A simplified dosage chart for non-doctors is available here.
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. |
Download the above chart in PDF format click here.
A simplified dosage chart for non-doctors is also available here.
Notes
- If mifepristone is available (preferable), follow the regimen prescribed for mifepristone + misoprostola
- Included in the WHO Model List of Essential Medicines
- For incomplete/inevitable abortion women should be treated based on their uterine size rather than last menstrual period (LMP) dating
- Leave to take effect over 1–2 weeks unless excessive bleeding or infection
- An additional dose can be offered if the placenta has not been expelled 30 minutes after fetal expulsion
- 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
- Including ruptured membranes where delivery indicated
- Follow local protocol if previous cesarean or transmural uterine scar
- If only 200μg tablets are available, smaller doses can be made by dissolving in water (see instructions here)
- Where oxytocin is not available or storage conditions are inadequate
- 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.
Misoprostol dosage graph
Figure 1: Safe single doses of vaginal misoprostol for producing uterine contractions at various gestations. For the first trimester 800µcg 24 hourly can be safely used. In the second trimester 200µcg 12 hourly is a common dose, whilst beyond 24 weeks 25µcg 6 hourly is usually used. If a higher dose than this is used, then uterine hyperstimulation with uterine rupture or fetal distress might be the result
Francés: Pautas de dosificación de Misoprostol ici
Español: Pautas de dosificación de Misoprostol aquí