[Misoprostol: off-label use in the treatment of post-partum hemorrhage]

Current knowledge on off-label use of misoprostol for prevention and treatment of post-partum haemorrhage (PPH).

Systematic review of French and English literature by searching in PubMed, The Cochrane Library and recommendations of international scholarly societies and the World Health Organization.

Oral misoprostol reduces the risk of severe PPH (≥1L) by more than 80% when compared to a placebo (P<0.02, RR 0.20 [0.04-0.91]), and reduces the risk of moderate PPH (500 mL) by almost 50% (P<0.0001, RR 0.53 [0.39-0.74]). These results are confirmed by numerous studies. On the other hand, compared to oxytocin, misoprostol is slightly less efficient in preventing PPH. Severe PPH is significantly more frequent in patients receiving misoprostol when compared to those receiving 10 IU of syntocinon intravenously or intramuscularly (RR 1.39 [1.19-1.63]). Use of misoprostol is associated with a higher risk of using other uterotonics (P<0.001). Regarding treatment of PPH, misoprostol (800 μg sublingual) could be an alternative to oxytocin (40 IU intravenous) when the later is not available. Active bleeding is equivalently stopped with misoprostol and with oxytocin (RR 1.12 [0.92-1.37]). However, more side effects are recorded with misoprostol, especially diarrhoea, nausea and vomiting but also tremors (RR 2.80 [2.25-3.49]) and fever above 38°C (RR 8.07 IC [5.52-11.8]).

In prevention of PPH, a single dose of 600 μg of misoprostol sublingual (3 tablets of 200 μg) can be indicated during the third stage of labour, when oxytocin is not available. For treatment of PPH caused by uterine atony, a single dose of 800 μg of misoprostol sublingual (4 tablets of 200 μg) can be indicated if oxytocin is not an option. Combined use of misoprostol and oxytocin has not been proved to be more efficient.