Missed abortion

(also known as silent or delayed miscarriage)

The full guidance on missed abortion has been published in the International Journal of Gynecology and Obstetrics 2007;99(supp 2):S182-5, and is available as a read-only pfd file here.

Recommended Dosages:

800 mcg vaginally 3-hourly (x2), or 600mcg 3 hourly sublingually (x2)

A single dose of 800 mg vaginal misoprostol is recommended for this indication. Alternatively, 600 mg misoprostol can be administered sublingually.

Treatment may be repeated twice with a 3 h interval but more studies are needed to evaluate the additional efficacy of repeated doses of misoprostol.

Course of treatment
The diagnosis of missed abortion is made by bi-manual examination and ultrasound. If judged necessary serum b-HCG could be analyzed as well. A second ultrasound after 1-2 weeks may be needed to confirm the diagnosis.
All women should be given the choice between surgical, expectant or medical management.
There is no clinical reason to withhold misoprostol for the treatment of missed abortion in women with previous caesarean section.

After administration of misoprostol, hospitalization is not necessary as the time to expulsion varies considerably – it may occur in hours or over several weeks. Bleeding may last for more than 14 days with additional days of light bleeding or spotting. Uterine contractions usually start within a few hours following misoprostol. Routine antibiotic coverage is not necessary, but paracetamol or NSAIDs can be used for pain relief. The woman should be advised to contact a provider in case of heavy bleeding or signs of infection.

The effectiveness of the treatment depends on the diagnosis and on the time until follow-up and evaluation.
Follow-up is best performed at 1 to 2 weeks after treatment where complete evacuation of the uterus is confirmed by history, clinical examination of the uterus, and with ultrasound if necessary.
A pregnancy test may also be needed. In the event of failure (or infection or heavy bleeding), a surgical evacuation may be needed. However, if the woman is clinically stable and willing to continue to wait for her uterus to empty, it is acceptable to give her another dose of misoprostol, 800 mg vaginally or 600 mg sublingually.

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 so as to provide guidance to clinicians worldwide. The excerpt above is taken from:

K. Gemzell-Danielsson, P.C. Ho, R. Gómez Ponce de León, A. Weeks, B. Winikoff. Misoprostol to treat missed abortion in the first trimester. International Journal of Gynecology and Obstetrics 2007;99(supp 2):S182-5.