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A Pilot Study of Guided Conservative Hysteroscopic Evacuation of Early Miscarriage

  • Shiri Weinberg
    Affiliations
    Department of Obstetrics and Gynecology, Assuta Ashdod University Hospital (affiliated with the Faculty of Health Sciences, Ben Gurion University), Ashdod, Israel (all authors)
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  • Moty Pansky
    Correspondence
    Corresponding author: Moty Pansky, MD, Department of Obstetrics and Gynecology, Assuta Ashdod University Hospital, 7 Harefua St, Ashdod, Israel.
    Affiliations
    Department of Obstetrics and Gynecology, Assuta Ashdod University Hospital (affiliated with the Faculty of Health Sciences, Ben Gurion University), Ashdod, Israel (all authors)
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  • Irad Burshtein
    Affiliations
    Department of Obstetrics and Gynecology, Assuta Ashdod University Hospital (affiliated with the Faculty of Health Sciences, Ben Gurion University), Ashdod, Israel (all authors)
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  • Uzi Beller
    Affiliations
    Department of Obstetrics and Gynecology, Assuta Ashdod University Hospital (affiliated with the Faculty of Health Sciences, Ben Gurion University), Ashdod, Israel (all authors)
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  • Hila Goldstein
    Affiliations
    Department of Obstetrics and Gynecology, Assuta Ashdod University Hospital (affiliated with the Faculty of Health Sciences, Ben Gurion University), Ashdod, Israel (all authors)
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  • Oshri Barel
    Affiliations
    Department of Obstetrics and Gynecology, Assuta Ashdod University Hospital (affiliated with the Faculty of Health Sciences, Ben Gurion University), Ashdod, Israel (all authors)
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      ABSTRACT

      Study Objective

      To evaluate initial feasibility and experience with guided hysteroscopic morcellation for uterine evacuation of early miscarriage.

      Design

      A prospective pilot study of 10 cases.

      Setting

      A tertiary university hospital in Israel.

      Patients

      Women with confirmed early miscarriage at a gestational age of below 10 weeks from the last menstrual period.

      Interventions

      From May 2020 to October 2020, the hysteroscopic TruClear tissue removal system (Medtronic, Minneapolis, MN) was used for evacuation of early miscarriage in 10 women. The procedures were recorded.

      Measurements and Main Results

      Data including the length of the procedure, visibility, complete evacuation, bleeding, complications, and follow-up ultrasonography (US) were recorded. The mean duration of the procedure was 24 minutes. Complete evacuation was recorded in all cases. No adverse events were recorded in any of the 10 procedures. Normal uterine cavity without evidence of retained products of conception was documented in follow-up evaluation by US in all cases. Four patients underwent a follow-up office hysteroscopy that demonstrated a normal cavity without evidence of adhesions. In 4 cases (40%), an additional suction curettage was performed immediately after the hysteroscopic procedure owing to obscured visibility or an abnormal US scan at the end of the procedure. However, retained products of conception were found in only 1 of these 4 suction specimens (25%).

      Conclusion

      Hysteroscopic morcellation under vision seems to be a safe and feasible technique for management of early missed abortion. This method may have potential as an innovative treatment of miscarriage in selected cases. Further studies are needed to refine the indications and the surgical technique.

