Surgical procedures to evacuate incomplete miscarriage
Vacuum aspiration of the uterus is preferable to dilation and curettage for the management of incomplete abortion. Since the manual vacuum aspiration technique is somewhat easier to teach, it use would be easier to implement in developing countries. There are recurring costs with the use of this technique. Staff in health-care facilities need to be trained adequately before they can start using it.
RHL Commentary by Kestler E
1. EVIDENCE SUMMARY
This review compares the safety and efficacy of available surgical methods for the management of incomplete abortion. There are two procedures most widely used for this purpose: The instrumental curettage and vacuum aspiration. The first one is performed with a rigid metal curette, in the operation room and usually under general anesthesia. The second uses suction from electrical or manual syringe sources, plastic or metal cannula for evacuating the uterus and can be performed on an outpatient basis, under local anesthesia or analgesia.
Twenty-five studies were identified, but only two met the eligibility requirements established by the reviewers. Most trials did not qualify because they were not randomized. The reviewers concluded that vacuum aspiration of the uterus is preferable to curettage. This preference is based mainly on the results of one trial from Zimbabwe showing similar efficacy, shorter procedure duration, less blood loss and less need for anaesthesia and pain relief with suction curettage.
The methodology followed was adequate. The analysis of the studies was correct. The authors adequately determined the outcomes to be assessed, but unfortunately only two variables are evaluated in the studies (uterine perforation and the need of uterine re-evacuation) and only one study has complete information for the evaluation of the other variables. Another limitation is that both studies had relatively small sample sizes, one study did not describe the screening methodology and the other had a considerable number of losses on the follow-up. Although the review was conducted appropriately the scarcity of data limits the strength of the conclusions.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
Incomplete abortion is one of the most frequent obstetric emergencies. It is the second most common cause of admission, after delivery, for most of the hospitals in the developing world. When a woman arrives at the facility it is difficult to determine whether the abortion process has been spontaneous or induced under potentially unsafe conditions. Around 90% of unsafe abortions performed worldwide are estimated to take place in developing countries(1). It can be assumed that a significant proportion of these patients have the abortion induced outside the health system and then go to the facilities to complete the uterine evacuation. Especially in settings where termination of first trimester pregnancy is not legal or even when it is legal the services are not accessible the proportion of unsafe abortions are likely to be higher. In a multicentre study conducted in South Africa 15% of women admitted with incomplete abortion were found to have severe morbidity mainly related to infection (2). health system must be prepared to provide appropriate technology for the management of these cases.
2.2. Feasibility of the intervention
Uterine aspiration, either manual or electric, is an essential technology for rural or urban health care settings for most countries of the developing world. Every obstetric hospital should include this technology (either aspiration or curettage) within their surgical procedures for the management of the incomplete abortion.
2.3. Applicability of the results of the Cochrane Review
The two trials included in the review were conducted in Singapore (1969) and Zimbabwe (1993). There is no biologic reason to expect that the performance of both techniques would be different in different settings provided that there is trained staff to perform them.
2.4. Implementation of the intervention
It would be possible to implement these interventions in health care settings. Manual aspiration (suction) could be easier to implement as the technique could be somewhat easier to teach. It should be remembered that there are recurring costs with the implementation of manual aspiration such as cannulae and suction syringe replacements. Any hospital, health-care facility or maternity house staff should be trained before embarking on this technique.
It would be useful if, in the future, training in this technique is included in obstetric curricula, not only in medical schools, but extended to the different health-care levels of both developing and developed countries.
It is difficult to understand how such a leading cause of maternal morbidity and mortality can be so under-evaluated, both in terms of the quantity and the quality of the research.
This Cochrane Review should be viewed as a drive to stimulate research in this area. There is, on the one hand, the need to design more methodologically sound investigations, and on the other, to include more variables not included in the current review.
It is also important to evaluate the performance of this procedure by other health-care personnel (i.e., nurses and midwives). This would enable isolated rural settings lacking medical personnel, to perform this type of uterine evacuation in cases of bleeding due to incomplete abortion and thus save lives.
- WHO. Abortion: A tabulation of available data on the frequency and mortality if unsafe abortion. 2nd Edition. Geneva, Switzerland: WHO (WHO/FHE/MSM/93.13) 1994 .
- Rees H, Katzenellenbogen J, Shabodien R, Jewkes R, Fawcus S, McIntyre J, Lombard C, Truter H. The epidemiology of incomplete abortion in South Africa. South African medical journal 1997;87;87:432-437.
This document should be cited as: Kestler E. Surgical procedures to evacuate incomplete miscarriage: RHL commentary (last revised: 8 January 2002). The WHO Reproductive Health Library; Geneva: World Health Organization.