Management of Missed Abortion
The management of missed abortion should primarily involve offering patients a choice between medical management with misoprostol (800 μg vaginally as a single dose), surgical evacuation (vacuum aspiration or D&E), or expectant management, with medical management using vaginal misoprostol being the most effective first-line treatment option for most patients. 1
Diagnosis Confirmation
- Missed abortion is defined as a pregnancy with findings that definitively indicate it will not progress, with the gestational sac remaining in the uterine cavity with no expulsion
- Diagnostic criteria include:
- Crown-rump length ≥7 mm with no cardiac activity
- Mean sac diameter ≥25 mm with no embryo 1
- Confirmation should include transvaginal ultrasound to verify absence of cardiac activity and gestational age
Treatment Options
1. Medical Management (First-line)
- Recommended regimen: Misoprostol 800 μg vaginally as a single dose 1
- Effectiveness: Approximately 90% success rate in achieving complete evacuation without surgical intervention 1
- Vaginal route advantages over oral administration:
- Follow-up should be scheduled in 7-14 days with transvaginal ultrasound to confirm complete evacuation 1
2. Surgical Management
Indicated for:
- Heavy bleeding
- Signs of infection
- Patient preference
- Failed medical management 1
Methods:
- Vacuum aspiration (preferred) - associated with decreased blood loss, less pain, and shorter procedure duration compared to sharp curettage 4
- Dilation and evacuation (D&E)
- Success rate: 93.6% 1
Benefits:
- Quicker resolution
- Lower risk of prolonged bleeding
- Lower risk of infection, hemorrhage, and retained tissue requiring additional procedures compared to medical management 1
- Office-based D&C under ultrasound guidance has shown very low complication rates (0.87% retained products of conception) 5
3. Expectant Management
- Less commonly chosen due to unpredictable time interval until spontaneous evacuation
- Higher risk of incomplete evacuation requiring subsequent intervention
- Patients should be informed of risks and provided with clear instructions on when to seek emergency care 1
Prevention of Rh Sensitization
- Anti-D immunoglobulin (50 μg) is recommended for all Rh-negative patients with missed abortion 1
Algorithm for Management Decision
- Confirm diagnosis with transvaginal ultrasound
- Assess patient factors:
- Hemodynamic stability
- Presence of infection
- Gestational age
- Patient preference
- Contraindications to medications
- Recommend treatment:
- For stable patients without contraindications: Offer medical management with vaginal misoprostol as first-line
- For patients with heavy bleeding, infection, or preference for surgical approach: Proceed with vacuum aspiration or D&E
- For patients who prefer minimal intervention and understand risks: Offer expectant management
- Follow-up in 7-14 days with transvaginal ultrasound to confirm complete evacuation
- For incomplete evacuation:
- Consider second dose of misoprostol
- Proceed to surgical evacuation if medical management fails
Complications and Management
- Infection: Prompt administration of antibiotics and possible surgical evacuation
- Hemorrhage: Surgical evacuation, fluid resuscitation if needed
- Retained products of conception: Consider second dose of misoprostol or surgical intervention 1
Patient Support
- Provide emotional support and counseling resources
- Discuss contraception options if desired 1
- Explain expected symptoms (cramping, bleeding) and when to seek emergency care
By following this evidence-based approach to missed abortion management, clinicians can optimize outcomes while respecting patient preferences and minimizing complications.