Background: Missed abortion is a common complication (1-5% of pregnancies) involving the retention of a non-viable embryo or fetus within utero. Diagnosis relies on ultrasound, revealing halted development and absent fetal heartbeat. If untreated it poses emotional distress and infection risk. Treatment options are surgical evacuation or medical management with abortifacients. Vaginal misoprostol is preferred for higher efficacy and quicker results, while oral misoprostol is more convenient but slightly less effective with longer treatment times. Both the rotes offer non-invasive alternatives to surgery, in management option of missed abortion. Objective: To compare the effectiveness of vaginal misoprostol over oral misoprostol in the medical management of missed abortion during the first trimester of pregnancy. Methods: The randomized controlled trial (RCT) was carried in the Department of Obstetrics and Gynecology, Institute of Child and Mother Health (ICMH), Matuail, Dhaka. The sampling method was random selection according to the availability of the patients. Data were collected from women aged 18-35 years. Patients diagnosed with missed abortion through ultrasonography (USG) and received medical management with vaginal misoprostol were considered as group I (n=36), while those received oral misoprostol comprised as group II (n=36). The outcome of termination of pregnancy in between group I and II were measured. The descriptive and inferential analysis was carried out using SPSSv26. p-value < 0.05 was considered as statistically significant. Results: This study found that vaginal misoprostol was significantly more effective than oral misoprostol, with a success rate of 80.6% compared to 55.6% (p=0.042). Vaginal misoprostol also required fewer doses and shorter induction-expulsion times (p=0.028, p=0.004). Surgical intervention was needed less frequently in the vaginal group (19.4% vs. 44.4%, p=0.042). Adverse effects differed, with more nausea/vomiting and fever in the oral group and more severe cramps and diarrhea in the vaginal group. Hemoglobin levels decreased similarly in both groups. The duration of bleeding favored vaginal misoprostol, but patient satisfaction significantly favored it as well (75.0% vs. 44.5%, p=0.029). Conclusion: Vaginal misoprostol is more effective than oral misoprostol in the medical management of missed abortion during the first trimester of pregnancy.