Postpartum intrauterine pressure studies of the uterotonic effect of oral misoprostol and intramuscular syntometrine

Uterine balloon tamponade as an adjunct to misoprostol for the treatment of uncontrolled postpartum haemorrhage: a randomised controlled trial in Benin and Mali

OBJECTIVE

To assess the effectiveness of low-cost uterine tamponade as an adjunct to misoprostol for the treatment of uncontrolled postpartum haemorrhage (PPH) in low-resource settings.

DESIGN

Randomised controlled trial.

SETTING

Seven healthcare facilities in Cotonou, Benin and Bamako, Mali.

POPULATION

Women delivering vaginally who had clinically diagnosed PPH that was suspected to be due to uterine atony, who were unresponsive to oxytocin and who needed additional uterotonics.

METHODS

Women were randomly assigned to receive uterine balloon tamponade with a condom-catheter device or no tamponade; both groups were also given intrarectal or sublingual misoprostol.

MAIN OUTCOME MEASURE

Proportion of women with invasive surgery or who died before hospital discharge.

RESULTS

The proportion of primary composite outcome did not differ significantly between the tamponade arm (16%; 9/57) and the standard second line treatment arm (7%; 4/59): relative risk 2.33 (95% CI 0.76 to 7.14, p=0.238). A significantly increased proportion of women with tamponade and misoprostol versus misoprostol alone had total blood loss more than 1000 mL: relative risk 1.52 (95% CI 1.15 to 2.00, p=0.01). Case fatality rate was higher in the tamponade group (10%; 6/57) than in the control group (2%; 1/59) (p=0.059).

TRIAL REGISTRATION NUMBER

ISRCT Registry Number 01202389; Post-results.

Prostaglandins for preventing postpartum haemorrhage

BACKGROUND

Prostaglandins have mainly been used for postpartum haemorrhage (PPH) when other measures fail. Misoprostol, a new and inexpensive prostaglandin E1 analogue, has been suggested as an alternative for routine management of the third stage of labour.

OBJECTIVES

To assess the effects of prophylactic prostaglandin use in the third stage of labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 January 2011). We updated this search on 25 May 2012 and added the results to the awaiting classification section.

SELECTION CRITERIA

Randomised trials comparing a prostaglandin agent with another uterotonic or no prophylactic uterotonic (nothing or placebo) as part of management of the third stage of labour. The primary outcomes were blood loss 1000 mL or more and the use of additional uterotonics.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and trial quality and extracted data.

MAIN RESULTS

We included 72 trials (52,678 women). Oral or sublingual misoprostol compared with placebo is effective in reducing severe PPH (oral: seven trials, 6225 women, not totalled due to significant heterogeneity; sublingual: risk ratio (RR) 0.66; 95% confidence interval (CI) 0.45 to 0.98; one trial, 661 women) and blood transfusion (oral: RR 0.31; 95% CI 0.10 to 0.94; four trials, 3519 women).Compared with conventional injectable uterotonics, oral misoprostol was associated with higher risk of severe PPH (RR 1.33; 95% CI 1.16 to 1.52; 17 trials, 29,797 women) and use of additional uterotonics, but with a trend to fewer blood transfusions (RR 0.84; 95% CI 0.66 to 1.06; 15 trials; 28,213 women). Additional uterotonic data were not totalled due to heterogeneity. Misoprostol use is associated with significant increases in shivering and a temperature of 38º Celsius compared with both placebo and other uterotonics.

AUTHORS' CONCLUSIONS

Oral or sublingual misoprostol shows promising results when compared with placebo in reducing blood loss after delivery. The margin of benefit may be affected by whether other components of the management of the third stage of labour are used or not. As side-effects are dose-related, research should be directed towards establishing the lowest effective dose for routine use, and the optimal route of administration.Neither intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the management of the third stage of labour especially for low-risk women; however, evidence has been building for the use of oral misoprostol to be effective and safe in areas with low access to facilities and skilled healthcare providers and future research on misoprostol use in the community should focus on implementation issues.

Prostaglandins for preventing postpartum haemorrhage

BACKGROUND

Prostaglandins have mainly been used for postpartum haemorrhage (PPH) when other measures fail. Misoprostol, a new and inexpensive prostaglandin E1 analogue, has been suggested as an alternative for routine management of the third stage of labour.

OBJECTIVES

To assess the effects of prophylactic prostaglandin use in the third stage of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group's Trials Register (February 2007) and PubMed (July 2006).

SELECTION CRITERIA

Randomized trials comparing a prostaglandin agent with another uterotonic or no prophylactic uterotonic (nothing or placebo) as part of management of the third stage of labour. The primary outcomes were blood loss 1000 ml or more and the use of additional uterotonics.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and trial quality and extracted data.

MAIN RESULTS

Thirty-seven misoprostol and nine intramuscular prostaglandin trials (42,621 women) were included. Oral (seven trials, 2849 women) or sublingual misoprostol (relative risk (RR) 0.66; 95% confidence interval (CI) 0.45 to 0.98; one trial, 661 women) compared to placebo may be effective in reducing severe PPH and blood transfusion (RR 0.31; 95% CI 0.10 to 0.94; five oral misoprostol trials, 3519 women). The severe PPH analysis of oral misoprostol trials was not totalled due to significant heterogeneity. Compared to conventional injectable uterotonics, oral misoprostol was associated with higher risk of severe PPH (RR 1.32; 95% CI 1.16 to 1.51; 16 trials, 29,042 women) and use of additional uterotonics but with fewer blood transfusions (RR 0.81; 95% CI 0.64 to 1.02; 15 trials, 27,858 women). Additional uterotonic data were not totalled due to heterogeneity. Misoprostol use is associated with significant increases in shivering and a temperature of 38 degrees Celsius. There are scarce data comparing injectable prostaglandins with the conventional injectable uterotonics on severe PPH and the use of additional uterotonics, the primary outcomes of this review.

