Misoprostol

Prompt treatment of postabortion complications, whether the abortion is spontaneous (miscarriage) or induced, can save women’s lives. The PAC Consortium seeks to make technology and drugs for the treatment of postabortion complications more widely available.  Evidence shows that misoprostol is a safe technology that can be used by mid-level providers and other health care workers for uterine evacuation. It can be used in settings close to the community, like health posts where lower level providers work and infection prevention capacity may be poor, as long as referral plans are in place for failed evacuations.

PAC Consortium | General Resources | Training Materials | Studies & Assessments


PAC Consortium Materials

Misoprostol for Postabortion Care
Misoprostol for PAC Task Force, Updated August 2014
This factsheet provides guidance on who can use misoprostol for PAC, the recommended regimens, and minimum requirements for treatment of incomplete abortion or miscarriage with misoprostol. Use of misoprostol for PAC is endorsed by WHO, FIGO, ACOG, ICM and other international organizations. It reflects the recommendations on misoprostol for PAC stated in the 2012 WHO publication “Safe Abortion: Technical and Policy Guidance for Health Systems.” Also available in French.

General Resources

Ethical guidelines on conscientious objection in training
FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health, 2014

The American College of Obstetricians and Gynecologists Practice Bulletin no. 150. Early pregnancy loss
Committee on Practice Bulletins-Gynecology, 2015

Mifepristone plus misoprostol or misoprostol-alone for treatment of intrauterine fetal death 12-24 weeks’ LMP
Gynuity Health Projects, 2014
Gynuity Health Projects convened an expert meeting in 2013 looking at the use of mifepristone and misoprostol for treatment of intrauterine fetal death 12-24 weeks’ LMP. Professionals with epidemiological, clinical and programmatic expertise reached consensus on the appropriate use of mifepristone and misoprostol or misoprostol-alone to induce fetal and placental expulsion with a demised fetus. The results were compiled in a brochure called “Instructions for Use – (IFU).” The information in this document may serve as a basis for the development of clinical practice guidelines and patient and provider education materials.

Mifepristone plus misoprostol or misoprostol-alone for abortion induction in pregnancies 12-24 weeks’ LMP
Gynuity Health Projects, 2014
Gynuity Health Projects convened an expert meeting in 2013 looking at the use of mifepristone and misoprostol for abortion induction in pregnancies 12-24 weeks’ LMP. Professionals with epidemiological, clinical and programmatic expertise reached consensus on the appropriate use of mifepristone and misoprostol or misoprostol-alone for termination of pregnancies with a live fetus. The results were compiled in a brochure called “Instructions for Use – (IFU).” The information in this document may serve as a basis for the development of clinical practice guidelines and patient and provider education materials.

Map of Misoprostol Approval
Gynuity Health Projects
Gynuity Health Projects tracks the approval of misoprostol throughout the world. This map reflects the latest information about the registration of this medication. If you become aware of registration in new countries, please write to pubinfo@gynuity.org.

High Impact Practices in Family Planning Brief
USAID, 2013
Provision of family planning services and commodities as part of treatment for incomplete abortion is one of the three proven High Impact Practices for Family Planning identified by USAID. Contraceptive counseling should be offered immediately following treatment and should occur in the same location.

Misoprostol in Obstetrics and Gynaecology (website)
Weeks, Fiala, and others, including experts convened by WHO
Misoprostol in Obstetrics and Gynaecology
This independent website provides the dosage guidelines for misoprostol that were produced by an expert group convened by WHO in Bellagio in February 2007 along with extensive resources on availability, off-label use, dangers, etc. The bibliography section includes close to 2,000 articles and resources related to misoprostol. Also available in Dutch and Spanish.

In Kenya, use of misoprostol for postabortion care gains momentum
This article was published in Medical Abortion Matters (May 2012)
Thanks to recent policy changes and the positive results of a pilot study, Kenya is poised to realize the full benefits of misoprostol for postabortion care (PAC).

The Role of Misoprostol in Scaling-Up PAC Services
Sahin-Hodoglugil N and Prata N, 2011
This letter is a response to the RamaRao et al. article “Postabortion Care: Going to Scale“. The authors highlight the need to include misoprostol in scale-up of PAC services, as it is highly effective and can be provided at the community-level by trained providers.

