BACKGROUND AND PURPOSE:

• Ghosh et al. (Cochrane Database of Systematic Reviews, 2021) estimated the relative effectiveness and safety profiles for the different management methods for early miscarriage

METHODS:

• Systematic review and meta-analysis
• Inclusion criteria
  • RCTs
  • Studies that examined the effectiveness or safety of methods for miscarriage management
• Study design
  • Early miscarriage: ≤14 weeks of gestation (including missed and incomplete)
  • Certainty of evidence was assessed using GRADE criteria
  • Relative effects for the primary outcomes are reported subgrouped by the type of miscarriage (incomplete and missed miscarriage)
  • To determine the relative effects and rankings of all available methods, the authors performed pairwise meta-analyses and network meta-analysis
• Primary outcome
  • Complete miscarriage
  • Composite outcome of death or serious complications

RESULTS:

• 78 trials | 17,795 women
• Trial arms: 158
  • Misoprostol: 33% of trial arms
  • Suction aspiration: 32%
  • Expectant management or placebo: 16%
  • Dilatation and curettage: 11%
  • Mifepristone plus misoprostol: 6%
  • Suction aspiration plus cervical preparation: 2%

Primary Outcome: Complete Miscarriage

• 59 trials | 12,591 women
• Five methods may be more effective than expectant management or placebo for achieving a complete miscarriage
  • Suction aspiration after cervical preparation
    • RR 2.12 (95% CI, 1.41 to 3.20); low-certainty evidence
  • Dilatation and curettage
    • RR 1.49 (95% CI, 1.26 to 1.75); low‐certainty evidence
  • Suction aspiration
    • RR 1.44 (95% CI, 1.29 to 1.62); low‐certainty evidence
  • Mifepristone plus misoprostol
    • RR 1.42 (95% CI, 1.22 to 1.66); moderate‐certainty evidence
  • Misoprostol
    • RR 1.30 (95% CI, 1.16 to 1.46); low‐certainty evidence
• The highest ranked
  • Surgical method: suction aspiration after cervical preparation
  • Non-surgical method: mifepristone plus misoprostol
• All surgical methods were ranked higher than medical methods
• Subgroup analyses by type of miscarriage (missed or incomplete) agreed with the overall analysis—surgical methods were the most effective treatment, followed by medical methods and then expectant management or placebo
  • However, there are possible subgroup difference in the effectiveness of the available methods
• Planned subanalysis of ≤9 weeks vs >9 weeks was not doable
  • Only 5 trials specified gestational age <9 weeks

Primary Outcome: Composite Outcome of Death And Serious Complications

• 35 trials | 8161 women
  • No deaths were reported
  • Composite outcome entirely composed of serious complications (e.g. blood transfusions, uterine perforations, hysterectomies, and ICU admissions)
• Majority of complications were related to blood transfusions | Uterine perforation was also documented  
• Data too limited to derive conclusion
  • However, expectant management or placebo was associated with more serious complications vs interventions

CONCLUSION:

• The authors state

Surgical methods were ranked highest for managing a miscarriage, followed by medical methods, which in turn ranked above expectant management or placebo

Expectant management or placebo had the highest chance of serious complications, including the need for unplanned or emergency surgery

The type of miscarriage (incomplete vs missed) may contribute to inconsistency and heterogeneity in the data, and will be explored further in a future update 

Learn More – Primary Sources:

Methods for managing miscarriage: a network meta-analysis

Related ObG Topics:

Managing Early Pregnancy Loss

MifeMiso RCT results: Mifepristone Plus Misoprostol or Misoprostol Alone for Miscarriage Treatment?

Expectant Management vs Misoprostol for the Treatment of Miscarriage

Is Surgical Evacuation Needed Following Incomplete Miscarriage?