Misoprostol, sold under the brand name Cytotec among others, is a medication used to prevent and treat stomach ulcers, start labor, cause an abortion, and treat postpartum bleeding due to poor contraction of the uterus. For abortions it is used by itself and with mifepristone or methotrexate
Misoprostol is a synthetic prostaglandin E1 analogue that is used off-label for a variety of indications in the practice of obstetrics and gynecology, including medication abortion, medical management of miscarriage, induction of labor, cervical ripening before surgical procedures, and the treatment of postpartum hemorrhage. Due to its wide-ranging applications in reproductive health, misoprostol is on the World Health Organization Model List of Essential Medicines. This article briefly reviews the varied uses of misoprostol in obstetrics and gynecology.
he FDA approved medication abortion using 600 mg of oral mifepristone, a progesterone antagonist, with 400 µg of oral misoprostol 48 hours later for pregnancies up to 49 days of gestation. However, there is excellent evidence of efficacy up to 63 days of gestation using the regimens of 200 mg of mifepristone orally followed by home administration of either 800 µg of buccal misoprostol in 24 to 36 hours or 800 µg of vaginal misoprostol in 6 to 48 hours.22,23 Women then return 4 to 14 days later for a clinical evaluation to document complete abortion. Success rates for these regimens range from 95% to 98%, with failure due to ongoing pregnancy in approximately 1%. In the United States, most women undergo ultrasound for pregnancy dating and confirmation of complete abortion. However, serial serum β-human chorionic gonadotropin (βhCG) levels can also be used to confirm complete abortion.
Candidates for medication abortion must be able to adhere to the treatment regimen as well as have access to a telephone and transportation to a medical facility in case of emergency. Multiple gestation is not a contraindication to medication abortion provided that the pregnancy is no more than 49 to 63 days, depending on the regimen being used. Contraindications to mifepristone medication abortion include hemorrhagic disorder; concurrent anticoagulant therapy; inherited porphyria's; chronic adrenal failure; concurrent long-term systemic corticosteroid use; confirmed or suspected ectopic or molar pregnancy; allergy to mifepristone, misoprostol, or other prostaglandin; and unwillingness to undergo a vacuum aspiration if needed. If the woman has an intrauterine device in place, it must be removed before treatment. Women with serious systemic illnesses (eg, severe cardiac, renal, or liver disease or severe anemia) should be evaluated individually to determine which method of abortion is safest. Rhesus (Rh)-negative women typically receive Rh immune globulin on the day of mifepristone administration.
Medication abortion necessarily involves heavy bleeding and cramping as the pregnancy is expelled. Other transient side effects from misoprostol include nausea, vomiting, diarrhea, fever, and chills. At the follow-up visit, ongoing pregnancies are most commonly treated with suction curettage because of the risk of congenital anomalies. Women with persistent nonviable pregnancies may opt for expectant management, a repeat dose of misoprostol, or suction curettage. Mifepristone medication abortion is safe with an estimated complication rate of 2.2 per 1000 women. The most frequent complications are heavy bleeding requiring curettage and/or transfusion and infection. The estimated mortality rate for mifepristone abortion is 1 per 100,000 women, most commonly due to fatal sepsis Where mifepristone is not available, medication abortion can be accomplished with methotrexate and miso The objective was to learn what complications some women experienced in Madagascar following use of misoprostol for abortion and what treatment they received post misoprostol use.
This was a qualitative study in 2015–2016 among women who had experienced complications after use of misoprostol, with or without additional methods, for abortion; what information they received before use; what dosage and regimens they used; what complications they experienced; and what treatment they received postuse. We initially conducted in-depth, semistructured interviews with 60 women who had undergone an abortion that resulted in complications. The results presented here are based on interviews with the subset of 19 women who had used misoprostol.
he 19 women were aged 16–40, with an average age of 21–26 at interview and average age of 18–21 at abortion. To obtain an abortion, they sought advice from partners, friends, family members, and/or traditional practitioners and health care providers. Misoprostol was easily accessible through the formal and informal sectors, but the dosages and regimens the women used on the advice of others were extremely variable, did not match WHO guidelines and were apparently ineffective, resulting in failed abortion, incomplete abortion, heavy bleeding/hemorrhage, strong pain and/or infection.
Health care providers who provide abortion care and treatment of abortion complications need training in correct misoprostol use and treatment of complications. Women and pharmacy workers also need this information. Law and policy reforms are needed to allow training and provision of safe services. Further research is needed on the extent and impact of incorrect misoprostol administration.
Most of the women said they were only able to give an estimate of how many weeks pregnant they were at the time of misoprostol use. A small number had used misoprostol as soon as they noticed they had delayed menses. The estimates of the others varied from 2 to 2.5 months pregnant, to about 3 months pregnant, about 4 months pregnant and 5 months pregnant, but almost all were below 12 weeks.
Their use of misoprostol was also haphazard. Ten of the women had used misoprostol in varying dosages following a consultation with a midwife or doctor; seven had self-administered the pills in amounts they decided upon themselves; and two had used the pills following a consultation with a traditional birth attendant. Most of the seven women who self-medicated took the pills orally. They took between 8 and 20 tablets, spaced out at different intervals — half an hour, an hour, 2 h or 12 h. Only two women who self-administered the misoprostol used vaginal administration. Of those two, one woman used 10 Cytotec pills in total, administering two tablets vaginally every 3 h. The other inserted one misoprostol tablet vaginally and took nine tablets orally every 30 min.
When the misoprostol was prescribed by a health care provider, the administration and number of tablets were just as varied as with self-use. Some prescribed oral use only (for example, taking anything from 7 to 12 tablets one by one at hourly intervals). One midwife in a health center prescribed four pills, one every evening. Others prescribed combined vaginal and oral administration — for example, inserting between one and four tablets vaginally and then taking between 2 and 10 tablets orally, one by one, at hourly intervals. One traditional birth attendant prescribed one tablet of misoprostol every 12 h for 2 days to one woman. Some health professionals also used another method along with the misoprostol (for example, a probe or an oxytocin injection), or prescribed misoprostol preceding a curettage. One woman described some kind of simultaneous surgical intervention:
“The doctor made me lie down on a bed. First, he introduced I don't know, a round thing. It seemed to me that it turned like a spring does, when he inserted it in the passage. Afterwards, he introduced the probe, and he left the probe in. And he said, ‘You're going home, but you're going to come back here tomorrow.’ He gave me Cytotec, Cytotec, small tablets, he gave me some. He said: ‘Here are the Cytotec tablets, when it's seven o'clock sharp, you'll swallow two and you'll introduce two in the vagina. When it's eight o'clock, you'll do the same thing. When it's nine o'clock, you'll do the same. Then at ten o'clock, it's the last time.’”
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