The review includes a wide variety of different interventions which have been analysed across 23 different comparisons. These were compared with surgical management, expectant management, placebo, or different types of medical interventions were compared with each other. The main interventions examined were vaginal, sublingual, oral and buccal misoprostol, mifepristone and vaginal gemeprost.
Further research is needed on drug doses, routes of administration and potential adverse effects, including future fertility, and also on women's views of drug treatment, surgery and waiting for spontaneous miscarriage.įorty-three studies (4966 women) were included. The use of misoprostol can have some side effects such as nausea and diarrhoea, but risks of severe blood loss or pelvic infection were not higher compared to surgical treatment or expectant management. Using misoprostol as an alternative to surgical treatment may decrease the need for surgery for women with an early fetal death. Mifepristone did not appear to provide any additional benefit when added to misoprostol. However the quality of this evidence was found to be very low and so we are not convinced of these findings. Single studies found mifepristone to be more effective than placebo and vaginal misoprostol to be more effective than expectant management. There was little difference between different routes of giving misoprostol when trials compared the vaginal route with placing it under the tongue or between oral and vaginal misoprostol. Vaginal misoprostol made little difference to pelvic infection, blood loss, pain or women's satisfaction/acceptability of method when compared to surgical management. Vaginal misoprostol was less effective in accomplishing a complete miscarriage compared to surgical management and may be associated with more nausea and diarrhoea. It is uncertain whether vaginal misoprostol when compared to placebo reduces blood loss or pain because the quality of the evidence for these outcomes was found to be very low. Vaginal misoprostol may hasten miscarriage when compared with placebo but made little difference to rates of nausea, diarrhoea or to whether women were satisfied with the acceptability of the method. The quality of the evidence ranged from very low or low for most comparisons. Furthermore, we compared different doses and administration routes in order to detect which regimen most often induces a complete miscarriage with the fewest side effects.įor this updated review, 43 randomised clinical trials involving 4966 women with non-viable pregnancies at less than 24 weeks' gestation were included. We set out to determine if medical treatment is as good as, or better than, surgical treatment or expectant management (waiting for the expulsion to happen). These can be avoided if the non-viable pregnancy is treated with medication, or if the woman is able to wait for a spontaneous expulsion. It carries risks of damage to the uterus or cervix and possible development of fibrous tissue in the inner lining of the uterus. Surgical treatment has the disadvantage of requiring anaesthesia.
Gastro-intestinal side effects such as nausea and diarrhoea, cramping or abdominal pain and fever have been reported with misoprostol. Women who retain the dead embryo/fetus can experience severe blood loss or develop an infection of the womb. Waiting for spontaneous expulsion is also possible. These and similar drugs may be useful in bringing on expulsion in women with a non-viable pregnancy and can be used before 24 weeks' gestation. Mifepristone blocks the activity of progesterone, a hormone that supports pregnancy. Misoprostol and gemeprost are synthetic prostaglandin E analogues that can stimulate expulsion of the embryo/fetus from the uterus. In the past, treatment for a deceived embryo/fetus, has usually been by dilatation and curettage (D&C) surgery, but drugs have now been developed to replace the need for surgery which may be helpful for the expulsion to happen. Sometimes an embryo may not have even developed ('empty sac'). This natural death of an embryo or fetus ('non-viable pregnancy' or 'intrauterine fetal death', depending on the duration of pregnancy) can be identified by ultrasound before symptoms like blood loss and abdominal pain occur. A miscarriage is the spontaneous death and/or expulsion of an embryo or fetus from the uterus before it is able to survive on its own.
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