Science Friday: Which is better after miscarriage? Surgery or waiting?

In May 2014, the effectiveness and safety of expectant (waiting) management vs. surgical management of first trimester miscarriage were compared.

In surgical intervention, a dilation and curettage (D&C) is performed to evacuate the tissue from the uterus–most commonly in the case of a missed miscarriage (fetus with no heart activity) or incomplete miscarriage (part of tissue stays in body). The most common side effect of a D&C is infection.

Waiting it out, or expectant management, is a common surgical alternative that results in complete evacuation in 79% of cases. It is easy, effective, safe and cost-effective from a medical standpoint.

In the study, 217 women with missed miscarriage and incomplete miscarriage in their first trimester participated. They were randomly assigned to surgical or expectant management. The groups were demographically and conditionally equivalent. Women in the surgical management group underwent a D&C. Women in expectant management group were advised to use acetaminophen tablets to relieve pain.

81.4% of patients undergoing expectant management were successful with loss of uterine contents within 4 weeks. 18.6% had to have surgical uterine evacuation because products still remained in the uterus.

95.7% of women in the surgical group had successful D&Cs.  5.2% had emergency surgical uterine evacuation. 4.3% had second curettage due to incomplete evacuation in first procedure.

The average duration of bleeding was 11 days in expectant group and 7 days in surgical group. The average duration of pain was 8.1 days in the expectant group and 5.5 days in the surgical group. These differences were both statistically significant.

Both methods had the same complication rate, however, the pelvic infection was significantly lower in the expectant than the surgical group (1.9 vs 3.5 %, respectively).

So what does this mean? First of all, talk to your doctor about the pros and cons of expectant vs surgical management of miscarriage. It could be that your personal health situation points to one method over the other. You must also think about, and share, your personal feelings with your doctor. Some women want to eliminate the physical evidence of a miscarriage as soon as possible, and some are content waiting for the physical evidence to evacuate naturally.

Either way, this small study indicated that expectant management (waiting) is safe and effective, but that surgical management is ultimately more successful.

Want to read the paper? See below or go to http://www.ncbi.nlm.nih.gov/pubmed/24240972.

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

Al-Ma’ani W1, Solomayer EF, Hammadeh M.

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.

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s