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Mifepristone and Misoprostol Protocol for Early Pregnancy Loss
Aka: Mifepristone and Misoprostol Protocol for Early Pregnancy Loss, Mifepristone and Misoprostol Protocol for Termination of Pregnancy
- Indications
- Early Pregnancy Loss (<84 days)
- Termination of Pregnancy (<77 days, FDA approved for <70 days)
- Contraindications
- Adrenal Insufficiency (Mifepristone)
- Chronic Corticosteroid use (Mifepristone)
- Suspected Ectopic Pregnancy, Septic Abortion or hemodynamic instability
- Bleeding Disorder
- Protocol
- Start: Mifrepristone (Mifeprex) 200 mg orally once
- Mifepristone is obtained directly from manufacturer by licensed medical provider
- Next: Misoprostol (Cytotec) 800 mcg vaginal, buccal, sublingual 24-48 hours later
- Efficacy improves if followed by second dose Misoprostol 800 mcg 4 hours after first
- 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
- 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
- Efficacy
- Effectiveness >95% up to 63 day gestation
- 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
- 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
- Imaging: Obstetric Ultrasound Indications
- 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
- Labs
- Rh Status
- Administer RhoGAM if Rh Negative
- 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
- References
- MacNaughton (2021) Am Fam Physician 103(8) 473-80 [PubMed]
- Schreiber (2018) N Engl J Med 378(23): 2161-70 [PubMed]