For a more detailed look at this topic, please see my online course: Medications for Abortion and Pregnancy Loss. Ever invested in accessible education, here’s a quick breakdown of using medications when working with miscarriage.
Medication management of pregnancy loss and abortion has been around for decades and is undergoing constant research and development. In many places around the world, it is the fastest growing and most prevalent form of abortion care and considered widely to be safe and effective. Research and practice of using medications for pregnancy loss are also expanding, in an area where the previously considered options were only to watch and wait at home or to have a potentially invasive D&C (uterine evacuation with instruments through the cervix).
Typically, the medication protocols involve a combination of medications, including medications to affect/end the growth and development of a pregnancy, and separate medications to induce contractions and soften a cervix so a uterus can expel the pregnancy. These medications are typically used in the first trimester of pregnancy. However, protocols exist well into the second and early third trimester, and community experimentation has shown alternative administration protocols to be very effective.
Slowly but surely, there is a growing body of literature and medical practice around administering medication protocols for early pregnancy loss. The delay in the uptake of medications for miscarriage management is often tied to the stigma of these medications and research around them being typically used for abortion. It is also tied to a reluctance to update practice after years of other practices (watch and wait, D&C, etc.) Research on these medications as used for miscarriage management specifically is much more sparse, and without this dedicated research, providers are often concerned about implementing changes despite the physiology between an early abortion and an early miscarriage being nearly identical. There are perhaps even more misconceptions around medication administration for miscarriage and other pregnancy loss than there is for abortion. As a reproductive health and justice issue, I perhaps feel even more passionate about advocating for properly informed choice in pregnancy loss management, including medication where appropriate than I do about abortion, simply because there is so much less attention paid to it.
The Medications
Mifepristone
Mifepristone, otherwise known as RU-486 or “the Abortion Pill”, is the first step in many medication protocols for managing abortion and miscarriage: it ENDS the pregnancy. It is typically packaged alone, sourced from a medical provider or regulated pharmacy, and is expensive, often a few hundred dollars (USD). It is typically followed by the medication misoprostol: this EXPELS the pregnancy that Mifepristone ended.
As an anti-progestogen, Mifepristone primarily blocks progesterone in the body and triggers a cascade of effects, including endometrial decidual degeneration (the shedding of the uterine lining), the release of natural prostaglandins, cervical softening, and an increased receptivity in uterine muscle to respond to prostaglandins (like misoprostol). When the uterine lining starts to shed, the pregnancy (embryo) detaches, which also triggers a decrease in important hormones sustaining and being produced by the pregnancy (a decrease in hCG often leads to a decrease in progesterone, which the pregnancy depends on).
As the cervix softens, and the uterine lining starts to shed, and receptivity to prostaglandins increases and the pregnancy starts to detach, adding in a second prostaglandin medication like misoprostol to induce uterine contractions completes the loss/abortion.
Misoprostol
Misoprostol is a prostaglandin analogue that binds to myometrial cells, causing contractions of smooth muscle tissue. It is typically used in combination protocols for abortion and miscarriage management as the second step. Typically Mifepristone or Methotrexate will be used as the first step to end the pregnancy and prompt the start of the process of release from the uterine walls, and then this is followed up with misoprostol to soften the cervix and induce strong uterine contractions to expel whatever is in the uterus.
Almost as common as misoprostol is used in combination with other medications to manage abortion and pregnancy loss, it is also often used alone to manage abortion and pregnancy loss. This has been shown to be effective, affordable, and widely more accessible than combination protocols.
Misoprostol was developed to treat stomach ulcers but has developed many obstetrical uses, most of which are off-label all over the world, meaning these uses are well-researched and widely used but often not officially approved by drug regulators in that country. This does not stop them from being used for obstetric indications often.
Misoprostol is the drug name, and it goes by many trade names worldwide, including Cytotec, Misoclear, and others.
The Protocols
There are different kinds of pregnancy losses, in different parts manifestations at different gestations, and they will respond to different medications differently. Looking at medication management of pregnancy loss can be a bit more complex but is a worthy exploration.
For now, let’s divide our exploration by type of pregnancy loss.
Missed Abortion / Miscarriage
This is the most common form of pregnancy loss. Over 25% of pregnancies in the first trimester end in miscarriage, many of them what are called “missed abortions” or “missed miscarriages”. A missed abortion is when a pregnancy stops growing and developing, but the body holds onto it and doesn’t expel right away. This is most commonly detected on a routine pregnancy ultrasound when someone is expecting to see a healthy 10-week embryo at their dating ultrasound and are instead told that there's a 7-week embryo with no heartbeat. As in: the pregnancy stopped growing at 7 weeks, but the body has held onto it for three more weeks. In this case, people are often presented with a few options: to watch and wait to see if a spontaneous miscarriage will occur, to manage it with aspiration or D&C (suction or instruments entering the uterus through the cervix to extract the contents of the uterus), or to take medications to encourage expulsion.
In this case, what I’m describing is typically before 13 weeks (in the first trimester), and the following are appropriate medication protocols
up to 13 weeks LMP:
diagram with protocol for missed abortion medication management using misoprostol up to 13 weeks LMP
Misoprostol (800mcg) vaginally, every 3 hours, for 2-3 doses
or
Misoprostol (600mcg) sublingual, every 3 hours, for 2-3 doses
Look familiar? It is almost identical to medication abortion in the first trimester! Physiologically, they are almost identical processes, so it makes sense their medication administration protocols would be similar.
