Iranian Society of Gynecology Oncology

Document Type : Case Report Article


1 Department of Anesthesiology, Ayatollah Mousavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran

2 Department of Operating Room, Faculty of Nursing and Midwifery, Zanjan University ofMedical Sciences, Zanjan, Iran

3 Ph.D Candidate of Medical Education, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran

4 Department of Emergency & Critical Care, School of Nursing, Zanjan University of Medical Sciences, Zanjan, Iran

5 Department of Cardiac Anesthesiology, Ayatollah Mousavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran

6 School of Science, Engineering and Environment, University of Salford, Manchester, UK


Pyrexia and shivering are the most popular side effects of postpartum administration of misoprostol, but other side effects of this drug are very rare. A 27-year-old pregnant female patient was admitted to Ayatollah Mousavi hospital (Zanjan, Iran), complaining about severe headache and the primary diagnosis of cerebral venous thrombosis. Treatment was successful after primary investigations and planed therapy for Cerebral Venous Thrombosis (CVT). Following the decision on terminating the pregnancy, five tablets of Sublingual misoprostol (200 mg) was used once evacuation of pregnancy remnants was done. About thirty minutes after the administration of misoprostol, onset of severe shivering and tachycardia (201/min) with high fever (about 41°C) and hypertension (182/123 mmHg) was observed. National Adverse Drug Reaction (ADR) form was completed. All of symptoms were alleviated 30 minutes after administration of Paracetamol 1gram (Intravenous infusion) followed by Metoprolol 50 mg (orally). According to the literature, we listed the various side effects of misoprostol. Even though the side effects of misoprostol are diverse and rare, the simultaneous occurrence of these side effects is not cited till date. These incidents are reported to the authorities as per ADR policy; nonetheless, no preventive measures are implemented. This necessitates medical educational policies to be taken into consideration to educate healthcare providers throughout their professional career as well as research.


 Pyrexia and shivering are the most popular side effects of postpartum administration of misoprostol, but other side effects of this drug are very rare. A 27-year-old pregnant female patient was admitted to Ayatollah Mousavi hospital (Zanjan, Iran), complaining about severe headache and the primary diagnosis of cerebral venous thrombosis. Treatment was successful after primary investigations and planed therapy for Cerebral Venous Thrombosis (CVT).


Main Subjects


Misoprostol is a prostaglandin E1 analog derivative which is used to prevent stomach ulcers, start labor and to treat postpartum hemorrhage due to poor contraction of the uterus (1). Also, it is used for its uterotonic characteristics, oral administration, and stability in ambient temperatures (2). Misoprostol has oral, vaginal, rectal and sublingual formation (3). Many studies have reported that the administration of misoprostol by the sublingual route is superior to oral and vaginal administration routs, (4-6), as it is assumed that the minor side effects occur if taken sublingually. The most popular side effect of misoprostol administration to remove placental remnants after postpartum are fever and shivering, but other side effects of this drug are scarce (4,7). While these incidents are reported via ADR forms, the preventive measures to promote patient safety remain unclear. Hence, medical educational policies are required to probe the possible safety measures and fostering them. We are reporting a case of a pregnant woman with rare adverse drug reactions such as malignant hyperthermia, cardiac dysrhythmia and hypertension crisis following sublingual administration of misoprostol in postpartum ward with cerebral venous thrombosis.

Case Presentation
A 27-year-old pregnant female patient (G2P1L1) was admitted to Ayatollah Mousavi hospital (Zanjan, Iran) due to severe headache. Patient symptoms started with sudden onset of headache and its severity was intensified during pregnancy. Patient vital signs upon admission were: Blood Pressure =140/90 mmHg, Temperature=37.4°C, Respiratory Rate=25/min, Heart Rate=125/min. Upon admission Magnesium sulfate (2 gr) was infused and the patient was carried to the critical care unit. Neurology consultation was performed, and neurologists suggested brain imaging using MRI and MRV. The results revealed left sigmoid venous sinus thrombosis and heparin infusion was commenced immediately (Figure 1). Once the decision was made about terminating the pregnancy, surgical approach was implemented to evacuate the pregnancy remnants. Following the procedure, to control the post-surgical hemorrhage, misoprostol (200 mg) was prescribed by gynecologist Five tablets of Sublingual misoprostol (200 mg) were used once evacuation of pregnancy remnants was done. About thirty minutes after the administration of misoprostol, tachycardia (201/min) and severe shivering with a high fever (about 41 °C) and hypertension (182/123 mmHg) were suddenly developed (Figure 2). Then Paracetamol 1000 mg was infused, followed by oral Metoprolol 50 mg immediately beside the nursing care process (including removing the covering blankets, applying ice packs, and injection of sodium chloride 0.9%). All the mentioned symptoms alleviated after 30 minutes to 1 hour. These symptoms were considered to be related to the adverse effects of misoprostol which resolved by appropriate treatment (Figure 2). The listed complications were registered with the Iranian Adverse Drug Reaction Association with file number 33-77-8-01.

