Recommendation:
- Medical methods or vacuum aspiration may be offered for treatment of incomplete or missed abortion.
- Recommended medication regimen:
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- Incomplete abortion: Misoprostol 600mcg orally in a single dose or 400mcg in a single dose buccally, sublingually or, in the absence of vaginal bleeding, vaginally.
- Missed abortion: Misoprostol 800mcg buccally, sublingually or, in the absence of vaginal bleeding, vaginally every three hours until pregnancy expulsion (generally 1-3 doses). Where available, add pretreatment with mifepristone 200mg orally 1-2 days before misoprostol.
-
In practice:
- Uterine size, not gestational age, should be used to determine treatment for postabortion care.
Strength of recommendation: Strong
Quality of evidence: Moderate
Incomplete abortion
A 2021 systematic review and network meta-analysis examining methods for managing miscarriage before 13 weeks gestation included 26 randomized trials reporting on 5,735 women who were treated for incomplete abortion (Ghosh et al., 2021). Suction aspiration (RR 1.19, 95% confidence interval [CI] 1.09, 1.31) and misoprostol therapy (RR 1.14, 95%CI 1.03, 1.25) were slightly more effective than expectant management or placebo in achieving abortion completion, however success rates were similar for all management strategies. Reported completion rates range from 52-85% for expectant management, 80-99% for treatment with misoprostol, and 91-100% for surgical treatment (Kim et al., 2017). Oral, sublingual and vaginal misoprostol show similar efficacy and side effect profiles; lengthening the time to follow-up assessment increases the success of misoprostol treatment (Kim et al., 2017).
Missed abortion
A 2021 systematic review and network meta-analysis examining methods for managing miscarriage before 13 weeks gestation included 16 randomized trials reporting on 4,397 women who were treated for missed abortion (Ghosh et al., 2021). Suction aspiration (RR 2.43, 95%CI 1.69, 3.49), mifepristone plus misoprostol (RR 1.82, 95%CI 1.28, 2.58) and misoprostol alone (RR 1.67, 95%CI 1.18, 2.37) were all more effective in achieving a complete abortion than expectant management or placebo treatment. Four randomized controlled trials found that people with a missed abortion who receive pretreatment with mifepristone before receiving misoprostol are more likely to successfully complete their abortion than those who receive misoprostol only. In Schreiber et al. (2018), women received either mifepristone, followed 24 hours later by a single dose of 800mcg misoprostol vaginally, or misoprostol with no pretreatment. Abortion success, determined the day after misoprostol was used, was 84% in the mifepristone group compared to 67% in the misoprostol-only group. In another study (Sinha et al., 2018), women received either mifepristone or placebo, followed 48 hours later by identical multidose regimens of misoprostol. Abortion success rates were 87% and 58% respectively; more women in the mifepristone group than in the placebo group expelled the pregnancy after a single misoprostol dose (66% compared to 11%, respectively) and had a significantly shorter induction to abortion interval (4.7 hours compared to 8 hours, respectively). A third study of mifepristone or placebo, followed 48 hours later by misoprostol 800mcg, demonstrated successful expulsion in 83% and 76% of the 696 women in the trial, respectively, at seven days post-mifepristone (Chu et al., 2020). A fourth study including 216 participants found a success rate of 94% when mifepristone was used, compared to 83% when misoprostol-only was used, when follow-up occurred more than 2 weeks after medication administration (Bettencourt-Silva et al., 2023). . Management of early pregnancy loss with mifepristone and misoprostol is associated with a lower rate of subsequent uterine evacuation procedures (Benson, Gunaje, Holt, Gore, & Dalton, 2024). In a prospective cohort study, risk of failure following mifepristone and misoprostol for missed abortion was increased among people with a uterine size of greater than nine weeks gestation (Ehrnsten et al., 2019). Despite the relatively high cost of mifepristone, two studies from the United States and one from the United Kingdom have shown that use of a combined mifepristone and misoprostol regimen for treatment of missed abortion is cost-effective, particularly in settings where surgical evacuation of the uterus is performed in an operating theater (Berkley, Greene, & Wittenberger, 2020; Nagendra et al., 2020; Okeke Ogwulu et al., 2021). The World Health Organization (WHO), the Society of Family Planning, and the National Institute for Health Care and Excellence (NICE) recommend the addition of mifepristone to misoprostol when treating early pregnancy loss (WHO, 2024; Tarleton, Benson, Moayedi, & Trevino, 2025; NICE, 2023).
