Does symptomatology at presentation correlate with successful expectant management of first trimester miscarriage: a prospective observational study

Predictors of successful expectant and medical management of miscarriage: A systematic review

INTRODUCTION

15.3% of pregnancies result in miscarriage, management options include expectant, medical, or surgical. However, each patient has a range of variables, which makes navigating the available literature challenging when supporting individual patient decision-making. This systematic review aims to investigate whether there are any specific predictors for miscarriage management outcome.

MATERIAL AND METHODS

The following databases were searched, from the start of each database up to April 2023: PubMed, Medline, and Google Scholar. Inclusion criteria were studies interrogating defined predictors for expectant or medical management of miscarriage success. Exclusion criteria were poor quality, review articles, trial protocols, and congress abstracts. Data collection was carried as per PRISMA guidelines. Quality assessment for each study was assessed using the QUIPS proforma.

RESULTS

Relevant predictors include demographics, ultrasound features, presenting symptoms, and biochemical markers. Across the 24 studies there is heterogeneity in miscarriage definition, predictors reported, and management outcomes used. Associations with certain variables and miscarriage management outcomes are described. Ten studies assessed the impact of miscarriage type on expectant and/or medical management. The majority found that a diagnosis of incomplete miscarriage had a higher success rate following expectant or medical management compared to missed miscarriage or anembryonic pregnancy.

CONCLUSIONS

We conclude that there is evidence supporting the possibility to offer personalized miscarriage management advice with case specific predictors. Further larger studies with consistent definitions of predictors, management, and outcomes are needed in order to better support women through the decision-making of miscarriage management.

Predictors of complete miscarriage after expectant management or misoprostol treatment of non-viable early pregnancy in women with vaginal bleeding

Purpose

To identify predictors of complete miscarriage after expectant management or misoprostol treatment of non-viable early pregnancy in women with vaginal bleeding.

Methods

This was a planned secondary analysis of data from a published randomized controlled trial comparing expectant management with vaginal single dose of 800 µg misoprostol treatment of women with embryonic or anembryonic miscarriage. Predefined variables—serum-progesterone, serum-β-human chorionic gonadotropin, parity, previous vaginal deliveries, gestational age, clinical symptoms (bleeding and pain), mean diameter and shape of the gestational sac, crown-rump-length, type of miscarriage, and presence of blood flow in the intervillous space—were tested as predictors of treatment success (no gestational sac in the uterine cavity and maximum anterior–posterior intracavitary diameter was ≤ 15 mm as measured with transvaginal ultrasound on a sagittal view) in univariable and multivariable logistic regression.

Results

Variables from 174 women (83 expectant management versus 91 misoprostol) were analyzed for prediction of complete miscarriage at ≤ 17 days. In patients managed expectantly, the rate of complete miscarriage was 62.7% (32/51) in embryonic miscarriages versus 37.5% (12/32) in anembryonic miscarriages (P = 0.02). In multivariable logistic regression, the likelihood of success increased with increasing gestational age, increasing crown-rump-length and decreasing gestational sac diameter. Misoprostol treatment was successful in 80.0% (73/91). No variable predicted success of misoprostol treatment.

Conclusions

Complete miscarriage after expectant management is significantly more likely in embryonic miscarriage than in anembryonic miscarriage. Gestational age, crown-rump-length, and gestational sac diameter are independent predictors of success of expectant management. Predictors of treatment success may help counselling women with early miscarriage.

Expectant versus surgical management of first-trimester miscarriage: a randomised controlled study

INTRODUCTION

The aim of this study is to compare the efficacy and safety of expectant management with surgical management of first-trimester miscarriage.

METHODS

This randomised prospective study was conducted in the Gynaecology Department at University of Saarland Hospital, Germany between February 2011 and April 2012. A total of 234 women were recruited following diagnosis of the first-trimester incomplete or missed miscarriage and randomised into two groups: 109 women were randomised to expectant management (group I), and 125 women to surgical management (groupII). All women were examined clinically and sonographically during the follow-up appointments at weekly intervals for up to 4 weeks as appropriate. The outcome measures were: efficacy, short-term complications and duration of vaginal bleeding and pain.

RESULTS

Of 234 eligible women, 17 were lost to follow-up, and the remaining 217 women were analysed. The baseline characteristics were similar in both groups. The total success rate at 4 weeks was lower for expectant than for surgical management (81.4 vs 95.7 %; P = 0.0029). The type of miscarriage was a significant factor affecting the success rate. For missed miscarriage, the success rates for expectant versus surgical management were 75 and 93.8 %, respectively. For women with incomplete miscarriage, the rates were 90.5 and 98 %. No differences were found in the number of emergency curettages between the two study groups. The duration of bleeding was significantly more in the expectant than the surgical management (mean 11 vs 7 days; P < 0.0001). The duration of pain was also more in the expectant than the surgical group (mean 8.1 vs 5.5 days; P < 0.0001). The total complication rates were similar in both groups (expectant 5.9 % vs surgical group 6.1 %; P = 0.2479). However, the pelvic infection was significantly lower in the expectant than the surgical group (1.9 vs 3.5 %, respectively; P = 0.0146).

CONCLUSION

Expectant management of clinically stable women with first-trimester miscarriage is safe and effective and avoids the need for surgery and the subsequent risk of anaesthesia in about 81.4 % of cases, and has lower pelvic infection rate than surgical curettage. However, surgical management is more successful, and with a shorter duration of bleeding and pain. Therefore, the patient's preference should be considered in the counselling process.