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Clinical Guidelines

These dosage guidelines were produced by the expert group convened by WHO in Bellagio in February 2007.  They are published in a supplement to the International Journal of Gynecology and Obstetrics (2007, vol. 99) and can be read by following the links to each indication or as a collection. These do not represent the final WHO guidelines, but were consensus papers produced by the experts at the conference.

In addition to the papers below, there is a foreword by the president of FIGO, Dorothy Shaw, an introduction to misoprostol by Weeks and Faundes, and an overview of misoprostol pharmacology by Tang et al.

The table below can be downloaded as a free wallchart in word or pdf formats. The full FIGO Recommended Dosages chart can be downloaded as a pdf 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.

Indication      Dosage                       Notes

Induced abortion     (0-12 weeks)

 800mcg vaginally 12-hrly x3 Ideally used 48h after mifepristone 200mg
Missed abortion    (0-12 weeks) 800mcg vaginal 3-hrly or sublingual 600mcg 3-hourly Give 2 doses and leave to work for 1-2 weeks (unless heavy bleeding or infection)
Incomplete abortion (0-12 weeks) 600mcg orally single dose Leave to work for 2 weeks (unless heavy bleeding or infection)
Induced abortion   (13-22 weeks) 400mcg vaginally 3-hrly x5 Use 200mcg only in women with caesarean scar. Ideally used 48h after mifepristone 200mg
Intrauterine fetal death 13-17 wks: 200mcg pv 6-hrly.
18-26 wks: 100mcg pv 6-hrly.
27+ wks: 25-50mcg pv 4-hrly		 Reduce doses in women with previous caesarean section
Induction of labour 25mcg vaginally 4-hrly or 50 mcg orally 4-hrly or 20mcg oral solution 2-hrly Do not use if previous caesarean section. Instructions on preparing the oral solution can be found here.
PPH prophylaxis 600mcg orally or sublingually stat Not as effective as oxytocin or ergometrine.
Exclude second twin before administration.
Do not repeat within 2h
PPH treatment 600mcg orally or sublingually stat Limited evidence for benefit - use conventional oxytocics first
Cervical ripening 400mcg vaginally 3h before procedure
 Use for insertion of intrauterine device, surgical termination of pregnancy, dilatation and curettage, hysteroscopy
Taken from Weeks A & Faúndes A. Misoprostol in obstetrics and gynecology. International Journal of Gynecology and Obstetrics 2007;99,S156–S159. PDF (133 KB)

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