Intrauterine Fetal Death (> 24 wks)

Group

Gestational age

Route

Dose

Time period

Max. Dose 

Levels of Evidence

Notes

Bellagio/FIGO

13-17 wks

18-26 wks

27-43 wks

Vaginal

Vaginal

Vaginal

200µg

100µg

25-50µg

6-hrly

6-hrly

4-hrly

4 x

4 x

6 x

I B

Reduce doses in women with previous caesarean section

WHO

37-42 wks

Vaginal

Vaginal

25µg

50µg

6-hrly

6-hrly

2 x

4 x

I A

I A

First Line

Only use  IF two doses of 25µg has not succeeded in expelling fetus in 4 wks

NICE

-

-

-

-

-

-

No guidelines

RCOG

<26 wks

27 wks +

Vaginal

Vaginal

100µg

25-50µg

6-hrly

4-hrly

4 x

6 x

I A

Can be used with previous caesarean section may have to reduce doses

SOGC

-

-

-

-

-

-

No guidelines

ACOG

-

-

-

-

-

-

No visible guidelines

Gynuity

-

Oral

Sub

600 µg

400 µg

3-hrly

3-hrly

2 x

I B

POPPHI

-

-

-

-

-

-

-

FLASOG p47

13-17 wks

18-26 wks

3^rd trimester (unripe cervix)

3^rd trimester

(unresponsive after above treatment)

Vaginal

Vaginal

Vaginal

Vaginal

200µg

100µg

25µg

50µg

12-hrly

12-hrly

6-hrly

6-hrly

4 x

4 x

2 x

4 x

I B

Do not use oxytocin within 6 hours of misoprostol

Higher the dose higher chance of uterine rupture

Induction of Labour (live fetus> 24 wks)

Route

Dose

Time period

Max. Dose 

Levels of Evidence

Notes

Bellagio/FIGO

Vaginally

Orally

Oral solution (aq)

25µg

50µg

20µg

4-hrly

4-hrly

2-hrly

6 x

6 x

12 x

I A/B

Do not use if previous caesarean section

WHO

Oral

Vaginal

50µg

25µg

6-hrly

6-hrly

Doesn’t specify

I A

From 2010 draft

NICE

Vaginal

25 µg

6-hrly

Doesn’t specify

IA

It is not recommended by NICE to be used for IOL – only for IUFD.

RCOG

Vaginal

25 µg

6-hrly

Doesn’t specify

IA

Adopted NICE 2008

SOGC

-

-

-

-

Latest guidelines from 1996/2001

Guidelines from 2001 do not advocate using Misoprostol.

ACOG

-

-

-

-

-

Should be avoided in women with previous caesarean section – induce uterine rupture

Gynuity

-

-

-

-

-

No Guidelines

POPPHI

Vaginal

25µg

6-hrly

Doesn’t specify

I B

-

FLASOG p32

Vaginal

Oral

25µg

100µg

6-hrly

6-hrly

3 x day

I B

-

Postpartum Haemorrhage Prophylaxis

*STAT = single dose taken immediately

Route

Dose

Time period

Max. Dose 

Level of evidence

Notes

Bellagio/

FIGO

 Orally

Sublingual

600µg

600µg

STAT

STAT

1

1

IA

Not as effective as oxytocin or ergometrine. Exclude second twin before administration.

Do not repeat within 2 hours.

WHO

Oral

600µg

STAT

1

I A

Only use if there is no oxytocic treatment available

As LAST RESORT

NICE

-

-

-

-

-

No  Guidelines

RCOG

Oral

600µg

STAT

1

IA

Warns of adverse effects

SOGC

Oral

Sublingual

Rectal

600-800 µg

STAT

1

II-1 B

Should combine with IM injection 0.2 mg Ergovine

ACOG

-

-

-

-

-

Gynuity

Oral

600 µg

STAT

1

IB

Administer in 3^rd stage of labour – part of AMTSL

Additional Misoprostol should NOT be given after initial 6 hours of this dose

POPPHI

Oral

600µg

STAT

1

IB

Exclude second baby

Take tablet one minute after birth and perform uterine massage immediately

FLASOG

Oral

Rectal

600µg

600µg

STAT

STAT

1

1

IB

Use as last line treatment only if no alternative is available

Postpartum Haemorrhage Treatment

*STAT = single dose taken immediately

Route

Dose

Time period

Max. Dose  

Level of evidence

Notes

Bellagio/

FIGO

 Orally

Sublingual

600µg

600µg

-           

STAT

1

IB

Limited evidence for benefit – use conventional oxytocics first. 

WHO

Sublingual

800µg

STAT

1

IA

Only use if there is no oxytocic treatment available

As LAST RESORT

NICE

Guidelines state should not be used alone

-

-

-

-

Treatment combinations of ergometrine

/oxytocin/

misoprostol. No doses given.

RCOG

Oral

Rectal

600 µg

1000µg

STAT

STAT

1

1

II

II

If Contraindicated

ONLY if PPH due to Uterine Atony

SOGC

Oral or Sublingual

Rectal

400 -800 µg

800-1000µ

STAT

STAT

1

1

-           

OFF LABEL – not approved in Canada – risk of higher pyrexia.

OFF LABEL

ACOG

-

-

-

-

-

No guidelines

Gynuity

Oral

600 µg

STAT

1

IB

Administer in 3^rd stage of labour – part of AMTSL

Additional Misoprostol should NOT be given after initial 6 hours of this dose

POPPHI

Oral

Sublingual

Rectal

600µg

800 µg

1000 µg

STAT

STAT

STAT

1

1

1

IB

Only use if there is no oxytocic treatment available

FLASOG

Oral

Rectal

600µg

600µg

STAT

STAT

1

1

IB

Use of Misoprostol ONLY if there is no alternative treatment

OFFLABLE – insufficient evidence