Misoprostol on Law & Order SVU

Some of you may have seen the episode of Law & Order SVU that aired on 11-17-2010 entitled “Gray”.

The episode centered around accusations of rape against one male student at the fictional Hudson University.  The first half of the episode focused on the accusations made and how the lead detective’s daughter was indirectly involved.  Then, the drama really began.

In the course of the investigation, the detectives learn that the accused may have willingly caused his girlfriend to abort their 8 week old fetus without her knowledge.  Supposedly, he had applied a substance, he dubbed “love potion no. 9″, to himself prior to intercourse.  Supposedly, that substance was a mixture of petroleum jelly and misoprostol.

Here is where I went from purely being a viewer enjoying one of my favorite shows to a birth professional wondering how a drug that most women have never heard of had become a prominent feature of the second half of this episode. It is interesting to note that according to The American Congress of Obstetricians and Gynecologists (ACOG), in 2006 approximately 1 in 5 women had their labors induced , and misoprostol is a commonly used agent for this purpose.

What is misoprostol? Well, it is the generic name for an anti-ulcer medication otherwise known as Cytotec.  It is an oral tablet that is dispensed in either 100mcg or 200mcg per tablet and the recommended dosage is 1 tablet 4 times a day
with a meal.  According to the package insert under “Indications and Usage” it states: “Cytotec (misoprostol) is indicated for reducing the risk of NSAID (nonsteroidal anti-inflammatory drugs, including aspirin)-induced gastric ulcers in patients at high risk of complications from gastric ulcer, e.g., the elderly and patients with concomitant debilitating disease, as well as patients at high risk of developing gastric ulceration, such as patients with a history of ulcer.”  In the section labeled “Precautions”, it states the following: “Labor and delivery:  Cytotec can induce or augment uterine contractions.  Vaginal administration of Cytotec, outside of its approved indication (italics are mine), has been used as a cervical ripening agent, for the induction of labor and for treatment of serious postpartum hemorrhage in the presence of uterine atony.” and here is the point that all women who may be presented with the option of inducing labor using this very common method need to note: “A major adverse effect of the obstetrical use of Cytotec is the hyperstimulation of the uterus which may progress to uterine tetany with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy), or amniotic fluid embolism.  Pelvic pain, retained placenta, severe genital bleeding, shock, fetal bradycardia, and fetal and maternal death have been reported.”  The statement continues: ” There may be increased risk of uterine tachysystole, uterine rupture, meconium passage, meconium staining of amniotic fluid, and Cesarean delivery due to uterine hyperstimulation with the use of higher doses of Cytotec, including the manufactured 100mcg tablet.  The risk of uterine rupture increases with advancing gestational ages and with prior uterine surgery, including Cesarean delivery.”  Further down in that section, the insert states: “Nursing mothers: Misoprostol is rapidly metabolized in the mother to misoprostol acid, which is biologically active and is excreted in breast milk.  There are no published reports of adverse effects of misoprostol in breast-feeding infants of mothers taking misoprostol.  Caution should be exercised when misoprostol is administered to a nursing woman.”  Early in the insert, it is noted that the maximum concentration of misoprostol acid in breast milk was seen within 1 hour of the patient taking the dose.

So, let’s break this down into easy-to-understand language.  Basically, what this insert tells us is that the FDA has approved the use of misoprostol, or Cytotec, for the treatment of ulcers.  It tells us that, while it is commonly used for induction of labor, using it this way is “outside of its approved indication”.  This is commonly known as using a drug “off-label”.  This is not illegal, but it is also not regulated.  Therefore, it is imperative that consumers, and remember that a hospital patient, any hospital patient, is still also a consumer and has the right and the responsibility to become fully informed about any medical treatment, pharmaceutical or otherwise, that a physician may offer.  Some of the risks of misoprostol include contractions that are extremely prolonged and could be life-threatening to the baby, a marked decrease in the flow of blood between the uterus and placenta, uterine rupture, excessively frequent contractions, and release of the baby’s first bowel movement in utero which can be a sign of fetal distress.  It also tells us that infants who are breastfed within an hour of their mother’s taking an oral dose of misoprostol will be exposed to it through her milk.

Now that we have a basic understanding of what misoprostol is and what it is used for, let’s get back to the episode.

The episode continues with the unfortunate death of the accused’s girlfriend, which is apparently due to her succumbing to toxic shock syndrome, a bacterial infection, that was caused by “incomplete expulsion of the products of conception”.  According to the ME in the episode, her immune system had been compromised by the application of the misoprostol directly to her cervix.  One detective then cynically responds that misoprostol is “the gift that keeps on giving”.

What does this mean for you?

Well, now that this drug has received some national attention, albeit in the fictional arena of a primetime drama, and despite some inaccuracies that are inherent to that arena, you will hopefully be more inclined to stop and ask questions about the method of induction your physician or midwife may recommend.  The tablets come in 2 different dosages, 100mcg or 200mcg, but the recommended dosage for induction according to World Health Organization is 20-25mcg orally every 2 hours or 25mcg vaginally every 4 hours.  The difficulty with this is that the tablets are manufactured to be taken whole, in their 100mcg or 200mcg amounts.  This means that the tablets must be cut; and anyone who has attempted to cut a pill in 2 pieces, let alone 4, knows how difficult it is to accurately do that, leaving the true dosage in each piece questionable at best.  This should be an important consideration for anyone who is offered this method of induction.

Having said all of that, I feel it important to admit that 13 years ago, I was given Cytotec orally to induce labor in my second pregnancy.  Admittedly, I was not the birth-savvy woman that I am today; and knowing what I do now, I would most likely handle my son’s birth differently.  Thankfully, my labor went beautifully and he and I came out of it healthy, happy, and whole.  But, I feel that it is my duty to help other women have access to the facts so that you all can make truly informed decisions, if and when, you are faced with them.

Ethan summer 2009

Bottom line is this.  Sometimes we can learn a lot from television.  Or at least we can begin a conversation that will lead us to become more knowledgeable about the world around us.  I have said it many times in my work.  I am not anti-intervention, I am pro-informed consent.  I hope that this post has helped you to become better informed about a very common intervention in birthing rooms around the country.