A 2017 systematic review and network meta-analysis of misoprostol management of missed abortion, which included 18 studies reporting on 1,802 women, concluded that misoprostol 800mcg vaginally or 600mcg sublingually are the most effective treatments (Wu et al., 2017). A single dose of misoprostol 800mcg vaginally results in successful uterine evacuation in 76 to 93% of women (Fernlund et al., 2017; Mizrachi et al., 2017; Ngoc et al., 2004). In two studies, when women were managed expectantly over seven days after a single dose of misoprostol, their abortion success rates increased over time (Ngoc et al., 2004) up to 88% at seven days compared with 72% at four days (Mizrachi et al., 2019). Although a number of studies have reported an increase in abortion success when an additional dose of misoprostol is administered 24 (Barcelo et al., 2012; Graziosi et al., 2004; Muffley, Stitely, & Gherman, 2002), 48 (Lyra et al., 2017) or 72 hours after the initial dose (Gilles et al., 2004; Zhang et al., 2005), it has been unclear whether this is due to the additional medication or the increased time to evaluation. A 2017 trial which randomized women to receive a single dose of misoprostol 800mcg vaginally, or to receive an additional dose of misoprostol after four days, found that both groups had nearly identical success rates after seven days: 77 and 76% respectively (Mizrachi et al., 2017).
Misoprostol 600mcg sublingually repeated every three hours following the initial dose for a maximum of two more doses achieves abortion success rates of 88-92% (Tang et al., 2003; Tang et al., 2006). No studies have evaluated single doses of sublingual misoprostol for treatment of missed abortion.
Who can provide postabortion care for individuals with a uterine size less than 13 weeks gestation?
The World Health Organization (WHO) makes service delivery recommendations for the provision of postabortion care for individuals with a uterine size of less than 13 weeks gestation (WHO, 2024). Health workers with the skills to perform transcervical procedures, and a bimanual examination to diagnose pregnancy and determine gestational age based on uterine size, can be trained to perform vacuum aspiration for postabortion care. WHO advises that uterine aspiration is within the scope of practice for specialty and general medical practitioners, and recommends the provision of vacuum aspiration by associate and advanced associate clinicians, midwives, and nurses based on moderate certainty evidence of safety and effectiveness. Traditional and complementary medicine professionals are recommended to provide uterine aspiration based on low certainty evidence of safety and effectiveness, and WHO suggests that auxiliary nurses and auxiliary nurse midwives may be able to perform aspiration in settings where they provide basic emergency obstetric care (WHO, 2024). WHO advises that all cadres of health care workers (specialty and general medical practitioners, associate and advanced associate clinicians, midwives, nurses, auxiliary nurses and auxiliary nurse midwives, traditional and complementary medicine professionals, pharmacists and pharmacy workers, and community health workers) can safely and effectively provide medical management of uncomplicated incomplete abortion and missed abortion, based on a variety of evidence and the expected skills and knowledge for that type of health worker (WHO, 2024). For further information about health worker roles in abortion care, Appendix C: World Health Organization recommendations for health worker roles in abortion care.
Resources
Protocols for Medical Abortion (dosage card)
Abortion Care Videos – Ipas: Caring for a Woman with a Miscarriage
References
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Benson, L. S., Gunaje, N., Holt, S. K., Gore, J. L., & Dalton, V. K. (2024). Outcomes after early pregnancy loss management with mifepristone plus misoprostol vs misoprostol alone. JAMA Network Open, 7(10), e2435906.
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