Science-ish Friday: People Have Misconceptions About Miscarriage, And That Can Hurt

By Katherine Hobson
May 8, 2015

Courtesy of NPR

Most people think a miscarriage is rare, and many believe that if a woman loses a pregnancy that she brought it upon herself. Neither of those things is true, but the enduring beliefs cause great pain to women and their partners.

“I felt alone until I realized there is this big, secret miscarriage club — one that nobody wants to be a member of — and when I realized it existed, I felt angry that no one told me they had active membership.”

In fact, almost half of people who have experienced a miscarriage or whose partner has had one feel guilty, according to a survey to be published Monday in Obstetrics & Gynecology. More than a quarter of them felt shame. Many felt they’d lost a child.

When NPR asked visitors to its Facebook page to tell us what they wished people knew about miscarriage, the response was overwhelming — 200 emails and counting, many heartbreaking. Their sentiments often echoed what the survey found.

“I wish people knew how much it’s possible to miss a person you have never met, and to mark time by their absence,” wrote one woman. “I will always think about how old my baby would be now and what our lives would be like if I hadn’t lost the pregnancy.”

The survey came about after Dr. Zev Williams realized that many of his patients had misconceptions about miscarriage. “I’d tell them how common a miscarriage was, and they seemed shocked,” says Williams, an OB-GYN who directs the Program for Early and Recurrent Pregnancy Loss at Einstein College of Medicine of Yeshiva University and Montefiore Medical Center in New York.

In fact, between 15 percent and 20 percent of clinically recognized pregnancies end in miscarriage, defined as a pregnancy loss earlier than 20 weeks of gestation. (Pregnancy loss after that point is called a stillbirth.) Miscarriage is actually “by far the most common complication of pregnancy,” says Williams. He and his colleagues wanted to find out how widespread some of the mistaken beliefs about miscarriage are.

They asked 1,084 adults about miscarriage and its causes. They also asked the 15 percent of survey respondents who had suffered a miscarriage, or whose partner had, about their experience. The results echoed what he’d seen in his patients: Some 55 percent of all respondents believed that miscarriage occurred in 5 percent or less of all pregnancies.

The cultural silence around miscarriage contributes to those misunderstandings, Williams says. “A lot of other conditions that people used to speak of only in hushed tones, like cancer and AIDS, we speak about a lot more,” he says.

Not so for miscarriage. Because early pregnancy loss is so common, women are often advised not to share their pregnancy news with friends and family until the start of the second trimester. At that point the chance of miscarriage has drastically declined. But that secrecy means women who do miscarry in the first trimester may not get the support they need, Williams says.

“It’s bizarre that the topic is so taboo,” wrote one reader on Facebook. “I really feel an obligation now, having had a miscarriage, to mention my miscarriage when I’m talking about fertility or the process of conceiving or childbirth.” She added a sentiment that many other women expressed: “I felt alone until I realized there is this big, secret miscarriage club — one that nobody wants to be a member of — and when I realized it existed, I felt angry that no one told me they had active membership.”

Chromosomal abnormalities in the fetus cause 60 percent of miscarriages. A handful of other medical conditions are also known to cause miscarriage. Most survey respondents knew that genetic or medical problems were the most common cause of early pregnancy loss. But they also mistakenly believed that other factors could trigger a miscarriage: a stressful event (76 percent); lifting something heavy (64 percent); previous use of contraception like an IUD (28 percent) or birth control pills (22 percent); and even an argument (21 percent). Some 22 percent believed that lifestyle choices, like using drugs, tobacco or alcohol, were the single biggest cause of miscarriages. That’s not true.

Those who shared their experiences with NPR said many of those myths were repeated back to them by friends, family or colleagues after their own miscarriages. One said someone blamed her high heels. That kind of talk can be incredibly painful, even if you know you have the facts on your side.

“I wish people understood that miscarriages are the flip side of the coin,” wrote one woman. “If you’ve had a healthy pregnancy that went full term — you won a lottery. Short of obvious substance abuse and bull riding — your healthy baby is not the result of anything you did or didn’t do. As much as you want to think you are in control — you aren’t. And the same goes when I lost each pregnancy — as much as I wish I could have been — it was not in my control.”

