All methods are reasonable for the management of early miscarriage

Reference

Chu J, Hardy P, Beeson L, Coomarasamy C. What is the best method for managing early miscarriage? BMJ 2020;368:l6438. doi: 10.1136/bmj.l6438

Synopsis

These authors identified relevant Cochrane Reviews and recent randomized studies that attempted to answer this question. Women with abdominal pain or vaginal bleeding early in their pregnancy (< 14 weeks') should be assessed by ultrasound, and women who are hemodynamically unstable should be treated with emergency suction curettage. Otherwise, women should be offered expectant management, medical treatment, or surgical management. Based on 3 Cochrane reviews of 24 studies of 5577 women, surgical approaches have the highest success rate of complete miscarriage (96%), followed by medical management (81%) and expectant management (56%). However, in the first trimester medical and surgical management produce similar outcomes in indirect comparison (network meta-analysis). The optimal length of time of expectant management is not clear. United Kingdom guidelines suggest 1 week to 2 weeks and US guidelines suggest up to 8 weeks before intervening, except in women with excessive bleeding. For medical management, 800 micrograms of misoprostol can be given vaginally or orally, with 600 to 800 micrograms repeated for incomplete miscarriage. Oral mifepristone, 200 mg, if available, may provide additional benefit if given 24 hours before misoprostol, based on the results of one study.