Results of an international trial in this week’s issue of THE LANCET show that oxytocin is superior to the hormone derivative misoprostol in reducing maternal blood loss immediatley after childbirth.
Bleeding after delivery is a leading cause of maternal illness and death. Active management of the third stage of labour, including intravenous use of a uterotonic agent, has been shown to reduce blood loss. Misoprostol has been suggested for this purpose because it has strong uterotonic effects, can be given orally, is inexpensive, and does not need refrigeration for storage. José Villar and colleagues from the WHO did a multicentre randomised controlled trial to determine whether oral misoprostol is as effective as oxytocin during the third stage of labour.
Women about to deliver vaginally in hospitals from nine countries were randomly assigned 600 mg misoprostol orally or 10 IU oxytocin (intravenously or intramuscularly, according to normal practice). Medication was given immediately after delivery. The primary outcomes were blood loss of 1000 mL or more and the use of additional uterotonics.
366 (4%) of 9264 women on misoprostol had a measured blood loss of 1000 mL or more, compared with 263 (3%) of 9266 on oxytocin. 1398 (15%) women in the misoprostol group and 1002 (11%) in the oxytocin group required additional uterotonics. Misoprostol use was also associated with a significantly higher incidence of shivering and raised body temperature in the first hour after delivery.
In an accompanying Commentary (p 682), Philip Darney from the University of California, San Francisco, USA, considers the wider context for obstetric misoprostol use. He comments: “No one has proposed that misoprostol should replace oxytocin or ergonovine for prophylaxis of postpartum haemorrhage in city hospitals around the world where the trial was conducted. Instead, they want it available to midwives for deliveries in women’s homes and to doctors in rural health posts to treat women who may bleed to death because parenteral drugs are not practical to administer or not available. In these situations cheap pills have clear advantages over injectables, even if the pills are a third less effective than the injections, as the WHO Group found.”
Contact: Dr José Villar, UNDP/UNFA/WHO/World Bank Special Programme of Research,Development and Research Training in Human Production,Department of Reproductive Health and Research,CH-1211 Geneva 27,Switzerland;T) +41 22 791 3327;F) +41 22 791 4171; E) villarj@who.ch
Dr Philip D Darney, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco General Hospital, University of California, San Francisco, CA 94110, USA; T) +1 415 502 4091; F) +1 415 502 8479; E) darney@ob.ucsf.edu
Journal
The Lancet