The feelings of guilt, shame and enormous loss reported in the survey were a common theme among those who told their stories to NPR. “I felt, and feel, literally broken, and betrayed by my body,” wrote one woman. “It’s irrational, but there is such a deep shame attached to not being able to carry a baby to term…. I don’t want another baby, I want THIS baby, the one I thought I would have, the one I started planning for, hoping for, dreaming about, talking to. All that got taken away from me.”

Not everyone was so deeply affected; some said the miscarriage came as a relief, either because the pregnancy was unwanted, or because they’d known something wasn’t quite right. Or they said it was painful at the time, but that they’d moved on and weren’t particularly haunted by the loss. “You have every right to feel ALL of your emotions you have,” wrote one person. “Whether you feel grief or relief, your emotions are never wrong.”

But because the loss can be so great, people said they wished others would acknowledge a miscarriage without reverting to a laundry list of well-intentioned but hurtful lines: “Well, at least you know you can get pregnant.” (One reader said this was particularly upsetting after her seventh miscarriage.) “You can always try again.” “If you adopt, you’ll get pregnant.” “It happens for a reason.” “It’s God’s plan.” (That, wrote another reader, sounds an awful lot like “God doesn’t want you to be a parent.”)

Far better, people said, is to simply say, “I’m sorry. Is there anything I can do for you?”

Over and over again, we heard a wish that there was more private and public discussion of miscarriage. “Many women in my family had suffered one or more, and I had no idea until I had one myself,” wrote one woman. “I felt that no one I knew had gone through this.”

Several readers said this code of silence was even stronger for the partners of women who miscarry. One reader wrote that her husband “had hopes and dreams and fears and so much joy tied up into 9.5 weeks of cells,” but he didn’t get time off work, flowers or well-wishes from colleagues or visits from friends to “listen to him cry,” as she did. Instead, “He had to suffer alone.”

The new survey found that 46 percent of respondents who’d miscarried said they felt less alone when friends talked about their own miscarriages. Even a celebrity’s disclosure of miscarriage helped.

“I wish people knew how much it’s possible to miss a person you have never met, and to mark time by their absence.”

One person who recently suffered a miscarriage summed it up: “While I’m definitely still healing emotionally, I would be happy to talk more about it. So many people grieve silently, but I’ve found that talking really helps the most.”

That’s the kind of conversation that Williams says he and his co-authors would like to spark with their survey. “Miscarriage is ancient. It’s always been there.” And all too often, he says, “people often blame themselves and don’t discuss it.”

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Science Friday: Chromosome errors cause many pregnancies to end before they are even detected

by Rajiv McCoy, PhD candidate in Biology at Stanford University and Dmitri Petrov, Professor of Biology and Associate Chair of the Biology Department at Stanford University

Given the fact that there are seven billion people on Earth, one might conclude that human beings are pretty good at reproducing. But fewer than 30% of all fertilization events result in successful pregnancy, even for young, fertile couples.

image-20150408-18080-1o0ax59
The pregnancy loss iceberg. Larsen et al. BMC Medicine 2013 11:154

The remaining 70% of conceptions result in pregnancy loss, with most of these losses occurring before the mother misses a menstrual period. This means that many pregnancies begin and end before the mother even notices. These early pregnancy losses are one reason why it generally takes several months for couples to achieve a successful pregnancy. But why is pregnancy loss so common?

Current evidence suggests that both the process of egg formation (this is called meiosis) in the mother’s ovaries and the initial embryonic cell divisions (called mitosis) just after fertilization are extremely error-prone, producing embryos with too many or too few chromosomes.
What happens after fertilization?

During fertilization, the sperm and egg fuse so that the resulting embryo will have 23 chromosomes inherited from the father and 23 chromosomes inherited from the mother. If all goes well, the subsequent cell divisions in the embryo (called mitotic divisions) simply replicate this 46-chromosome set as new cells are formed.

Chromosomes contain genes, the blueprints for human development. When processes go awry in meiosis or mitosis, chromosomes can go into the wrong cell or get lost completely, drastically altering this blueprint. The resulting cell will not possess the standard 46-chromosome set – an imbalance that is the defining feature of aneuploidy. This means that many genes will either be missing or present in extra copies, placing cells under stress.

Embryos with many aneuploid cells rarely survive. Trisomy 21, the genetic cause of Down syndrome, is one of the rare forms of aneuploidy in which the baby can survive to live birth. The vast majority of embryos affected with other aneuploidies perish in early development.
What causes aneuploidy?

