Special preventive measures: misoprostol in action potx

Section IVSpecial preventive measures: misoprostol in action 177 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp... uterotonics a

Section IV

Special preventive measures:

misoprostol in action

177 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp

uterotonics are not present or practical for use.’

The Working Group of the Goa International Conference on the Prevention of

Post Partum Hemorrhage, July 15, 2006, Goa, India

16 MISOPROSTOL IN PRACTICE

M Potts

Prior to the availability of misoprostol, it was

impossible to carry any significant element of

emergency obstetric care into homes where

women deliver without a skilled birth attendant

As a low-cost, easy-to-administer, powerful

uterotonic with an excellent safety profile and

long shelf-life, misoprostol has a revolutionary

potential to reduce death and morbidity from

postpartum hemorrhage in precisely those

situa-tions where it is most common – delivery at

home without a skilled birth attendant

In a placebo-controlled, community-based

miso-prostol orally immediately after delivery

sig-nificantly reduced postpartum hemorrhage (see

Addendum) Research in Indonesia, Nepal and

elsewhere is showing that community

volun-teers with minimal training can teach illiterate

women to self-administer misoprostol effectively

rectal dose of misoprostol can be used to treat

postpartum hemorrhage, in situations where an

appropriate technology exists to diagnose blood

loss (such as blood-soaked sarong or ‘kanga’),

and where births are attended by traditional

birth attendants (TBAs) In Tanzania, illiterate

TBAs, with a brief training, used misoprostol to

bring about a highly significant reduction in the

number of women who needed to be referred to

Although these measures may seem revolu-tionary at first glance, they should be viewed as

an essential step towards a long-term strategy where all women can be delivered by a certified midwife or physician practicing active manage-ment of the third stage of labor Over the past half-century, countries such as Sri Lanka and Thailand have brought maternal mortality to low levels by ensuring over 90% of deliveries are attended by a skilled person able to use an oxytocic, and ultimately all countries should follow such a path

economic collapse and the spread of HIV/ AIDS in some African countries and the endless recruitment of skilled health professions from developing to developed countries will make the road to providing comprehensive obstetric care long and slow During this interval, widespread access to misoprostol and the education to use it safely during home births have the potential to make a significant contribution – perhaps even the single most important contribution – to reducing the global burden of deaths from postpartum hemorrhage The only other practi-cal intervention with the potential to reduce postpartum hemorrhage in low-resource set-tings is realistic access to family planning, as all women who wish to limit childbearing are at risk

of postpartum hemorrhage, and the older, 156

higher-parity women, who have the greatest

unmet need for family planning, are at even

higher risk

References

1 Wiknjosastro G, Sanghvi H Preventing PPH

among women living in areas where a high

proportion of births are not attended by skilled

providers: Safety, acceptability, feasibility and

project of community-based distribution of miso-prostol for prevention of PPH in rural Indonesia

Proceedings of Preventing Postpartum Hemorrhage:

From Research to Practice, Bangkok, Thailand,

January 20–24, 2004:31–7

2 Prata N, Mbaruka G, Campbell M, Potts M, Vahidnia F Controlling postpartum hemorrhage

after home births in Tanzania Int J Gynaecol

Obstet 2005;90:51–5

157

Misoprostol in practice

Editors’ Addendum

The Editors wish to bring the reader’s

atten-tion to the paper referred to by Professor

Potts on page 156 This paper has been

pub-lished in the October 7, 2006 issue of The

Lancet To the Editors’ knowledge, this is the

largest placebo-controlled study of

miso-prostol for the prevention of postpartum

hemorrhage, and the results showed that

misoprostol significantly reduced the rate of

postpartum hemorrhage in the patients who

were administered this agent in comparison to

the patients who received the placebo control

The full title of the paper and all authors

are:

post-partum hemorrhage in a community setting

Univer-sity of Illinois, Chicago College of Medicine,

Child Health and Human Development

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MANAGEMENT OF POSTPARTUM HEMORRHAGE AT THE

COMMUNITY LEVEL

N Prata

The ability to manage postpartum hemorrhage

at the community level is an essential element in

any program to decrease maternal mortality

the deliveries in developing countries occur at

home without the presence of a skilled birth

The efficacy, safety, and importance of

miso-prostol use for postpartum hemorrhage

man-agement are well established for hospital-based

signifi-cant impact will probably be at the household

level, where most deliveries occur Some studies

have tested such technology in home births, and

all of them produced encouraging results During one intervention trial in rural Kigoma, Tanzania, Prata and colleagues demonstrated that traditional birth attendants (TBAs), who assist in most home deliveries, were able to diag-nose postpartum hemorrhage and effectively

