Prophylactic antibiotics for uterine evacuation procedures to manage miscarriage

BACKGROUND: Procedural management of early pregnancy loss (EPL) involves removing any residual pregnancy tissue from the uterus. Clinical evidence and guidance are clear that antibiotic treatment is needed for women experiencing EPL, with signs and symptoms of infection. However, it is less clear whether prophylactic antibiotics are routinely required during procedural management in those without features of infection. OBJECTIVES: To evaluate the effectiveness of routine antibiotic prophylaxis for women undergoing uterine evacuation procedures to manage early pregnancy loss. SEARCH METHODS: We searched the Cochrane Fertility Regulation Review Group trials register, CENTRAL, MEDLINE, Embase, Global Health (Ovid), Scopus (conference abstracts only), and grey literature in October 2023. We checked references and contacted study authors and experts in the field to identify additional studies. SELECTION CRITERIA: We included randomised controlled trials comparing prophylactic antibiotics with placebo or no treatment. Trials with a cluster-randomised design and trials published only in abstract form were also eligible for inclusion. We included all types of EPL managed with surgical uterine evacuation. There was no gestational age limit. We excluded women with signs and symptoms of infection. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted and checked data for accuracy, and assessed the certainty of evidence using the GRADE approach. We contacted the authors of the ongoing trial for additional information. MAIN RESULTS: = 63%; 3 studies, 3574 participants; very low-certainty evidence). Meta-analysis of three studies also found that prophylactic antibiotics may reduce hospitalisation for treatment of infection, but the effect was very uncertain (RR 0.76, 95% CI 0.40 to 1.46; I² = 0%; 3 studies, 3859 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: When all studies were considered, the evidence suggested that routine antibiotic prophylaxis may reduce uterine infection amongst women undergoing uterine evacuation procedures to manage early pregnancy loss (EPL), but the evidence is of low certainty. It is important to note that the quality of the evidence included was seriously affected by poor follow-up and high non-compliance with antibiotic prophylaxis. A sensitivity analysis based on three trials assessed to have low risk of bias (85% of the total participants), demonstrated a larger effect size with high certainty, resulting in a 43% reduction in the risk of uterine infection rates with antibiotic prophylaxis. Prophylactic antibiotics may reduce hospitalisation for treatment of infection, and may reduce the need for a course of antibiotics to treat infection after uterine evacuation procedures to treat EPL, but this evidence is very uncertain. Data were limited and uncertain with regard to potential adverse effects, such as vomiting, diarrhoea, allergy, and anaphylaxis.