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• Use the term "embryonic/fetal demise" (with "fetal demise" specifically at ≥11 weeks gestation) rather than outdated terminology like "blighted ovum" 1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 (<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 is the preferred first-line option when mifepristone is unavailable 1, 2, 3
• Vaginal route is superior to oral: Vaginal misoprostol has higher success rates, shorter induction-to-expulsion intervals, greater patient satisfaction, and fewer side effects (particularly less nausea, vomiting, and crampy pain) compared to oral administration 4

Surgical Management:

• Vacuum aspiration is the procedure of choice for first trimester, associated with less blood loss and pain compared to sharp curettage 1
• Surgical evacuation has lower rates of complications compared to medical management: hemorrhage (9.1% vs 28.3%), infection (1.3% vs 23.9%), and retained tissue requiring additional procedures (1.3% vs 17.4%) 5

Second Trimester (14-24 weeks)

• Dilation and evacuation (D&E) is the preferred method for gestational ages from approximately 14 weeks through 24 weeks 5
• D&E demonstrates superior safety compared to medical methods throughout the second trimester with significantly lower complication rates 5
• Must be performed in a hospital setting by experienced providers, particularly at advanced gestational ages 5

Critical Contraindications to Expectant Management

Active evacuation is mandatory—expectant management is absolutely contraindicated in missed abortion because: 1

• Confirmed fetal demise requires active evacuation
• Risk of intrauterine infection increases with time
• Risk of coagulopathy and maternal sepsis with prolonged retention of conception products
• Any bleeding is a contraindication to expectant management

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
• Fetal tachycardia (if applicable)

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. Combined hormonal contraceptives or implants can be initiated immediately without waiting for next menses. 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—this increases maternal morbidity 1
• Do not wait for fever before diagnosing infection in the setting of missed abortion 1
• Do not use misoprostol for cervical preparation or induction in women with previous cesarean delivery 6
• Do not attempt D&E beyond 24 weeks without specific maternal indications 5

Patient Counseling on Treatment Options

When patients are allowed to choose between medical and surgical management, a large percentage choose medical management 2. However, counsel patients that:

• Surgical evacuation offers faster resolution, lower bleeding risk, lower infection risk, and lower chance of requiring additional procedures 5
• Medical management avoids surgical risks (perforation, anesthesia complications), can be performed in outpatient/home settings before 9 weeks, and gives patients more control over the process 1, 6
• Both options are safe and effective when appropriately selected 7, 3