A comparison of medical management with misoprostol and surgical management for early pregnancy failure

An estimated 15% of clinically apparent pregnancies are complicated by early pregnancy failure, most commonly in the form of spontaneous abortion, anembryonic gestation, or embryonic or fetal death. Approximately one of every 4 women will experience an early pregnancy failure. Expectant management is an option for incomplete spontaneous abortion, but frequently fails when used for embryonic or fetal death or anembryonic gestation. Misoprostol has become an increasingly favored treatment because it evacuates the uterus more promptly. This randomized trial, conducted at several centers, compared misoprostol treatment with vacuum aspiration in 652 women with first-trimester pregnancy failure. They were randomly assigned, in a 3:1 ratio, to receive 800 μg misoprostol vaginally or to undergo vacuum aspiration. Misoprostol was given on day 1 and followed by a second dose on day 3 if expulsion was not complete. Vacuum extraction was done on day 8 if expulsion remained incomplete. Treatment was considered to have failed if a misoprostol-treated patient required surgery or if vacuum aspiration was repeated within 30 days. The most common form of early pregnancy failure, present in 58% of cases, was embryonic or fetal death, and the next most common, occurring in 36% of cases, was anembryonic gestation. Gestational age averaged 7.6 weeks. In women who completed the trial, success rates were 84% for those given misoprostol and 97% in those having vacuum aspiration. In misoprostol-treated women, products of conception were expelled entirely after a single dose in 71% of cases. A second dose was effective in 60% of cases when needed, for an overall success rate by day 8 of 84%. Success rates were lowest when there was an anembryonic gestation. In neither treatment group was the success rate related to gestational age at the time of treatment. Hemorrhage and pelvic infection were rare in both groups. Decreased hemoglobin was more frequent in misoprostol-treated women and they also were likelier to report nausea, vomiting, abdominal pain, and more severe pain. Nevertheless, 83% would recommend misoprostol treatment and 78% would probably or definitely have it again if necessary. Misoprostol, administered vaginally, is an effective and safe means of managing early pregnancy failure.