AUTHORS' CONCLUSIONS

Misoprostol orally or sublingually at a dose of 600 mcg shows promising results when compared to placebo in reducing blood loss after delivery. The margin of benefit may be affected by whether other components of management of the third stage of labour are used or not. As side-effects are dose-related, research should be directed towards establishing the lowest effective dose for routine use, and the optimal route of administration. Neither intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the management of the third stage of labour especially for low-risk women.

Misoprostol for treating postpartum haemorrhage: a randomized controlled trial [ISRCTN72263357]

BACKGROUND: Postpartum haemorrhage remains an important cause of maternal death despite treatment with conventional therapy. Uncontrolled studies and one randomised comparison with conventional oxytocics have reported dramatic effects with high-dose misoprostol, usually given rectally, for treatment of postpartum haemorrhage, but this has not been evaluated in a placebo-controlled trial. METHODS: The study was conducted at East London Hospital Complex, Tembisa and Chris Hani Baragwanath Hospitals, South Africa. Routine active management of the third stage of labour was practised. Women with more than usual postpartum bleeding thought to be related to inadequate uterine contraction were invited to participate, and to sign informed consent. All routine treatment was given from a special 'Postpartum Haemorrhage Trolley'. In addition, participants who consented were enrolled by drawing the next in a series of randomised treatment packs containing either misoprostol 5 x 200 microg or similar placebo, which were given 1 orally, 2 sublingually and 2 rectally. RESULTS: With misoprostol there was a trend to reduced blood loss >/=500 ml in 1 hour after enrolment measured in a flat plastic 'fracture bedpan', the primary outcome (6/117 vs 11/120, relative risk 0.56; 95% confidence interval 0.21 to 1.46). There was no difference in mean blood loss or haemoglobin level on day 1 after birth < 6 g/dl or blood transfusion. Side-effects were increased, namely shivering (63/116 vs 30/118; 2.14, 1.50 to 3.04) and pyrexia > 38.5 degrees C (11/114 vs 2/118; 5.69, 1.29 to 25). In the misoprostol group 3 women underwent hysterectomy of whom 1 died, and there were 2 further maternal deaths. CONCLUSIONS: Because of a lower than expected incidence of the primary outcome in the placebo group, the study was underpowered. We could not confirm the dramatic effect of misoprostol reported in several unblinded studies, but the results do not exclude a clinically important effect. Larger studies are needed to assess substantive outcomes and risks before misoprostol enters routine use.

Prostaglandins for prevention of postpartum haemorrhage

BACKGROUND

Prostaglandins have mainly been used for postpartum haemorrhage when other measures fail. Misoprostol, a new and inexpensive prostaglandin E1 analogue, has been suggested as an alternative for routine management of the third stage of labour.

OBJECTIVES

To assess the effects of prophylactic prostaglandin use in the third stage of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register (March 2003).

SELECTION CRITERIA

Randomized or quasi-randomized trials comparing a prostaglandin agent with another uterotonic or no prophylactic uterotonic (nothing or placebo) as part of management of the third stage of labour. There were no language preferences.

DATA COLLECTION AND ANALYSIS

Eligibility, trial quality and data extraction were done by two reviewers independently.

MAIN RESULTS

Twenty-four misoprostol and eight intramuscular prostaglandin trials (34,203 participants) were included. The data comparing oral misoprostol to no uterotonics/placebo are from five trials and difficult to interpret because of the heterogeneity between trials. However, the data do not suggest a substantive reduction in the rate of postpartum haemorrhage or other measures of blood loss. Oral misoprostol 600 mcg shows clinically and statistically significantly more blood loss = 1000 ml compared with conventional injectable uterotonics (seven trials, 22,749 women, 3.6% versus 2.7%; relative risk (RR) 1.34, 95% confidence interval (CI) 1.16 to 1.55). Shivering and elevated body temperature (> 38 masculine C) are the main side-effects of misoprostol and are dose related (600 mcg versus 400 mcg: shivering - two trials, RR: 1.33; 95% CI: 1.07 to 1.64). Compared to oxytocin the RR of any shivering with 600 mcg oral misoprostol is 3.29 (seven trials, 22746 women; 19.7% versus 6.0%, 95% CI 3.03 to 3.56) and temperature greater than 38 masculine C is RR 6.78 (seven trials, 22,09 women; 6.3% versus, 95% CI 5.55 to 8.30). Injectable prostaglandins are associated with reduced mean blood loss in the third stage of labour (weighted mean difference -70 ml, 95% CI -73 to -67 ml) when compared to conventional injectable uterotonics but have more side-effects. There are scarce data from this comparison on severe postpartum haemorrhage and the use of additional uterotonics, the primary outcomes of this review.

REVIEWER'S CONCLUSIONS

Neither intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the active management of the third stage of labour especially for low-risk women. Future research on prostaglandin use after birth should focus on the treatment of postpartum haemorrhage rather than prevention where they seem to be more promising.