Figure 1. Left sigmoid venous sinus thrombosis in MRI and MRV

Figure 2.
Electrocardiogram of a patient experiencing tachycardia following Misoprostol administration Left: Tachycardia is evident by HR: 270 b/min Right: Normal sinus rhythm in the same patient after controlling the symptom (HR:90/min).


Besides the various applications of misoprostol, it is applied for the therapy of postpartum hemorrhage (8). Using the correct dose is vital for safe treatment (9). The most popular side effects associated with administration of misoprostol in patients experiencing postpartum hemorrhage are pyrexia and shivering (10). These side effects are more popular in oral and sublingual routes of administration compared to rectal or Intravaginal routes (Table 1). 

Table 1. Various routs and dosage of misoprostol

        Route     Onset of action   Duration of action
        Oral      8 min    About 2 h
        Sublingual      11 min    About 3 h
        Vaginal      20 min    About 4 h
        Rectal      100 min    About 4 h

Following the oral treatment of misoprostol, it is quickly and almost totally absorbed from the gastrointestinal system (11). As the result of a single dosage of 400 microgram of oral misoprostol, its plasma rate rises quickly and peaks in approximately 30 minutes (12). Due to the high concentration of plasma produced in oral routes, recent studies have focused on its sublingual routes for abortion. This medication is observed to be soluble, which can be dissolved in 20 min when it is administered via sublingual membrane. It is also discovered that sublingual misoprostol has the quickest and highest peak time concentration beside the greatest bioavailability compared to the other routes (13). This report also compared this case with other case reports in the literature from 1990 to 2021. Data sources were PubMed, Embase, Google Scholar, DOAJ, Medline, Web of Science, Psych Info and CINAHL without language restriction (Table 2). Search strategy was: ((Postpartum OR Puerperium OR Pregnan* OR Gravid* OR Labor OR Obstetric) AND (Misoprostol OR Novo-Misoprostol OR Novo Misoprostol OR SC-29 OR SC-30 OR Cytotec) AND (Complication OR side effects OR adverse effects)). In this review, 600 articles were found, of which 150 remained during the review of the title and summary. Finally, by carefully studying the text by the authors, 33 articles in the form of case reports had expressed the Side effects of misoprostol. The peak concentration is obtained about 30 minutes after sublingual and oral treatment, compared to vaginal with almost 75 minutes. Consequently, it seems that sublingual and oral routes have the same onset of action (14). This is due to the fast absorption of sublingual mucosa and evading from the first pass metabolism. (15). In studies on misoprostol to prevent postpartum hemorrhage, shivering has been reported in 32-57% of patients receiving misoprostol (10). Hyperpyrexia of greater than 40 °C has been stated in various patients following 600 micrograms; and hyperpyrexia accompanied by delirium has been stated following 800 micrograms orally (14-19). Although the side effects of misoprostol are numerous and rare (Table 1), the simultaneous occurrence of these side effects is not cited till date. The primary interesting point regarding our case is the simultaneous occurrence of multiple side effects. Additionally, another highlighting point is the occurrence of cardiac dysrhythmia as a new side effect in this patient which had not been reported at the time of this report. Majority of such reports, which are recorded in ADR organizations, are crucial for various reasons. Firstly, utilizing continuous professional development of educational policies, clinicians can be well prepared to treat these situations appropriately to save lives. Also, ADR organization can reflect these reports to pharmaceutical companies to improvise the products. Besides, having set the appropriate educational policies, these reports could be included in medical school curriculum as clinical case-report-based education (20). Despite the versatility of such reports, there has been no reports available regarding the possible consequent actions among these reports. This can be considered a huge gap in health and safety regulations as well as educational and research policies. There is no point in keeping the records unless they are utilized in promoting patient health and safety via precise and concise educational timetable and content. Hence, medical education regulators and public health authorities are recommended to take ADR reports into account. Also, further studies are required to investigate various aspects of including case-report learning in medical education modules (21). As mentioned, the side effects of these medications are classified as serious ones. To prevent them, two approaches are suggested in order to be aware of the side effects of medications. First, the skills of health care workers regarding pharmaceutical matters should be improved in continuous education programs. Training content can include, but not limited to, prescribing, type of medication, side effect monitoring, and professional training updates (22). The second approach is to pay attention to a person's professional identity as a guardian of the patient's health (23). By including this section in the curriculum of medical students, this platform can be created so that students first get to know the dangers of these drugs, and then write prescriptions for the patient with more attention.



