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Letter to the Editor
Gynecol Obstet Invest 2007;64:82–83 DOI: 10.1159/000099651
A Double-Blind Randomized Controlled Trial of Oral Misoprostol and Intramuscular Syntometrine in the Management of the Third Stage of Labor
Niraj N. Mahajan Kshitija Mahajan Rajani Soni
Padhar Hospital, Padhar , India
ability of safe blood transfusion services and prior knowledge of blood pressure of-ten is not available [2] . The use of miso-prostol is certainly vital in developing countries to prevent postpartum hemor-rhage (PPH).
Ng et al. mention quantifying the blood loss clinically in their study. It is well known that clinical estimates of blood loss frequently fall below the actual amount and the incidence of PPH is underreported by 30–50% [4, 5] . The protocol used by the WHO in their multicenter randomized trial of misoprostol in the management of the third stage of labor recommended to start measuring blood loss immediately after cutting the cord, change dirty linen and receivers, to use a flat bedpan or buck-et, collect all blood, clots, and swabs soaked with blood and to transfer all the contents into a measuring jar provided for analysis [6] . In light of underestimation of blood loss, we believe the WHO protocol should have been adopted for accuracy. We there-fore seek justification.
Dear Sir, We read with interest the paper by Ng
et al. [1] regarding oral misoprostol and in-tramuscular syntometrine in the manage-ment of the third stage of labor.
We agree misoprostol to be a time-proven efficacious drug for the manage-ment of the third stage of labor. Misopros-tol has a long shelf life, is stable, easy to administer (oral/rectal) and very eco-nomical. In developing countries, health resources are meager and the best health-care does not outreach the underprivi-leged rural masses. Misoprostol plays an important role where vaginal deliveries take place away from hospitals or medical facilities and are supervised only by birth attendants (who may not be qualified to administer parenteral oxytocins) [2, 3] or most often, not supervised at all. Re-use of needles for parenteral administration is common practice, thus posing a major risk of the spread of blood-borne infec-tions such as hepatitis B, hepatitis C, or human immunodeficiency virus (HIV) infection. Further, there is lack of avail-
Received: December 18, 2006 Accepted: December 18, 2006 Published online: February 15, 2007
Dr. Niraj N. Mahajan Padhar Hospital, Padhar, Betul District Madhya Pradesh 460005 (India) Tel. +91 714 126 3046, Fax +91 714 126 3346 E-Mail [email protected]
© 2007 S. Karger AG, Basel0378–7346/07/0642–0082$23.50/0
Accessible online at:www.karger.com/goi
References
1 Ng PS, Lai CY, Sahota DS, Yuen PM: A dou-ble-blind randomized controlled trial of oral misoprostol and intramuscular syntomet-rine in the management of the third stage of labor. Gynecol Obstet Invest 2007; 63: 55–60.
2 O’Brien P, El-Refaey H: The management of the third stage of labor using misoprostol in low-risk women. Contemp Rev Obstet Gyne-col 1997; 9: 27–32.
3 Surbek DV, Fehr PM, Hosli I, Holzgreve W: Oral misoprostol for third stage of labor: a randomized placebo-controlled trial. Obstet Gynecol 1999; 94: 255–258.
4 Tourne G, Collet F, Lasnier P, Seffert P: Use-fulness of a collecting bag for the diagnosis of postpartum haemorrhage. J Gynecol Ob-stet Biol Reprod 2004; 33: 229–234.
5 Prata N, Mbaruku G, Campbell M: Using the kanga to measure post-partum blood loss. Int J Gynaecol Obstet 2005; 89: 49–50.
6 Gulmezoglu AM, Villar J, Ngoc NT, Piaggio G, Carroli G, Adetoro L, Abdel-Aleem H, Cheng L, Hofmeyr G, Lumbiganon P, Unger C, Prendiville W, Pinol A, Elbourne D, El-Refaey H, Schulz K; WHO Collaborative Group to Evaluate Misoprostol in the Man-agement of the Third Stage of Labour: WHO multicentre randomised trial of misoprostol in the management of the third stage of la-bour. Lancet 2001; 358: 689–695.
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Letter to the Editor Gynecol Obstet Invest 2007;64:82–83 83
We have repeatedly stressed this point in our previous studies related to the use of misoprostol in the management of PPH [1, 2] . More importantly, the amount of clini-cal estimation of blood loss does not reflect the actual hemoglobin change. Over 25% of the women who were defined as having PPH had a peripartum hemoglobin drop of over 20%. That is the reason why we chose to use the peripartum change in he-moglobin level as our primary outcome measure.
We thank Dr. Mahajan and colleagues for their comments on our study [1] . We agree with them that misoprostol is a use-ful uterotonic drug in developing coun-tries for the prevention of postpartum hemorrhage (PPH). We also concur on their comment on the estimation of blood loss. Clinical estimation of blood loss un-derestimates true blood loss, whereas the weighing method described in the WHO study could overestimate it as the presence of amniotic fluid could not be excluded.
Dr. Pong Mo Yuen Department of Obstetrics and Gynaecology Shatin, N.T. Hong Kong, SAR (China) Tel. +852 2632 2810, Fax +852 2636 0008 E-Mail [email protected]
References
1 Ng PS, Lai CY, Sahota DS, Yuen PM: A dou-ble-blind randomized controlled trial of oral misoprostol and intramuscular syntomet-rine in the management of the third stage of labor. Gynecol Obstet Invest 2007; 63: 55–60.
2 Ng PS, Chan ASM, Sin WK, Tang LCH, Cheung KB, Yuen PM: A multicentre ran-domised controlled trial of oral misoprostol and i.m. syntometrine in the management of the third stage of labour. Hum Reprod 2001;
16: 31–35.
Reply
P.M. Yuen P.S. Ng D.S. Sahota
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