Medicine, Surgery, or Watch & Wait: Management of Spontaneous Abortion in the First Trimester

CASE PRESENTATION

• 39 yo G5P3013 with past history of ectopic pregnancy presents with several hours of spotting progressing to light bright red vaginal bleeding that spontaneously resolved.

• Patient is approximately 9 weeks pregnant based on her LMP

• No prior Ob contact for this pregnancy

• Mild cramping prior to presentation but denied pain at the time of exam.

• Exam and lab/imaging findings:

• Afebrile, vital signs stable

• Declined bimanual and speculum exam

• Abdomen was nontender to palpation

• b-HCG was 14,162

• Transvaginal US demonstrated IUP consistent with 6 wks gestation, no detectable fetal HR (normal for gestational age), and small subchorionic hemorrhage (images below)

The patient was discharged home with GYN f/u in 1 week

• 3 days later, she returned to the ED with bleeding in excess of her normal menses, passage of clots, and abdominal cramping

• Exam, lab, imaging findings:

• Stable vital signs

• Speculum exam: os open with blood in the vault

• b-HCG at this time was 12,738

• Subsequent TVUS performed by radiology was no longer able to visualize a gestational sac and noted that the cervix was open with fluid within the cervical canal

CLINICAL QUESTION: How do we decide between medical, surgical, and expectant management in early pregnancy loss?

SUMMARY OF EVIDENCE

Management of threatened and complete spontaneous abortion (SAB) primarily involves expectant management with follow-up to ensure that the pregnancy has progressed appropriately or that products of conception (POC) have been fully evacuated. In threatened abortion, there is little evidence for the use of progestin (1) or bed rest (2), and although some clinicians prefer to evacuate the uterus medically or surgically following a complete abortion, there does not appear to be any evidence either for or against this practice. This writing will therefore focus on management of incomplete SAB.

Several studies have been performed to compare medical, surgical, and expectant management of incomplete SAB.

• One randomized, controlled trial (RCT) demonstrated that surgical management resulted in the lowest rate of unplanned hospitalizations; however, there was no difference between these management methods with respect to rates of gynecological infection (3).

• Another RCT compared expectant management, vaginal misoprostol, and surgical evacuation in management of incomplete abortion in 78 patients.

• They found that although expectant management was successful in most women with incomplete SAB (82%), there were significantly more days of vaginal bleeding reported with both expectant management and vaginal misoprostol than with surgical evacuation (7 days for expectant management, 8 days for medical management, and 3 days for surgical evacuation) (4).

• Additionally, there was a somewhat higher success rate with vaginal misoprostol (90%) than with expectant management (82%), with a still higher success rate of surgical evacuation (97%), though this study did not report whether these differences in success rates were statistically significant.

• Although 2 women in the expectant and misoprostol groups required antibiotic treatment for endometritis, none of the women in the surgical evacuation group were treated for postoperative infection (though again, there was no mention of statistical significance, potentially due to small sample size).

A Cochrane review examining RCT’s that compared management options for incomplete early pregnancy loss found no difference between vaginal misoprostol and expectant care, in terms of completion rates or the need for surgical evacuation (5). However, there were substantial side effects noted with misoprostol use, though it was unclear whether these side effects were primarily induced by oral vs. vaginal administration.

In counseling patients with respect to treatment choice for incomplete abortion, it is important to understand the motivations behind patient preferences.

• One mixed-methods study examined the factors leading to patients’ decision between surgical, medical, and expectant management (6).

• The study demonstrated that patients who chose surgical evacuation did so due to loss acceptance, favorable perceptions of surgery, and a desire to expedite the completion of the SAB; the group choosing medical management cited a desire for timed completion of the SAB in a more intimate setting, aversion to surgery or anesthesia, and a perception that medical management would improve future fertility (though, as noted above, this latter perception does not have evidence to support it).

RECOMMENDATIONS

• Given the potential for increased risk of complications (i.e., endometritis requiring antibiotic treatment) and failure of medical and expectant management, surgical management of incomplete abortions is the best management option for a patient presenting with incomplete early pregnancy loss.

• In patients who prefer to avoid surgical management, expectant management has been shown to have comparable success rates to medical management, with the avoidance of the side effects of misoprostol and potentially fewer days of bleeding.

• In counseling patients regarding their options, it is also important to understand their reasoning for their treatment preferences to ensure that they are able to make a fully informed decision regarding their course of treatment.

References:

1. Progesterone for treating threatened miscarriage. Wahabi HA, Fayed AA, Esmaeil SA, Al Zeidan RA. Cochrane Database Syst Rev. 2011.

2. Bed rest during pregnancy for preventing miscarriage. Aleman A, Althabe F, Belizán J, Bergel E. Cochrane Database Syst Rev. 2005.

3. Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial). Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. BMJ. 2006;332(7552):1235. Epub 2006 May 17.

4. Spontaneous abortion: expectant management, medical treatment or surgical evacuation. Gronlund L, Gronlund A, Clevin L, Andersen B, Palmgren N, Lidegaard O. AOGS. 2002;81(8):781-782.

5. Medical treatments for incomplete miscarriage. Kim C, Barnard S, Neilson JP, Hickey M, Vazquez JC, Dou L. Cochrane Database Syst Rev. 2017 Jan 31;1:CD007223.

6. Treatment Decisions at the Time of Miscarriage Diagnosis. Schreiber CA, Chavez V, Whittaker PG, Ratcliffe SJ, Easley E, Barg FK. Obstet Gynecol. 2016 Dec;128(6):1347-1356.