Postpartum hemorrhage is the major cause of maternal death and morbidity worldwide, accounting for at least 100,000 deaths and 20 million morbidities annually. Postpartum hemorrhage is commonly attributed to uterine atony following delivery. Initial treatment includes use of either intravenous or intramuscular oxytocin and ergometrine, plus supportive measures. Parenteral prostaglandin is administered if bleeding persists. Surgical options, such as ligation of the iliac artery or, as last resort, hysterectomy, are indicated if all other measures fail. Misoprostol, a prostaglandin E1 analog commonly used for peptic ulcer disease, has been adapted for use in obstetrics and gynecology. O'Brien and colleagues investigated the effectiveness of rectally administered misoprostol for postpartum hemorrhage unresponsive to conventional first-line management.

Fourteen women who required emergency management of severe postpartum hemorrhage were included in the study. Median age of the women was 31.5 years, median gestation was 39 weeks and parity ranged from zero to five. Initial management of all women was similar. Hospital protocol for treatment of postpartum hemorrhage was followed, consisting of resuscitation, bimanual uterine compression and administration of parenteral ergometrine and oxytocin unless contraindicated because of preeclampsia. However, if bleeding persisted despite these measures, 1,000 mg of misoprostol was administered rectally.

Bleeding was controlled in all 14 women, and sustained uterine contractions were achieved within three minutes of administration of misoprostol. Estimated blood loss ranged from 500 to 2,000 mL, and 11 of the 14 women required blood transfusion (2 to 4 units of blood). The mode of delivery varied. Of the 14 women studied, eight had spontaneous vaginal vertex deliveries, two had emergency cesarean deliveries, two had ventouse extractions, one an elective cesarean delivery and one a vaginal breech delivery. Ten mothers experienced complications of pregnancy, including preeclampsia, abruption, retained placenta and breech presentation.

The authors conclude that misoprostol provided rapid, effective treatment of postpartum hemorrhage. Misoprostol is inexpensive and does not elevate blood pressure, which is particularly significant in patients with pre-eclampsia. Parenteral prostaglandins have several disadvantages: they are more expensive than misoprostol, they must be protected from light and heat, and they must be injected into muscle or the myometrium. In addition, they can elevate blood pressure, cause pulmonary edema and exacerbate asthma. The authors anticipate that rectally administered misoprostol could become the treatment of choice in postpartum hemorrhage that is unresponsive to oxytocin and ergometrine.

editor's note: Few physicians who have treated a patient with intractable postpartum hemorrhage remain unscathed. For ethical and practical reasons, a formal, randomized, controlled clinical trial evaluating the use of rectal misoprostol in postpartum hemorrhage may not be possible, or it may take years to report conclusive results. In the meantime, this impressive study suggests a new adjunctive therapy that may be particularly useful in developing countries where resources are limited.—a.d.w.