What is the recommended management for a missed abortion?

Management of Missed Abortion

For missed abortion, offer both medical management (misoprostol with or without mifepristone) and surgical evacuation (vacuum aspiration or D&E depending on gestational age), with the choice guided by gestational age, clinical stability, and patient preference—but avoid expectant management due to increased risks of infection, hemorrhage, and coagulopathy. 1

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis using specific ultrasound criteria:

• Crown-rump length ≥7 mm without cardiac activity definitively confirms embryonic/fetal demise 1
• Mean gestational sac diameter ≥25 mm without an embryo establishes early pregnancy loss 1
• Absence of embryo ≥14 days after initial visualization of gestational sac confirms the diagnosis 1
• Use the term "embryonic/fetal demise" (with "fetal demise" specifically at ≥11 weeks gestation) rather than outdated terminology like "blighted ovum" 1

Management Algorithm by Gestational Age

First Trimester (<12-13 weeks)

Medical Management:

• Combination therapy is superior: Mifepristone 200 mg orally followed by misoprostol 800 mcg vaginally/buccally is more effective than misoprostol alone, particularly for embryonic demise 1
• Misoprostol monotherapy: 800 mcg vaginally achieves high success rates (80-91.5%) and represents a safe first-line option 1, 2, 3
• Vaginal route is preferred over oral: Vaginal misoprostol demonstrates higher success rates, shorter induction-to-expulsion intervals, greater patient satisfaction, and fewer side effects (particularly less nausea, vomiting, and severe cramping pain) 4
• Success typically occurs within 10-11 hours of administration 5

Surgical Management:

• Vacuum aspiration is the procedure of choice for first trimester, associated with less blood loss and pain compared to sharp curettage 1
• Offers lower risk of prolonged bleeding (9.1% vs 28.3% medical), infection (1.3% vs 23.9% medical), and retained tissue requiring additional procedures (1.3% vs 17.4% medical) 6
• Can be performed as outpatient/day case procedure 1

Second Trimester (14-24 weeks)

• Dilation and evacuation (D&E) is the preferred method throughout this gestational range 6
• D&E demonstrates superior safety compared to medical methods with significantly lower complication rates 6
• Must be performed in hospital setting by experienced providers, particularly at advanced gestational ages 6
• Beyond 24 weeks, termination is typically considered only for maternal indications 6

Absolute Contraindications to Expectant Management

Do not wait for spontaneous expulsion in confirmed missed abortion due to:

• Increased risk of intrauterine infection that develops over time 1
• Risk of coagulopathy with prolonged retention of conception products 1
• Potential for maternal sepsis 1
• Hemorrhage risk increases with expectant approach 1

Critical Warning Signs Requiring Urgent Intervention

Do not wait for fever to diagnose infection—clinical symptoms may be less overt at earlier gestational ages. Look for: 1

• Maternal tachycardia
• Purulent cervical discharge
• Uterine tenderness
• Signs of hemodynamic instability

If infection is suspected: Initiate broad-spectrum antibiotics immediately and proceed with urgent evacuation without delay 1

Special Considerations

Rh-negative patients: All Rh-negative women with missed abortion should receive 50 μg of anti-D immunoglobulin to prevent alloimmunization 1

Contraceptive counseling: Provide immediately after treatment, as ovulation can resume within 2-4 weeks post-abortion 1. Combined hormonal contraceptives or implants can be initiated immediately without waiting for next menses 1. If starting within 7 days of abortion, no backup contraception is needed 1.

Common Pitfalls to Avoid

• Do not delay treatment waiting for spontaneous expulsion—earlier intervention offers improved safety 1
• Do not wait for fever before treating suspected infection—use clinical signs like tachycardia and uterine tenderness 1
• Do not use oral misoprostol when vaginal route is available—vaginal administration is more effective with fewer side effects 4
• Do not attempt D&E beyond 24 weeks without specific maternal indications 6
• Do not forget Rh prophylaxis in Rh-negative patients 1

Patient Preference Considerations

When both medical and surgical options are appropriate, patient preference should guide the final decision 1, 7. Medical management may be preferred by patients desiring home-based care, avoiding surgery/anesthesia, or wanting more control over the process 8, 2. Surgical management offers faster resolution, lower complication rates, and single-visit completion 6, 3.