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Intrauterine misoprostol for refractory postpartum hemorrhage
International Journal of Gynecology and Obstetrics 80 (2003) 67–68
Brief communication
Intrauterine misoprostol for refractory postpartum hemorrhage V.O. Oboro*, T.O. Tabowei, J.O. Bosah Maternity Unit, Zonal General Hospital, Kwale, Delta State, Nigeria Received 3 July 2002; received in revised form 3 September 2002; accepted 4 September 2002 Keywords: Misoprostol; Intrauterine; Atonic postpartum hemorrhage
A 37-year-old woman, para 4, who delivered at home 5 days previously presented to our hospital with a 1-day history of profuse vaginal bleeding containing clots. There was associated weakness and low abdominal pain, but no fever. A traditional birth attendant had conducted her delivery, but there was no history of retained placenta or excessive intrapartum vaginal bleeding. On presentation, she was pale but apyrexial. Her pulse rate was 110 beatsymin, and her blood pressure was 100y 60 mmHg. Her uterus was soft and approximately 14 weeks’ gestation in size, and the cervical os was open. Hemoglobin concentration was 6.0 gy dl and the results of the coagulation test were normal. Ultrasonography revealed retained products of conception in the uterus. The patient was administered the following intravenously: one dose of 0.5 mg of ergometrine; an infusion of 40 IU of oxytocin in 500 ml of normal saline solution; 1.5 g of cefuroxime every 8 h; and 500 mg of metronidazole every 8 h. Despite these measures, the uterus remained atonic and vaginal bleeding continued. Uterine evacuation of retained product of conception (ERPC) was *Corresponding author. Department of ObstetricsyGynaecology, LAUTECH College of Health Sciences, P.M.B. 4400, Osogbo, Osun State, Nigeria. E-mail address: [email protected] (V.O. Oboro).
performed under anesthesia. At the time of the procedure the vulva and vagina appeared normal, and there was no cervical laceration. The uterus was atonic and the cervix was dilated by approximately 4 cm, with continuous oozing of blood from the uterus. Clots and products of conception were evacuated, the ergometrine injection was repeated, and oxytocin administration continued. As these failed to control bleeding, bimanual uterine compression was applied and preparation for laparotomy began. Four tablets (800 mg) of misoprostol (Cytotec, Searle Pharmaceuticals, Wycomb, UK) was inserted into the uterus and bimanual compression continued. Thereafter, the uterus became firm and bleeding was significantly reduced. The patient was kept under observation for 48 h, during which the uterus remained contracted and bleeding was negligible. She received a total of 3 units of packed red cells. The results of the histological examination confirmed that the removed materials were placenta products, and there was no evidence of choriocarcinoma. She was given antibiotics and hematinics, and discharged with an hemoglobin concentration of 8.2 gydl. Postpartum hemorrhage remains a major cause of maternal mortality, particularly in developing
0020-7292/03/$30.00 䊚 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 0 2 0 - 7 2 9 2 Ž 0 2 . 0 0 3 0 1 - 6
68
V.O. Oboro et al. / International Journal of Gynecology and Obstetrics 80 (2003) 67–68
countries. Maternal mortality and morbidity due to postpartum hemorrhage has been estimated to be approximately 50 times more common in the developing than in developed countries. Factors contributing to this include the unavailability or ineffectiveness of routine oxytocic use in the third stage of labor. To be administered, oxytocic agents (oxytocin, ergometrine and syntometrine) require needles and syringes. Moreover, they require cool storage conditions (between 2 8C and 8 8C, and away from light); thus, their potency in tropical climates has been questioned. Misoprostol is a prostaglandin E1 analogue, originally marketed for use as an anti-ulcer drug, and is gaining popularity as a highly effective uterotonic agent. It has been used for pregnancy termination, labor induction, and prevention of postpartum hemorrhage. It is rapidly absorbed following oral administration, has few side effects, is stable at room temperature, and is inexpensive. The conventional management of an atonic postpartum hemorrhage include the administration of parenteral ergometrine, oxytocin, and, more recently, intramuscular prostaglandins, particularly carboprost. The latter is particularly suitable for postpartum hemorrhages refractory to the other oxytocic agents. As carboprost was not readily available, we decided upon the use of intrauterine misoprostol for this patient whose atonic postpartum hemorrhage continued despite the use of ergometrine and oxytocin, uterine evacuation, and bimanual compression. This decision was informed by previous reports of the effectiveness of the gemeprost pessary w1x, and of the insertion of a misoprostol tablet into the uterine cavity w2x in similar situations. Moreover, the effectiveness of misoprostol in the prevention of postpartum hemorrhage has been previously reported w3x. The oral route could not be used because the patient was under anesthesia, and the rectal route is uncertain in the presence of hypovolemia. Hence, intrauterine administration was our last resort before laparotomy. Tamponade with a balloon catheter could also be used in this circumstance, but appropriately
large balloon catheters (Sengstaken-Blakemore ¨ tube, Rusch catheter) were not available. The effectiveness of uterine packing with gauze is debatable, and therefore not used in this emergency. Although this report demonstrates the effectiveness of intrauterine misoprostol in controlling atonic postpartum hemorrhage, it is possible that the sustained uterine contractions were partly due to the delayed or cumulative effect of previously administered parenteral oxytocics w2x. Nevertheless, the procedure is recommended in the management of atonic postpartum hemorrhage that is refractory to conventional oxytocics in poorly resourced countries, where the other expensive and more complicated alternatives are not readily available, before resorting to laparotomy. There is currently no contraindication of major importance to the use of misoprostol in the management of postpartum hemorrhage. Most studies on the postpartum effect of oral misoprostol show that the most common side effects are transient shivering and asymptomatic fever, and both of which are regarded as nuisance rather than serious morbidity. Even though severe hyperthermia has been reported in the early postpartum period with misoprostol w4x, the side effects of prostaglandins are rare with misoprostol. Thus, misoprostol may be a ready alternative where prostaglandins are contraindicated in the management of refractory atonic postpartum hemorrhage. References w1x Barrington JW, Roberts A. The use of gemeprost pessaries to arrest postpartum hemorrhage. Br J Obstet Gynaecol 1993;100:691 –692. w2x Adekanmi OA, Purmessur S, Edwards G, Barrington JW. Intrauterine misoprostol for the treatment of severe recurrent atonic secondary postpartum hemorrhage. Br J Obstet Gynaecol 2001;108:541 –542. w3x Bamigboye AA, Hofmeyr GJ, Merrell DA. Rectal misoprostol in the prevention of postpartum hemorrhage. Am J Obstet Gynecol 1998;179:1043 –1046. w4x Chong YS, Chua S, Arulkumaran S. Severe hyperthermia following oral misoprostol in the prevention of postpartum hemorrhage. Br J Obstet Gynaecol 1997;90:703 –704.
Brief communication
Intrauterine misoprostol for refractory postpartum hemorrhage V.O. Oboro*, T.O. Tabowei, J.O. Bosah Maternity Unit, Zonal General Hospital, Kwale, Delta State, Nigeria Received 3 July 2002; received in revised form 3 September 2002; accepted 4 September 2002 Keywords: Misoprostol; Intrauterine; Atonic postpartum hemorrhage
A 37-year-old woman, para 4, who delivered at home 5 days previously presented to our hospital with a 1-day history of profuse vaginal bleeding containing clots. There was associated weakness and low abdominal pain, but no fever. A traditional birth attendant had conducted her delivery, but there was no history of retained placenta or excessive intrapartum vaginal bleeding. On presentation, she was pale but apyrexial. Her pulse rate was 110 beatsymin, and her blood pressure was 100y 60 mmHg. Her uterus was soft and approximately 14 weeks’ gestation in size, and the cervical os was open. Hemoglobin concentration was 6.0 gy dl and the results of the coagulation test were normal. Ultrasonography revealed retained products of conception in the uterus. The patient was administered the following intravenously: one dose of 0.5 mg of ergometrine; an infusion of 40 IU of oxytocin in 500 ml of normal saline solution; 1.5 g of cefuroxime every 8 h; and 500 mg of metronidazole every 8 h. Despite these measures, the uterus remained atonic and vaginal bleeding continued. Uterine evacuation of retained product of conception (ERPC) was *Corresponding author. Department of ObstetricsyGynaecology, LAUTECH College of Health Sciences, P.M.B. 4400, Osogbo, Osun State, Nigeria. E-mail address: [email protected] (V.O. Oboro).
