Clinical Guidelines

These dosage guidelines are produced by FIGO and based on guidelines produced by WHO, FIGO and Bellagio group.

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.

Gynuity have a wide range of useful resources available regarding misoprostol use which can be found 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 abortion¹ (1st Trimester)	800mcg vaginally or sublingual 3-hrly (max x3 within 12 hrs)^a	Ideally used 48h after mifepristone 200mg
Missed abortion (1st Trimester)	800mcg vaginally 3-hrly (max x2) or sublingual 600mcg 3-hourly (max x2)^b	Give 2 doses and leave to work for 1-2 weeks (unless heavy bleeding or infection)
Incomplete abortion^2,3 (1st Trimester)	600mcg orally single dose^a or 400mcg sublingual single dose^a	Leave to work for 2 weeks (unless heavy bleeding or infection)
Cervical ripening pre-instrumentation (1st Trimester)	400mcg vaginally 3-hrs or sublingually 2-3 hrs before procedure^a	Use for insertion of intrauterine device, surgical termination of pregnancy, dilatation and curettage, hysteroscopy
Induced abortion^1,4/Interruption of pregnancy (2nd Trimester)	400mcg vaginally or sublingually 3-hrly (max x5)^a	Most effective when used 48h after mifepristone 200mg.
Intrauterine fetal death	Intrauterine fetal death⁴:13-17 wks: 200mcg vaginally 6-hrly (max x4)^c. Intrauterine fetal death⁴:18-26 wks: 100mcg vaginally 6-hrly (max x4)^c.	Reduce doses in women with previous caesarean section. For fetal death in the third trimester see 'Induction of Labour' below.
Induction of labour^2,5	25mcg vaginally 6-hrly or 25 mcg orally 2-hrly^d	Do not use if previous caesarean section. Instructions on preparing the oral solution can be found here.
PPH prophylaxis²	600mcg orally single dose^e	Not as effective as oxytocin. Exclude second twin before administration.
PPH treatment	800mcg sublingually single dose^f

PPH - Post-Partum Haemorrhage

Notes
1. Only use where legal and with mifepristone, where available
2.Included in the WHO Model List of Essential Medicines
3. Leave to work for 1-2 weeks unless excessive bleeding or infection
4. Halve dose if previous caesarian section or uterine scar
5. Make sure you use the correct dosage - overdose can lead to
complications. Do not use if previous caesarian section.
References
a. WHO/RHR. Safe abortion: technical and policy guidance for health systems (2nd edition), 2012
b. Gemzell-Danielsson et al. IJGO, 2007
c. Gomez Ponce de Leon et al. IJGO,2007
d. WHO recommendations for induction of labour, 2011
e. FIGO Guidelines: Prevention of PPH with misoprostol, 2012
f. FIGO Guidelines: Treatment of PPH with misoprostol, 2012

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