What is the recommended application and dosage of a Mefigest (mifepristone and misoprostol) kit for a female of reproductive age with no significant medical history or contraindications undergoing a medical abortion or managing a miscarriage?

Mefigest Kit Application for Medical Abortion

The Mefigest kit (mifepristone 200 mg + misoprostol 800 mcg) should be administered as follows: mifepristone 200 mg orally first, followed by misoprostol 800 mcg administered vaginally or buccally 6-8 hours later (or up to 24-48 hours later), and is effective for medical abortion up to 77 days (11 weeks) gestation or for management of early pregnancy loss up to 84 days (12 weeks) gestation. 1, 2

Dosing Regimen

Standard Protocol

• Mifepristone: Administer 200 mg orally as the initial dose 2, 3, 4
• Misoprostol: Follow with 800 mcg administered vaginally or buccally 6-8 hours after mifepristone (though intervals up to 24-48 hours are also effective) 2, 3, 5
• The 6-8 hour interval is preferred as it results in significantly fewer side effects (less nausea, vomiting, and heavy bleeding) compared to the 24-hour interval, while maintaining equivalent efficacy (95.8% vs 98.1% success rates) 5

Route of Administration

• Vaginal administration of misoprostol is preferred over oral administration, particularly for gestations beyond 49 days, as it improves efficacy 6
• Buccal administration (placing tablets between cheek and gum for 30 minutes before swallowing) is an acceptable alternative to vaginal administration 2

Gestational Age Limits

• Medical abortion: Effective up to 77 days (11 weeks) gestation 2
• Early pregnancy loss management: Effective up to 84 days (12 weeks) gestation 2
• Success rates for gestations ≤49 days range from 92-97%, with vaginal misoprostol improving efficacy at >49 days 6

Pre-Treatment Requirements

Gestational Age Confirmation

• Determine gestational age using ultrasonography or menstrual history 2
• Ultrasonography is required when:
  • Gestational dating cannot be confirmed using clinical data alone 2
  • Risk factors for ectopic pregnancy are present 2
• The method can be provided safely without routine ultrasonography if dating is certain and ectopic pregnancy risk is low 6

Contraindications to Exclude

• Confirmed or suspected ectopic pregnancy 2
• Intrauterine device (IUD) in place (must be removed first) 2
• Chronic adrenal failure or long-term corticosteroid therapy 2
• Hemorrhagic disorders or anticoagulant therapy 2
• Inherited porphyrias 2

Expected Effects and Management

Normal Expected Effects

• Cramping and bleeding are expected therapeutic effects of the medications 2
• Bleeding lasts an average of 9-16 days 2
• Heavy bleeding occurs in 38-54% of women, typically stopping by 7-8 days 4

Side Effect Management

• Misoprostol-related symptoms (low-grade fever, nausea, vomiting, diarrhea) can be managed with:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and fever 2
  • Antiemetics for nausea and vomiting 2
• Pain scores are typically moderate (median 4.5-5.5 on a 10-point scale), with 18-25% of women requiring intramuscular opiate analgesia 4

Follow-Up and Confirmation of Success

Assessment Methods

• Clinical history combined with one of the following 2:
  • Serial quantitative beta-hCG levels (should decline appropriately)
  • Urine pregnancy testing (should become negative within 4-6 weeks)
  • Ultrasonography (to confirm empty uterus)
• First follow-up: 7 ± 1 days after initiating treatment 5
• Second follow-up: Approximately 2 weeks after mifepristone administration 5

Management of Incomplete Abortion

• If abortion has not occurred at first follow-up, offer a second dose of misoprostol 800 mcg 5
• Treatment is considered a failure if suction aspiration is required for any indication 5

Rare Complications to Monitor

• Ongoing pregnancy: Rare with proper dosing 2
• Infection: Occurs in 13-38% with expectant management but significantly less with active treatment 1
• Hemorrhage requiring intervention: Uncommon but monitor for excessive bleeding 2
• Undiagnosed ectopic pregnancy: Emphasizes importance of proper screening 2
• Need for unplanned uterine aspiration: Occurs in 1.3-17.4% depending on method 1

Critical Safety Considerations

Rh Status Management

• All Rh-negative women must receive anti-D immunoglobulin 1
• Recommended dose: 50 mcg for first trimester abortion or miscarriage 1
• Fetomaternal hemorrhage occurs in 32% of spontaneous abortions, making prophylaxis essential 1

Infection Recognition

• Do not wait for fever to diagnose infection - symptoms may be subtle in early gestation 1
• Warning signs include:
  • Maternal tachycardia 1
  • Purulent cervical discharge 1
  • Uterine tenderness 1
• If infection suspected: initiate broad-spectrum antibiotics immediately and proceed with urgent surgical evacuation 1

Post-Abortion Contraception

• Ovulation can resume within 2-4 weeks post-abortion, making immediate contraceptive counseling essential 1, 7
• Contraceptive methods can be initiated within the first 7 days after abortion, including immediately after the procedure 7
• If contraception is started within 7 days of abortion, no backup method is needed 1
• Long-acting reversible contraceptives (LARCs) are the most effective option for preventing subsequent unintended pregnancy 7

Home-Based Administration

• Self-administration of misoprostol at home is safe and effective 6
• Women can administer misoprostol as soon as 6 hours after taking mifepristone, providing flexibility 5
• Medical abortion before 9 weeks can be performed in outpatient or home settings, offering advantages in cost and convenience 1