eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Missed Abortion: Treatment & Medication

Author: James L Lindsey, MD, Consulting Staff, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center; Assistant Clinical Professor, Department of Obstetrics and Gynecology, Stanford University School of Medicine
Coauthor(s): Veronica R Rivera, MD, Staff Physician, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center
Contributor Information and Disclosures

Updated: Oct 9, 2008

Treatment

Medical Care

Expectant waiting is an alternative to medical or surgical treatment for first trimester missed abortion. A recent Cochrane review found that although expectant management resulted in an increased incidence of returning tissue, bleeding, and unplanned surgical intervention, it was a reasonable alternative for women to did not wish to undergo other therapy.1

The most common medical regimen used to evacuate the uterus is 400-800 mcg per vagina of misoprostol (Cytotec) in single or multiple doses. Although misoprostol is commonly used for this indication, technically it is an "off label" use of the medication. Trials have found success rates ranging from 70-90%. Some studies show that oral misoprostol is also an option. Sublingual administration has equivalent efficacy to vaginal misoprostol, and this method has become more popular. Other medical agents, such as mifepristone (RU-486), have been used in combination with misoprostol, but studies have failed to show increased efficacy. The addition of mifepristone also substantially increases the expense.

Surgical Care

Surgical evacuation has been the standard of care in treating missed abortion, with suction curettage being the most common method. This procedure is typically performed in an outpatient setting. Advantages to surgical evacuation include immediate and definitive treatment with fewer medical visits. However, with the increasing experience with medical abortion, more missed abortions are being terminated with misoprostol.

Medication

Although the risk of Rho(D) alloimmunization is minimal following missed abortion, anti-D immune globulin should be administered to women who are Rho(D) negative. This is not necessary if the father is Rho(D) negative.

Immunoglobulins

May decrease autoantibody production and increase solubilization and removal of immune complexes.


Rho(D) immune globulin (RhoGAM)

Suppresses immune response of nonsensitized Rho(D)-negative mothers exposed to Rho(D)-positive blood from the fetus as a result of a fetomaternal hemorrhage, abdominal trauma, amniocentesis, abortion, full-term delivery, or transfusion accident.

Adult

<13 weeks' gestation: 50 mcg IV within 3 h, but may administer within 72 h
>13 weeks' gestation: 300 mcg IV

Pediatric

Administer as in adults

Documented hypersensitivity; patients who have received Rho(D)-positive blood within last 3 mo

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in thrombocytopenia, bleeding disorders, or IgA deficiency

Prostaglandins

Used for cervical ripening and termination of pregnancy.


Misoprostol (Cytotec)

Not approved for use in pregnancy, yet is an invaluable medication widely used for cervical preparation for abortion, labor induction, and as a medical abortifacient. Provides safe, passive method of cervical dilatation and should be considered for preabortion ripening when prior uterine surgery (ie, LEEP, C-section) are known risk factors for uterine perforation during surgical abortion. Can be administered orally or vaginally. Some studies show premoistening tablets placed vaginally helps absorption. Patients can be instructed in self-administration to help time the dose in synchrony with their abortion procedure.
In a study by Singh of primigravid women (6-11 wk gestation), 93.3% achieved dilatation of the cervix of 8 mm or greater after 3 h postintravaginal misoprostol 400 mcg, whereas only 16.7% of women achieved this after 2 h of 600 mcg. The 600-mcg group had slightly greater adverse effects (eg, bleeding, abdominal pain, fever >38ºC). Dosage intended for cervical ripening can induce abortion in some patients. Oral doses of 100-400 mcg can be combined with vaginal insertion of prostaglandins to enhance cervical dilatation.

Adult

Cervical ripening: 25-100 mcg (vaginally) for term pregnancies, lower doses may need to be repeated q4-6h
Termination: 200-800 mcg, most patients do not need repeat dosing for 24 h

Pediatric

Not established

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Caution in renal impairment and the elderly

More on Missed Abortion

Overview: Missed Abortion
Differential Diagnoses & Workup: Missed Abortion
Treatment & Medication: Missed Abortion
Follow-up: Missed Abortion
Multimedia: Missed Abortion
References
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References

  1. [Best Evidence] Nanda K, Peloggia A, Grimes D, Lopez L, Nanda G. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev. 2006;(2):CD003518. [Medline].

  2. American College of Obstetrics and Gynecology. Early Pregnancy Loss. The American College of Obstetrics and Gynecology, Compendium of Selected Publications. 1995.

