Misoprostol in Obstetrics and Gynecology
Weeks A, Faundes A.
Int J Gynaecol Obstet 2007;99:S156–S159..
Misoprostol has considerable potential for both good and harm in obstetrics and gynecology. It is unlicensed for many of the therapeutic procedures for which it is used, and prescribers could be vulnerable to litigation should things go wrong. The International Federation of Gynecology and Obstetrics (FIGO) has brought out recommended dosages for its use at the various stages of pregnancy-provided, of course, that its use is legal (eg, in the termination of pregnancy). The data are based on the work of the Bellagio Group.
However, oxytocin remains the first-line drug as it is more effective than misoprostol. It should be noted that the misuse of oxytocin is the biggest single cause of intrapartum complications. Its abuse by overdosage is implicated in two-thirds of medicolegal cases resulting in suboptimal outcomes,1 in two-thirds of cases of severe asphyxia,2 and, more recently, in half of cases resulting in abnormal cord blood gases.3
The overenthusiastic use of oxytocin is dangerous. The overenthusiastic use of misoprostol is equally dangerous and the guidelines as to its proper use do not guarantee safety. There are other, safer ways of inducing labor using balloon catheters.4
First, do no harm should be the priority high in our thoughts when using these powerful agents.5
| Early Pregnancy | ||
| Termination of pregnancy | 800 µg vaginally | 12 hourly maximum 3 doses |
| Incomplete miscarriage | 600 µg orally | Single dose |
| “Missed” miscarriage | 800 µg vaginally | 3 hourly maximum 2 doses OR |
| 600 µg sublingually | 3 hourly maximum 2 doses | |
| Cervical priming (1st trimester) | 400 µg vaginally | 3 hours preprocedure |
| Midtrimester | ||
| Termination of pregnancy | 400 µg vaginally | 3 hourly maximum 5 doses |
| Intrauterine fetal death, 13–17 weeks | 200 µg vaginally | 6 hourly maximum 4 doses |
| Intrauterine fetal death, 18–26 weeks | 100 µg vaginally | 6 hourly maximum 4 doses |
| Third Trimester | ||
| Intrauterine fetal death | 25–50 µg vaginally | 4 hourly maximum 6 doses |
| Induction of labor | 25 µg vaginally | 4 hourly maximum 6 doses OR |
| 20 µg oral solution | 2 hourly maximum 12 doses | |
| Postpartum | ||
| Postpartum hemorrhage prophylaxis | 600 µg orally or sublingually | Single dose |
Footnotes
These summaries are reproduced from the Journal Article Summary Service, a monthly publication summarizing clinically relevant articles from the recent world literature. Please see http://www.jassonline.com or e-mail atholkent@mweb.co.za for more information.
References
- 1.Jonsson M, Nordén SL, Hanson U. Analysis of malpractice claims with a focus on oxytocin use in labour. Acta Obstet Gynecol Scand. 2007;86:315–319. doi: 10.1080/00016340601181318. [DOI] [PubMed] [Google Scholar]
- 2.Berglund S, Grunewald C, Pettersson H, Cnattingius S. Severe asphyxia due to delivery-related malpractice in Sweden 1990–2005. BJOG. 2008;115:316–323. doi: 10.1111/j.1471-0528.2007.01602.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Jonsson M, Nordén-Lindeberg S, Östlund I, Hanson U. Metabolic acidosis at birth and suboptimal care-illustration of the gap between knowledge and clinical practice. BJOG. 2009;116:1453–1460. doi: 10.1111/j.1471-0528.2009.02269.x. [DOI] [PubMed] [Google Scholar]
- 4.Pennell CE, Henderson JJ, O’Neill MJ, et al. Induction of labour in nulliparous women with an unfavourable cervix: a randomised controlled trial comparing double and single balloon catheters and PGE2 gel. BJOG. 2009;116:1443–1452. doi: 10.1111/j.1471-0528.2009.02279.x. [DOI] [PubMed] [Google Scholar]
- 5.Steer P. Editor’s choice. BJOG. 2009;116:i–ii. doi: 10.1111/j.1471-0528.2009.02366.x. [DOI] [PubMed] [Google Scholar]