This randomized controlled trial and parallel cohort study compared curettage and expectant management in women who had an incomplete evacuation of the uterus after misoprostol treatment for first-trimester miscarriage. The study was conducted in the Netherlands from June 2012 and July 2014. The primary outcome, treatment success, was a sonographic finding of an empty uterus 6 weeks after study entry or an uneventful course. Analyses of cost-effectiveness and cost-utility were performed. Costs of health care utilization, informal care, and lost productivity were included. Bootstrapping was used to estimate cost-effectiveness planes and cost-effectiveness acceptability curves. Data were analyzed according to the intention-to-treat principle.
A total of 256 women from 27 hospitals were included; of these, 95 had curettage and 161 expectant management. Treatment was successful in 96% of the women treated with curettage and 83% of those treated with expectant management; the mean difference was 13%, with a 95% confidence interval (CI) of 5 to 20. Mean health care costs in the curettage group were significantly higher than in the expectant management group (mean difference, €1157; 95% CI, 955–1388). The incremental cost-effectiveness ratio for curettage compared with expectant management was €8586 for 1 extra successfully treated woman. The cost-effectiveness acceptability curve showed that the probability that curettage was cost-effective was 95% at a willingness-to-pay of €18 200/extra successfully treated woman.
The data indicate that curettage is not cost-effective compared with expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment. Based on these results, the authors believe that curettage in this population should be restrained. Further studies are needed to determine whether there are factors that predict the probability of an empty uterus after expectant management. This could enable clinicians to offer tailored treatment to their patients.