What is the usual management for a missed abortion prior to 10 weeks?

Management of Missed Abortion Prior to 10 Weeks

The management of a missed abortion prior to 10 weeks includes three primary options: expectant management, medical management with misoprostol (with or without mifepristone), or surgical evacuation through aspiration or curettage. 1, 2

Treatment Options

Expectant Management

• Involves waiting for spontaneous expulsion of pregnancy tissue without intervention 1
• Appropriate for patients with minimal symptoms and no signs of infection 2
• Success rates vary but are generally lower than medical or surgical management 1
• May take days to weeks for complete expulsion 2

Medical Management

• First-line option for many patients due to non-invasive nature 3
• Medication regimens:
  • Misoprostol alone: 800 mcg vaginally or orally 4
  • Combined regimen: Mifepristone followed by misoprostol (more effective) 3
• Vaginal administration of misoprostol shows higher success rates (92.9%) compared to oral administration (89.0%) 4
• Vaginal route also demonstrates shorter induction-to-expulsion interval and greater patient satisfaction 5
• Success rates for medical management range from 80-90% 4, 5

Surgical Management

• Options include:
  • Aspiration (manual or electric vacuum aspiration) - preferred for pregnancies <10 weeks 1
  • Dilation and curettage (D&C) 2
• Success rates approach 100% for complete evacuation 6
• Provides immediate resolution but carries risks of anesthesia and surgical complications 3
• May be preferred when:
  • Medical management fails 4
  • Patient has heavy bleeding 7
  • Infection is present 2
  • Patient prefers immediate resolution 3

Special Considerations

Rh Status Management

• For Rh-negative women with missed abortion <10 weeks:
  • Current evidence is equivocal regarding the necessity of RhD immune globulin administration 8
  • Some guidelines recommend against RhD testing and RhIg administration for spontaneous abortion at <12 weeks 8
  • However, the Society for Maternal-Fetal Medicine notes that data on risks of alloimmunization after early pregnancy loss do not convincingly demonstrate the safety of forgoing RhIg 8
  • Consider RhIg administration as part of shared decision-making 8

Follow-up Care

• Follow-up evaluation is recommended 1-2 weeks after treatment to confirm complete evacuation 1
• Ultrasound assessment may be performed to ensure complete evacuation 2
• Contraceptive counseling should be provided 1

Complications to Monitor

• Hemorrhage requiring transfusion 2
• Infection and sepsis (more common in incomplete evacuation) 1
• Uterine perforation (with surgical management) 2
• Asherman syndrome (intrauterine adhesions) following aggressive curettage 1

Algorithm for Management Decision

1. Assess patient stability and preference
2. If hemodynamically unstable or signs of infection: Surgical management 2
3. If stable with no contraindications:
   • Offer all three options (expectant, medical, surgical) 1
   • For those choosing medical management, vaginal misoprostol is preferred over oral route 5
   • For those desiring immediate resolution, surgical evacuation provides highest success rate 6
4. For Rh-negative women: Consider RhIg administration based on shared decision-making 8