Treatment of Missed Abortion
Active evacuation of the uterus is the recommended treatment for missed abortion, with both medical management (misoprostol with or without mifepristone) and surgical evacuation (vacuum aspiration or D&E) being safe and effective options, though expectant management is contraindicated due to increased risks of infection, hemorrhage, and maternal morbidity. 1, 2
Management Options
Surgical Evacuation (Preferred Method)
- Vacuum aspiration is the gold standard for first-trimester missed abortion (<12 weeks), offering superior outcomes compared to sharp curettage with less blood loss (-17 mls), less pain (RR 0.74), and shorter procedure duration (-1.2 minutes) 3
- Dilation and evacuation (D&E) is preferred for second-trimester cases, with significantly lower complication rates: hemorrhage (9.1% vs 28.3% medical), infection (1.3% vs 23.9% medical), and retained tissue (1.3% vs 17.4% medical) 1, 2
- Surgical evacuation can be performed as an outpatient or day-case procedure under local anesthesia with sedation or general anesthesia 4, 5
Medical Management (Alternative Option)
- Misoprostol 400-600 mcg vaginally is effective in 71-74% of cases within one week, with or without mifepristone pretreatment 6
- Mifepristone 600 mg orally followed by misoprostol 400 mcg vaginally does not significantly improve success rates over misoprostol alone 6
- Medical management is most successful when gestational age is <75 days and β-hCG levels are between 2,000-20,000 IU/L 6
- Average time to expulsion is 10-11 hours after misoprostol administration 7
- Medical management results in longer bleeding duration (6.9-7.1 days vs 2.5 days with surgery) 6
Critical Contraindications to Expectant Management
Never choose expectant management for confirmed missed abortion due to the following risks 1, 8:
- Maternal morbidity occurs in 60% of cases with expectant management vs 33% with active treatment 2
- Intraamniotic infection risk: 38% with expectant management vs 13% with active treatment 8
- Postpartum hemorrhage: 23.1% with expectant management vs 11% with active treatment 8
- Maternal death rate: 45 per 100,000 with expectant management of previable complications 8
Infection Recognition and Management
Do not wait for fever to diagnose infection - clinical deterioration can be rapid (median 18 hours from infection identification to death) 1, 8:
- Look for maternal tachycardia, purulent cervical discharge, uterine tenderness, and fetal tachycardia (if applicable) 1
- Initiate broad-spectrum antibiotics immediately if infection is suspected 1
- Proceed with urgent evacuation without delay for confirmatory tests 1
Essential Adjunctive Care
- All Rh-negative women must receive anti-D immunoglobulin (50 μg for first trimester) to prevent alloimmunization, as 32% of spontaneous abortions involve fetomaternal hemorrhage 1, 2, 5
- Perioperative antibiotics are beneficial and should be administered 5
- Fresh tissue examination is mandatory after any evacuation to confirm complete abortion and rule out ectopic or molar pregnancy 5
Common Pitfalls to Avoid
- Delaying treatment while awaiting spontaneous expulsion - infection risk increases significantly with duration of retained products (median 5 days to infection onset) 8
- Using sharp curettage instead of vacuum aspiration for first-trimester cases - vacuum aspiration is demonstrably superior 3, 5
- Performing multiple or aggressive curettage procedures, which increases Asherman syndrome risk 1, 8
- Failing to provide adequate analgesia/sedation during procedures 3