Alternatively, new research is actually seeing greater efficacy when including Mifepristone, again, identical to first trimester abortion.
up to 13 weeks LMP:
diagram with protocol for missed abortion medication management using Mifepristone and Misoprostol up to 13 weeks LMP
Mifepristone (200mg), taken orally with water
24-48 hours pass
Misoprostol (800mcg), taken vaginally
If necessary, you can repeat the misoprostol dose every 3 hours.
I think for a long time there was an impression that the Mifepristone piece that was a typical part of a medication abortion protocol was unnecessary in cases of missed abortion because Mifepristone’s primary function was to end the pregnancy and in the case of a missed abortion, the pregnancy was already anded. However, over time greater understanding has shown that the whole cascade of mechanism within Mifepristone includes cervical softening, endometrial tissue sloughing, and hormonal adjustment to promote expulsion which clearly the body had not taken care of on its own in the case of missed abortion: so it was equally relevant in cases of missed abortion.
I would like to underline another point here ONE MORE TIME FOR THE PEOPLE IN THE BACK: medication management of missed abortion often needs multiple doses of misoprostol, just like an early abortion does. So often I see MDs prescribe one 600-800mcg dose to their patients as sufficient management of missed abortion. And then when it is ineffective, patients need to come back and get repeat prescriptions and repeat the whole process multiple times. This is not time or cost effective: just prescribe enough in the first place!
Intrauterine Fetal Demise
Intrauterine fetal demise describes a baby that dies in the womb. This is often discovered when fetal movement ceases and there is often no explanation given for why it happens. It typically describes losses in the later second trimester and third trimester. While labour may start on its own, it may not. In that case, misoprostol is often used to start labour:
diagram with protocol for IUFD medication management using misoprostol in the second and third trimesters
13-26 weeks LMP:
Misoprostol (200mcg), vaginally, sublingually, or buccally, every 4-6 hours until expulsion
26-27 weeks LMP:
Misoprostol (100mcg), vaginally, sublingually, or buccally, every 4 hours until expulsion
28+ weeks LMP:
Misoprostol (25mcg), vaginally every 6 hours until expulsion
Or
Misoprostol (25mcg), orally every 2 hours until expulsion
In later inductions like this, a common observation is that many doses of miso will be given, and the body will show no symptoms, and then all of a sudden the labour will start swiftly and the baby will be delivered rapidly. Most of these are done in hospitals, and nurses or doctors typically don’t make it into the room fast enough. It is quite common that these babies are delivered alone on the toilet as the labour started quickly after a whole lot of nothing all day.
Efficacy
When used for the purposes of first trimester abortion, medication abortion protocols are effective (roughly) as follows:
Mifepristone + Misoprostol: 95-98% effective
Methotrexate + Misoprostol: 90-97% effective
Misoprostol Alone: 80-90% effective
When used for first trimester miscarriage management, medication abortion protocols are effective (roughly) as follows:
Mifepristone + Misoprostol: 83% at day 1, 89% at day 8, 91% at day 30
Misoprostol alone: 67% at day 1, 74% at day 8, 75% at day 30
These numbers are based on one experimental study. Personally, I think their doses of misoprostol should have been higher and more frequent to lend to greater success while still staying within the margin of safety.
When using medications for first trimester miscarriage or abortion, if you fall in the small category of people it was not effective for, you can wait three days, and repeat the whole protocol again. In almost all cases, I’ve seen it be effective the second time around.
When used for second trimester abortion, medication abortion protocols typically only include misoprostol, though emerging evidence is showing the value of adding Mifepristone, too. The stats for second trimester currently show:
Mifepristone + Misoprostol: 96-98% effective
Misoprostol alone: 90% effective
As more and more studies are done pushing limits on how many doses may be administered safely, research is showing near total efficacy in the second trimester when unlimited proper dosing is offered, under careful supervision.
In conclusion, the highest rates of success for miscarriage and abortion management in all trimesters is with a combination protocol of Mifepristone and Misoprostol. However, given the complications of accessing Mifepristone, when Misoprostol is the only medication available, its efficacy is often considered acceptable and is usually successful on second administration if it wasn’t on first administration.
For more information…
For a comprehensive look at Medication Abortion including exploring Mifepristone, Misoprostol, and Methortreaxate for both abortion and pregnancy loss, including:
Histories and Contexts
Current Events and Developments
Effects and Side Effects
Troubleshooting and Complications
Considerations and Contraindications
How to prepare to support the body before, during, and after
How to research this topic well
And more…
Check out my Course !
(Approx 4-5 hrs content). In this course we take a look at three primary medications used for abortion, miscarriage, and pregnancy loss: Mifepristone, Methotrexate, and Misoprostol. We look at these medication’s histories, physiologies, pharmacokinetics, how we can expect them to work in our bodies, proper dosing across circumstances of pregnancy and all trimesters, effects and side effects, preparing our bodies, experiencing release, and recovery. We also look at troubleshooting and complications, considerations and complications, current events, gathering good quality information, access chains and local networks. We also have a lively and vulnerable Q&A!