SOCIAL EM & POPULATION HEALTH
Mifepristone in the Emergency Department: Evidence-Based Management of Early Pregnancy Loss
SAEM PULSE | MAY-JUNE 2025
By Juhi Varshney, MD; Katarina Bielinski, PharmD; Kelly Pfiefer, MD; Marta Rowh, MD, PhD; Ian Bishop, MD, MPH; and Mark Supino, MD; on behalf of the SAEM Academy for Women in Academic Emergency Medicine
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Early pregnancy loss (EPL) is a common diagnosis in the emergency department (ED). The standard of care includes three options: expectant, medical, and procedural management. Procedural management typically involves uterine aspiration performed by an obstetrician-gynecologist (OB-GYN). Medical management, however, falls within the scope of emergency medicine, yet it remains underutilized in many EDs. There is broad consensus that the medications used for medical management of EPL—misoprostol
and mifepristone—are safe and generally well tolerated. Although these medications are also used for medical abortion, which has contributed to some confusion and stigma, a substantial body of evidence supports their effectiveness in treating EPL when used together. Misoprostol can be used alone or in combination with mifepristone. Many EDs include misoprostol on their formularies. When used alone, misoprostol has a success rate of 67% at day three. When combined with mifepristone, success rates
increase to 83% at day three and 89% at day eight. Some studies have found the combination to be 92–96% effective. Patients also appear to experience fewer adverse effects and are less likely to require uterine aspiration when both medications are used. The American College of Obstetricians and Gynecologists recommends the addition of mifepristone to EPL treatment when available. Despite this evidence, mifepristone is not included on the hospital formulary in many EDs. Emergency physicians interested in offering