Surgical management of miscarriage and abortion

A woman is bleeding in early pregnancy and the scan shows an empty sac. Your job in the next twenty minutes is not to reach for the curette — it is to be certain the pregnancy is truly non-viable, to decide whether she needs theatre at all, and, if she does, to evacuate safely with antibiotics, anti-D and histology in place. Most early pregnancy loss can be managed without surgery; the art is recognising the woman who cannot be.^[1][4]

Overview and definition

Miscarriage is the spontaneous loss of a pregnancy before 24 weeks, and it is common: an estimated 15 per cent of recognised pregnancies end in miscarriage, and around a quarter of women will experience one in their lifetime.^[3] Early miscarriage — loss in the first 14 weeks — is the province of this topic, because it is here that uterine evacuation is offered and where the surgical, medical and expectant arms diverge.^[3][4]

The surgical options are narrower than the old vocabulary implies. ^[4]

• Manual vacuum aspiration (MVA) — a handheld, often awake, office-or-theatre technique using a self-locking syringe and rigid cannulae; licensed across the first trimester.
• Electric vacuum aspiration (EVA) — theatre, usually under anaesthesia, an electric pump driving suction through a cannula; for larger gestations or the heavy bleeder.
• Sharp dilation and curettage (D&C) — the historical method of scraping the cavity with a metal curette; retired as a sole technique because it traumatises the basal endometrium and raises adhesion risk.^[4]
• Medical management — misoprostol alone or after mifepristone; the comparator, not the technique, but the decision you weigh surgery against.^[5]
• Expectant management — letting the miscarriage complete on its own; suitable for the stable, informed woman.^[8][9]

References13ShowHide

1. [1]Coomarasamy A, Gallos ID, Papadopoulou A, et al. Sporadic miscarriage: evidence to provide effective care Lancet, 2021.PMID 33915095
2. [2]Lissauer D, Wilson A, Hewitt CA, et al. A Randomized Trial of Prophylactic Antibiotics for Miscarriage Surgery N Engl J Med, 2019.PMID 30865795
3. [3]Ghosh J, Papadopoulou A, Devall AJ, et al. Methods for managing miscarriage: a network meta-analysis Cochrane Database Syst Rev, 2021.PMID 34061352
4. [4]H Al Wattar B, Murugesu N, Tobias A, et al. Management of first-trimester miscarriage: a systematic review and network meta-analysis Hum Reprod Update, 2019.PMID 30753490
5. [5]Chu JJ, Devall AJ, Beeson LE, et al. Mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage (MifeMiso): a randomised, double-blind, placebo-controlled trial Lancet, 2020.PMID 32853559
6. [6]Preisler J, Kopeika J, Ismail L, et al. Defining safe criteria to diagnose miscarriage: prospective observational multicentre study BMJ, 2015.PMID 26400869
7. [7]Doubilet PM, Benson CB, Bourne T, et al. Diagnostic criteria for nonviable pregnancy early in the first trimester N Engl J Med, 2013.PMID 24106937
8. [8]Nielsen S, Hahlin M, Platz-Christensen J Randomised trial comparing expectant with medical management for first trimester miscarriages Br J Obstet Gynaecol, 1999.PMID 10453830
9. [9]Nanda K, Lopez LM, Grimes DA, et al. Expectant care versus surgical treatment for miscarriage Cochrane Database Syst Rev, 2012.PMID 22419288
10. [10]Grentzer J, McNicholas C, Eisenberg DL, Peipert JF Comparison of procedure time between manual and electric vacuum aspiration for pregnancy termination between 10-14 weeks Contraception, 2022.PMID 35417756
11. [11]Schreiber CA, Ratcliffe SJ, Quinley KE Serum biomarkers may help predict successful misoprostol management of early pregnancy failure Reprod Biol, 2015.PMID 26051455
12. [12]Qureshi H, Massey E, Kirwan D, et al. BCSH guideline for the use of anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn Transfus Med, 2014.PMID 25121158
13. [13]Karanth L, Jaafar SH, Kanagasabai S, et al. Anti-D administration after spontaneous miscarriage for preventing Rhesus alloimmunisation Cochrane Database Syst Rev, 2013.PMID 23543581