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Misoprostol usefulness on Post Partum Hemorrhage (PPH) among high risk mothers
Abstract
Background: Some studies are affirming that Misoprostol is superior to conventional treatment with oxytocin and ergometrine in reducing postpartum hemorrhage. Some are denying its superiority while others are just recommending it for low risk women. Objectives: 1) To find out whether the addition of Misoprostol to the conventional Oxytocin and Ergometrine treatment will reduce the duration and quantity of postpartum hemorrhage among high risk mothers. 2) to know the extent of side effects and patent satisfaction with Misoprostol. Setting& design : Hospital setting in Elsiaed maternity hospital Misurata ; Observational comparative design. Sampling method and statistical techniques used : Convenient sampling ; Proportions and Chi square test. Methodology:. About 100 pregnant mothers were delivered using Misoprostol 400 Mcg orally (Buccal tablets) in addition to the conventional treatment of oxytocin (10 IU) and ergometrine (0.2 mg).Another group of 100 mothers (comparison group) was delivered using only conventional treatment without Misoprostol. The duration, quantity of PPH. the side effects and the patents' perspectives regarding the third stage management were compared between the two groups. Results: Less bleeding among 76% of mothers ; p< 0.001, shorter duration among 77% p< 0.001 with fewer side effects among 18(18%) were observed with mothers in the Misoprostol group than the conventional treatment group. More number of mothers 86(86%) are satisfied with in the Misoprostol group than in conventional group, 68(68%). (P<0.001) Conclusions: Misoprostol is effective among high risk mothers. It reduces the duration and quantity of post partum bleeding and has very fewer side effects. It can be safely used in third stage labor.
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Objective To compare oral misoprostol 400 μg with intramuscular oxytocin 10 IU in the routine management of the third stage.
Design Double-blind placebo controlled trial.
Setting Main referral hospital and its associated polyclinics in Accra, Ghana.
Population Four hundred and one low risk women, in the second stage of labour with anticipated vaginal delivery, who entered labour spontaneously.
Methods After delivery of the anterior shoulder of the baby, the women were randomised to receive either: 1. misoprostol 400 μg powder in water orally and 1 mL normal saline intramuscular injection (placebo); or 2. powdered cellulose in water orally (placebo) and 1 mL oxytocin 10 IU intramuscular injection.
Main outcome measures Change in haemoglobin concentration from before delivery to 12 hours postpartum. Secondary outcomes included need for additional oxytocics, blood loss > 500 mL and > 1000 mL, operative intervention for postpartum haemorrhage, and side effects, including nausea, vomiting, diarrhoea, shivering and elevated temperature.
Results Demographic characteristics were similar. There was no significant difference in change in haemoglobin concentration between the two groups (0.60 g/dL for misoprostol and 0.55 g/dL for oxytocin; relative difference 9.6%; 95% CI 20.5–39.6%; P= 0.54). There were no significant differences in secondary outcomes with the exception of shivering, which occurred more frequently in the misoprostol group (22.2%vs 5.7%; relative risk 4.73; 95% CI 2.31–9.68; P < 0.0001).
Conclusions In low risk women oral misoprostol appears to be as effective in minimising blood loss in the third stage of labour as intramuscular oxytocin. Shivering was noted more frequently with misoprostol use, but no other side effects were noted. Misoprostol has great potential for use in the third stage of labour especially in developing countries.
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To review the management of postpartum hemorrhage (PPH).
Fifteen cases of severe PPH were retrospectively analyzed for clinical parameters and management.
Nine patients had a hysterectomy while selective arterial embolization was carried out in 7 cases. One patient had focus clearance. The main causes of postpartum hemorrhage requiring operative management were disseminated intravascular coagulation (DIC), uterine arteriovenous fistula and malformation, placental abnormality, uterine myoma and laceration.
Upon recognition of postpartum hemorrhage, the most effective management should be initiated. Every effort should be made to stabilize the patient and maintain her reproductive capability.
