Zahedan University of Medical Sciences

Misoprostol use to prevent and treat postpartum hemorrhage (PPH) in birthing centers and Rural Delivery Facilities (SDFs) in southeast of Iran

Report from: ZAUMS Family and  Reproductive Health Department
Published on: 16 May 2019

Providing skilled birth attendance as well as access to emergency obstetric care have been considered as the main global strategies to target high maternal mortality ratios (1). Since the establishment of the primary health care (PHC) system in Iran, the country has witnessed an improvement in all aspects of the population health including a significant reduction in the maternal mortality ratio (2). As it has been stipulated in the Iranian PHC Network Development Plan, Rural Delivery Facilities (RDFs) that are led by midwives have been established to improve access to maternal health services, particularly the skilled birth attendance for women living in remote and rural areas (3).

The contribution of 19 midwife-led Rural Delivery Facilities (RDFs) affiliated with Zahedan University of Medical Sciences in Sistan and Balouchetsan, southeast Iran, to the maternal health has been substantial, as more than 13000 deliveries per year take place in those units. Considering the huge impact of these units in decreasing unsafe deliveries and improving antenatal and postpartum care, the number of these units  increased to 28 in 2010. The Rural Delivery Facilities (RDFs)  are integral parts of rural health center and a general practitioner is in charge of the center and supervises and directs all activities of the center. Delivery services are rendered round the clock in delivery units and 2 midwives per shift are in attendance. The midwives provide delivery services and take care of pregnant and puerperal mothers. If encountering any problem, the pregnant women are referred to the physician of the center and if necessary the cases are dispatched to hospital by ambulance. The distance of these units to the nearest hospital or treatment center is 45-210 km, which is 45 minutes to 3.5 hours’ drive.

The analysis of 5-year maternal death records (2009-2013) of Zahedan University of Medical Sciences revealed that the most common cause of maternal mortality was bleeding in the third stage of delivery. One of the reasons was the poor control of maternal hemorrhage and the resulting maternal hemorrhagic shock during transfer to the hospital.

Uterine atony is a common cause of primary postpartum hemorrhage, which remains a major cause of pregnancy-related mortality for women worldwide. Uterotonic medications such as oxytocin, methergene, as the first and second line agents are commonly used to restore uterine tone. Misoprostol is a synthetic prostaglandin E(1) analogue that is used for a variety of indications in the practice of obstetrics and gynecology, including pharmacological abortion, medical management of miscarriage, induction of labor, cervical ripening before surgical procedures, and the treatment of postpartum hemorrhage (4). Misoprostol is an adjunct to other uterotonic agents, but it can be a life-saving medication in resource-limited practice environments (5).

A systematic review and meta-analysis of maternal deaths and dose-related effects of misoprostol to prevent and treat postpartum hemorrhage concluded that there are enormous benefits of using an effective oral uterotonic in the third stage of labor (6). Further research is essential to better assess the potential beneficial and harmful effects of the drug. However, the use of misoprostol should not detract from international efforts to ensure that all childbearing women have access to conventional uterotonics that have been proven safe and effective (6).

To address the problem of management of postpartum hemorrhage the outpatient settings, it was suggested that the pre-hospital guideline for management of postpartum hemorrhage and hemorrhagic shock be developed by the faculty members in Zahedan University of Medical Sciences. In Iran, the use of misoprostol is only approved for obstetrics and gynecology indications in the hospital settings. Given the fact that there is a long distance between SDFs and hospitals, usually more thna 1 hour dirve, it was necessary  to consider including the use of misoprostol in the proposed guideline for this intervention. Misoprostol vas only recommended when other uterotonic medications (such as oxytocin and methergene) in treatment of atony of the uterus were ineffective. Therefore, a request was made to the Ministry of Health and Medical Education to issue a permit for the use of misoprostol in RDFs. Following obtaining the approval and developing the guidelines for misoprostol use, RDFs were provided with misoporstol. The recommended dosage is 200 micro gram for sublingual use and 800 microgram for rectal administration. Midwives can administer misoprostol during transferring pregnant women to hospital, only after consulting the on-call obstetrician/gynecologist at the referral hospital. In the mean time, other  measure to manage hemorrhagic shock such as crystalloid fluid therapy should be performed simultaneously until reaching the hospital.