      Keywords

      Management of early miscarriage today is done either medically or surgically by dilatation and curettage (D&C).
      Optimal management necessitates complete evacuation of the uterus with minimal endometrial damage (to conserve future fertility) and minimal need for future follow-up and intervention. D&C and aspiration curettage in the first trimester are safe procedures, with a small percentage of major complications (approximately 0.16%) or minor complications (approximately 1%) [
      • Upadhyay UD
      • Desai S
      • Zlidar V
      • et al.
      Incidence of emergency department visits and complications after abortion.
      ]. However, these procedures are done blindly and rely mainly on the experience of the surgeon. Some of the well-known complications of D&C include uterine perforation, retained products of conception (RPOC), and adhesion formation, which are probably related to the “blindness” of the procedure [
      • Ben-Ami I
      • Melcer Y
      • Smorgick N
      • Schneider D
      • Pansky M
      • Halperin R.
      A comparison of reproductive outcomes following hysteroscopic management versus dilatation and curettage of retained products of conception.
      ,
      • Golan A
      • Dishi M
      • Shalev A
      • Keidar R
      • Ginath S
      • Sagiv R.
      Operative hysteroscopy to remove retained products of conception: novel treatment of an old problem.
      ,
      • Hooker AB
      • Aydin H
      • Brölmann HA
      • Huirne JA.
      Long-term complications and reproductive outcome after the management of retained products of conception: a systematic review.
      ]. In a recent systematic review [
      • Hooker A
      • Fraenk D
      • Brölmann H
      • Huirne J.
      Prevalence of intrauterine adhesions after termination of pregnancy: a systematic review.
      ], the rate of intrauterine adhesions (IUAs) after D&C for miscarriages ranged between 16% and 21% and higher in cases of a repeat D&C, although the clinical significance of these adhesions is unclear [
      • Hooker AB
      • Lemmers M
      • Thurkow AL
      • et al.
      Systematic review and meta-analysis of intrauterine adhesions after miscarriage: prevalence, risk factors and long-term reproductive outcome.
      ]. Hysteroscopic evacuation under vision aims to limit removal to the gestational tissue. A recent report presented the feasibility of guided hysteroscopic resection of missed miscarriage [
      • de Codt M
      • Balza C
      • Jadoul P
      • et al.
      Hysteroscopic resection for missed abortion: feasibility, operative technique and potential benefit compared to curettage.
      ] using a different hysteroscopic instrument—a hysteroscopic resectoscope—and found the procedure to be safe and efficient.
      Embryoscopy and fetoscopy have been used increasingly in the evaluation and treatment of miscarriages in the last 2 decades. Direct vision of the embryo in the gestational sac enables evaluation and documentation of fetal morphology as well as diagnosis of some anatomic malformations. Embryoscopy before evacuation of the uterus allows assessment of fetal malformations and direct and accurate sampling of fetal tissues for genetic testing [
      • Campos-Galindo I
      • García-Herrero S
      • Martínez-Conejero JA
      • Ferro J
      • Simón C
      • Rubio C.
      Molecular analysis of products of conception obtained by hysteroembryoscopy from infertile couples.
      ,
      • Feichtinger M
      • Wallner E
      • Hartmann B
      • Reiner A
      • Philipp T.
      Transcervicalembryoscopic and cytogenetic findings reveal distinctive differences in primary and secondary recurrent pregnancy loss.
      ,
      • Philipp T
      • Kalousek DK.
      Transcervicalembryoscopy in missed abortion.
      ]. Hysteroscopic morcellation has been used for intrauterine tissue extraction for more than a decade. Hysteroscopic morcellators have been shown to allow rapid and complete resection of polyps, myomas, uterine septa, and RPOC [
      • Shazly SA
      • Laughlin-Tommaso SK
      • Breitkopf DM
      • et al.
      Hysteroscopic morcellation versus resection for the treatment of uterine cavitary lesions: a systematic review and meta-analysis.
      ]. In cases of RPOC, treatment with the morcellator has been associated with low rates of IUAs of approximately 3% [
      • Hamerlynck TW
      • van Vliet HA
      • Beerens AS
      • Weyers S
      • Schoot BC.
      Hysteroscopic morcellation versus loop resection for removal of placental remnants: a randomized trial.
      ]. These instruments use a rotating blade and a suction system that facilitate the removal of the specimen under direct visualization. When compared with standard resectoscopic technique, the use of hysteroscopic morcellators probably saves time and allows for more complete removal of the specimen [
      • Shazly SA
      • Laughlin-Tommaso SK
      • Breitkopf DM
      • et al.
      Hysteroscopic morcellation versus resection for the treatment of uterine cavitary lesions: a systematic review and meta-analysis.
      ].
      Use of the hysteroscopic morcellator for resection of pregnancy contents in early miscarriage, if feasible, may prove beneficial compared with the standard D&C procedure currently used to treat this condition. This technique may allow selective targeting of only the trophoblastic and fetal tissues, thus decreasing the damage caused by D&C to the entire uterine cavity. This technique was previously described in only 1 case report of a woman with previous Asherman syndrome and was found to be feasible, although the authors state that visibility was poor while resecting the implantation site owing to high vascularization [
      • Harpham M
      • Abbott J.
      Use of a hysteroscopic morcellator to resect miscarriage in a woman with recurrent Asherman's syndrome.
      ]. Considering these possible advantages, we believed that this technique deserves further evaluation.

