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May 2015, Vol 3, No 5 - Inside Women’s Health
Nicole E Cieri, PharmD, BCPS
Jamie Fery, PHARMDc
Stacie Lampkin, PharmD, BCACP, AE-C
Paige Schultz, PHARMDc

Misoprostol is a synthetic prostaglandin E1 analogue that has labeled uses for the prevention of nonsteroidal anti-inflammatory drug (NSAID)-induced gastric ulcers and the medical termination of pregnancies.1

Misoprostol also has off-label uses, and is recommended by the American College of Obstetricians and Gynecologists (ACOG) for the treatment of incomplete or missed abortions.1

Medically, an incomplete abortion is defined as a failed pregnancy in which a woman has not passed all of the fetal tissue, whereas a missed abortion is when a woman has a nonviable fetus in her uterus.2 Both of these conditions are the result of a spontaneous abortion; the preferred term is miscarriage, because abortion is typically assumed to be an elective pregnancy termination.3

For pharmacists and patients, this nomenclature can be misleading. A misoprostol prescription with an indication for abortion can indicate either an elective abortion or miscarriage. Regardless of indication, judgments and assumptions should never be made when dispensing misoprostol. To tailor counseling to the appropriate indication, it is vital to clarify its use. This can be done by asking the patient, “What did the doctor tell you this medication was for?” When the indication is determined to be a miscarriage, it can be an uncomfortable topic to discuss. Unfortunately, miscarriages in the first trimester occur in 1 in 4 women, and rates may be even higher in older women.3 Because of this high frequency, pharmacists may find it challenging to dispense to and counsel patients who are receiving misoprostol for a miscarriage.

Pharmacists in the community setting have the final patient interaction prior to them taking a medication in a situation that is emotionally draining. Counseling may require the pharmacist to step outside of their comfort zone. Although the topic may be uncomfortable, it is essential to counsel on expectations of treatment, including side effects, and to address any additional concerns the patient may have about their miscarriage.

Misoprostol Efficacy and Administration

According to ACOG, misoprostol has a complete expulsion rate in approximately 66% to 99% of women who receive the medication for incomplete or missed miscarriages.2 The treatment is most effective when initiated immediately after the miscarriage.4 Guidelines recommend a single dose of 600 mcg orally or 400 mcg sublingually for incomplete abortions, and 800 mcg vaginally4 or 600 mcg sublingually for missed abortions.2 However, vaginal administration may not be preferred because of the potential for decreased absorption secondary to vaginal bleeding.4 Keep in mind that regardless of the route of administration, the medication dosage form is a tablet. It is vital to ensure patients understand how to administer their medication via the specified route of administration (Table 1).4

Table 1

For a missed abortion, a woman may repeat the dose every 3 hours for up to 2 additional doses, if needed.1,2 Additional doses are not recommended in incomplete abortion cases. Patients should follow up with their physicians 1 to 2 weeks after treatment to confirm the evacuation of the fetus and the completion of the miscarriage.2,4 In cases where the initial misoprostol treatment cycle did not succeed, surgical removal of the fetal tissue may be considered, or a second misoprostol treatment regimen may be prescribed.5 A universal recommendation has not yet been established, and there is no consensus on the efficacy of multiple treatment cycles.

Advantages of misoprostol are that it allows for a less invasive and more economic route of postmiscarriage care compared with surgical evacuation of the uterus, which was used historically. It is not suitable for all miscarriages; ACOG recommends misoprostol in women whose uterine size is less than 12 weeks of gestation.2

Misoprostol Side Effects

Most patients will experience vaginal bleeding that is heavier than a typical menses.6 However, heaviness and length of bleeding will vary from woman to woman. Heavy bleeding may last approximately 4 days and may continue to a lighter bleeding or spotting. Regardless of the heaviness, the median bleeding time has been reported to be 12 days and the duration may last longer than 30 days.6 Because bleeding is likely to occur when using misoprostol, patients should be counseled regarding common bleeding patterns, and informed that this may vary among patients. Other possible side effects include abdominal cramping, nausea, vomiting, fever and chills, and diarrhea—but these are seen less often.5

For pain management of abdominal cramping, over-the-counter ibuprofen or other NSAIDs should be recommended, provided that the patient does not have contraindications for their use.2 If these analgesics are not sufficient in treating the pain, refer the patient to a healthcare provider.

