Complication Clinical Presentation Management Options Occurrence Rate
Problematic bleeding and/or cramping
  • Prolonged cramping, pain and/or bleeding
  • Retained gestational sac or tissue may be seen on US; inappropriate decline in hCG
  • Expectant management
  • Repeat misoprostol
  • Uterine aspiration
(varies by study & GA)
Continuing Pregnancy
  • May have scant bleeding after medications, persistent pregnancy symptoms
  • Ongoing viable intrauterine pregnancy (growing gestational sac or cardiac activity on US; rapidly rising hCG)
  • Uterine aspiration
  • Repeat misoprostol (if embryonic pole seen, expulsion occurred in 36% with and 54% without gestational cardiac activity)1
  • Repeat mifepristone and misoprostol (patient-centered approach but lacking evidence)
ā‰¤63 d: <1%2,3

64-70 d:
3.6% with 1 dose, 0.4% with 2 doses2,3

71-77 d: 1.6% with 2 doses3


  • Typical endometritis: fever (>24 hours after misoprostol), pelvic/abdominal pain, vaginal discharge with odor, uterine/adnexal tenderness
  • Atypical endometritis: included here for historical importance.
    • Incidence: extremely rare; 0.58 per 100,000 MABs in U.S.
    • Etiology: Clostridium sordelii- or perfringens-mediated toxic shock syndrome; can be severe or fatal.
    • Occurs 2-7 days after MAB
    • Symptoms: nausea, abdominal bloating, diarrhea, pain, malaise
    • Signs: usually afebrile, tachycardic, hypotensive, elevated WBC & hgb
  • Follow CDC guidelines for antibiotic therapy
  • Uterine aspiration if retained tissue present
  • Immediate hospitalization and aggressive treatment for atypical infection
0.01-0.5%2, 5

< 10 case reports by CDC4

Ectopic Pregnancy
  • May be asymptomatic or present with minimal bleeding or inappropriate decline in hCG after misoprostol, persistent positive urine pregnancy test
  • May present with pelvic/abdominal pain, history of bleeding or spotting during the pregnancy, shoulder pain, tachycardia/hypotension.
  • Treat or refer as appropriate
(in study of GA < 6 weeks in the U.S.)2
Excessive Bleeding
  • Heavy or prolonged vaginal bleeding with associated signs or symptoms (may include Hgb drop >2 points, orthostatic hypotension, tachycardia)
  • True hemorrhage is life-threatening emergency; rare but can occur
  • May result from retained pregnancy tissue; may present 2-5 weeks after mifepristone
  • Medical management (misoprostol, NSAIDs)
  • Uterine aspiration
  • FeSo4
  • Blood transfusion
  • FeSo4
<0.02-0.6% 2,5

  1. Reeves 2008
  2. SFP ACOG 2014 Clinical Guidelines
  3. NAF Clinical Practice Guidelines 2020
  4. Meites 2010
  5. Chen 2015


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