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Knowledge of correct dosages of misoprostol in reproductive health
International Journal of Gynecology and Obstetrics
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
Knowledge of correct dosages of misoprostol in reproductive health
Nishigandh Deole , Andrew Weeksa University Hospitals Coventry and Warwickshire, Coventry, UKb Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
1%–2%). Of the respondents, 177 (65%) worked mainly in public hospitals,21 (8%) worked in private hospitals, and the rest were from academic
institutions. In total, 249 (92%) were specialists in obstetrics and
gynecology; the rest were non-specialists providing obstetrics and
Received in revised form 16 November 2009Accepted 9 December 2009
gynecology care. When asked about the source of their informationregarding correct dosages, 134 (49%) listed their hospital protocol or
guidelines. The most commonly used doses are listed in .
Although most practitioners used appropriate dosages of miso-
prostol in the ﬁrst trimester and for induction of labor at term, there
was a considerable difference among the dosages used for the re-maining indications—particularly for intrauterine fetal death (IUFD).
Although the data were not strictly comparable, lower dosages forlabor induction were reported in the present study than in the survey
The prostaglandin E1 analog misoprostol is a powerful uterotonic
that is effective for labor induction, uterine evacuation, and prevention
Recommended dosages of misoprostol by indication, per Bellagio group.
and treatment of postpartum hemorrhage Its low cost and ease ofstorage/administration make it ideally suited to use in low-resource
settings. The patent holder has never applied to get a license for any of
these indications and, consequently, misoprostol is used off-label in most
countries. Furthermore, dosage regimens are complex because they vary
by indication, gestation, and route of administration; there is therefore
potential for the dangerous use of incorrect doses. To address this issue, a
WHO-convened expert group met in Bellagio, Italy, in 2007 to create
dosage guidelines ), which were adopted by FIGO in 2009.
The aim of the present study was to identify the range of misoprostol
dosage regimens used by a sample of clinicians worldwide and to
compare it with the dosages recommended by the Bellagio expert group.
A survey was conducted between May and October 2008 using the
online survey tool SurveyMonkey (SurveyMonkey, Portland, OR,
USA). The snowball technique was used, whereby the survey was
ﬁrst sent to all clinicians known by the authors to be working in
reproductive health. These recipients were asked to complete the
survey and forward the request to other clinicians who they thought
would be suitable. In addition, the survey was advertised in a news-
letter sent out by the Royal College of Obstetricians and Gynaecolo-
gists, and the Society of Obstetricians and Gynaecologists of Canada.
In total, there were 271 respondents, of whom 211 (78%) completed
all questions of the survey. The geographic spread of responses was: 46%
from Canada; 14% from the USA; 17% from the UK; 5% from Brazil; 5% from
Uganda; 3% from India; and 10% from other countries (each comprising
device, surgical termination ofpregnancy, dilatation andcurettage, and hysteroscopy
⁎ Corresponding author. Clifford Bridge Road, Coventry CV2 2DX, UK. Tel.: +44 0121
Abbreviations: PPH, postpartum hemorrhage; stat, single dose taken immediately.
a Permission to reproduce table from Ref. granted by the International Federation
of Gynecology and Obstetrics (FIGO).
Table 2The most common initial dose, frequency, and route of administration of misoprostol.
Abbreviation: stat, single dose taken immediately.
a Values are given as route (percentage).
b Values are given as dose (percentage).
c Values are given as frequency (percentage).
d Used lower than recommended dose.
e Used higher than recommended dose.
by Clarke et al. However, there was no difference in the dosages
third trimesters—indicate an urgent need to disseminate international
used for the induction of labor in women with IUFD. Clinicians often
evidence-based guidelines more widely. The recent decision by FIGO to
consider the risks to be lower with induction for IUFD, and it is true
adopt and publicize the Bellagio group guidelines will contribute to the
that less fetal supervision is needed. However, with reduced
safer use of misoprostol worldwide and is, therefore, to be welcomed.
monitoring, a greater tolerance of vaginal bleeding and hyperstimu-lation, and the lack of electronic fetal monitoring (which may show
the ﬁrst warning signs of uterine rupture), women in this situation areat increased risk of uterine rupture. Therefore, we believe that it is
AW was one of the WHO experts at the Bellagio conference at
inappropriate to increase the dose above that used for labor induction
with a live infant. In the present survey, 63% and 60% of clinicians usedinitial doses that were higher than those recommended for second-
and third-trimester fetal death, respectively, despite the fact that 77%
 Elati A, Weeks AD. The use of misoprostol in obstetrics and gynaecology. BJOG
of respondents were from the USA, Canada, or the UK—where there is
easy access to dosage guidelines. In resource-poor settings, the risk of
 Weeks A, Faúndes A. Misoprostol in obstetrics and gynecology. Int J Gynaecol
incorrect dosage is increased and there is less monitoring available.
 Clark S, Blum J, Blanchard K, Galvão L, Fletcher H, Winikoff B. Misoprostol use in
The potentially serious maternal and fetal complications of inappro-
obstetrics and gynecology in Brazil, Jamaica, and the United States. Int J Gynaecol
priate misoprostol dosage—particularly uterine rupture in the second and
0020-7292/$ – see front matter 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Consequences of delay in obstetric care for maternal and perinatal outcomes
Department of Obstetrics and Gynecology, CSMMU, Lucknow, India
The timing of medical interventions for obstetric emergencies is vital
to prevent maternal and neonatal morbidity and mortality. A principal
model of maternal mortality is the “3 delays model” – delay in seeking
care; delay in identifying and reaching medical facilities; and delay in
Received in revised form 2 November 2009Accepted 20 November 2009
receiving adequate and appropriate treatment . Recognized causes ofthese delays in low-resource countries are transport availability, the
costs involved, and accessibility to health facilities.
The present study was conducted in a tertiary hospital in Lucknow,
India, from April 2007 to January 2008. Institutional ethical clearance for
the study was obtained. Pregnant women presenting at the hospital with
hemodynamic instability or loss of consciousness were considered eligiblefor inclusion. After informed consent had been provided, the patientscompleted a questionnaire examining demographic proﬁle, nature ofillness, and educational status of the couple. The time taken for each
⁎ Corresponding author. Department of Obstetrics and Gynecology, CSMMU Lucknow,
B-2 Sector B, Aliganj, Lucknow 226024, India.
woman to reach the hospital from when a problem had been recognized
was recorded. A delay was analyzed in terms of maternal and perinatal
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