A woman at 10 weeks of gestation undergoes medical abortion with mifepristone 200 mg followed by misoprostol 800 mcg vaginally 48 hours later. She returns 2 weeks later with persistent spotting. Ultrasound shows a 10 mm thick endometrium. Serum β-hCG is 110 mIU/mL. What is the most appropriate next step?
- A Immediate surgical uterine evacuation (vacuum aspiration)
- B Repeat misoprostol 800 mcg vaginally and review in 1 week ✓
- C Clinical expectant management — low β-hCG indicates inevitable complete abortion
- D Re-administration of mifepristone 200 mg followed by misoprostol
Explanation
In an incomplete medical abortion at 2 weeks follow-up with a serum β-hCG of 110 mIU/mL (which, while low, is not at baseline) and thickened endometrium, the recommended approach per RCOG and WHO guidelines is a second dose of misoprostol (surgical intervention is not automatically indicated with low β-hCG). Surgical intervention is reserved for haemodynamic instability, heavy bleeding, patient preference, or evidence of retained products causing significant symptoms. A single rising or persistently elevated β-hCG after 4 weeks should raise concern for retained products or gestational trophoblastic disease, but at 2 weeks with low hCG, expectant or repeat medical management is preferred.
Reference: Williams Obstetrics, 26th ed.
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Written and medically reviewed by the StethoPrep medical team.