancy failure as an alternative to dilation and evacuation (D&E) and conservative management.

DESIGN

Prospective historical cohort study comparing effectiveness of gestational sac aspiration (study group) to conservative management (control group) with follow-up until negative quantitative beta human chorionic gonadotropin testing is achieved (Canadian Task Force classification II-1).

SETTING

An infertility treatment center.

PATIENTS

Among 60 women with failed early pregnancies that were achieved by in vitro fertilization or intrauterine insemination, 20 underwent gestational sac aspiration, whereas 40 chose conservative management.

INTERVENTIONS

Gestational sac aspiration was done by transvaginal ultrasound-guided needle aspiration under conscious sedation. Aspirated tissue was sent for karyotyping. Both study and control (conservative management) groups received close follow-up with ultrasound and serial beta human chorionic gonadotropin measurements.

MEASUREMENTS AND MAIN RESULTS

There was no significant difference in age, infertility factor, or treatment between study and control groups. Mean gestational age was 8 versus 6 weeks in study and control groups, respectively (p < .05). One and 11 patients required D&E in the study and control groups, respectively (p < .05). Karyotyping was successful in all except one patient in the study group. Chromosomal abnormalities were found in 36% of products of conception. No significant complications occurred

CONCLUSION

Gestational sac aspiration is a simple and safe outpatient technique that is more effective than conservative management of early pregnancy failure and less invasive than D&E. Moreover, the technique provides a high probability of obtaining a noncontaminated adequate gestation tissue sample for chromosomal study.

A randomized study comparing efficacy and patient satisfaction in medical or surgical treatment of miscarriage

OBJECTIVE

To compare the efficacy of the medical treatment to surgical uterine evacuation and patient satisfaction in each group.

DESIGN

A randomized, controlled study.

SETTING

An outpatient clinic in the Department of Gynecology and Obstetrics in Oulu University Hospital, Oulu, Finland.

PATIENT(S)

Ninety-eight eligible women who had had miscarriages.

INTERVENTION(S)

Medical treatment of miscarriage (n = 49) with 200 mg of mifepristone and 0.8 mg of misoprostol 1-3 days after the event or surgical uterine evacuation (n = 49). Questionnaires to collect data of experienced pain and patient satisfaction.

MAIN OUTCOME MEASURE(S)

The complete abortion rate with the primary treatment (primary outcome) and the patient satisfaction (secondary outcome).

RESULT(S)

The success rate was equal (100% in surgical and 90% in medical group). More infections were diagnosed in the surgical group. Surgically treated patients were more satisfied with the treatment (100% vs. 88%). Medical treatment was considered more painful and fewer patients (70% vs. 91%) would choose the medical method in the future.

CONCLUSION(S)

Medical treatment is an effective alternative to surgical treatment and increases the choice available to women. Surgical treatment is associated with more infections. More medically treated patients experienced pain and dissatisfaction.

Expectant, medical or surgical treatment for spontaneous abortion in first trimester of pregnancy: a cost analysis

BACKGROUND

Misoprostol and expectant care have been shown to be acceptable alternatives to routine surgical evacuation for treatment of spontaneous abortion in the first trimester of pregnancy. The objective of this study was to analyse the cost of expectant care, misoprostol therapy and surgical evacuation.

METHODS

A decision tree was designed to simulate the clinical outcome and health care resource utilization of surgical evacuation, misoprostol and expectant care for patients presenting with uncomplicated spontaneous abortion in the first trimester of pregnancy. Clinical inputs were estimated from literature and the cost analysis was conducted from the perspective of a public health care provider in Hong Kong.

RESULTS

The base-case analysis showed that the misoprostol group (1000 US dollars per patient) was the least costly alternative, followed by the expectant care (1172 US dollars per patient) and surgical evacuation (2007 US dollars per patient). Rates of complete abortion using misoprostol and expectant care were identified as influential factors. Monte Carlo simulation (10000 cohorts) showed that the misoprostol and the expectant care groups were less costly than the surgical evacuation group 100 and 88% of the time. The misoprostol group was less costly than the expectant group 100% of the time.

CONCLUSIONS

Misoprostol therapy appears to be the least costly approach for treatment of uncomplicated spontaneous abortion.