      Aims

      The primary aim of the current pilot study was to assess the feasibility of resection of an early missed abortion using a standard hysteroscopic morcellator (tissue removal device).
      The secondary aims included documentation of complications, incomplete removal of RPOC, and IUA formation at follow-up hysteroscopy.

      Hypothesis

      In this pilot feasibility study, we hypothesized that we would be able to achieve complete evacuation of RPOC from the uterine cavity using the TruClear Elite (7.25 mm or 6.25 mm) tissue removal system (Medtronic, Minneapolis, MN). This would allow treatment of miscarriage under direct visualization focusing only on the implantation site, thus reducing the potential damage to the uninvolved uterine cavity area.

      Materials and Methods

      Ten women eligible for the study were recruited. The institutional review board at Assuta Ashdod University Hospital approved the protocol (registration number: 0005-20-AAA), and all participants gave written informed consent. The study was registered in the National Institutes of Health database as well as the Israeli Ministry of Health database. Enrollment began in May 2020 and was completed in November 2020. The trial was registered with the Israeli clinical trials registry, MyTrial Israeli Ministry of Health clinical trial registration system, on March 15, 2020 (https://my.health.gov.il/CliniTrials/Pages/MOH_2020-07-12_009131.aspx).
      Patients were recruited from the population of patients referred for evacuation of the uterus owing to missed miscarriage at Assuta Ashdod University Hospital. All patients with a diagnosis of missed miscarriage were first presented with the options of watchful waiting, medical treatment with misoprostol (when appropriate), or D&C. Only patients who chose surgical evacuation were invited to join the study. Patients who consented to participate and met the inclusion criteria were included in the study.
      The inclusion criteria for participation in the study were as follows:
      • Patients referred for D&C owing to a missed miscarriage with a gestational age of below 10 weeks from the last menstrual period.
      • Patients aged 21 to 50 years.
      • No other medical conditions.
      • Patients who were able to give informed consent.
      The exclusion criteria included the following:
      • Women without the ability to give consent (owing to cognitive or language barriers).
      • Women requiring immediate treatment (owing to excessive bleeding, fever, and so on).
      • Women with previous cesarean sections.
      • Women with documented subchorionic hematoma, malformed uterus, or submucosal myomas.
      • Women with a history of failed operative or diagnostic hysteroscopy in the past owing to pain or cervical stenosis.
      All patients underwent a US scan by one of the researchers, and the findings were documented before the procedures.

       Surgical Technique and Follow-up

      All procedures were performed in the surgical theater under general anesthesia. The cervix was dilated, if needed, up to 8 mm in diameter. Embryoscopy with the TruClear Elite (7.25 mm or 6.25 mm) tissue removal system was performed (Fig. 1), and the findings were recorded in the data collection sheet. The location of the pregnancy, size, and specific embryonic findings were documented. Because this was a feasibility study, we did not use the embryoscopic findings for diagnosis or have our pathologist review the anatomic findings in the images to assess for the possible cause of miscarriage. Most procedures were also documented on video (Supplemental Videos 1 and 2). After embryoscopy, the system was activated, and the RPOC were removed using the TruClear Elite tissue removal system. The fluid deficit was measured using Dyonics 25 fluid management system (Smith & Nephew, Watford, UK). Owing to a previous report of poor visibility and to improve safety in this feasibility study, all procedures were performed under abdominal US guidance to minimize the possibility of perforation (Supplemental Video 3). A transvaginal US examination was performed at the end of each procedure to document an empty uterine cavity. Good visibility was defined as the ability to continuously visualize the uterine walls and the specimen without the need to stop the procedure to obtain a clear field of vision. Moderate visibility was defined as any kind of disturbance in the field of vision that necessitated stopping the procedure and waiting for the field of vision to clear before being able to visualize the uterine walls and the specimen. In case of poor visualization, the procedure was abandoned, and routine suction curettage was performed using abdominal US for guidance. In cases of suspected RPOC on transvaginal US, the procedure was completed with suction curettage, and the suction curettage tissue specimen was sent separately from the hysteroscopic morcellation sample for histopathologic examination to assess for the presence of chorionic villi that would indicate incomplete evacuation with the hysteroscopic morcellator.
      Fig 1
      Fig. 1Patient assessment following hysteroscopic morcellation of missed miscarriage. RPOC = 413 Retained Products of Conception.
      All patients were scheduled for a follow-up appointment, including a US scan, to document recovery and evaluate the uterine cavity at 2 to 4 weeks after the procedure. Diagnostic hysteroscopy was offered to all patients 6 weeks after the procedure. The patients had the option to opt out of having the follow-up hysteroscopy performed if the US examination was normal and if there was no clinical indication for the procedure apart from research purposes.
      All data were documented and recorded on the case report forms. All information related to general medical and operative procedural data was documented and tabulated. Complications were classified according to the Clavien-Dindo classification [
      • Dindo D
      • Demartines N
      • Clavien PA.
      Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
      ]. Information related to complications (date of occurrence, description, severity, treatment, and resolution) was recorded at the time of occurrence. Information collected during the study included data regarding patient demographics; US findings; surgical data regarding the procedure; and patient follow-up, including the findings in follow-up US and hysteroscopy.
      Owing to the innovative nature of the study, an interim report was submitted to the institutional review board after the first 5 cases that included detailed information on all the procedures.

