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Question clinique
What is the best method for managing early miscarriage?
L’Essentiel
Following ultrasound confirmation, women with miscarriage but without severe bleeding should be offered the choice of expectant management for up to 8 weeks or the option of immediate medical or surgical management. 5
Référence
Plan de l'etude: Practice guideline
Financement: Self-funded or unfunded
Cadre: Various (guideline)
Sommaire
These authors identified relevant Cochrane Reviews and recent randomized studies that attempted to answer this question. Women with abdominal pain or vaginal bleeding early in their pregnancy (< 14 weeks') should be assessed by ultrasound, and women who are hemodynamically unstable should be treated with emergency suction curettage. Otherwise, women should be offered expectant management, medical treatment, or surgical management. Based on 3 Cochrane reviews of 24 studies of 5577 women, surgical approaches have the highest success rate of complete miscarriage (96%), followed by medical management (81%) and expectant management (56%). However, in the first trimester medical and surgical management produce similar outcomes in indirect comparison (network meta-analysis). The optimal length of time of expectant management is not clear. United Kingdom guidelines suggest 1 week to 2 weeks and US guidelines suggest up to 8 weeks before intervening, except in women with excessive bleeding. For medical management, 800 micrograms of misoprostol can be given vaginally or orally, with 600 to 800 micrograms repeated for incomplete miscarriage. Oral mifepristone, 200 mg, if available, may provide additional benefit if given 24 hours before misoprostol, based on the results of one study.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA