Use of misoprostol in the treatment of postpartum hemorrhage: a pharmacoepidemiological approach

Development and validation of a stability-indicating method, structural elucidation of new degradation products from misoprostol by LC-MS time-of-flight, and an ex vivo study of vaginal permeation

Misoprostol (MSP) is commonly prescribed in obstetrics and gynecology clinical practice for labor induction, cervical ripening, first-trimester pregnancy termination, and the treatment of postpartum hemorrhage. Furthermore, there is a lack of comprehensive discussion evaluating how different commercially available formulations influence the overall efficacy of MSP, even though reports indicate issues with the quality of these formulations, particularly regarding stability and vaginal absorption processes. This study investigates the stability of MSP under acidic conditions and its in vitro permeation using swine vaginal mucosa. A forced degradation study was conducted using 0.2 M HCl, and a high-efficiency LC method was developed. Three degradation products were identified and characterized using electrospray ionization-high-resolution quadrupole-time-of-flight-MS, with respective m/z values of 391.2508, 405.2705, and 387.2259, respectively. These results suggest that the degradation mechanism involves dehydration of the β-hydroxy ketone moiety, followed by isomerization to its most resonance-stable form and de-esterification. Finally, the in vitro permeation study revealed that the esterified form of MSP was unable to permeate the mucosa and required prior degradation for any component to be detected in the receptor fluid.

Misoprostol Administration Before Hysteroscopy Procedures - A Retrospective Analysis

OBJECTIVE

 To evaluate the use of misoprostol prior to hysteroscopy procedures regarding technical ease, the presence of side effects, and the occurrence of complications.

METHODS

 This is a retrospective, observational, analytical, case-control study, with the review of medical records of 266 patients followed-up at the Gynecological Videoendoscopy Sector of the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto of the Universidade de São Paulo (HCFMRP - USP, in the Portuguese acronym) from 2014 to 2019, comparing 133 patients who used the drug before the procedure with 133 patients who did not.

RESULTS

 The occurrence of postmenopausal uterine bleeding was the main indication for hysteroscopy and revealed a statistical difference between groups (p < 0.001), being present in 93.23% of the patients in the study group and in 69.7% of the patients in the control group.: Only 2 patients (1.5%) in the study group reported adverse effects. Although no statistical differences were observed regarding the occurrence of complications during the procedure (p = 0.0662), a higher total number of complications was noted in the group that used misoprostol (n = 7; 5.26%) compared with the group that did not use the drug (n = 1; 0.75%), a fact that is clinically relevant. When evaluating the ease of the technique (measured by the complete performance of all steps of the hysteroscopy procedure), it was verified that although there was no difference between groups (p = 0.0586), the control group had more than twice as many incompletely performed procedures (n = 17) when compared with the group that used misoprostol previously (n = 8), which is also clinically relevant.

CONCLUSION

 The use of misoprostol prior to hysteroscopy in our service indicated that the drug can facilitate the performance of the procedure, but not without side effects and presenting higher complication rates.

Prophylactic effect of rectal and sublingual misoprostol on postpartum hemorrhage in mothers with preeclampsia following cesarean section surgery; a double-blind randomized controlled trial

Background

Postpartum hemorrhage is one of the three major causes of maternal morbidity and mortality, so delay in the diagnosis and proper management of postpartum hemorrhage is of great importance. The present study aimed to determine the prophylactic effect of misoprostol on postpartum hemorrhage in patients with preeclampsia.

Methods

This was a double-blind randomized controlled clinical trial performed on 128 pregnant women with preeclampsia undergoing cesarean section in Kamali hospital in Karaj. After cesarean delivery, immediately after clamping the umbilicus, the first group was administered 400 μg of rectal misoprostol and the second group was given 400 μg of sublingual misoprostol. The third group (control) was given 30 units of oxytocin during surgery and within 12 h after surgery, respectively. Hemoglobin and hematocrit were measured 24 h later. The estimated bleeding rate by the physician, the need for additional medication to control bleeding, and the amounts of hemoglobin and hematocrit in the first 24 h were compared in the three groups. Finally, the obtained information was entered into SPSS version 21 and analyzed using statistical tests.

Results

The mean hemoglobin and hematocrit levels 6 and 12 h after cesarean section were significantly lower in the oxytocin group than in the sublingual and rectal misoprostol groups (Hemoglobin level (mg/dl) for oxytocin group 10.39 ± 0.73 and 9.53 ± 1.09 vs. sublingual misoprostol 11.05 ± 0.71 and 10.39 ± 0.84 vs. rectal misoprostol 10.92 ± 0.85 and 10 ± 1.01; hematocrit level for Hemoglobin level (%) for oxytocin group 31.27 ± 2.29 and 28.64 ± 2.93 vs. sublingual misoprostol 33.09 ± 2.20 and 31.05 ± 2.37 vs. rectal misoprostol 32.54 ± 2.7 and 29.92 ± 2.86) (p < 0.005). The mean estimation of visual bleeding in the oxytocin group was higher than the other three groups, followed by the rectal and the sublingual groups, respectively. However, there was no significant difference between the three groups regarding visual bleeding. There was no significant difference in hemoglobin and hematocrit between the two groups of sublingual and rectal misoprostol before and 6 and 12 h after the surgery (P > 0.05).

Conclusion

It seems that sublingual or rectal misoprostol administration along with oxytocin is associated with a reduction in postpartum cesarean section bleeding compared to oxytocin administration alone.

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Hemoglobin level 6 and 12 h after cesarean section is significantly lower in the oxytocin group compared to the sublingual misoprostol group.

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Sublingual or rectal misoprostol administration along with oxytocin is associated with a reduction in postpartum cesarean section bleeding.

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Hemoglobin level 6 and 12 h after cesarean section is significantly lower in the oxytocin group compared to the rectal misoprostol group.

Effect of Baogong Zhixue Granules Combined with Tranexamic Acid Injection on the Hemodynamics and Reproductive System in Patients with Postpartum Hemorrhage after Cesarean Section

Objective

To investigate the effect of Baogong Zhixue granules combined with tranexamic acid injection on the hemodynamics and reproductive system in patients with postpartum hemorrhage (PPH) after cesarean section.

Methods

The data of 90 puerperae undergoing cesarean section in our hospital from January 2019 to January 2020 were retrospectively analyzed. According to the order of admission, they were equally divided into the control group (CG) and experimental group (EG). CG was treated with tranexamic acid injection combined with oxytocin, while EG was treated with Baogong Zhixue granules combined with tranexamic acid injection to compare the clinical observation indexes between the two groups.

Results

Compared with CG, EG achieved remarkably less amount of bleeding at 2 h and 24 h after delivery (P < 0.001), lower postpartum APTT, PT, HR, and MAP (P < 0.001), shorter maintenance time of uterine contraction and lochia (P < 0.001), and lower postpartum FSH and LH (P < 0.001). After delivery, EG had higher postpartum Fib and descending speed of uterine fundus and E₂ compared with CG (P < 0.001).

Conclusion

Baogong Zhixue granules combined with tranexamic acid injection have little effect on the reproductive system of PPH patients after cesarean section, stabilize the hemodynamics, and improve the coagulation function. Therefore, further research on the combined treatment can provide better hemostatic schemes for such patients.

Hemorragia postparto: intervenciones y tratamiento del profesional de enfermería para prevenir shock hipovolémico

Introducción: En Colombia la hemorragia postparto es la segunda causa de mortalidad en mujeres gestantes de 24 a 34 años con 6,9 casos por cada 1000 nacidos vivos. Después del parto se prevé que el 8.2% de las mujeres latinoamericanas presentarán hemorragia postparto. Objetivo: Describir el cuidado de enfermería a mujeres que presentan hemorragia postparto para disminuir el riesgo de shock hipovolémico, a través de una revisión integrativa de la literatura. Metodología: Revisión integrativa de la literatura siguiendo la propuesta por Sasso, de Campos y Galvão, se realizó una búsqueda en ClinicalKey, LILACS, CINAHL, Epistemonikos, Cochrane Library, PubMed, Scielo y Google Scholar; se incluyeron artículos publicados en los últimos cinco años, en español, inglés y portugués, se clasificaron por nivel de evidencia y grado de recomendación. Esta investigación es de bajo riesgo por ser de tipo documental. Resultados: Se recopilaron 41 artículos definitivos. La información se organizó en: cuadro clínico, cuidados de enfermería y dificultades en la atención gineco-obstétrica. Discusión: El profesional de enfermería debe identificar barreras en la atención evaluando la capacidad resolutiva de las instituciones y analizando los casos de muerte materna. Se recomienda el uso de misoprostol con oxitocina o únicamente de carbetocina y la combinación de ergometrina con oxitocina según el volumen de sangrado. Conclusión: Es pertinente realizar un examen físico para reconocer signos de inestabilidad hemodinámica, y de shock hipovolémico. Además, los diagnósticos e intervenciones de enfermería se enfocan en brindar cuidados de calidad, para evitar complicaciones como la muerte.

Retrospective Study on the Pattern of Off-label Use of Misoprostol in Tabuk, Saudi Arabia

Introduction:

Off-label drug use (OLDU) refers to the prescription of a currently available and marketed medication for a use that has never been approved by the Food and Drug Administration (FDA). Misoprostol is one of the drugs which is used off-label. This drug, authorized for the treatment or prevention of peptic ulcers and other stomach disorders, is commonly used off-label for inducing labor or intrauterine device insertion. This research focuses on identifying the percentage of morbidity and mortality by off-label use of misoprostol; classifying the most common off-label misoprostol use in Tabuk hospitals; and determining the availability of policy and procedures behind prescribing the off-label misoprostol.

Materials and Methods:

Retrospective observational study was carried out. Data were collected from patients’ files for those admitted to the maternity wards in Tabuk Hospitals from March 2019 until September 2019.

Results:

Approximately 53% of cases were diagnosed with missed abortion. The mean time for abortion after administering misoprostol was 20.7 ± 28.2h. About 76% of women had an indication of bleeding. Guidelines were not followed with respect to dosage regimen. The mean of hospital stay was 3 days. There were no significant complications associated with the administration of misoprostol.

Conclusion:

There is no policy and procedure available in the hospital regarding off-label use of misoprostol. Moreover, physicians have low adherence to the guideline in terms of dosage, interval, and route of administration for each indication in obstetrics and gynecology.