Adverse Events Due to Miscarriage

With miscarriage being such an emotional time, patients may not have a clear understanding of why the remnants of the pregnancy need to be evacuated or know the more severe adverse events of miscarriage to watch out for, including infection and hemorrhage.2,4

Patients with miscarriages are at risk for infections due to dilation of the cervix. Antibiotic prescriptions are more commonly prescribed for patients with postsurgical abortion, although they may also be prescribed to miscarriage patients taking misoprostol. It is important that all miscarriage patients be counseled to be aware of signs of infection, including vaginal discharge with strong odor, fever, chills, and/or abdominal/uterine cramping.4 If they experience any of these symptoms, they should contact their physician or obstetrician right away. Hemorrhage is also a concern with miscarriages. It can be a result of damage to the reproductive organs or coagulopathy.

As the patient passes the contents of the uterus, vaginal bleeding will occur. If the patient experiences abnormally heavy and prolonged bleeding, she should contact her obstetrician immediately.

After receiving counseling on more severe adverse events of miscarriage, patients may be concerned, and their concerns must be addressed. Patients need to know to monitor for these signs and symptoms to reduce the risk for complications through early detection.

Miscarriage Counseling

Interaction with a pharmacist can positively impact the emotional outcomes of a patient with a miscarriage. It should be acknowledged by expressing words of sympathy for the loss of her child (eg, “I am sorry for your loss”); this can help put the patient at ease and provide an opportunity for discussion. Psychological outcomes improve if the emotional issues are discussed. However, be mindful that a woman may be confused, anxious, and/or depressed. She may be blaming herself for the miscarriage, due to the misconceptions that stress, exercise, or sexual activity could lead to early pregnancy loss.3 When appropriate, pharmacists can encourage women and their families to consider additional counseling by providing patients with information about available resources, such as support groups, Internet forums, or remembrance events. Forums can be helpful resources for women to read about other miscarriage stories, and possibly share their own experiences. Examples of forums that can be recommended can be found in Table 2.7-11

Table 2

October is National Miscarriage Awareness month; there are many events held during this time for a woman and her family to remember their lost child. The annual Wave of Light is on October 15 at 7 pm in your time zone; participants can light a candle for at least 1 hour to honor those lost to miscarriage, stillbirth, or neonate death. Finally, try to be aware of options that are available in your patient care area, so you may better suit your patient and her family’s needs.

Future Fertility

It is important to clarify that misoprostol will have no impact on future fertility.3 Many women may not realize that ovulation can occur as soon as 2 weeks after a miscarriage.2,4 There is no recommended amount of time that a woman should wait to reattempt pregnancy.4 However, each patient should consult with their physicians to determine when the most ideal time would be for her to try and conceive. Recommendations may vary among physicians and should be individualized per patient.

In addition, patients who are emotionally unstable may not be psychologically prepared to become pregnant soon after their miscarriage. In these patients, contraception options should be discussed and put into practice to prevent a possible unwanted pregnancy. The use and compliance of contraception is higher in patients who are counseled on its importance at the initiation of misoprostol treatment.2 Contraceptive medications and misoprostol can be initiated at the same time with no interactions.4

Conclusion

When a prescription for misoprostol is brought into your pharmacy, it can be for either an elective abortion or a spontaneous miscarriage. The terms abortion and miscarriage may be used interchangeably, so communication is necessary to understand why the patient is taking misoprostol. Regardless of the indication, pharmacists should provide a judgment-free environment and counsel patients on the medication (see “Patient Voice”). These interactions should begin with providing comforting words to the patient, and transition into the use of misoprostol and encouraging discussion about miscarriage. By following these best practices, pharmacists will be able to make a difference in the emotional well-being of patients receiving misoprostol for a miscarriage.

