Misoprostol in obstetrics and gynecology

Although misoprostol is generally not registered for reproductive health use, it is widely used by gynecologists and obstetricians. In a survey on the use of misoprostol conducted in three contrasting countries (Brazil, Jamaica and the USA), 61% of obstetricians and gynecologists stated that they used it to evacuate the uterus after intrauterine fetal death, 57% used it for missed abortions, and 46% to induce labor [1]. Its popularity may be accounted for by the fact that it is as effective as the best available prostaglandin at softening the cervix and producing contractions of the uterus, while at the same time being low-cost and heat-stable. The absence of registration for its obstetrical and gynecological applications is an important problem. The pharmaceutical industry is normally responsible for informing physicians about drugs' indications, effectiveness, correct dosages, route of administration, dosage interval, contraindications, precautions, side-effects and management of complications. However, as misoprostol is generally not registered for reproductive health indications, the industry has neither provided this information for physicians nor packaged the drug in appropriate dosages. The result is that this drug is used in many different ways according to informal local protocols. While this may not be a serious problem in early pregnancy, the use of too high a dose in late pregnancy can have serious consequences. In induction of labor, for example, too high a dose of misoprostol may cause uterine hyperstimulation and rupture of the uterus, thus jeopardizing the life of the mother and of the fetus [2–4]. Misoprostol is an analogue of prostaglandin E1 (PG E1) which was registered in many countries during the second half of the 1980s under the proprietary name Cytotec (Pharmacia), for the treatment of peptic ulcers, particularly those caused by non-steroidal anti-inflammatory drugs [5– 7]. Its use for this purpose is contraindicated for pregnant women as it may cause uterine contractions and miscarriage. In Brazil, as in many other countries where abortion is illegal, employees of retail pharmacies are accustomed to selling a wide range of drugs to “bring on periods”. In the 1980s they realized that the uterine “side-effect” of Cytotec made it a highly effective drug for “bringing on periods” in cases of delayed menses. The knowledge that misoprostol was very effective at causing abortions spread rapidly and, by the end of the 1980s, a high proportion of clandestine abortions in Brazil were induced by misoprostol [8,9]. Similar