| Contraindications |
| Suspected or confirmed ectopic pregnancy |
| GTD |
| High risk of uterine rupture (more than one prior hysterotomy, a prior classical or T-shaped uterine incision, or extensive transfundal uterine surgery [eg, myomectomy]) |
| IUD (must be removed before misoprostol is administered) |
| Allergy to prostaglandins |
| Other contraindications to medical or surgical uterine evacuations (eg, hemodynamically unstable, coagulopathy) |
| Relative contraindications |
| Moderate risk of uterine rupture (one prior low transverse or low vertical hysterotomy, multigravidity, or uterine anomaly) |
| Pretreatment evaluation and preparation |
| Medical history and physical examination |
| Confirmation of pregnancy, gestational age, pregnancy location, and absence of GTD (via history and physical with serum or urine hCG testing and/or transvaginal ultrasound) |
| Complete blood count |
| Blood group and Rh(D) typing; give anti Rh(D) immune globulin, if indicated |
| Remove IUD, if present |
| Treatment effects and patient counseling |
| Bleeding: Usually commences within 24 hours, lasting 7 to 10 days. Patients should be counseled about bleeding and to call or return to the clinic in the following scenarios: |
- 48 hours have passed and bleeding has been less than a normal menstrual period
|
- Soaking more than 2 pads per hour for 2 consecutive hours
|
- Bleeding persists for more than 2 weeks
|
- Heavy bleeding recurs 2 or more weeks after treatment
|
- Feeling dizzy or lightheaded
|
| Cramping and pain: Symptoms are often more intense than a menstrual period. Nonsteroidal anti-inflammatory drugs or other analgesia can be used without decreasing treatment effectiveness. Patients should be instructed to call if pain greatly exceeds menstrual cramps and/or persists after products of conception have been expelled or ≥24 hours after last misoprostol dose. Patients with severe or persistent pain should be evaluated for uterine rupture, particularly if risk factors are present. |
| Chills and fever: Common, but generally transient. Patients should be instructed to call if a temperature of ≥100.4°F (≥38°C) persists for ≥24 hours after taking misoprostol. |
| Diarrhea, nausea, and vomiting: Misoprostol may exacerbate pregnancy-related nausea or vomiting and may cause diarrhea; symptoms are generally transient. Antiemetic or antidiarrheal medications can be given. Patients should be instructed to call if symptoms persist for 48 hours or more after last dose. |
