Hysteroscopy No Match for Standard Care in Incomplete Spontaneous Abortion

Operative hysteroscopy did not lead to better outcomes compared with vacuum aspiration for patients presenting with incomplete spontaneous abortions during the first trimester of pregnancy, according to a French randomized trial.

During 2-year follow-up, 62.8% of those who underwent operative hysteroscopy had a pregnancy of at least 22 weeks' gestation versus 67.6% of those who underwent the standard vacuum aspiration (P=0.23), reported Cyrille Huchon, MD, PhD, of the University of Paris Cité, and co-authors in JAMA.

Time-to-event analyses showed no statistically significant difference for this primary outcome between the groups (HR 0.87, 95% CI 0.71-1.07).

"The findings of our trial contradict the past studies that have accumulated a low to moderate level of evidence of the value of hysteroscopic resection compared with the traditional vacuum aspiration," they study authors wrote.

Both groups had similar rates of new miscarriages, ectopic pregnancies, grade ≥3 Clavien-Dindo surgical complications, and reinterventions to remove remaining products of conception. But compared with vacuum aspiration, duration of hospitalization (P=0.03) and surgery (P<0.001) were significantly longer in the hysteroscopy group.

"These unfavorable outcomes, with practical issues of medical costs and time burdens on patients, in combination with the lower success rate, clearly support inferiority of hysteroscopy vs vacuum aspiration," they added.

Vacuum aspiration can lead to scarring in the uterine cavity, which could impact future fertility, Huchon and team explained. Because "hysteroscopy to remove retained product of conception is performed under direct visualization control, it may theoretically reduce risks to the uterine cavity and therefore improve future fertility," they wrote.

However, they concluded that the present study "provides evidence that vacuum aspiration should remain the standard of care for patients with incomplete spontaneous abortion of the first trimester of pregnancy."

"Surgical management by hysteroscopy of incomplete spontaneous abortions in patients wishing to conceive again was not associated with either more subsequent births or a better safety profile than vacuum aspiration," they added. "Moreover, operative hysteroscopy was not feasible in all cases."

Julie Gutierrez, MD, of the McGovern Medical School at UTHealth Houston, told MedPage Today that hysteroscopy is not routinely used in the U.S., though it can be in select circumstances, while vacuum aspiration is common practice.

"This study confirms that patients should have the autonomy to choose how they want to manage their miscarriage without fear of reproductive repercussions down the line," said Gutierrez, who was not involved in the study.

"I appreciate that the outcome was not just development of adhesion formation, but rather a pregnancy past 22 weeks," she said. "That's the outcome clinically relevant for patients."

For the single-blind HY-PER (Effectiveness of Hysteroscopy in the Treatment of Intrauterine Trophoblastic Retentions) study, which took place from November 2014 to May 2017, Huchon and colleagues included 563 patients (mean age 32.6 years) from 15 French hospitals who were randomized in a 1:1 ratio to hysteroscopy or vacuum aspiration. All patients were in their first trimester and wanted to become pregnant again.

Hysteroscopy could not be completed for 19 patients, 18 of which were converted to vacuum aspiration (eight with inability to completely resect, seven with insufficient visualization, two with anesthetic complications that required a shortened procedure, and one with equipment failure). One hysteroscopy also failed due to a false passage during cervical dilatation.

Huchon and team noted that the number of patients who crossed over from hysteroscopy to vacuum aspiration could limit the interpretation of the intention-to-treat analysis, which was a limitation to the study. Furthermore, the study was limited to the surgical treatment of patients with incomplete spontaneous abortion during the first trimester of pregnancy, and the findings may not be generalizable to patients with persistent retained products of conception after 14 weeks of gestation.

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