Prostaglandins for preventing postpartum haemorrhage

  • Review
  • Intervention

Authors

  • A Metin Gülmezoglu,

    Corresponding author
    1. World Health Organization, UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, Geneva, Switzerland
    • A Metin Gülmezoglu, UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, 20 Avenue Appia, Geneva, 1211, Switzerland. gulmezoglum@who.int.

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  • Fatu Forna,

    1. Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia, USA
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  • José Villar,

    1. World Health Organization, Department of Reproductive Health and Research, Geneva, Switzerland
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  • G Justus Hofmeyr

    1. University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, Department of Obstetrics and Gynaecology, East London Hospital Complex, East London, Eastern Cape, South Africa
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Abstract

Background

Prostaglandins have mainly been used for postpartum haemorrhage (PPH) when other measures fail. Misoprostol, a new and inexpensive prostaglandin E1 analogue, has been suggested as an alternative for routine management of the third stage of labour.

Objectives

To assess the effects of prophylactic prostaglandin use in the third stage of labour.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2007) and PubMed (July 2006). We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 7 January 2011 and added the results to the awaiting classification section.

Selection criteria

Randomized trials comparing a prostaglandin agent with another uterotonic or no prophylactic uterotonic (nothing or placebo) as part of management of the third stage of labour. The primary outcomes were blood loss 1000 ml or more and the use of additional uterotonics.

Data collection and analysis

Two review authors independently assessed eligibility and trial quality and extracted data.

Main results

Thirty-seven misoprostol and nine intramuscular prostaglandin trials (42,621 women) were included. Oral (seven trials, 2849 women) or sublingual misoprostol (relative risk (RR) 0.66; 95% confidence interval (CI) 0.45 to 0.98; one trial, 661 women) compared to placebo may be effective in reducing severe PPH and blood transfusion (RR 0.31; 95% CI 0.10 to 0.94; five oral misoprostol trials, 3519 women). The severe PPH analysis of oral misoprostol trials was not totalled due to significant heterogeneity.

Compared to conventional injectable uterotonics, oral misoprostol was associated with higher risk of severe PPH (RR 1.32; 95% CI 1.16 to 1.51; 16 trials, 29,042 women) and use of additional uterotonics but with fewer blood transfusions (RR 0.81; 95% CI 0.64 to 1.02; 15 trials, 27,858 women). Additional uterotonic data were not totalled due to heterogeneity. Misoprostol use is associated with significant increases in shivering and a temperature of 38 ºCelsius.

There are scarce data comparing injectable prostaglandins with the conventional injectable uterotonics on severe PPH and the use of additional uterotonics, the primary outcomes of this review.

Authors' conclusions

Misoprostol orally or sublingually at a dose of 600 mcg shows promising results when compared to placebo in reducing blood loss after delivery. The margin of benefit may be affected by whether other components of management of the third stage of labour are used or not. As side-effects are dose-related, research should be directed towards establishing the lowest effective dose for routine use, and the optimal route of administration.

Neither intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the management of the third stage of labour especially for low-risk women.

[Note: The 52 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

Plain language summary

Prostaglandins for preventing postpartum haemorrhage

Injectable uterotonic is the drug of choice for routine third stage management. Misoprostol may be used where no injectable uterotonic is available.

After her baby is born, the woman's womb (uterus) muscles contract and bleeding decreases. If the womb does not contract, postpartum haemorrhage (heavy bleeding) can occur, which can be life threatening. Prostaglandin, oxytocin and ergometrine are drugs that cause contractions of the womb (uterotonics). The review of 46 trials, involving 42,621 women, found that oral or sublingual prostaglandin (misoprostol) may be useful in places where injectable uterotonics are not available, and is not as effective as oxytocin and has more side-effects. The main side-effects are shivering and high temperature occurring in a significant proportion of women. Injectable prostaglandin may be effective in reducing blood loss but has adverse effects and costs more.

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