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2007;9:102108
10.1576/toag.9.2.102.27311 www.rcog.org.uk/togonline
Key content:
Miscarriage has traditionally been treated by surgical evacuation, on the
assumption that any retained tissue increases the risk of infection and
haemorrhage.
Over the last decade, effective non-surgical alternatives have been advocated to
minimise unnecessary surgical intervention while maintaining low rates of
morbidity and mortality.
Improved access to early pregnancy assessment units and greater awareness among
women has led to increasing demand for more conservative management of
miscarriage.
Learning objectives:
To learn about the use of appropriate miscarriage terminology.
To learn about the advantages and disadvantages of expectant, medical and
surgical management.
To understand that womens choice is paramount in planning treatment.
Ethical issues:
Guidance on the sensitive disposal of fetal remains is essential.
Keywords early pregnancy assessment units / expectant management / medical
management / miscarriage / surgical evacuation
Please cite this article as: Sagili H, Divers M. Modern management of miscarriage. The Obstetrician & Gynaecologist 2007;9:102108.
Author details
Haritha Sagili MD MRCOG DFFP
Senior House Officer Obstetrics and
Gynaecology
Department of Obstetrics and Gynaecology
Nobles Hospital
Isle of Man, IM4 4RJ, UK
Email: harithas@hotmail.com
(corresponding author)
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Introduction
Miscarriage accounts for approximately 50 000
inpatient admissions in the United Kingdom
annually (Department of Health statistics, 2005).1 It
is common, occurring in 1520% of all pregnancies,
and can have both medical and psychological
consequences. While maternal death is rare after
miscarriage, particularly in the first trimester, on
which this review focuses, it has featured in
previous Confidential Enquiries into Maternal
Deaths in the UK, particularly after surgical
procedures in association with sepsis. Ectopic
pregnancy, recurrent miscarriage, gestational
trophoblastic disease and pregnancy of unknown
location are not discussed.
Early pregnancy
assessment units
Speculum examination
Recommended term
Previous term
Ultrasound appearance
Clinical presentation
Threatened miscarriage
Threatened abortion
Complete miscarriage
Complete abortion
Incomplete miscarriage
Incomplete abortion
Missed miscarriage
Delayed miscarriage
Silent miscarriage
Early fetal demise
(These reflect different stages
in the same process)
Inevitable miscarriage
Missed abortion
Anembryonic pregnancy
Blighted ovum
Review
Table 1
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Treatment
See Figure 1.3,4,6
Non-viable pregnancy
The term non-viable pregnancy includes
incomplete, silent, delayed and missed miscarriage
and early fetal demise.
Expectant management
Up to 70% of women will choose expectant
management if given the choice.16 A review by
Butler17 showed that expectant management is
successful within 26 weeks without increasing
complications in 8090% of women with
incomplete spontaneous miscarriage and 6575%
of women with delayed miscarriage or an empty
sac. Womens experiences with expectant
management revealed a mean worst pain of 5.9 on
an 11-point scale.18 The satisfaction rates were
92.9% with family physician care and 84.6% with
hospital care. Bleeding varied, but was often very
heavy. The median daily levels of bleeding and pain
were highest during the first 8 days from the start of
bleeding and decreased thereafter in the 188
women managed expectantly.19
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Figure 1
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Table 2
Comparison of management
regimes6,16,17,21,23,24,26,28,36,3840,42
Expectant
Medical
Surgical
8091
2576
6195 (prostaglandin)
4093 (prostaglandin)
7084 (mifepristone
prostaglandin)
1410.40
23
1036
0
No differences between different treatment modalities
95100
95100
95100
1086.20
23
1044
0
1585.30
23
25
7.7
Comparison of different
methods of management
There are few robust randomised controlled studies
with sufficient numbers of women to enable true
comparison between expectant, medical and
surgical management for incomplete miscarriage
and early fetal demise (Table 2). The MIST trial36
revealed significantly more unplanned admissions
and unplanned surgical curettage procedures after
expectant management and medical management
than after surgical management, although the risk
of infection was low (23%), regardless of
treatment modality. A recent meta-analysis37 to
quantify the relative benefits and risks of different
management options for first-trimester
miscarriage reported that surgical treatment had
the best success rate, followed by medical and
expectant treatment, although many studies were
of poor methodological quality.
The 2006 Cochrane review38 identified five trials
comparing expectant with surgical management.
Expectant care led to a higher risk of incomplete
miscarriage, bleeding and need for surgical
evacuation of the uterus, while surgery resulted in a
significantly greater risk of infection (relative risk
0.29, CI 0.090.87, P 0.03). However, there was
no strong medical argument for either approach
and the individual womans preference was
considered the major concern.
Filmy intrauterine adhesions are present in 7.7% of
women examined hysteroscopically following
surgical evacuation but not in those managed
conservatively or medically. Long-term conception
rates and pregnancy outcomes are no different
following medical or surgical evacuation for
miscarriage, the median time to pregnancy being
8 months in both groups.39,40
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Cost analysis
Conflicting results have been reported on the cost
effectiveness of different treatment strategies.4143
Analysis of pooled data from 29 reports found
misoprostol the least costly alternative ($1 000 [US
dollars] per woman), followed by expectant care
($1 172) and surgical evacuation ($2 007).41
Misoprostol and expectant care groups were shown
to be less costly than the surgical evacuation group
100% and 88% of the time, while the misoprostol
group was less costly than the expectant group
100% of the time.
In an economic evaluation of the MIST trial,42
expectant management was shown to be cheaper
(net societal cost per woman estimated at
1 086.20) than both medical (1 410.40) and
surgical management (1 585.30). Overall, it was
the most cost effective.
In a study by Rocconi et al,43 expectant
management ($915 [US dollars] cost per cure) was,
similarly, more cost effective than both medical
($1 149) and conventional surgical management
($2 333), although manual vacuum aspiration, a
technique little used in the UK, was the most cost
effective ($793).
Disposal of products of
conception
Guidance from the Royal College of Obstetricians
and Gynaecologists6 on early pregnancy loss
recommends that tissue obtained at the time of a
miscarriage should be submitted for histological
examination to exclude trophoblastic disease and
ectopic pregnancy. Each hospital trust should have
a clear system and protocol for the sensitive
disposal of fetal remains.3 A Scottish study47 to
determine the extent to which health professionals
2007 Royal College of Obstetricians and Gynaecologists
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Conclusion
Modern treatment of miscarriage should provide a
rapid, sympathetic diagnosis and adequate
counselling. All women with early pregnancy
problems should preferably have prompt access to a
dedicated early pregnancy assessment unit that
provides efficient management, counselling and
access to appropriate information. At all times
women should be supported in making informed
choices about their care and management: Given
the lack of clear superiority of either approach, the
womans preference should play a dominant role in
decision making. Expectant and medical
management of first-trimester miscarriage possess
significant economic advantages over traditional
surgical management.48
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