Blood loss measurement was standardized by employing the traditional blood collection tool used by women in the region – the local garment

study also showed that the ability to manage postpartum hemorrhage in home births resulted

158

Intervention Non-intervention

Odds ratio

(95% CI)

Referrals

111 8

24.5 1.8

73 75

18.5 19.0

1.3 0.1

(1.0–1.7) (0.0–0.2)

Additional interventions among PPH cases n = 111 n = 73

Intravenous fluids

Blood transfusion

Manual removal of placenta

Repair of tears

Hysterectomy

b 1b 1 1 0 0 0 0

0.9 0.9 0.9 0.0 0.0 0.0 0.0

c69c 25 16 17 4 1 7

94.5 34.3 21.9 23.3 5.5 1.4 9.6

records not available for one patient; three patients did not need additional interventions; another three were

included: Amoxyl tablets, methergin, and misoprostol

Source: Prata N, et al Controlling postpartum hemorrhage after home births in Tanzania Int J Gynaecol

Obstet 2005;90:51–5

births, Kigoma, Tanzania

in important reductions in the number of

refer-rals and the need for additional interventions,

key factors in resource-poor settings (Table

1).This is particularly helpful in rural areas

methods of measuring blood loss after delivery

are difficult to devise, all women could be

misoprostol after delivery of the baby Its safety

and efficacy in the hands of TBAs were shown

in a randomized, controlled trial in the

other reasons, women deliver at home alone or

in the presence of a family member,

self-admin-istration of a prophylactic dose of misoprostol,

distributed during pregnancy by trained

com-munity health-care workers, are both viable

options that can produce promising results, as

was shown in other studies in Indonesia, Nepal,

and Afghanistan

It will be many decades before all women in

low-resource settings can receive skilled

atten-tion at delivery in their homes In the meantime,

misoprostol has the potential to make a

signifi-cant difference in reducing maternal mortality

It should be made available for use in all settings

including home births, and particularly in those where it must be self-administered

References

1 Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF WHO analysis of causes of

mater-nal death: a systematic review Lancet 2006;367:

1066–74

2 AbouZahr C, Wardlaw T Maternal mortality at

the end of a decade: signs of progress? Bull WHO

2001;79:561–8

3 Villar J, Gulmezoglu AM, Hofmeyr GJ, Forna F Systematic review of randomized controlled trials

of misoprostol to prevent postpartum

hemor-rhage Obstet Gynecol 2002;100:1301–12

4 Prata N, Mbaruku G, Campbell M, Potts M, Vahidnia F Controlling postpartum hemorrhage

after home births in Tanzania Int J Gynaecol

Obstet 2005;90:51–5

5 Prata N, Mbaruku G, Campbell M Using the

Kanga to measure postpartum blood loss Int J

Gynaecol Obstet 2005;89:49–50

6 Walraven G, Blum J, Dampha Y, et al

Miso-prostol in the management of the third stage of labour in the home delivery setting in rural

Gam-bia: a randomised controlled trial Br J Obstet

Gynaecol 2005;112:1277–83

159

Management at the community level

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ORAL MISOPROSTOL FOR PREVENTION OF POSTPARTUM HEMORRHAGE BY PARAMEDICAL WORKERS IN INDIA

(AN ICMR TASK FORCE STUDY)

N Chandhiok

Paramedical workers conduct deliveries in the

rural areas of India where active management of

the third stage of labor is not routinely practised

and uterotonic agents are only provided for the

management of postpartum bleeding A

multi-site, cluster-randomized, feasibility study was

carried out to determine if paramedical workers

from rural Peripheral Health Centers (PHCs)

could actively manage the third stage of labor

using oral misoprostol to prevent postpartum

hemorrhage Six hundred women each received either active management of the third stage

