Evidence lacking for use of misoprostol in PPH prevention

By Ingrid Grasmo, medwireNews Reporter

There is insufficient evidence for the effectiveness of misoprostol in preventing postpartum hemorrhage (PPH), suggest findings from a review of available research published in the Journal of the Royal Society of Medicine.

Originally developed for treating gastric ulcers, misoprostol is being increasingly used in low- and middle-income countries for preventing PPH. Indeed, some countries have put it on the Essential Medicine Lists despite a lack of evidence supporting use for this indication.

"The most effective preventive strategy for PPH is prevention of anemia, good antenatal care including good hygiene, sanitation, and good care during labor," said lead study author Allyson Pollock (Queen Mary University of London, UK) in a press release.

"Developed countries would not dream of giving women misoprostol during labor on the basis of the current evidence, yet industry and health practitioners are pushing it hard in developing countries," she added.

Of the 172 identified studies of misoprostol use in labor, only six had enough information to be included in the review. All six used misoprostol 600 µg in the intervention arm; three assessed misoprostol alongside components of active management of the third-stage labor (AMTSL), two used expectant management of labor, and one allowed birth attendants to choose management practice.

Review findings showed no significant differences in PPH incidence or referral to higher centers among the three AMTSL studies, although one showed a significant decrease in severe PPH with misoprostol. Two of the other three studies showed significant decreases in overall PPH incidence. All studies found a significantly increased risk for shivering with misoprostol.

The researchers note that the included studies were biased by use of alternative uterotonics in the control arm, confounding management practices, subjective assessment, and exclusion of high-risk women (except in one study).

All six studies concluded that misoprostol holds beneficial effects, but Pollock and team note that the results of the studies do not fully support the conclusions.

PPH incidence decreased over time in both the control and intervention groups among the two landmark papers that informed the World Health Organization's (WHO) decision to include misoprostol on the Essential Medicines List. This indicates that factors other than pharmacologic intervention influence PPH risk.

"We urge the WHO to urgently review its decision to put misoprostol on its Essential Medicines List," said Pollock.

"Misoprostol is being used inappropriately at present, and the money being spent on purchasing the drug would be better spent elsewhere, for instance, in ensuring there are skilled attendants during delivery and adequate antenatal services that can detect and help prevent complications."

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