This study was a retrospective, descriptive case series conducted at Rabia Balkhi Hospital, a major tertiary obstetric referral center in Kabul, Afghanistan. Medical records of all women diagnosed with first-trimester missed abortion and managed with misoprostol between April 1, 2014, and March 31, 2015, were reviewed.

Study Population and Sampling

A universal sampling strategy was employed. All women meeting the diagnostic criteria for first-trimester missed abortion during the study period were included. No sampling or selection procedures were applied.

Women were eligible for inclusion if they were diagnosed with first-trimester missed abortion at a gestational age of ≤13+6 weeks, based on the last menstrual period and confirmed by ultrasonography. The diagnosis of missed abortion was established according to standard sonographic criteria, defined as the absence of fetal cardiac activity in an embryo with a crown–rump length of at least 7 mm or an anembryonic gestation with a mean gestational sac diameter of 25 mm or greater. Only patients who received vaginal misoprostol as the initial method of management were enrolled. Patients presenting with incomplete abortion, inevitable abortion, or septic abortion were excluded. Women with known coagulation disorders or documented hypersensitivity to prostaglandins were also excluded to ensure patient safety and diagnostic consistency with WHO–endorsed criteria for early pregnancy loss (13).

All included patients received an initial dose of 800 micrograms of misoprostol administered vaginally. During the study period, two dosing regimens were used in the obstetric unit: either three doses administered at 3-hour intervals or four doses administered at 8-hour intervals. The use of these regimens reflected differences in attending physicians’ clinical preferences. At the time of treatment, both dosing schedules were considered acceptable within the institution and consistent with prevailing regional practice.

Patients were observed for up to 24 hours following misoprostol administration to assess treatment response. Treatment success was defined as resolution of the missed abortion without the need for dilation and curettage (D&C). This included both complete spontaneous expulsion and cases in which evacuation and curettage (E&C) was performed only to remove minor retained products of conception after expulsion had already begun. In this clinical context, E&C was regarded as a minor follow-up procedure rather than a primary surgical intervention and was therefore not classified as treatment failure. Treatment failure was defined as the absence of uterine evacuation after completion of the prescribed misoprostol regimen, necessitating D&C.

Data were collected retrospectively from inpatient medical records, ultrasound logs, and hospital registries using a standardized data abstraction form. Extracted variables included maternal age, gravidity, gestational age, misoprostol dosing interval, treatment outcome, type of follow-up procedure performed, and any documented complications such as hemorrhage, infection, or uterine rupture. All patient identifiers were removed prior to data analysis to ensure confidentiality.

Data Analysis

Data were analyzed using Microsoft Excel. Descriptive statistics (frequencies, percentages, means, and ranges) were used to summarize patient characteristics and outcomes. Associations between maternal age, gravidity, dosing interval, and treatment failure were explored descriptively due to the small failure subgroup (n=22), which limited statistical power for inferential testing.

Ethical Considerations

Permission to access medical records was granted by Rabia Balkhi Hospital Administration. Ethical approval was obtained from the Ghalib University Research Ethics Committee (Approval Code: Af-Gh.U.H-R.E.C.2025_0033). As this was a retrospective study using anonymized records, informed consent was waived.

Results

During the one-year study period, 21,616 gynecological patients presented to the Outpatient Department of Rabia Balkhi Hospital, of whom 5,037 (23.3%) were admitted. A total of 492 women met the inclusion criteria for first-trimester missed abortion and received misoprostol management. The mean maternal age for the full cohort was 28.5 ± 5.2 years. Consistent with the demographic characteristics of the hospital’s patient population, the majority of women in the cohort were multigravida, as reflected in the gravidity profile of the treatment failure subgroup. A summary of patient distribution relative to total admissions is presented in Table 1.

Table 1: Gynecological Patient Admissions and Missed Abortion Cases

Of the 492 patients treated with vaginal misoprostol, 470 (95.5%) achieved treatment success, defined as resolution of missed abortion without the need for dilation and curettage (D&C). Treatment failure occurred in 22 patients (4.5%), all of whom required D&C (Table 2).

Treatment success consisted of two categories

Complete spontaneous expulsion occurred in 67 patients (13.6%). In the remaining 403 patients (81.9%), misoprostol induced uterine expulsion followed by evacuation and curettage (E&C).

E&C was performed only to remove minor retained products after the onset of expulsion and was not classified as treatment failure, as misoprostol successfully initiated uterine evacuation.

Table 2: Response to Vaginal Misoprostol (800 mcg)

Factors Associated with Treatment Failure: Descriptive comparisons were conducted to explore associations between patient characteristics and treatment failure. Inferential statistical testing was not performed due to the small size of the failure group (n = 22), which limits statistical power.

Among the 22 patients who experienced treatment failure, 31.8% were aged 20–28 years, 40.9% were aged 30–38 years, and 27.3% were aged 40 years or older (Table 3). Of the treatment failures, 2 patients (9.1%) were primigravida, while 20 patients (90.9%) were multigravida (Table 4). Regarding the misoprostol dosing schedule among failed cases, 10 patients (45.5%) had received misoprostol at 8-hour intervals, whereas 12 patients (54.5%) had received misoprostol at 3-hour intervals (Table 5). These descriptive patterns indicate a higher proportion of treatment failures among multigravida women and those aged 30–38 years.

Table 3: Treatment Failure by Maternal Age Group (n=22)

Table 4: Treatment Failure by Gravidity Status (n=22)

Table 5: Treatment Failure by Dosing Interval (n=22)

Across all 492 patients, no major complications including hemorrhage, uterine rupture, or infection were documented in the medical records. Among the 22 patients who underwent D&C following failed medical management, no complications were reported (Table 6). Mild expected effects of misoprostol (e.g., cramping, light bleeding) were not categorized as complications.

