Special preventive measures: misoprostol in action potx

Section IV Special preventive measures: misoprostol in action 177 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:20:34 Color profile: Generic CMYK printer profile Composite Default screen ‘With the emerging evidence on the use of various routes of administration of misoprostol, particularly in the non-hospital setting, it is becoming clear that this drug should be available at the community level in the hands of trained personnel, especially where oxytocin, Uniject and other uterotonics are not present or practical for use.’ The Working Group of the Goa International Conference on the Prevention of Post Partum Hemorrhage, July 15, 2006, Goa, India 16 MISOPROSTOL IN PRACTICE M. Potts Prior to the availability of misoprostol, it was impossible to carry any significant element of emergency obstetric care into homes where women deliver without a skilled birth attendant. As a low-cost, easy-to-administer, powerful uterotonic with an excellent safety profile and long shelf-life, misoprostol has a revolutionary potential to reduce death and morbidity from postpartum hemorrhage in precisely those situa- tions where it is most common – delivery at home without a skilled birth attendant. In a placebo-controlled, community-based trial in India, administration of 600 µg miso - prostol orally immediately after delivery sig - nificantly reduced postpartum hemorrhage (see Addendum). Research in Indonesia, Nepal and elsewhere is showing that community volun - teers with minimal training can teach illiterate women to self-administer misoprostol effectively and responsibly 1 (see Chapter 19). A 1000 µg rectal dose of misoprostol can be used to treat postpartum hemorrhage, in situations where an appropriate technology exists to diagnose blood loss (such as blood-soaked sarong or ‘kanga’), and where births are attended by traditional birth attendants (TBAs). In Tanzania, illiterate TBAs, with a brief training, used misoprostol to bring about a highly significant reduction in the number of women who needed to be referred to hospital or receive intravenous treatment 2 . Although these measures may seem revolu- tionary at first glance, they should be viewed as an essential step towards a long-term strategy where all women can be delivered by a certified midwife or physician practicing active manage- ment of the third stage of labor. Over the past half-century, countries such as Sri Lanka and Thailand have brought maternal mortality to low levels by ensuring over 90% of deliveries are attended by a skilled person able to use an oxytocic, and ultimately all countries should follow such a path. Unfortunately, rapid population growth, economic collapse and the spread of HIV/ AIDS in some African countries and the endless recruitment of skilled health professions from developing to developed countries will make the road to providing comprehensive obstetric care long and slow. During this interval, widespread access to misoprostol and the education to use it safely during home births have the potential to make a significant contribution – perhaps even the single most important contribution – to reducing the global burden of deaths from postpartum hemorrhage. The only other practi - cal intervention with the potential to reduce postpartum hemorrhage in low-resource set - tings is realistic access to family planning, as all women who wish to limit childbearing are at risk of postpartum hemorrhage, and the older, 156 178 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 06 September 2006 14:27:54 Color profile: Generic CMYK printer profile Composite Default screen higher-parity women, who have the greatest unmet need for family planning, are at even higher risk. References 1. Wiknjosastro G, Sanghvi H. Preventing PPH among women living in areas where a high proportion of births are not attended by skilled providers: Safety, acceptability, feasibility and program effectiveness (SAFE) demonstration project of community-based distribution of miso - prostol for prevention of PPH in rural Indonesia. Proceedings