Misoprostol for the Prevention of Postpartum Hemorrhage

1
Misoprostol for the Prevention of Postpartum
Hemorrhage

• Lisa J. Thomas, MD, FACOG
• Womens Commission for Refugee Women and Children

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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

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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

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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

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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

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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 countrys drug regulatory
  authority
• Currently registered
• Nigeria, India, Nepal, Bangladesh
• Registration underway
• Indonesia, Egypt, Ethiopia, Tanzania, Zambia
• Dossier prepared and submitted or in process

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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)

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Websites

• http//whqlibdoc.who.int/hq/2007/WHO_MPS_07.06_eng
  .pdf
• www.accesstohealth.org
• www.venturestrategies.org
• http//www.pphprevention.org/publications.phpTech
  nical_Briefs