Prevention of postpartum haemorrhage

The full guidance on the prevention of postpartum haemorrhage has been published in the International Journal of Gynecology and Obstetrics 2007;99(supp 2):S198-201, and is available as a read-only pfd file here.

Recommended Dosage: 600mcg orally or sublingually stat

Regimen

A single dose of misoprostol 600 mg orally or sublingually is indicated for prevention of PPH in settings where injectible conventional uterotonics are not available.

Course of Treatment

Misoprostol should be administered by skilled attendants immediately after delivery of the newborn, and after checking that there is no multiple pregnancy. This medication should be followed 1 to 3 minutes later by cord clamping and controlled cord traction as part of the active management of the third stage of labor. Unskilled providers should give misoprostol only after delivery of the placenta because of the risk of inadvertently giving the misoprostol before the delivery of a second twin.

If there is continued hemorrhage, then great care should be taken before repeating misoprostol as cumulative doses may result in side-effects. Causes of hemorrhage other than atony should be sought and the woman should be immediately transferred to a facility where PPH can be treated. In the event of continued hemorrhage, a minimum of 2 hours should lapse after the original dose before a second dose is given. If the initial dose was associated with pyrexia or marked shivering, then at least 6 hours should lapse before the second dose is given.

These recommendations are produced by an expert group on misoprostol brought together by WHO in Bellagio, Italy in Feb 2007. These recommendations do not reflect official WHO guidelines, but have been released early so as to provide guidance to clinicians worldwide. The excerpt above is taken from:

Z Alfirevic, J Blum, G Walraven, A Weeks, B Winikoff. Prevention of Postpartum Hemorrhage with Misoprostol. International Journal of Gynecology and Obstetrics 2007;99(supp 2):S198-201.

Alternative Guidelines

Additional guidelines for the prevention of postpartum haemorrhage are available here.

Postpartum Haemorrhage Prophylaxis

STAT = single dose taken immediately

Route*

Dose

Time period

Max. Dose

Level of evidence

Notes

Bellagio/

FIGO

Orally

Sublingual

600µg

600µg

STAT

STAT

1

1

IA

Not as effective as oxytocin or ergometrine. Exclude second twin before administration.

Do not repeat within 2 hours.

WHO

Oral

600µg

STAT

1

I A

Only use if there is no oxytocic treatment available

As LAST RESORT

NICE

-

-

-

-

-

No Guidelines

RCOG

Oral

600µg

STAT

1

IA

Warns of adverse effects

SOGC

Oral

Sublingual

Rectal

600-800 µg

STAT

1

II-1 B

Should combine with IM injection 0.2 mg Ergovine

ACOG

-

-

-

-

-

Gynuity

Oral

600 µg

STAT

1

IB

Administer in 3^rd stage of labour – part of AMTSL

Additional Misoprostol should NOT be given after initial 6 hours of this dose

POPPHI

Oral

600µg

STAT

1

IB

Exclude second baby

Take tablet one minute after birth and perform uterine massage immediately

FLASOG

Oral

Rectal

600µg

600µg

STAT

STAT

1

1

IB

Use as last line treatment only if no alternative is available

Postpartum Haemorrhage Prophylaxis *STAT = single dose taken immediately
	Route	Dose	Time period	Max. Dose	Level of evidence	Notes
Bellagio/ FIGO	Orally Sublingual	600µg 600µg	STAT STAT	1 1	IA	Not as effective as oxytocin or ergometrine. Exclude second twin before administration. Do not repeat within 2 hours.
WHO	Oral	600µg	STAT	1	I A	Only use if there is no oxytocic treatment available As LAST RESORT
NICE	-	-	-	-	-	No Guidelines
RCOG	Oral	600µg	STAT	1	IA	Warns of adverse effects
SOGC	Oral Sublingual Rectal	600-800 µg	STAT	1	II-1 B	Should combine with IM injection 0.2 mg Ergovine
ACOG	-	-	-	-	-
Gynuity	Oral	600 µg	STAT	1	IB	Administer in 3^rd stage of labour – part of AMTSL Additional Misoprostol should NOT be given after initial 6 hours of this dose
POPPHI	Oral	600µg	STAT	1	IB	Exclude second baby Take tablet one minute after birth and perform uterine massage immediately
FLASOG	Oral Rectal	600µg 600µg	STAT STAT	1 1	IB	Use as last line treatment only if no alternative is available