Misoprostol versus oxytocin for treatment of post-partum haemorrhage.
Article Type: Clinical report
Subject: Uterine bleeding (Care and treatment)
Uterine bleeding (Prevention)
Uterine bleeding (Research)
Misoprostol (Dosage and administration)
Misoprostol (Comparative analysis)
Oxytocin (Dosage and administration)
Oxytocin (Comparative analysis)
Pub Date: 05/01/2010
Publication: Name: Reproductive Health Matters Publisher: Reproductive Health Matters Audience: General Format: Magazine/Journal Subject: Family and marriage; Health; Women's issues/gender studies Copyright: COPYRIGHT 2010 Reproductive Health Matters ISSN: 0968-8080
Issue: Date: May, 2010 Source Volume: 18 Source Issue: 35
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: Burkina Faso; Egypt; Turkey; Vietnam Geographic Code: 6BURK Burkina Faso; 7EGYP Egypt; 7TURK Turkey; 9VIET Vietnam
Accession Number: 236247749
Full Text: The relative place of misoprostol and oxytocin in the prevention and treatment of postpartum haemorrhage (PPH)--a major cause of maternal mortality and morbidity--has been controversial. There was hope that misoprostol would be the ideal drug: it is a potent uterotonic, can be used orally, and can be stored at ambient temperature. Oxytocin, the standard of care, needs parenteral administration and must be refrigerated if stored for extended periods. Many studies have compared misoprostol and oxytocin for prevention of PPH. Oxytocin is considered the drug of choice with misoprostol being an alternative when oxytocin use is not possible. Fewer studies have dealt with treating PPH.

Two studies compare the efficacy of sublingual misoprostol and intravenous oxytocin for treatment of PPH and look at whether misoprostol can be recommended. In one study, 9,348 women not exposed to prophylactic oxytocin had blood loss measured after vaginal delivery at four hospitals in Ecuador, Egypt and Vietnam. 978 (10%) were diagnosed with primary PPH and were randomly assigned to receive 800[micro]g misoprostol (n=488) or 40IU oxytocin (n=490). Additional blood loss of 300 mL or greater after treatment occurred for 147 (30%) of women receiving misoprostol and 83 (17%) receiving oxytocin (RR 1.78, 95% CI 1.40-2.26), confirming that oxytocin is the drug of choice for PPH in hospital settings but that misoprostol might be a suitable first-line treatment alternative. Shivering and fever were also significantly more common with misoprostol than with oxytocin. (1)

In the other study, 31,055 women exposed to prophylactic oxytocin had blood loss measured after vaginal delivery at five hospitals in Burkina Faso, Egypt, Turkey, and Viet Nam. 809 (3%) were diagnosed with PPH and were randomly assigned to receive 800 [micro]g misoprostol (n=407) or 40 IU oxytocin (n=402). Additional blood loss of 300 mL or greater after treatment occurred for 139 (34%) receiving misoprostol and 123 (31%) receiving oxytocin (RR 1.12, 95% CI 0.92-1.37), showing that misoprostol had a non-statistically significant increase in the risk of blood loss. Similar trends were observed for other outcomes, such as additional blood loss of 1000ml or more, a drop in haemoglobin, or blood transfusion. Again, oxytocin had fewer side effects than misoprostol. The investigators conclude that misoprostol is clinically equivalent due to uterine atony in women who have received oxytocin prophylactically during the third stage of labour, but that oxytocin is still the drug of choice. (2)

A comment considers whether misoprostol could be used for treating PPH in the community. In women not exposed to uterotonics during labour, misoprostol should be used for treating PPH if oxytocin is not available. However, extreme caution is needed if women have already received prophylactic misoprostol. Side-effects are dose-dependent, and giving misoprostol for both treatment and prophylaxis would expose women to a high dose. Moreover, the efficacy of treating PPH with misoprostol after its use for prophylaxis is still unknown. The use of intramuscular oxytocin for treating the remaining cases of PPH should be explored. Both drugs have their place but oxytocin is the drug of choice, and every effort should be made to make it widely accessible, including at the community level. Misoprostol is an option when oxytocin is not available, which should become increasingly uncommon. (3)

(1.) Winikoff B, Dabash R, Darwish E, et al. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women not exposed to oxytocin during labour: a double-blind, randomised, non-inferiority trial. Lancet 2010;375:210-26.

(2.) Blum J, Winikoff B, Raghavan S, et al. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: a double-blind, randomised, non-inferiority trial. Lancet 2010;375:217-23.

(3.) Buekens P, Althabe F. Post-partum haemorrhage: beyond the confrontation between misoprostol and oxytocin. Lancet 2010;375:176-78.
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