NEW YORK (Reuters Health) – For the nonsurgical management of first-trimester miscarriage, delayed medical treatment (i.e., monitoring for expulsion followed, if needed, by mifepristone and/or misoprostol) “may not be a reasonable option,” clinicians from France conclude based on a study they conducted.
They found that delaying medical treatment for first trimester miscarriage increases the likelihood that vacuum aspiration will be necessary, relative to immediate medical treatment.
About 11% of pregnancies end in miscarriage in the first three months, the study team notes in a report online December 19 in the American Journal of Obstetrics and Gynecology.
For decades, surgical evacuation of the uterus was performed in the vast majority of women. However, recently medical treatment and expectant management have found favor.
Dr. Antoine Torre from Poissy-Saint Germain en Laye Hospital and colleagues conducted an open-label randomized trial involving 182 women diagnosed with spontaneous abortion before 14 weeks’ gestation.
The investigators assigned half of the women to immediate medical treatment (oral mifepristone followed 48 hours later by vaginal misoprostol) and half to sequential management (one week of watchful waiting followed, if necessary, by the above-described medical treatment).
Vacuum aspiration was performed in case of treatment failure, hemorrhage, pain, infection, or patient request.
Compared to immediate medical treatment, expectant management resulted in twice as many vacuum aspirations overall (43.5% vs 19.1%; P < 0.001), four times as many emergency vacuum aspirations (20% vs 4.5%; P = 0.001), and twice as many unplanned trips to the emergency department (34.1% vs 16.9%, P = 0.009), the investigators report.
“Immediate medical treatment was successful in 80.9% of women, in keeping with earlier data,” they point out. The “most striking finding,” they say, was the lower efficacy of delayed medical treatment (52.8%) compared to immediate medical treatment (80.9%). “This difference has not been reported previously,” they say.
To Dr. Torre and colleagues’ surprise, both the expectant and delayed medical phases of the sequential management were less successful than they anticipated. In studies, the success rate of expectant management has ranged from 18% to 81%, with the variability due largely to differences in the proportions of each type of miscarriage, they note.
They point out that their study population included not only women with missed miscarriage, but also women with inevitable or incomplete miscarriage, whose response to expectant management is better. As a result, they were unable to accurately predict the success rate of expectant management, they say.
Despite the limitations of the study, Dr. Torre and colleagues conclude that expectant management “appears unattractive” for nonsurgical treatment of first-trimester miscarriage because it leads to more vacuum aspirations and healthcare utilization.
They advise that once diagnosis of first-trimester miscarriage is definitively made, immediate treatment, either medical or surgical, should be offered.
SOURCE:
Immediate versus Delayed Medical Treatment for First-Trimester Miscarriage: A Randomized Trial
Am J Obstet Gynecol. 2011. Published online December 19, 2011