Aneuploidy is associated with maternal age. Female meiotic errors (these are errors in the eggs themselves) increase from a frequency of less than 20% in mothers younger than 30 years old to greater than 60% in mothers older than 45. Errors in sperm, called paternal meiotic errors, are comparatively rare, affecting fewer than 5% of sperm cells.

But age isn’t the only factor influencing aneuploidy. Our recent work in collaboration with the genetic testing company Natera, published in Science, suggests that risk is also influenced by a common genetic variant in the mother’s genome.

Even when the egg and sperm are normal, aneuploidies often arise after fertilization, during the first three embryonic cell divisions. These initial cell divisions of the embryo are controlled by maternal machinery pre-loaded into the egg.

Unlike meiotic errors in the egg, mitotic errors do not increase with age, but affect all age groups.
A maternal genetic variant influences aneuploidy risk

Using data from in vitro fertilized (IVF) embryos screened by our collaborators at Natera, we found that mothers with a particular genetic variant on chromosome 4 tend to produce embryos with more mitotic aneuploidies – the aneuploidies that arise during post-fertilization cell division.

This effect was observed for mothers of all ages and from diverse ethnic backgrounds. This genetic variant is surprisingly common; approximately half of all people carry at least one copy of this risk variant.

The most likely suspect is a gene called Polo-like kinase 4 (PLK4), which is known to be a master regulator of the centrosome cycle. The centrosome is molecular machine that is responsible for proper cell division and distribution of chromosomes.

We estimated that each copy of the risk variant increases the rate of aneuploidy by about 3%, regardless of the mother’s age. Having two copies doubles this risk. This increased risk could be especially important for older mothers who are already more prone to aneuploidy. It is likely that there are other genetic variants that contribute to aneuploidy risk to a lesser degree, and further work will be required to determine if this is the case.

Because of the established link between aneuploidy and pregnancy loss, we hypothesized that the aneuploidy risk variant might also affect embryo survival. We found that mothers with the high-risk genotypes had fewer embryos available for testing, suggesting that their embryos are less likely to survive very early developmental stages due to aneuploidy.

Given these results, it seems like this genetic variant could influence the average time it takes to achieve successful pregnancy, an idea that we are hoping to investigate further.
A signature of natural selection: comparison to the Neanderthals

Normally, natural selection weeds out damaging variation, reducing it to very low frequency. But the aneuploidy risk variant is very common. Hoping to learn more about the evolutionary history of this variant, we compared human genomes to Neanderthals and Denisovans, our ancient hominin relatives.

Comparison of a modern human skull and Neanderthal skull in the Cleveland Museum of Natural History. hairymuseummatt (original photo), DrMikeBaxter (derivative work) via Wikimedia Commons, CC BY

Despite the fact that the harmful genetic variant is relatively common in humans, it was absent in these close relatives, meaning that it likely rose rapidly in frequency in an ancestral population of humans. If this is true, it means that this version of this gene was actually somehow beneficial (and maybe still is) while simultaneously being harmful in the context of early development.

So what could possibly have been the benefit?

We aren’t sure at this point, but we speculate that for ancient humans, there might have been a benefit to having a reduced probability of successful pregnancy per intercourse. Maybe the benefit had to do with infanticide – men may be less likely to kill a baby if there is a chance it is their child, and not that of a rival. Likewise, lower probability of pregnancy per intercourse might encourage repeated mating with the same female, fostering pair bonding and paternal investment. This hypothesis was first proposed by Alexander and Noonan in 1979 to help explain the human-specific trait of concealed ovulation and continuous sexual receptivity – women do not externally signal or limit intercourse to the fertile portion of their cycles as do some other primates.

Another idea is based on the fact that PLK4 is often mutated in human cancers. Could there be a beneficial effect of the risk variant in the context of cancer? PLK4 plays yet another role in testes development. Could the aneuploidy risk variant have a beneficial effect in this context?

We are hoping that additional data and future research can shed more light on this signal of human-specific adaptation. Is it real or simply an artifact of chance events in human evolution? Did our ancestors have lower rates of aneuploidy? What about Neanderthals, Denisovans, and living non-human primates? And perhaps the most basic question: why is human aneuploidy so common? Armed with modern genomic technologies, we can continue to chip away at these questions to understand not only the medical aspects of aneuploidy risk, but also the broader evolutionary basis of this intriguing trait.

Science-ish Friday: ‘What Kind of Mother Is 8 Months Pregnant and Wants an Abortion?’