  3. Bagratee JS, Khullar V, Regan L, et al. A randomized controlled trial comparing medical and expectant management of first trimester miscarriage. Hum Reprod. Feb 2004;19(2):266-71. [Medline].

  4. Callen PW. Ultrasound in Obstetrics and Gynecology. 4th ed. Philadelphia, Pa: WB Saunders; 2000.

  5. Cho FN, Chen SN, Tai MH, Yang TL. The quality and size of yolk sac in early pregnancy loss. Aust N Z J Obstet Gynaecol. Oct 2006;46(5):413-8. [Medline].

  6. Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early pregnancy failure--current management concepts. Obstet Gynecol Surv. Feb 2001;56(2):105-13. [Medline].

  7. Demetroulis C, Saridogan E, Kunde D, Naftalin AA. A prospective randomized control trial comparing medical and surgical treatment for early pregnancy failure. Hum Reprod. Feb 2001;16(2):365-9. [Medline].

  8. Graziosi GC, Mol BW, Ankum WM, Bruinse HW. Management of early pregnancy loss. Int J Gynaecol Obstet. Sep 2004;86(3):337-46. [Medline].

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  10. Hurd WW, Whitfield RR, Randolph JF, Kercher ML. Expectant management versus elective curettage for the treatment of spontaneous abortion. Fertil Steril. Oct 1997;68(4):601-6. [Medline].

  11. Lelaidier C, Baton-Saint-Mleux C, Fernandez H, et al. Mifepristone (RU 486) induces embryo expulsion in first trimester non-developing pregnancies: a prospective randomized trial. Hum Reprod. Mar 1993;8(3):492-5. [Medline].

  12. Luise C, Jermy K, May C, et al. Outcome of expectant management of spontaneous first trimester miscarriage: observational study. BMJ. Apr 13 2002;324(7342):873-5. [Medline].

  13. Morin L, Van den Hof MC. SOGC clinical practice guidelines. Ultrasound evaluation of first trimester pregnancy complications. Number 161, June 2005. Int J Gynaecol Obstet. Apr 2006;93(1):77-81. [Medline].

  14. [Best Evidence] Neilson JP, Hickey M, Vazquez J. Medical treatment for early fetal death (less than 24 weeks). Cochrane Database Syst Rev. Jul 19 2006;3:CD002253. [Medline].

  15. Ngoc NT, Blum J, Westheimer E, et al. Medical treatment of missed abortion using misoprostol. Int J Gynaecol Obstet. Nov 2004;87(2):138-42. [Medline].

  16. [Best Evidence] Petrou S, Trinder J, Brocklehurst P, Smith L. Economic evaluation of alternative management methods of first-trimester miscarriage based on results from the MIST trial. BJOG. Aug 2006;113(8):879-89. [Medline].

  17. Pridjian G, Moawad AH. Missed abortion: still appropriate terminology?. Am J Obstet Gynecol. Aug 1989;161(2):261-2. [Medline].

  18. [Best Evidence] Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial). BMJ. May 27 2006;332(7552):1235-40. [Medline].

  19. [Best Evidence] Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial). BMJ. May 27 2006;332(7552):1235-40. [Medline].

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Further Reading

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Keywords

blighted ovum, anembryonic pregnancy, anembryonic gestation, pregnancy failure prior to 20 weeks gestation, spontaneous abortion, early pregnancy failure, fetal demise, mifepristone, Mifeprex, RU 486, RU-486, RU486, misoprostol, fetal chromosomal abnormalities, maternal disease, embryonic anomalies, placental abnormalities, uterine anomalies, ectopic pregnancy, intrauterine pregnancy

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Contributor Information and Disclosures

Author

James L Lindsey, MD, Consulting Staff, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center; Assistant Clinical Professor, Department of Obstetrics and Gynecology, Stanford University School of Medicine
James L Lindsey, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Society for Colposcopy and Cervical Pathology, and California Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Veronica R Rivera, MD, Staff Physician, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center
Veronica R Rivera, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Suzanne R Trupin, MD, Clinical Professor of Obstetrics and Gynecology, University of Illinois College of Medicine-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center
Suzanne R Trupin, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Association of Reproductive Health Professionals, International Society for Clinical Densitometry, and North American Menopause Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard S Legro, MD, Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Pennsylvania State University College of Medicine; Consulting Staff, Milton S Hershey Medical Center
Richard S Legro, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Endocrine Society, Phi Beta Kappa, and Society of Reproductive Surgeons
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

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