DMalignant hyperthermia, cardiac dysrhythmia, and hypertension crisis are rare side effects of misoprostol 500 µg administration. Early diagnosis and treatment of adverse drug reactions are crucial in the prevention of severe complications. Due to the importance of preventing such adverse reactions, it is suggested that authorities share the retrieved ADR data with medical schools, clinics, and continuous professional development institutions with the aim of adjusting educational curriculum. These modifications can initially make clinicians, nurses, and pharmacists familiar with uncommon adverse reactions to sublingual administration of misoprostol. Besides, pharmaceutical companies can also improvise their products based on the ADR reports. Correspondingly, utilizing reports-based learning as a part of medical education curriculum, students can benefit from a practical clinical learning.



We thank this patient and her family for allowing us to report side effects. We also thank the administrative and radiology unit of Ayatollah Mousavi Hospital in Zanjan for providing us with the patient documents.





Ethical Approval

The patient has given written consent to report drug side effects without her name and surname. The listed complications were registered with the Iranian Adverse Drug Reaction Association with file number 33-77-8-01.

Conflicts of Interest

The authors declare no conflicts of interest.


1. Decamps Mini D, Pelofi J, Treisser A. Off-label drug use of the misoprostol in gynecology & obstetrics: From a medico-economics benefit to a potential legal risk. Gynecol Obstet Fertil. 2015;43(6):453-8. [DOI:10.1016/j.gyobfe.2015.04.010] [PMID]
2. Stanton C, Nand DN, Koski A, Mirzabagi E, Brooke S, Grady B, et al. Accessibility and potency of uterotonic drugs purchased by simulated clients in four districts in India. BMC pregnancy and childbirth. 2014;14(1):386. [DOI:10.1186/s12884-014-0386-y] [PMID] [PMCID]
3. Uncu Y, Karahasan M, Uyaniklar Ö, Uncu G. Prophylactic misoprostol for the prevention of postpartum hemorrhage: a randomized controlled trial. Eur Rev Med Pharmacol Sci. 2015;19(1):15-22.
4. Milani F, Sharami SH, Arjmandi S. Comparison of sublingual and vaginal misoprostol for second-trimester pregnancy terminations. J Family Reprod Health. 2014;8(1):41.
5. Sääv I, Kopp Kallner H, Fiala C, Gemzell-Danielsson K. Sublingual versus vaginal misoprostol for cervical dilatation 1 or 3 h prior to surgical abortion: a double-blinded RCT. Human Reproduction. 2015;30(6):1314-22. [DOI:10.1093/humrep/dev071] [PMID]
6. Milani F, Roya Faraji M, Kobra Bloukimoghadam M, Salma Momenzadeh M, et al. Comparison of 25 ĩg Sublingual and 50 ĩg Intravaginal Misoprostol for Cervical Ripening and Labor: A Randomized Controlled Equivalence Trial. Arch Iran Med. 2014;17(10):652.
7. Bulusu R, Ray P, Rani A, Handa P. Comparison of side effects of misoprostol by oral and rectal routes in active management of third stage of labour. J Evid Based Med Health. 2017;4(3):146-9. [DOI:10.18410/jebmh/2017/29]
8. Smith JM, Baawo SD, Subah M, Sirtor-Gbassie V, Howe CJ, Ishola G, et al. Advance distribution of misoprostol for prevention of postpartum hemorrhage (PPH) at home births in two districts of Liberia. BMC Pregnancy Childbirth. 2014;14(1):189. [DOI:10.1186/1471-2393-14-189] [PMID] [PMCID]
