Women experiencing a complete abortion require no treatment; they have already successfully passed the pregnancy. Women with a missed, incomplete, or inevitable abortion can be offered the choice of expectant management, medication, or uterine aspiration.
Does your patient want to wait it out?
The success rate for expectant management depends on the time-frame studied and the type of EPL.11 (Success in EPL is defined as complete uterine evacuation.) Patients who choose this approach are usually seen every 1 to 2 weeks so that you can evaluate symptoms and do a physical examination. In some cases, assessment also includes serial serum human chorionic gonadotropin (hCG) testing or ultrasonography.
Expectant management is usually more efficacious for women with an incomplete abortion than for women with anembryonic gestation or embryonic demise.12-16 TABLE W1, available at jfponline.com, provides a comparison of the efficacy of expectant management and misoprostol. In 1 observational study of 1096 women who chose expectant management, 91% of those with incomplete abortion were successful and 84% completed within 14 days of diagnosis. By comparison, only 59% of those with a missed abortion completed within 14 days.17
According to a study performed by Wieringa-de Waard and colleagues, increased bleeding appears to be the greatest predictor of completion. They showed that the median blood flow and pain were heaviest on the third day of vaginal bleeding, which then decreased steeply after 8 days to slight bleeding and spotting. Of the patients they followed, 50% completed during the first 8 days of bleeding.18
A Cochrane review of 5 studies comparing expectant management with vacuum aspiration found expectant management carried a higher risk of incomplete miscarriage, need for vacuum aspiration, and bleeding. In contrast, vacuum aspiration was associated with a significantly higher risk of infection.19
A low-cost option that can speed things up
EPL can be treated with prostaglandins to hasten the time to completion.20 Misoprostol is a synthetic prostaglandin E1 analog that causes contractions of the uterus and gastrointestinal tract. This medication is approved by the US Food and Drug Administration (FDA) only for the treatment of gastric ulcers, but it is commonly used off-label for labor induction, postpartum hemorrhage, and cervical ripening prior to gynecological procedures—as well as for the management of miscarriage.21 Misoprostol’s low cost and stability at room temperature make it easy to use.22
Route of administration. Although misoprostol is manufactured and approved for oral use only, administration by vaginal, buccal, or sublingual routes can increase the desired effect on the uterus, with the added benefit of decreased gastrointestinal side effects.23
The dosage and dosing intervals for misoprostol for treatment of EPL have not been well established. A comprehensive review article recommends a single dose of 800 mcg vaginal misoprostol or, alternatively, 600 mcg sublingual misoprostol for anembryonic pregnancy or embryonic/fetal demise.24 A single dose of 600 mcg oral or 400 mcg sublingual misoprostol is recommended for incomplete abortion.25 The vaginal route may not be feasible when bleeding is heavy.
Safety and efficacy. Multiple studies have found that misoprostol is a safe and acceptable alternative to vacuum aspiration or expectant management.11,26-29
A study comparing 652 women randomized to misoprostol vaginally or vacuum aspiration found that 84% of the misoprostol group had complete expulsion within 8 days of treatment initiation.30
Infection rates. The Miscarriage Treatment (MIST) trial randomized 1200 women with a diagnosis of embryonic demise or incomplete abortion at <13 weeks to medical (n=398), expectant (n=399), or vacuum aspiration management (n=403).31 Overall, the researchers found a low incidence of gynecologic infection (2.3%), and no evidence of difference in the infection rate attributable to the type of management selected.
Antibiotic use to reduce infection rates after misoprostol for EPL has not been studied. Nonetheless, a recent retrospective study examined infection rates after medical abortion with mifepristone and misoprostol.32 The study demonstrated a reduction in severe infection rates from 0.25 per 1000 abortions to 0.06 per 1000 (absolute reduction, 0.19 per 1000; 95% confidence interval [CI], 0.02-0.34; P=.03) with the routine use of doxycycline 100 mg PO twice daily for 7 days. The risk reduction is in comparison to the prior practice of either testing for sexually transmitted infection (STI) or using prophylactic doxycycline. The authors also reported a decrease in infection rate with a change from vaginal to buccal administration of misoprostol. The benefit of this change is unknown, because the practice of routine screening for STI or routine antibiotic provision was introduced at the same time.32