Evaluation of postpartum blood loss after misoprostol-induced labour Author's Reply
Article first published online: 16 SEP 2009
© 2009 The Authors Journal compilation © RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
BJOG: An International Journal of Obstetrics & Gynaecology
Volume 116, Issue 11, pages 1535–1536, October 2009
How to Cite
Elsedeek, M. (2009), Evaluation of postpartum blood loss after misoprostol-induced labour Author's Reply. BJOG: An International Journal of Obstetrics & Gynaecology, 116: 1535–1536. doi: 10.1111/j.1471-0528.2009.02275.x
- Issue published online: 16 SEP 2009
- Article first published online: 16 SEP 2009
- Accepted 19 May 2009.
We appreciate the interest in our paper about misoprostol-induced labour once more, and are pleased to address the concerns of Dr Wuntakal and Dr Erskine.1
The efficacy of misoprostol in the management of postpartum haemorrhage because of uterine atony is not questioned and there is robust evidence in literature about it. This apparent paradox, however, can be resolved knowing that the pharmacokinetics and pharmacodynamics of misoprostol, on uterine myometrium and cervical collagen are quite different in the antepartum from the postpartum periods.
In our original work, we did not analyse blood loss by parity, but when this was done, the duration of labour was non-significantly shorter among multiparous women, but this again correlated with initial Bishop score. Parity per se neither correlated with the duration of labour nor the postpartum blood loss.
We agree that ambulation during the first stage of labour might be preferred by some women, but here we are discussing induced labour, and not spontaneous childbirth. Intravenous drip is the only recommended method of administering oxytocin during labour. We also agree that different routes of administration might be preferred by different women, vaginal examination, however, would be inevitable for assessment of progress of labour. Vaginal misoprostol can be self administered. Most important is that the effect of misoprostol is not different using different routes of administration,2 justifying the speculation that the same results of this study would have been obtained using oral or sublingual route.
The Cochrane review of Kelly et al.3 entitled ‘oxytocin alone for cervical ripening and labour induction’ evaluates oxytocin efficacy in induction of labour. In this review, women with unfavourable cervix induced by oxytocin alone had higher incidence of unsuccessful vaginal delivery than those who had pre-induction ripening by vaginal prostin. Postpartum blood loss was not a main outcome measure in this review.
In the trial of Prager et al.,4 when 25 μg vaginal misoprostol were used for induction, the mean induction delivery interval was 17.3 hours and maternal outcome was not different from balloon catheter and dinoprostone although postpartum blood loss was not clearly stated. These results indicate that even if the 25 μg dose did not correlate with blood loss, this was on the expense of efficacy, because whatever the impact of misoprostol on the course of labour it is likely to be dose dependent.
Finally, we think that all of the suggestions recommended in the letter would be good ideas for further studies.