What is the recommended management for a missed abortion?

Management of Missed Abortion

For missed abortion, surgical evacuation via vacuum aspiration (for pregnancies <12 weeks) or dilation and evacuation (D&E) (for pregnancies ≥12 weeks) is the preferred management approach, as it has significantly lower rates of hemorrhage, infection, and retained tissue requiring additional procedures compared to medical or expectant management. 1, 2

Why Active Management is Mandatory

Expectant management is absolutely contraindicated in missed abortion because:

• Risk of intrauterine infection increases with time as retained products remain in the uterus 1
• Potential for coagulopathy develops with prolonged retention of fetal tissue 1
• Maternal sepsis risk escalates, particularly beyond 48-72 hours of confirmed fetal demise 1
• Hemorrhage can occur unpredictably and may be severe 1, 2

Treatment Options: Surgical vs. Medical

Surgical Evacuation (Preferred)

Vacuum aspiration or D&E offers superior outcomes:

• Hemorrhage rate: 9.1% (surgical) vs. 28.3% (medical) 1
• Infection rate: 1.3% (surgical) vs. 23.9% (medical) 1
• Retained tissue requiring repeat procedure: 1.3% (surgical) vs. 17.4% (medical) 1
• Single-visit completion with immediate confirmation of complete evacuation 2

Gestational age determines the specific surgical approach:

• <12 weeks: Vacuum aspiration (manual or electric) is the method of choice 1, 2
• ≥12 weeks: D&E is the safest procedure for second-trimester missed abortion 1

Medical Management (Alternative Option)

Medical management with misoprostol may be offered to select patients who:

• Strongly prefer to avoid surgery 1, 3
• Are hemodynamically stable with no active hemorrhage 2
• Have no signs of intrauterine infection 2
• Are at <12 weeks gestation 2, 4

Recommended regimen: Misoprostol 600 mcg orally as a single dose, with success rate of 91.5% 5, 4

Alternative regimens include:

• Vaginal misoprostol 800 mcg (efficacy 89-93%) 6
• Vaginal misoprostol 600 mcg, repeated once after 4 hours if needed (efficacy 56.8% complete expulsion, but provides cervical dilation in 94.6% for subsequent surgical completion) 7

Critical Pre-Treatment Assessment

Rule out infection immediately - do not wait for fever to develop:

• Maternal tachycardia (heart rate >100 bpm) 1
• Purulent or foul-smelling cervical discharge 1
• Uterine tenderness on examination 1
• Elevated white blood cell count 1

If infection is suspected: Initiate broad-spectrum antibiotics immediately and proceed with urgent surgical evacuation 1

Absolute Contraindications to Medical Management

• Confirmed or suspected intrauterine infection 2
• Hemodynamic instability or severe hemorrhage 2
• Gestational age >12 weeks 2, 4
• Previous cesarean delivery or uterine surgery (misoprostol carries risk of uterine rupture) 8, 9

Essential Rh Immunoprophylaxis

All Rh-negative women must receive anti-D immunoglobulin:

• Dose: 50 mcg for first-trimester losses 2
• Timing: Administer as soon as diagnosis is confirmed 2
• Rationale: Fetomaternal hemorrhage occurs in 22-32% of spontaneous abortions 1, 2
• Failure to provide prophylaxis risks alloimmunization affecting future pregnancies 2

Post-Treatment Follow-Up

Immediate contraceptive counseling is mandatory:

• Ovulation can resume within 2-4 weeks post-abortion 2
• Combined hormonal contraceptives or implants can be initiated immediately after complete abortion 10, 2
• If started within 7 days of abortion, no backup contraception is needed 10, 2
• If started >5 days after bleeding begins, use backup contraception for 7 days 10, 2

Clinical follow-up should confirm:

• Complete evacuation (via ultrasound if any concern for retained tissue) 1
• Resolution of bleeding 1
• Absence of infection 1

Common Pitfalls to Avoid

• Delaying treatment while awaiting "spontaneous passage" - this increases infection and hemorrhage risk 1
• Waiting for fever before diagnosing infection - early signs are more subtle 1
• Forgetting Rh immunoprophylaxis - this is a critical step that cannot be omitted 2
• Using misoprostol in women with prior cesarean delivery - this significantly increases uterine rupture risk 8, 9
• Choosing medical management for gestations >12 weeks - surgical evacuation is safer at this gestational age 1, 2