Even with the marvels of modern ob.gyn. care, women still die of postpartum hemorrhage, especially in developing countries and anywhere that resources are limited. Two studies published this week in The Lancet support the off-label use of oral misoprostol as an alternative to intravenous oxytocin. Oxytocin is the first-choice medication for postpartum hemorrhage, according to the World Health Organization. The problem is, oxytocin requires refrigeration, plus someone who has IV equipment and knows how to use it. Misoprostol tablets can be stored easily and given orally.
Each of the two randomized trials included more than 800 women. In one study, oxytocin was significantly more effective than misoprostol at controlling postpartum bleeding with no prophylactic treatment. But bleeding was controlled within 20 minutes for 90% of the women in the misoprostol group (vs. 96%) of the women in the oxytocin group, which lead the researchers to conclude that misoprostol might be a viable option in certain circumstances, despite the lack of statistical significance.
In the second study, oxytocin was not significantly more effective than misoprostol at controlling bleeding after 20 minutes when women in both treatment groups received oxytocin prophylactically.
These studies are promising, but one gap in the research is whether giving misoprostol prophylactically, as well as postpartum, can reduce bleeding even more. If oxytocin isn’t feasible postpartum, it may not be available for prophylactic use, either.
For my World Wide Med column in Internal Medicine News, I interview doctors about their experiences practicing medicine in parts of the world where resources are limited. I have so far focused on internists, not ob.gyns., but some of these physicians, and many other U.S. physicians who have practiced overseas, may well have been involved in delivering babies in resource-limited circumstances simply because they were the only ones there. I wonder how these doctors handled postpartum hemorrhage in those situations?