Inpatient medical management can be difficult to organize. It is dependent on the availability of an inpatient bed, preferably in a side room to allow some degree of privacy. As both of these resources are relatively scarce, this can be hard to achieve.
The alternative management option would be medical management in an outpatient setting. This appears to be successful and acceptable to women.18 In terms of management of incomplete miscarriage, there appears to be little increased efficacy over expectant management and therefore managing these women medically may lead to unnecessarily increased rates of gastrointestinal side effects.3
The real advantage of medical management is in the outpatient management of early fetal demise, where the success rates vastly supersede those of expectant management. There appears to be no difference in the success rates of medical management with regard to gestation sac size or crown-rump length.5 Unlike expectant management, the absence of vaginal bleeding does not decrease the success rates.18
Although still not absolutely clear, the evidence suggests optimal management is with vaginally administered misoprostol, presumably ensuring effective blood levels with minimal side effects. In terms of practicability it would be beneficial perhaps to give one vaginal dose of misoprostol in the early pregnancy clinic, to ensure optimal bioavailability. Then either prescribe oral, lower misoprostol doses to be administered at home or a further dose of vaginal misoprostol (which has been shown to be successfully self-inserted).21,27
As for expectant management, women need to be informed in no uncertain terms of the amount of bleeding and pain that they are likely to experience and the diarrhoea and vomiting that they may expect as side effects of misoprostol. If the patient is not likely to be compliant then a conservative management approach is not a safe option. If medical management fails and surgical curettage is carried out, it appears that there may be less surgery-related complications, probably due to the softening effect on the cervix allowing easier instrumentation of the uterine cavity.26
Outpatient medical management should however only be practiced in units which have the facility for 24-hour contact and the option to review and potentially admit patients who experience excessive pain and/or haemorrhage.
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