PPH 2nd edn #23.vp

The current gold standard for treating postpartum hemorrhage (PPH) due to atony is intravenous (IV) oxytocin1. However, access to this specific drug and the capacity for its timely intravenous administration are lacking in settings with limited resources, especially at lower levels of the health care system. Misoprostol, a tablet that requires no additional supplies and/or specialized skills to administer, has the potential to play an important role as a firstline treatment for PPH in such settings. Interest in its use for both prevention and treatment of PPH has a decades-long history, and in 2011 misoprostol was added to the World Health Organization’s (WHO) Model List of Essential Medicines for PPH prevention2. Recent research demonstrates misoprostol’s safety and efficacy as compared with oxytocin. Prior to 2010, the published literature on misoprostol for the treatment of PPH consisted of several small non-randomized trials that examined various doses and routes of administration as either a first-line treatment or an adjunct to standard uterotonics, a handful of case reports (treating 82 women) and one community-based intervention study3–14. Although these studies were insufficient to recommend a specific regimen for treatment with misoprostol, they provided a rationale for further investigation. Perhaps of greater import, health care providers worldwide have been using the drug for ad hoc treatment of PPH, despite the absence of conclusive evidence and consensus on an optimal regimen. In 2010, three seminal studies provided evidence on the utility of sublingual misoprostol in the treatment of PPH. Two large multicenter, double-blind, placebo-controlled, randomized trials compared the effectiveness, safety and acceptability of 800 μg sublingual misoprostol with 40 IU intravenous oxytocin15,16. Another large multicenter, doubleblind, randomized trial assessed 600 μg sublingual misoprostol when used as an adjunctive treatment for PPH (i.e. when given at the same time as the standard uterotonic treatment)17. The sublingual route of administration of misoprostol was chosen in all these trials because of its rapid uptake, long-lasting duration of effect and high bioavailability compared with other routes of misoprostol administration18.