Society protocols for medication management of second-trimester pregnancy loss

Source	Sequential mifepristone and misoprostol (preferred)			Misoprostol monotherapy (alternative if mifepristone is unavailable)
Source	Mifepristone dosing and administration	Interval between mifepristone and first dose of misoprostol	Misoprostol dosing and administration
American College of Obstetricians and Gynecologists^[1], endorsed by the Society of Family Planning and the Society of Maternal-Fetal Medicine	200 mg orally (single dose)	24 to 48 hours	800 mcg PV, followed by 400 mcg PV/SL every 3 hours as needed or 400 mcg buccally every 3 hours as needed Maximum number of doses: 5	600 to 800 mcg PV, followed by 400 mcg PV/SL every 3 hours as needed or 400 mcg PV/SL every 3 hours as needed Maximum number of doses: 5
World Health Organization^[2]	200 mg orally (single dose)	36 to 48 hours	800 mcg PV, followed by 400 mcg PV/SL every 3 hours as needed or 400 mcg orally, followed by 400 mcg PV/SL every 3 hours as needed Maximum number of doses: 5	400 mcg PV/SL every 3 hours as needed Maximum number of doses: 5

Medication management of second-trimester (13+0 to 19+6 weeks of gestation) pregnancy loss generally involves a single dose of mifepristone followed 24 to 48 hours later by repeated doses of misoprostol to induce passage of uterine contents. Regimens provided are extrapolated from society guidelines for second-trimester abortion. For additional information, refer to the clinical topic reviews on pregnancy loss.

PV: intravaginal; SL: sublingual.

References:

ACOG Practice Bulletin No. 135: Second-trimester abortion. Obstet Gynecol 2013; 121:1394.
Medical management of abortion. World Health Organization. Geneva, Switzerland 2018.

Courtesy of Sarah Prager, MD, MAS, Elizabeth Micks, MD, MPH, and Vanessa K. Dalton, MD, MPH.

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Society protocols for medication management of second-trimester pregnancy loss