Hysteroscopic resection as primary management in case of early pregnancy loss: time for a paradigm shift?

RESEARCH QUESTION: What is the potential role of hysteroscopic resection (HsR) of early pregnancy loss (EPL) according to its feasibility and efficacy, including in the outpatient setting, for early-stage pregnancies?

DESIGN: Retrospective cohort study and literature review. Patients undergoing HsR of EPL in the authors' tertiary fertility centre between November 2022 and January 2024 were included. Patients with gestational sacs <20 mm could choose local anaesthesia; patients with larger gestational sacs were managed under sedation. Feasibility, tolerability and complications were evaluated. Postoperative retained products of conception (RPOC) were assessed after the first menstrual period. Gestational tissue was analysed for aneuploidy using chromosomal microarray analysis.

RESULT: Thirty-six patients were included, with a mean ± SD age of 36.7 ± 4.1 years. Mean gestational age and gestational sac size were 9 + 1/7 weeks and 27.5 mm, respectively. Mean procedure time was 17.7 min, with no peri- or postoperative complications. Outpatient procedures (n = 10) were well tolerated, with one requiring conversion to sedation. One (1/36, 2.8%) patient had postoperative RPOC. Chromosomal analysis was performed in 32 patients and was conclusive in 26 (81.3%) cases; 53.8% of cases were chromosomically abnormal.

CONCLUSION: HsR of EPL is feasible and safe, with low incidence of RPOC and reliable genetic results. It can be performed under general or local anaesthesia based on the size of the gestational sac. HsR may be a preferable alternative to aspiration curettage, especially for patients with recurrent EPL or risk of intrauterine adhesions. Further comparative studies are warranted to support this paradigm shift.