Zhang J et al. (2005) A comparison of medical management with misprostol and surgical management for early pregnancy failure. N Engl J Med 353: 761–769

The current treatment of choice for early pregnancy failure is vacuum aspiration. Medical management with misoprostol is a novel therapy, but no large trials have yet investigated the efficacy and safety of this drug. Zhang et al. compared misoprostol with surgical management for treatment of women with early pregnancy failure.

In this randomized trial, women were eligible if they had an anembryonic gestation, embryonic or fetal death, or incomplete or inevitable spontaneous abortion. In total, 652 women were enrolled, of whom 491 were randomly assigned to receive 800 μg misoprostol administered vaginally, and 161 women to have vacuum aspiration on study day 1. If the uterus did not completely expel all intended contents by day 3, a repeat 800 μg dose was given.

In the misoprostol group, successful expulsion of intended contents, after a second misoprostol dose when necessary, occurred in 84% of women who completed the trial. If the uterus still did not completely expel all intended contents by day 8, vacuum aspiration was offered. This compared with a success rate of 97% in the vacuum aspiration group. Misoprostol treatment failed in 16% of women, whereas 3% of women in the surgical group required a second operation.

The authors conclude that misoprostol is safe and effective for the treatment of early pregnancy failure and an acceptable alternative to surgical management. The risk of hemorrhage and pelvic infection was low (1% or less), similar to that of surgical management. Side effects were generally mild and tolerable.