It is a fetal intrauterine death without expulsion of the products of conception.

Background Information:

Incomplete abortion: Clinical presence of an open cervical os and bleeding, whereby all products of conception have not been expelled from the uterus, or the expelled products are not consistent with the estimated duration of pregnancy. Common symptoms include vaginal bleeding and abdominal pain. Uncomplicated incomplete abortion can result after an induced or spontaneous abortion (i.e. miscarriage).

Intrauterine fetal demise (IUFD; fetal death): The intrauterine death of a fetus at any point in time during the pregnancy.

Medical methods of abortion (medical abortion): Use of pharmacological agents to terminate a pregnancy.

Miscarriage (spontaneous abortion): Spontaneous loss of a pregnancy prior to 24 weeks’ gestation, that is, before the fetus is usually viable outside the uterus. The clinical signs of miscarriage are vaginal bleeding, usually with abdominal pain and cramping. If the pregnancy has been expelled, the miscarriage is termed “complete” or “incomplete” depending on whether or not tissues are retained in the uterus.

Missed abortion: Arrest of pregnancy development where the embryo/fetus/embryonic tissue or empty gestational sac remains in the uterus and the cervical os is closed. Symptoms may include pain and/or bleeding, or there may be no symptoms at all.

Post-abortion care: Provision of services after an abortion, such as contraceptive services and linkage to other needed services in the community or beyond. It can also include management of complications after an abortion.

Surgical methods of abortion (surgical abortion): Use of transcervical procedures for terminating pregnancy, including vacuum aspiration, and dilatation and evacuation (D&E).

Key Messages:

Abortion:

1. Methods of Surgical abortion

For surgical abortion at <14 weeks

Recommend vacuum aspiration

Recommend against the practice of dilatation and sharp curettage (D&C), including sharp curette checks (i.e. to “complete” the abortion) following vacuum aspiration.

For surgical abortion at >=14 weeks

Recommend dilatation and evacuation (D&E).

2. Medical management of induced abortion

For medical abortion at <12 weeks

Recommend the use of 200 mg mifepristone administered orally, followed 1-2 days later by 800 ug misoprostol administered vaginally, sublingually or buccally. The minimum recommended interval between use of mifepristone and misoprostol is 24 hours.

When using misoprostol alone: Recommend the use of 800 ug misoprostol administered vaginally, sublingually or buccally.

(New) Suggest the use of a combination regimen of letrozole plus misoprostol (letrozole 10 mg orally each day for 3 days followed by misoprostol 800 ug sublingually on the fourth day) as a safe and effective option.

For medical abortion at >=12 weeks

Recommend the use of 200 mg mifepristone administered orally, followed 1-2 days later by 400 ug misoprostol administered vaginally, sublingually or buccally every 3 hours. The minimum recommended interval between use of mifepristone and misoprostol is 24 hours.

When using misoprostol alone: Suggest the use of repeat doses of 400 ug misoprostol administered vaginally, sublingually or buccally every 3 hours.

3. Missed abortion

(New) For missed abortion at <14 weeks

For individuals preferring medical management: Recommend the use of combination mifepristone plus misoprostol over misoprostol alone.

Recommended regimen: 200 mg mifepristone administered orally, followed by 800 ug misoprostol administered by any route (buccal, vaginal or sublingual).

Alternative regimen: 800 ug misoprostol administered by any route (buccal, vaginal or sublingual).

4. Intrauterine fetal demise (IUFD)

For medical management of IUFD at >=14 to <= 28 weeks

Suggest the use of combination mifepristone plus misoprostol over misoprostol alone.

Suggested regimen: 200 mg mifepristone administered orally, followed 1-2 days later by repeat doses of 400 ug misoprostol administered sublingually or vaginally every 4-6 hours. The minimum recommended interval between use of mifepristone and misoprostol is 24 hours.

Alternative regimen: Repeat doses of 400 ug misoprostol administered sublingually or vaginally every 4-6 hours.

Post-abortion:

1. Follow-up care or additional services

Following uncomplicated surgical or medical abortion

Recommend that there is no medical need for a routine follow-up visit. However, information should be provided about the availability of additional services if they are needed or desired.

2. Incomplete abortion

For incomplete abortion at <14 weeks

Recommend either vacuum aspiration or medical management

For the medical management of incomplete abortion at <14 weeks uterine size

Suggest the use of 600 ug misoprostol administered orally or 400 ug misoprostol administered sublingually.

For the medical management of incomplete abortion at >=14 weeks uterine size

Suggest the use of repeat doses of 400 ug misoprostol administered sublingually, vaginally or buccally every 3 hours.

Useful Links:

Link to related WHO news release:

https://www.who.int/news/item/09-03-2022-access-to-safe-abortion-critical-for-health-of-women-and-girls

Link to the new guidance documents:

https://www.who.int/publications/i/item/9789240039483

Link to Previous article (Part 1):

https://communitymedicine4all.com/2022/03/15/who-issues-new-guidance-on-abortion-9-march-2022-part-1/

Link to Previous article (Part 2):

https://communitymedicine4all.com/2022/03/15/who-issues-new-guidance-on-abortion-9-march-2022-part-2/

What is fetal intrauterine death?

What is complete and incomplete abortion?

What occurs when a fetus dies and is expelled from the body?