Question
What is the effectiveness and safety of medical management for incomplete miscarriage?
Relevance to nursing care
The term 'incomplete miscarriage' denotes tissue remaining in the uterus following the event. Previously, surgical curettage was deemed best practice in treating a woman following an incomplete miscarriage. This is because it can be performed quickly and also allows histological examination of the tissues. More recently less invasive treatments have been introduced in order to reduce risk of infection and take a more natural approach to the event. The shift from taking a surgical to taking a medical one will inevitably involve non-medical healthcare professionals to a greater degree.
Study characteristics
Only randomised controlled trials were considered for this review.1 Fifteen studies involving 2750 women and 70 meta-analyses are included. Generally, the quality of the trials was good although it was not possible to blind clinicians and participants in the majority of studies. As stated in the title, studies of up to 24 weeks of gestation had the potential to be included. However, all the studies addressed medical treatment for incomplete miscarriage before 13 weeks. The intervention was medical treatment, that is, drug treatment by any route (including oral and vaginal) or between different drugs or doses of drug, or duration of time of treatment compared with surgical management (including surgical evacuation or curettage) or expectant management (including placebo). All but one study compared Misoprostol, an abortifacient, which can be given orally or vaginally. The review did not state that the intervention should be performed by any specific healthcare professional.
The main outcomes in the review were complete miscarriage, surgical evacuation and death or serious complications. Other, secondary outcomes included unplanned surgical intervention, blood transfusion, haemorrhage/blood loss, anaemia, days of bleeding, pain relief, pelvic infection, cervical damage, digestive disorders, hypertensive disorders, duration of stay in hospital, psychological effects, subsequent fertility, women's views/acceptability of method, death, serious morbidity, pathology of fetal/placental tissue and costs.
Results are as follows.
Misoprostol versus expectant care
* Meta-analysis indicated no significant difference between Misoprostol and expectant care for complete miscarriage (two studies of 150 women), surgical evacuation (two studies of 308 women) and death or serious complications (one study of 126 women).
* All secondary outcomes measured (unplanned surgical intervention, blood transfusion, pain relief and pelvic infection) showed no difference between vaginal Misoprostol and expectant care.
Misoprostol versus surgery
* Nine studies (n = 1499) compared Misoprostol versus surgery and showed no difference in complete miscarriage and death or serious complications. There were fewer surgical evacuations with Misoprostol (risk ratio (RR) 0.07, 95% confidence interval (CI) 0.03-0.18 in eight studies of 1538 women).
* Secondary outcomes showed no difference in pain relief, blood transfusion, anaemia, pelvic infection and cervical damage (although only one study assessed this outcome) and women's satisfaction. There was more unplanned surgery and more days of bleeding and more nausea with Misoprostol compared with surgery.
Vaginal Misoprostol versus surgery
* Four studies (n = 339) were included in this comparison. Three studies of 154 women found that fewer women had a complete miscarriage with vaginal Misoprostol compared with surgery (RR 0.90, 95% CI 0.82-0.99 in three studies of 154 women). Fewer women had surgical evacuation with vaginal Misoprostol compared with women who had immediate surgery (average RR 0.18, 95% CI 0.08-0.44 in three studies of 315 women). There was no difference in the outcome of death or serious complications.
* In secondary outcomes there was a higher incidence of unplanned surgery (average RR 5.56, 95% CI 1.11-27.90 in three studies of 315 women). Women treated with vaginal Misoprostol had more days of bleeding (mean difference 2.76, 95% CI 1.55-3.97 in two studies of 131 women) and used more pain relief (RR 1.75, 95% CI 1.21-2.54 in three studies of 313 women). Women were more satisfied with surgery but the real difference was small. There was no difference in blood transfusion, anaemia, pelvic infection and digestive disorders between the two interventions.
Oral Misoprostol versus surgery
* Four studies found no difference between the two interventions for complete miscarriage (n = 1143 women). Fewer women had surgical evacuation with oral Misoprostol (average RR 0.05, 95% CI 0.02-0.10 in four studies of 1143 women). There were no data for the primary outcome of death or serious complications.
* The secondary outcome of unplanned surgery showed that more women required this in the Misoprostol group (RR 7.07, 95% CI 2.34-21.30 in three studies of 843 women). Less pain relief was required with oral Misoprostol (RR 0.85, 95% CI 0.77-0.92 in one study with 212 women). There was more nausea (RR 4.77, 95% CI 2.68-8.49 in three studies with 959 women) and vomiting (RR 2.59, 95% CI 1.29-5.21 in three studies with 959 women) with oral Misoprostol. There was no difference between the two interventions for pelvic infection, cervical damage and women's views.
Vaginal plus oral Misoprostol versus surgery
* One study (n = 80) found no difference in complete miscarriage and less surgical evacuation with Misoprostol. The other primary outcome of death or serious complications was not reported.
* The only secondary outcomes reported were days of bleeding and pelvic infection and they showed no difference between the two interventions.
Vaginal Misoprostol versus oral Misoprostol
* One study (n = 201) showed no difference in complete miscarriage or surgical evacuation. The other primary outcome of death or serious complications was not reported.
* All secondary outcomes reported (unplanned surgery, pain relief and digestive disorders) showed no difference between the interventions.
Oral Misoprostol 600 [mu]g versus oral Misoprostol 1200 [mu]g
* Two studies (n = 469) found there was no difference between the primary outcomes of complete miscarriage and the need for surgical evacuation (one study of 295 women). Death or serious complications could not be calculated from the data.
* In the secondary outcomes assessed there was no difference in unplanned surgery, women's views/satisfaction or digestive disorders.
Oral mifepristone plus vaginal Misoprostol versus surgery
* One study (n = 19) showed no difference between any of the primary outcomes and the secondary outcome of pelvic infection.
Vaginal prostaglandin E1 (gemeprost) versus surgery
* One study (n = 34) made this comparison. It was of uncertain quality and none of the primary outcomes was reported. Of the secondary outcomes only unplanned surgery was reported but no risk ratio could be calculated.
Implications for nursing care
The current evidence shows that medical treatment with Misoprostol and expectant care are satisfactory alternatives to routine surgical evacuation. The advantage of Misoprostol and expectant care is that surgery can be avoided thus reducing its adverse effects. This is particularly relevant in relatively poor countries.
Long-term follow up in one included study found that the woman's future fertility did not differ according to the type of miscarriage management. The lack of difference in facilitating a complete abortion between interventions suggests that women should be offered a choice within local resource constraints.
Implications for research
More studies are needed to be able to definitively discern the most effective treatment following incomplete miscarriage. This is particularly urgent in women of 13-24 weeks of gestation as there were no studies in this range. The review suggests larger, multicentre studies are required. Many healthcare professionals working in this important area of care are well placed to become involved in such studies.
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