The role of Misoprostol in the third stage of labour

Postpartum haemorrhage (PPH) is a leading cause of maternal death in both developing and industrialised countries. Its prevention is therefore of utmost importance. This thesis investigates the role of misoprostol, a prostaglandin E1 analogue, in the prevention of PPH, when orally administered in the third stage of labour. At first a physiological intrauterine pressure study was conducted to investigate the postpartum uterine response to different oral Misoprostol doses. Misoprostol was found to have a very fast onset and prolonged duration of action. A significant rise in uterine contractility was seen regardless of the dosage used. Two observational pilot studies were concurrently conducted; the first investigated the efficacy of 600 ugm of oral misoprostol for management of the third stage of labour, the second examined the efficacy of two lower doses; 400 and 500 ugm. The three groups were compared in terms of PPH rate (blood loss >= 500 mL), third stage events, and perceived incidence of side effects. These studies were followed by a randomised-controlled trial comparing oral misoprostol to standard management of the third stage of labour. Patients were randomised to receive either 500 ugm of oral misoprostol, or the standard regimen of either syntometrine, syntocinon, or ergometrine, depending on maternal condition. This study had two primary end-points: the incidence of PPH, and the incidence and perceived severity of side effects in the two arms. The main side effects of oral misoprostol were shivering and rise in temperature. Shivering occurred within 5 to 10 minutes of delivery, and lasted for 20 to 40 minutes. A significant rise in temperature was obvious within the first 15 minutes of drug administration, followed by a second significant rise occurring shortly after the onset of visible shivering. The therapeutic value of Misoprostol was tested in the treatment of PPH due to uterine atony using the rectal route of administration, which has obvious advantages in PPH patients. The efficacy of 1000 ugm rectally administered misoprostol was investigated for the management of atonic PPH, unresponsive to conventional therapy. Misoprostol administration was quickly followed by firm contraction of the uterus and cessation of haemorrhage. The series of studies described in this thesis prove that oral misoprostol may be effectively used for prevention of PPH, and may also play a role in its treatment. Misoprostol has great potential to reduce maternal mortality due to PPH, and may well be the perfect agent for use over the world