References

  1. Lexicomp Online, Lexi-Drugs Online, Hudson, OH: Lexi-Comp, Inc.; 2015; December 22, 2014.
  2. The American Congress of Obstetricians and Gynecologists. Misoprostol for post abortion care. ACOG Committee Opinion. 2009;1-4: No 427.
  3. Prine LW, Macnaughton H. Office management of early pregnancy loss. Am Fam Physician. 2011;84:75-82.
  4. World Health Organization, Department of Reproductive Health and Research. Safe abortion: technical and policy guidance for health systems. 2nd ed. http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf ?ua=1. Published 2012. Accessed February 5, 2015.
  5. Allen R, O’Brien BM. Uses of misoprostol in obstetrics and gynecology. Rev Obstet Gynecol. 2009;2:159-168.
  6. Davis AR, Hendlish SK, Westhoff C, et al. Bleeding patterns after misoprostol vs surgical treatment of early pregnancy failure: results from a randomized trial. Am J Obstet Gynecol. 2007;196:31.e1-7.
  7. Unspoken Grief. http://unspokengrief.com. Updated February 5, 2015. Accessed February 5, 2015.
  8. American Pregnancy Association. After a miscarriage: surviving emotionally. http://americanpregnancy.org/preg nancy-loss/miscarriage-surviving-emotionally. Updated January 2014. Accessed April 20, 2015.
  9. Miscarriage Support Group. http://miscarriage.support groups.com. Updated February 3, 2015. Accessed February 5, 2015.
  10. M.E.N.D. www.mend.org/support. Updated 2013. Accessed April 20, 2015.
  11. Center for Loss in Multiple Birth, Inc. www.climb-sup port.org. Updated 2015. Accessed April 20, 2015.
Patient Voice
Patients taking Misoprostol Misunderstood
Kaitie Richardson, BS

Kaitie Richardson, BS, Financial Services/Banking Professional, provides a patient’s perspective on her experience with misoprostol and the importance of managing patients with a miscarriage

I have always appreciated—frankly, always expected—that my pharmacist asked whether I had any questions about the medications I was taking. Unfortunately, in a time when I needed it most, it was not offered. I am sharing my miscarriage experience as a complement to the “Misoprostol Patients Misunderstood: How to Manage Patients with Miscarriages” article, to hopefully spread awareness and reduce the chance of a negative experience for other women who may have been/are misunderstood during a miscarriage.

Going through a miscarriage is a significant emotional rollercoaster. For me, it all began during my 12-week ultrasound appointment, where I was shocked to find out the baby didn’t have a heartbeat. The physician prescribed medication to manage my missed abortion, including pain medication, antibiotics, and misoprostol. When my doctor explained what was happening, I was so overwhelmed with emotion that I was not paying much attention, much less asking any questions.

I dropped off my prescription at the pharmacy shortly after the appointment. I had been crying in the car before I arrived, and I am sure I looked visibly upset. After a short while, I went back to pick up the medications, including misoprostol. I was never asked if I had any questions about the medication or if I needed to speak with the pharmacist in a more private area. Instead, I felt like I was being judged for picking up the misoprostol—as if it was my decision to end my pregnancy. My perception of the transaction was that they just assumed I knew what I was doing with the medication because I had already spoken to my doctor and chosen to end my pregnancy.

Being in the mental state that I was in, I took 4 pills every few hours (the instructions on the bottle were to take 4 pills orally 3 times daily), not taking into account that I should have been spreading it out over a 24-hour period, and not for the hours I was awake. Could I have spoken up and simply asked the pharmacist to clarify? Yes; however I felt very judged and embarrassed, and I didn’t feel comfortable speaking up.

Furthermore, I was never counseled on the side effects of the medication or what to expect. Misoprostol is a very harsh medication. I experienced a lot of vomiting and diarrhea; however, the stomach cramping was not as awful as I expected. The entire process was very draining and I slept a lot; it was probably more emotionally than physically draining. I knew once I took that first dose that meant the baby was going to be forced out. But I had no idea what to expect—was it going to happen in 20 minutes, an hour? The waiting game was difficult to bear. For me, the placental sac passed after 9 hours and then a lot of tissue continued to pass for the next couple of days. It didn’t end there; it took about 1.5 months for the bleeding to completely stop and during this time I had numerous ultrasounds, check-ups, and 2 more rounds of misoprostol. One of these rounds consisted of the same pills, but they were inserted vaginally. Once again, I was not counseled on the medication or how to use it.

Looking back at my experience, I think it is imperative for pharmacists not to judge patients when dispensing prescriptions regardless of indication. My overall miscarriage and pharmacy experience could have been greatly improved with some simple customer service and counseling. A warm greeting makes such a difference. Then, taking the time to make sure to ask if we have any questions about the medication and provide counseling on how to use it and what to expect from it. When a patient tells you they have a miscarriage, it might be uncomfortable or you might not know what to say. However, acknowledging the miscarriage and saying “I am sorry for your loss” goes a long way, and in my case, would have been welcomed. Finish the interaction with a genuine, “I hope you feel better.”

Do not be afraid to talk to a patient about their miscarriage. We have questions, and we want you to ask us how we are doing, so that we feel comfortable asking these questions. We want to feel like you care. And if you feel like something should be said, chances are we are waiting for you to say it.

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