Effect of Preoperative Rectal Misoprostol on Blood Loss during and after Cesarean Section
Asmaa Hassan Ramadan Hassan;
Abstract
Cesarean section is the most common major surgical procedure performed on women worldwide and its rates continue to rise steadily in both developed and developing countries. Epidemiologic data report a C.S. incidence of 20-30 % worldwide, with comparable rate in high-income and low-income countries. This increasing incidence has been observed despite the recommendation of the WHO to keep it below 10–15% .
Postpartum hemorrhage is the leading cause of maternal mortality, accounting for about 35% of all maternal deaths. Studies from developed countries report an increase in the rate of PPH, which has been attributed (at least in part) to a rise in the rate of C.S . PPH affects approximately 2% of all women who give birth: it is associated not only with nearly one quarter of all maternal deaths globally but is also the leading cause of maternal mortality in most low-income countries. PPH following a Cesarean section has been defined as blood loss over 1000 ml.
The most common cause of PPH is the failure of the uterus to contract adequately, which is responsible for approximately 70% of primary PPHs. The efficacy of routine administration of uterotonic agents, mainly oxytocin, to reduce the frequency of postpartum hemorrhage after vaginal birth is well-established. Although most obstetric units use intravenous oxytocin, given as either a bolus or an infusion, as a first-line agent to prevent uterine atony and reduce blood loss during Cesarean section, 10–42% of women receiving oxytocin were found to require additional oxytocic agents, such as ergot alkaloids and prostaglandins . Oxytocin is both light and heat sensitive, administered by injection, which requires both a skilled health provider and a clean needle , and requires cold storage, which limits its use in developing countries.
Misoprostol, as a prostaglandin E1 (PGE1) analogue, not only has strong uterotonic activity through selectively binding E–series prostanoid receptors (Ep2/Ep3) but is also relatively inexpensive and is stable at room temperature, unlike other prostaglandins. Rectally administrated misoprostol is associated with slower absorption, lower peak level, and reduced adverse effect when compared with oral and sublingual routes .
Several studies are performed about the efficacy of misoprostol for management of postpartum hemorrhage and most of them have shown the effectiveness of misoprostol for management of postpartum hemorrhage .
Neither the use nor the efficacy of misoprostol during Cesarean section has been well studied. Although several studies concluded that misoprostol was as effective as oxytocin in reducing blood loss during cesarean section , a systematic and comprehensive summary of the pertinent evidence has not been published . We therefore performed a meta-analysis to compare the efficacy and safety of misoprostol in reducing blood loss during and after cesarean section.
This was a prospective, randomized controlled trial study the effect of preoperative administration of rectal misoprostol on blood loss during and after C.S . A total 200 pregnant patients were recruited in this study who was divided into 2 groups study group (100 cases) and control group (100 cases) . Each women in the study group (Group I) received a total preoperative dose of 400 µg rectal misoprostol, administrated as 2 individual 200 µg tablets , whereas women in the control group (Group II) received preoperative 2 rectal placebo tablets.
Women with abnormal laboratory result or abnormal sonographic finding were excluded from the study .
Misoprostol or placebo was inserted rectally after urinary catheterization before skin incision . Preoperative Hb level & hematocrit value was measured 1 hour before the surgery while postoperative Hb level & hematocrit value was measured 24 hours after surgery. Differences in the Hb , HCT values before and after delivery were estimated in each group . Assessment of the intraoperative blood loss was started after the uterine incision by collection of the blood loss and the by weighing surgical towels. Postoperative blood loss was assessed during the first 24 hours after surgery by weighing the pads . The drug side effects as regards post operative fever, vomiting , nausea and shivering were noted and compared in both groups.
Results of the study group receiving misoprostol were compared with control group receiving placebo.
Results in the current study showed that: as regard demographic data : Mean age for misoprostol group was 33.91 ± 4.51 yrs. Mean age for placebo group was 32.97 ± 4.28 yrs. Mean height for misoprostol group was 162.19 ± 4.24 cm, Mean height for placebo group was 163.35 ± 3.50 cm. Mean weight for misoprostol group was 84.33 ± 6.44 Kg, Mean weight for placebo group was 83.34 ± 5.68 kg. Mean BMI for misoprostol group was 28.2 ± 2.5, Mean BMI for placebo group was 29.1 ± 1.8. Mean parity for misoprostol group was 2.1 ± 1.3 , Mean parity for placebo group was 2.2 ± 1.4 There is no significant difference between both group as regard age , weight , height , BMI , parity (p>0.05).