9. Duduyemi AO, Okafor IP, Oridota ES. Misoprostol, Magnesium Sulphate and Anti-shock garment: A knowledge, availability and utilization study at the Primary Health Care Level in Western Nigeria. PloS one. 2019;14(3):e0213491. [DOI:10.1371/journal.pone.0213491] [PMID] [PMCID]
10. Shin HJ, Lee SR, Roh A-m, Lim Y-m, Jeong KA, Moon H-S, et al. Anaphylactic shock to vaginal misoprostol: a rare adverse reaction to a frequently used drug. Obstet Gynecol Sci. 2018;61(5):636-40. [DOI:10.5468/ogs.2018.61.5.636] [PMID] [PMCID]
11. Aung HH, Soe A, Aye NN. Effect of misoprostol on the pharmacokinetics of sustained release diclofenac in Myanmar healthy male volunteers. Siriraj Medical Journal. 2017;69(2):75-9.
12. Wu HL, Marwah S, Wang P, Wang QM, Chen XW. Oral Misoprostol Versus Vaginal Misoprostol In Management Of Anembryonic Pregnancy: Faculty of Medicine, Cairo University; 2016. Sci Rep. 2017;7:1664.
13. Makled A, Alsaied A, Ismail O, Farhan S. Effect of Sublingual Misoprostol on Intraoperative Blood Loss During Abdominal Hysterectomy: Randomized Controlled Trial. Egypt J Hospital Med. 2017;69(1): 1692-7. [DOI:10.12816/0040119]
14. Sweed MS, El-Saied MM, Abou-Gamrah AE, El-Sabaa HA, Abdel-Hamid MM, Hemeda H, et al. Rectal vs. sublingual misoprostol before cesarean section: double-blind, three-arm, randomized clinical trial. Arch gynecol obstet. 2018;298(6):1115-22. [DOI:10.1007/s00404-018-4894-2] [PMID]
15. Frye LJ, Byrne ME, Winikoff B. A crossover pharmacokinetic study of misoprostol by the oral, sublingual and buccal routes. The European Journal of Contraception & Reproductive Health Care. 2016;21(4):265-8. [DOI:10.3109/13625187.2016.1168799] [PMID]
16. Sharma N, Das R, Santa Singh Ahanthem KR. Misoprostol Induced Convulsion-A Rare Side Effect of Misoprostol. J Clin Diagn Res: JCDR. 2017;11(2):QD01. [DOI:10.7860/JCDR/2017/23396.9189] [PMID] [PMCID]
17. Durocher J, Bynum J, León W, Barrera G, Winikoff B. High fever following postpartum administration of sublingual misoprostol. BJOG. 2010;117(7):845-52. [DOI:10.1111/j.1471-0528.2010.02564.x] [PMID] [PMCID]
18. Bajwa SK, Bajwa SJS, Kaur H, Goraya SPS, Singh A, Kaurishar H. Management of third stage of labor with misoprostol: A comparison of three routes of administration. Perspect Clin Res. 2012;3(3):102-8. [DOI:10.4103/2229-3485.100666] [PMID] [PMCID]
19. Valadan M, Mojarad M, Feizabad E. The Effect of Various Dosages of Misoprostol for Cervical Preparation Before the Hysteroscopy. J Obstet Gynecol Cancer Res. 2020; 5 (3) :88-92. [DOI:10.30699/jogcr.5.3.88]
20. Florek AG, Dellavalle RP. Case reports in medical education: a platform for training medical students, residents, and fellows in scientific writing and critical thinking. J Med Case Rep. 2016 Apr 6;10:86. [DOI:10.1186/s13256-016-0851-5] [PMID] [PMCID]
21. Ortega-Loubon C, Culquichicón C, Correa R. The Importance of Writing and Publishing Case Reports During Medical Training. Cureus. 2017;9(12):e1964. [DOI:10.7759/cureus.1964]
22. Cullen MW, Geske J, Anavekar N, McAdams J, Beliveau, ME; Ommen, SR and et al. Reinvigorating Continuing Medical Education:Meeting the Challenges of the Digital Age. Mayo Clin Proc. 2019;94(12):2501-9. [DOI:10.1016/j.mayocp.2019.07.004] [PMID]
23. Cruess SR, Cruess RL, Steinert Y. Supporting the development of a professional identity: General principles, Med Teach, 2019;41:6, 641-9, [DOI:10.1080/0142159X.2018.1536260] [PMID]
