Joy S D, Sanchez-Ramos L, Kaunitz A M
Department of Obstetrics & Gynecology, University of Florida Health Science Center, Jacksonville, FL, USA.
Int J Gynaecol Obstet. 2003 Aug;82(2):143-52. doi: 10.1016/s0020-7292(03)00146-2.
To systematically review the efficacy of misoprostol compared with placebo or other uterotonics in preventing maternal morbidity associated with the third stage of labor.
We identified, retrieved, evaluated, abstracted data, and assessed the quality of all published studies (from January 1996 to May 2002) which assessed misoprostol's efficacy in minimizing uterine blood loss during the third stage of labor. Seventeen studies included 28170 subjects; of these, approximately one-half received misoprostol with the remainder receiving either a placebo or another uterotonic agent. An estimate of the odds ratio (OR) and risk difference for dichotomous outcomes was calculated using a random- and fixed-effects model. Continuous outcomes were pooled using a variance-weighted average of within-study difference in means.
In assessing studies comparing misoprostol with placebo, those who received oral misoprostol had a decreased risk of needing additional uterotonics (OR 0.64, 95% confidence interval 0.46, 0.90). Compared with placebo, use of misoprostol was associated with an increased risk for shivering and pyrexia. In contrast, in studies comparing misoprostol with oxytocin, oxytocin was associated with significantly lower rates of postpartum hemorrhage, maternal shivering and pyrexia. In studies comparing misoprostol with Syntometrine, misoprostol was associated with higher rates of the need for additional uterotonic agent as well as shivering.
Misoprostol was inferior to oxytocin and other uterotonics with regard to any of the third stage of labor outcomes assessed. However, when compared to placebo, misoprostol had a decreased risk of needing additional uterotonics. Thus, in less-developed countries where administration of parenteral uterotonic drugs may be problematic, misoprostol represents a reasonable agent for the management of the third stage of labor. Additional randomized clinical trials examining objective outcome measures (i.e. need for blood transfusion or 10% hemoglobin change) may further define benefits and risks of misoprostol use during the third stage of labor.
系统评价米索前列醇与安慰剂或其他宫缩剂相比，在预防与第三产程相关的孕产妇发病方面的疗效。
我们识别、检索、评估、提取数据，并评估了所有已发表研究（1996年1月至2002年5月）的质量，这些研究评估了米索前列醇在减少第三产程子宫出血方面的疗效。17项研究纳入了28170名受试者；其中，约一半接受米索前列醇，其余接受安慰剂或其他宫缩剂。使用随机效应模型和固定效应模型计算二分结局的比值比（OR）和风险差估计值。连续结局采用研究内均值差异的方差加权平均值进行汇总。
在评估米索前列醇与安慰剂对比的研究中，口服米索前列醇的患者需要额外使用宫缩剂的风险降低（OR 0.64，95%置信区间0.46，0.90）。与安慰剂相比，使用米索前列醇会增加寒战和发热的风险。相比之下，在米索前列醇与缩宫素对比的研究中，缩宫素与产后出血、产妇寒战和发热的发生率显著较低相关。在米索前列醇与卡贝缩宫素对比的研究中，米索前列醇与需要额外使用宫缩剂以及寒战的发生率较高相关。
在评估的任何第三产程结局方面，米索前列醇均不如缩宫素和其他宫缩剂。然而，与安慰剂相比，米索前列醇需要额外使用宫缩剂的风险降低。因此，在注射用宫缩剂给药可能存在问题的欠发达国家，米索前列醇是管理第三产程的合理药物。进一步的随机临床试验，检查客观结局指标（即输血需求或血红蛋白变化10%），可能会进一步明确米索前列醇在第三产程使用中的益处和风险。
