Clinical Updates in Reproductive Health

Recommended medication regimen for treatment of incomplete and missed abortion for 13 weeks or larger uterine size

Last reviewed: February 15, 2021

Recommendation:

  • · Medical methods or D&E may be offered for treatment of incomplete abortion or intrauterine demise.

  • Incomplete abortion: Misoprostol 400mcg buccally, sublingually or, in the absence of vaginal bleeding, vaginally every three hours until expulsion.

  • Intrauterine fetal demise (up to 24 weeks): Misoprostol 400mcg sublingually or, in the absence of vaginal bleeding, vaginally every 4-6 hours until expulsion. Where available, add pretreatment with mifepristone 200mg orally 1-2 days before misoprostol.

Strength of recommendation: Strong

Quality of evidence: Low

Background

The majority of postabortion care research and programs focus on women with uterine size less than 13 weeks (Ipas, 2013). However, where unsafe abortion is prevalent, as many as 40% of women needing postabortion care present at or after 13 weeks gestation (Ministry of Health of Kenya, Ipas, & Guttmacher Institute, 2013). Women may present with incomplete abortion, retained placenta, fetal demise or ruptured membranes, all of which require uterine evacuation.

Medical regimens

Evidence is limited to suggest the optimal medical regimen for postabortion care at or after 13 weeks uterine size, but systematic reviews of the literature suggests that at least 200mcg vaginally, sublingually or buccally given every six hours is effective (Bracken et al., 2014; Mark, Borgatta, & Edelman, 2015). Two trials that randomized women to treatment with 200mcg or 400mcg of vaginal misoprostol found that the higher dose of misoprostol resulted in higher expulsion rates at 24 and 48 hours (Dickinson & Evans, 2002; Eslamian, Gosili, Jamal, & Alyassin, 2007; World Health Organization [WHO], 2018). Pretreatment with mifepristone 1-2 days before misoprostol increases rates of abortion success within 24 hours and reduces the time to fetal expulsion (Chaudhuri & Datta, 2015; Panda & Singh, 2013). A systematic review of medical treatment for intrauterine fetal demise found when the dose of 400mcg was administered every four hours, it was more effective with lower rates of adverse events when compared with other doses; however, no direct comparisons exist to inform whether four hours is indeed the ideal interval (Cleeve, Fonhus & Lavelanet, 2019)

D&E

No studies have compared medical management versus vacuum aspiration or D&E for postabortion care at or after 13 weeks. D&E can be offered to women for postabortion care where skilled providers and supportive facilities exist (WHO, 2014).

Resources

Protocols for Medical Abortion (dosage card)

References

Bracken, H., Ngoc, N. T., Banks, E., Blumenthal, P. D., Derman, R. J., Patel, A., . . . Winikoff, B. (2014). Buccal misoprostol for treatment of fetal death at 14-28 weeks of pregnancy: A double-blind randomized controlled trial. Contraception, 89(3), 187-192. DOI:10.1016/j.contraception.2013.11.014

Chaudhuri, P., & Datta, S. (2015). Mifepristone and misoprostol compared with misoprostol alone for induction of labor in intrauterine fetal death: A randomized trial. Journal of Obstetrics and Gynaecology Research, 41(12), 1884-1890.

Cleeve, A., Fonhus, M.S., & Lavelanet, A. (2019). A systematic review of the effectiveness, safety, and acceptability of medical management of intrauterine fetal death at 14-28 weeks of gestation. International Journal of Gynaecology and Obstetrics, 147(3), 301-312.

Dickinson, J. E., & Evans, S. F. (2002). The optimization of intravaginal misoprostol dosing schedules in second-trimester pregnancy termination. American Journal of Obstetrics & Gynecology, 186(3), 470-474.

Eslamian, L., Gosili, R., Jamal, A., & Alyassin, A. (2007). A prospective randomized controlled trial of two regimens of vaginal misoprostol in second trimester termination of pregnancy. Acta Medica Iranica, 45(6), 497-500.

Ipas. (2013). Woman-centered postabortion care: Reference manual (2nd ed.). K.L. Turner & A.B. Huber (Eds.). Chapel Hill, NC: Ipas.

Mark, A., Borgatta, L., & Edelman, A. (2015). Second trimester postabortion care for ruptured membranes, fetal demise, and incomplete abortion. International Journal of Obstetrics & Gynaecology, 129(2), 98-103.

Ministry of Health of Kenya, Ipas, and Guttmacher Institute. (2013). Incidence and complications of unsafe abortion In Kenya: Key findings of a national study. African Population and Health Research Center: Nairobi.

Panda, S., Jha, V., & Singh, S. (2013). Role of combination of mifepristone and misoprostol verses misoprostol alone in induction of labour in late intrauterin [sic] fetal death: A prospective study. Journal of Family and Reproductive Health, 7(4), 177-179.

World Health Organization. (2014). Clinical practice handbook for safe abortion. Geneva: World Health Organization Press.

World Health Organization. (2018). Medical management of abortion. Geneva: World Health Organization Press.