of Preventing Postpartum Hemorrhage: From Research to Practice, Bangkok, Thailand, January 20–24, 2004:31–7 2. Prata N, Mbaruka G, Campbell M, Potts M, Vahidnia F. Controlling postpartum hemorrhage after home births in Tanzania. Int J Gynaecol Obstet 2005;90:51–5 157 Misoprostol in practice Editors’ Addendum The Editors wish to bring the reader’s atten- tion to the paper referred to by Professor Potts on page 156. This paper has been pub- lished in the October 7, 2006 issue of The Lancet. To the Editors’ knowledge, this is the largest placebo-controlled study of miso- prostol for the prevention of postpartum hemorrhage, and the results showed that misoprostol significantly reduced the rate of postpartum hemorrhage in the patients who were administered this agent in comparison to the patients who received the placebo control. The full title of the paper and all authors are: R. J. Derman 1 , B. S. Kodkany 2 ,S.S. Goudar 2 , S. E. Geller 3 , V. A. Naik 2 ,M.B. Bellad 2 , S. S. Patted 2 , A. Patel 4 ,S.A. Edlavitch 1 , T. Hartwell 5 , H. Chakraborty 5 , N. Moss 6 . Oral misoprostol in preventing post- partum hemorrhage in a community setting. 1 University of Missouri-Kansas City School of Medicine; 2 Jawaharlal Nehru Medical College, Belgaum, Karnataka, India; 3 Univer- sity of Illinois, Chicago College of Medicine, USA; 4 John H. Stroger Jr. Hospital of Cook County, USA; 5 Statistics and Epidemiology, RTI International; 6 National Institute of Child Health and Human Development. 179 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 04 September 2006 13:53:27 Color profile: Generic CMYK printer profile Composite Default screen 17 MANAGEMENT OF POSTPARTUM HEMORRHAGE AT THE COMMUNITY LEVEL N. Prata The ability to manage postpartum hemorrhage at the community level is an essential element in any program to decrease maternal mortality from postpartum hemorrhage 1 , as most of the deliveries in developing countries occur at home without the presence of a skilled birth attendant 2 . The efficacy, safety, and importance of miso - prostol use for postpartum hemorrhage man- agement are well established for hospital-based settings 3 . However, misoprostol’s most signifi- cant impact will probably be at the household level, where most deliveries occur. Some studies have tested such technology in home births, and all of them produced encouraging results. During one intervention trial in rural Kigoma, Tanzania, Prata and colleagues demonstrated that traditional birth attendants (TBAs), who assist in most home deliveries, were able to diag - nose postpartum hemorrhage and effectively and safely administer 1000 µg of rectal miso - prostol to control postpartum hemorrhage 4 . Blood loss measurement was standardized by employing the traditional blood collection tool used by women in the region – the local garment that is colloquially referred to as a ‘kanga’ 5 . This study also showed that the ability to manage postpartum hemorrhage in home births resulted 158 Intervention Non-intervention Odds ratio (95% CI) Main outcomes of the study n % n % PPH (blood loss ≥ 500 ml) Referrals 111 8 24.5 1.8 73 75 18.5 19.0 1.3 0.1 (1.0–1.7) (0.0–0.2) Additional interventions among PPH cases n = 111 n =73 Type of additional interventions a Intravenous fluids Blood transfusion Manual removal of placenta Repair of tears Hysterectomy Other medical interventions d b 1 b 1 1 0 0 0 0 0.9 0.9 0.9 0.0 0.0 0.0 0.0 c 69 c 25 16 17 4 1 7 94.5 34.3 21.9 23.3 5.5 1.4 9.6 a Number of cases do not add up to total referred, some women had more than one intervention; b hospital records not available for one patient; three patients did not need additional interventions; another three were referred for other reasons than PPH; c hospital records not available for four patients; four patients did not need additional interventions; two cases referred for other reasons than PPH; d medical interventions included: Amoxyl tablets, methergin, and misoprostol. Source: Prata N, et al. Controlling postpartum hemorrhage after home births in Tanzania. Int J Gynaecol Obstet 2005;90:51–5 Ta bl