Misoprostol in the management of postpartum haemorrhage

Abstract

Postpartum haemorrhage (PPH), mostly due to atony of the uterus, remains an important cause of maternal morbidity and mortality worldwide. Therefore, prevention and treatment of PPH with uterotonics such as prostaglandins is an important tool in perinatal management. Misoprostol is a cheap, thermostable, prostaglandin E1 derivate. It is a potent uterotonic and cervical priming agent. It is available in a tablet and can be administered orally, vaginally, rectally or sublingually, with different pharmacokinetic profiles. The oral and sublingual route result in the fastest onset of action and strongest initial uterotonic effect. Rectally, there is a prolonged uterine contraction after a slow onset of action. On the basis of available literature it can be concluded that misoprostol is not the first choice for active management of third stage of labor, when conventional uterotonics are available. Two case reports, two observational studies and a single-blinded randomised study support the use of misoprostol in the treatment of PPH. Two small randomised controlled trials combining different routes of administration could not confirm these findings. Larger trials are required to identify the best drug combinations, route, and dose, before misoprostol can be recommended for routine use in the treatment of PPH.