Mean preoperative hemoglobin for misoprostol group was 11.24 ± 1.34 g/dl, Mean preoperative hemoglobin for placebo group was 11.78 ± 1.29 g/dl. There is non significant difference between both group as regard preoperative hemoglobin (p>0.05). Mean postoperative hemoglobin for misoprostol group was 10.7 ± 1.37 g/dl , Mean postoperative hemoglobin for placebo group was 9.93 ± 1.28 g/dl . There is significant difference between both group as regard postoperative hemoglobin (p<0.05).The delta change in hemoglobin in misoprostol group was -0.048 ± 0.030, The delta change in hemoglobin in placebo group was -0.158 ± 0.046, There is highly significant difference between both group. ie there is highly significant change in hemoglobin in placebo group than misoprostol group (p<0.01).
As regard hematocrite value , Mean preoperative hematocrite for misoprostol group was 33.90 ± 3.75 % , Mean preoperative hematocrite for placebo group was 35.65 ± 3.67 %. There is non significant difference between both group as regard preoperative hematocrite (p>0.05). Mean postoperative hematocrite for misoprostol group was 32.13 ± 3.68 %, Mean postoperative hematocrite for placebo group was 30.04 ± 3.48 % . There is significant difference between both group as regard postoperative hematocrite (p<0.05) .The delta change in hematocrite in misoprostol group was -0.052 ± 0.031, The delta change in hematocrite in placebo group was -0.155 ± 0.038. There is highly significant difference between both group. i.e. there is highly significant change in hematocrite in placebo group than misoprostol group (p<0.01).
Mean intra-operative blood loss for misoprostol group was 302.11 ± 70.80 ml , Mean intra-operative blood loss for placebo group was 465.29 ± 88.33 ml . There is significant difference between both group as regard intra operative blood loss (P <0.05). Mean postoperative blood loss for misoprostol group was 124.26 ± 39.78 ml, Mean postoperative blood loss for placebo group was 242.12 ± 50.61 ml. There is highly significant difference between both group as regard post operative blood loss (P <0.001).
Postpartum hemorrhage is the leading cause of maternal mortality, accounting for about 35% of all maternal deaths. Studies from developed countries report an increase in the rate of PPH, which has been attributed (at least in part) to a rise in the rate of C.S . PPH affects approximately 2% of all women who give birth: it is associated not only with nearly one quarter of all maternal deaths globally but is also the leading cause of maternal mortality in most low-income countries. PPH following a Cesarean section has been defined as blood loss over 1000 ml.
The most common cause of PPH is the failure of the uterus to contract adequately, which is responsible for approximately 70% of primary PPHs. The efficacy of routine administration of uterotonic agents, mainly oxytocin, to reduce the frequency of postpartum hemorrhage after vaginal birth is well-established. Although most obstetric units use intravenous oxytocin, given as either a bolus or an infusion, as a first-line agent to prevent uterine atony and reduce blood loss during Cesarean section, 10–42% of women receiving oxytocin were found to require additional oxytocic agents, such as ergot alkaloids and prostaglandins . Oxytocin is both light and heat sensitive, administered by injection, which requires both a skilled health provider and a clean needle , and requires cold storage, which limits its use in developing countries.
Misoprostol, as a prostaglandin E1 (PGE1) analogue, not only has strong uterotonic activity through selectively binding E–series prostanoid receptors (Ep2/Ep3) but is also relatively inexpensive and is stable at room temperature, unlike other prostaglandins. Rectally administrated misoprostol is associated with slower absorption, lower peak level, and reduced adverse effect when compared with oral and sublingual routes .
Several studies are performed about the efficacy of misoprostol for management of postpartum hemorrhage and most of them have shown the effectiveness of misoprostol for management of postpartum hemorrhage .
Neither the use nor the efficacy of misoprostol during Cesarean section has been well studied. Although several studies concluded that misoprostol was as effective as oxytocin in reducing blood loss during cesarean section , a systematic and comprehensive summary of the pertinent evidence has not been published . We therefore performed a meta-analysis to compare the efficacy and safety of misoprostol in reducing blood loss during and after cesarean section.
