From the Guidelines
Incomplete abortion or miscarriage occurs in about 10-20% of clinically recognized pregnancies, with the majority happening in the first trimester. The management of incomplete abortion or miscarriage involves three main options: expectant, medical, or surgical.
- Expectant management involves waiting for natural expulsion and is successful in 65-80% of cases within 2-6 weeks 1.
- Medical management typically uses misoprostol 800mcg vaginally or 600mcg sublingually, which is 80-90% effective within 1-2 weeks.
- Surgical management via vacuum aspiration or dilation and curettage is nearly 100% effective and provides immediate resolution. Follow-up should occur 1-2 weeks after treatment to confirm complete expulsion through clinical assessment, ultrasound, or serum hCG levels.
- Signs of complete resolution include cessation of bleeding, closed cervical os, and return of the uterus to normal size. Patients should be monitored for complications such as heavy bleeding (soaking more than two pads per hour for two consecutive hours), severe pain, fever, or foul-smelling discharge, which may indicate infection or retained tissue requiring immediate medical attention. Emotional support is also essential as many patients experience grief or depression following pregnancy loss 1. The risk of venous thromboembolism (VTE) is also a concern in early pregnancy loss, with an incidence of 5.7 per 10,000, although there may be an increasing risk between 10 and 13 weeks’ gestation 1. The most effective management option should be chosen based on the individual patient's needs and medical history, with the goal of minimizing morbidity, mortality, and improving quality of life.
From the Research
Incidence of Incomplete Abortion or Miscarriage
- Incomplete abortion is a major problem that should be effectively managed with safe and appropriate procedures 2, 3.
- Miscarriage occurs in 10% to 15% of pregnancies 4, 5.
Follow-up for Incomplete Abortion or Miscarriage
- The traditional treatment after miscarriage has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus') 4, 5.
- Medical treatments, or expectant care (no treatment), may also be effective, safe, and acceptable alternatives to routine surgical evacuation 4, 5.
- Vacuum aspiration is safe, quick to perform, and less painful than sharp curettage, and should be recommended for use in the management of incomplete miscarriage 2, 3.
- Misoprostol treatment is also an acceptable alternative to routine surgical evacuation, with a slightly lower incidence of complete miscarriage and fewer surgical evacuations, but more unplanned procedures and nausea 4, 5.
- There is limited evidence on the long-term follow-up of women who have had incomplete abortion or miscarriage, but one study found no difference in subsequent fertility between medical treatment, expectant care, and surgical evacuation 4, 5.
Comparison of Treatment Options
- Vacuum aspiration is associated with statistically significantly decreased blood loss, less pain, and shorter duration of procedure compared to sharp curettage 2, 3.
- Misoprostol treatment is associated with a slightly lower incidence of complete miscarriage, fewer surgical evacuations, but more unplanned procedures and nausea compared to surgical evacuation 4, 5.
- There is no clear evidence of one regimen of misoprostol being superior to another in terms of effectiveness and safety 4, 5.