24. Nayki U, Taner C, E, Mizrak T, Nayki C, Derin G: Uterine Rupture during Second Trimester Abortion with Misoprostol. Fetal Diagn Ther 2005;20:469-71. [DOI:10.1159/000087115] [PMID]
25. Kim JO1, Han JY, Choi JS, Ahn HK, Yang JH, Kang IS, Song MJ, Nava-Ocampo AA. Oral misoprostol and uterine rupture in the first trimester of pregnancy: a case report .Reprod Toxicol. 2005;20(4):575-7. [DOI:10.1016/j.reprotox.2005.04.014] [PMID]
26. Akhan SE, Iyibozkurt AC, Turfanda A. Unscarred uterine rupture after induction of labor with misoprostol: a case report. Clin Exp Obstet Gynecol. 2001;28(2):118-20.
27. Belmajdoub M, Alaoui FZF, Chaara H, Melhouf A. Uterine rupture in patients with healthy uterus: misoprostol complication (case study and literature review Pan Afr Med J. 2018;31:223. eCollection. [Article in French] [DOI:10.11604/pamj.2018.31.223.12906]
28. Mazhar F, Sultana J, Shahzad A. Misoprostol-induced Acute Coronary Syndrome in a Premenopausal Woman: A Case Report with Literature Review. Current Drug Safety. 2018;13;65-8. [DOI:10.2174/1574886312666171122100929] [PMID]
29. Tolefac PN, Minkande JZ. Sublingual misoprostol and hyperpyrexia: case report with temperature curve. BMC Res Notes. 2017;26: 10(1):329. [DOI:10.1186/s13104-017-2661-2] [PMID] [PMCID]
30. Matthesen T1, Olsen RH, Bosselmann HS, Lidegaard. Cardiac arrest induced by vasospastic angina pectoris after vaginally administered misoprostol. Ugeskr Laeger. 2017; 179(26):V02170167. [Article in Danish]
31. Sharma N, Das R, Ahanthem SS, Reddy K. Misoprostol Induced Convulsion-A Rare Side Effect of Misoprostol. J Clin Diagn Res. 2017:11(2): 2017. [DOI:10.7860/JCDR/2017/23396.9189] [PMID] [PMCID]
32. Rouzi AA, Almarzouki A, Tallab F, Ashkar L. Medical management of early pregnancy failure with misoprostol with rupture of the cesarean section scar pregnancy.Clin Exp Obstet Gynecol. 2017;44(3):477-9. [DOI:10.12891/ceog3422.2017] [PMID]
33. Egbe TO, Halle-Ekane GE, Tchente CN, Nyemb JE, Belley-Priso E.Management of uterine rupture: a case report and review of the literature. BMC Res Notes. 2016 .21;9(1):492. [DOI:10.1186/s13104-016-2295-9] [PMID] [PMCID]
34. Kiran S, Bansal T. Sublingual Administration of Drugs: Be Cautious. Anesth Analg. 2016 Jul;123(1):254. Anesth Analg. 2016;123(1):254. [DOI:10.1213/ANE.0000000000001346] [PMID]
35. Kaiser J, Royer PA. Profound Hyperthermia After Postpartum Rectal Misoprostol Administration. Obstet Gynecol. 2016;127(6):1067-9. [DOI:10.1097/AOG.0000000000001394] [PMID]
36. Nunes ML, Friedrich MA, Loch LF. Association of misoprostol, Moebius syndrome and congenital central alveolar hypoventilation. Case report. Arq Neuropsiquiatr. 1999;57(1):88-91. [DOI:10.1590/S0004-282X1999000100017] [PMID]
37. Khabbaz AY, Usta IM, El-Hajj MI, Abu-Musa A, Seoud M, Nassar AH. Rupture of an unscarred uterus with misoprostol induction: case report and review of the literature. J Matern Fetal Med. 2001;10(2):141-5. [DOI:10.1080/jmf.] [PMID]
38. Torriente MC. Silent Uterine Rupture with the Use of Misoprostol for Second Trimester Termination of Pregnancy: A Case Report. Obstet Gynecol Int. 2011;2011:584652. [DOI:10.1155/2011/584652] [PMID] [PMCID]
39. Sánchez O1, Guerra D. Moebius syndrome due to the use of misoprostol. Case report. Invest Clin. 2003;44(2):147-53. [Article in Spanish]
