Future fertility following conservative management of complete abortion

Misoprostol treatment for early pregnancy loss: an international survey

RESEARCH QUESTION

What is the global variability in misoprostol treatment for the management of early pregnancy loss (EPL)?

DESIGN

An international web-based survey of fertility specialists and obstetrics and gynaecology clinicians was conducted between August and November 2020. The survey consisted of 16 questions addressing several aspects of misoprostol treatment for EPL.

RESULTS

Overall, 309 clinicians from 80 countries participated in the survey, of whom 67.3% were fertility specialists. Nearly one-half (47.9%) of the respondents let the patient choose the first line of treatment (expectant management, misoprostol treatment or surgical aspiration) according to her own preference. The 248 respondents who administer misoprostol in their daily practice were asked further questions; 59.7% of them advise patients to take the medication at home. The most common dose and route of administration is 800 µg administered vaginally. Only 28.6% of participants use mifepristone pretreatment. Variation in the timing of the first follow-up visit after misoprostol administration was wide, ranging from 24 h to 1 week in most clinics. In case of incomplete expulsion, only 42.3% of the respondents routinely administer a second dose. The timing of the final visit and the definition of successful treatment also differed greatly among respondents.

CONCLUSIONS

There is large variability in the use of misoprostol for the management of EPL. High-quality research is necessary to examine several aspects of the treatment. Particularly, the timing and effectiveness of a second dose administration and the criteria to decide on treatment failure or success deserve more research in the future.

Reproductive outcome after early pregnancy loss treated with misoprostol versus surgical aspiration

RESEARCH QUESTION

Does long-term reproductive outcome after early pregnancy loss (EPL) differ between women who are treated with misoprostol and surgical aspiration.

DESIGN

A historic cohort study of all women who were diagnosed with early pregnancy loss (≤12 weeks), in a single medical centre, between September 2016 and August 2017, was conducted. The women were treated with either misoprostol or surgical aspiration according to their own preferences. Women who were lost to follow-up or did not attempt to conceive again were excluded. The primary outcome measure was the cumulative pregnancy rate within 12 months from intervention.

RESULTS

Baseline characteristics were comparable between women who received misoprostol (n = 163) and women who underwent surgical aspiration (n = 122). Women who received misoprostol had a higher rate of interventions for retained products of conception (11.0% versus 3.3%, respectively; P = 0.015). The misoprostol and the surgical aspiration groups did not differ in rate of repeated miscarriages (17.8% versus 21.3%, respectively; P = 0.45), or pregnancy rate within 6 months (58.3% versus 50.0%, respectively; P = 0.16), 12 months (78.5% versus 78.7%, respectively; P = 0.97) and 24 months (92.0% versus 91.8%, respectively; P = 0.94). Live birth rate within 24 months was comparable (62.0% versus 58.2%, respectively; P = 0.52), as well as gestational age at birth (38.5 versus 38.6 weeks, respectively; P = 0.81) and birthweight (3295 versus 3161 g, respectively; P = 0.07).

CONCLUSIONS

Long-term reproductive outcomes are comparable in women with EPL who are treated with either misoprostol or surgical aspiration. Our findings may help counselling patients facing EPL who have concerns about their future reproduction.

Fertility and obstetric outcomes after curettage versus expectant management in randomised and non-randomised women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage

OBJECTIVE

To assess fertility and obstetric outcomes in women treated with curettage or undergoing expectant management for an incomplete miscarriage after misoprostol treatment.

STUDY DESIGN

Between June 2012 and July 2014, we conducted a multicentre randomised clinical trial (RCT) with a parallel cohort study for non-randomised women, treated according to their preference. In the RCT 30 women were allocated curettage and 29 expectant management. In the cohort 197 women participated; 65 underwent curettage and 132 women underwent expectant management. Primary outcome was curation, defined as either an empty uterus on sonography at six weeks or an uneventful clinical follow-up. We used questionnaires to assess fertility and obstetric outcome of the first new pregnancy subsequent to study enrolment.

RESULTS

Curation was seen in 91/95 women treated with curettage (95.8%) versus 134/161 women managed expectantly (83.2%) (p=0.003). The response rate was 211/255 (82%). In 198 women pursuing a new pregnancy, conception rates were 92% (67/73) in the curettage group versus 96% (120/125) in the expectant management group (OR 0.96, 95% CI 0.89;1.03, p=0.34), with ongoing pregnancy rates of 87% (58/67) versus 78% (94/120), respectively (OR 1.12, 95% CI 0.99;1.28, p=0.226). Preterm birth rates were 1/46 in the curettage group versus 8/81 in the expectant management group (OR 0.22, 95% CI 0.03;1.71 P=0.15). Caesarean section rates were 23% and 24% for women in the curettage group and expectant management group respectively.

