title: MisoREST: surgical versus expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage: a randomized controlled trial.
abstract: Is curettage more effective than expectant management in case of an incomplete evacuation after misoprostol treatment for first trimester miscarriage?
  
  
  
  Curettage leads to a higher chance of complete evacuation but expectant management is successful in at least 76% of women with an incomplete evacuation of the uterus after misoprostol treatment for first trimester miscarriage.
  
  
  
  In 5-50% of the women treated with misoprostol, there is a suspicion of incomplete evacuation of the uterus on sonography. Although these women generally have minor symptoms, such a finding often leads to additional curettage.
  
  
  
  From June 2012 until July 2014, we conducted a nationwide multicenter randomized controlled trial (RCT). Women who had had primary misoprostol treatment for miscarriage with sonographic evidence of incomplete evacuation of the uterus were randomly allocated to either curettage or expectant management (1:1), using a web-based application.
  
  
  
  We included 59 women in 27 hospitals; 30 were allocated to curettage and 29 were allocated to expectant management. A successful outcome was defined as sonographic finding of an empty uterus 6 weeks after randomization.
  
  
  
  Baseline characteristics of both groups were comparable. Empty uterus on sonography or uneventful clinical follow-up was seen in 29/30 women (97%) allocated to curettage compared with 22/29 women (76%) allocated to expectant management (RR 1.3, 95% CI 1.03-1.6) with complication rates of 10% versus 10%, respectively (RR 0.97, 95% CI 0.21-4.4). In the group allocated to curettage, no woman required re-curettage, while two women (6.7%) underwent hysteroscopy (for other or unknown reasons). In the women allocated to expectant management, curettage was performed in four women (13.8%) and three women (10.3%) underwent hysteroscopy.
  
  
  
  Due to a strong patient preference, mainly for expectant management, the targeted sample size could not be included and the trial was stopped prematurely.
  
  
  
  In women suspected of incomplete evacuation of the uterus after misoprostol, curettage is more effective than expectant management. However, expectant management is equally safe and prevents curettage for most of the women. This finding could further restrain the use of curettage in the treatment of first trimester miscarriage.
  
  
  
  This study was funded by ZonMw, a Dutch organization for Health Research and Development, project number 80-82310-97-12066. There were no conflicts of interests.
  
  
  
  Dutch Trial Register NTR3310, http://www.trialregister.nl TRIAL REGISTRATION DATE: 27 February 2012.
  
  
  
  12 June 2012.
authors: Department of Obstetrics and Gynaecology, Academic Medical Center, P.O. Box 22770, 1100 DE Amsterdam, the Netherlands m.lemmers@amc.uva.nl.|Department of Obstetrics and Gynaecology, VU Medical Center, P.O. Box 7057, 1007 MB Amsterdam, the Netherlands.
authors: M
authors: M
authors: Lemmers
authors: Department of Obstetrics and Gynaecology, Academic Medical Center, P.O. Box 22770, 1100 DE Amsterdam, the Netherlands.
authors: M A C
authors: MA
authors: Verschoor
authors: Department of Obstetrics and Gynaecology, Academic Medical Center, P.O. Box 22770, 1100 DE Amsterdam, the Netherlands.
authors: K
authors: K
authors: Oude Rengerink
authors: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, the Netherlands.
authors: C
authors: C
authors: Naaktgeboren
authors: Clinical Research Unit, University of Amsterdam, Academic Medical Center, P.O. Box 22770, 1100 DE Amsterdam, the Netherlands.
authors: B C
authors: BC
authors: Opmeer
authors: Clinical Research Unit, University of Amsterdam, Academic Medical Center, P.O. Box 22770, 1100 DE Amsterdam, the Netherlands.
authors: P M
authors: PM
authors: Bossuyt
authors: Department of Obstetrics and Gynaecology, VU Medical Center, P.O. Box 7057, 1007 MB Amsterdam, the Netherlands.
authors: J A F
authors: JA
authors: Huirne
authors: Department of Obstetrics and Gynaecology, Groene Hart Hospital, P.O. Box 1098, 2800 BB Gouda, the Netherlands.
authors: C A H
authors: CA
authors: Janssen
authors: Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis West, P.O. Box 9243, 1006 AE Amsterdam, the Netherlands.
authors: C
authors: C
authors: Radder
authors: Department of Obstetrics and Gynaecology, University Medical Center Groningen, P.O. Box 30001, 9700 RB Groningen, the Netherlands.
authors: E R
authors: ER
authors: Klinkert
authors: Department of Obstetrics and Gynaecology, Atrium Medical Center, P.O. Box 4446, 6401 CX Heerlen, the Netherlands.
authors: J
authors: J
authors: Langenveld
authors: Department of Obstetrics and Gynaecology, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, the Netherlands.
authors: R
authors: R
authors: Catshoek
authors: Department of Obstedtrics and Gynaecology, Deventer Hospital, P.O. Box 5001, 7400 GC Deventer, the Netherlands.
authors: L
authors: L
authors: Van der Voet
authors: Department of Obstetrics and Gynaecology, Reinier de Graaf Hospital, P.O. Box 5011, 2600 GA Delft, the Netherlands.
authors: F
authors: F
authors: Siemens
authors: Department of Obstetrics and Gynaecology, Maxima Medical Center, Postbus 7777, 5500 MB Veldhoven, the Netherlands.
authors: P
authors: P
authors: Geomini
authors: Department of Obstetrics and Gynaecology, Sint Franciscus Gasthuis, Rotterdam, P.O. Box 10900, 3004 BA Rotterdam, the Netherlands.
authors: M H
authors: MH
authors: Van Hooff
authors: Department of Obstetrics and Gynaecology, Martini Hospital Groningen, P.O Box 30033, 9700 RM Groningen, the Netherlands.
authors: J M
authors: JM
authors: Van der Ploeg
authors: Department of Obstetrics and Gynaecology, University Medical Center St. Radboud, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands.
authors: S F P J
authors: SF
authors: Coppus
authors: Department of Obstetrics and Gynaecology, Academic Medical Center, P.O. Box 22770, 1100 DE Amsterdam, the Netherlands.
authors: W M
authors: WM
authors: Ankum
authors: The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, 55 King William Road, North Adelaide SA 5006; and The South Australian Health and Medical Research Institute, Adelaide, Australia.
authors: B W J
authors: BW
authors: Mol
mesh_terms: D000020:Abortifacient Agents, Nonsteroidal / Q000627:therapeutic use*; D000027:Abortion, Incomplete / Q000601:surgery*; D000022:Abortion, Spontaneous / Q000188:drug therapy* / Q000601:surgery; D000328:Adult; D000072700:Conservative Treatment / Q000379:methods*; D003475:Curettage / Q000379:methods*; D005260:Female; D006801:Humans; D016595:Misoprostol / Q000627:therapeutic use*; D011247:Pregnancy; D011261:Pregnancy Trimester, First; D017211:Treatment Failure; D016896:Treatment Outcome
chemical_list: D000020:Abortifacient Agents, Nonsteroidal; D016595:Misoprostol
keywords: abortion; expectant management; miscarriage; surgery; uterus