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Managing Miscarriage Medically

Vaginal misoprostol is effective, safe, and tolerable, and most women prefer it over surgery.

Misoprostol is increasingly being used as an alternative to vacuum aspiration for women with early pregnancy loss who need or elect intervention. In this NIH-funded, multicenter trial, U.S. investigators compared the two interventions among women presenting with first-trimester anembryonic gestation, embryonic or fetal death, or incomplete or inevitable spontaneous abortion; women with heavy bleeding were excluded. Overall, 491 women were randomized to receive misoprostol (800 µg administered vaginally into the posterior fornix via speculum) and 161 to undergo vacuum aspiration. Women in the misoprostol group returned on day 3: If vaginal sonography showed incomplete expulsion of the products of conception, a second misoprostol dose was administered. On day 8, if expulsion still was incomplete, vacuum aspiration was offered.

The mean gestational age at enrollment was 7.6 weeks. In the misoprostol group, 71% of women had complete expulsion of the products of conception after one dose, and 84% after two doses. The success rate in the vacuum-aspiration group was 90%. Success rates did not differ significantly by gestational age.

Hemorrhage or pelvic infection occurred in fewer than 1% of women in each group; fever developed in 3% of the misoprostol group and 4% of the vacuum-aspiration group; and no maternal sepsis occurred. A drop in hemoglobin 3 g/dL occurred in a significantly greater proportion of the misoprostol group than the vacuum-aspiration group, as did nausea, vomiting, and abdominal pain. Nonetheless, acceptability of treatment did not differ between the groups. Among misoprostol recipients, 78% said they would probably or definitely choose misoprostol if needed in the future; 73% of those who had undergone vacuum aspiration in a previous pregnancy said they would use misoprostol in the future.

Comment: These findings indicate that vaginal administration of misoprostol, following the investigators’ protocol, is effective, safe, tolerable, and preferred over surgery by most women. Although misoprostol tablets are inexpensive, the need for additional ultrasound studies and office visits must be factored into the overall cost of treatment.

— Andrew M. Kaunitz, MD

Published in Journal Watch Women's Health October 4, 2005

Citation(s):

Zhang J et al. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med 2005 Aug 25; 353:761-9.

• Medline abstract (Free)

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