Postpartum hemorrhage in the developed world: whither misoprostol?

We reviewed the literature to determine the optimal medical treatment of postpartum hemorrhage caused by uterine atony. Of the available uterotonics, only misoprostol and oxytocin have undergone rigorous comparative study. Of the 2, misoprostol is inferior: 2 recent well-done randomized trials with enrollment of more than 2200 patients demonstrated that, in situations in which prophylactic oxytocin has already been utilized, additional oxytocin is as effective as or better than misoprostol in terminating bleeding, while avoiding the high rate of fever (22-58%) associated with misoprostol. The second of these trials demonstrated that misoprostol does not augment the effect of oxytocin. We conclude that in settings in which oxytocin is available, oxytocin should remain the mainstay of both prophylaxis and first-line treatment of postpartum hemorrhage caused by uterine atony. In the developed world, the use of misoprostol for postpartum hemorrhage should be infrequent.