Expectant Management vs. Surgical Treatment for Miscarriage

Clinical Question

What is the safety and effectiveness of expectant management versus surgical treatment for first-trimester miscarriage?

Evidence-Based Answer

Expectant management and surgical treatment are safe and effective for first-trimester miscarriage. Among patients who choose expectant management, there is a lower rate of pelvic infection but higher rates of mild bleeding, need for unplanned surgical treatment, and incomplete miscarriage.

Practice Pointers

When a nonviable first-trimester pregnancy is diagnosed, women have the option of waiting for the uterine contents to pass, choosing medical management with medications such as misoprostol (Cytotec), or undergoing dilation and curettage. Without intervention, more than 65 percent of missed abortions and 80 percent of incomplete and first-trimester abortions pass naturally within two to six weeks.1 Misoprostol 600 to 1,200 mcg vaginally on day 1, with a repeat dose if indicated on day 3, has been proven safe and effective. Success rates approach 95 percent, and women find their experience satisfactory.2,3 Surgical management includes vacuum extraction, suction curettage, or sharp curettage with or without dilation. Surgical management is the definitive treatment when other methods fail.

Nanda and colleagues reviewed the literature for trials comparing expectant management with surgical treatment for miscarriage. They found five trials with a total of 689 participants.

Expectant management had higher rates of incomplete miscarriage, need for unplanned surgical treatment, and bleeding, but a lower rate of pelvic infection (relative risk 0.29; 95% confidence interval, 0.09 to 0.87). Rates of infection ranged from 0 to 10 percent. Overall, there were two women in expectant management groups who required blood transfusion. However, rates of hemorrhage greater than 500 mL and bleeding requiring transfusion were not statistically significant between expectant management and surgical treatment groups. Two to 20 percent of women in the expectant management groups needed surgery. Unplanned surgical management usually was attributed to unacceptable pain, bleeding, or patient request. There were no differences in serious adverse events between the expectant management and surgical treatment groups.

Rates of complete abortion varied by study. In one study, the rate of complete abortion in the expectant management group was 81 percent at less than two weeks and 93 percent at seven weeks. Surgical treatment had a complete abortion rate of 97 percent at less than two weeks; no patients required second procedures. There is no clear indication for routine surgical management; therefore, patient preference should be respected.

Exercises for Mechanical Neck Disorders

Clinical Question

How effective is exercise therapy for mechanical neck pain?

Evidence-Based Answer

There is some evidence that a variety of exercises help patients with mechanical neck pain. Evidence is strongest for a multimodal approach that includes exercise and mobilization or manipulation of the cervical spine, although this research has been criticized for having an imperfect control group.

Practice Pointers

Mechanical neck pain is caused by a variety of injuries and disease processes, including whiplash, myofascial neck pain, and degenerative cervical spine disease. Kay and colleagues reviewed the literature for randomized and quasi-randomized clinical trials on treatments for neck pain. Most studies (24) were of mechanical neck pain alone. The researchers also found one study of mechanical neck pain with some radicular signs, three studies of headache of cervical origin, and three involving a mixed group of patients with neck pain and neck disorder associated with headache or radicular symptoms. Studies were of fair quality. Although an earlier version of this systematic review was inconclusive, subsequent systematic reviews by other groups have found a benefit with exercise.

The authors found limited evidence of benefit for mechanical neck pain with a variety of types of exercise activity: active range-of-motion exercises without resistance, stretching and strengthening exercises, strengthening exercises alone, and eye-fixation exercises to improve proprioception. The strongest evidence, from four studies, was found for a multimodal approach that included exercise and mobilization or manipulation of the cervical spine (number needed to treat = 4 to 5).

The Philadelphia Panel, a panel of physicians and methodologic experts from the United States and Canada, developed an evidence-based guideline for the treatment of musculoskeletal disorders.1 According to this guideline, there is good evidence (grade A for pain and function, grade B for patient global assessment) to include supervised exercise programs alone, including proprioceptive and traditional exercises, for the management of chronic neck pain (i.e., lasting longer than 12 weeks).1 The Philadelphia Panel does not endorse manual therapy (i.e., cervical mobilization or manipulation) because the control group did not receive sham manual therapy.