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Spontaneous abortion: Management

INTRODUCTION

Spontaneous abortion, also known as miscarriage, refers to a pregnancy that ends spontaneously before the fetus has reached a viable gestational age. The management of different types of spontaneous abortion will be discussed here. Other aspects of spontaneous abortion, including the clinical manifestations and diagnosis of the different types of abortion, are reviewed separately. (See "Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnostic evaluation".)

THREATENED ABORTION

Women with threatened abortion have traditionally been managed expectantly until their symptoms resolve, a definitive diagnosis of nonviable pregnancy can be made, or there is progression to an inevitable, incomplete, or complete abortion.

The use of progestins to reduce the risk of miscarriage among women with threatened abortion is controversial. A meta-analysis that included four randomized trials with a total of 421 women found that the rate of spontaneous abortion was statistically significantly lower with progestin treatment compared with placebo or no treatment (14 versus 26 percent; relative risk 0.53; 95% CI 0.35 to 0.79) [1]. Progestins were administered either orally or vaginally, and subgroup analysis found a significant decrease in the rate of abortion only for oral progestins; the analysis of vaginal progestins lacked sufficient statistical power to detect a difference. There was no significant increase in congenital anomalies or pregnancy-induced hypertension in the progestin group. However, the meta-analysis was limited by the small number of participants and events and poor methodological quality of studies. Many miscarriages are caused by genetic abnormalities in the conceptus. It is unlikely that progestins could prevent a miscarriage of this etiology. The data are insufficient to make a recommendation for or against progestins for women with threatened abortion.

Bed rest is commonly recommended, but randomized trials have not found that bed rest at home or in the hospital is beneficial in preventing fetal loss in women with threatened spontaneous abortion [2]. Abstinence from sexual intercourse is also typically advised, although there are no data to support this.

There are no high quality data that support use of human chorionic gonadotropin, uterine muscle relaxants (eg, tocolytics, beta-agonists), or vitamin supplementation for preventing pregnancy loss in women with threatened abortion [3-5].

               

