What is the recommended management approach for a missed abortion in emergency medicine?

Management of Missed Abortion in Emergency Medicine

The recommended management approach for missed abortion in emergency medicine is surgical evacuation through aspiration manual endouterine (AMEU) for pregnancies less than 12 weeks, as this method has lower risks of hemorrhage (9.1% vs 28.3%) and infection (1.3% vs 23.9%) compared to medical management. 1

Diagnostic Approach

• Transvaginal ultrasonography is the diagnostic method of choice to confirm fetal non-viability and rule out other complications such as ectopic pregnancy 2
• Diagnostic criteria for missed abortion include absence of cardiac activity in an embryo/fetus or an empty/irregular gestational sac 1
• Serial β-hCG measurements can help confirm the diagnosis, as levels typically fail to rise appropriately or decrease in missed abortion 1

Management Options

Surgical Management

• Aspiration manual endouterine (AMEU) is preferred for pregnancies less than 12 weeks due to:
  • Lower risk of hemorrhage (9.1% vs 28.3% with medical method) 1
  • Lower risk of infection (1.3% vs 23.9% with medical method) 1
  • Lower rate of retained tissue requiring additional procedures (1.3% vs 17.4%) 1
• Dilatation and evacuation (D&E) is the safest procedure for both first and second trimester missed abortions 1

Medical Management

• If patient prefers non-surgical approach, misoprostol can be offered as an alternative 3
• Most effective regimens:
  • Vaginal misoprostol 800 μg (56.8% complete evacuation rate) 4
  • Sublingual misoprostol 600 μg (84.5% complete evacuation rate) 5
• Vaginal route shows higher success rate, shorter induction-to-expulsion interval, greater patient satisfaction, and fewer side effects compared to oral administration 6

Additional Management Considerations

Rh Status Evaluation

• Administer 50 μg of anti-D immunoglobulin to all Rh-negative women with documented first-trimester pregnancy loss 2
• This prevents alloimmunization which could affect future pregnancies 1

Infection Prevention

• Monitor for signs of infection (fever, malodorous discharge, severe pain) 1
• Prophylactic antibiotics are not routinely recommended unless there are signs of infection 1

Complications to Monitor

• Hemorrhage: May require transfusion in severe cases 1
• Infection and sepsis: More common in incompletely evacuated missed abortions 1
• Uterine perforation: Possible complication during surgical procedures 1
• Asherman syndrome: Long-term complication of aggressive or repeated uterine curettage 1

Follow-up Care

• Clinical follow-up to confirm complete resolution of the missed abortion 1
• Contraceptive counseling to prevent unintended pregnancies 1
• Psychological support as needed, as the experience can be traumatic 1

Common Pitfalls to Avoid

• Failing to confirm the diagnosis with ultrasound before initiating treatment 2
• Not checking Rh status and missing the opportunity to provide anti-D immunoglobulin to Rh-negative women 2, 1
• Inadequate pain management during medical or surgical evacuation 1
• Insufficient follow-up to ensure complete evacuation of pregnancy tissue 1