e 1 Controlling postpartum hemorrhage (PPH) with a 1000 µg of misoprostol (intervention) in home births, Kigoma, Tanzania 180 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:20:34 Color profile: Generic CMYK printer profile Composite Default screen in important reductions in the number of refer - rals and the need for additional interventions, key factors in resource-poor settings (Table 1).This is particularly helpful in rural areas. In settings where culturally appropriate methods of measuring blood loss after delivery are difficult to devise, all women could be administered a prophylactic dose of 600 µg misoprostol after delivery of the baby. Its safety and efficacy in the hands of TBAs were shown in a randomized, controlled trial in the Gam - bia 6 . In addition, in places where, for cultural or other reasons, women deliver at home alone or in the presence of a family member, self-admin - istration of a prophylactic dose of misoprostol, distributed during pregnancy by trained com - munity health-care workers, are both viable options that can produce promising results, as was shown in other studies in Indonesia, Nepal, and Afghanistan. It will be many decades before all women in low-resource settings can receive skilled atten- tion at delivery in their homes. In the meantime, misoprostol has the potential to make a signifi- cant difference in reducing maternal mortality. It should be made available for use in all settings including home births, and particularly in those where it must be self-administered. References 1. Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of causes of mater - nal death: a systematic review. Lancet 2006;367: 1066–74 2. AbouZahr C, Wardlaw T. Maternal mortality at the end of a decade: signs of progress? Bull WHO 2001;79:561–8 3. Villar J, Gulmezoglu AM, Hofmeyr GJ, Forna F. Systematic review of randomized controlled trials of misoprostol to prevent postpartum hemor - rhage. Obstet Gynecol 2002;100:1301–12 4. Prata N, Mbaruku G, Campbell M, Potts M, Vahidnia F. Controlling postpartum hemorrhage after home births in Tanzania. Int J Gynaecol Obstet 2005;90:51–5 5. Prata N, Mbaruku G, Campbell M. Using the Kanga to measure postpartum blood loss. Int J Gynaecol Obstet 2005;89:49–50 6. Walraven G, Blum J, Dampha Y, et al. Miso- prostol in the management of the third stage of labour in the home delivery setting in rural Gam- bia: a randomised controlled trial. Br J Obstet Gynaecol 2005;112:1277–83 159 Management at the community level 181 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:20:34 Color profile: Generic CMYK printer profile Composite Default screen 18 ORAL MISOPROSTOL FOR PREVENTION OF POSTPARTUM HEMORRHAGE BY PARAMEDICAL WORKERS IN INDIA (AN ICMR TASK FORCE STUDY) N. Chandhiok Paramedical workers conduct deliveries in the rural areas of India where active management of the third stage of labor is not routinely practised and uterotonic agents are only provided for the management of postpartum bleeding. A multi- site, cluster-randomized, feasibility study was carried out to determine if paramedical workers from rural Peripheral Health Centers (PHCs) could actively manage the third stage of labor using oral misoprostol to prevent postpartum hemorrhage. Six hundred women each received either active management of the third stage of labor with 600 µg of oral misoprostol (inter - vention) or the current government guidelines for prevention of postpartum hemorrhage (controls). The primary outcome was blood loss after delivery and this was measured using a calibrated blood collection drape. Baseline characteristics were comparable in both groups and over 70% of women had 160 Intervention Comparison Tablet misoprostol (n = 600) Injection methergine (n = 531) Tablet methergine (n = 58) None † (n = 11) Total (n = 600) Duration of third stage of labor (min) (mean ± SD) 7.9 ± 4.2 11.1 ± 4.1*** 9.6 ± 5.0*** 5.9 ± 2.4 10.9 ± 4.3*** Blood loss (ml) Mean ± SD Median Q1–Q3 Range Postpartum hemorrhage 139.7 ± 100.4 100 90–150 25–1300 4 (0.7) 211.8 ± 80.6*** 200*** 150–250 30–750 4 (0.8) NS 211.6 ± 83.0*** 