Mifepristone and misoprostol (combination pack)

How it works

Mifepristone blocks progesterone receptors, sensitising the myometrium and softening the cervix, after which misoprostol stimulates uterine contractions and cervical ripening to complete expulsion.

Prescribing in practice

• Mifepristone is taken first and misoprostol after an interval; warn that significant bleeding and cramping are expected and that the woman must have access to urgent care for haemorrhage or signs of incomplete or continuing pregnancy.
• It should be used within an appropriate provider framework with confirmation of gestation and exclusion of contraindications such as suspected ectopic pregnancy, an in-situ intrauterine device, chronic adrenal failure or severe uncontrolled asthma.
• If the pregnancy continues after exposure there is a recognised risk of fetal harm, so treatment failure must be actively followed up.

Monitoring

Confirm successful completion clinically or with follow-up testing, and assess bleeding, pain and any signs of infection or retained products.

Counselling the patient

• Take the mifepristone first, then the misoprostol after the interval your clinician specifies.
• Heavy bleeding and cramping are expected; seek urgent help for very heavy bleeding, fever, severe pain or feeling faint.
• Attend any follow-up to confirm the process is complete, and start contraception when advised.

Evidence & guidelines

Sequential mifepristone followed by misoprostol is the regimen recommended by NICE and the RCOG for medical termination and miscarriage management.