Clinical Question: Is vaginal administration of misoprostol an effective treatment for missed abortion?

Setting: Outpatient (primary care)

Study Design: Cohort (prospective)

Synopsis: Currently, women with missed abortion (i.e., anembryonic gestation or embryonic death) are offered expectant observation or surgical curettage. Intravaginal misoprostol is a medical therapy that may provide rapid evacuation of the uterus without surgical intervention. In this case series, 41 women were given 800 mcg of misoprostol intravaginally, with a second course of treatment if uterine evacuation did not occur within 24 hours. Typically, painful uterine contractions began within six hours of administration of misoprostol, with the heaviest bleeding 10 to 16 hours after administration. The success rate was 78 percent, with 26 women receiving one dose and six women requiring a second dose. No cases of endometritis, uncontrolled bleeding requiring curettage, or severe gastrointestinal side effects were noted.

Bottom Line: Intravaginal misoprostol is a reasonable third alternative to expectant observation and surgical intervention for missed abortion. Further study is needed to determine which treatment is best, although randomized trials will be difficult to undertake because women may not be willing to be randomized. (Level of Evidence: 4)