This was a prospective, randomized controlled trial study the effect of preoperative administration of rectal misoprostol on blood loss during and after C.S . A total 200 pregnant patients were recruited in this study who was divided into 2 groups study group (100 cases) and control group (100 cases) . Each women in the study group (Group I) received a total preoperative dose of 400 µg rectal misoprostol, administrated as 2 individual 200 µg tablets , whereas women in the control group (Group II) received preoperative 2 rectal placebo tablets.
Women with abnormal laboratory result or abnormal sonographic finding were excluded from the study .
Misoprostol or placebo was inserted rectally after urinary catheterization before skin incision . Preoperative Hb level & hematocrit value was measured 1 hour before the surgery while postoperative Hb level & hematocrit value was measured 24 hours after surgery. Differences in the Hb , HCT values before and after delivery were estimated in each group . Assessment of the intraoperative blood loss was started after the uterine incision by collection of the blood loss and the by weighing surgical towels. Postoperative blood loss was assessed during the first 24 hours after surgery by weighing the pads . The drug side effects as regards post operative fever, vomiting , nausea and shivering were noted and compared in both groups.
Results of the study group receiving misoprostol were compared with control group receiving placebo.
Results in the current study showed that: as regard demographic data : Mean age for misoprostol group was 33.91 ± 4.51 yrs. Mean age for placebo group was 32.97 ± 4.28 yrs. Mean height for misoprostol group was 162.19 ± 4.24 cm, Mean height for placebo group was 163.35 ± 3.50 cm. Mean weight for misoprostol group was 84.33 ± 6.44 Kg, Mean weight for placebo group was 83.34 ± 5.68 kg. Mean BMI for misoprostol group was 28.2 ± 2.5, Mean BMI for placebo group was 29.1 ± 1.8. Mean parity for misoprostol group was 2.1 ± 1.3 , Mean parity for placebo group was 2.2 ± 1.4 There is no significant difference between both group as regard age , weight , height , BMI , parity (p>0.05).
Mean preoperative hemoglobin for misoprostol group was 11.24 ± 1.34 g/dl, Mean preoperative hemoglobin for placebo group was 11.78 ± 1.29 g/dl. There is non significant difference between both group as regard preoperative hemoglobin (p>0.05). Mean postoperative hemoglobin for misoprostol group was 10.7 ± 1.37 g/dl , Mean postoperative hemoglobin for placebo group was 9.93 ± 1.28 g/dl . There is significant difference between both group as regard postoperative hemoglobin (p<0.05).The delta change in hemoglobin in misoprostol group was -0.048 ± 0.030, The delta change in hemoglobin in placebo group was -0.158 ± 0.046, There is highly significant difference between both group. ie there is highly significant change in hemoglobin in placebo group than misoprostol group (p<0.01).
As regard hematocrite value , Mean preoperative hematocrite for misoprostol group was 33.90 ± 3.75 % , Mean preoperative hematocrite for placebo group was 35.65 ± 3.67 %. There is non significant difference between both group as regard preoperative hematocrite (p>0.05). Mean postoperative hematocrite for misoprostol group was 32.13 ± 3.68 %, Mean postoperative hematocrite for placebo group was 30.04 ± 3.48 % . There is significant difference between both group as regard postoperative hematocrite (p<0.05) .The delta change in hematocrite in misoprostol group was -0.052 ± 0.031, The delta change in hematocrite in placebo group was -0.155 ± 0.038. There is highly significant difference between both group. i.e. there is highly significant change in hematocrite in placebo group than misoprostol group (p<0.01).
Mean intra-operative blood loss for misoprostol group was 302.11 ± 70.80 ml , Mean intra-operative blood loss for placebo group was 465.29 ± 88.33 ml . There is significant difference between both group as regard intra operative blood loss (P <0.05). Mean postoperative blood loss for misoprostol group was 124.26 ± 39.78 ml, Mean postoperative blood loss for placebo group was 242.12 ± 50.61 ml. There is highly significant difference between both group as regard post operative blood loss (P <0.001).
Other data
| Title | Effect of Preoperative Rectal Misoprostol on Blood Loss during and after Cesarean Section | Other Titles | تأثير عقار الميزوبرستول الشرجى على فقدان الدم خلال وبعد الولادة القيصرية | Authors | Asmaa Hassan Ramadan Hassan | Issue Date | 2014 |
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