Misoprostol -

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• Mode of Action
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• Side Effects - Explained
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Clinical Indications for Misoprostol

Misoprostol (brand name: Cytotec) is a drug that is used for the prevention of non-steroidal anti-inflammatory drug (NSAID)-induced stomach ulcers. It is also used  to induce labour and as an abortion agent.

Misoprostol is a synthetic prostaglandin E1 (PGE1) analogue.

Misoprostol is commonly prescribed in obstetrics off-label for induction of labour by promoting uterine contractions and the ripening (effacement or thinning) of the cervix. Misoprostol is considered to be more effective than oxytocin and dinoprostone to stimulate the contractions of the uterus. It is also cheaper than either of these two drugs. It has been used for mothers with a previous caesarean section scar but great caution is required as there is a risk of scar rupture.

The American College of Obstetricians and Gynecologists advocates misoprostol for induction of labor, and it is on the WHO essential drug list for labour induction.

Misoprostol is one of the drugs used for medical abortions. Both medical and surgical methods can be used to remove products of conception in the case of missed or incomplete miscarriage, retained postpartum placenta, and for elective abortion. It is also less complicated to administer and less expensive.

In many countries it is used in conjunction with mifepristone (RU-486) administration to terminate the pregnancy of a woman. After mifepristone is taken orally, misoprostol is taken 24–72 hours later, causing the expulsion of the fetus and associated pregnancy products in approximately 92% of the cases.

Misoprostol is sometimes used to treat early fetal death in the absence of spontaneous miscarriage, but further research is needed to establish a safe, effective protocol.

It can also be used to dilate the cervix in preparation for a surgical abortion, particularly in the second trimester. Misoprostol is also used to prevent and treat post-partum hemorrhage, but it has more side effects and is less effective than oxytocin for this purpose.⁰²⁰¹It may have a place in emergency situations.

Although the practice remains uncommon, some gynecologists are now using low doses of misoprostol to soften the cervix prior to the insertion of intrauterine devices. This is particularly helpful in nulliparous women where insertion may be difficult.

Misoprostol has also been shown in a randomized trial to assist cervical ripening and therefore simplifying insertion of operative hysteroscopes. Self-administered vaginal misoprostol of 1000 micrograms at home the evening before operative hysteroscopy is safe and highly acceptable, although a small proportion of women experienced severe lower abdominal pain. There is a risk of lower abdominal cramping pain and light preoperative bleeding with this regimen, which is very cheap and easy to use. ⁰⁸⁰¹

Misoprostol Side effects and contraindications

Misoprostol is contraindicated for those who are allergic to non-steroidal anti-inflammatory agents.

The most commonly reported adverse effect of taking a misoprostol 200 µg tablet by mouth four times a day to reduce the risk of NSAID-induced gastric ulcers is diarrhoea and intestinal discomfort.

The next most commonly reported adverse effects of taking a misoprostol 200 µg tablet by mouth four times a day to reduce the risk of NSAID-induced gastric ulcers are: abdominal pain, nausea, flatulence, headache, dyspepsia, vomiting, and constipation, but none of these adverse effects occur more often than when taking placebos.

Misoprostol should not be used as treatment by pregnant women to reduce the risk of NSAID-induced gastric ulcers because it increases uterine tone and contractions in pregnancy which may cause partial or complete abortions, and because its use in pregnancy has been associated with birth defects.

Concern has been expressed about the overuse or misuse of misoprostol for labour induction. It can cause uterine rupture (particularly in women who have previously had a caesarean section), fetal death, and severe fetal brain damage if there is uterine hyperstimulation. Misoprostol should only be presecribed by a doctor with precautions.