CONCLUSION

In women with an incomplete evacuation of the uterus after misoprostol treatment, curettage and expectant management does not lead to different fertility and pregnancy outcomes, as compared to expectant management.

Intrauterine Adhesions Following Miscarriage: Look and Learn

OBJECTIVE

To examine the incidence of intrauterine adhesions (IUA) following the management of miscarriage in women with previously documented normal uterine cavities.

METHODS

We conducted a retrospective cohort study from two fertility clinics with standard practice protocols for evaluating the uterine cavity prior to infertility treatment and following clinical pregnancy loss. A database query and manual chart review identified 144 women with normal uterine cavities who experienced a miscarriage between January 2010 and November 2012 and returned to the clinic for follow-up hysteroscopy. Following documentation of a non-viable clinical pregnancy using transvaginal ultrasound, patients chose expectant, medical, or surgical management according to standardized clinical protocols. The primary outcome was the detection of IUA. Secondary outcomes included the presence of retained products of conception and various risk factors associated with the development of IUA.

RESULTS

The incidence of IUA following early pregnancy loss was 6.3%. There were no significant differences in patient characteristics between those with and without IUA. There was a significant association between IUA and increasing uterine size, particularly in the presence of multiple gestation (P = 0.039). Mechanical suction dilatation and curettage (D&C) was a risk factor for IUA, but manual vacuum aspiration was not a risk factor (P = 0.003). Retained products of conception were found in 13.9% of study participants, and the incidence did not differ among management options.

CONCLUSIONS

This appears to be the first documentation of IUA that were entirely attributable to the index miscarriage or its management. There appears to be an increased risk of IUA following D&C with larger uteri and multiple pregnancies and following mechanical suction D&C.

Misoprostol treatment for early pregnancy failure does not impair future fertility

AIMS

To examine whether misoprostol treatment for first trimester missed abortion affects future fertility.

PATIENTS AND METHODS

In a historical prospective approach, we analyzed our database for patients treated with misoprostol. All eligible patients underwent an interview according to a questionnaire, which includes their demographic characteristics, obstetric, gynecologic and infertility history. They were asked about the side effects, intention and subsequent ability to conceive. Their future pregnancy rates were calculated and compared to the acceptable figures in the literature.

RESULTS

The infertility rates among our patients were similar to those reported in the general population. Pregnancy rates 2 years after treatment were similar to the previously published reports, except for lower rates during the first three months post-treatment. Although no between-group differences were observed in the subsequent pregnancy rates, 2 years following misoprostol treatment in ≤35 versus >35 years old patients, primi- versus multigravida and nulli- versus parous women, higher pregnancy rates were observed in patients ≤35 versus >35 years old, primi- versus multigravida and nulli- versus, parous, during the first 3 months following misoprostol treatment.

CONCLUSION

Misoprostol treatment, for women with first trimester missed abortion and favorable reproductive history, is an acceptable treatment with no detrimental effect on future fertility.

A randomised controlled trial of expectant management versus surgical evacuation of early pregnancy loss

OBJECTIVE

To show whether a clinically significant difference in success rates exists between expectant and surgical management of early pregnancy loss.

STUDY DESIGN

Randomised controlled trial comparing expectant versus surgical management of early pregnancy loss over a 1-year period from 1st January to 31st December 2009 at Sultanah Aminah Hospital, Johor Bahru. Pregnant women with missed or incomplete miscarriages at gestations up to 14 weeks were recruited in this study. The success rate in the surgical group was measured as curettage performed without any complications during or after the procedure, while the success rate in the expectant group was defined as complete spontaneous expulsion of products of conception within 6 weeks without any complication.

RESULTS

A total of 360 women were recruited and randomised to expectant or surgical management, with 180 women in each group. There was no statistically significant difference in the success rate between the groups and between the different types of miscarriage. With expectant management, 131 (74%) patients had a complete spontaneous expulsion of products of conception, of whom 106 (83%) women miscarried within 7 days. However, the rates of unplanned admissions (18.1%) and unplanned surgical evacuations (17.5%) in the expectant group were significantly higher than the rates (7.4% and 8% respectively) in the surgical group. The complications in both groups were similar.