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Literature review current through: Sep 2014. | This topic last updated: Oct 23, 2013.
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References
Top
  1. Wahabi HA, Fayed AA, Esmaeil SA, Al Zeidan RA. Progestogen for treating threatened miscarriage. Cochrane Database Syst Rev 2011; :CD005943.
  2. Aleman A, Althabe F, Belizán J, Bergel E. Bed rest during pregnancy for preventing miscarriage. Cochrane Database Syst Rev 2005; :CD003576.
  3. Devaseelan P, Fogarty PP, Regan L. Human chorionic gonadotrophin for threatened miscarriage. Cochrane Database Syst Rev 2010; :CD007422.
  4. Lede R, Duley L. Uterine muscle relaxant drugs for threatened miscarriage. Cochrane Database Syst Rev 2005; :CD002857.
  5. Rumbold A, Middleton P, Pan N, Crowther CA. Vitamin supplementation for preventing miscarriage. Cochrane Database Syst Rev 2011; :CD004073.
  6. Savaris RF, de Moraes GS, Cristovam RA, Braun RD. Are antibiotics necessary after 48 hours of improvement in infected/septic abortions? A randomized controlled trial followed by a cohort study. Am J Obstet Gynecol 2011; 204:301.e1.
  7. Finkielman JD, De Feo FD, Heller PG, Afessa B. The clinical course of patients with septic abortion admitted to an intensive care unit. Intensive Care Med 2004; 30:1097.
  8. Forna F, Gülmezoglu AM. Surgical procedures to evacuate incomplete abortion. Cochrane Database Syst Rev 2001; :CD001993.
  9. Sotiriadis A, Makrydimas G, Papatheodorou S, Ioannidis JP. Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis. Obstet Gynecol 2005; 105:1104.
  10. Nanda K, Peloggia A, Grimes D, et al. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev 2006; :CD003518.
  11. Neilson JP, Gyte GM, Hickey M, et al. Medical treatments for incomplete miscarriage (less than 24 weeks). Cochrane Database Syst Rev 2010; :CD007223.
  12. Trinder J, Brocklehurst P, Porter R, et al. Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial). BMJ 2006; 332:1235.
  13. Demetroulis C, Saridogan E, Kunde D, Naftalin AA. A prospective randomized control trial comparing medical and surgical treatment for early pregnancy failure. Hum Reprod 2001; 16:365.
  14. Harris LH, Dalton VK, Johnson TR. Surgical management of early pregnancy failure: history, politics, and safe, cost-effective care. Am J Obstet Gynecol 2007; 196:445.e1.
  15. Grimes DA. Unsafe abortion: the silent scourge. Br Med Bull 2003; 67:99.
  16. Tunçalp O, Gülmezoglu AM, Souza JP. Surgical procedures for evacuating incomplete miscarriage. Cochrane Database Syst Rev 2010; :CD001993.
  17. Prieto JA, Eriksen NL, Blanco JD. A randomized trial of prophylactic doxycycline for curettage in incomplete abortion. Obstet Gynecol 1995; 85:692.
  18. Neilson JP, Hickey M, Vazquez J. Medical treatment for early fetal death (less than 24 weeks). Cochrane Database Syst Rev 2006; :CD002253.
  19. Blum J, Winikoff B, Gemzell-Danielsson K, et al. Treatment of incomplete abortion and miscarriage with misoprostol. Int J Gynaecol Obstet 2007; 99 Suppl 2:S186.
  20. Graziosi GC, van der Steeg JW, Reuwer PH, et al. Economic evaluation of misoprostol in the treatment of early pregnancy failure compared to curettage after an expectant management. Hum Reprod 2005; 20:1067.
  21. Zhang J, Gilles JM, Barnhart K, et al. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med 2005; 353:761.
  22. de Jonge ET, Makin JD, Manefeldt E, et al. Randomised clinical trial of medical evacuation and surgical curettage for incomplete miscarriage. BMJ 1995; 311:662.
  23. Chung TK, Lee DT, Cheung LP, et al. Spontaneous abortion: a randomized, controlled trial comparing surgical evacuation with conservative management using misoprostol. Fertil Steril 1999; 71:1054.
  24. Muffley PE, Stitely ML, Gherman RB. Early intrauterine pregnancy failure: a randomized trial of medical versus surgical treatment. Am J Obstet Gynecol 2002; 187:321.
  25. Bagratee JS, Khullar V, Regan L, et al. A randomized controlled trial comparing medical and expectant management of first trimester miscarriage. Hum Reprod 2004; 19:266.
  26. Khan RU, El-Refaey H, Sharma S, et al. Oral, rectal, and vaginal pharmacokinetics of misoprostol. Obstet Gynecol 2004; 103:866.
  27. Davis AR, Hendlish SK, Westhoff C, et al. Bleeding patterns after misoprostol vs surgical treatment of early pregnancy failure: results from a randomized trial. Am J Obstet Gynecol 2007; 196:31.e1.
  28. Weeks A, Faúndes A. Misoprostol in obstetrics and gynecology. Int J Gynaecol Obstet 2007; 99 Suppl 2:S156.
  29. Kollitz KM, Meyn LA, Lohr PA, Creinin MD. Mifepristone and misoprostol for early pregnancy failure: a cohort analysis. Am J Obstet Gynecol 2011; 204:386.e1.
  30. Ledger WL, Sweeting VM, Chatterjee S. Rapid diagnosis of early ectopic pregnancy in an emergency gynaecology service--are measurements of progesterone, intact and free beta human chorionic gonadotrophin helpful? Hum Reprod 1994; 9:157.
