1st trimester incomplete abortion

(also known as incomplete miscarriage or retained products of conception)

The full guidance on incomplete abortion has been published in the International Journal of Gynecology and Obstetrics 2007;99(supp 2):S186-9, and is available as a read-only pfd file here.

Recommended Dosage: 600 mcg orally, single dose

Regimen

A single dose of 600 mg oral or 400 mg sublingual misoprostol is indicated for treatment of incomplete abortion and miscarriage for women presenting with uterine size equivalent to a 12 week gestation.

600 mg oral misoprostol has been used to evacuate the uterus safely for thousands of women participating in clinical trials worldwide. 400 mg sublingual misoprostol is being used in several ongoing trials and has been shown to be as safe and effective as the 600 mg oral dose. At this time, however, there is less evidence supporting use of this lower dose regimen. The current evidence does not support the use of repeated doses.

Course of Treatment

The course of treatment is brief and essentially involves two outpatient visits. At the first visit, the incomplete abortion status should be confirmed by history and clinical exam and eligibility for misoprostol assessed.

The crucial clinical findings are an open cervical os and a uterine size less than 12 weeks gestation.

Where available, ultrasound may be used as an additional diagnostic tool if incomplete abortion status cannot be confirmed with history and clinical exam. Information about misoprostol management, possible side effects and success rate should be given to the woman. Given the small risk of retained uterine products following treatment, surgical back up may be needed to empty the uterus for some women.

It is important to explain to women that the expulsion can occur over several hours to several weeks and that bleeding will most likely be heavy for about 3 – 4 days, followed by light bleeding or spotting for several weeks.

Routine antibiotic coverage is not necessary and local norms regarding antibiotic use should be followed. The provider may determine that the woman requires antibiotic coverage based on history or clinical exam.

Depending on the health care system and her wishes, the woman can take the misoprostol either at the health facility or at home. She should be given contact details and encouraged to consult the facility or the provider about any questions or concerns.

When used in studies, a single dose of 600 mg oral misoprostol successfully evacuated the uterus in nearly all women. Given that the method may fail in some women, it is recommended that all women have a follow-up visit in 7 – 14 days during which time clinical history and a bi-manual exam should enable the provider to determine the absence of symptoms and that the uterus is firm and well involuted. In cases of uncertainty, an ultrasound examination may be needed to confirm a complete expulsion.

Care should be taken not to over-diagnose ‘failed medical management’; for instance, a ‘thickened endometrium’ is not a good predictor of the need for surgery. A decision for surgical completion should be based on the clinical condition of the woman and not on the ultrasound picture. Surgical intervention is not recommended prior to 7 days after treatment unless medically necessary (i.e. for haemostatic or infection control).

At the follow-up appointment, providers should give contraceptive counseling and provision of a suitable contraceptive method if desired. Future research on at-home follow up may eliminate the need for the follow up visit at the health facility. If the abortion is not complete at the follow up visit and the woman is clinically stable and willing to continue to wait for her uterus to empty, it is acceptable practice to give her another dose of misoprostol.

The regimen recommended in this chapter applies to misoprostol use in incomplete abortion when the uterine size is not larger than expected in a 12 week pregnancy; however, the length of amenorrhea prior to starting treatment may be longer than 12 weeks.

Misoprostol can be used when the uterus is larger than a 12 weeks’ gestation; however, the regimen is different. Typically, lower doses are needed for efficacy and safety when the uterus is larger

These recommendations are produced by an expert group on misoprostol brought together by WHO in Bellagio, Italy in Feb 2007. These recommendations do not reflect official WHO guidelines, but have been released early so as to provide guidance to clinicians worldwide. The excerpt above is taken from:

J Blum, B Winikoff, K Gemzell-Danielsson, PC Ho, R Schiavon, A Weeks. Treatment of incomplete abortion and miscarriage with misoprostol. International Journal of Gynecology and Obstetrics 2007;99(supp 2):S186-9.

Alternative guidelines on incomplete abortion are available here.