Gynuity Instuctions for use: Misoprostol for Prevention of Postpartum Hemorrhage
Publication date: 2004
M I S O P R O S T O L F O R P R E V E N T I O N O F P O S T PA R T U M H E M O R R H A G E BACKGROUND Misoprostol is a prostaglandin E1 analog generally registered for preven- tion and treatment of gastric ulcers resulting from chronic administration of nonsteroidal anti-inflammatory drugs (NSAIDs). As misoprostol also induces uterine contractions, it is commonly used off-label for prevention of postpartum hemorrhage (PPH). Active management of the third stage of labor (AMTSL) is a proven method for reducing PPH. AMTSL consists of the administration of a prophylactic uterotonic, controlled cord traction, and uterine massage during the third stage. In the absence of availability of conventional injectable uterotonics, studies have demonstrated that misoprostol can be used effectively and safely for the prevention of PPH. The following information is presented for the guidance of healthcare providers in community-based settings where access to oxytocin is limited. INDICATION AND USAGE Misoprostol is indicated for prevention of postpartum hemorrhage after normal vaginal delivery. DOSAGE AND ADMINISTRATION The recommended regimen for preven- tion of postpartum hemorrhage with misoprostol is a single dose of 600 mcg misoprostol orally administered during the third stage of labor. Notes: Currently, there is insufficient evidence to recommend a lower dose of misoprostol for PPH prevention in community-based settings. As more evidence becomes available on lower doses (ranging from 200-400mcg), these Instructions for Use will be reviewed and updated with information on an optimal dose. This document will be periodically reviewed and updated with current information and research developments. © 2007 Gynuity Health Projects. July 2007 SUGGESTED CITATION Instructions for Use: Misoprostol for Prevention of Postpartum Hemorrhage. Expert review organized by Gynuity Health Projects. July 2007. For more information, refer to www.gynuity.org INSTRUCTIONS FOR USE FEVER Fever is less common than shivering and does not necessarily indicate infection. Elevated body temperature is often preceded by shivering, peaks 1-2 hours after taking misoprostol, and gradually subsides within 2-8 hours. An antipyretic can be used for relief of fever, if needed. If fever or shivering persists beyond 24 hours, the woman should seek medical attention to rule out infection. DIARRHEA, NAUSEA AND VOMITING Diarrhea may also occur following administration of misoprostol but should resolve within a day. Nausea and vomiting may occur and will resolve 2 to 6 hours after taking misoprostol. An antiemetic can be used if needed. CRAMPING Cramping or painful uterine contractions, as commonly occurs after childbirth, usually begin within the first few hours and may begin as early as 30 minutes after misoprostol administration. Nonsteroidal anti-inflammatory drugs or other analgesia can be used for pain relief without affecting the success of the method. POSTPARTUM BLEEDING Excessive bleeding, before or after placental delivery, should be referred immediately for additional care. Additional misoprostol should not be given within six hours of the initial dose. Use of misoprostol for PPH prevention is effective in reducing postpartum blood loss following vaginal delivery. When compared with no prophylactic administration of a uterotonic during the third stage of labor, misoprostol lowers postpartum blood loss. Studies have shown misoprostol to be less effective than oxytocin, and as good as oral ergometrine if not better. CONTRAINDICATIONS History of allergy to misoprostol or other prostaglandins. PRECAUTIONS • Providers should confirm that there is no undiagnosed second twin before giving the misoprostol. If there is any uncertainty, or if the birth attendant is unqualified to make the decision, then misoprostol is best given after delivery of the placenta. • Small amounts of misoprostol or its active metabolite may appear in breast milk. No adverse effects on nursing infants have been reported (Derman et al 2006). EFFECTS AND SIDE EFFECTS Prolonged or serious side effects are rare. SHIVERING Shivering is the most common side effect of misoprostol following its postpartum administration. It usually occurs within the first hour of taking misoprostol. This side effect is transient and will subside 2-6 hours after delivery.