Home Listing method Primary hysteroscopic treatment of miscarriages: is it our future or just a fad?

Primary hysteroscopic treatment of miscarriages: is it our future or just a fad?


In this issue of JMIG, we highlight a pilot study of the primary hysteroscopic management of early miscarriages. Historically, patients have been offered dilation and curettage (D&C) as the only surgical treatment option for miscarriage. Usually performed without ultrasound guidance, D&C can be associated with complications, including bleeding, infection, and perforation.1–3 It is important to note that D&C can disrupt the basal layer of the endometrium, resulting in increased risk intrauterine adhesions and subsequent subfertility.1 Risk of intrauterine adhesions. after miscarriage have been reported up to 40% and may be increased with repeated operative procedures.1,3 As pointed out by Weinberg et al. In this issue of JMIG, reducing the risk of perioperative morbidity from D&C, repeated procedures, development of intrauterine adhesions, and associated subfertility are important considerations when treating early miscarriages.

The safety of hysteroscopy in miscarriage can be inferred from the extensive literature on hysteroscopic management used for the treatment of retained products of conception (RPOC). A recent systemic review and meta-analysis comprising 20 studies and 2000 patients cited a rate of 91% of complete resection after one procedure and a rate of 0.07% of post-surgical intrauterine adhesions.3 There was a complication rate of 2% which included perforation, fluid overload, fever and hemorrhage.

There are a few retrospective reports of hysteroscopy as the primary treatment for early miscarriages. by Codt et al. presented a retrospective cohort study comparing results in patients who underwent primary hysteroscopic management of early miscarriage with D&C or hysteroscopy with cold loop resectoscope.2 Complications, including cervical lacerations, perforations uterine and endometritis were rare in both treatment groups. Bleeding, defined as blood loss of more than 500 ml, occurred in two cases in the D&C group.

When considering the primary hysteroscopic management of an early miscarriage, one proposed advantage is the potential for site-directed biopsy of the tissue. Cholkeri-Singh, Zamfirova, and Miller compared fetal tissue samples from early miscarriage patients who underwent D&C alone to those undergoing a directed biopsy under hysteroscopic visualization followed by D&C. Hysteroscopic-directed fetal tissue biopsy significantly reduced the rate of maternal contamination of specimens.4 Although this method of biopsy may provide patients with additional information to guide the management of future pregnancies, this fetal genetic test may not be appropriate. than in a small subset of these patients.

In this prospective pilot study, Weinberg et al. used a morcellator which is probably more available and preferred over a loop electrode by most gynecologists.5 They focused on performing their morcellator safely using both abdominal ultrasound for intraoperative guidance and vaginal ultrasound at the end of the procedure to confirm complete removal of the tissue. Four of their ten patients had suspected residual tissue by transvaginal ultrasound with D&C and then performed immediately. Only one of these patients had confirmed pathologic villi which were attributed to a second sac at a different location. No intraoperative complications were reported, and no patient retained any products on postoperative follow-up ultrasound. The authors stressed that this was a pilot study and that their technique might only be appropriate for selected patients. It is important to note the authors’ emphasis on the safety of their surgical technique, including obtaining prospective approval from the IRB and listing their study protocol on the ministry’s registry site. Israeli Health (https://my.health.gov.il/CliniTrials/Pages/MOH_2020-07-12_009131.aspx).

Primary hysteroscopic management of early miscarriages has possible benefits, including a high rate of complete ablation in one procedure, the ability to perform a targeted tissue biopsy, and the potential to reduce intra-adhesion formation. uterine while probably not significantly increasing the risk of perioperative complications. The limitations include the potentially higher cost and the necessary surgical resources and expertise. Prospective studies are needed to assess complications, costs and patient satisfaction. Surgical management of early miscarriages is an important option for women and reporting new innovative techniques is a core mission of JMIG. We look forward to future prospective studies to explore and confirm the value and role of this approach… or show that it is a well-intentioned but temporary fad!

The references

  • 1

    Hooker AB, Lemmers M, Thurkow AL, et al. Systematic review and meta-analysis of intrauterine adhesions after miscarriage: prevalence, risk factors and long-term reproductive outcomes. Hum Reprod Update. 2014; 20 (2): 262-278. doi: 10.1093 / humupd / dmt045

  • 2

    by Codt M, Balza C, Jadoul P, et al. Hysteroscopic resection for missed abortion: feasibility, operative technique and potential benefit compared to curettage. Surg before. 2020; 7: 64. doi: 10.3389 / fsurg.2020.00064

  • 3

    Vitale SG, Parry JP, Carugno J, et al. Surgical and reproductive outcomes after hysteroscopic ablation of retained conception products: a systematic review and meta-analysis. J Minim Invasive Gynecol. 2021; 28 (2): 204-217. doi: 10.1016 / j.jmig.200.10.028

  • 4

    Cholkeri-Singh A, Zamfirova I, Miller CE. Increased detection of fetal chromosomes through the use of operative hysteroscopy during evacuation of products of conception for a diagnosed miscarriage. J Minim Invasive Gynecol. 2020; 27 (1): 160-165. doi: 10.1016 / j.jmig.2019.03.014

  • 5

    Weinberg S, Pansky M, Burshtein I, Beller U, Goldstein H, Barel O. A pilot study on guided conservative hysteroscopic evacuation of early miscarriages. J Minim Invasive Gynecol. 2021; XXX (XXX); XXX. doi: 10.1016 / j.jmig.2021.04.017

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