Misoprostol and medical abortion in Africa
Ipas, 2009
In sub-Saharan Africa, estimates for maternal mortality reach 920 deaths — mostly caused by postpartum hemorrhage — per 100,000 live births. This four-page brochure describes how the medicine misoprostol, a proven yet underutilized technology, can prevent and treat a number of pregnancy-related conditions, including postpartum hemorrhage and incomplete abortion.

ACOG Committee Opinion: Misoprostol for Postabortion Care
American College of Obstetricians and Gynecologists (ACOG), Committee on International Affairs, 2009
The ACOG Committee on International Affairs released their opinion on the use of misoprostol for PAC.  They note that there is increasing evidence that misoprostol is a safe, effective, and acceptable method to achieve uterine evacuation for women needing PAC.

Application to WHO Essential Medicines List
Gynuity Health Projects, 2008
The World Health Organization has included misoprostol for treatment of incomplete abortion and miscarriage in its Model List of Essential Medicines (EML). Gynuity Health Projects submitted the application to WHO based on strong evidence for misoprostol’s safety and efficacy in the treatment of incomplete abortion and miscarriage; a number of other agencies submitted letters in support of the application.  The inclusion of misoprostol in the EML may improve access to the medication where the need for it is greatest.

Training Materials

Uso de Misoprostol en obstetricia y ginecología (Use of Misoprostol in obstetrics and gynecology)
Federación Latinoamericana de Sociedades de Obstetricia y Ginecología, 2013
This manual (only available in Spanish) is intended to provide guidance for health practitioners to make appropriate treatment decisions regarding the use of Misoprostol for obstetric and gynecologic conditions including but not limited to induction of labor, abortion, incomplete and missed abortion, and postpartum hemorrhage.

Misoprostol for treatment of incomplete abortion: A training guide
Ipas and Gynuity, 2012
This training guide is intended for programmers and trainers intending to introduce misoprostol for incomplete abortion in low-resource settings. It provides approaches to prepare providers including efficacy, safety, and acceptability; eligibility, criteria, and precautions; dosing, timing, and routes of administration; visit schedule and management of complications; counseling and information provision; and integration of misoprostol into existing PAC services. Available in English, French, and Spanish.

Misoprostol use in postabortion care: A service delivery toolkit
Ipas and Venture Strategies Innovations, 2011
This toolkit is designed to help district or national-level clinicians, facility managers or program managers initiate the use of misoprostol as a medical treatment for incomplete abortion or integrate misoprostol into existing postabortion care services. Select tools are available for download below:

Misoprostol for Treatment of Incomplete Abortion: An Introductory Guidebook
Gynuity Health Projects, 2009
This resource is for clinicians and women’s health advocates.  Based on current scientific evidence, the guidebook offers detailed information about misoprostol for this indication including: efficacy, safety and acceptability; eligibility criteria and precautions; dosing, timing and routes of administration; visit schedule and management of complications; counseling and information provision; integration of misoprostol into existing PAC services.  This document is available in additional languages on Gynuity’s website.

Providing Medical Abortion in Low-resource Settings: An Introductory Guidebook, 2nd Edition
Gynuity Health Projects, 2004, 2009
This tool was developed for health care providers and policy makers who are interested in introduction of medical methods for safe termination of early pregnancy. It describes evidence-based regimens and practical considerations for introducing the method as part of abortion care, especially as related to low-resource settings.

Instructions for Use: Misoprostol for Treatment of Incomplete Abortion and Miscarriage
Gynuity Health Projects, Reproductive Health Technologies Project, 2008
The information in this document may serve as a basis for the development of clinical practice guidelines and patient and provider education materials. The brochure was updated in June, 2008 based on new information and research developments.  Also available in Spanish, Turkish, French, Russian, Arabic, Portuguese.