Today, a story of a woman who had an abortion at 36 weeks. It is incredibly sad, just to warn you ahead of time–but I just had to share.

by Rachel Bertsche
April 30, 2015

“When Kate, a 29-year-old mom outside Boston, found out she was pregnant with a second daughter, she was elated. Then, at 36 weeks along, she got the news that is every expecting parent’s worst nightmare: Her baby, whom she would later name Rose, had two brain malformations. Kate decided to have an abortion, and eventually found solace in a support group on the website Ending a Wanted Pregnancy.”

Continue Reading…

Science Friday: Pregnancy complications predict heart disease risk

February 18, 2012

If you develop pregnancy-related hypertensive disorders or diabetes, you may have an increased risk of cardiovascular disease later in life, according to research in Circulation: Journal of the American Heart Association. Women who developed pregnancy-related hypertension (preeclampsia) or diabetes were at increased risk of cardiovascular disease (CVD) later in life.

Preeclampsia was associated with a wider range of CVD risk factors and may be a better predictor of CVD in middle age than other pregnancy-related complications.

“We wanted to learn about possible explanations as to why women with pregnancy complications tend to have more heart disease later in life,” said Abigail Fraser, M.P.H., Ph.D., School of Social and Community Medicine at the University of Bristol, United Kingdom.

Researchers studied 3,416 pregnant women enrolled in the Avon Longitudinal Study of Parents and Children in the early 1990s. Among them, 1,002 (29.8 percent) had one pregnancy complication, 175 (5.2 percent) had two and 26 (0.8 percent) had three.

The complications included gestational or pregnancy diabetes, hypertensive (or high blood pressure-related) disorders of pregnancy (also known as preeclampsia), preterm delivery, and size of babies at birth (top and bottom 10 percent in weight). Researchers correlated these with cardiovascular (CVD) risk factors measured 18 years later when the women were an average of 48 years old.

Researchers then calculated the women’s odds of experiencing a cardiovascular event in the next decade using the 10-year CVD Framingham risk score, which includes such factors as age, total and HDL (“good”) cholesterol, systolic blood pressure, diabetes and smoking status.

They found:

Preeclampsia, gestational diabetes and giving birth to babies small for gestational age were associated with an increased risk of heart disease. Each complication was associated with different CVD risk factors.
Gestational diabetes was associated with a 26 percent and preeclampsia 31 percent greater risk of developing heart disease in middle age.
Among women who experienced these pregnancy complications, gestational diabetes was associated with higher levels of fasting glucose and insulin.
Preeclampsia was associated with higher body mass index and larger waist circumference, as well as higher blood pressure, lipids and insulin.
Women who gave birth to babies large for gestational age had larger waist circumference and higher concentrations of blood glucose. Those who had preterm babies had higher blood pressure.

“Pregnancy may provide an opportunity to identify women at increased risk of heart disease while they are relatively young; thus, it would be useful for medical professionals to have information on pregnancy complications so they can recommend lifestyle changes and any necessary medical intervention sooner,” Fraser said. “A woman who experiences complications during pregnancy should be proactive and ask her doctor about future CVD risk and steps she should take to modify her risk.”

The women in the study had not experienced a CVD event, so the researchers couldn’t determine whether preeclampsia and/or pregnancy diabetes have separate, independent effects on future CVD risk.

A larger study with longer follow-up could help determine whether pregnancy complications could affect how the 10-year CVD Framingham risk score is calculated for these women, Fraser said.

Furthermore, because the study population was predominantly white, replicating the research with other racial groups will provide additional data on the association between pregnancy complications and CVD risk, she said.

The British Heart Association, Wellcome Trust and United States National Institute of Diabetes and Digestive and Kidney Diseases funded the research.

A. Fraser, S. M. Nelson, C. Macdonald-Wallis, L. Cherry, E. Butler, N. Sattar, D. A. Lawlor. Associations of Pregnancy Complications with Calculated CVD Risk and Cardiovascular Risk Factors in Middle Age: The Avon Longitudinal Study of Parents and Children. Circulation, 2012; DOI: 10.1161/CIRCULATIONAHA.111.044784

Science Friday: Recurrent miscarriage raises heart attack risk.

December 2, 2010

Recurrent miscarriage increases a woman’s chance of having a heart attack fivefold in later life, indicates research published online in the journal

Research indicates that miscarriage is one of the commonest complications of pregnancy, occurring in up to one in five pregnancies.