Table 6: Complications in Treatment Failure Group (n=22)

Table 7 summarizes the final clinical outcomes following misoprostol administration. Treatment success was defined as resolution of the missed abortion without the need for D&C. This included both complete spontaneous abortion and incomplete abortion managed with E&C, a minor follow-up procedure performed after misoprostol-induced expulsion had begun. In contrast, treatment failure was defined solely as the need for D&C, which was performed only when misoprostol failed to initiate uterine evacuation.

Table 7: Final Management Outcomes Following Misoprostol Administration (Success = Avoidance of D&C)

Table 8: Comparison of Findings from Rabia Balkhi Hospital with Published Literature

This retrospective case series evaluated the efficacy of 800 mcg vaginal misoprostol for managing first-trimester missed abortion at Rabia Balkhi Hospital. The primary outcome demonstrated that 95.5% (470/492) of patients avoided D&C, indicating that misoprostol was effective in initiating uterine evacuation in the vast majority of cases. However, only 13.6% (67/492) achieved complete spontaneous expulsion without any procedural assistance. The remaining successful cases (81.9%) required E&C to remove residual products of conception after expulsion had already begun. Thus, the 95.5% success rate reflects avoidance of D&C, rather than completion of management without any procedural intervention.

Treatment failure occurred in only 4.5% (22/492) of patients, all of whom required D&C. Among the failure group, most were multigravida (90.9%) and fell within the 30–38-year age group. No major complications were recorded. Collectively, these findings support the role of vaginal misoprostol as a highly effective and safe first-line approach for reducing the need for D&C in this setting. The overall success rate of 95.5% in our study compares favorably with rates reported in similar international studies. For instance, research from Mumbai and Pakistan reported higher failure rates of 8.7% and 10%, respectively (10-13). The superior efficacy observed in our cohort may be attributed to differences in patient demographics, strict adherence to a standardized protocol, or variations in gestational age at presentation (Table 8).

A significant contribution of this study is the analysis of factors associated with treatment failure, which have been less frequently reported in previous literature. We found that multigravidity was a prominent characteristic among non-responders, with 90.9% of failures occurring in MG patients. This finding suggests that obstetric history may influence uterine responsiveness to prostaglandins, a factor not extensively discussed in the studies from Mumbai or Pakistan (10-13). Similarly, we described the age distribution of non-responders, identifying those women aged 30-38 accounted for the largest proportion (40.9%) of failures. While the biological rationale for this is unclear and may be confounded by gravidity, it highlights a potential demographic for closer monitoring. The dosing regimen in our study (800 mcg vaginally, repeated every 3 or 8 hours) aligns with the WHO recommendations and previously published protocols (12, 13). The similar failure rates across the two interval groups (3-hour vs. 8-hour) in our non-responders suggest that the total dose or individual patient factors may be more critical to success than the interval alone, though this requires further prospective investigation.

The high efficacy and excellent safety profile of misoprostol demonstrated in this study support its role as a cornerstone of medical management for missed abortion. It offers a non-invasive alternative to D&C, thereby avoiding risks such as uterine perforation, cervical trauma, hemorrhage, and anesthesia-related complications (8, 9). This is particularly advantageous in resource-limited settings like Afghanistan, where surgical capacity and access may be constrained.

The identification of multigravidity as a potential predictor of failure has direct clinical implications. It suggests that MG patients may benefit from enhanced pre-treatment counseling regarding the possibility of requiring additional doses or surgical intervention. This allows for better management of patient expectations and preparedness. The primary strength of this study is its contribution of robust local data from a major Afghan hospital, filling a significant evidence gap. The use of a universal sample over a one-year period provides a comprehensive picture of real-world clinical outcomes.

Limitations

This study has several limitations inherent to its retrospective design. The analysis depended on the completeness and accuracy of medical records, which may have resulted in minor data omissions. Additionally, although the overall sample size was large, the number of treatment failures (n = 22) was relatively small. This limited our ability to conduct robust statistical analyses or identify independent predictors of treatment failure. As a result, characteristics observed more frequently among non-responders—such as multigravidity—should not be interpreted as definitive predictors, but rather as potential factors or common features observed within the failure group. Future studies with larger failure cohorts and multivariable analyses are needed to determine whether such characteristics represent true associations. Another limitation is the absence of long-term follow-up data, which prevented assessment of future fertility outcomes or late complications such as intrauterine adhesions. Furthermore, this study was conducted in a single tertiary hospital in Kabul, which may limit the generalizability of the findings to other healthcare settings in Afghanistan or beyond. Despite these limitations, the study provides important real-world evidence from a major clinical center and highlights areas in need of further research.

Conclusion

Vaginal misoprostol is a highly effective and safe treatment for first-trimester missed abortion at Rabia Balkhi Hospital, with a success rate exceeding 95%. This study provides crucial local evidence to guide clinical practice and policy in Afghanistan. Future prospective studies with larger sample sizes are warranted to confirm the associations between multigravidity, age, and treatment failure. Research should also investigate optimal, patient-tailored dosing regimens and incorporate long-term follow-up and patient-centered outcomes, such as satisfaction and psychological impact, to further optimize care.

Acknowledgements

The authors would like to thank the staff of the Medical Records Department at Rabia Balkhi Hospital for their assistance in data collection. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing Interests

The authors declare that they have no competing interests relevant to this study.

References