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Reference: BJOG 2013 Feb;120(3):277 (level 1 [likely reliable] evidence)
Postpartum hemorrhage is a major cause of maternal death in many low-resource countries around the world. While injected oxytocin is commonly used for hemorrhage prophylaxis in institutional settings, its use may be impractical if not impossible in areas where home birth is the norm and even skilled birth attendants are rare. A recent systematic review evaluated the evidence for oral misoprostol for the prevention of postpartum hemorrhage in such settings.
The review included 2 randomized trials and 4 non-randomized controlled trials comparing oral misoprostol vs. placebo or no treatment for women during the third stage of labor. The misoprostol dose was 600 mcg in 5 trials and 400 mcg in the other. Trained health workers administered the drug in 4 trials. In 2 trials, the drug was distributed to pregnant women following counseling during an antenatal visit with instruction for use during birth.
Oral misoprostol reduced the incidence of postpartum hemorrhage in an analysis of 4 studies with 6,072 patients (risk ratio 0.58, 95% CI 0.38-0.87), with an NNT of 14-63 given a hemorrhage rate of 12% in controls. Use of additional uterotonics and rates of referral for hemorrhage were also significantly reduced with misoprostol. Misoprostol was associated with an increased risk of shivering (risk ratio 2.18, 95% CI 1-4.72).
For more information, see the Prophylactic uterotonics in third stage of labor topic in DynaMed.