Use of oral misoprostol in the prevention of postpartum haemorrhage

The misoprostol third stage of labour study: a randomised controlled comparison between orally administered misoprostol and standard management

OBJECTIVE

To compare misoprostol with standard oxytocic regimens in the prevention of postpartum haemorrhage.

DESIGN

Randomised controlled trial.

SETTING

Obstetric unit in a large teaching hospital.

METHODS

One thousand women randomised to 500 microg misoprostol given orally or to standard oxytocic regimens of oxytocin, oxytocin with ergometrine, or ergometrine.

MAIN OUTCOME MEASURES

Incidence of postpartum haemorrhage and the incidence and severity of side effects.

RESULTS

Postpartum haemorrhage occurred in 12% of women given misoprostol and in 11% of women given standard oxytocic drugs (relative risk (RR) 1.10, 95% confidence interval (CI) 0.79, 1.55). Blood loss of 1000 mL or more occurred in 2% of women in each group. Nausea, headache, dizziness and tiredness were less frequent with misoprostol (RR (95% CI) 0.71 (0.59, 0.84); 0.53 (0.38, 0.74); 0.73 (0.61, 0.87) and 0.88 (0.83, 0.94) respectively). The main side effects of misoprostol were shivering (RR 1.95, 95% CI 1.69, 2.25) and a rise in temperature (difference in mean rise 0.34 degrees C, 95% CI 0.26, 0.42).

CONCLUSION

Oral misoprostol for the prevention of postpartum haemorrhage was comparable to standard oxytocics. Many side effects were less common with misoprostol but shivering and pyrexia were more common. Larger randomised trials are needed before establishing the equivalence between misoprostol and standard oxytocic drugs in the prevention of postpartum haemorrhage.

A double-blind placebo controlled randomised trial of misoprostol and oxytocin in the management of the third stage of labour

OBJECTIVE

To compare oral misoprostol 400 microg with intramuscular oxytocin 10 IU in the routine management of the third stage.

DESIGN

Double-blind placebo controlled trial.

SETTING

Main referral hospital and its associated polyclinics in Accra, Ghana.

POPULATION

Four hundred and one low risk women, in the second stage of labour with anticipated vaginal delivery, who entered labour spontaneously.

METHODS

After delivery of the anterior shoulder of the baby, the women were randomised to receive either: 1. misoprostol 400 microg powder in water orally and 1 mL normal saline intramuscular injection (placebo); or 2. powdered cellulose in water orally (placebo) and 1 mL oxytocin 10 IU intramuscular injection.

MAIN OUTCOME MEASURES

Change in haemoglobin concentration from before delivery to 12 hours postpartum. Secondary outcomes included need for additional oxytocics, blood loss > 500 mL and > 1,000 mL, operative intervention for postpartum haemorrhage, and side effects, including nausea, vomiting, diarrhoea, shivering and elevated temperature.

RESULTS

Demographic characteristics were similar. There was no significant difference in change in haemoglobin concentration between the two groups (0.60 g/dL for misoprostol and 0.55 g/dL for oxytocin; relative difference 9.6%; 95% CI 20.5-39.6%; P = 0.54). There were no significant differences in secondary outcomes with the exception of shivering, which occurred more frequently in the misoprostol group (22.2% vs 5.7%; relative risk 4.73; 95% CI 2.31-9.68; P < 0.0001).

CONCLUSIONS

In low risk women oral misoprostol appears to be as effective in minimising blood loss in the third stage of labour as intramuscular oxytocin. Shivering was noted more frequently with misoprostol use, but no other side effects were noted. Misoprostol has great potential for use in the third stage of labour especially in developing countries.

Postpartum haemorrhage

Postpartum haemorrhage can be either primary (within 24 hours of delivery) or secondary (within the following weeks). This article reviews the factors that may help anticipation of postpartum haemorrhage, and looks at issues involved in the management and treatment of women with this condition.

A randomized clinical trial comparing oral misoprostol with synthetic oxytocin or syntometrine in the third stage of labour

This is a multicentre, blocked, randomized trial to compare the efficacy of oral misoprostol 400 microg with current injectable uterotonic agents (oxytocin/ Syntometrine) used prophylactically in the third stage of labour. Main outcome measures were blood loss, use of a second uterotonic agent and difference in haemoglobin level from antepartum to postpartum. Data analysis from 863 women showed a statistically significant increase in both the mean blood loss (p < 0.001) and the rate of postpartum haemorrhage > 500 mL, (RR 2.72: 95% C1 1.73-4.27) in the misoprostol group compared to the oxytocin/Syntometrine group. The use of a second uterotonic agent was higher in the misoprostol group (RR 2.89: 95% Cl 2.00-4.18) as well as a greater decrease in postpartum haemoglobin (p = 0.015). Oral misoprostol 400 microg is significantly less effective than the traditional intramuscular uterotonic agents currently used and therefore cannot be considered as a viable option to these agents in the management of the third stage of labour.