200*** 150–280 25–415 – 171.8 ± 178.3 100 100–160 100–700 1 (9.1) 211.0 ± 83.4*** 200*** 150–250 25–750 5 (0.8) NS Additional measures Uterotonics Intravenous fluids Blood transfusion Referred to higher level of health facility for PPH 4 4 1 2 (0.3) 2*** 2*** – 1 (0.2) – – – 1 1 – 1 (0.2) 3*** 3*** – 2 (0.3) ***p < 0.001; **p < 0.01 when compared with the intervention; † group was not compared with intervention due to small sample NS , not significant; PPH, postpartum hemorrhage Ta bl e 1 Outcome of intervention. Figures in parentheses are percentages 182 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:20:34 Color profile: Generic CMYK printer profile Composite Default screen moderate anemia. The paramedical workers were able to provide the intervention according to the guidelines in almost all deliveries (99%). There was a significant reduction in the dura - tion of the third stage of labor (7.9 ± 4.2 vs. 10.9 ± 4.3 min, p < 0.001), and the measured blood loss after delivery in the intervention group (139.7 ± 100.4 ml vs. 211.0 ± 83.4 ml, p < 0.001). This magnitude of reduction is significant for a country such as India where 80% of the women are anemic at the time of delivery and any reduction in blood loss is considered highly beneficial. The overall incidence of postpartum hemorrhage observed in the study was extremely low (< 1% in both groups), and the study size was not adequate to address the reduction in postpartum hemor - rhage at such low incidence (Table 1). As most deliveries in rural areas take place at home, there is a need to extend this study for all domiciliary deliveries. ACKNOWLEDGEMENT This communication is based on the following previously published article at the Editor’s request: Chandhiok N, Dhillon BS, Datey S, Mathur A, Saxena NC. Oral misoprostol for prevention of postpartum hemorrhage by paramedical workers in India. Int J Gynaecol Obstet 2006;92:170–5 161 Prevention by paramedical workers in India 183 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:20:34 Color profile: Generic CMYK printer profile Composite Default screen 19 OVERVIEW OF MISOPROSTOL STUDIES IN POSTPARTUM HEMORRHAGE A. Hemmerling INTRODUCTION These tables of peer-reviewed misoprostol studies were compiled to provide the reader with comprehensive references to the use of misoprostol in practice since 1997, for both prevention and treatment of postpartum hemor - rhage. The tables include both randomized and non-randomized trials, and they represent a diversity of situations. Table 1 provides an overview of 32 studies in the prevention of postpartum hemorrhage (including dosage and route of administration). Table 2 gives an overview of seven studies in the treatment of postpartum hemorrhage (including dosage and route of administration). 162 184 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 15:04:27 Color profile: Generic CMYK printer profile Composite Default screen 163 Overview of misoprostol studies in postpartum hemorrhage Authors Institutions Study title Journal n Participants in misoprostol group Dosage of misoprostol Route of administration Participants in control group(s) Control agent(s) Prata N, Hamza S, Gypson R, et al. Bixby Program in Population, Family Planning and Maternal Health, School of Public Health, University of California, Berkeley, USA Misoprostol and active management of the third stage of labor Int J Gynaecol Obstet 2006 Jul 6 [epub ahead of print] 8 2532 1189 600 µg oral 1343 current AMTSL practices Nellore V, Mittal S, Dadhwal V Dept. of Obstetrics and Gynecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India Rectal misoprostol vs. 15-methyl prostaglandin F 2α for the prevention of PPH Int J Gynaecol Obstet 2006; 94:45–6 8 120 60 400 µg rectal 60 125 µg 15-methyl prostaglandin F 2α i.m. Chandhiok N, Dhillon BS, Datey S, et al. Division of Reproductive Health and Nutrition, Indian Council of Medical Research, New Delhi, India Oral misoprostol for prevention of PPH by paramedical workers in India Int J Gynaecol Obstet 2006; 92:170–5 8 1200 600 600 µg oral 600 current government guidelines for PPH