【正文】 ence. Researchers and providers must continue to work to further refine the indications for misoprostol in many areas. However, several indications are already supported by highquality evidence. Given its low cost and ease of use, misoprostol has the potential to improve women’s health worldwide.8 / 8。g orally together with 400 181。g every 6 hours, or a 600 181。g of sublingual misoprostol plus 100 mg of diclofenac or 100 mg of diclofenac alone 1 hour before NovaT IUD Although baseline cervical dilation was similar in both groups, providers rated the insertion procedure as “easy” in 74% of the misoprostol group pared with 55% in the control group (P = .04). However, the majority of the IUD insertions were unplicated in both groups. There was no difference between the groups in terms of pain scores during IUD insertion or overall side effects.Medical Management of MiscarriageMisoprostol is an option for the medical management of early pregnancy failure, including anembryonic pregnancies and embryonic demise, and inplete abortion for women at 12 weeks or less of ,67 Contraindications include pelvic infection or sepsis, hemodynamic instability or shock, allergy to misoprostol, known bleeding disorder, concurrent anticoagulant therapy, and confirmed or suspected ectopic or molar If the woman has an IUD in place, it must be removed before treatment. Similar to medication abortion, cramping and bleeding will occur with pregnancy passage and side effects such as nausea, vomiting, diarrhea, fever, and chills may be Studies have shown, however, that misoprostol is acceptable to most women for this ,70For early pregnancy failure, the most monly used regimen is a single dose of 800 181。g of buccal misoprostol for 2 to 4 hours, and 800 181。g of misoprostol vaginally 3 to 4 hours, 400 181。 concurrent anticoagulant therapy。g of vaginal misoprostol in 6 to 48 hours. Women then return 4 to 14 days later for a clinical evaluation to document plete abortion. Success rates for these regimens range from 95% to 98%, with failure due to ongoing pregnancy in approximately 1%. In the United States, most women undergo ultrasound for pregnancy dating and confirmation of plete abortion. However, serial serum βhuman chorionic gonadotropin (βhCG) levels can also be used to confirm plete abortion.Candidates for medication abortion must be able to adhere to the treatment regimen as well as have access to a telephone and transportation to a medical facility in case of emergency. Multiple gestation is not a contraindication to medication abortion provided that the pregnancy is no more than 49 to 63 days, depending on the regimen being used. Contraindications to mifepristone medication abortion include hemorrhagic disorder。g. There are data evaluating oral, vaginal, and sublingual routes of administration. Effective regimens are 400 181。g of buccal misoprostol for at least 90 minutes, 600 181。g of oral misoprostol or placebo 3 hours prior to endometrial This study found no evidence of an effect on cervical resistance, success rate for obtaining the biopsy, and the ease of performing the biopsy. However, the study was underpowered for these endpoints. The study did note significantly more pain with the biopsy and uterine cramping in the misoprostol group.Based on a single, small study, IUD insertion in nulliparous women may be facilitated by misoprostol use. A Swedish trial randomized 80 women to 400 181。g every 6 hours, 400 181。g vaginally every 6 hours for a 48hour period. There is also evidence that the addition of 200 mg of mifepristone to the induction protocol decreases the interval to delivery for termination of Induction of labor with misoprostol in the setting of a previous cesarean delivery scar, although contraindicated in the third trimester, can be safely performed in the second trimester. The data on the absolute risk of induction of labor in this setting are lacking. Many studies on secondtrimester induction with misoprostol have excluded patients with a previous cesarean delivery due to the fear of uterine rupture. Importantly, however, several randomized studies did include patients with a previous cesarean ,74,78 No adverse effects occurred in these patients. Furthermore, several retrospective studies have specifically addressed the safety of misoprostol use for secondtrimester induction in the case of a prior cesarean delivery. In one of the largest retrospective studies on the subject, 188 women with a previous cesarean delivery underwent induction of labor between 17 and 24 weeks of The dose of misoprostol was 400 181。g administered every 4 to 6 ,85Postpartum HemorrhageMisoprostol has been used both as prevention and treatment of postpartum hemorrhage secondary to its uterotonic properties. Several randomized, controlled trials88–90 and a large, prospective, observational study91 have examined the use of misoprostol as an agent for the prevention of postpartum hemorrhage. There are insufficient data to support the use of misoprostol as a primary preventive measure for postpartum hemorrhage when conventional injectable uterotonics (such as oxytocin and/or methylergotomine) are available as part of the management of the third stage