Surgical vs expectant Management in incomplete miscarriage: a randomised comparison

Abstract

INTRODUCTION: Incomplete miscarriage is a common presentation in gynaecology. Surgical evacuation has been the cornerstone of management and an estimated 88% still undergo such interventions worldwide. Due to its risk of complications as well as the heavy financial burden on the health system, expectant management is suggested as an alternate management option in some selected patients. OBJECTIVE: To compare the efficacy and the safety of surgical and expectant management of incomplete miscarriage. METHOD: Study included 105 consecutive women presenting with incomplete miscarriage with a POA less than 14 weeks and was carried out at the university gynaecology unit, North Colombo teaching hospital, Ragama from August 2005 to May 2006. Fifty' one subjects received surgical evacuation while 54 underwent expectant management by random allocation. Surgical evacuation was carried out within 24 hours of ultrasound evaluation and a repeat scan was performed 24 hours after the procedure. The expectant group received inward treatment till bleeding settled and was followed up weekly as out¬patients to confirm complete expulsion. RESULTS: The mean age, POA, duration of bleeding and the haemoglobin level were similar in the two groups. The mean (SD) AP diameter of the retained products was 18.37(4.91) mm and 16.64(1.64), (P>0.05), in the surgical and expectant groups, respectively. A complete evacuation was achieved in all subjects in the surgical evacuation group as confirmed by ultrasound the following day. In the expectant group one subject required an emergency evacuation due to excessive bleeding. Complete expulsion was achieved in 85.1% (n-46) after one week and in 96.2% (n=52) after two weeks. No significant difference was observed in the mean change of haemoglobin level between the two groups. In the surgical group one subject required blood transfusion while another require a laparotomy following uterine perforation. Sepsis was not detected in any subject. The duration of hospital stay was significantly reduced in the expentant group with a mean (SD) stay of 1.5 days compared to 2.4 in the surgical group (p< 0.0001). CONCLUSION: In complete miscarriage with reduced amounts of retained products, expectant management is an option that could be offered. Expectant management up to 1 week will avert surgical intervention in 85% and up to 2 weeks in 96% of patients without an increased risk of complications. The decreased duration of hospital stay will be beneficial for both women as well as the health care providers.