COMPARING MANAGEMENT OPTIONS FOR EPL

Clinically stable people can choose among the following management options to achieve completion of EPL, or switch from one to another during the process:

• Expectant management (“watchful waiting”)
• Medication management with misoprostol, adding mifepristone where available
• Aspiration in an outpatient or operating room setting

Choosing from among these options is a preference-sensitive decision (Shorter 2018), as each option is safe and relatively effective, and greater satisfaction is reported when treated according to preference.

Studies show a wide range of success rates for expectant and medication management, varying by type of EPL, US vs clinical endpoints, and management timing (i.e. when aspiration is offered). Expectant management is more successful when the process of expulsion has already begun, compared to other types of EPL. Cliniciansshould offer counseling specific to the type of EPL (anembryonic, EPL in progress, etc.), success rates (see Comparison Table below), and the time they are willing to wait until completion.

Expectant Management

Expectant or spontaneous completion of EPL can be offered to those who are clinically stable, for 6-8 weeks if they remain stable and amenable. “Watchful waiting” may avoid intervention and attendant side effects or complications (Nanda 2012; See Table below).

Clinicians may reassess every 1-2 weeks by telehealth or in-person to monitor progress and confirm continued preference for expectant management vs. another option for faster resolution. Pain and other symptom management can be addressed similarly to medication abortion (see Ch. 4: Pain Management).

Given slightly increased rates of bleeding with expectant vs. aspiration management (Ghosh 2021), people with anemia (e.g. hgb < 9) or those with other bleeding risks (i.e. bleeding disorders or use of anticoagulants) may be best managed with aspiration (Nanda 2012). Clinicians should also consider additional factors that may impact safety such as local laws/policies, risk for criminalization if higher level of care is indicated urgently, and potential need for travel to or from more or less restricted areas.

Medication Management

Medication management offers a shorter, more predictable time to completion with less follow up when compared to expectant management, avoids uterine aspiration, and is a cost-effective outpatient option that may be available through a primary care clinician. Pain and other symptom management can be addressed similarly to medication abortion (see Ch. 4: Pain Management). Prophylactic antibiotics are not recommended for medication management of EPL (SFP 2025).

Mifepristone and Misoprostol

Treatment with mifepristone 200 mg orally followed by misoprostol results in a higher likelihood of successful EPL management than treatment with misoprostol alone (relative risk 1.25), with significantly less likelihood of uterine aspiration (relative risk 0.37), and a trend toward less bleeding (Schreiber 2018, Dzuba 2015). Additional cost of mifepristone is usually offset by fewer follow-up visits. If presenting with heavier bleeding (≥2 pads/hour), may skip Mifepristone, add Motrin, and seek ER care if no improvement in 1 hour. Misoprostol is dosed 7-48 hours after mifepristone, much like with medication abortion. Mifepristone requires one clinician in an organization to register with a mifepristone manufacturer (See Ch. 4: Medication Abortion).

<sup>1. Highest success rates: vaginal misoprostol taken between 7-20h after mifepristone (Flynn 2021)
2. 800mcg misoprostol should be repeated 4 hours later if > 9 weeks or if no bleeding < 9 weeks
3. Sublingual dosing safe and effective, but may be associated with higher side effect profile</sup>

Misoprostol Alone

Misoprostol alone is effective and safe in treating EPL, when mifepristone is not available or covered. Although dosing guidelines vary, evidence supports that the misoprostol doses below are equally effective for managing incomplete EPL (Do 2020, Kim 2017). Some studies show higher levels of bleeding and more follow-up with misoprostol compared to aspiration (Davis 2007, Ghosh 2021, Zhang 2005), so individuals with severe anemia (Hgb <9) or bleeding risk factors may be best managed with aspiration (See Chapter 3: Hemorrhage Risk Factors).

Uterine Aspiration

Uterine aspiration is the most definitive and rapid EPL management option and has the highest success rate (Ghosh 2021). Aspiration may be chosen to avoid medication side effects or for expedited procedural care in the office. MVA or EVA can be performed safely in the outpatient office or the ED. Costs and bleeding-related complications are greater in the OR vs. office settings, and may add unnecessary patient burdens (Dalton 2006). If uterine aspiration is used to manage EPL, there is moderate evidence for the use of prophylactic antibiotics (ACOG 2018, Islam 2021, SFP 2025). See Chapter 6: Aspiration Steps.

Comparison of Management Options for EPL