       Statistical Analysis

      The small number of patients allowed for descriptive statistics only. Deidentified data were reviewed and entered into a spreadsheet. The data were summarized, and comparisons were presented according to the type of variable. Frequencies were presented for categorical (mostly binary) variables, means and standard deviations (SDs) for numerical variables.

      Results

      Ten patients were recruited and treated over a period of 6 months.
      The mean age of the patients was 34.4 years (range 24–44 years, SD 7.2), and the average body mass index was 26.8 kg/m2 (range 19.1–38.6 kg/m2, SD 6.0). The median gravidity was 3 (range 1–18, SD 5.1), and the median parity was 2 (range 0–14, SD 3.9). The median gestational age at the time of the procedure was 9w1d according to the last menstrual period (range 7w1d–9w5d, SD 1 week). More demographic data are presented in Table 1.
      Table 1Patient Charecteristics and demographic data
      Patient no.Age, yrsBMI, kg/m2GravidityParityGestational age according to LMPCRL, mmGestational age according to CRLIndication
      12722.4327w1d25w6dMissed miscarriage 7/5 wk
      24433.218149w5d56w1dMissed miscarriage

      9/6 wk
      32720.1109w3dBlighted ovum, no visible embryoNAMissed miscarriage

      9/5 wk
      44330.81178w3d2.76w0dMissed miscarriage

      8/6 wk
      52419.1219w1d56w1dMissed miscarriage

      9/6 wk
      63628.6328w3d11.97w1dMissed miscarriage

      9/7 wk
      72738.6328Blighted ovum, no visible embryoNAMissed miscarriage

      8/5 wk
      83629.4329w5d188w0dMissed miscarriage

      9/8 wk
      93822.6219w3d2.86w0dMissed miscarriage

      9/6 wk
      104223.4439w1d259w0dMissed miscarriage 9/9 wk
      BMI = body mass index; CRL = crown-rump length; LMP = last menstrual period; NA = not applicable.
      Most of the procedures were recorded on video (Supplemental Videos 1 and 2). No complications occurred in any of the procedures, and complete evacuation of the uterus was achieved in all the procedures. The average time for completion of the procedure, measured from onset of anesthesia to completion of the evacuation, was 24.1 minutes (range 9–50 minutes, SD 12.7) (Table 2). Eight cases (80%) were performed with the TruClear 7.25-mm tissue removal system, and 2 cases (20%) were performed with the 6.25-mm device. No significant difference in outcomes was noted between the 2 instruments in terms of operative time, complications, visibility, and success of the procedure. In all the cases, moderate to good visibility was documented throughout the procedure. In 5 cases (50%), visibility was moderate owing to excessive bleeding from the implantation site; however, visibility was sufficient for the completion of the procedure without the need for US guidance in all the cases.
      Table 2Procedural data
      Patient no.GA according to LMPGA according to CRLLocation of the gestational sac on hysteroscopyLength of the procedure, minEstimated blood loss, mLDevice diameter, mmVisibility during the procedureUltrasonographic evaluation at the end of the hysteroscopyFluid deficitNeed for suction curettageComplicationsHistopathologicconditionWas the hysteroscopic evacuation successful?
      17w1d5w6dPosterior wall9Minimal

