The use of Misoprostol in Gynecology and Obstetrics

A synthetic prostaglandin E1 analogue Misoprostol is marketed as the oral preparation that prevents tread gastroduodenal damage induced by NSAIDs nonsteroidal anti-inflammatory drugs. Misoprostol is also used for a variety of indications in the practice of gynecology and obstetrics, including medication abortion, medical management of miscarriage, cervical ripening before the surgical procedures, induction of labor, and the treatment of postpartum hemorrhage. 

Medication abortion 

The FDA approved medication abortion in 2000, using 600mg of oral mifepristone, which is a progesterone antagonist, with 400µg of oral Misoprostol for pregnancies that are up to 49 days of the gestation. There is much excellent evidence of efficiency for pregnancies up to 63 days of gestation using the regimens of 200mg of mifepristone followed orally by home administration of either 800µg of vaginal Misoprostol in 6-48 hours or 800µg of buccal Misoprostol in 24-36 hours. 

It’s recommended for women to return to the clinic 4 to 14 days later for clinical evaluation to document the complete abortion. Success rates range from 95 to 98 percent, while failure due to the ongoing pregnancy is around 1 percent. The majority of women undergo ultrasound for their pregnancy confirmation of complete abortion in the United States. In case of emergency, women who would like to have a medication abortion have to be able to adhere to a treatment regimen and also to have access to transportation and telephone of a medical facility. 

Contraindications to medication abortion with mifepristone may include concurrent anticoagulant therapy, hemorrhagic disorder, inherited porphyrias, concurrent long term systemic corticosteroid use, allergy to Misoprostol, mifepristone, or other prostaglandins, suspected or confirmed ectopic or molar pregnancy, and unwillingness to undergo a surgical abortion if needed. In case a woman has an IUD in place, it has to be removed before treatment. Women with some severe systemic illnesses such as acute cardiac, liver disease, renal or severe anemia need to be individually evaluated to determine which method of abortion would be the safest.  

The Use in First and Second Trimesters

Generally, the evidence is demonstrating many advantages of Misoprostol over other available alternatives for use in the medical management of miscarriage in the first and second trimesters. The benefits of Misoprostol are that it has fewer side effects, it’s at least as effective as alternatives, it’s much more practical to use, and it’s more affordable. Some recent research reports suggest that the alternatives to Misoprostol are used with a diminishing frequency. When using lower doses of Misoprostol, the occurrence of the maternal side effects is reduced, compared with the higher cumulate doses. The impacts of Misoprostol are dose-dependent and generally may include uterine contractions, cervical softening and dilation, vomiting, nausea, diarrhea, chills, and fever.

Medical Management of Miscarriage

Misoprostol can also be an option for the medical management of early pregnancy failure, including embryonic demise, anembryonic pregnancies, and an incomplete abortion for women that are at 12 or fewer weeks of gestation. In case a woman has an IUD, it has to be removed before the treatment. Similar to the medication abortion bleeding and cramping will occur with the pregnancy passage, and some side effects such as vomiting, nausea, diarrhea, chills, or fever. However, studies have shown that the Misoprostol is acceptable to most women for this indication

Conclusion

Misoprostol has many applications in gynecology and obstetrics. The FDA supports its off label use as long as it’s based on the sound of the medical evidence. It’s, however, a powerful drug that has to be used with care. The evidence-based information about the safest regimens of Misoprostol should be widely disseminated to prevent its inappropriate use. Given its ease of use and low cost, Misoprostol has a considerable potential to improve women’s health worldwide.