II. Indications
- Early Pregnancy Loss (<84 days)
- Termination of Pregnancy (<77 days, FDA approved for <70 days)
III. Contraindications
- Adrenal Insufficiency (Mifepristone)
- Chronic Corticosteroid use (Mifepristone)
- Suspected Ectopic Pregnancy, Septic Abortion or hemodynamic instability
- Bleeding Disorder
IV. Protocol
- Start: Mifrepristone (Mifeprex) 200 mg orally once
- Mifepristone is obtained directly from manufacturer by licensed medical provider
- Mifrepristone 200 mg is as effective as 600 mg dose
- Next: Misoprostol (Cytotec) 800 mcg vaginal, buccal, sublingual 24-48 hours later
- Vaginal Misoprostol is significantly more effective than oral route, with less gastrointestinal adverse effects
- Sublingual Misoprostol is is also more effective than oral Misoprostol
- Efficacy improves if followed by second dose Misoprostol 800 mcg 4 hours after first
- Second dose is recommended when Gestational Age >63 days (9 weeks)
- Misoprostol may be repeated for up to 3 total doses
- For buccal dosing, hold two of the 200 mcg Misoprostol in each cheek (total 800 mcg) for 30 minutes
- For vaginal dosing, insert four of 200 mcg Misoprostol in vagina (total 800 mcg), and lie supine for 30 minutes
- Vaginal Misoprostol is significantly more effective than oral route, with less gastrointestinal adverse effects
- Adjunctive, symptomatic management
- NSAIDs
- Heating pad
- Consider Ondansetron for Antiemetic
- Precautions for urgent or emergent return
- Fever
- Foul Vaginal Discharge
- Significant abdominal or Pelvic Pain >24 hours after Misoprostol dose
- Heavy Vaginal Bleeding (e.g. 4 pads in 4 hours)
- Persistent symptoms of ongoing pregnancy
-
Contraception
- May be started after Misoprostol dose
V. Efficacy
- Effectiveness >95% up to 63 day gestation
- Safe for same day use without Ultrasound, if within 42 days of first day of LMP (and no major risk factors for Ectopic Pregnancy)
VI. Adverse Effects
- Nausea or Vomiting
- Diarrhea
- Strong uterine cramping and heavier Vaginal Bleeding follows Misoprostol dose
- Onset within several hours
- Persists for 3-5 hours
- Lighter Vaginal Bleeding may persist for 9-16 days
VII. Complications
- Unplanned uterine aspiration required for pain or bleeding (8%)
- Significant Hemorrhage requiring transfusion (2%)
- Septic Abortion or pelvic infection (1.3%)
- Undiagnosed Ectopic Pregnancy
- Ongoing pregnancy
VIII. Imaging: Obstetric Ultrasound Indications
- Background
- Ultrasound is not needed in regular Menses, LMP within 56 days and no Ectopic Pregnancy risks or symptoms
- Ultrasound may be required by local law before Termination of Pregnancy
- Confirm Early Pregnancy Loss
- Confirm intrauterine pregnancy (not Ectopic Pregnancy)
- Assess Gestational Age to meet criteria for protocol
- Early Pregnancy Loss (<84 days)
- Termination of Pregnancy (<77 days, FDA approved for <70 days)
- Also obtain for risk of Ectopic Pregnancy
- Adnexal Mass
- Pelvic Inflammatory Disease
- Pregnancy with IUD in place
- Adnexal Mass or pain
IX. Labs
- Rh Status
- Administer RhoGAM if Rh Negative
- Home Urine Pregnancy Test
- Urine Pregnancy Test should be negative at 4 to 6 weeks after protocol
-
Quantitative bhCG
- Obtained to monitor serially to confirm completed Miscarriage
- Expect bHCG to fall by 50% in first 24 hours after Misoprostol
- Expect bHCG to fall by 80% in first 7 days after Misoprostol