      (<50)
      7.25GoodEmpty cavity<500 mLNoNoHysteroscopy: RPOCYes
      29w5d6w1dPosterior wall25507.25MediumEmpty cavity<500 mLNoNoHysteroscopy: RPOCYes
      39w3dNA; blighted ovumPosterior and left lateral wall391007.25MediumSuspected RPOC<500 mLYesNoHysteroscopy: RPOC suction curettage; decidua onlyYes
      48w3d6w0dPosterior and left lateral wall241507.25GoodEmpty cavity<500 mLNoNoHysteroscopy: RPOCYes
      59w1d6w1dUterine isthmus121007.25GoodEmpty cavity1500 mLNoNoHysteroscopy: RPOCYes
      68w3d7w1dUterine isthmus502007.25MediumSuspected retained RPOC2000 mLYesNoHysteroscopy: RPOC

      suction curettage; decidua only
      Yes
      78NA; blighted ovumPosterior wall151006.25GoodEmpty cavity<500 mLNoNoHysteroscopy: RPOCYes
      89w5d8w0dAnterior wall352007.25MediumSuspected RPOC<500 mLYesNoHysteroscopy: RPOC

      suction curettage; RPOC
      No
      99w3d6w0dAnterior wall15Minimal (<50)6.25GoodEmpty cavity<500 mLNoNoHysteroscopy: RPOCYes
      109w1d9w0dRight anterior wall172007.25MediumSuspected RPOC<500 mLYesNoHysteroscopy: RPOC

      suction curettage; decidua only

      Yes
      GA = gestational age; CRL = crown-rump length; LMP = last menstrual period; NA = not applicable; RPOC = retained products of conception.
      Incomplete evacuation by hysteroscopy occurred in 1 case (10%). In 4 cases (40%), the US evaluation was suggestive of RPOC at the end of the procedure, and a suction curettage was performed after the hysteroscopic evacuation. The hysteroscopic evacuation tissue and suction tissue were sent for histopathologic examination separately. In 3 of these cases, the suction specimen returned as decidua only, without RPOC. In only 1 case (Supplemental Video 3), the suction specimen did contain RPOC. In this case, a second collapsed gestational sac was suspected on the posterior wall of the uterus; however, only the larger gestational sac was evacuated, and the smaller one was not treated with the TruClear Elite device because it was thought to be a decidual reaction and not recognized at the time of the procedure as an actual sac. One patient was treated with vasopressin because bleeding had obscured the hysteroscopic image. Twenty units of vasopressin were diluted in 100 mL of saline and injected into the cervix at the 4 o'clock and 8 o'clock positions; however, the vision was not significantly improved after injecting vasopressin.
      No complications (uterine perforation, excessive hemorrhage, RPOC, or IUAs) were documented in any of the procedures, and all women were discharged on the day of the procedure. The average estimated blood loss as assessed by the surgeons on the basis of a clinical evaluation was 115 mL (range 25–200 mL). One patient returned to the emergency department a few days after a successful procedure owing to vaginal bleeding (this can also be classified as a Dindo-Clavien grade 1 complication, although no treatment was needed because the bleeding was consistent with normal postprocedure status). She was assessed, reassured, and discharged after a normal evaluation.
      A follow-up US was performed in all cases 2 to 4 weeks after the procedure. All US scans were normal. Only 4 women (40%) agreed to undergo a diagnostic hysteroscopy 6 weeks after the procedure (Fig. 2). In all these cases (4/4), the uterine cavity seemed normal, and no IUAs were seen (Table 3).
      Fig 2
      Fig. 2Embryoscopic Evaluation prior to hysteroscopic morcellation.
      Table 3Follow-up D"?>data
      Patient no.Return to emergency department after the procedureUltrasonographic evaluation 2 wk after the procedure, endometrial thickness, mmRPOCFeverBleeding or spotting for more than 4 days after the procedureHysteroscopic evaluation at 6 wk after the procedureNeed for further intervention or evaluation
      1Yes, bleeding at 2 d; normal evaluation; discharged2NoNoYes (6 d)Normal cavityNo
      2No8NoNoNoPatient chose to opt outNo
      3No4.4NoNoNoNormal cavityNo
      4No5NoNoNoPatient chose to opt outNo
      5No6.9NoNoNoNormal CavityNo
      6No2NoNoNoNormal cavityNo
      7No4NoNoNoPatient chose to opt outNo
      8NoNoNoYesPatient chose to opt outNo
      9NoNoNoNoPatient chose to opt outNo
      10NoNoNoNoPatient chose to opt outNo
      RPOC = retained products of conception.

