Which of the following is the best decision for management in the near future?

A 28-year-old woman who has never been pregnant missed a menstrual period 4 weeks ago, an unusual circumstance for her. She has been using a barrier method of contraception. Until the past week she noticed nausea, but yesterday she passed much blood and now says she feels better, although she is still bleeding. Her beta-hCG level was 2,500 mIU, but the test was repeated 48 hours later and the level found to be 1,000 mIU. Pelvic examination is negative for adnexal mass and tenderness. Transvaginal pelvic ultrasound reveals intrauterine tissue. You diagnose missed spontaneous abortion. The patient’s vital signs are normal and her hemoglobin is within normal limits. She is not seriously concerned and in little pain. Which of the following is the best decision for management in the near future?

(A) Expectant observation
(B) Intravaginal misoprostol, 800 g
© Surgical evacuation of the uterus
(D) Naproxen, 500 mg twice daily if needed to control uterine cramps
(E) Initiation of oral contraceptive medication

The answer is B. Medical management of missed abortion is highly successful when the situation is uncomplicated and ectopic pregnancy is ruled out. Intravaginal misoprostol, a prostaglandin E analog, allows successful evacuation of the uterine contents. Dilatation and curettage is necessary when there is evidence of infection, bleeding is severe, or if the patient is extremely anxious or presses for such intervention. If the uterus is empty on ultrasonic study and expelled products of conception are confirmed and if none of the aforementioned complications are present, expectant observation only is needed. Symptomatic treatment ofcramps is inappropriate, as is initiation of contraception at this time. Naproxen, as an NSAID, is a protaglandin inhibitor, would delay evacuation of the uterus.