Misoprostol compared with methylergometrine for the prevention of postpartum haemorrhage: a double-blind randomised trial

OBJECTIVE

To compare the efficacy and side effects of misoprostol, compared with methylergometrine, for the prevention of postpartum haemorrhage.

DESIGN

A double-blind, randomised clinical trial of 200 women with apparently normal pregnancies.

SETTING

University teaching hospital.

PARTICIPANTS

Two hundred women with apparently normal pregnancies.

METHODS

After the baby had been born, all women received two capsules by mouth and the contents of an ampule by intravenous injection. Each woman only received one active product. The capsules contained either a total of 600 microg misoprostol or placebo, and the ampule 200 microg of methylergometrine or placebo.

MAIN OUTCOME MEASURES

Need for further oxytocic drugs, blood pressure, the presence of side effects, mean haemoglobin and haematocrit three days after delivery.

RESULTS

Two hundred women completed the study (100 received methylergometrine and 100 misoprostol). Postpartum haemorrhage occurred in 4.3% of the methylergometrine group and 8.3% of the misoprostol group (P = 0.57). The need for further oxytocic drugs was 4.4% and 12.8% after methylergometrine and misoprostol, respectively (P = 0.065). One hour after the birth of the baby there was no difference in the mean systolic blood pressure (117 +/- 12 mmHg versus 115 +/- 11 mmHg) (P = 0.26) or the mean diastolic blood pressure (72 +/- 10 mmHg versus 71 +/- 11 mmHg for the groups receiving methylergometrine or misoprostol, respectively) (P = 0.97). The mean temperature in the misoprostol group rose to 37.4 degrees C, compared with 37 degrees C in the methylergometrine group (P < 0.0001). In the misoprostol group 34% developed fever (> 38 degrees C) compared with 3% in the methylergometrine group (P < 0.0001). Shivering (visual analogue score > or = 8) also occurred more often after misoprostol (42%) than after methylergometrine (8.5%) (P < 0.0001). The haemoglobin level (g/dL) on the third postpartum day was similar for both groups ( 11.0 and 11.2 for methylergometrine and misoprostol, respectively) (P = 0.39).

CONCLUSIONS

This study suggests that although protection from postpartum haemorrhage using parenteral methylergometrine and oral misoprostol is nearly equal, misoprostol is associated with more side effects.

The use of rectal misoprostol as active pharmacological management of the third stage of labor

OBJECTIVE

To compare the effectiveness of rectal Misoprostol versus combined intramuscular oxytocin and ergometrine (O-E) in the management of the third stage of labor.

METHODS

Low-risk women in 3rd stage of labor were allocated to receive either rectal Misoprostol [200micrograms (n = 25), 400 micrograms (n = 45)] or 5-units oxytocin and 0.2 mg ergometrine intramuscularly (n = 75). Clinical and hematological parameters were compared using t and chi-square tests.

RESULTS

Both groups were well matched and had similar duration of the 3rd-stage of labor. Misoprostol users had lower 3rd-stage estimated blood loss and needed less further ecbolics compared to O-E group. Postpartum Hb and Hct levels were significantly lower in O-E group than Misoprostol group. Postpartum hypertension occurred more in O-E group. Subjects in Misoprostol group had more shivering. Subjects receiving 200 micrograms and 400 microgram Misoprostol had similar outcome variables.

CONCLUSION

Rectal Misoprostol may be used safely in the management of the third stage of labor.

Treatment of severe postpartum hemorrhage by rectally administered gemeprost pessaries

OBJECTIVE

To assess the efficacy of rectally administered gemeprost pessaries in the treatment of severe postpartum hemorrhage.

DESIGN

Retrospective analysis of a twelve month period in which all patients having postpartum hemorrhage treated with rectal gemeprost were analyzed.

SETTING

Royal Darwin Hospital, Northern Territory, Australia.

POPULATION

Fourteen women with established postpartum hemorrhage not responding to oxytocine and ergometrine regimens, or not responsive to oxytocine and having contraindications to ergometrine.

MAIN OUTCOME MEASURES

Per vaginum bleeding with continued postpartum hemorrhage; adverse patient reactions to gemeprost; need for operative intervention.

RESULTS

All patients who were treated with rectally administered gemeprost pessaries had cessation of bleeding per vaginum. There were no adverse side effects noted from the medication and no patient required surgical treatment.

CONCLUSIONS

Rectally administered gemeprost administered pessaries appear to be safe and effective method of treating severe postpartum hemorrhage in those patients in whom the standard oxytocic regimens fail. This form of treatment may avoid the need for parenteral prostaglandins or surgical intervention.

