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Meta-Analysis
. 2012 Mar 14;2012(3):CD003518.
doi: 10.1002/14651858.CD003518.pub3.

Expectant care versus surgical treatment for miscarriage

Kavita Nanda  1 , Laureen M Lopez, David A Grimes, Alessandra Peloggia, Geeta Nanda
Affiliations
Meta-Analysis

Expectant care versus surgical treatment for miscarriage

Kavita Nanda et al. Cochrane Database Syst Rev. .

Abstract

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.

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Conflict of interest statement

None known.

Figures

1.1
1.1. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 1 Miscarriage not complete (<= 2 weeks).
1.2
1.2. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 2 Miscarriage not complete (6 to 8 weeks).
1.3
1.3. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 3 Needed (additional or unplanned) surgical evacuation.
1.4
1.4. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 4 Needed (additional or unplanned) surgical evacuation (sensitivity analysis).
1.5
1.5. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 5 Localized pelvic infection by 8 weeks.
1.6
1.6. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 6 Mean (standard deviation) days of bleeding.
1.8
1.8. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 8 Bleeding >= 9 days.
1.9
1.9. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 9 Bleeding with need for transfusion.
1.10
1.10. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 10 Hemorrhage > 500 mL.
1.11
1.11. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 11 Mean (standard deviation) days of pain.
1.13
1.13. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 13 Pain (scale 0 to 3).
1.14
1.14. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 14 Extra analgesic taken.
1.15
1.15. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 15 Costs by 8 weeks for hospital care and broader impacts (UK pounds sterling, 2001‐02 prices).
1.17
1.17. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 17 Days of sick leave after management of miscarriage.
1.18
1.18. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 18 Days to return to usual activities >= 7.
1.19
1.19. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 19 Participant satisfaction with management.
1.20
1.20. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 20 State anxiety inventory.
1.21
1.21. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 21 State anxiety inventory within expectant care group.
1.22
1.22. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 22 HADS Anxiety >=11 at 8 weeks.
1.23
1.23. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 23 HADS Depression >=11 at 8 weeks.
1.24
1.24. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 24 SF‐36 Mental health scale at 8 weeks.
1.25
1.25. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 25 SF‐36 Physical health scale at 8 weeks.
1.26
1.26. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 26 Subsequent conception.
1.27
1.27. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 27 Live births by 5 years.
1.28
1.28. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 28 Cervical tear.
1.29
1.29. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 29 Endometritis.
1.30
1.30. Analysis
Comparison 1 Expectant care versus surgical treatment for miscarriage, Outcome 30 Perioperative complications.
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Update of

References

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