Prostaglandins for prevention of postpartum haemorrhage.

BACKGROUND: Prostaglandins have mainly been used for postpartum haemorrhage when other measures fail. Misoprostol, a new and inexpensive prostaglandin E1 analogue, has been suggested as an alternative for routine management of the third stage of labour.

OBJECTIVES: The objective of this review was to assess the effects of prophylactic prostaglandin use in the third stage of labour.

SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register were searched. Researchers in the field were also contacted. Date of latest search: June 2001.

SELECTION CRITERIA: Randomized or quasi-randomized trials comparing a prostaglandin agent with another uterotonic or no prophylactic uterotonic (nothing or placebo) as part of management of the third stage of labour. There were no language preferences.

DATA COLLECTION AND ANALYSIS: Eligibility, trial quality and data extraction were done by two reviewers independently.

MAIN RESULTS: Fourteen misoprostol and eight intramuscular prostaglandin trials were included. Oral misoprostol 600 mcg is less effective than conventional injectable uterotonics in reducing blood loss >= 1000 mls (relative risk (RR): 1.36, 95% confidence interval (CI): 1.17 to 1.58), and the use of additional uterotonics. Shivering and elevated body temperature (> 38 degrees C) are the main side-effects of misoprostol and are dose related. Compared to oxytocin the RR of any shivering is 3.4 (95% CI: 3.01 to 3.56) and temperature > 38C is 6.96 (95% CI: 5.95 to 8.57). The data comparing oral misoprostol to no uterotonics/placebo are from three trials involving 1700 women and difficult to interpret because of the heterogeneity between trials. However, the data do not suggest a substantive reduction in the rate of postpartum haemorrhage or other measures of blood loss so far. Injectable prostaglandins are associated with reduced blood loss in the third stage of labour (weighted mean difference: -70 mls, 95% CI: -73 to -67 mls) when compared to conventional injectable uterotonics but have more side-effects.

REVIEWER'S CONCLUSIONS: Neither intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the active management of the third stage of labour especially for low-risk women. However, it seems prudent to use prostaglandins as a last resort for the management of intractable postpartum haemorrhage refractory to other measures. Future research should focus on management of postpartum haemorrhage where prostaglandins seem to be more promising.