Methods for managing miscarriage: a network meta-analysis

Ghosh, Jay; Papadopoulou, Argyro; Devall, Adam J.; Jeffery, Hannah C.; Beeson, Leanne; Do, Vivian; Price, Malcolm J; Tobías, Aurelio; Tunçalp, Özge; Lavelanet, Antonella; Gülmezoglu, A. Metin; Coomarasamy, Arri; Gallos, Ioannis D

doi:10.1002/14651858.cd012602.pub2

Cited by 33 publications

(36 citation statements)

References 267 publications

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“…The surgery may be performed immediately or after unsuccessful expectant or medical treatment. A recent network meta-analysis ranked surgical methods above expectant and medical treatment in terms of efficacy . Vacuum aspiration is the reference standard for surgical treatment.…”

Section: Introductionmentioning

confidence: 99%

“…A recent network meta-analysis ranked surgical methods above expectant and medical treatment in terms of efficacy. 5 Vacuum aspiration is the reference standard for surgical treatment. The procedure is not done with direct visualization and has known risks of scarring of the uterine cavity, which can compromise postoperative fertility, with an estimated 30% risk of intrauterine adhesions.…”

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confidence: 99%

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Operative Hysteroscopy vs Vacuum Aspiration for Incomplete Spontaneous Abortion

Huchon

Drioueche

Koskas

et al. 2023

JAMA

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ImportanceVacuum aspiration is commonly used to remove retained products of conception in patients with incomplete spontaneous abortion. Scarring of the uterine cavity may occur, potentially impairing future fertility. A procedural alternative, operative hysteroscopy, has gained popularity with a presumption of better future fertility.ObjectiveTo assess the superiority of hysteroscopy to vacuum aspiration for subsequent pregnancy in patients with incomplete spontaneous abortion who intend to have future pregnancy.Design, Setting, and ParticipantsThe HY-PER randomized, controlled, single-blind trial included 574 patients between November 6, 2014, and May 3, 2017, with a 2-year duration of follow-up. This multicenter trial recruited patients in 15 French hospitals. Individuals aged 18 to 44 years and planned for surgery for an incomplete spontaneous abortion with plans to subsequently conceive were randomized in a 1:1 ratio.InterventionsSurgical treatment by hysteroscopy (n = 288) or vacuum aspiration (n = 286).Main Outcomes and MeasuresThe primary outcome was a pregnancy of at least 22 weeks’ duration during 2-year follow-up.ResultsThe intention-to-treat analyses included 563 women (mean [SD] age, 32.6 [5.4] years). All aspiration procedures were completed. The hysteroscopic procedure could not be completed for 19 patients (7%), 18 of which were converted to vacuum aspiration (8 with inability to completely resect, 7 with insufficient visualization, 2 with anesthetic complications that required a shortened procedure, 1 with equipment failure). One hysteroscopy failed due to a false passage during cervical dilatation. During the 2-year follow-up, 177 patients (62.8%) in the hysteroscopy group and 190 (67.6%) in the vacuum aspiration (control) group achieved the primary outcome (difference, −4.8% [95% CI, −13% to 3.0%]; P = .23). The time-to-event analyses showed no statistically significant difference between groups for the primary outcome (hazard ratio, 0.87 [95% CI, 0.71 to 1.07]). Duration of surgery and hospitalization were significantly longer for hysteroscopy. Rates of new miscarriages, ectopic pregnancies, Clavien-Dindo surgical complications of grade 3 or above (requiring surgical, endoscopic, or radiological intervention or life-threatening event or death), and reinterventions to remove remaining products of conception did not differ between groups.Conclusions and RelevanceSurgical management by hysteroscopy of incomplete spontaneous abortions in patients intending to conceive again was not associated with more subsequent births or a better safety profile than vacuum aspiration. Moreover, operative hysteroscopy was not feasible in all cases.Trial RegistrationClinicalTrials.gov Identifier: NCT02201732

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Section: Introductionmentioning

confidence: 99%

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confidence: 99%

Operative Hysteroscopy vs Vacuum Aspiration for Incomplete Spontaneous Abortion

Huchon

Drioueche

Koskas

et al. 2023

JAMA

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“…A subgroup analysis showed that surgical and clinical methods might be more beneficial in patients with missed miscarriages than in those with incomplete miscarriages. 34 Concerning the limitations of the present study, we can cite: lack of standardization for some of the outcomes considered. For instance, some studies reported "pain" as the number of patients who presented with symptoms after treatment, whereas some reported, using a mean visual analog scale (VAS).…”