To systematically review the efficacy of misoprostol compared with placebo or other uterotonics in preventing maternal morbidity associated with the third stage of labor.
We identified, retrieved, evaluated, abstracted data, and assessed the quality of all published studies (from January 1996 to May 2002) which assessed misoprostol's efficacy in minimizing uterine blood loss during the third stage of labor. Seventeen studies included 28170 subjects; of these, approximately one-half received misoprostol with the remainder receiving either a placebo or another uterotonic agent. An estimate of the odds ratio (OR) and risk difference for dichotomous outcomes was calculated using a random- and fixed-effects model. Continuous outcomes were pooled using a variance-weighted average of within-study difference in means.
In assessing studies comparing misoprostol with placebo, those who received oral misoprostol had a decreased risk of needing additional uterotonics (OR 0.64, 95% confidence interval 0.46, 0.90). Compared with placebo, use of misoprostol was associated with an increased risk for shivering and pyrexia. In contrast, in studies comparing misoprostol with oxytocin, oxytocin was associated with significantly lower rates of postpartum hemorrhage, maternal shivering and pyrexia. In studies comparing misoprostol with Syntometrine, misoprostol was associated with higher rates of the need for additional uterotonic agent as well as shivering.
Misoprostol was inferior to oxytocin and other uterotonics with regard to any of the third stage of labor outcomes assessed. However, when compared to placebo, misoprostol had a decreased risk of needing additional uterotonics. Thus, in less-developed countries where administration of parenteral uterotonic drugs may be problematic, misoprostol represents a reasonable agent for the management of the third stage of labor. Additional randomized clinical trials examining objective outcome measures (i.e. need for blood transfusion or 10% hemoglobin change) may further define benefits and risks of misoprostol use during the third stage of labor.
To assess the efficacy of buccal misoprostol to decrease bleeding after vaginal delivery.
This was a randomized study of patients between 22 weeks and 42 weeks of gestation with anticipated vaginal delivery. Patients were given either a 200-mug misoprostol tablet or placebo in the buccal space at the time of cord clamping. A continuous dilute intravenous oxytocin infusion was given to all patients at delivery of the placenta. Postpartum hemorrhage was defined as blood loss exceeding 500 mL. Sample size calculations based on previous studies assumed a 13% incidence of postpartum hemorrhage in the control group. To show a statistically significant reduction of postpartum hemorrhage a total of 1,604 patients would be required in each group.
A total of 848 patients were enrolled and 756 randomly assigned, 377 in the misoprostol group and 379 in the placebo group. Demographic, antepartum, and intrapartum characteristics were similar between the groups. The incidence of postpartum hemorrhage, 3% compared with 5%, (relative risk 0.65, 95% confidence interval 0.33-1.29, P = .22), mean estimated blood loss, 322 compared with 329 mL, (P = .45), and mean minutes of the third stage of labor, 6.7 compared with 6.9 (P = .52) were similar between the groups, misoprostol and placebo, respectively. Hemoglobin difference before and after delivery, need for second or third uterotonic agent, and all measured neonatal variables including birth weights, and umbilical cord pH were similar between the groups.
Buccal misoprostol at cord clamping is no more effective than placebo in reducing postpartum hemorrhage.
Postpartum hemorrhage, frequently due to uterine atony, is an important cause of maternal death and morbidity. The knowledge of causes, of antenatal and intrapartum risk factors and of physiopathological changes in hemodynamics and coagulation during pregnancy are essential for the management of the condition. At the present time, many efforts are made to organize a multidisciplinary approach to this complication of delivery involving clinical and laboratory staffs, since the rapid correction of hypovolemia, the diagnosis and treatment of defective coagulation, the surgical and pharmacological control of bleeding are mandatory. Several medical options have been developed and the surgical management includes traditional and newer conservative procedures with variable success rates. The developments in the treatment of postpartum hemorrhage may reduce hysterectomy that is to be considered the last resort to resolve the hemorrhage in some cases. In the modern management of postpartum hemorrhage protocols and guidelines should be available in every delivery room.