The authors base their findings on more than 11,500 women who were taking part in the Heidelberg arm of EPIC, a large European study that is tracking the impact of diet and lifestyle on disease, particularly cancer.

All the women had been pregnant at least once, and the authors were particularly interested in those whose pregnancies had ended prematurely, either as a result of miscarriage or abortion, or whose babies had been stillborn.

Among the entire group, almost one in four (25%) had had at least one detectable miscarriage, while almost one in five (18%) had had at least one abortion. A further 2% had experienced a stillbirth.

Of those 2876 women who had miscarried, 69 had done so more than three times. These women tended to weigh more; those who had experienced a stillbirth were less physically active and higher rates of diabetes and high blood pressure, all of which are independent risk factors for heart attack and stroke.

Over a period of around 10 years, 82 women had a heart attack and 112 had a stroke.

No significant association was found between any of the types of pregnancy loss and an increased risk of stroke. But strong patterns emerged for stillbirth and miscarriage.

But having at least one stillbirth increased the risk of a heart attack by 3.5 times. But those women who had had more than three miscarriages were nine times as likely to have a heart attack.

The magnitude of the risk fell after adjusting for influential factors, such as weight, smoking, and alcohol consumption but it was still high, being five times as great.

Each miscarriage increased heart attack risk by 40% and those women who miscarried more than twice were more than four times as likely to have a heart attack.

“These results suggest that women who experienced spontaneous pregnancy loss are at a substantially higher risk of [heart attack] later in life,” comment the authors.

“Recurrent miscarriage and stillbirth are strong gender predictors for [this] and thus should be considered as important indicators for monitoring cardiovascular risk factors and preventive measures,” they add.

Elham Kharazmi, Laure Dossus, Sabine Rohrmann, Rudolf Kaaks. Pregnancy loss and risk of cardiovascular disease: a prospective population-based cohort study (EPIC-Heidelberg). Heart, 2010; DOI: 10.1136/hrt.2010.202226

Science Friday: Miscarriage and heart disease connection

Pregnancy loss, cardiovascular disease connected by new study

July 16, 2014

The Annals of Family Medicine published an article detailing research showing that women with a history of pregnancy loss are at higher risk for cardiovascular disease later in adulthood than other women, work completed by physicians in the Center for Primary Care and Prevention (CPCP) at Memorial Hospital of Rhode Island.
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The article “Risk of Cardiovascular Disease Among Postmenopausal Women with Prior Pregnancy Loss: The Women’s Health Initiative” stems from the analysis of data from the maternity experiences of a sample of 77,701 women, according to Donna Parker, ScD, director for community health and research with the CPCP. Of those, 30.3 percent reported a history of miscarriage, 2.2 percent a history of stillbirth, and 2.2 percent a history of both.

“We found that the adjusted odds for coronary heart disease in women who had one or more stillbirths was 1.27 (95 percent confidence interval (CI), which is a measure of reliability, 1.07-1.51) compared with women who had no stillbirths,” Dr. Parker says. “For women with a history of one miscarriage, the odds ratio was 1.19 (95 percent CI, 1.08-1.32). For women with a history of two or more miscarriages, the odds ratio was 1.18 (95 percent CI, 1.04-1.34) compared with no miscarriage.”

The researchers found no significant association of ischemic stroke and pregnancy loss, she adds. The association between pregnancy loss and coronary heart disease appeared to be independent of hypertension, body mass index, waist-to-hip ratio and white blood cell count.

“These findings contribute to the growing body of evidence that the metabolic, hormonal and hemostatic pathway alterations that are associated with a pregnancy loss may contribute to the development of coronary heart disease in adulthood,” Dr. Parker continues.

Women with a history of miscarriage or a single stillbirth should be closely monitored and receive early intervention from their primary care physician so risk factors such as diabetes, hypertension, cholesterol, obesity, smoking and diet can be closely monitored and controlled.

Journal Reference:

D. R. Parker, B. Lu, M. Sands-Lincoln, C. H. Kroenke, C. C. Lee, M. O’Sullivan, H. L. Park, N. Parikh, R. S. Schenken, C. B. Eaton. Risk of Cardiovascular Disease Among Postmenopausal Women with Prior Pregnancy Loss: The Women’s Health Initiative. The Annals of Family Medicine, 2014; 12 (4): 302 DOI: 10.1370/afm.1668

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.