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Journal of Bangladesh College of Physicians and SurgeonsVol. 25, No. 2, May 2007 Misoprostol Versus Oxytocin in the Active Management
of the Third Stage of Labour
oxytocin (P>0.50). Measured blood loss of more than 1000
Summary:
ml occured 2.38% of the misoprostol group compared with
Objective : A randomised controlled trial was performed in
1.58% in the oxytocin group (P>0.50). There was no
Sir Solimullah Medical College Mitford Hospital, a tertiary
significant difference in the need for additional oxytocin
hospital in Dhaka City for one year to compare oral
drugs or blood transfusion in women of both groups.
misoprostol with intramascular oxytocin in the prevention
Significant side effect of misoprostol were shivering
of post partum haemorrhage (PPH). Method: A total of 400
(P<0.01). Conclusion : Oral misoprostol is as effective as
women were randomised to received either 400mg
intramascular oxytocin in the prevention of PPH.
misoprostol orally or 10 I.U oxytocin intramascularly. The
Shivering and transient pyrexia were special side effects of
incidence of post partum haemorrhage and side effects
misoprostol. Misoprostol has potential in reducing the high
were examined. Result: The demographic and labour
incidence of PPH in developing countries.
characteristic were comparable. PPH occured in 3.80% of
women given misoprostol and in 2.63% of those given
(J Bangladesh Coll Phys Surg 2007; 25 : 73-76)
Introduction :
also very useful for cervical ripening and induction of Post partum haemorrhage (PPH) is a serious labour. 6,7 It is also used in 1st and 2nd trimester obstetrics problem and primary PPH is said to occur abortion and has been shown in several randomised in about 5-8% of deliveries.1 Maternal mortality in placebo controlled trial to significantly reduce risk of Bangladesh is about 3 per 1000 live birth.2 Among PPH and also control of PPH.6 It is stable at room the other causes haemorrhage ranging 20-25% of temperature, low cost, easily administrable, available cause of maternal mortality and 12% due to in tablet form and definitely advantageous than the other PGs with few systemic side effect. Its haemorrhage. PPH is one of the leading cause of absorption is rapid and effect on the post partum maternal mortality in developing country. 3,4 The common cause of PPH is uterine atony (80%).1 The Our aim was to show the effectivity of oral underlying principle in active management is to misoprostol versus oxytocin for the active excite powerful uterine contraction following birth of management of third stage of labour to reduce the risk the head or anterior shoulder of the baby, which minimise the blood loss in third stage approximatelyto 1/ Materials and Methods :
5th.3 Prostaglandin are hormone naturally present This is a prospective longitudinal study was in the uterus that causes contraction during labour.5 conducted in the Gynae department of Sir Solimullah Misoprostol is a synthetic 15-doxy 16 hydroxy-16 Medical College Mitford Hospital during the period methyl analogue of naturally occurring prostaglandin of January 2003 to December 2003. A total of 400 E1 (PGE1). Because of its prostagladin activity it is (Four) hundred parturient women were randomised toreceived either 400 microgram (μg) of misoprostol Dr. Nilufar Sultana, MBBS, FCPS (Gynae), Assistant Prof.
orally or 10 I.U oxytocin intramascularly just after (Gynaecology), Begum Khaleda Zia Medical College, Dhaka.
cord clamping labouring women either nulliparous or Prof. Mahmuda Khatun, MBBS, FCPS (Gynae), Professor & multiparous with no known risk for excessive third Head of the Dept. of Gynae & obst., SSMC & Mitford stage blood loss, vertex presentation, no previous caesarean section delivery, induced, augmented or Address of Correspondence: Dr. Nilufar Sultana, MBBS, FCPS
spontaneous labour were included. Among the 400 Assistant Prof. (Gynaecology), Begum Khaleda Zia MedicalCollege, Dhaka.
patients, 210 patients were selected for misoprostol Received: 6 December, 2004
Accepted: 10 November, 2006
and 190 were selected for intramascular oxytocin.
Journal of Bangladesh College of Physicians and Surgeons Outcome measures were incidence of post partum Results:
haemorrhage, estimation of average blood loss. the Among the 400 patients, 210 were assigned to receive length of the third stage of labour, the percentage of misoprostol and 190 received oxytocin randomely. At women requiring manual removal of Placenta, further randomization the two group were well balanced oxytocin and blood transfusion and the side effect of and comparable for demographic and labour both the groups. Blood loss was estimated on approximate basis by the delivering physician after In misoprostol group significant number of patient developed shivering, which was statistically Statistical analysis was performed using SPSS significant than the oxytocin group. Other parameters Programme. Data were analysed by chi-square test (x of both groups showed no significant difference.
to compare frequency distribution. A difference was The result of both groups are shown in the following considered statistically significant at p value 0.05 level.
tables. n=total number of patient. no=number.
Post partum haemorrhage due to uterine atonicity. x2= 0.4409 df. 1, P>0.50In table 1, 8 patient in misoprostol group and 5 patient in oxytocin group develop PPH, which is not significant statistically.
Table-II
Table II shows average blood loss in each patient in both group 325.4 ml and 375 respectively which is notsignificant statistically. Table-III
Measured blood loss > 1000 ml occurred x2= 0.328, P>0.50In this table; more than 1000 ml blood was lost in 5 & 3 patients in misoprostol & oxytocin group respectivelywhich is not significant. Table-IV
Additional Oxytocin drugs require before and after separation of placenta. x2= 0.1978, P>0.50Additional oxytocin required for further uterine contraction in 5 and 6 patients respectively in two group whichis not significant statistically.
