Add-on intrauterine misoprostol lowers PPH risk during caesarean delivery

Adding intrauterine misoprostol to oxytocin significantly reduced the incidence of postpartum haemorrhage (PPH) in women who underwent caesarean section (CS) compared with oxytocin alone, according to a study presented at RCOG 2024.

Globally, PPH is the leading cause of maternal deaths, affecting more than one-third of all maternal deaths in Asia and Africa. Excessive bleeding during and after CS is a major cause of maternal morbidity and mortality in many low-income countries, according to the researchers.

In the treatment of PPH, the use of uterotonics (oxytocin alone as the first choice) plays a crucial role. Other injectable uterotonics and misoprostol are recommended as alternatives for the prevention of PPH in settings where oxytocin is unavailable. [https://iris.who.int/bitstream/handle/10665/75411/9789241548502_eng.pdf]

“The evidence from the current study was fairly strong to prove the efficacy and safety of intrauterine misoprostol 400 mcg in the prevention of PPH in CS delivery, especially when added to oxytocin,” the researchers noted.

This study enrolled 300 pregnant women (37–40 weeks gestation) who underwent elective or emergency CS. Participants were randomly assigned to receive either intrauterine misoprostol 400 mcg and intravenous oxytocin 10 IU or oxytocin alone after delivery (n=150 in each group). Baseline characteristics, such as age, BMI, and gestational age, were comparable between the treatment groups.

As a result, patients treated with misoprostol and oxytocin achieved significantly reduced blood loss than those treated with oxytocin alone (440.19 vs 677.38 mL; p<0.001). [RCOG 2024, abstract MTeP-54]

In addition, the combination regimen resulted in significantly reduced blood loss intraoperatively (408.27 vs 486.04 mL; p<0.001) and during the first 6 hours after delivery (58.87 vs 63.29 mL; p<0.05) compared with oxytocin only.

Significantly fewer women on misoprostol and oxytocin also required additional uterotonics intraoperatively than those on oxytocin alone (7 vs 11; p>0.05), with a much lesser reduction in haemoglobin level observed in the combination group (0.46 vs 1.2; p=0.14). “Thus, the need for postoperative blood transfusion was avoided,” said the researchers.

“[Taken together, treatment with misoprostol and oxytocin] reduced the need for blood transfusion, extra ecbolic, and additional intervention, along with a less reduction in postoperative haemoglobin and haematocrit levels when compared with oxytocin alone. Additionally, it is as safe as oxytocin alone,” the researchers noted.

“Overall, intrauterine misoprostol (400 mcg), added to oxytocin infusion during CS, was effective in decreasing intraoperative and postoperative blood loss and preventing PPH,” said the researchers.

“Misoprostol is also effective via the intrauterine route. It is convenient to insert misoprostol during CS to prevent intrapartum haemorrhage and PPH,” they added. “We believe this generalization will help reduce the tragic effect of PPH specifically in low developed countries.”