1. Misoprostol for PAC Task Force Presentations PAC Consortium Meeting May 26, 2009

2. Why do we care? Abortion and complications of incomplete abortion are among the largest contributors to maternal morbidity and mortality in low resource countries Misoprostol works, is less invasive than surgery and quicker than expectant management In many places, safe surgical care and surgical equipment still not widely available

3. Misoprostol for PAC Where we’ve come from : Little known about misoprostol; no evidence-based regimen Concerns about “mis” or incorrect use

4. Misoprostol for PAC What we’ve accomplished so far: Established evidence-based regimens Incorporation in country PNPs Misoprostol added as PAC Technology PAC Consortium Consensus document published in IJGO –Dec 07 Instructions for Use - 8 languages ACOG statement – Feb 09 Introductory Guidebook - May 09 Misoprostol listed in WHO EDL for incomplete abortion indication!! – April 09

5. Gynuity’s Recent Studies CountryGroupsNEfficacy^ 600 mcg oral misoprostol vs. surgery Dao et al 2007 (Burkina Faso) misoprostol vs. MVA46094.5% vs 99.1% Bique et al 2007 (Mozambique) misoprostol vs. MVA10091 % vs. 100.0% Shwekerela et al 2007 Tanzania misoprostol vs. MVA30099 % vs. 100.0% Ghanamisoprostol vs. MVA22099% vs.99.1% Indiamisoprostol vs. D&C12297% vs.100% 400 mcg sublingual vs. 600 mcg oral misoprostol Moldova/ Madagascar sublingual misoprostol oral misoprostol 30094.5% vs. 94.6% 400 mcg sublingual misoprostol vs. surgery (D&C or MVA) Ecuador/Venezuelamisoprostol vs. surgery28094% vs. 100% Egyptmisoprostol vs. surgery700>96% vs. 99% Mauritania/Nigermisoprostol vs. surgery400>96% vs. 100%

6. Instructions for Use: Miso for PAC Purpose: Guidance for clinicians/medical personnel Dissemination via fact sheets, clinical training, websites, inclusion in scientific articles, etc. Content: Shadows a standard product label for use of misoprostol for incomplete abortion and miscarriage

7. Instructions for Use: Indication and usage Misoprostol is indicated for treatment of incomplete abortion and miscarriage for women with uterine size less than or equal to 12 weeks LMP at presentation For incomplete abortion: – 600 mcg orally or 400 mcg sublingually For missed abortion: – 800 mcg vaginally (efficacy: 60-93%)

8. Introductory Guidebook Based on current scientific evidence, the guidebook offers detailed information on: Efficacy, safety and acceptability; Eligibility criteria and precautions; Dosing, timing and routes of administration; Visit schedule and management of complications; Counseling and information provision; Integration of misoprostol into existing PAC services.

9. ACOG Committee Opinion Drafted by expert committee Summarizes situation of PAC as well as current literature Makes protocol recommendations based on many GHP studies.

10. WHO Essential Medicines List What is the EML: The Model EML serves as a guide for the dev’t of national and institutional lists and has led to a global acceptance of the concept of essential medicines as a means to promote health equity. Basis for medicines selection in emergency situations, guiding the responses of humanitarian assistance agencies to country requests for assistance in acute emergency settings.

11. WHO Essential Medicines List Application submitted to the WHO by GHP. Approval for inclusion of misoprostol for incomplete abortion indication - April 2009. With respect to use of misoprostol for the treatment of incomplete abortion, the Committee decided that the evidence showed that misoprostol is as effective as surgery and in some settings may be safer as well as cheaper and therefore recommended inclusion of the 200 micrograms tablet on the complementary list with a note indicating the appropriate use; * for management of incomplete abortion and miscarriage.

12. Essential Medicines WHO Model List

13. Misoprostol for PAC What more needs to be done: Efforts towards a registered labeled product for txt of incomplete abortion More evidence/experience needed from OR-type studies on use At lower levels of health care system By non – physician providers As first- line treatment Qualitative research Other?