misoprostol and Uterine-Inertia

Postpartum hemorrhage (PPH) is the leading preventable cause of maternal morbidity and mortality worldwide. Uterine atony is identified as the underlying etiology in up to 80% of PPH. This serves as a contemporary review of the epidemiology, risk factors, pathophysiology, and treatment of uterine atony.. Rates of postpartum hemorrhage continue to rise worldwide with the largest fraction attributed to uterine atony. A simple 0-10 numerical rating score for uterine tone was recently validated for use during cesarean delivery and may allow for more standardized assessment in clinical and research settings. The optimal prophylactic dose of oxytocin differs depending on the patient population, but less than 5 units and as low as a fraction of one unit is needed for PPH prevention, with an increased requirements within that range for cesarean birth, those on magnesium, and advanced maternal age. Carbetocin is an appropriate alternative to oxytocin. Misoprostol shows limited to no efficacy for uterine atony in recent studies. Several uncontrolled case studies demonstrate novel mechanical and surgical interventions for treating uterine atony.. There is a critical, unmet need for contemporary, controlled studies to address the increasing threat of atonic PPH.

Topics: Female; Humans; Misoprostol; Oxytocics; Oxytocin; Postpartum Hemorrhage; Pregnancy; Uterine Inertia

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality, and uterine atony is the leading cause of postpartum hemorrhage. Risk factors for uterine atony include induced or augmented labor, preeclampsia, chorio-amnionitis, obesity, multiple gestation, polyhydramnios, and prolonged second stage of labor. Although a risk assessment is recommended for all parturients, many women with uterine atony do not have risk factors, making uterine atony difficult to predict. Oxytocin is the first-line drug for prevention and treatment of uterine atony. It is a routine component of the active management of the third stage of labor. An oxytocin bolus dose as low as 1 IU is sufficient to produce satisfactory uterine tone in almost all women undergoing elective cesarean delivery. However, a higher bolus dose (3 IU) or infusion rate is recommended for women undergoing intrapartum cesarean delivery. Carbetocin, available in many countries, is a synthetic oxytocin analog with a longer duration than oxytocin that allows bolus administration without an infusion. Second line uterotonic agents include ergot alkaloids (ergometrine and methylergonovine) and the prostaglandins, carboprost and misoprostol. These drugs work by a different mechanism to oxytocin and should be administered early for uterine atony refractory to oxytocin. Rigorous studies are lacking, but methylergonovine and carboprost are likely superior to misoprostol. Currently, the choice of second-line agent should be based on their adverse effect profile and patient comorbidities. Surgical and radiologic management of uterine atony includes uterine tamponade using balloon catheters and compression sutures, and percutaneous transcatheter arterial embolization.

Topics: Carboprost; Female; Humans; Misoprostol; Oxytocics; Oxytocin; Postpartum Hemorrhage; Pregnancy; Uterine Inertia

We reviewed the literature to determine the optimal medical treatment of postpartum hemorrhage caused by uterine atony. Of the available uterotonics, only misoprostol and oxytocin have undergone rigorous comparative study. Of the 2, misoprostol is inferior: 2 recent well-done randomized trials with enrollment of more than 2200 patients demonstrated that, in situations in which prophylactic oxytocin has already been utilized, additional oxytocin is as effective as or better than misoprostol in terminating bleeding, while avoiding the high rate of fever (22-58%) associated with misoprostol. The second of these trials demonstrated that misoprostol does not augment the effect of oxytocin. We conclude that in settings in which oxytocin is available, oxytocin should remain the mainstay of both prophylaxis and first-line treatment of postpartum hemorrhage caused by uterine atony. In the developed world, the use of misoprostol for postpartum hemorrhage should be infrequent.