performed under anesthesia. At the time of the procedure the vulva and vagina appeared normal, and there was no cervical laceration. The uterus was atonic and the cervix was dilated by approximately 4 cm, with continuous oozing of blood from the uterus. Clots and products of conception were evacuated, the ergometrine injection was repeated, and oxytocin administration continued. As these failed to control bleeding, bimanual uterine compression was applied and preparation for laparotomy began. Four tablets (800 mg) of misoprostol (Cytotec, Searle Pharmaceuticals, Wycomb, UK) was inserted into the uterus and bimanual compression continued. Thereafter, the uterus became firm and bleeding was significantly reduced. The patient was kept under observation for 48 h, during which the uterus remained contracted and bleeding was negligible. She received a total of 3 units of packed red cells. The results of the histological examination confirmed that the removed materials were placenta products, and there was no evidence of choriocarcinoma. She was given antibiotics and hematinics, and discharged with an hemoglobin concentration of 8.2 gydl. Postpartum hemorrhage remains a major cause of maternal mortality, particularly in developing
0020-7292/03/$30.00 䊚 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 0 2 0 - 7 2 9 2 Ž 0 2 . 0 0 3 0 1 - 6
68
V.O. Oboro et al. / International Journal of Gynecology and Obstetrics 80 (2003) 67–68
countries. Maternal mortality and morbidity due to postpartum hemorrhage has been estimated to be approximately 50 times more common in the developing than in developed countries. Factors contributing to this include the unavailability or ineffectiveness of routine oxytocic use in the third stage of labor. To be administered, oxytocic agents (oxytocin, ergometrine and syntometrine) require needles and syringes. Moreover, they require cool storage conditions (between 2 8C and 8 8C, and away from light); thus, their potency in tropical climates has been questioned. Misoprostol is a prostaglandin E1 analogue, originally marketed for use as an anti-ulcer drug, and is gaining popularity as a highly effective uterotonic agent. It has been used for pregnancy termination, labor induction, and prevention of postpartum hemorrhage. It is rapidly absorbed following oral administration, has few side effects, is stable at room temperature, and is inexpensive. The conventional management of an atonic postpartum hemorrhage include the administration of parenteral ergometrine, oxytocin, and, more recently, intramuscular prostaglandins, particularly carboprost. The latter is particularly suitable for postpartum hemorrhages refractory to the other oxytocic agents. As carboprost was not readily available, we decided upon the use of intrauterine misoprostol for this patient whose atonic postpartum hemorrhage continued despite the use of ergometrine and oxytocin, uterine evacuation, and bimanual compression. This decision was informed by previous reports of the effectiveness of the gemeprost pessary w1x, and of the insertion of a misoprostol tablet into the uterine cavity w2x in similar situations. Moreover, the effectiveness of misoprostol in the prevention of postpartum hemorrhage has been previously reported w3x. The oral route could not be used because the patient was under anesthesia, and the rectal route is uncertain in the presence of hypovolemia. Hence, intrauterine administration was our last resort before laparotomy. Tamponade with a balloon catheter could also be used in this circumstance, but appropriately
large balloon catheters (Sengstaken-Blakemore ¨ tube, Rusch catheter) were not available. The effectiveness of uterine packing with gauze is debatable, and therefore not used in this emergency. Although this report demonstrates the effectiveness of intrauterine misoprostol in controlling atonic postpartum hemorrhage, it is possible that the sustained uterine contractions were partly due to the delayed or cumulative effect of previously administered parenteral oxytocics w2x. Nevertheless, the procedure is recommended in the management of atonic postpartum hemorrhage that is refractory to conventional oxytocics in poorly resourced countries, where the other expensive and more complicated alternatives are not readily available, before resorting to laparotomy. There is currently no contraindication of major importance to the use of misoprostol in the management of postpartum hemorrhage. Most studies on the postpartum effect of oral misoprostol show that the most common side effects are transient shivering and asymptomatic fever, and both of which are regarded as nuisance rather than serious morbidity. Even though severe hyperthermia has been reported in the early postpartum period with misoprostol w4x, the side effects of prostaglandins are rare with misoprostol. Thus, misoprostol may be a ready alternative where prostaglandins are contraindicated in the management of refractory atonic postpartum hemorrhage. References w1x Barrington JW, Roberts A. The use of gemeprost pessaries to arrest postpartum hemorrhage. Br J Obstet Gynaecol 1993;100:691 –692. w2x Adekanmi OA, Purmessur S, Edwards G, Barrington JW. Intrauterine misoprostol for the treatment of severe recurrent atonic secondary postpartum hemorrhage. Br J Obstet Gynaecol 2001;108:541 –542. w3x Bamigboye AA, Hofmeyr GJ, Merrell DA. Rectal misoprostol in the prevention of postpartum hemorrhage. Am J Obstet Gynecol 1998;179:1043 –1046. w4x Chong YS, Chua S, Arulkumaran S. Severe hyperthermia following oral misoprostol in the prevention of postpartum hemorrhage. Br J Obstet Gynaecol 1997;90:703 –704.