Evidence-based management of recurrent miscarriage. Surgical management

Abstract

Objectives: (1) To analyse the anatomic-physiological bases, which justify that uterine anomalies could cause recurrent miscarriage; and (2) to study each one of these causes with regards to the evidence of their relationship with the recurrent miscarriage, as well as the evidence that surgical treatment also corrects the reproductive losses. Methods: Revision of the literature and our own investigations on uterine malformations and recurrent miscarriage. Results: Synechiae. The evidence for synechiae causing recurrent miscarriage is scarce. More probably, they are the result of repeated curettages and cause infertility. Leiomyomas. In up to 7% of women with recurrent miscarriage, the cause could lie in the presence of myomas. Present evidence suggests a beneficial effect of myomectomy as treatment, but there are no prospective studies that adequately confirm this. Cervical incompetence. It is defined as the incapacity to support or take a pregnancy to its full term due to a functional or structural defect of the cervix. Cervical cerclage is recommended at about 12–14 weeks of pregnancy after diagnosis made before pregnancy, but this operation is a controversial subject. The Cochrane revision concluded that cervical cerclage should not be offered to women at low or medium risk of mid-trimester loss, regardless of cervical length by ultrasound. However, none of the studies included in the meta-analysis based the randomization for carrying out prophylactic cerclage or not on a correct pre-gestational diagnosis, but only on history or on ultrasound. Congenital uterine anomalies. Many authors think that septate uterus is the anomaly with the worst reproductive results and propose metroplasty as soon as it is diagnosed. However, we find more reproductive losses in arcuate and bicornuate uteri and we have similar results to metroplasty when only carrying out a cerclage if there is cervical insufficiency. There is no randomized and prospective study, which analyses the necessity of metroplasty. Except in specific cases (20%), metroplasty is not necessary. Hypoplastic uterus-DES syndrome. The usefulness of hysteroscopic metroplasty in these cases is still to be demonstrated. There are no randomized studies. Conclusions: Surgical management is indicated only in a few cases of recurrent miscarriage: useful myomectomy, cervical cerclage if the incompetence is well diagnosed, metroplasty in some cases of recurrent miscarriage and septate or bicornuate uterus, and hysteroscopic metroplasty in septate and a Strassman operation for a bicornuate uterus.