Management of spontaneous abortion traditionally has been surgical evacuation of retained products of conception (ERPC). However, the development of high-resolution transvaginal sonography (TVS) allows for more accurate assessment of the amount of retained products of conception (POC) in the uterus. In women who do not have a significant amount of tissue remaining in the uterus, surgical management is not necessary and can result in iatrogenic postoperative complications. Prostaglandin analogs, such as misoprostol, have been shown to be effective in emptying the uterus following spontaneous abortion. Chung and colleagues evaluated the incidence of complications following treatment with misoprostol compared with that of ERPC in women who had spontaneous abortions.
All women who presented to a gynecologic unit with a diagnosis of spontaneous abortion were eligible for the study. Inclusion criteria consisted of evidence of retained products of conception by TVS and a positive urinary pregnancy test. Women who met the study criteria were randomized to receive routine ERPC or medical management. Patients in the medical management group received misoprostol in a dosage of 400 mg orally every four hours up to a maximum of 1,200 mg. TVS was repeated 24 hours later, and women with no evidence of retained products of conception were released. Those with significant products of conception remaining received surgical intervention consisting of a dilation and curettage. Principal outcomes measured were treatment complications in the hospital, short-term complications that occurred within two weeks of treatment, and medium-term complications that occurred up to six months after treatment.
A total of 604 women enrolled in the study, all with similar demographics, including age and gestation at presentation, previous history of spontaneous abortion, and parity. Approximately one half of the women who received misoprostol had retained products of conception and required surgical intervention. These women also had significantly more blood loss and gastrointestinal side effects and required more analgesia than women in the surgical treatment group. These side effects, while statistically significant, were of no clinical relevance. Overall, women taking misoprostol had significantly fewer total short- and medium-term complications than did women in the surgical treatment group. Complications such as retained products of conception and infection actually occurred more often in women in the surgical treatment group.
The authors conclude that misoprostol provides a safe, effective means of initial treatment for spontaneous abortion with retained products of conception. While gastrointestinal side effects are common with medical management, they are seldom severe. The addition of misoprostol to routine management of spontaneous abortion can significantly reduce the need for surgical intervention and ultimately reduce the overall rate of complications.