Topics: Female; Humans; Misoprostol; Oxytocics; Oxytocin; Postpartum Hemorrhage; Pregnancy; Treatment Outcome; Uterine Inertia

To determine whether buccal misoprostol during cesarean delivery in conjunction with active management of the third stage of labor reduces the need for additional uterotonic drugs.. A double-blind, randomized, placebo-controlled trial was performed in Monterrey, Mexico, between February 2008 and December 2013. Eligible women had risk factors for uterine atony and were to undergo cesarean delivery under epidural block. Using a computer-generated sequence and blocks of six, patients were randomly assigned to receive 400μg misoprostol or 800μg placebo buccally after cord clamping. Both groups received an intravenous oxytocin infusion. The primary outcome was the need for additional uterotonic drugs. Analyses were performed per protocol. Patients, investigators, and data analysts were masked to group assignment.. A total of 120 women were included in analyses (60 in each group). At least one additional uterotonic drug was required in 24 (40%) women in the placebo group versus 6 (10%) women in the misoprostol group (relative risk 0.16; 95% confidence interval 0.06-0.44). No adverse effects due to misoprostol were recorded.. Buccal misoprostol during cesarean delivery reduced the need for additional uterotonic drugs to treat uterine atony. ClinicalTrials.gov:NCT01733329.

Topics: Administration, Buccal; Adult; Cesarean Section; Double-Blind Method; Female; Humans; Infusions, Intravenous; Labor, Obstetric; Mexico; Misoprostol; Oxytocics; Oxytocin; Postpartum Hemorrhage; Pregnancy; Uterine Inertia; Young Adult

To compare the efficacy of rectally administered misoprostol with intravenous oxytocin infusion in preventing uterine atony and blood loss during cesarean delivery.. In this prospective, randomized, double-blind trial, 200 women undergoing cesarean delivery who did not have risk factors for postpartum hemorrhage were randomly allocated to receive either 800 microg of rectal misoprostol at the time of peritoneal incision or an intravenous infusion of oxytocin after delivery of the neonate. Primary outcome measures were estimated amount of intraoperative and postoperative (8 hours) blood loss and changes in hemoglobin levels 24 hours after delivery.. A total of 96 and 94 women were analyzed in the misoprostol and oxytocin groups, respectively. Intraoperative and postoperative blood loss was significantly lower in the misoprostol group than in the oxytocin group (503 vs 592 mL, P=0.003 and 74 vs 114 mL, P=0.045, respectively). The incidence of shivering was higher in the misoprostol group (8.3% vs 1.1%, P=0.018; RR 7.83; 95% confidence interval, 0.99-61.42).. Rectal misoprostol appears to be an effective alternative to intravenous oxytocin in preventing blood loss for routine use during cesarean delivery.. CTRI/2009/091/000075.

Topics: Administration, Rectal; Adult; Blood Loss, Surgical; Cesarean Section; Double-Blind Method; Female; Humans; Infusions, Intravenous; Misoprostol; Oxytocics; Oxytocin; Postoperative Complications; Pregnancy; Prospective Studies; Uterine Inertia; Young Adult

Topics: Adolescent; Carboprost; Delivery, Obstetric; Factor VII Deficiency; Female; Heterozygote; Humans; Misoprostol; Oxytocics; Perineum; Postpartum Hemorrhage; Pregnancy; Pregnancy Complications, Hematologic; Uterine Inertia

Postpartum haemorrhage (PPH), especially resulting from placenta accreta spectrum (PAS), has become a worldwide concern in maternity care. We describe a novel method of uterine compression sutures (the 'Nausicaa' technique) as an alternative to hysterectomy for patients who have suffered from major PPH. We applied this technique in 68 patients with major PPH during caesarean section (including 43 patients with PAS, 20 patients with placenta praevia totalis, and five patients with uterine atony), and none of these patients required further hysterectomy. We conclude that our Nausicaa suture is a simple and feasible alternative to hysterectomy in patients suffering from major PPH.

Topics: Adult; Cesarean Section; Female; Humans; Hysterectomy; Massage; Middle Aged; Misoprostol; Oxytocics; Oxytocin; Placenta Accreta; Placenta Previa; Postpartum Hemorrhage; Pregnancy; Severity of Illness Index; Suture Techniques; Treatment Failure; Uterine Inertia; Young Adult

