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Sir,

There were heated arguments in a teaching session for post-graduates in our institution recently regarding the time to administration of misoprostol after mifepristone in early pregnancy termination. In 2003, the World Health Organization (WHO) recommended that oral/vaginal misoprostol should be administered 36–48 hours after oral mifepristone. However, in our unit, based on previous studies, we administer misoprostol 24 hours after the last dose of mifepristone with 100% abortion rates.1 This is based on the pharmacokinetics of mifepristone, which produces a rapid response in the uterus (within 24 hours) by blocking the action of progesterone immediately. It has also been reported that 40% of patients start to bleed prior to misoprostol administration, indicating that the abortion process has already started,2 and so why should a woman wait for another 24 hours to complete the abortion?

The recent article published in your prestigious journal came to our rescue, although the subject of study was on the dose (400 versus 800 μg) and route (sublingual versus vaginal) of misoprostol for early medical abortion.3 In this study, misoprostol was administered 24 hours after mifepristone based on a randomised factorial-controlled equivalence trial in which similar efficacy to achieve complete abortion was demonstrated when vaginal misoprostol was given after either 24 or 48 hours.4 In addition, women in the 48-hour interval group experienced a higher rate of nausea, vomiting and abdominal pain after mifepristone administration than did women in the 24-hour group. Thus, a regimen combining the sublingual route with a shorter time to administration of misoprostol (24 hours) appears to be ideal in terms of efficacy and patient comfort, the sublingual route being far more aesthetic than vaginal insertion.

Medical termination of pregnancy is an important component of reproductive health services, accessed by a large number of women, and thus it is important that guidelines be updated more frequently. In the light of recent research and new data, is it not time for WHO to issue fresh guidelines regarding the route and time to administration of misoprostol for early pregnancy termination? Moreover, should not guidelines be a strategy to aid the clinician in his practice, rather than procedures to be followed blindly?

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