Geyman J P, Oliver L M, Sullivan S D
Department of Family Medicine, University of Washington, Seattle 98105, USA.
J Am Board Fam Pract. 1999 Jan-Feb;12(1):55-64. doi: 10.3122/15572625-12-1-55.
Spontaneous abortion is a common problem in everyday clinical practice, accounting for 15 to 20 percent of all recognized pregnancies. The traditional treatment of this problem has been surgical, emptying the uterus by dilatation and curettage (D&C). Recent therapeutic and laboratory advances call surgical therapy into question for many patients. It is believed that this pooled quantitative literature evaluation is the first with the goal to clarify the roles of expectant, medical, and surgical treatment of this common problem.
The literature review was focused on published studies in the English language of outcomes of therapy for spontaneous abortion in the first trimester. We looked for both observational and randomized controlled trials. A successful outcome of treatment required that three criteria be met: vaginal bleeding stopped by 3 weeks, products of conception fully expelled by 2 weeks, and absence of complications. Pooled weighted average success estimates and standard errors were determined for each study; 95 percent confidence intervals were calculated for each form of treatment. Sensitivity analysis compared randomized controlled trials with observational studies for both expectant and surgical treatment.
Of the 31 studies retrieved, 18 met inclusion criteria, including 9 involving expectant treatment (545 pooled patients), 3 for medical treatment (prostaglandin or antiprogesterone agents) (198 pooled patients), and 10 for surgical treatment (D&C) (1408 pooled patients). Successful outcomes were found in 92.5 percent of patients receiving expectant treatment, in 93.6 percent of those undergoing D&C, and in 51.5 percent of patients receiving medical treatment.
Expectant management of spontaneous abortion in the first trimester is safe and effective for many afebrile patients whose blood pressure and heart rate are stable and who have no excess bleeding or unacceptable pain. Transvaginal sonographic studies might be useful in patient selection, and serial chorionic gonadotropin monitoring should be considered while observing the initial course of expectant treatment. Currently there is insufficient evidence to support medical therapy of spontaneous abortion, and further research is needed to clarify the more limited role of surgical treatment.
自然流产是日常临床实践中的常见问题，占所有已确认妊娠的15%至20%。该问题的传统治疗方法是手术，通过扩张刮宫术（D&C）清空子宫。近期治疗和实验室方面的进展使许多患者对手术治疗产生质疑。据信，此次汇总定量文献评估是首次旨在阐明对这一常见问题进行期待治疗、药物治疗和手术治疗的作用。
文献综述聚焦于以英文发表的关于孕早期自然流产治疗结局的研究。我们查找了观察性研究和随机对照试验。治疗成功的结局要求满足三个标准：3周内阴道出血停止、2周内妊娠物完全排出、无并发症。为每项研究确定汇总加权平均成功估计值和标准误差；为每种治疗方式计算95%置信区间。敏感性分析比较了期待治疗和手术治疗的随机对照试验与观察性研究。
在检索到的31项研究中，18项符合纳入标准，包括9项涉及期待治疗（汇总患者545例）、3项药物治疗（前列腺素或抗孕激素制剂）（汇总患者198例）和10项手术治疗（D&C）（汇总患者1408例）。接受期待治疗的患者中有92.5%取得成功结局，接受D&C的患者中有93.6%取得成功结局，接受药物治疗的患者中有51.5%取得成功结局。
对于许多血压和心率稳定、无过多出血或不可接受疼痛的无发热孕早期自然流产患者，期待管理是安全有效的。经阴道超声检查可能有助于患者选择，在观察期待治疗的初始过程时应考虑连续监测绒毛膜促性腺激素。目前尚无足够证据支持自然流产的药物治疗，需要进一步研究以阐明手术治疗更有限的作用。