prevention Zachariah ES, Naidu M, Seshadri L Dept. of Obstetrics and Gynecology, Christian Medical College Hospital Vellore, India Oral misoprostol in the third stage of labor Int J Gynaecol Obstet 2006; 92:23–6 8 2023 730 400 µg oral [1] 617 [2] 676 [1] 10 IU oxytocin i.m. [2] 2 mg ergometrine i.v. Garg P, Batra S, Gandhi G Maulana Azad Medical College and Lok Nayak Hospital,Delhi,India Oral misoprostol vs. injectable methylergometrine in management of the third stage of labor Int J Gynaecol Obstet 2005; 91:160–1 8 200 100 600 µg oral 100 0.2 mg methylergometrine i.v. Ozkaya O, Sezik M, Kaya H, et al. Dept. of Obstetrics and Gynecology, School of Medicine, Suleyman Demirel University, Turkey Placebo-controlled randomized comparison of vaginal with rectal misoprostol in the prevention of PPH JObstet Gynaecol Res 2005;31: 389–93 8 150 [1] 50 [2] 50 400 µg [1] rectal [2] oral 50 placebo Hoj L, Cardoso P, Nielsen BB, et al. Dept. of Obstetrics and Gynecology, Aarhus University Hospital, Denmark Effect of sublingual misoprostol on severe PPH in a primary health center in Guinea-Bissau: randomized double-blind clinical trial BMJ 2005; 331:723 8 661 330 600 µg sublingual 331 placebo Continued Ta bl e 1 Misoprostol for prevention 185 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:20:36 Color profile: Generic CMYK printer profile Composite Default screen 164 POSTPARTUM HEMORRHAGE Authors Institutions Study title Journal n Participants in misoprostol group Dosage of misoprostol Route of administration Participants in control group(s) Control agent(s) Walraven G, Blum J, Dampha Y, et al. Farafenni Field Station, Medical Research Council Laboratories, Farafenni, Gambia Misoprostol in the management of the third stage of labor in the home delivery setting in rural Gambia: a randomizedcontrolledtrial BJOG 2005; 112:1277–83 8 1229 630 600 µg oral 599 2 mg ergometrine oral Vimala N, Mittal S, Kumar S, et al. Dept. of Obstetrics and Gynecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India Sublingual misoprostol versus methylergometrine for active management of the third stage of labor Int J Gynaecol Obstet 2004; 87:1–5 8 120 60 400 µg sublingual 60 0.2 mg methylergometrine i.v. Lam H, Tang OS, Lee CP, et al. Dept. of Obstetrics and Gynecology, Queen Mary Hospital,HongKongSAR, China A pilot-randomized comparison of sublingual misoprostol with syntometrine on the blood loss in third stage of labor Acta Obstet Gynecol Scand 2004;83: 647–50 8 60 30 600 µg sublingual 30 1 ml syntometrine i.v. (5 IU syntocinone and 0.5 mg ergometrine maleate) Caliskan E, Dilbaz B, Meydanli MM, et al. SSK Maternity and Women’s Health Teaching Hospital, Ankara, Turkey Oral misoprostol for the third stage of labor: a randomized controlled trial Obstet Gynecol 2003;101: 921–8 8 1574 388 600 µg oral [1] 404 [2] 384 [3] 398 [1] 600 µg misoprostol plus 10 IU oxytocin i.v. [2] 10 IU oxytocin i.v. [3] 10 IU oxytocin i.v. plus 0.2 mg methylergonovine maleate Oboro VO, Tabowei TO Maternity Unit, Zonal General Hospital, Kwale, Delta State, Nigeria Arandomizedcontrolledtrial of misoprostol vs. oxytocin in the active management of the third stage of labor Obstet Gynecol 2003;23: 13–16 8 496 247 600 µg oral 249 10 IU oxytocin i.m. Lumbiganon P, Villar J, Piaggio G, et al. Dept. of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Thailand Side-effects of oral misoprostol during the first 24 h after administration in thethirdstageoflabor BJOG 2002;109: 1222–6 8 1686 843 600 µg oral 843 10 IU oxytocin i.m. or i.v. Ta bl e 1 Continued 186 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:20:36 Color profile: Generic CMYK printer profile Composite Default screen [...]... oxytocin or 0.5 mg ergometrine or 1 ml syntometrine) 10 IU oxytocin i.m 1 ml syntometrine i.v (5 IU syntocinone and 0.5 mg ergometrine maleate 0.5 mg) 10 IU oxytocin i.m placebo Participants Participants in misoprostol Dosage of in control Route of group misoprostol administration group(s) Control agent(s) 203 A multicenter randomized controlled trial of oral misoprostol and i.m syntometrine in the... practices 10 IU oxytocin i.m 5 IU oxytocin i.v or 10 IU oxytocin i.m 9266 166 Continued 10 IU oxytocin i.m or i.v 20 IU oxytocin i.v [1] 200 [1] 2.5 IU oxytocin [2] 200 i.v [2] placebo 256 113 [1] 401 [1] 10 IU oxytocin [2] 407 i.v plus 600 µg [3] 402 misoprostol rectal [2] 10 IU oxytocin i.v [3] 10 IU oxytocin i.v plus 1 ml methylergometrine i.m 192 Color profile: Generic CMYK printer profile Composite... 