  31. Grønlund A, Grønlund L, Clevin L, et al. Management of missed abortion: comparison of medical treatment with either mifepristone + misoprostol or misoprostol alone with surgical evacuation. A multi-center trial in Copenhagen county, Denmark. Acta Obstet Gynecol Scand 2002; 81:1060.
  32. Stockheim D, Machtinger R, Wiser A, et al. A randomized prospective study of misoprostol or mifepristone followed by misoprostol when needed for the treatment of women with early pregnancy failure. Fertil Steril 2006; 86:956.
  33. Tam WH, Tsui MH, Lok IH, et al. Long-term reproductive outcome subsequent to medical versus surgical treatment for miscarriage. Hum Reprod 2005; 20:3355.
  34. Grossman D, Blanchard K, Blumenthal P. Complications after second trimester surgical and medical abortion. Reprod Health Matters 2008; 16:173.
  35. Lalitkumar S, Bygdeman M, Gemzell-Danielsson K. Mid-trimester induced abortion: a review. Hum Reprod Update 2007; 13:37.
  36. Chipchase J, James D. Randomised trial of expectant versus surgical management of spontaneous miscarriage. Br J Obstet Gynaecol 1997; 104:840.
  37. Ankum WM, Wieringa-De Waard M, Bindels PJ. Management of spontaneous miscarriage in the first trimester: an example of putting informed shared decision making into practice. BMJ 2001; 322:1343.
  38. Wieringa-de Waard M, Vos J, Bonsel GJ, et al. Management of miscarriage: a randomized controlled trial of expectant management versus surgical evacuation. Hum Reprod 2002; 17:2445.
  39. Nielsen S, Hahlin M, Platz-Christensen J. Randomised trial comparing expectant with medical management for first trimester miscarriages. Br J Obstet Gynaecol 1999; 106:804.
  40. Shelley JM, Healy D, Grover S. A randomised trial of surgical, medical and expectant management of first trimester spontaneous miscarriage. Aust N Z J Obstet Gynaecol 2005; 45:122.
  41. Banerjee S, Aslam N, Woelfer B, et al. Expectant management of early pregnancies of unknown location: a prospective evaluation of methods to predict spontaneous resolution of pregnancy. BJOG 2001; 108:158.
  42. Casikar I, Bignardi T, Riemke J, et al. Expectant management of spontaneous first-trimester miscarriage: prospective validation of the '2-week rule'. Ultrasound Obstet Gynecol 2010; 35:223.
  43. Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early pregnancy failure--current management concepts. Obstet Gynecol Surv 2001; 56:105.
  44. Ogden J, Maker C. Expectant or surgical management of miscarriage: a qualitative study. BJOG 2004; 111:463.
  45. Leung SW, Pang MW, Chung TK. Retained products of gestation in miscarriage: an evaluation of transvaginal ultrasound criteria for diagnosing an "empty uterus". Am J Obstet Gynecol 2004; 191:1133.
  46. Creinin MD, Harwood B, Guido RS, et al. Endometrial thickness after misoprostol use for early pregnancy failure. Int J Gynaecol Obstet 2004; 86:22.
  47. Fiala C, Safar P, Bygdeman M, Gemzell-Danielsson K. Verifying the effectiveness of medical abortion; ultrasound versus hCG testing. Eur J Obstet Gynecol Reprod Biol 2003; 109:190.
  48. Luise C, Jermy K, May C, et al. Outcome of expectant management of spontaneous first trimester miscarriage: observational study. BMJ 2002; 324:873.
  49. Petrou S, Trinder J, Brocklehurst P, Smith L. Economic evaluation of alternative management methods of first-trimester miscarriage based on results from the MIST trial. BJOG 2006; 113:879.
  50. Doyle, NM, Jimenez-Flores, DJ, Ramin, SM. Medical versus surgical management of missed abortions: An economic analysis. Obstet Gynecol 2004; 103:6S.
  51. You JH, Chung TK. Expectant, medical or surgical treatment for spontaneous abortion in first trimester of pregnancy: a cost analysis. Hum Reprod 2005; 20:2873.
  52. Rocconi RP, Chiang S, Richter HE, Straughn JM Jr. Management strategies for abnormal early pregnancy: a cost-effectiveness analysis. J Reprod Med 2005; 50:486.
  53. Niinimäki M, Karinen P, Hartikainen AL, Pouta A. Treating miscarriages: a randomised study of cost-effectiveness in medical or surgical choice. BJOG 2009; 116:984.
  54. Goldstein RR, Croughan MS, Robertson PA. Neonatal outcomes in immediate versus delayed conceptions after spontaneous abortion: a retrospective case series. Am J Obstet Gynecol 2002; 186:1230.
  55. Grimes D, Schulz K, Stanwood N. Immediate post-abortal insertion of intrauterine devices. Cochrane Database Syst Rev 2000; :CD001777.
  56. Barnhart KT, Sammel MD, Rinaudo PF, et al. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstet Gynecol 2004; 104:50.
  57. Stratton K, Lloyd L. Hospital-based interventions at and following miscarriage: literature to inform a research-practice initiative. Aust N Z J Obstet Gynaecol 2008; 48:5.
  58. Buchmayer SM, Sparén P, Cnattingius S. Previous pregnancy loss: risks related to severity of preterm delivery. Am J Obstet Gynecol 2004; 191:1225.
  59. Swingle HM, Colaizy TT, Zimmerman MB, Morriss FH Jr. Abortion and the risk of subsequent preterm birth: a systematic review with meta-analyses. J Reprod Med 2009; 54:95.
  60. Edlow AG, Srinivas SK, Elovitz MA. Second-trimester loss and subsequent pregnancy outcomes: What is the real risk? Am J Obstet Gynecol 2007; 197:581.e1.