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  6. Misoprostol for cervical priming prior to surgical management of 1st trimester miscarriage up to and including 13+0 weeks gestation (1011)
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Misoprostol for cervical priming prior to surgical management of 1st trimester miscarriage up to and including 13+0 weeks gestation (1011)

Objectives

To provide guidance for the prescription and administration of misoprostol to women prior to surgical management of miscarriage

Audience

All healthcare professionals involved in the surgical management of 1st trimester miscarriage

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Misoprostol is a synthetic prostaglandin E1 (PGE1) analogue.  It acts as a potent uterine stimulant.  Compared with no cervical priming, Misoprostol leads to reduction in failed surgical procedures and reduces the force required during cervical dilation.

Misoprostol should be administered prior to undertaking surgical evacuation of the uterus for women with a non-continuing pregnancy ≤13+0 gestation diagnosed according to NICE guidance for diagnostic criteria of miscarriage.

Misoprostol cervical preparation may not be required where patients have a diagnosis of an incomplete miscarriage, particularly where there is vaginal bleeding and the cervix has been examined as being open.

Prescribing and Administration

Misoprostol for cervical priming is a recognised use, but it is not licenced for this indication. 

Practitioners may consider sublingual or vaginal cervical preparation based on individual patient circumstance and wishes. 

Prior to administration, explain to the woman that cervical priming

  • Reduces the risk of incomplete procedure
  • Makes dilation easier
  • May cause bleeding and pain before the procedure

Sublingual administration

Misoprostol 400 micrograms (2 x 200 micrograms tablets) in a single dose should be placed in the buccal pouch and allowed to dissolve over a 15 minute period. If not dissolved within this timeframe it may be swallowed with small sip of water. 

It is suggested that this is given 2-3hours prior to the procedure to ensure sufficient cervical priming.  It can however be noted that where given by sub-lingual route, it can be effective for cervical priming if given at least 1 hour before the procedure. 

Sublingual misoprostol can cause more gastrointestinal side effects than vaginal misoprostol, and may be less acceptable for women. 

Vaginal administration

Misoprostol 400micrograms (2 x 200 micrograms tablets) in a single dose should be placed in the posterior fornix of the cervix and allowed to dissolve. Patient should therefore be advised to lie in semi recumbent position for 30 minutes post administration. 

It is suggested that vaginal misoprostol is given approximately 3 hours prior to procedure as it takes longer to achieve sufficient priming of the cervix for lower dilation force.  However, this is associated with more time with preoperative pain and bleeding than the sublingual route.

Side Effects

Possible short term side effects are usually apparent in the first few hours following administration. 

These include:

  • Nausea
  • Vomiting, this may affect the efficacy of the drug if it occurs within two hours of administration.
  • Diarrhoea
  • Weakness
  • Transient chills, shivering and fever
  • Dizziness
  • Abdominal and uterine cramps
  • Vaginal bleeding

Exclusion Criteria

  • Known hypersensitivity to misoprostol or any component of the product.

Caution

  • Caution advised in patients with a history cardiovascular disease where hypotension would be detrimental
  • If patient is breastfeeding, misoprostol acid in breast milk could cause undesirable effects such as diarrhoea in nursing infants.

Editorial Information

Last reviewed: 14/06/2023

Next review date: 31/05/2028

Author(s): Karen Dastey, Midwife, PRM.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 1011