Misoprostol dose-related shivering and pyrexia in the third stage of labour. WHO Collaborative Trial of Misoprostol in the Management of the Third Stage of Labour

OBJECTIVE

To select the misoprostol dose to be used in a large multicentre randomised trial comparing misoprostol with oxytocin in the routine management of the third stage of labour.

DESIGN

Randomised pilot trial, double-blinded with the use of double placebos.

SETTING

Two of the nine hospitals that will participate in the main multicentre trial. The hospitals were located in Johannesburg, South Africa and Khon Kaen, Thailand.

POPULATION

Women during second stage of labour about to be delivered vaginally.

METHODS

The trial had three arms: misoprostol 400 microg versus misoprostol 600 microg versus intramuscular oxytocin 10 IU. Each group received an injection and three tablets immediately after the birth of the baby.

MAIN OUTCOME MEASURES

Shivering and pyrexia rates were the main outcome measures. Data on other side effects and characteristics of the third stage of labour were also collected. Side effects were noted as none, mild, moderate or severe.

RESULTS

Both shivering and pyrexia (temperature > 38 degrees C) were most common in the 600 microg misoprostol group (28% and 7.5% for shivering and pyrexia, respectively) compared with 400 microg misoprostol (19% and 2%), and the oxytocin group (12.5% and 3%). The increase in shivering in the misoprostol 600 microg group was due primarily to a higher rate of moderate shivering. None of the women had a temperature > 40 degrees C. There were no increases in severe side effects and other adverse events in the misoprostol 600 microg group.

CONCLUSIONS

When used in the management of the third stage of labour oral misoprostol is associated with an increase in the rate of moderate shivering and pyrexia which seems to be dose-related. Based on the results of this pilot trial, the Steering Committee has decided to use 600 microg misoprostol in the main trial, comparing it with oxytocin, in order to achieve higher effectiveness.

Rectal misoprostol in the prevention of postpartum hemorrhage: a placebo-controlled trial

OBJECTIVE

This study investigated the effectiveness of rectal misoprostol in preventing postpartum hemorrhage.

STUDY DESIGN

In a randomized, placebo-controlled study, 550 women were randomly allocated to rectally receive 400 microg misoprostol or nonidentical placebo after normal vaginal delivery. Any excessive bleeding was actively managed with conventional oxytocic agents. Blood loss was measured directly.

RESULTS

The baseline variables were similar. Blood loss of > or = 1000 mL occurred in 4.8% (13/270) of the misoprostol group and 7% (19/272) of the placebo group. Additional oxytocic therapy was required by 3.3% and 4.7%, respectively. No predominance of side effects, particularly shivering, was noted in the misoprostol group.

CONCLUSIONS

Postpartum use of 400 microg rectal misoprostol was well tolerated and associated with a statistically nonsignificant trend toward less postpartum hemorrhage. The early active management of excessive bleeding with conventional oxytocic agents may have reduced the potential of the study to detect differences between the groups.

A randomised placebo controlled trial of oral misoprostol in the third stage of labour

OBJECTIVE

To compare oral misoprostol 400 microg with placebo in the routine management of the third stage of labour.

DESIGN

A double-blind placebo controlled trial. Setting The labour ward of an academic hospital in Johannesburg, South Africa with 7000 deliveries per annum.

PARTICIPANTS

Low-risk women expected to deliver vaginally.

METHODS

Women in labour were randomly allocated to receive either misoprostol 400 microg orally or placebo after the birth. Conventional oxytocics were given immediately if blood loss was thought to be more than usual. Postpartum blood loss in the first hour was measured by collection in a special flat plastic bedpan. Side effects were recorded.

MAIN OUTCOME MEASURES

Measured blood loss > or = 1000 ml within the first hour after birth. Use of additional oxytocics.

RESULTS

The groups were well matched. Measured blood loss > or = 1000 ml occurred in 15/250 (6%) after misoprostol and 23/250 (9%) after placebo (relative risk 0.65; 95% confidence interval 0.35-1.22). The difference may have been reduced by the greater use of conventional oxytocics in the placebo group, which was statistically significant for intravenous oxytocin infusion (2.8% vs 8.4%, relative risk 0.33, 95% confidence interval 0.14-0.77). Shivering was more common in the misoprostol group (19% vs 5%, relative risk 3.69; 95% confidence interval 2.05-6.64).

CONCLUSIONS

Shivering has been shown in this study to be a specific side effect of misoprostol administered orally in the puerperium. No serious side effects were noted. Misoprostol shows promise as a method of preventing postpartum haemorrhage. Because of the potential benefits for childbearing women, particularly those in developing countries, further research to determine its effects with greater certainty should be expedited.