32 0 121 81 395 – – 1 ml syntometrine i.m (5 IU syntocinone and 0.5 mg ergometrine maleate) plus 10 IU oxytocin i.v – placebo placebo current practices Participants Participants in misoprostol Dosage of in control Route of group misoprostol administration group(s) Control agent(s) Institutions Misoprostol for treatment Authors Table 2 Color profile: Generic CMYK printer profile Composite Default screen... methylergometrine i.v Color profile: Generic CMYK printer profile Composite Default screen Overview of misoprostol studies in postpartum hemorrhage 167 189 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:20:37 79 117 160 238 BJOG 2004; 111:1014–17 BMC Pregnancy Childbirth 2004;4:16 Misoprostol in the treatment of PPH in addition to routine... synthetic oxytocin or syntometrine in the third stage of labor 501 BJOG 2000; 8 401 A double-blind placebo 107:1111–15 controlled randomized trial of misoprostol and oxytocin in the management of the third stage of labor oral 600 µg oral rectal 400 µg oral oral 400 µg oral 600 µg 500 µg 400 µg 439 499 198 1032 339 300 standard oxytocic regimens (10 IU oxytocin i.m or 1 ml syntometrine i.m.) standard... Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:20:37 PPH, postpartum hemorrhage 14 18 64 Acta Obstet Gynecol Scand 2001;80: 835–9 Dept of Obstetrics & Gynaecology, Royal Free and University College London School, London, UK A randomized study comparing rectally administered misoprostol versus Syntometrine combined with an oxytocin infusion... University of Southern California Keck School of Medicine, Los Angeles, USA WHO Collaborative Group to Evaluate Misoprostol in the Management of the Third Stage of Labour Benchimol M, Gondry J, Mention JE, et al Gerstenfeld TS, Wing DA Gulmezoglu AM, Villar J, Ngoc NT, et al 18 530 243 Int J Gynaecol 8 499 Obstet 2001; 75:235–41 Misoprostol vs oxytocin in the third stage of labor Dept of Obstetrics and... Security Council: Maternity and Women’s Health Teaching Hospital, Kucukesat, Ankara, Turkey Caliskan E, Meydanli MM, Dilbaz B, et al 208 Ginecol Obstet 8 400 Mex 2002;70: 572–5 Vaginal misoprostol in the prevention of PPH Hospital de Ginecologia y Obstetricia de Monterrey, N L Mexico Quiroga Diaz R, Esparaza Arechiga M, Batiza Resendiz V, et al vaginal rectal rectal oral oral rectal oral 800 µg 600...165 187 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:20:36 200 8 600 J Gynecol Obstet Biol Reprod (Paris) 2001;30: 576–83 Am J Obstet 8 325 Gynecol 2001; 185:878–82 Role of misoprostol in the delivery outcome Rectal misoprostol vs intravenous oxytocin for the prevention of PPH after vaginal delivery Centre de Gynecologie... GJ, Ferreira S, Nikodem VC, et al 41 18 14 Int J Gynaecol Obstet 2001; 72:75–6 Obstet Gynecol 1998;92: 212–14 Management of severe PPH with misoprostol Rectally administered misoprostol for the treatment of PPH unresponsive to oxytocin and ergometrine: a descriptive study Abdel-Aleem H, Dept of Obstetrics & El-Nashar I, Gynecology, Faculty of Abdel-Aleem A Medicine, Assiut University, Assiut, Egypt O’Brien . of sublingual misoprostol on severe PPH in a primary health center in Guinea-Bissau: randomized double-blind clinical trial BMJ 2005; 331:723 8 661 330 600 µg sublingual 331 placebo Continued Ta. meantime, misoprostol has the potential to make a signifi- cant difference in reducing maternal mortality. It should be made available for use in all settings including home births, and particularly in. screen 163 Overview of misoprostol studies in postpartum hemorrhage Authors Institutions Study title Journal n Participants in misoprostol group Dosage of misoprostol Route of administration Participants in control group(s) Control