Chapter 3. Recommendations and best practice statements across the continuum of abortion care
Clinical services Recommendation 31: Medical management of missed abortion at gestational ages < 14 weeks (3.4.3)
3.4.3 Missed abortion
Missed abortion is when a pregnancy stops developing, where the embryo/fetus/embryonic tissue or empty gestation sac remains in the uterus and the cervical os is closed. Symptoms may include pain, bleeding or no symptoms at all. If an ultrasound is done, the scan may show an embryo or fetus without cardiac activity, or what appears to be an early developing pregnancy, with only a fluid-filled sac visible within the uterus (151). Medical, surgical (vacuum aspiration) and expectant management are all options for management of missed abortion.
CLINICAL SERVICES Recommendation 31 (NEW): Medical management of missed abortion at gestational ages < 14 weeks
For missed abortion at < 14 weeks, for individuals preferring medical management: Recommend the use of combination mifepristone plus misoprostol over misoprostol alone.
- Recommended regimen: 200 mg mifepristone administered orally, followed by 800 μg misoprostol administered by any route (buccal, sublingual, vaginal).*
- Alternative regimen: 800 μg misoprostol administered by any route (buccal, sublingual, vaginal).ǂ
- The decision about the mode of management (expectant, medical or surgical) of missed abortion should be based on the individual’s clinical condition and preference for treatment.
- Expectant management can be offered as an option on the condition that the woman, girl or other pregnant person is informed of the longer time for expulsion of the pregnancy tissue and the increased risk of incomplete emptying of the uterus.
- Pregnancy tissue should be treated in the same way as other biological material unless the individual expresses a desire for it to be managed otherwise.
* The minimum recommended interval between use of mifepristone and misoprostol is 24 hours.
ǂ If using the alternative regimen (misoprostol alone), it should be noted that at gestational ages ≥ 9 weeks, evidence shows that repeat dosing of misoprostol is more effective to achieve success of the abortion process. In this guideline we do not provide a maximum number of doses of misoprostol.
Regarding who is recommended to provide medical management of missed abortion at < 14 weeks of gestation, refer to Recommendation 28 for medical management of induced abortion at gestational ages < 12 weeks.
A systematic review was undertaken to address this key question. Twenty studies reporting on management for missed abortion were identified by the search strategy. These studies were conducted in China, Germany, India, Israel, Malaysia, Pakistan, Sweden, Thailand, United Kingdom, USA and Yemen. A summary of the evidence is presented in Supplementary material 2, EtD framework for Medical management of missed abortion at < 14 weeks.
Of these studies, 19 were assessed that included one of the following comparisons:
- Mifepristone and misoprostol versus misoprostol alone
- Medical versus expectant management
- Surgical versus medical/expectant management
Medical management in comparison to expectant management produced lower rates of ongoing pregnancy and higher rates of successful abortion (uterine evacuation without surgical intervention), based on moderate- to high-certainty evidence. When comparing the combination regimen with misoprostol alone, the combination regimen produced higher rates of successful abortion. This recommendation is based on moderate-certainty evidence. Complications and side-effects were also fewer, based on moderate- to high-certainty evidence. Women expressed greater satisfaction with the combination mifepristone plus misoprostol regimen, based on high-certainty evidence. Surgical management in comparison to medical and expectant management produced higher rates of successful abortion, based on low- to moderate-certainty evidence. Discussion of women’s values and preferences underlined the importance of offering the option of all three types of management to the woman. For the medical regimen, the expert panel determined that given the varied regimens of the included studies, the recommended and suggested regimens for induced abortion at < 12 weeks of gestation can be applied (see Recommendation 27).
KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO MANAGEMENT OF MISSED ABORTION
- Everyone has a right to privacy and confidentiality in sexual and reproductive health (SRH) care.
- Abortion regulation should be human rights and evidence based.
- States must ensure adequate access to essential medicines in an affordable and non-discriminatory manner.
- Everyone has the right to scientific progress and right to health, which requires the availability and accessibility, acceptability, and quality of medical abortion. This means that States should ensure access to abortion medicines, and that evidence-based standards and guidelines for the provision and delivery of SRH services, are (i) in place and (ii) routinely updated to incorporate medical advancements.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.