      Discussion

      Early miscarriage today is managed either medically or surgically. The surgical management is done by D&C. This is a blind procedure that relies on the performer's experience, and it is sometimes performed under US guidance. The procedure includes suction and curettage of the entire uterine cavity, and the possible complications include uterine perforation, RPOC, and adhesion formation. IUAs after D&C are relatively common, and their prevalence can reach more than 20% [
      • Hooker A
      • Fraenk D
      • Brölmann H
      • Huirne J.
      Prevalence of intrauterine adhesions after termination of pregnancy: a systematic review.
      ]. The short-term complications associated with RPOC include the need for a repeat procedure, infection, hemorrhage, and uterine and cervical trauma [
      • Golan A
      • Dishi M
      • Shalev A
      • Keidar R
      • Ginath S
      • Sagiv R.
      Operative hysteroscopy to remove retained products of conception: novel treatment of an old problem.
      ,
      • Smorgick N
      • Barel O
      • Fuchs N
      • Ben-Ami I
      • Pansky M
      • Vaknin Z.
      Hysteroscopic management of retained products of conception: meta-analysis and literature review.
      ]. The long-term complications include implantation failure owing to abnormal placentation and re-formation of IUAs [
      • Hooker AB
      • Aydin H
      • Brölmann HA
      • Huirne JA.
      Long-term complications and reproductive outcome after the management of retained products of conception: a systematic review.
      ,
      • Westendorp IC
      • Ankum WM
      • Mol BW
      • Vonk J.
      Prevalence of Asherman's syndrome after secondary removal of placental remnants or a repeat curettage for incomplete abortion.
      ].
      Optimal management of early missed miscarriage requires complete evacuation of the uterus with minimal endometrial damage (to conserve future fertility) and minimal need for future follow-up and intervention. Hysteroscopic evacuation has the potential to meet all these goals because it is done under direct vision [
      • de Codt M
      • Balza C
      • Jadoul P
      • et al.
      Hysteroscopic resection for missed abortion: feasibility, operative technique and potential benefit compared to curettage.
      ]. Consequently, it might decrease the rate of RPOC, along with the associated complications. A procedure that is performed under direct vision can also potentially decrease the risks of uterine perforation, endometrial trauma, and subsequent IUA formation and subfertility [
      • Smorgick N
      • Levinsohn-Tavor O
      • Ben-Ami I
      • Maymon R
      • Pansky M
      • Vaknin Z.
      Hysteroscopic removal of retained products of conception following first trimester medical abortion.
      ].
      The hysteroscopic technique for the management of RPOC has been used for more than 20 years, mainly by resectoscopy and hysteroscopic grasper [
      • Ben-Ami I
      • Melcer Y
      • Smorgick N
      • Schneider D
      • Pansky M
      • Halperin R.
      A comparison of reproductive outcomes following hysteroscopic management versus dilatation and curettage of retained products of conception.
      ,
      • Golan A
      • Dishi M
      • Shalev A
      • Keidar R
      • Ginath S
      • Sagiv R.
      Operative hysteroscopy to remove retained products of conception: novel treatment of an old problem.
      ,
      • Smorgick N
      • Barel O
      • Fuchs N
      • Ben-Ami I
      • Pansky M
      • Vaknin Z.
      Hysteroscopic management of retained products of conception: meta-analysis and literature review.
      ,
      • Smorgick N
      • Levinsohn-Tavor O
      • Ben-Ami I
      • Maymon R
      • Pansky M
      • Vaknin Z.
      Hysteroscopic removal of retained products of conception following first trimester medical abortion.
      ,
      • Alonso L
      • Nieto L
      • Carugno J.
      Hysteroscopic removal of retained products of conception implanted over a focal area of adenomyosis: a case report.
      ]. Over the past decade, the use of intrauterine tissue removal systems (also known as hysteroscopic morcellators) has emerged and been applied for the treatment of endometrial polyps, myomas, and RPOC [
      • Shazly SA
      • Laughlin-Tommaso SK
      • Breitkopf DM
      • et al.
      Hysteroscopic morcellation versus resection for the treatment of uterine cavitary lesions: a systematic review and meta-analysis.
      ,
      • Hamerlynck TW
      • van Vliet HA
      • Beerens AS
      • Weyers S
      • Schoot BC.
      Hysteroscopic morcellation versus loop resection for removal of placental remnants: a randomized trial.
      ,
      • van Dongen H
      • Emanuel MH
      • Wolterbeek R
      • Trimbos JB
      • Jansen FW.
      Hysteroscopic morcellator for removal of intrauterine polyps and myomas: a randomized controlled pilot study among residents in training.
      ].
