FindArticles / Health / Journal of Family Practice / April, 2003

Is rectal misoprostol as effective as oxytocin in preventing postpartum hemorrhage?

by Jessica M. Wright, Warren Newton

2 Caliskan E, Meydanli MM, Dilbaz B, Aykan B, Sonmezer M, Haberal A. Is rectal misoprostol really effective in the treatment of third stage of labor? A randomized controlled trial. Am J Obstet Gynecol 2002; 187:1038-1045. * PRACTICE RECOMMENDATIONS Rectal misoprostol is as effective as oxytocin in prevention of postpartum hemorrhage, though shivering and hyperthermia may result. The combination of oxytocin and methylergonovine was more effective in preventing postpartum hemorrhage than any single agent. Clinicians should consider rectal misoprostol a reasonable alternative to routine oxytocin during the third stage of labor, especially for patients who do not already have an intravenous line or are not receiving oxytocin, or in settings where refrigeration is not available. * BACKGROUND Recent reports suggest that rectal misoprostol prevents postpartum hemorrhage. This randomized controlled trial compared the effectiveness of rectal misoprostol with oxytocin and methylergotamine in preventing postpartum hemorrhage. * POPULATION STUDIED A total of 1606 women aged 19 to 31 years were recruited on admission in labor to a large urban hospital in Turkey. Exclusion criteria were gestational age <32 weeks, prior cesarean section, hypersensitivity to prostaglandins, and lack of measured predelivery or postpartum hemoglobin concentrations. The women in the study were of low socioeconomic status, with an average age of 25 years, an average parity of 0.7, and a baseline rate of anemia of 10%. This population may have a somewhat higher risk of postpartum hemorrhage than one in the US, but the results of this study should be generalizable to the typical family practice. * STUDY DESIGN AND VALIDITY This was a randomized trial with placebo controls and 4 arms: (1) rectal misoprostol, 400 [micro]g at delivery and 100 [micro]g at 4 and 8 hours postpartum; (2) 10 IU oxytocin given intravenously in 500 cc of saline solution; (3) oxytocin plus rectal misoprostol; or (4) 1 mL methylergotamine intramuscularly plus oxytocin. All treatments were given after cord clamping, and all patients received gentle traction on the cord, uterine massage, and manual removal of the placenta if necessary at 30 minutes. The resident physician in charge of labor recorded the data. Blood loss was measured by weighing collected blood and soiled sheets and by measurement of hemoglobin before and 24 hours after

delivery. Differences among groups were assessed by chi-square or Fisher exact tests for categorical data and by analysis of variance (ANOVA) and Tukey tests. The methodology of this study was excellent. Major strengths were randomized design with concealment of allocation, very good power, masking, objective measurement of blood loss, and attempts to standardize treatment other than the interventions. Weaknesses were relatively minor, including a difference in appearance between the misoprostol and its placebo, and the relative inattention to potentially important confounders such as parity, use of oxytocin before delivery, instrumental delivery, or postpartum transfusions. * OUTCOMES MEASURED Primary outcomes were drop in hemoglobin concentration and incidence of postpartum hemorrhage, defined as 500 mL. blood loss. Secondary outcomes included incidence of severe postpartum hemorrhage, defined as 1000 mL blood loss, need for additional oxytocic drugs, need for postpartum transfusion, length of third stage of labor, subsequent evacuation of the uterus, and side effects. Patient and clinician satisfaction, cost, and ease of administration were not addressed. * RESULTS Randomization succeeded in creating similar groups. There was no difference in the volume of blood loss among the oxytocin, misoprostol, and the misoprostol plus oxytocin groups. Compared with women getting oxytocin alone, women receiving misoprostol experienced more shivering (P<.05; number needed to harm [NNH]=13) and hyperthermia (P<.05; NNH=38). By contrast, women receiving the oxytocin plus methylergotamine at cord clamping had less frequent postpartum hemorrhage than those receiving misoprostol alone (P<.05; NNT=16) and less frequent severe hemorrhage (P=.03; NNT=40). There was no significant difference among the 4 groups in drop in hemoglobin concentration. Jessica M. Wright, MD, and Warren Newton, MD, MPH, Department of Family Medicine, University of North Carolina--Chapel Hill. E-mail: Warren_Newton@med.unc.edu. COPYRIGHT 2003 Dowden Health Media, Inc. COPYRIGHT 2008 Gale, Cengage Learning