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Management of first-trimester miscarriage : a systematic review and network meta-analysis
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Al Wattar, Bassel H., Murugesu, Nilaani, Tobias, Aurelio, Zamora, Javier and Khan, Khalid S. (2019) Management of first-trimester miscarriage : a systematic review and network meta-analysis. Human Reproduction Update, 25 (3). pp. 362-374. doi:10.1093/humupd/dmz002 ISSN 1355-4786.
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Official URL: https://doi.org/10.1093/humupd/dmz002
Abstract
Background
First-trimester miscarriage affects up to a quarter of women worldwide. With many competing treatment options available, there is a need for a comprehensive evidence synthesis.
Objectives and rationale
We conducted a systematic review and network meta-analysis to assess the effectiveness and safety of treatment options for first-trimester miscarriage: expectant management (EXP), sharp dilation and curettage (D+C), electric vacuum aspiration (EVAC), manual vacuum aspiration (MVA), misoprostol alone (MISO), mifepristone+misoprostol (MIFE+MISO) and misoprostol plus electric vacuum aspiration (MISO+EVAC).
Search methods
We searched MEDLINE, Embase, CINAHL, AMED and Cochrane Library from inception till June 2018. We included randomized trials of women with first-trimester miscarriage (<14 weeks gestation) and conducted a network meta-analysis generating both direct and mixed evidence on the effectiveness and side effects of available treatment options. The primary outcome was complete evacuation of products of conception. We assessed the risk of bias and the global network inconsistency. We compared the surface under the cumulative ranking curve (SUCRA) for each treatment.
Outcomes
A total of 46 trials (9250 women) were included. The quality of included studies was overall moderate with some studies demonstrating a high risk of bias. We detected unexplained inconsistency in evidence loops involving MIFE+MISO and adjusted for it. EXP had lower effectiveness compared to other treatment options. The effectiveness of medical treatments was similar compared to surgery. Mixed evidence of low confidence suggests increased effectiveness for MIFE+MISO compared to MISO alone (RR 1.49, 95% CI: 1.09–2.03). Side effects were similar among all options. Fewer women needed analgesia following EVAC compared to MISO (RR for MISO 0.43, 95% CI: 0.27–0.68) and in the EXP group compared to EVAC (RR 2.07, 95% CI: 1.25–3.41). MVA had higher ranking (low likelihood) for post-treatment infection and serious complications (SUCRA 87.6 and 79.2%, respectively) with the highest likelihood for post-treatment satisfaction (SUCRA 98%).
Wider implications
Medical treatments for first-trimester miscarriage have similar effectiveness and side effects compared to surgery. The addition of MIFE could increase the effectiveness of MISO and reduce side effects, although evidence is limited due to inconsistency. EXP has lower effectiveness compared to other treatment options.
Item Type: | Journal Article | ||||||||
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Alternative Title: | |||||||||
Subjects: | R Medicine > RG Gynecology and obstetrics | ||||||||
Divisions: | Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Biomedical Sciences > Cell & Developmental Biology Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Biomedical Sciences Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School |
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Library of Congress Subject Headings (LCSH): | Miscarriage, Women -- Health and hygiene | ||||||||
Journal or Publication Title: | Human Reproduction Update | ||||||||
Publisher: | Oxford University Press | ||||||||
ISSN: | 1355-4786 | ||||||||
Official Date: | May 2019 | ||||||||
Dates: |
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Volume: | 25 | ||||||||
Number: | 3 | ||||||||
Page Range: | pp. 362-374 | ||||||||
DOI: | 10.1093/humupd/dmz002 | ||||||||
Status: | Peer Reviewed | ||||||||
Publication Status: | Published | ||||||||
Reuse Statement (publisher, data, author rights): | This is a pre-copyedited, author-produced version of an article accepted for publication in Human Reproduction Update following peer review. The version of record Bassel H. Al Wattar, Nilaani Murugesu, Aurelio Tobias, Javier Zamora, Khalid S Khan, Management of first-trimester miscarriage: a systematic review and network meta-analysis, Human Reproduction Update, Volume 25, Issue 3, May-June 2019, Pages 362–374 is available online at: https://doi.org/10.1093/humupd/dmz002 | ||||||||
Access rights to Published version: | Restricted or Subscription Access | ||||||||
Date of first compliant deposit: | 9 January 2019 | ||||||||
Date of first compliant Open Access: | 12 February 2020 | ||||||||
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