Oral misoprostol versus injectable methylergometrine in management of the third stage of labor

Postpartum hemorrhage is the leading cause of maternal deaths in the developing world, accounting for 30% of such deaths in areas where maternal mortality is high; in the developed world, it is the cause of maternal deaths in less than 10% of births [1]. The present study was conducted in Lok Nayak Hospital, New Delhi, India during a 1-year period from 2002 to 2003. Two hundred pregnant women fulfilled the inclusion criteria, i.e. all primigravidas with singleton pregnancy who underwent normal vaginal delivery. These women were randomly allocated to either the (A) misoprostol (Misoprost-200, CIPLA, Boisar Road, Paighar, Thane) group, or (B) the control group receiving methylergometrine (Mem, Neon Laboratories, Virgonagar, Bangalore 560049) in a 1:1 ratio by random number sequence. Group A received 600 μg of misoprostol orally immediately after giving birth and after division of the umbilical cord. Group B received 0.2 mg of methylergometrine intravenously at delivery of the anterior shoulder of the infant. Primary and secondary outcomes are shown in Table 1. The results were comparable in both groups, except that shivering and fever occurred more frequently in the misoprostol group, but these effects were self-limiting. Similar results were obtained in study done by Amant et al. [2] and Ray et al. [3]. In the present study, although Misoprostol was given by mouth after delivery while Methylergometrine was given intravenously before delivery, Misoprostol was as effective as Methylergometrine in the management of third stage of labor [4], [5]. Methylergometrine is contraindicated in hypertension in pregnancy, and, when it is indicated, must be given by intramuscular or intravenous injection requiring a sterile needle and syringe, owing to concerns about hepatitis and HIV infection. It is not stable at high temperatures and requires special storage conditions (2–8 °C). Misoprostol, however, does not require special storage and its absorption is extremely rapid when taken orally. Its only disadvantage is cost (Rs.15 per tab), which is considerably higher than methylergometrine much higher than methylergometrine (Rs.2). Other prostaglandins can cause bronchospasm and myocardial infarction [6], but misoprostol does not cause these side effects, but it is contraindicated if patients are allergic to prostaglandins. If misoprostol were made available to the trained birth attendants who supervise the majority of births in India, the lives of many women dying of atonic postpartum hemorrhage could be saved in that country. Thus, the advantages of oral misoprostol make it a feasible drug to be used in the routine management of the third stage of labor in developing countries.