(inter-vention) or the current government guidelines

(controls) The primary outcome was blood loss after delivery and this was measured using a calibrated blood collection drape

Baseline characteristics were comparable in both groups and over 70% of women had

160

Tablet misoprostol

(n = 600)

Injection methergine

(n = 531)

Tablet methergine

(n = 58)

None † (n = 11)

Total

(n = 600)

Duration of third

stage of labor (min)

Blood loss (ml)

Median

Q1–Q3

Range

Postpartum hemorrhage

100 90–150 25–1300

4 (0.7)

200***

150–250 30–750

200***

150–280 25–415 –

100 100–160 100–700

1 (9.1)

200*** 150–250 25–750

Additional measures

Uterotonics

Intravenous fluids

Blood transfusion

Referred to higher level

of health facility for

PPH

4 4 1

2 (0.3)

–

1 (0.2)

– – –

1 1 –

1 (0.2)

–

2 (0.3)

due to small sample

moderate anemia The paramedical workers

were able to provide the intervention according

to the guidelines in almost all deliveries (99%)

There was a significant reduction in the

blood loss after delivery in the intervention

p < 0.001) This magnitude of reduction is

significant for a country such as India where

80% of the women are anemic at the time of

delivery and any reduction in blood loss is

incidence of postpartum hemorrhage observed

in the study was extremely low (< 1% in both

groups), and the study size was not adequate

to address the reduction in postpartum hemor-rhage at such low incidence (Table 1)

As most deliveries in rural areas take place at home, there is a need to extend this study for all domiciliary deliveries

ACKNOWLEDGEMENT

This communication is based on the following previously published article at the Editor’s request: Chandhiok N, Dhillon BS, Datey S, Mathur A, Saxena NC Oral misoprostol for

paramedical workers in India Int J Gynaecol

Obstet 2006;92:170–5

161

Prevention by paramedical workers in India

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OVERVIEW OF MISOPROSTOL STUDIES IN

POSTPARTUM HEMORRHAGE

A Hemmerling

INTRODUCTION

These tables of peer-reviewed misoprostol

studies were compiled to provide the reader

with comprehensive references to the use of

misoprostol in practice since 1997, for both

prevention and treatment of postpartum

hemor-rhage The tables include both randomized and

non-randomized trials, and they represent a diversity of situations Table 1 provides an overview of 32 studies in the prevention of

and route of administration) Table 2 gives an overview of seven studies in the treatment of postpartum hemorrhage (including dosage and route of administration)

162

Overview of misoprostol studies in postpartum hemorrhage

Participants in misoprostol

Participants in

F2α

F2α

i.m [2]

methylergometrine i.v.

2005;31: 389–93

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Participants in misoprostol

Participants in

2 oral

0.2 methylergometrine i.v.

2004;83: 647–50

1 i.v syntocinone 0.5 maleate)

2003;101: 921–8

[1] misoprostol 10 [2] i.v [3] i.v methylerg maleate

2003;23: 13–16

BJOG 2002;109: 1222–6

10 or

Overview of misoprostol studies in postpartum hemorrhage

i.v [3]

methylergometrine i.m.

2002;24: 149–54

Kundodyiwa TW,

2001;30: 576–83

i.v [2]

Gulmezoglu AM,

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Participants in misoprostol

Participants in

2001;91: 432–5

2001;16: 31–5

1 i.v syntocinone 0.5 maleate

st regimens oxytocin ergometrine 1

Obstet Gynaecol 1999;39: 414–19

st regimens oxytocin 1m i.m.)

Overview of misoprostol studies in postpartum hemorrhage

Gynaecol 1999;106: 1066–70

methylergometrine i.v.

1999;94: 255–8

Gynaecol 1998;105: 971–5

1998;77: 178–81

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Participants in misoprostol

Participants in

BMC Pregnancy Childbirth 2004;4:16

sublingual ad

2001;80: 835–9

1 i.m syntocinone 0.5 maleate) 10

1998;92: 212–14