40. Berghahn L, Christensen D, Droste S. Uterine rupture during second-trimester abortion associated with misoprostol. Obstet Gynecol. 2001;98(5):976-7. [DOI:10.1097/00006250-200111001-00037] [DOI:10.1016/S0029-7844(01)01546-0] [PMID]
41. Hofmeyr G, Milos D, Nikodem V, De Jager M. Limb reduction anomaly after failed misoprostol abortion. S Afr Med J. 1998;88(5):566.
42. Sahraei Z, Mirabzadeh M, Eshraghi A. Erythema multiforme associated with misoprostol: a case report. Am J Ther. 2016; 23(5):e1230-3. [DOI:10.1097/MJT.0000000000000193] [PMID]
43. Pirmez R, Freitas MET, Gasparetto EL, Araújo AP. Moebius syndrome and holoprosencephaly following exposure to misoprostol. Pediatr neurol. 2010;43(5):371-3. [DOI:10.1016/j.pediatrneurol.2010.05.026] [PMID]
44. Bennett BB. Uterine rupture during induction of labor at term with intravaginal misoprostol. Obstet Gynecol. 1997;89(5):832-3. [DOI:10.1016/S0029-7844(97)00036-7] [PMID]
45. Henderson CE, Hana RG, Woroch R, Reilly KD. Short interpregnancy interval and misoprostol as additive risks for uterine rupture: a case report. J Reprod Med. 2010;55(7-8):362-4.
46. Bond R, Zee V. Overdosage of misoprostol in pregnancy. Am J Obstet Gynecol. 1994;171 (2):561-2. [DOI:10.1016/0002-9378(94)90302-6] [PMID]
47. Fossaluzza V, Di Benedetto P, Zampa A, De Vita S. Misoprostol‐induced urinary incontinence. J Int Med. 1991;230(5):463-4. [DOI:10.1111/j.1365-2796.1991.tb00474.x] [PMID]
48. Abbas AM, Sheha AM, Hussein RS, Talaat E, Ali MN. First-trimester rupture of a scarred uterus after use of sublingual misoprostol: a case report. Proceed Obstet Gynecol. 2016;6(2):1-6. [DOI:10.17077/2154-4751.1317]
49. Stitely ML, Craw S, Africano E, Reid R. Uterine Scar Dehiscence Associated with Misoprostol Cervical Priming for Surgical Abortion: A Case Report. J Reprod Med. 2015;60(9-10):445-8.
50. Pallavee P, Samal R, Begum J, Ghose S. Foetal fibular hemimelia with focal femoral deficiency following prenatal misoprostol use: a case report. J Obstet Gynaecol. 2016;36(6):760-1. [DOI:10.3109/01443615.2016.1157152] [PMID]
51. Béné J, Alarcon P, Faucon M, Auffret M, Delfosse F, Becker T, et al. Anaphylactic shock after misoprostol in voluntary termination of pregnancy-a case report. Eur J Obstet Gynecol Reprod Biol. 2014;182:260-1. [DOI:10.1016/j.ejogrb.2014.09.012] [PMID]
52. Goffman D, Cole D, Bobby P, Garry D. Failed methotrexate termination of pregnancy: a case report. J Perinatol. 2006;26(10):645. [DOI:10.1038/] [PMID]
53. Rosa RFM, Travi GM, Valiatti F, Zen PRG, Pinto LL, Kiss A, et al. Poland syndrome associated with an aberrant subclavian artery and vascular abnormalities of the retina in a child exposed to misoprostol during pregnancy. Birth Defects Res A Clin Mol Teratol. 2007;79(6):507-11. [DOI:10.1002/bdra.20366] [PMID]
54. Marchese JW, Mullen MG, Doherty Jr JH. Proximal femoral focal deficiency and fibular hemimelia associated with misoprostol use: a case report. Clin Dysmorphol. 2012;21(4):229-30. [DOI:10.1097/MCD.0b013e3283590a95] [PMID]
55. Muñoz-Franco F, Lacunza-Ruiz FJ, Vázquez-Andrés DJ, Rodríguez-Hernández JR, Coronary artery vasospasm after misoprostol treatment for incomplete abortion: a case report. Contraception, 2019;100 (6):498-501. [DOI:10.1016/j.contraception.2019.08.003] [PMID]
56. M.K. Ramadan MK, Darido S, Bazzi Z, et al.First-Trimester Placenta Percre-ta Causing Massive Vaginal Bleeding Following the Use of Misoprostol: A Case Report. Int J Clin Case. 2020;4:12-5.