Expectant management of first-trimester miscarriage

Miscarriage is the most common complication of pregnancy, which creates a significant workload for health-care professionals. For decades, surgical evacuation of the uterus has remained the conventional treatment of first-trimester miscarriage. Recently, non surgical treatments have been introduced with increasing popularity. This review explores the evidence in support of expectant management of first-trimester miscarriage. It is safe, effective and well-tolerated by women. It enhances women's choice and control. It generates significant cost savings compared with the traditional surgical management. Accurate diagnosis, counselling, 24/7 telephone advice and follow-up are among the important aspects of expectant management. More studies are needed to develop methods for identifying miscarriages suitable for expectant management.

Incidence of pregnancy after expectant, medical, or surgical management of spontaneous first trimester miscarriage: long term follow-up of miscarriage treatment (MIST) randomised controlled trial

OBJECTIVES

To compare fertility rates after the three methods of managing early miscarriage in women recruited to the MIST (miscarriage treatment) randomised controlled trial.

SETTING

Early pregnancy clinics of acute hospitals in the south west region of England.

PARTICIPANTS

1199 women who had had an early miscarriage (<13 weeks) confirmed by scan.

INTERVENTION

Expectant, medical, or surgical management.

MAIN OUTCOME MEASURES

Self reported pregnancy rates and live birth rates.

RESULTS

Of 1199 women recruited to the trial, 1128 consented to follow-up. Of these, 762 women replied giving pregnancy details (68% response rate). Respondents were representative of the trial participants. The live birth rate five years after the index miscarriage was similar in the three management groups: 177/224 (79%, 95% confidence interval 73% to 84%) in the expectant management group, 181/230 (79%, 73% to 84%) in the medical group, and 192/235 (82%, 76% to 86%) in the surgical group. There was also no significant difference according to previous birth history. Older women and those with previous miscarriages were significantly less likely to subsequently give birth.

CONCLUSION

Method of miscarriage management does not affect subsequent pregnancy rates with around four in five women giving birth within five years of the index miscarriage. Women can be reassured that long term fertility concerns need not affect their choice of miscarriage management.

TRIAL REGISTRATION

National Research Register N0467011677/N0467073587.

Does dilation and curettage versus expectant management for spontaneous abortion in patients undergoing in vitro fertilization affect subsequent endometrial development?

In in vitro fertilization patients, treatment of spontaneous abortion with dilation and curettage (D&C) versus expectant management has no long-term effect on subsequent endometrial development, as measured by change in endometrial thickness. A transient reduction in endometrial thickness was found within the first 6 months after D&C, which is a novel finding, but it is likely to have little or no effect on pregnancy rates given the small absolute effect on endometrial thickness.

A randomised double blind trial comparing misoprostol or placebo in the management of early miscarriage

OBJECTIVES

To study if misoprostol 400 microg, administered vaginally, increased the successful resolution of early miscarriage compared with placebo.

DESIGN

Randomised, double blind placebo controlled study.

SETTING

Sahlgrenska University Hospital, Göteborg, Sweden.

SAMPLE

One hundred and twenty-six women seeking medical attention for early miscarriage.

METHOD

Women with a non-viable, first trimester miscarriage were randomised to vaginal administration of misoprostol 400 microg or placebo.

MAIN OUTCOME MEASURES

Main outcome measure was the proportion of successful complete resolution of miscarriage. Secondary outcomes were incidence of infection, bleeding, gastrointestinal side effects, pain, use of analgesics and length of sick leave between groups.

RESULTS

Sixty-four patients were randomised to misoprostol and 62 to placebo. Eighty-one percent in the misoprostol and 52% in the placebo group had a complete miscarriage within one week of the primary visit (RR 1.57; 95% CI 1.20-2.06). Patients in the misoprostol group reported more pain as assessed on a visual analogue scale (60.4 [31.0] vs 43.8 [37.1] mm; P < 0.007) and required analgesics more often (83%vs 61%, RR 1.35; 95% CI 1.08-1.70). There were no significant differences in the occurrence of gastrointestinal side effects, infection, reduction in haemoglobin or sick leave between the groups.

CONCLUSIONS

Treatment with 400 mug misoprostol administered vaginally increased the success rate of resolvement of uncomplicated early miscarriages compared with placebo. However, women who received misoprostol experienced more pain and required more analgesics than those who did not.

Expectant management of first-trimester miscarriage in clinical practice

BACKGROUND

The aim of this study was to evaluate treatment efficacy and patient compliance in women with an early miscarriage managed expectantly in routine clinical practice.

METHODS

During 1995-98, 263 consecutive women who sought medical attention for an ongoing or incomplete miscarriage (gestational length <99 days), and who were circulatory stable and had a gestational residue measuring 15-50 mm (anterio-posterior, A-P diameter) on ultrasound examination were invited to participate in this study. Hemoglobin (Hb), C-reactive protein (CRP), human chorionic gonadotrophin (hCG), progesterone and Rh-factor were analyzed and a questionnaire regarding the pregnancy, duration of genital bleeding and number of days of absenteeism was completed on admission and after 1 and 4 weeks.

