What is the recommended medication for managing miscarriage in the emergency department (ED)?

Medication for Miscarriage Management in the Emergency Department

For incomplete or missed miscarriage in the ED, misoprostol 800 µg administered vaginally is the recommended medical treatment, with success rates of 77-90% for complete evacuation without surgery. 1, 2, 3

Clinical Context and Diagnosis

The primary concern when evaluating first-trimester bleeding and pain in the ED is distinguishing between viable pregnancy, ectopic pregnancy, and miscarriage (spontaneous abortion). 4 Emergency physicians must use ultrasound and β-hCG levels to establish the diagnosis before initiating treatment. 4

Medical Management Protocol for Miscarriage

Initial Dosing Regimen

Administer misoprostol 800 µg intravaginally as a single dose in the ED, then discharge the patient home with appropriate counseling and follow-up instructions. 1, 2, 5

• The initial 800 µg vaginal dose achieves complete miscarriage in 55-77% of cases without requiring additional intervention 1, 2
• If the gestational sac persists on follow-up ultrasound at 48 hours, a second dose of 800 µg misoprostol can be administered, increasing overall success to 78-90% 1, 2
• Alternative routes include oral (400-800 µg), sublingual (400-800 µg), or buccal administration, though vaginal administration appears equally effective with potentially fewer gastrointestinal side effects 3, 6

Patient Selection Criteria

Medical management is appropriate for women with confirmed missed or incomplete miscarriage at less than 12-13 weeks gestation who are hemodynamically stable and willing to comply with follow-up. 2, 5, 6

Specific inclusion criteria:

• Ultrasound-confirmed missed abortion or incomplete miscarriage 2, 5
• Gestational age less than 12-13 weeks 2, 5, 6
• Gestational sac diameter less than 40 mm 1
• No active heavy bleeding or signs of infection 1, 2
• Hemodynamically stable 2
• Patient preference for medical over surgical management 2, 5

Comparison with Surgical Management

Medical treatment with misoprostol is slightly less effective than surgical evacuation (96% vs 100% complete miscarriage) but avoids anesthesia and surgical risks. 3 Surgical evacuation is required in approximately 10-23% of cases after medical management fails. 1, 2, 3 However, women's satisfaction rates are comparable between medical and surgical approaches (satisfaction scores averaging 8.6/10 for medical management). 3, 5

Expected Side Effects and Management

Common Side Effects

Nausea occurs in approximately 30% of patients, diarrhea in 20-40%, and these are significantly more common than with surgical management. 4, 3

• Nausea: RR 2.50 compared to surgery 3
• Vomiting: RR 1.97 compared to surgery 3
• Diarrhea: RR 4.82 compared to surgery 3
• Abdominal cramping pain is expected and typically managed with oral analgesics 1, 2, 5

Provide oral analgesics (NSAIDs or acetaminophen) at the time of misoprostol administration and prescribe additional pain medication for home use. 2, 5

Pain Management

The mean pain score on visual analog scale is approximately 6.7/10 during medical management. 5 Adequate analgesia should be prescribed prophylactically rather than waiting for severe pain to develop. 2, 5

Follow-Up Protocol

Schedule clinical and ultrasonographic evaluation 48 hours after initial misoprostol administration to assess for complete expulsion. 1, 2

• If gestational sac persists at 48 hours, administer second dose of 800 µg vaginal misoprostol 1, 2
• Perform final evaluation 7 days after treatment initiation 2
• If gestational sac remains after second dose, surgical evacuation should be offered 1, 2
• Complete expulsion occurs within 2 days in 94% of successful cases 1

Emergency Return Precautions

Instruct patients to return immediately for severe abdominal pain, heavy vaginal bleeding (soaking more than 2 pads per hour for 2 consecutive hours), fever, or signs of hemodynamic instability. 2, 5

Emergency consultation rates are approximately 5-7% with this protocol, most commonly for severe pain or hemorrhage. 1, 5 Emergency surgical evacuation is required in approximately 2-5% of cases due to hemorrhagic complications. 1

Special Considerations

Rh Status

Administer 50 µg of anti-D immunoglobulin to all Rh-negative women with documented first-trimester pregnancy loss to prevent Rh-D alloimmunization. 4, 7

Contraindications to Medical Management

Absolute contraindications include:

• Hemodynamic instability 2
• Active infection or signs of sepsis 1, 2
• Known allergy to misoprostol 2
• Inflammatory bowel disease 2
• Inability to comply with follow-up 2

Hospitalization Considerations

Approximately 12-16% of patients require hospitalization, primarily for pain management or surgical evacuation. 1 Most women (93%) prefer home-based treatment over hospital admission when given the choice. 5

Important Clinical Pitfall

Do not confuse management of miscarriage with management of ectopic pregnancy—the evidence provided focuses on ectopic pregnancy treatment with methotrexate, which is NOT appropriate for intrauterine miscarriage. 4, 7 Methotrexate (50 mg/m² IM) is specifically indicated for unruptured ectopic pregnancy, not for miscarriage management. 7 The distinction must be made definitively with ultrasound before initiating any medical treatment.