Which evacuation method for missed abortion is preferred by women with recurrent pregnancy loss?

Abstract Study question Is medical or surgical evacuation for missed abortion (MA) preferred by women with recurrent pregnancy loss (RPL)? Which factors are determining for the women’s preference? Summary answer Sixty-seven percent of the participants preferred surgical evacuation. Side effects and a history of unsuccessful medical evacuation in their first MA were determining factors. What is known already Guidelines currently recommend medical rather than surgical evacuation after MA. The success rates defined as adequate evacuation of the uterine cavity after MA without further intervention are reported to be 80% and 97% for medical and surgical evacuation, respectively. Medical evacuation is associated with heavier and longer duration of bleeding and higher intensity of pain. Surgical evacuation increases the risk of uterine perforation and Asherman’s syndrome. Studies have found that women are more satisfied and have better subsequent mental health when they can decide themselves which method they would choose. Study design, size, duration An online questionnaire was sent October 5th, 2022, to 157 RPL patients who had experienced both medical and surgical evacuation for MA admitted to a center for RPL between January 2016 and September 2022. Eighty-seven (55.4%) patients completed the survey before deadline after being sent reminders. Sixty (69%) of the women had received a medical evacuation and 27 (31%) surgical evacuation for their first MA. Participants/materials, setting, methods The mean age of the respondents was 37 years (SD ± 0.5) and they had had at least three pregnancy losses. The questionnaire featured questions regarding the women’s experiences with medical and surgical evacuation, preferred evacuation method if they would have another MA, and determining factors for their preference. Categorical variables were compared using χ2 test and Wilcoxon Signed Rank Test. Analyses were conducted to determine associations between potential determining factors for preferred evacuation method. Main results and the role of chance A significantly higher intensity of pain was experienced, and analgesics were required for a significantly longer period after a first medical evacuation compared to a first surgical evacuation (p < 0.001 and p = 0.006). Bleeding, pain, sick leave, and mental discomfort had a significant impact on the choice of another evacuation method at the time of next MA in women who experienced a medical abortion first. As many as 40% had experienced failure of the first medical evacuation with need for subsequent surgical evacuation for complete evacuation; this was confirmed by consulting the patient’s medical records. The odds ratio (OR) for preferring medical evacuation at next MA was 3.3 if the women had given birth before (p = 0.011). The OR for preferring medical evacuation at next MA was 0.3, if the women had received medical evacuation for their first MA (p = 0.015). There were no statistically significant associations between preferring medical evacuation and the following factors: BMI, age at first evacuation and menstrual pain. Two thirds (66.7%) of the women would prefer surgical evacuation for their next MA, while the remaining women (33.3%) would prefer medical evacuation. Limitations, reasons for caution The response rate of 55.4% was lower than expected 70% which implicates a risk of sampling bias such as a predominance of patients with a history of complicated evacuations responding to the questionnaire. Due to the retrospective design, recollection bias could also impact the results. Wider implications of the findings In this study population, medical evacuation was associated with a stronger experience of side effects and a higher failure rate than expected, which may explain why more women preferred surgical evacuation for their next MA. This may suggest current evacuation recommendations for MAs should become more individualized than currently. Trial registration number Not applicable