RESULTS

Expectant management was considered to be complete (vaginal ultrasound, gestational residue <15 mm after 1 week) in 83%. The patients who were managed successfully by expectant management had a smaller gestational residue (p = 0.026) and a lower mean serum progesterone level (p = 0.025) on referral than in the group of women with failed expectant management. A gynecologic infection was diagnosed in seven cases (3%) and five of the infections were in the group of women who underwent dilatation and curettage. No patient required a blood transfusion. The mean number of days of absenteeism was 3.2 days. There were no differences in Hb levels before or after treatment, number of bleeding days or absenteeism between the groups.

CONCLUSIONS

Expectant management of clinically stable patients with symptoms of early miscarriage is safe, efficient and well tolerated.

The role of ultrasound in the expectant management of early pregnancy loss

OBJECTIVE

To define the sonographic criteria which best determine the likelihood of successful expectant management of early pregnancy failure (EPF).

METHODS

Women with an ultrasound diagnosis of EPF at 7-14 weeks' gestation were offered the option of expectant management or surgical evacuation.

RESULTS

Five hundred and forty-five women had a diagnosis of EPF; 298 with incomplete miscarriage and 247 with missed miscarriage or an embryonic pregnancy. A total of 305 women opted for expectant management, with an overall success rate of 86%. The success rate for incomplete miscarriage (96%) was significantly better than that for missed miscarriage (62%).

CONCLUSION

This study demonstrates that EPF can be safely managed expectantly. Ultrasound has an invaluable role in predicting the likelihood of successful expectant management enabling patients to make an informed choice about their medical care.

Midwifery management of first trimester bleeding and early pregnancy loss

As many as 25% of women experience bleeding in the first and early second trimester of pregnancy; about half of these will have a miscarriage or, more rarely, ectopic or molar pregnancy loss. This can be a difficult time for women because of the uncertainty of the outcome, lack of preventative measures, and emotional significance of early pregnancy loss. The qualities that characterize midwifery care, including providing complete information, encouraging self-determination, and being sensitive to the emotional state, are particularly important at this time. This article reviews the epidemiology; physiologic process; signs and symptoms of first trimester bleeding; miscarriage and other early pregnancy losses; and methods of clinical, biochemical, and sonographic evaluation. A framework to guide midwifery evaluation and management, based on confirmation of an intrauterine pregnancy followed by the determination of viability, is presented. Surgical, medical, and expectant management of nonviable pregnancy, management of viable pregnancy when bleeding persists, and follow-up care, including screening for psychological sequelae, are discussed. Case studies and specific clinical guidelines for midwifery care, consultation, collaboration, and referral are included. Understanding the emotional significance of first trimester bleeding and loss as a basis for sensitive care throughout the management process is addressed.

Diagnostic and therapeutic decision-making with transvaginal sonography for first trimester spontaneous abortion, clinically thought to be incomplete or complete

The purpose of this study was to evaluate the diagnostic accuracy of transvaginal sonography for first trimester spontaneous abortions, thought to be incomplete or complete, in patients with postabortion bleeding or uterine cramping within 5 days of abortion. In a prospective study, 78 patients underwent transvaginal sonography to evaluate the maximum anteroposterior diameter of the uterine cavity on the long axis view and echo pattern of the retained products of conception. Patients were divided into three groups: those with a normal uterine cavity or a uterine cavity with fluid collection without echogenic foci (n = 13, group A), those with a uterine cavity containing fluid mixed with solid components (n = 38, group B), and those with a uterine cavity containing solid components (n = 27, group C). Group A was considered not to have retained products of conception, and the latter two groups were considered to have retained products of conception. Patients in group A were assigned to receive conservative treatment. In groups B and C, patients with significant vaginal bleeding during 48 h of follow-up underwent elective curettage and those with minimal-mild bleeding received conservative management. A total of 73 patients (12 in group A, 35 in group B and 26 in group C) completed the study. There were no differences in any of selected reproductive data of the groups (p > 0.05). In group B, all patients with uterine cavity diameter of 10 mm or greater underwent elective curettage. In group C, all patients with a diameter of the uterine cavity 8 mm or greater underwent elective curettage. The overall complication and patient satisfaction rates were approximately 14% and 88%, respectively. Transvaginal sonographic findings can be used as a decision factor in the management of patients with first trimester spontaneous abortion to reduce the need for an elective curettage by approximately 58%.