Misoprostol, Expectant Management, and the Evidence Behind Management Options of Incomplete Abortion

Miscarriage occurs in 10-15% of pregnancies. Historically, the "gold standard managment" for incomplete abortions was surgical dilation and curretage. However, the risk of infection, hemorrhage, cervical injury, uterine rupture, and anesthesia complications with routine surgical intervention opened the door for less invasive management options to replace conventional therapy. These options include medical (misoprostol) and expectant management. In today's practice of, Emergency Medicine providers are typically subject to varying practice patterns by obstetrics consultants. A January 2017 Cochrane review aimed to identify if medical management or expectant management is safe and accetpable. This post will summarize the Cochrane review.

Study Design: 24 randomized control trials of 5577 women

  • 3 RCT's of 355 women compared misoprostol to expectant management and showed no significant difference in complete miscarriage rate (RR 1.23, 95% CI 0.72-2.1), need for surgical intervention (RR 0.62, 95% CI 0.17-2.26), or need for unplanned surgical intervention (RR 0.62, 95% CI 0.17-2.26).
  • 16 RCT's of 4044 women compared misoprostol to surgical managment. Patients who received misoprostol had a slightly lower incidence of complete miscarriage than in the surgical groups (RR 0.96). Patients who received misoprostol had less surgical procedures (RR 0.05) but and a higher incidence of unplanned surgical procedures (RR 5.03). There was no significant difference in patient satisfaction. Patients who received misoprostol had higher incidences of nause and vomiting.
  • 5 RCT's compared routes of administration (vaginal, oral) and doses of misoprostol and found no evidence to suggest one route of superior to other.

Authors Conclusion: The authors of this paper conclude that misoprostol and expectant care are safe and acceptable alternatives of surgical management. 

1. Kim C. et al. "Medical Treatments for Incomplete Miscarriage." Cochrane Pregancy and Childbirth Group. Cochrane Database of Systematic Reviews. Jan 31 2017.