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Misoprostol for the Prevention of Postpartum Hemorrhage
Lisa J. Thomas, MD, FACOG
Women’s Commission for Refugee Women and Children
Misoprostol • Background
– PGE1, heat stable, inexpensive
– Indications, Dosage, and Routes• Abortion, Incomplete Abortion, Induction of Labor • Prevention and Treatment of PPH
– Global Burden of PPH• 25% of Maternal Deaths Worldwide• 34% of Maternal Deaths in Africa (hemorrhage)• Impossible to predict based on risk factors• Urgent BEMOC/CEmOC• Prevention is critical
– AMTSL• Oxytocin is drug of choice in hospital settings• Skilled care required
Growing Evidence for Effectiveness
• Oral Misoprostol in preventing postpartum haemorrhage in resource-poor communities: A Randomized Controlled Trial. Derman et al, The Lancet 2006…
– DB, placebo-controlled* (1620 randomized)– Miso 600 mcg po within 5 mins cord clamp/cut – Expectant management* third stage of labor
– Misoprostol • Less blood loss• Less blood transfusion• Increased shivering and fever
WHO Recommendations for the Prevention of PPH
• “In the absence of AMTSL, a uterotonic drug (oxytocin or misprostol) should be offered by a health worker trained in its use for prevention of PPH”
• Includes auxiliary nurse-midwives, community midwives, village midwives, and health visitors if they have been specially trained
FIGO/ICM Call to Action
– National obstetric and midwifery associations to lead efforts to implement miso/PPH
– Address legislative, regulatory, and policy barriers
– Call upon national regulatory agencies and policy makers to approve miso for PPH prevention and treatment
Misoprostol Registration(for Prevention of PPH)
• Registration gives license to market a specific product for a specific indication
• Legalizes drug import and sale
• Registration dossier prepared/submitted by a manufacturer/distributor pair
• Decision made by country’s drug regulatory authority
• Currently registered– Nigeria, India, Nepal, Bangladesh
• Registration underway*– Indonesia, Egypt, Ethiopia, Tanzania, Zambia
*Dossier prepared and submitted or in process
Next Steps
• Community Based PPH Prevention– Distribution by CHVs with client education– Invest in training and supervision– SAFE (prevent misuse)
• PPH prevention as an indication for use of misoprostol on WHO essential medicines list
• More research on optimal dose/route (Lower dose)
Websites
• http://whqlibdoc.who.int/hq/2007/WHO_MPS_07.06_eng.pdf
• www.accesstohealth.org
• www.venturestrategies.org
• http://www.pphprevention.org/publications.php#Technical_Briefs
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