Misoprostol to reduce intraoperative and postoperative hemorrhage during cesarean delivery: a systematic review and metaanalysis

Abstract

OBJECTIVE To evaluate the efficacy and safety of prophylactic misoprostol use at cesarean delivery for reducing intraoperative and postoperative hemorrhage. STUDY DESIGN Systematic review and meta-analysis of randomized controlled trials. RESULTS Seventeen studies (3174 women) were included of which 7 evaluated misoprostol versus oxytocin and 8 evaluated misoprostol plus oxytocin versus oxytocin. Overall, there were no significant differences in intraoperative and postoperative hemorrhage between sublingual or oral misoprostol and oxytocin. Rectal misoprostol, compared with oxytocin, was associated with a significant reduction in intraoperative and postoperative hemorrhage. The combined use of sublingual misoprostol and oxytocin, compared with the use of oxytocin alone, was associated with a significant reduction in the mean decrease in hematocrit (mean difference, −2.1%; 95% confidence interval [CI], −3.4 to −0.8) and use of additional uterotonic agents (relative risk, 0.33; 95% CI, 0.18-0.62). Compared with oxytocin alone, buccal misoprostol plus oxytocin reduced the use of additional uterotonic agents; rectal misoprostol plus oxytocin decreased intraoperative and postoperative blood loss, mean fall in hematocrit, and use of additional uterotonic agents; and intrauterine misoprostol plus oxytocin reduced the mean fall in hemoglobin and hematocrit. Women receiving misoprostol, alone or combined with oxytocin, had a higher risk of shivering and pyrexia. CONCLUSION Misoprostol combined with oxytocin appears to be more effective than oxytocin alone in reducing intraoperative and postoperative hemorrhage during caesarean section. There were no significant differences in intraoperative and postoperative hemorrhage when misoprostol was compared to oxytocin. However, these findings were based on a few trials with methodological limitations.

Randomized controlled trial comparing carbetocin, misoprostol, and oxytocin for the prevention of postpartum hemorrhage following an elective cesarean delivery

“…A Chinese study [22] reported that a 600‐μg dose of misoprostol was superior to oxytocin in the prevention of postpartum bleeding. Another systematic review [9], which examined the use of prophylactic misoprostol during cesarean deliveries, included data from 17 studies (3174 patients). Generally, when compared to oxytocin, misoprostol alone did not demonstrate any significant improvements in the prevention of intra‐ and post‐operative hemorrhage [9]; however, combination misoprostol–oxytocin was more effective than oxytocin alone in reducing intra‐ and post‐operative hemorrhage during cesarean deliveries [9].…”

“…Alternative treatments have been investigated, including prostaglandins, such as misoprostol, and oxytocin agonists, such as carbetocin [8]. Misoprostol is a prostaglandin E 1 analogue with strong uterotonic properties and has been suggested as an alternative to injectable uterotonic agents for preventing PPH [9]. It is cheap, heat stable, and can be administered through multiple routes; however, it is known to be less effective than oxytocin in preventing PPH [10].…”

Comparison between syntocinon, misoprostol and carbetocin in reducing blood loss in elective caesarean section

“…A Chinese study [21] reported that a 600-μg dose of misoprostol was superior to oxytocin in the prevention of postpartum bleeding. Another systematic review [22] which examined the use of prophylactic misoprostol during cesarean deliveries, included data from 17 studies (3174 patients). Generally, when compared to oxytocin, misoprostol alone did not demonstrate any significant improvements in the prevention of intra-and post-operative hemorrhage [22] .…”

An elevated amniotic fluid prostaglandin F2αconcentration is associated with intra-amniotic inflammation/infection, and clinical and histologic chorioamnionitis, as well as impending preterm delivery in patients with preterm labor and intact membranes

“…Prostaglandins are considered the mediators of parturition [127–145], and they (unlike oxytocin) can stimulate myometrial contractility [146–158] during the first, second, and third trimesters, induce cervical remodeling [22, 24, 27, 159–168], and participate in extracellular matrix degradation leading to rupture of the membranes [30, 132, 169–177]. The main prostaglandins found in amniotic fluid are prostaglandin E 2 (PGE 2 ) and prostaglandin F 2α (PGF 2α ) [142, 178, 179].…”