Last reviewed: October 16, 2022
Recommendation:
- Medical methods or dilatation and evacuation (D&E) may be offered for treatment of incomplete abortion or intrauterine fetal demise.
- Recommended medication regimen:
- Incomplete abortion: Misoprostol 400mcg buccally, sublingually or, in the absence of vaginal bleeding, vaginally every three hours until expulsion.
- Intrauterine fetal demise (up to 24 weeks): Misoprostol 400mcg buccally, sublingually or, in the absence of vaginal bleeding, vaginally every 4-6 hours until expulsion. Where available, add pretreatment with mifepristone 200mg orally 1-2 days before misoprostol.
In practice:
- Uterine size, not gestational age, should be used to determine treatment for postabortion care.
Strength of recommendation: Strong
Quality of evidence: Low
Background
The majority of postabortion care research and programs focus on people with uterine size less than 13 weeks (Ipas, 2013). However, where unsafe abortion is prevalent, as many as 40% of women needing postabortion care present at or after 13 weeks gestation (Ministry of Health of Kenya, Ipas, & Guttmacher Institute, 2013). Individuals may present with incomplete abortion, retained placenta, fetal demise or ruptured membranes, all of which require uterine evacuation.
Medical regimens
Evidence is limited to suggest the optimal medical regimen for postabortion care at or after 13 weeks uterine size, but systematic reviews of the literature suggests that at least 200mcg vaginally, sublingually or buccally given every six hours is effective (Bracken et al., 2014; Mark, Borgatta, & Edelman, 2015). Two trials that randomized women to treatment with 200mcg or 400mcg of vaginal misoprostol found that the higher dose of misoprostol resulted in higher expulsion rates at 24 and 48 hours (Dickinson & Evans, 2002; Eslamian et al., 2007). Pretreatment with mifepristone 1-2 days before misoprostol increases rates of abortion success within 24 hours and reduces the time to fetal expulsion (Allanson et al., 2021; Bracken et al., 2020; Chaudhuri & Datta, 2015; Panda & Singh, 2013). A systematic review of medical treatment for intrauterine fetal demise found when the dose of 400mcg was administered every four hours, it was more effective with lower rates of adverse events when compared with other doses; however, no direct comparisons exist to inform whether four hours is indeed the ideal interval (Cleeve, Fonhus & Lavelanet, 2019)
D&E
No studies have compared medical management versus vacuum aspiration or D&E for postabortion care at or after 13 weeks. D&E can be offered for postabortion care where skilled providers and supportive facilities exist (World Health Organization [WHO], 2022).
Who can provide postabortion care for individuals with a uterine size of 13 weeks gestation or larger?
WHO makes service delivery recommendations for the provision of postabortion care for individuals with a uterine size of 13 weeks gestation or larger (WHO, 2022). WHO advises that D&E is within the scope of practice of specialty medical practitioners, and recommends provision of D&E by generalist medical practitioners based on expected competencies for that role. WHO suggests that in settings where established mechanisms exist to include associate and advanced associate clinicians, midwives, and traditional and complementary medicine professions in other tasks related to maternal and reproductive health care, they can safely and effectively provide D&E, based on expected skills and knowledge for these health worker roles. WHO recommends the provision of medical management of IUFD by specialty and general medical practitioners, and suggests that in contexts where established and easy access to appropriate surgical backup and other infrastructure necessary to address possible complications exists, associate and advanced associate clinicians, midwives, nurses, auxiliary nurses and auxiliary nurse midwives, and traditional and complementary medicine professionals can also safely and effectively provide this service, based on the expected competencies for these health workers (WHO, 2022). For further information about health worker roles in abortion care, see Appendix C: World Health Organization recommendations for health worker roles in abortion care.
Resources
Protocols for Medical Abortion (dosage card)
References
Allanson, E.R., Copson, S., Spilsbury, K., Criddle, S., Jennings, B., Doherty, D.A., Wong, A.M., & Dickinson, J.E. (2021). Pretreatment with mifepristone compared with misoprostol alone for delivery after fetal death between 14 and 28 weeks gestation: A randomized controlled trial. Obstetrics & Gynecology, 137(5), 801-809.
Bracken, H., Ngoc, N. T., Banks, E., Blumenthal, P. D., Derman, R. J., Patel, A., . . . Winikoff, B. (2014). Buccal misoprostol for treatment of fetal death at 14-28 weeks of pregnancy: A double-blind randomized controlled trial. Contraception, 89(3), 187-192. DOI:10.1016/j.contraception.2013.11.014
Bracken, H., Ngoc, N.T.N., Ha, D.Q., Paredes, N.R., Quyet, V.B., Linh, N.T.H., Ortiz, M.A., Bousieguez, M., & Winikoff, B. (2020). Mifepristone pretreatment followed by misoprostol 200mcg buccal for the medical management of intrauterine fetal death at 14-28 weeks: A randomized, placebo-controlled, double blind trial. Contraception, 102(1), 7-12.
Chaudhuri, P., & Datta, S. (2015). Mifepristone and misoprostol compared with misoprostol alone for induction of labor in intrauterine fetal death: A randomized trial. Journal of Obstetrics and Gynaecology Research, 41(12), 1884-1890.
Cleeve, A., Fonhus, M.S., & Lavelanet, A. (2019). A systematic review of the effectiveness, safety, and acceptability of medical management of intrauterine fetal death at 14-28 weeks of gestation. International Journal of Gynaecology and Obstetrics, 147(3), 301-312.
Dickinson, J. E., & Evans, S. F. (2002). The optimization of intravaginal misoprostol dosing schedules in second-trimester pregnancy termination. American Journal of Obstetrics & Gynecology, 186(3), 470-474.
Eslamian, L., Gosili, R., Jamal, A., & Alyassin, A. (2007). A prospective randomized controlled trial of two regimens of vaginal misoprostol in second trimester termination of pregnancy. Acta Medica Iranica, 45(6), 497-500.
Ipas. (2013). Woman-centered postabortion care: Reference manual (2nd ed.). K.L. Turner & A.B. Huber (Eds.). Chapel Hill, NC: Ipas.
Mark, A., Borgatta, L., & Edelman, A. (2015). Second trimester postabortion care for ruptured membranes, fetal demise, and incomplete abortion. International Journal of Obstetrics & Gynaecology, 129(2), 98-103.
Ministry of Health of Kenya, Ipas, and Guttmacher Institute. (2013). Incidence and complications of unsafe abortion In Kenya: Key findings of a national study. African Population and Health Research Center: Nairobi.
Panda, S., Jha, V., & Singh, S. (2013). Role of combination of mifepristone and misoprostol verses misoprostol alone in induction of labour in late intrauterin [sic] fetal death: A prospective study. Journal of Family and Reproductive Health, 7(4), 177-179.
World Health Organization. (2022). Abortion Care Guideline. Geneva: World Health Organization.