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Miscarriage is the most prevalent pregnancy complication, affecting about 20 to 30 percent of all pregnancies, mostly during the first trimester. I was aware of these statistics before my own experience, but I was still taken by surprise—not just by the emotional strain of the loss, but also by the difficult decisions I faced in completing the physical process of the miscarriage.
Pregnancy loss can occur in various ways. Sometimes it resolves naturally, without any intervention required. Other times, bleeding starts but then halts. Many miscarriages are identified in the same way mine was, during a routine ultrasound that revealed no heartbeat. It was obvious that the pregnancy was no longer viable, but I wasn't experiencing bleeding, and my body showed no indication of expelling the tissues.
We are typically presented with three choices for managing a miscarriage in the first trimester:
Let nature take its course, a process known as “expectant management” by doctors.
Undergo a procedure to remove the tissue through surgery, often referred to as “dilation and curettage” or D&C, which is a form of surgical management.
Take medication to induce a full miscarriage, a method known as “medical management.”
These options aren't flawless, and it can be daunting to weigh their risks and benefits while simultaneously processing the unfortunate news. I experienced this overwhelming feeling a few years ago, which led me to reference a study published earlier this summer. This study revealed ways to optimize medical management. The challenge lies in the fact that the ideal medication regimen includes a commonly used abortion drug, and restrictions on its use not only restrict women's access to abortion but also hinder evidence-based miscarriage care.
Before diving into the new study, let's briefly review the other available methods for managing a miscarriage.
Expectant management is a natural process, but it can be slow and unpredictable.
It may take weeks for a miscarriage to resolve naturally. One study on expectant management found that 40% of miscarriages were completed within one week, 70% within two weeks, and 81% by around seven weeks. The success rate was lower if there had been no bleeding yet or if the cervix remained closed (typically diagnosed as a “missed miscarriage” or “anembryonic pregnancy”), with only 52% of these cases resolving within two weeks using expectant management.
In the meantime, we find ourselves in a state of uncertainty, hoping the bleeding doesn't begin at an inconvenient time. Sacha Krieg, assistant professor of obstetrics and gynecology at Oregon Health & Science University, noted, 'Most patients say that just waiting that period of time and feeling pregnant but knowing it’s not a successful pregnancy—it’s really difficult.'
If the process drags on for too long, your OB might suggest trying another method. Otherwise, there’s a risk of 'retained products of conception,' meaning you could need multiple procedures to remove these calcified products from the uterus. While this is rare, as Krieg mentioned, 'I have seen that happen.'
After my miscarriage was confirmed, I spent two painful weeks waiting for the bleeding to begin—still experiencing pregnancy-related nausea and breast tenderness—yet my body stubbornly clung to the pregnancy. At that point, my OB advised a D&C, leading us to the next option.
Surgical management is quick and predictable but more invasive and costly.
Another way to manage a miscarriage is through surgical aspiration, which removes the pregnancy tissue from the uterus. This can be done in a doctor's office using a small suction device or in a surgery center with a more involved procedure called dilation and curettage (D&C). The latter requires stronger anesthesia and is more expensive. Surgical management has been the most commonly used method for completing a miscarriage, and in cases with heavy bleeding or signs of infection, it may be necessary.
The surgical method offers a quick and predictable solution, allowing you to avoid the bleeding and cramping that typically accompany the passing of the pregnancy. However, you may need to take a day off work for the procedure, and it’s usually more expensive than other options, depending on your insurance. (With my high-deductible insurance plan, my D&C medical bills totaled over $2,800. Despite that, the procedure itself was simple with a fast recovery, and I was relieved to move forward.)
There are, however, some real—though very rare—risks associated with a D&C, including anesthesia complications, uterine perforation, and the development of scar tissue or uterine adhesions. This last issue is particularly concerning for women with recurrent miscarriages who undergo multiple D&C procedures, as adhesions can lead to infertility, according to Krieg.
Medical management provides some control and is more affordable—if effective.
Medical management allows you to manage the miscarriage privately and comfortably at home, with more control than expectant management. The medication most commonly used is misoprostol (brand name Cytotec), a synthetic prostaglandin that helps soften the cervix and stimulate contractions in the uterus. (It’s also used to induce labor, treat postpartum bleeding, and as a treatment for peptic ulcers.) Misoprostol is inexpensive, stable at room temperature, and can be prescribed by your doctor for pickup at your local pharmacy.
In an ideal scenario, you could take misoprostol on a Friday evening and complete the miscarriage over the weekend. Like expectant management, you’ll experience heavy bleeding—greater than a typical period—often with cramping. Your doctor will usually prescribe pain medication and advise on how to monitor the bleeding. If you’re soaking more than three pads per hour for two to three hours, it’s time to visit the emergency room, said Krieg, but this is rare. 'Most women know when it’s too much,' she noted. Misoprostol may even reduce the risk of excessive bleeding by restricting blood flow to the uterus.
The drawback of misoprostol is that, like expectant management, it doesn't always succeed. For instance, one large study showed that 71 percent of women experienced a complete miscarriage within three days of using misoprostol. The remainder required a second dose, which boosted the overall success rate to 84 percent by day eight. If it’s ineffective, patients typically need a D&C.
