ABSTRACT
Medical Vs. Expectant Management l Medical management involved mostly vaginal miso-
prostol (9) l 24 RCTs, n ¼ 1888, of embryonic/fetal demise or anem-
bryonic pregnancy l Vaginal misoprostol compared with expectant man-
agement: l Shortens the time to achieve complete uterine evacuation:
l At less than 24 hours after treatment (RR 4.73, 95% CI 2.70-8.28)
l At less than 48 hours after treatment (RR 5.74, 95% CI 2.70-12.19)
l Results in less need for uterine curettage l Does not show a significant difference in need for
blood transfusion (RR 0.2, 95% CI 0.01-4.0) l Does not have a significant increase in nausea (RR
1.38, 95% CI 0.43-4.40) or diarrhea (RR 2.21, 95% CI 0.35-14.06)
l Dosage of vaginal misoprostol: When compared with lower dosages, 800 mg vaginal misoprostol is more effective at completing uterine emptying (RR 0.85, 95% CI 0.72-1.00) with similar incidence of nausea
l No advantage of “wet” versus “dry” preparation of vaginal misoprostol or of adding methotrexate
l Oral misoprostol is less effective than vaginal misoprostol in emptying the uterus (RR 0.90, 95% CI 0.82-0.99)
l Sublingual misoprostol is equivalent to vaginal misoprostol in inducing complete uterine emptying but was associated with more frequent diarrhea
l Mifepristone: Two trials of mifepristone added to misoprostol show conflicting results
l Conclusion: Medical management with 800 mg of vaginal misoprostol is significantly more effective than expectant management (9,17)
Expectant Vs. Surgical Management l Cochrane review of five RCTs, n ¼ 689 (18)
l Expectant management has a higher incidence of the following: l Incomplete miscarriage (RR 5.3, 95% CI 2.57-11.22)
l Of note, time interval to diagnose incomplete miscarriage differed among studies
l Need for unplanned or additional surgical emptying of the uterus (RR 4.78, 95% CI 1.99-11.48)
l Bleeding l More days of bleeding [weighted mean differ-
ence (WMD) 1.59, 95% CI 0.74-2.45] l Greater amount of bleeding (WMD 1.00, 95%CI
0.60-1.40) l Expectant management has a lower incidence of infec-
tion (RR 0.29, 95% CI 0.09-0.87) l Although differences were found between expectant
versus surgical management, none of these differences were clinically serious
l Patient preference should guide decision-making (18)