To compare maternal morbidity before and after implementation of a postpartum hemorrhage (PPH) protocol that included misoprostol.. A retrospective analysis was performed using data from 34 631 deliveries recorded at a Spanish hospital between January 1, 2007, and December 31, 2014. The PPH protocol was implemented in 2009 and included use of misoprostol and the Bakri balloon.. The pre-implementation and post-implementation groups comprised 9394 and 25 237 women, respectively. Women in the pre-implementation group tended to have lower hemoglobin levels than did those in the post-implementation group: 811 (8.6%) versus 1349 (5.3%) for levels less than 90 g/L, and 272 (2.9%) versus 497 (2.0%) for levels less than 80 g/L (both P<0.001). Implementation of the PPH protocol was also associated with a decrease in the frequency of postpartum hysterectomies owing to uterine atony (0.11 cases per 1000 deliveries vs 0.53 cases per 1000 deliveries for the pre-implementation group; P=0.063). Pregnancy length, maternal age, neonatal weight at delivery, multiple pregnancy, previous cesarean delivery, parity, operative vaginal delivery, induced labor, cesarean delivery, and not using the PPH protocol were found to predict postpartum anemia in the multivariate analysis (all P<0.001).. Implementation of the PPH protocol decreased rates of postpartum anemia and postpartum hysterectomy owing to uterine atony.

Topics: Adult; Anemia; Cesarean Section; Delivery, Obstetric; Female; Humans; Hysterectomy; Misoprostol; Oxytocics; Postpartum Hemorrhage; Pregnancy; Retrospective Studies; Uterine Inertia; Young Adult

To compare trends in the etiology and management of severe postpartum hemorrhage (PPH) during 2 time periods: 2000-2004 (Period 1) versus 2005-2008 (Period 2).. Medical records with a diagnosis of PPH were identified by ICD-9 codes for immediate, third-stage, delayed, and secondary. PPH and post- partum coagulation defect. Subjects having a PPH within 24 hours of delivery who also received blood component therapy (defined as severe PPH) during Period 1 were compared with those from Period 2.. There were 109 and 119 cases identified from Periods 1 and 2, respectively. Uterine atony was the most common cause of severe PPH during both time periods. In the second time period women with severe PPH had a lower mean hematocrit (p<0.05), a greater mean BMI (p<0.05), and more induced labor (p<0.01) as compared to the first time period. A greater proportion of the women in the second time period received misoprostol (p<0.0001) and platelets (p<0.05). The proportions of other therapies and surgical interventions remained unchanged, as did the ultimate outcomes.. At a single large institution over the course of a 9-year period the management of severe PPH changed to include a greater utilization of misoprostol and platelet therapy.

Topics: Female; Humans; Misoprostol; Oxytocics; Postpartum Hemorrhage; Postpartum Period; Pregnancy; Risk Factors; Uterine Inertia

Shivering and fever are common side effects of misoprostol. An unexpectedly high rate of fever above 40°C was documented among Ecuadorian women given treatment with 800mcg of sublingual misoprostol to manage postpartum hemorrhage (PPH) (36%). Much lower rates have been reported elsewhere (0-9%).. From February to July 2010, an open-label pilot study was conducted in Quito, Ecuador to determine whether a lower dose--600mcg sublingual misoprostol--would result in a lower incidence of high fever (≥40°C). Rates of shivering and fever with 600mcg sublingual regimen were compared to previously documented rates in Ecuador following PPH treatment with 800mcg sublingual misoprostol.. The 600mcg dose resulted in a 55% lower rate of high fever compared with the 800mcg regimen (8/50; 16% vs. 58/163; 36%; relative risk 0.45 95% CI 0.23-0.88). Only one woman had severe shivering following the 600mcg dose compared with 19 women in the 800mcg cohort (2% vs. 12%; relative risk 0.17 (0.02-1.25)). No cases of delirium/altered sensorium were reported with the 600mcg dose and women's assessment of severity/tolerability of shivering and fever was better with the lower dose.. 600mcg sublingual misoprostol was found to decrease the occurrence of high fever among Ecuadorian women when given to treat PPH. This study however was not powered to examine the efficacy of this treatment regimen and cannot be recommended at this time. Future research is needed to confirm whether other populations, outside of Quito, Ecuador, experience unusually high rates of elevated body temperature following sublingual administration of misoprostol for treatment of PPH. If indeed similar trends are found elsewhere, larger trials to confirm the efficacy of lower dosages may be justified.. Clinical trials.gov, Registry No. NCT01080846.

Topics: Administration, Sublingual; Adolescent; Adult; Dose-Response Relationship, Drug; Female; Fever; Humans; Misoprostol; Pilot Projects; Postpartum Hemorrhage; Pregnancy; Shivering; Uterine Inertia; Young Adult