New research offers ways to enhance medical management.
Courtney Schreiber, associate professor of obstetrics and gynecology at the University of Pennsylvania, noted in an email that the initial success rate left both her and her patients feeling frustrated. As a result, she designed a trial to test whether taking an additional medication, mifepristone, prior to misoprostol could improve outcomes. Schreiber and her team randomly assigned a racially and socioeconomically diverse group of 300 women to either take misoprostol alone or to take mifepristone followed by misoprostol 24 hours later. Women who had already experienced significant bleeding or had an open cervix were excluded, as misoprostol alone is already highly effective in those cases. The findings were published in June in the *New England Journal of Medicine*.
The study found that adding mifepristone to the treatment protocol significantly improved the outcome. Among those who used misoprostol alone, 67 percent had a successful miscarriage within four days and one dose of misoprostol. Meanwhile, 84 percent of those who received mifepristone followed by misoprostol completed the process in the same timeframe.
The remaining women in both groups were given a choice for the next steps: they could either wait longer, take a second dose of misoprostol, or opt for uterine aspiration. Overall, only 9 percent of the women who began with mifepristone ultimately required surgical aspiration, compared to 24 percent of those in the misoprostol-only group.
There was no noticeable difference between the groups in terms of pain intensity or bleeding, and the occurrence of infections or the need for blood transfusions was very low and comparable across both groups. Those who used mifepristone experienced vomiting more often than those on misoprostol (27% vs. 15%), but other symptoms like fatigue, headaches, dizziness, chills, nausea, diarrhea, cramping, and fever were similarly reported in both groups.
In an editorial accompanying the study, Carolyn Westhoff, a professor of obstetrics and gynecology at Columbia University Medical Center, mentioned that while the study didn't address the cost, 'faster treatment success would likely reduce costs (such as additional office visits, ultrasounds, and aspiration procedures) and minimize the related inconvenience.'
I personally opted for a D&C rather than medical management because I wasn’t willing to endure more waiting and uncertainty. If we had been aware of the higher success rates with mifepristone and it had been available to me, I might have chosen that path. I believe I would have preferred to save money, avoid surgery, and miscarry at home, sharing my grief with my husband.
Why access to mifepristone is restricted
However, there's a significant challenge in accessing mifepristone. It is also used to terminate pregnancies (in combination with misoprostol), and it's regulated by the FDA under a Risk Evaluation and Mitigation Strategy (REMS). These REMS restrictions mean that mifepristone is not available as a prescription at retail pharmacies. Instead, it must be stocked by certified medical providers, who are required to apply for and receive certification as mifepristone providers.
Krieg noted that most obstetricians don't stock mifepristone unless they provide abortions, and under the current system, many might not wish to change that. 'If a practice doesn’t want to be associated with pregnancy terminations, whether for safety reasons or other concerns, they may hesitate to offer it,' she said. Some physicians may also face restrictions from their institutions or health systems in becoming mifepristone providers. If mifepristone is only available through abortion providers, it would be out of reach for many women experiencing miscarriage, as six states only have one abortion provider and in some areas, it can take over 12 hours to reach the nearest one.
In the editorial accompanying Schreiber’s paper, Westhoff argued that requiring patients and providers to navigate the REMS process to access mifepristone is unnecessary. 'This restriction creates burdens for both women and clinicians, delaying care and likely reducing the use of this safer, more effective treatment approach,' she wrote.
The American College of Obstetricians and Gynecologists (ACOG) concurs. After the FDA reaffirmed the REMS in 2016, ACOG issued the following statement:
The REMS 'is no longer necessary for mifepristone, given its established safety. The requirement is inconsistent with the regulations for other drugs that carry similar or greater risks, especially considering the substantial benefit mifepristone offers to patients.'
Advocating for the removal of these restrictions, other authors have pointed out that the death rate associated with mifepristone is lower than that of erectile dysfunction drugs, which are not subject to a REMS plan. Mifepristone's safety history shows that complications such as infection and heavy bleeding are rare, treatable, and also occur with other OB-GYN procedures. There is no evidence suggesting that requiring women to obtain the medication from a healthcare provider rather than a pharmacy reduces the risks—only that it increases the cost of distribution and limits access for women in need of it.
Krieg stated that mifepristone provides a more effective and efficient method for completing a miscarriage. She expressed a desire to see fewer restrictions on prescribing the drug, noting that many of her patients, especially those in rural areas, must travel long distances to her office, which presents an obstacle to access.
If you experience a miscarriage and opt for medical management, it may require self-advocacy to receive evidence-based care in the current restrictive environment. If your healthcare provider does not offer mifepristone, inquire about the reasons behind this decision and ask for a referral to someone who does. (You can find mifepristone providers here—though the lists may not be exhaustive.)
Schreiber emphasized that all healthcare professionals caring for women who might experience a miscarriage should be registered and capable of providing mifepristone. Women seeking this treatment should be aware that mifepristone is only available through a clinician’s office and should advocate for its availability wherever they seek care.
