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Expectant versus medical management for retained products of conception after medical termination of pregnancy: A randomized controlled study

  • Yossi TZUR
    Correspondence
    Corresponding author: Yossi Tzur, MD, Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, 6 Weizman St., Tel Aviv, 6423906, Israel, Phone: +972-3-6925603
    Affiliations
    Department of Obstetrics and Gynecology, Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Roza BERKOVITZ SHPERLING
    Affiliations
    Department of Obstetrics and Gynecology, Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Tamar GOITEIN INBAR
    Affiliations
    Ben-Gurion School of Medicine, Beer-Sheva, Israel, affiliated to the Ben-Gurion University of the Negev, Beer-Sheva, Israel
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  • Shikma BAR-ON
    Affiliations
    Department of Obstetrics and Gynecology, Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Yaron GIL
    Affiliations
    Department of Obstetrics and Gynecology, Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Ishai LEVIN
    Affiliations
    Department of Obstetrics and Gynecology, Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Aviad COHEN
    Affiliations
    Department of Obstetrics and Gynecology, Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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      ABSTRACT

      BACKGROUND

      Despite the rise of medical treatments for the termination of pregnancy, to-date no prospective trial has evaluated the efficacy of misoprostol in treating retained products of conception after induced termination of pregnancy.

      OBJECTIVE

      To compare medical management with misoprostol with expectant management for retained products of conception after first trimester medical termination of pregnancy.

      STUDY DESIGN

      An open-label randomized controlled trial conducted at a university-affiliated tertiary medical center. Consenting consecutive women who underwent a routine 3-week follow-up evaluation after medical termination of pregnancy and had a sonographic suspicion of retained products of conception, defined as sonographic evidence of intra-uterine remnant (>12 mm) with a positive Doppler flow, were recruited. The participants were randomized into a medical treatment group (800 mcg of sublingually administered misoprostol) or expectant management. They all underwent repeat ultrasound scans every 2 weeks until a maximum of 6 weeks, and those suspected for persistent retained products of conception were referred to operative hysteroscopy. The primary endpoint was successful treatment defined as no need for surgical intervention due to persistent retained products of conception within 8 weeks from pregnancy termination.

      RESULTS

      There were no significant differences in demographic characteristics between the study groups. The median sonographically demonstrated retained product length was 20 mm (interquartile range, [IQR] 17-25) in the medically managed group compared with 20 mm (IQR 17-26) in the expectantly managed group (P=.733). Treatment succeeded in 42/68 (61.8%) women in the medically managed group compared with 36/63 (57.1%) women in the expectantly managed group (relative risk [RR] = 1.12, 95% confidence interval [CI] 0.74-1.70; P=.590). There was no difference in adverse outcomes between the 2 groups.

      CONCLUSION

      There is no clinically meaningful advantage for medical treatment with misoprostol compared with expectant management after first trimester medical termination of pregnancy in women with suspected retained products of conception. Surgical intervention can be avoided in up to 60% of women who are managed expectantly over 8 weeks of follow-up.

      Keywords

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