To compare the effects of oral misoprostol 800 mug with intramuscular oxytocin 10 IU in routine management of the third stage of labour.
This randomized controlled trial was performed in a rural district hospital in Ghana, West Africa, and enrolled women in labour with anticipated vaginal delivery and no known medical contraindication to prostaglandin administration. Women were randomized to receive oral misoprostol 800 mug or intramuscular oxytocin 10 IU. Blood samples were taken to determine hemoglobin concentration before delivery and at 12 hours post partum. Treatment was administered at delivery of the anterior shoulder. The primary outcome was the change in hemoglobin concentration from before to after delivery. Secondary outcomes included other measures of blood loss and presumed medication side effects.
In total, 450 women were enrolled in the study. Their baseline characteristics were similar. There was no significant difference between the groups in the change in hemoglobin concentration (misoprostol 1.07 g/dL and oxytocin 1.00 g/dL). The only significant secondary outcomes were shivering (80.7% with misoprostol vs. 3.6% with oxytocin) and pyrexia (11.4% with misoprostol, none with oxytocin).
Routine use of oral misoprostol 800 microg appears to be as effective as 10 IU parenteral oxytocin in minimizing blood loss during the third stage of labour, as determined by change in hemoglobin concentration. Misoprostol appears to be a safe, inexpensive, and effective uterotonic for use in rural and remote areas, where intravenous oxytocin may be unavailable.
The purpose of this study was to compare misoprostol 600 microg intrarectally with conventional oxytocics in the treatment of third stage of labor.
In a controlled trial, 1606 women were randomly grouped to receive (1) oxytocin 10 IU plus rectal misoprostol, (2) rectal misoprostol, (3) oxytocin 10 IU, and (4) oxytocin 10 IU plus methylergometrine. The main outcome measures were the incidence of postpartum hemorrhage and a drop in hemoglobin concentration from before delivery to 24 hours after delivery.
The incidence of postpartum hemorrhage was 9.8% in the group that received only rectal misoprostol therapy compared with 3.5% in the group that received oxytocin and methylergometrine therapy (P =.001). There were no significant differences among the 4 groups with regard to a drop in hemoglobin concentrations. Significantly more women needed additional oxytocin in the group that received only rectal misoprostol therapy, when compared with the group that received oxytocin and methylergometrine therapy (8.3% vs 2.2%; P <.001). The primary outcome measures were similar in the group that received only rectal misoprostol therapy and the group that received only oxytocin therapy.
Rectal misoprostol is significantly less effective than oxytocin plus methylergometrine for the prevention of postpartum hemorrhage.
To assess the efficacy of rectal misoprostol as second-line therapy in the management of primary postpartum hemorrhage (PPH) as compared to methylergonovine maleate.
This was a retrospective cohort study. Charts from July 2000 to February 2005 were reviewed. Inclusion criteria were patients between 37 and 42 weeks' gestational age who received a clinical diagnosis of PPH following delivery of a singleton pregnancy and who required a second uterotonic following initial oxytocin therapy. The control group represented those receiving methylergonovine maleate (18 patients), and the study group consisted of those receiving misoprostol (40 patients).
There was no significant difference in maternal age, gestational age, parity or type of delivery between the 2 groups. There was no significant difference between the 2 groups in the need for blood transfusion (methylergonovine maleate group, 0/18 [0%], misoprostol group, 5/40 [12.5%] [p = 0.11]), the need for third-line medical therapy (methylergonovine maleate group, 10/18 [55.5%], misoprostol group, 22/40 [55%] [p = 0.961) or the need for any surgical intervention (methylergonovine maleate, 4/18 [22.2%], misoprostol 5/40 [12.5%] [p = 0.51]).
This limited study suggests that rectal misoprostol is comparable to methergine as second-line therapy for the treatment of 1 primary postpartum hemorrhage.