›Higher failure rate than misoprostol
›Patient selection criteria
›Reliable follow-up and access to emergency care
›Hemodynamically stable without active significant hemorrhage
›No signs of infection
›Monitoring plan
›Serial beta-hCG every 48 hours until undetectable
›Ultrasound in 7 to 14 days to confirm complete expulsion
›Misoprostol (medical evacuation)
›Misoprostol 800 mcg vaginally for incomplete abortion
›Insert high into posterior vaginal fornix
›Onset of action 1 to 4 hours
›Repeat dose no earlier than 3 hours after first dose if incomplete response
›Mifepristone pretreatment improves complete expulsion rate
›Mifepristone 200 mg PO 24 hours before misoprostol
›Relative risk of complete expulsion 1.25 compared to misoprostol alone
›When available, mifepristone-misoprostol combination is preferred
›Efficacy and timing
›Complete expulsion within 7 days in 70 to 80% with vaginal misoprostol alone
›Follow-up ultrasound at 7 to 14 days to confirm
›Surgical evacuation offered if medical management fails
›Analgesic therapy
›Ibuprofen 600 to 800 mg PO every 6 to 8 hours
›Maximum 3,200 mg per 24 hours
›First-line for uterine cramping associated with expulsion
›Opioid analgesics for severe pain
›Codeine or oxycodone at standard doses
›Short course only; reassess at each contact
›Uterine aspiration (suction curettage)
›Manual vacuum aspiration (MVA)
›Preferred surgical technique for first-trimester incomplete abortion
›Comparable efficacy and safety to electric vacuum aspiration
›Can be performed in ED or procedure room under local anesthesia
›Electric vacuum aspiration
›Performed in operating room setting
›For gestations > 12 weeks or MVA unavailable
›Sharp curettage (D&C)
›Avoided when MVA available due to higher perforation and adhesion risk
›Reserved for situations where aspiration devices unavailable
›Pre-procedural antibiotic prophylaxis
›Doxycycline 100 mg PO 1 hour before procedure
›Reduces post-procedure infection risk
›ACOG Class I recommendation for antibiotic prophylaxis with surgical evacuation
›Complications of surgical evacuation
›Uterine perforation
›0.1 to 0.3% incidence with MVA
›Laparoscopy or laparotomy if perforation suspected with instability
›Intrauterine adhesions (Asherman syndrome)
›Risk increases with sharp curettage and infection
›Minimize with aspiration technique
Infection management (septic abortion)
›Empiric antibiotic regimen for septic abortion
›Ampicillin-sulbactam 3 g IV every 6 hours
›Broad gram-positive, gram-negative, and anaerobic coverage
›Renal dose adjustment required for GFR < 30 mL/min
›Alternative: piperacillin-tazobactam 4.5 g IV every 6 hours
›Extended infusion over 4 hours per local protocol
›Preferred if pseudomonal risk or more severe infection
›Add doxycycline 100 mg IV every 12 hours for chlamydial coverage
›Transition to oral when tolerating PO
›Total 14 days course for confirmed PID component
›Clindamycin 900 mg IV every 8 hours plus gentamicin 5 mg/kg IV daily
›Alternative regimen with excellent uterine tissue penetration
›Monitor renal function with aminoglycosides
›Duration of antibiotics
›Continue IV antibiotics until 24 to 48 hours afebrile after uterine evacuation
›Transition to oral completion after clinical improvement
›Total course 10 to 14 days for septic abortion
›Rh(D) immune globulin administration
›Indicated for all Rh-negative unsensitized patients with pregnancy bleeding
›Prevents alloimmunization that could harm future pregnancies
›ACOG Class I recommendation; AJOG evidence-based guidance
›Dose
›50 mcg (300 IU) for gestations < 12 weeks
›300 mcg if gestational age uncertain or dose unavailable
›Timing
›Within 72 hours of bleeding onset or procedure
›Later administration still provides partial protection up to 13 days
›Contraindication
›Rh-positive patients
›Already sensitized (indirect Coombs positive)