Dosage Guidelines

This independent site has been set up to distribute dosage guidelines for the use of misoprostol in obstetrics and gynaecology. The correct dosage varies greatly according to gestation, indication and route of administration – using the correct dosage is vital for success and to prevent complications.

These dosage guidelines are produced by FIGO and WHO. They are based on those originally produced by the Bellagio group in 2007 but updated regularly since. The most recent 2017 guidelines were publshed in the  Int J Gynecol Obstet.

Recommended doses of Misoprostol (Cytotec®) are provided in this site along with instructions for use. The table below can be downloaded as a free A4 wallchart ,  compact easy reference cards, gestational calendars and in various languages .

Gynuity have a wide range of useful resources available regarding misoprostol use which can be found here.

A full pictorial guide on how to safely make up a 200ml batch of a 1 microgram per ml solution of misoprostol for oral administration can be found here. A 2015 study found that misoprostol tablets degenerate if they are exposed to air and moisture (5% less misoprostol content after 2 days), so keep them in their foil packets until needed!

Indication Dosage Notes
Pregnancy Termination
a,b,1 (1st Trimester)
800mcg sublingually 3-hrly or vaginally/buccally every 3-12hrs (2-3 doses) Ideally used 48h after mifepristone 200mg
Missed abortion
c,2 (1st Trimester)
800mcg vaginally 3-hrly (x2) or 600mcg sublingual 3-hourly (x2) Give 2 doses and leave to work for 1-2 weeks (unless heavy bleeding or infection)
Incomplete abortion
a,2,3,4 (1st Trimester)
600mcg orally single dose or 400mcg sublingual single dose or 400-800mcg vaginally single dose Leave to work for 2 weeks (unless heavy bleeding or infection). A detailed description of the treatment can also be found here
Cervical ripening for surgical abortion
a,d
<13 weeks: 400mcg sublingually 1 hr before procedure or vaginally 3 hrs before procedure
13-19 weeks: 400mcg vaginally 3-4hrs before procedure
Can use also for insertion of intrauterine device, dilatation and curettage and hysteroscopy
Pregnancy Termination
1,5,6(<26wks) 1,5,9(>26wks)
(2nd/3rd Trimester)
13-24 wks: 400mcg vaginally/sublingually/buccal 3-hrly
25-26 wks: 200mcg vaginally/sublingually/buccal 4-hrly
27–28 weeks: 200μg pv/sl/bucc every 4 hours
>28 weeks: 100μg pv/sl/bucc every 6 hours
Most effective when used 48h after mifepristone 200mg. A detailed document on this topic is available here
Intrauterine fetal death
f,g,1,5,6
13-26 wks: 200mcg vaginally/sublingually/ buccal 4-6-hrly
27-28 wks: 100mcg vaginally/sublingually/buccal 4-hrly
>28wks: 25mcg vaginally 6-hrly or 25mcg oral 2-hrly
Reduce doses in women with previous caesarean section.

For fetal death in the third trimester see ‘Induction of Labour’ below.

Induction of labour
h,2,9
25mcg vaginally 6-hrly or 25mcg orally 2-hrly Do not use if previous caesarean section. Instructions on preparing the oral solution can be found here.
PPH prophylaxis
i,2,10/j,11 (secondary preventation)
600mcg orally single dose
or for PPH secondary prevention (approx >350ml blood loss): 800mcg sublingual single dose
Where oxytocin is not available or storage conditions are inadequate.
Exclude second twin before administration.
PPH treatment
k,2,10
800mcg sublingually single dose Where oxytocin is not available or storage conditions are inadequate.

 

A simplified dosage chart for non-doctors is also available here.
Notes

  1. If mifepristone is available (preferable), follow the regimen prescribed for mifepristone + misoprostola
  2. Included in the WHO Model List of Essential Medicines
  3. For incomplete/inevitable abortion women should be treated based on their uterine size rather than last menstrual period (LMP) dating
  4. Leave to take effect over 1–2 weeks unless excessive bleeding or infection
  5. An additional dose can be offered if the placenta has not been expelled 30 minutes after fetal expulsion
  6. Several studies limited dosing to 5 times; most women have complete expulsion before use of 5 doses, but other studies continued beyond 5 and achieved a higher total success rate with no safety issues
  7. Including ruptured membranes where delivery indicated
  8. Follow local protocol if previous cesarean or transmural uterine scar
  9. If only 200μg tablets are available, smaller doses can be made by dissolving in  water (see instructions here)
  10. Where oxytocin is not available or storage conditions are inadequate
  11. Option for community based program

References

a)  WHO Clinical practice handbook for safe abortion, 2014
b)  v on Hertzen et al. Lancet, 2007; Sheldon et al. 2016 FIAPAC abstract
c)  Gemzell-Danielsson et al. IJGO, 2007
d)  Sääv et al. Human Reproduction, 2015; Kapp et al. Cochrane Database of Systematic Reviews, 2010
e)  Dabash et al. IJGO, 2015
f)  Perritt et al. Contraception, 2013
g)  Mark et al. IJGO, 2015
h)  WHO recommendations for induction of labour, 2011
i)   FIGO Guidelines: Prevention of PPH with misoprostol, 2012
j)   Raghavan et al. BJOG, 2015
k)  FIGO Guidelines: Treatment of PPH with misoprostol, 2012

Warning!

Misoprostol is a very powerful stimulator of uterine contractions in late pregnancy and can cause fetal death and uterine rupture if used in high doses. Follow the dosage regimes carefully and do not exceed those doses.