Misoprostol Versus Oxytocin in the Active Management of the Third Stage of Labour Time required for the separation of placenta in each patient of both group is not statistically significant. Table-VI
Patient required manual removal of placenta x2= 0.2456, df 1, P>0.50Manual removal of placenta require only 2 patients in misoprostol & I in oxytocin group respectively which isstatistically not significant.
Table-VII
Pain during third stage of Labour x2= 0.1978, P>0.50Here only 5 and 4 patients developed pain respectively in both group which is also not statistically significant.
Table-VIII
Character Misoprostol (n=210) Oxytocin (n=190) x2= 7.296, df 1, P<0.01 (Significant) x2= 7.488, df 1, P<0.50 ( not significant) This table shows, 13 patients in misoprostol group 2 patient in oxytocin group developed shevering after use ofdrugs. This is statistically significant. Diarrhoea & fever develop about 4 & 2 patient respectively in both groupwhich is not statistically significant Journal of Bangladesh College of Physicians and Surgeons Discussion
Conclusion :
Misoprostol, is a synthetic PGE1. analogue. Its FDA Oral misoprostol is as effective as intramascular approved indication is for the prevention of stomach oxytocin in the prevention of PPH. So, oral ulcer in patient taking non steroidal anti-inflamatory misoprpstol can replace intramascular oxytocin in the drugs. Because of its prostaglandin activity it is also active managment of third stage of labour in low risk used for reducing the risk of PPH and also to control women in developing countries especially as it is of PPH.6,7 It is available in tablet form and can be administered orally and it is thermostable in tropical given orally and rectally for the active management ofthird stage of labour. In this study, we gave 400 conditions. Shivering and transient pyrexia were microgram (μgm) of misoprostol orally in one group specific side effects of misoprostol which has (n=210) and intramascular oxytocin 10 I.U. in another potential in reducing the high incidence of PPH in group (n=190). The incidence of PPH in misoprostol group and oxytocin group were 3.80% versus (vs) References :
2.63% which is comparable to another study e.g. 1% K Begum, TIMA. Faruq, N. Sultana. Management of severe us 0% respectively done by OboroVO, Tobowei TO.9 primary post partum Haemorrhage: A New but simple The estimated average blood loss in each patient of suturing techinque. Journal of Bangladesh college of this study was 325.4 ml in misoprostol group and 375 physician and surgeons, 2002 May; 20 (2): 49-53.
ml in Oxytocin group respectively which coincide Bangladesh Bureau of Statistics, 1999 Nov. P-37 with 345 ml vs 417 ml in another study done by D.C. Dutta, Safe Motherhood, obstetric care and the Surbek DV et al.10 The length of third stage labour in Society, epidimiology of obstetrices, chapter-37: Fifth each patient in present study was 4 minute 49 sec in misoprostol group and 5 minute in oxytocin group Abu Jamil Faisel, Brian Mc. Carthy, Jeanna Mc. Dermott which is less than another study e.g 8 minute vs 9 Hani Atrash, Michael Lane- Post partum infection and minute but similar regarding statistical significance haemorrhage in Rural Bangladesh, J. of Bang. Fertility because both studies shows no significant difference between two group.10 Blood loss more than 1000ml in Alfirevic Z. Oral misoprostol for induction of labour.
present study was 2.38% vs 1.58% which is Cochranc Review Abstracts 2002. up dated 04/01/2002.
comparable to another study e.g. 3.7% vs 2% done by S Nahar. Rectal use of Misoprostol in controlling post kundodyiwa Tw et al. 11 The additional oxytocin partum haemorrhage (PPH) Journal of Bangladesh College before or after placental separation was used less often of Physician and Surgeons: 2003 Jan, 21 (1): 10-13.
in both groups such as 2.38% vs 2.63% which is Myer S. Bornstein, M.D and Don Shuwarger, M.D: comparable to another study 16% vs 38% e.g. both Protocol: Misoprostol (Cytotec) for cervical Ripening and study shows no statistically significant difference.10 induction of Labour obgyn. net/english/06/misoprostal Regarding blood transfusion, it was 1.90% vs. 1.58% respectively in this study which is comparable to Karim A. Antiulcer PG misoprostol. single and mutiple dose study done by kundodyiwa Tw et al.11 The manual pharmaco-kinetic profile. Prostaglandines : 1987:33 (Suppl) removal of placenta required 0.95% vs 0.53% respectively in this study which is also similar to one Obore VO. Tabowei TO. A randomised controlled tiral of study.10 There were no significant difference in pain misoprostol Versus oxytocin in the active management of during third stage of labour, post partum fever or the third stage of labour. J obstel Gynaecol 2003 Jan: 23 (1): diarrhoea but shivering was more in the misoprostol group which was observed in present study and all Surbek DV. Fehr PH, Hosli I, Holzgreve W. Oral other studies which is statistically more significant Misporostol for third stage of labour: a randomized placebo- than the oxytocin group. 9,10,11 From above discussion controlled trial. Obstel Gynaecol 1999 Aug; 94 (2): 255-8 it has been observed that in all the parameter except Kundodyiwa TW, Majoko F, Rusakawni Kos. Misoprostol shivering there were no significant difference between Versus oxytocin in the third stage of labour, Int. J Gyanaecol the misoprostol group and oxytocin group.

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