Abstract Background: Manual vacuum aspiration (MVA) is a safe and effective technology for the treatment of missed miscar-riage but it is not widely available and affordable in rural areas particularly in low resource countries. Misoprostol is an alternative to manual vacuum aspiration for the treatment of missed miscarriage. Aim of Study: The purpose of this study was to compare the effectiveness, patient satisfaction and hematocrit drop of misoprostol versus MVA to understand the potential role of misoprostol as a first line for treatment of first trimester missed miscarriage. Patients and Methods: A Randomized Controlled Trial was conducted from January 2020 to January 2021 at Mansoura University Maternity Hospital. Included 70 participants were randomized to treatment with either MVA or 800µg vaginal misoprostol. The main outcome measures assessed at 1 week follow up were complete uterine evacuation, patient's accept-ability and satisfaction. Results: There is no statistically significant difference between studied groups regarding success rate and mean patient satisfaction score immediately and after one week, 82.9% of misoprostol group and 94.3% of MVA group suc-cesses. The mean hemoglobin and hematocrit after treatment illustrated statistically significant lower mean value among misoprostol group than MVA group (10.07 & 10.91, respec-tively for Hb) and (30.75 & 33, respectively for hematocrit value). Hemoglobin drop for both groups illustrated no statis-tically significant difference between studied groups. There is statistically significant negative correlation between en-dometrial thickness/mm and satisfaction after one week among both group. Conclusion: Both misoprostol and MVA had high rates of satisfaction and complete uterine evacuation, which could ultimately reduce maternal complications from abortion. Medical treatment is as effective as surgical treatment of first trimester missed miscarriages. Recommendations: Although misoprostol is a very effec-tive drug, the health care professional should have thorough knowledge of the dose, side effects, complications and contraindications before prescribing it. More studies with larger sample size are needed to elucidate the optimal method for missed miscarriage management and patient satisfaction.