Section: Discussionmentioning

confidence: 92%

Efficacy, Safety, and Acceptability of Misoprostol in the Treatment of Incomplete Miscarriage: A Systematic Review and Meta-analysis

Silva,

Araujo,

Simões

et al. 2023

Rev Bras Ginecol Obstet

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Objective To assess the efficacy, safety, and acceptability of misoprostol in the treatment of incomplete miscarriage. Data sources The PubMed, Scopus, Embase, Web of Science, Cochrane Library, and Clinical Trials databases (clinicaltrials.gov) were searched for the relevant articles, and search strategies were developed using a combination of thematic Medical Subject Headings terms and text words. The last search was conducted on July 4, 2022. No language restrictions were applied. Selection of studies Randomized clinical trials with patients of gestational age up to 6/7 weeks with a diagnosis of incomplete abortion and who were managed with at least 1 of the 3 types of treatment studied were included. A total of 8,087 studies were screened. Data collection Data were synthesized using the statistical package Review Manager V.5.1 (The Cochrane Collaboration, Oxford, United Kingdom). For dichotomous outcomes, the odds ratio (OR) and 95% confidence interval (CI) were derived for each study. Heterogeneity between the trial results was evaluated using the standard test, I2 statistic. Data synthesis When comparing misoprostol with medical vacuum aspiration (MVA), the rate of complete abortion was higher in the MVA group (OR = 0.16; 95%CI = 0.07–0.36). Hemorrhage or heavy bleeding was more common in the misoprostol group (OR = 3.00; 95%CI = 1.96–4.59), but pain after treatment was more common in patients treated with MVA (OR = 0.65; 95%CI = 0.52–0.80). No statistically significant differences were observed in the general acceptability of the treatments. Conclusion Misoprostol has been determined as a safe option with good acceptance by patients.

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“…Since misoprostol is administered on an outpatient basis in our study, this translates into greater cost savings for medically treated women. In the meta‐analysis by Ghosh et al 30 surgical methods ranked highest for the management of a failed abortion, followed by medical methods. In conclusion, in our environment, UC has a higher success rate, greater satisfaction, and a lower incidence of side effects, although significantly higher cost, compared to misoprostol in MA.…”

Section: Discussionmentioning

confidence: 99%

Intravaginal misoprostol versus uterine curettage for missed abortion: A cost‐effectiveness analysis

Torres-Miranda

Gómez

Lobo-Gonçalves

et al. 2022

J of Obstet and Gynaecol

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Purpose To evaluate the cost‐effectiveness of a strategy based on direct‐acting uterine curettage (UC) versus a pre‐direct‐acting misoprostol (1600 mg) in patients with missed abortion (MA), from the perspective of a National Health System. Methods An open prospective cohort study was carried out at Reina Sofía University Hospital (Córdoba, Spain) from January 1, 2019 to December 31, 2019 in 180 patients diagnosed with MA. The patients chose medical treatment with intravaginal misoprostol (800 μg/4 h) or UC after receiving complete and detailed information. The effectiveness, clinical characteristics of the patients, costs of treating and managing the disease, and satisfaction with the procedures were recorded. Results One hundred and forty‐five patients (80.6%) chose misoprostol versus 35 patients (19.4%) who chose UC. The effectiveness of misoprostol has been 42% evaluated at 48 h; UC success rate has been 100%. The incidence of side effects is significantly higher in patients treated with misoprostol (p < 0.05); as well as the number of care received by the patient (p < 0.05). Satisfaction is higher in patients treated with UC (p < 0.05). However, the cost is almost 5‐folds higher in patients treated with UC (p < 0.05). Conclusion UC has a higher success rate, greater satisfaction, and a lower incidence of side effects, although significantly increases the cost compared to misoprostol in MA.

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Methods for managing miscarriage: a network meta-analysis

Cited by 33 publications

References 267 publications

Operative Hysteroscopy vs Vacuum Aspiration for Incomplete Spontaneous Abortion

Operative Hysteroscopy vs Vacuum Aspiration for Incomplete Spontaneous Abortion

Efficacy, Safety, and Acceptability of Misoprostol in the Treatment of Incomplete Miscarriage: A Systematic Review and Meta-analysis

Intravaginal misoprostol versus uterine curettage for missed abortion: A cost‐effectiveness analysis

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