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Recent clinical data show that misoprostol is safe and efficacious for many uses during pregnancy,2,3 especially for the termination of unwanted pregnancy. Misoprostol, in conjunction with mifepristone or methotrexate, is safe and effective for the termination of early pregnancy. In France and China, for example, early abortion regimens involving mifepristone and misoprostol have been used by more than 1 million women, with success rates in the range of 92 to 95 percent.4 Moreover, misoprostol alone may also be safe and effective for early abortion; the success rate for a vaginal regimen is over 90 percent.5,6
Misoprostol has a number of advantages over other drugs and methods traditionally used for the reproductive health indications noted above. It is inexpensive, stable in a variety of climates, and widely available because of its use for gastrointestinal indications. Censure of the use of misoprostol during pregnancy inappropriately discourages its potential use, under supervision, for these indications, to the detriment of women's health worldwide. Cautions about misoprostol should be limited to its use in women with early pregnancy who intend to continue their pregnancies to term.
Kelly Blanchard, M.Sc.
Beverly Winikoff, M.D., M.P.H.
Population Council
New York, NY 10017
Charlotte Ellertson, Ph.D.
Population Council
04000 Mexico, D.F., Mexico
References
9 weeks' gestation. Eur J Contracept Reprod Health Care 1997;2:181-185. [Medline]
To the Editor: We thank Blanchard et al. for their comments. We agree that "the suitability of administering misoprostol during pregnancy depends entirely on the intended effect." Our study was not intended as a review of the beneficial effects or efficacy of misoprostol for off-label indications, but rather as a post-marketing–surveillance approach to evaluate the magnitude of adverse effects of misoprostol after its use during the first trimester of pregnancy. The study was prompted by requests from physicians seeking information about the risk–benefit ratio of misoprostol when used to treat gastric ulcers in pregnant women or in women of childbearing age. Of paramount concern was the potential for prolonged fetal exposure during organogenesis to a drug prescribed for reasons specific to the mother.
A review of the published evidence led us to hypothesize that fetal exposure to misoprostol early in the first trimester, with continued progression of pregnancy to term, might be associated with Möbius' syndrome. Our decision to perform a case–control study was predicated on the fact that, in the absence of free access to abortion, Brazilian women commonly identify misoprostol as an abortifacient,1,2 and consequently, the prevalence of misoprostol use in pregnancy there has been estimated at 10 percent.3
In labeling misoprostol as a new teratogen in our article, we underscored the biologic plausibility of vascular disruption or an ischemic event in the embryonic brain stem as the cause of fetal damage. Our conclusion that the administration of misoprostol during pregnancy should be discouraged was made in the context of our study population — that is, women who tried to induce abortion early in the first trimester, using oral doses of misoprostol that were ineffective for this purpose.
The correct name of one author is Synthia Lordello, not Cordello, as published.
Anne L. Pastuszak, M.Sc.
Hospital for Sick Children
Toronto, ON M5G 1X8, Canada
Lavinia Schüler, M.D., Ph.D.
Universidade Federal do Rio Grande do Sul
90046-900 Porto Alegre, Brazil
References
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