Studies and Assessments

Comparison of treatment of incomplete abortion with misoprostol by physicians and midwives at district level in Uganda: a randomised controlled equivalence trial
Klingberg-Allvin M, Cleeve A, Atuhairwe S, Tumwesigye NM, Faxelid E, Byamugisha J, Gemzell-Danielsson, 2015

Oral misoprostol as first-line care for incomplete abortion in Burkina Faso
Blandine T, Ouattara AZ, Coral A, Hassane C, Clotaire H, Dao B, Lankoande J, Diop A, Blum J, 2012
This study examined oral misoprostol use for treatment of incomplete abortion in lower-level hospitals where PAC services were not previously available. 100 women presented with incomplete abortion and 98% had a complete abortion within 1 week of using 400 mcg of misoprostol.  Women using misoprostol for incomplete abortion reported high levels of satisfaction, tolerable side-effects, and less pain than experienced in previous surgical evacuations. In Burkina Faso, misoprostol was easily integrated into PAC services and provided a cost-effectively, acceptable, and effective technology for uterine evacuation.

Misoprostol as first-line treatment for incomplete abortion at a secondary-level health facility in Nigeria
Fawole AO, Diop A, Adeyanju AO, Aremu OT, Winikoff B, 2012
The feasibility and efficacy of nurse-midwives administering 400mcg sublingual misoprostol to treat incomplete abortion was studied at a secondary-level health facility in Nigeria. The results corroborated with those of previous randomized-control trials.  92.2% of women achieved complete uterine evacuation within 2 weeks and 95.5% of women were either satisfied or very satisfied with the treatment. A majority of women did report adverse events, most frequently pain or cramping and normal bleeding.

Misoprostol para el tratamiento del aborto incompleto en Guatemala
Gynuity and Planned Parenthood Global, 2012
This study examined the effectiveness of misoprostol use for treatment of incomplete abortion at the Hospital Nacional San Juan de Dios de Amatitlan (HNA) in Guatemala. Of the 87 women given a single dose of 400mcg of misoprostol sublingually who completed follow-up, only one had a complication. Overall, women in the study were satisfied with the treatment and reported that any pain experienced was acceptable or very acceptable. Only available in Spanish.

An evaluation of interventions to introduce misoprostol for postabortion care in Kenya
J. Mulama and I. Mwanzo, 2010
Ipas commissioned this evaluation to understand the successes and challenges of the implementation of the use of misoprostol in postabortion care in five health facilities in the Rift Valley, Kenya, in 2009.

Notes from the field: Resource needs and considerations for the introduction of misoprostol into existing PAC services
Ipas Nigeria and Society of Gynaecology and Obstetrics of Nigeria, 2010
In 2009, the Society of Gynaecology and Obstetrics of Nigeria and Ipas Nigeria conducted a research study in three hospitals in Nigeria. The primary objectives of the study were to understand health facilities and provider needs; document the experiences and perceptions of health-care providers regarding the use of misoprostol; and explore the experiences, acceptability, and satisfaction with the misoprostol treatment among women.

Offering misoprostol as an alternative to manual vacuum aspiration for treatment of incomplete abortion in Nigeria – Lessons from a multi-site introduction
Ipas Nigeria and Society of Gynaecology and Obstetrics of Nigeria, 2010
This report demonstrates the results of a study conducted by Ipas Nigeria and the Society of Gynaecology and Obstetrics of Nigeria in 2009. The purpose of the research was to to evaluate the introduction of misoprostol for the treatment of incomplete and missed abortion into existing postabortion care (PAC services) in three tertiary hospitals.

The Role of Misoprostol in Scaling Up Postabortion Care
International Perspectives on Sexual and Reproductive Health, Volume 37, Number 3, September 2011.

Treatment of incomplete abortion and miscarriage with misoprostol
J. Blum; B. Winikoff; K. Gemzell-Danielsson; P.C. Ho; R. Schiavon; A. Weeks
International Journal of Gynecology and Obstetrics, 2007
A literature review was conducted to determine whether misoprostol is an effective treatment for incomplete abortion and, if so, to recommend an appropriate regimen.  All English language articles published before October 2007 using misoprostol in at least one of the study arms were reviewed to determine the efficacy of misoprostol when used to treat incomplete abortion in the first trimester.  All available unpublished data previously presented at international scientific meetings were also reviewed.  Sufficient evidence was found in support of misoprostol as a safe and effective means of non-surgical uterine evacuation.