Antepartum

Mifepristone and Misoprostol Protocol for Early Pregnancy Loss

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Mifepristone and Misoprostol Protocol for Early Pregnancy Loss, Mifepristone and Misoprostol Protocol for Termination of Pregnancy

  • Indications
  1. Early Pregnancy Loss (<84 days)
  2. Termination of Pregnancy (<77 days, FDA approved for <70 days)
  • Contraindications
  1. Adrenal Insufficiency (Mifepristone)
  2. Chronic Corticosteroid use (Mifepristone)
  3. Suspected Ectopic Pregnancy, Septic Abortion or hemodynamic instability
  4. Bleeding Disorder
  • Protocol
  1. Start: Mifrepristone (Mifeprex) 200 mg orally once
    1. Mifepristone is obtained directly from manufacturer by licensed medical provider
    2. Mifrepristone 200 mg is as effective as 600 mg dose
  2. Next: Misoprostol (Cytotec) 800 mcg vaginal, buccal, sublingual 24-48 hours later
    1. Vaginal Misoprostol is significantly more effective than oral route, with less gastrointestinal adverse effects
      1. Sublingual Misoprostol is is also more effective than oral Misoprostol
    2. Efficacy improves if followed by second dose Misoprostol 800 mcg 4 hours after first
    3. For buccal dosing, hold two of the 200 mcg Misoprostol in each cheek (total 800 mcg) for 30 minutes
    4. For vaginal dosing, insert four of 200 mcg Misoprostol in vagina (total 800 mcg), and lie supine for 30 minutes
  3. Adjunctive, symptomatic management
    1. NSAIDs
    2. Heating pad
    3. Consider Ondansetron for Antiemetic
  4. Precautions for urgent or emergent return
    1. Fever
    2. Foul Vaginal Discharge
    3. Significant abdominal or Pelvic Pain >24 hours after Misoprostol dose
    4. Heavy Vaginal Bleeding (e.g. 4 pads in 4 hours)
    5. Persistent symptoms of ongoing pregnancy
  5. Contraception
    1. May be started after Misoprostol dose
  • Efficacy
  1. Effectiveness >95% up to 63 day gestation
  2. Safe for same day use without Ultrasound, if within 42 days of first day of LMP (and no major risk factors for Ectopic Pregnancy)
    1. Goldberg (2022) Obstet Gynecol 139(5): 771-80 [PubMed]
  • Adverse Effects
  1. Nausea or Vomiting
  2. Diarrhea
  3. Strong uterine cramping and heavier Vaginal Bleeding follows Misoprostol dose
    1. Onset within several hours
    2. Persists for 3-5 hours
    3. Lighter Vaginal Bleeding may persist for 9-16 days
  • Complications
  1. Unplanned uterine aspiration required for pain or bleeding (8%)
  2. Significant Hemorrhage requiring transfusion (2%)
  3. Septic Abortion or pelvic infection (1.3%)
  4. Undiagnosed Ectopic Pregnancy
  5. Ongoing pregnancy
  1. Confirm Early Pregnancy Loss
  2. Confirm intrauterine pregnancy (not Ectopic Pregnancy)
  3. Assess Gestational age to meet criteria for protocol
    1. Early Pregnancy Loss (<84 days)
    2. Termination of Pregnancy (<77 days, FDA approved for <70 days)
  4. Also obtain for risk of Ectopic Pregnancy
    1. Adnexal Mass
    2. Pelvic Inflammatory Disease
    3. Pregnancy with IUD in place
    4. Adnexal Mass or pain
  • Labs
  1. Rh Status
    1. Administer RhoGAM if Rh Negative
  2. Quantitative bhCG
    1. Obtained to monitor serially to confirm completed Miscarriage
    2. Expect bHCG to fall by 50% in first 24 hours after Misoprostol
    3. Expect bHCG to fall by 80% in first 7 days after Misoprostol
  • References
  1. MacNaughton (2021) Am Fam Physician 103(8) 473-80 [PubMed]
  2. Schreiber (2018) N Engl J Med 378(23): 2161-70 [PubMed]
  3. Zhang (2022) Cochrane Database Syst Rev (5): CD002855 [PubMed]