Pharmacists can play an important role in counseling women who experience early pregnancy loss. It is important for patients to know that routine activities, such as exercise, sexual intercourse, and working, do not cause early pregnancy loss. About 50% of all cases of early pregnancy loss are attributable to fetal chromosomal abnormalities.1  

The American College of Obstetricians and Gynecologists (ACOG) defines early pregnancy loss as a nonviable, intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus without a heartbeat within the first 12 weeks of gestation.1 During the first trimester, the terms "early pregnancy loss," "miscarriage," and "spontaneous abortion" are used interchangeably.1 Options for early pregnancy loss include allowing the miscarriage to progress naturally (expectant management), medical treatment, and surgical evacuation.2 

Here are 5 things pharmacists should know about misoprostol for early pregnancy loss management:

1. Misoprostol has been studied for early pregnancy loss. Misoprostol, a prostaglandin E1 analogue, reduces the need of suction dilation and curettage (D&C) by up to 60% and shortens the time to completion compared with placebo.1 The addition of mifepristone (progesterone receptor antagonist) to misoprostol has been studied as a treatment for early pregnancy loss. However, there is insufficient evidence to demonstrate that this regimen is superior to misoprostol alone. The ACOG does not recommend the routine use of mifepristone for the treatment of early pregnancy loss.1

2. Vaginal administration of misoprostol is recommended for increased efficacy. The recommended dose of misoprostol is 800 mcgs (4 200-mcg tablets) inserted vaginally.Study results have demonstrated that vaginal administration is more effective than oral use of misoprostol. One dose is about 70% effective, and 2 is about 84% effective.1 

3. Patient counseling is important for appropriate administration. Pharmacists should educate patients about the proper administration of the tablets. Administration should take place in the morning or early afternoon. Patients should wash their hands with soap and water and place each tablet one at a time into the vagina as high as possible. Instruct patients to rest for about 30 minutes after inserting the medication. 

4. Tell patients that heavy bleeding may occur. Bleeding usually occurs within 4 to 48 hours after misoprostol administration. If bleeding does not occur within 48 hours, then a repeat misoprostol dose should be administered.1 Counsel patients that bleeding is usually heavier than menses and is generally accompanied by severe cramping. It is normal to see the passage of blood clots and tissue. Heavy bleeding and cramping usually last for about 4 hours. Patients should be relaxing during this time and not engaging in strenuous activity. Educate patients about the importance of having a family member or friend stay with them for support. Recommend that patients contact their obstetrician-gynecologist (OB-GYN) if they are soaking 2 maxi pads per hour for 2 consecutive hours.1 Misoprostol adverse effects may include diarrhea and dizziness. Light bleeding may last for about 2 weeks. 
 
Patients may take OTC acetaminophen to help manage the pain or prescription pain medication (eg, acetaminophen with codeine), along with the misoprostol may be used. It is important for patients not to take both OTC and prescription pain medication to avoid exceeding the daily recommended dose of acetaminophen.
 
Women who are Rh(D) negative should receive Rh(D)-immune globulin within 72 hours of the first misoprostol administration.1

5. Follow-up is important after misoprostol administration. Advise patients to follow up with their OB-GYN within 7 to 14 days for an ultrasound to ensure the complete passage of tissue.If tissue remains, then patients can repeat the misoprostol dose or have a D&C.1
 
Pharmacists can provide education and support for patients experiencing early pregnancy loss.


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REFERENCES
  1. American College of Obstetricians and Gynecologists. Early pregnancy loss. acog.org/Resources-And-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Early-Pregnancy-Loss. Published May 2015. Accessed November 28, 2017.
  2. Mayo Clinic. Miscarriage. mayoclinic.org/diseases-conditions/pregnancy-loss-miscarriage/symptoms-causes/syc-20354298. Accessed November 28, 2017.