      Until recently, hysteroscopy was not considered as an option for primary management of early missed abortion. A large case series was recently published using resectoscopic evacuation of early miscarriages under vision [
      • de Codt M
      • Balza C
      • Jadoul P
      • et al.
      Hysteroscopic resection for missed abortion: feasibility, operative technique and potential benefit compared to curettage.
      ]. This technique was reported to be safe and feasible.
      Hysteroscopic treatment of early miscarriage has several limitations, especially the higher cost of the equipment, longer duration of the procedure, and risk of potential fluid overload. Because traditional D&C has low costs, a relatively short learning curve, and a simple preprocedural setup compared with operative hysteroscopy, the use of hysteroscopy in this procedure should probably be reserved for certain specific indications. In cases of patients with recurrent pregnancy loss or previous Asherman syndrome, direct visualization may be able to minimize possible endometrial damage and decrease the trauma to uninvolved uterine walls. It could also potentially reduce the risk of RPOC and perforation. The addition of embryoscopy might have other advantages as well in the management of miscarriage, such as morphologic assessment of the embryo and obtainment of accurate specimens for genetic analysis [
      • Campos-Galindo I
      • García-Herrero S
      • Martínez-Conejero JA
      • Ferro J
      • Simón C
      • Rubio C.
      Molecular analysis of products of conception obtained by hysteroembryoscopy from infertile couples.
      ].
      This study has several limitations. It is a pilot feasibility and safety study, and the small sample size does not allow us to draw any conclusions regarding the ability to reduce complications or to accurately determine the best surgical technique or the exact case selection that is most suitable for this procedure. Furthermore, only 40% of our patients chose to undergo follow-up hysteroscopy after the procedure, which limited our ability to assess postoperative adhesion formation. Another limitation is our method of estimating blood loss, which was based on the clinical impression of the surgeons and is prone to overestimation owing to the use of hysteroscopy fluid. Indeed, our average estimated blood loss was 115 mL, higher than that usually reported in the literature of approximately 40 mL [
      • Clare CA
      • Hatton GE
      • Shrestha N
      • et al.
      Intraoperative blood loss during induced abortion: A comparison of anesthetics.
      ]. Nevertheless, this method of hysteroscopic morcellation of missed miscarriage does show promising results because the procedure seems feasible and safe.
      Four of our patients had a suction D&C in addition to hysteroscopy at the end of the procedure owing to US findings suggestive of RPOC; however, only one of them had histopathologic evidence of RPOC in the D&C material. The reason for this high percentage of D&C lies in our study protocol. Because this was a pilot study, and we did not know how good the visibility would be, we planned wide safety margins. Therefore, our study protocol included a vaginal US scan after every procedure even if the cavity seemed empty on hysteroscopic evaluation. If there were any signs of RPOC on US scan, a suction curettage was performed. In our study, we found the US scan to be much less specific for RPOC than hysteroscopy because 75% of the cases (3/4) sent for histopathologic examination on the basis of US evaluation were found to be negative for trophoblastic tissue. In the future, once we gain more experience with the procedure and know more about its limitations, we may choose to rely solely on the hysteroscopic findings at the end of the procedure if the visibility is good.
      Our current experience in this pilot feasibility study suggests that hysteroscopic morcellation is a feasible and safe technique for evacuation of the uterus in early miscarriages (embryolysis). By performing the procedures under direct visualization and focusing solely on the implantation site, we may reduce the risk of further IUA formation as well as the rate of RPOC as opposed to the common treatments used today, either medical (misoprostol) or surgical. The successful use of the small 6.25 mm device that is also used for office procedures raises the possibility of performing this procedure in the office setting; however, patient distress owing to embryo visualization during the procedure must be considered. This option requires further research.
      Further studies are needed to assess the possible benefits of this method and to refine the indications and surgical technique.

      Conclusion

      Hysteroscopic morcellation of early miscarriage is safe and feasible. This technique may be a valid treatment modality in selected patients such as those with recurrent miscarriage or previous Asherman syndrome.

      Appendix. Supplementary materials

      References

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