Expectant management, as long as the woman is clinically stable, is a safe option to consider in a first trimester miscarriage and can avoid the need for surgery. However, the likelihood of spontaneous expulsion of the pregnancy declines rapidly after a week of expectant management and the emotional toll of prolonging the completion of the pregnancy loss can be significant.
Women who have an incomplete miscarriage respond better to expectant management than those with a missed or an anembryonic pregnancy loss.
Risks of expectant management include a risk of incomplete miscarriage and the need for subsequent surgical or medical management and heavy bleeding and pain.
Misoprostol is a prostaglandin analogue that is licensed to be used in the treatment of peptic ulcers. It can be given orally, vaginally, rectally and sublingually. Misoprostol has the effect of inducing uterine contractions and softening the cervix and can be used for the treatment of incomplete, missed and anembryonic pregnancy loss.
Incomplete miscarriages can be managed with misoprostol with success rates of up to 99% whilst success rates in missed and anembryonic miscarriage are not as high and are said to be of the order of 60-83%.
The recommended dosage according to NICE guidelines is:
Missed miscarriage: single dose of 800micrograms of misoprostol either vaginally or orally.
Incomplete miscarriage: single dose of 600miscrograms either vaginally or orally
Risks of medical management using misoprostol include diarrhoea, vomiting, abdominal pain, fever and chills and incomplete miscarriage requiring a surgical procedure. Heavy bleeding can be experienced requiring admission to hospital in a small number of cases.