A Cochrane review [Abstract] 1 included 24 studies with a total of 5577 subjects with gestational age less than 13 weeks. Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; 2 studies, 150 women, random-effects; very low-quality evidence), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. For unplanned surgical intervention, there was not any difference between misoprostol and expectant care (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence).
Sixteen trials involving 4044 women addressed the comparison of misoprostol (7 studies used oral administration, 6 studies used vaginal, 2 studies sublingual, 1 study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.96, 95% CI 0.94 to 0.98; 15 studies, 3862 women, random-effects; very low-quality evidence) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.05, 95% CI 0.02 to 0.11; 13 studies, 3070 women, random-effects; very low-quality evidence) but more unplanned procedures (average RR 5.03, 95% CI 2.71 to 9.35; 11 studies, 2690 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.50, 95% CI 1.53 to 4.09; 11 studies, 3015 women, random-effects; low-quality evidence). No difference in women's satisfaction between misoprostol and surgery was identified (average RR 1.00, 95% CI 0.99 to 1.00; 9 studies, 3349 women, random-effects; moderate-quality evidence). More women had vomiting and diarrhoea with misoprostol compared with surgery (vomiting: average RR 1.97, 95% CI 1.36 to 2.85; 10 studies, 2977 women, random-effects; moderate-quality evidence; diarrhoea: average RR 4.82, 95% CI 1.09 to 21.32; 4 studies, 757 women, random-effects; moderate-quality evidence).Five trials compared different routes of administration, or doses, or both, of misoprostol. There was no clear evidence of one regimen being superior to another.
A Cochrane review [Abstract] 2 included 7 studies with a total of 1521 subjects. The expectant-care group was more likely to have an incomplete miscarriage by 2 weeks (RR 3.98; 95% CI 2.94 to 5.38; 4 trials, n=1263) or by 6 to 8 weeks (RR 2.56; 95% CI 1.15 to 5.69; 3 trials, n=430). The need for unplanned surgical treatment was greater for the expectant-care group (RR 7.35; 95% CI 5.04 to 10.72; 5 trials, n=1454). The mean percentage needing surgical management in the expectant-care group was 28%, while 4% of the surgical-treatment group needed additional surgery. The mean percentage needing blood transfusion was 1.4% for expectant care compared with none for surgical management. Results were mixed for pain. Diagnosis of infection was similar for the two groups (RR 0.63; 95% CI 0.36 to 1.12), as were results for various psychological outcomes. Pregnancy data were limited. Costs were lower for the expectant-care group (MD -499.10; 95% CI -613.04 to -385.16; in UK pounds sterling).
A network meta-analysis [Abstract] 3 included 78 randomised trials involving 17 795 women. In the incomplete miscarriage subgroup, suction aspiration and dilatation and curettage were compared with expectant management and medical treatment. The evidence was low to moderate. Anyhow, surgical methods were more effective than medical treatment or expectant management.
A prospective cohort study 4 assessed the acceptability and efficacy of vaginal misoprostol (800 µg) for first trimester miscarriage. Of 967 patients, 514 (53.2%) women were eligible for and consented to misoprostol. Surgical treatment was performed in the remaining 453 (46.8%) patients. One dose of misoprostol was successful in 69.8% (n=359) of patients, whereas 20 women required urgent surgery for bleeding (n=19) or suspected infection (n=1). Among the remaining 135 patients, 20 (14.8%) refused the second dose of misoprostol and opted for surgery. Expulsion of the gestational sac was obtained in 74 additional cases who completed the medical protocol, for an overall success rate of 87.7% (433/494). The majority of women receiving misoprostol did not experience any short-term complication (92.0%) or side effect (93.8%). Eight (1.6%) cases requiring delayed surgery for retained product of conception were identified at the postmedical treatment follow up, thus leading to an actual success rate of misoprostol of 86.0% (n=425).
A retrospective cohort study 3 (n=783) assessed the rate of surgical intervention for unsuccessful medical treatment with misoprostol in early pregnancy loss, according to gestational size by ultrasound. Gestational size greater than 9 weeks was independently associated with the need for surgical intervention compared with gestational size under 9 weeks (adjusted odds ratio 1.23, 95% Cl 1.01 to 1.51; P=0.040).
Date of latest search: 2025-09-16
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