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作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　October 8, 2009 — 根據10月9日線上第一版BMJ期刊的一篇隨機控制研究結果，流產之後，不論哪種流產處置方式，有八成婦女在五年內生育。
　　
　　英國Somerset郡、Westlake Surgery公司East Somerset Research Consortium的Lindsay F.P. Smith醫師寫道，數十年來，早期流產婦女的標準治療為排除剩餘的胚胎產物。這個處置方式逐漸受到質疑，現在，一般提供給婦女的是觀望(觀察與等待、沒有主動介入)與藥物處置。不過，有關此一處置方法對於後續受孕力影響的相關證據有限，後續受孕力是婦女及其照護者的主要議題。
　　
　　研究目標是比較MIST (流產處置)這項隨機控制試驗中，三種早期流產處置方式之後的婦女受孕率。在英國西南部緊急醫院的早期懷孕門診中，1,199名婦女在妊娠13週前流產，經掃描確認後隨機指派到觀望組、藥物組或手術處置組。研究初級終點為自我報告的懷孕比率和活產比率。
　　
　　同意接受追蹤的1,128名MIST研究對象中，762人回覆有關懷孕細節的問卷(回覆率68%)，這些婦女被視為整個試驗研究對象的代表。該次流產之後5年，這三組的活產比率相似：觀望組的224人中有177人(79%；95%信心區間[CI]為73% - 84%)、藥物組的230人中有181人(79%；95% CI，73% - 84%)、手術組的235人中有192人(82%；95% CI，76% - 86%)。
　　
　　過去的生育紀錄對於五年時的活產比率沒有顯著影響，但是在年長婦女以及曾經流產者，這些數據顯著較低。
　　
　　研究作者寫道，流產處置方法不會影響後續的生育率，有八成婦女在流產之後的五年內生育。婦女們可以放心，選擇的流產處置方式對於長期生育力沒有影響。
　　
　　研究限制包括，回覆率只有68%，雖存疑但有可能的是，某種處置方式引起本問卷無法測得之極早期的後續流產。
　　
　　研究作者結論表示，我們的結果確認，發生過三次以上流產的婦女可能會有後續的生育問題，因此需要研究其反覆流產的原因。婦女們可以放心的是，不論處置方法為何，流產之後，後續活產比率很高。這些可以補充選擇接受處置方式之資訊不足，個人也會因為臨床和經濟上的差異而有不同取捨。
　　
　　BMA Claire Wand基金會資助本研究。East Somerset Research Consortium提供贊助與研究統合管理。研究作者皆宣告沒有相關財務關係。
　　
　　BMJ. 2009;339:b3827.

Treatment Method After a Miscarriage Does Not Affect Subsequent Pregnancies

By Laurie Barclay, MD
Medscape Medical News

October 8, 2009 — After miscarriage, 4 of 5 women give birth within 5 years regardless of method of miscarriage management, according to the results of a randomized controlled trial reported in the October 9 Online First issue of the BMJ.

"For decades the standard treatment of women who experienced an early miscarriage was evacuation of retained products of conception," write Lindsay F.P. Smith, MD, FRCP, FRCGP, from East Somerset Research Consortium, Westlake Surgery, in West Coker, Somerset, United Kingdom, and colleagues. "This was increasingly questioned, and now women are usually offered expectant (watch and wait, no active intervention) and medical management as well....Little published evidence, however, has assessed the effect of management method on subsequent fertility — a key issue for women and those responsible for their care."

The goal of this study was to compare fertility rates after the 3 methods of managing early miscarriage in women enrolled in the MIST (miscarriage treatment) randomized controlled trial. At early pregnancy clinics of acute hospitals in southwest England, 1199 women who miscarried before 13 weeks of gestation, as confirmed by scan, were randomly assigned to expectant, medical, or surgical management. The primary endpoints of the study were self-reported pregnancy rates and live birth rates.

Of 1128 MIST participants who consented to follow-up, 762 replied to a request for pregnancy details (68% response rate), and these women were thought to be representative of the trial participants overall. Five years after the index miscarriage, all 3 groups had similar live birth rates: 177 of 224 in the expectant management group (79%; 95% confidence interval [CI], 73% - 84%), 181 of 230 in the medical group (79%; 95% CI, 73% - 84%), and 192 of 235 in the surgical group (82%; 95% CI, 76% - 86%).

Previous birth history did not significantly affect live birth rates at 5 years, but these were significantly lower in older women and in women with previous miscarriages.

"Method of miscarriage management does not affect subsequent pregnancy rates with around four in five women giving birth within five years of the index miscarriage," the study authors write. "Women can be reassured that long term fertility concerns need not affect their choice of miscarriage management."

Limitations of this study include response rate of 68% and the unlikely possibility that one management method might cause very early future losses that this type of questionnaire study might not detect.

"Our results confirm that women experiencing three or more miscarriages might have problems subsequently giving birth and thus need to be investigated for a recurrent cause," the study authors conclude. "Women can be reassured that after miscarriage their chance of a subsequent live birth is high, irrespective of management method. This information should complement the information that they might want to receive to enable them to choose which management method is personally preferable, bearing in mind the clinical and economic differences."

The BMA Claire Wand Fund supported this study. East Somerset Research Consortium provided sponsorship and research governance management for this study. The study authors have disclosed no relevant financial relationships.

BMJ. 2009;339:b3827.