The effectiveness of misoprostol in the management of pre-hospital hemorrhagic shock in rural and remote areas of Sistan and Balouchestan Province and in decreasing maternal mortality rate and improving  the general condition of pregnant women with hemorrhage at the time of admission to the hospitals has been investigated in a study conducted by ZAUMS academic members. The results of this study showed a significant improvement in the management of postpartum hemorrhage in the pre-hospital setting after the intervention. The related manuscript entitled "Empowering midwives to manage postpartum haemorrhage in rural areas of Islamic Republic of Iran: lessons learnt from cases of maternal death" is in press in Eastern Mediterranean Health Journal and it will be released after publication.

An intervention success story 

A 30 year old mother G5P4, residence of one of the villages under coverage of Jalgh rural health center in Saravan district. The distance between the place of residence of the patient and RDF in the health center was 75 Km (more than 1 hour drive). She attended the RDF complaining from labor pain at 9 p.m. The patient was considered as a high risk case on the grounds of high blood pressure and twin pregnancy. During pregnancy she had been visited by Behvarz (rural health worker, 8 times), midwife (3 times), and physician (twice) in rural health center and the results were recorded in her personal Maternal and Child Health Records Booklet. The mother did not go to hospital during first phase of delivery due to fear and long distance form hospital.

Vaginal examinations conducted on arrival by midwife at rural delivery facilities revealed full dilatation of the cervix and a 90% effacement. The second midwife, the physician and medical emergency technicians were immediately called because of the health condition of the patient. Considering the prospect of an immediate delivery, the patient was transferred to the delivery room of the SDF. According to the guidelines of the Ministry of Health, magnesium sulfate was injected and infusion was started because of the patient"s high blood pressure (150/90). The first twin was delivered 15 minutes after the injection and second was delivered 10 minutes after the first one. Soon after the exit of the second twin, 10 units Oxcytocin were intramuscularly injected to prevent postpartum hemorrhage. Ten minutes after delivery the bleeding worsened. Atony of uterus was diagnosed on the grounds of full exit of placenta and lack of tearing.

Considering the availability of ambulance, a second IV line was instantly inserted and ringer IV fluid plus 20 units oxytocin IV infusion started. Bimanual uterine compression massage is was performed and a Foley catheter was inserted as well. Methergene was not injected because of high blood pressure and per national guidelines, 1000 units misoprostol ( 800 units rectal and 200 units sublingual) were administered and the patient accompanied with a midwife was transferred to Saravan Hospital. During the trip, vital signs were regularly checked and serum therapy was in progress. Fortunately, after one hour the uterus started to contract and bleeding decreased. At 12 midnight the patient with a blood pressure of 110/85 pressure and a pulse rate of 95 and 1 + hemorrhage was admitted to the hospital.  After hospitalization, specialized therapeutic measures were taken and after 48 hours, the patient was discharged in a good general condition. In absence of these measures, especially administering misoprostol, the patient could have succumbed to postpartum hemorrhage.

Copyright © 2019 Zahedan University of Medical Sciences. All rights reserved. Date Updated: 16/05/2019.
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References:

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3. Moudi Z, Ghazi Tabatabaie M, Mahdi Tabatabaei S, Vedadhir A. Safe Delivery Posts: an intervention to provide equitable childbirth care services to vulnerable groups in Zahedan, Iran. Midwifery. 2014;30(10):1073-81.

4. Allen R, O"Brien BM. Uses of misoprostol in obstetrics and gynecology. Rev Obstet Gynecol. 2009;2(3):159-68.

5. Vallera C, Choi LO, Cha CM, Hong RW. Uterotonic Medications: Oxytocin, Methylergonovine, Carboprost, Misoprostol. Anesthesiol Clin. 2017;35(2):207-19.

6. Hofmeyr GJ, Gulmezoglu AM, Novikova N, Linder V, Ferreira S, Piaggio G. Misoprostol to prevent and treat postpartum haemorrhage: a systematic review and meta-analysis of maternal deaths and dose-related effects. Bull World Health Organ. 2009;87(9):666-77.