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J. Med. Sci. (Peshawar, Print) October 2013, Vol. 21, No. 4: 171-173 PRE-OPERATIVE USE OF MISOPROSTOL IN MAJOR Jamila Mehnaz Naib, Parveen Naveed, Sitwat Fatima Department of Obstetrics and Gynaecology, Khyber Teaching Hospital, Peshawar - Pakistan Objective: To study the effect of preoperative use of misoprostol on reducing blood loss in Major gynaecological
surgeries.
Material and Methods: This was a hospital based interventional study conducted in the department of Obstetrics
and Gynaecology, Khyber Teaching Hospital, Peshawar, Pakistan from March 2010 to November 2012. A total of 100
cases were studied in this comparative trial. Randomly selected 50 patients had preoperative per rectal insertion of
tablet misoprostol 400 micrograms 20 minutes prior to surgery and were compared to 50 other patients in whom no
misoprostol was used before or during surgery. All of these were elective gynaecological surgeries including
hysterectomies and myomectomies etc. Data was analyzed using SPSS.
Results: A total of 100 cases were studied, in 50 patients, preoperative insertion of misoprostol 400 micrograms was
carried out and 50 cases without its use were studied for comparison. Main outcome measures were approximate
per-operative blood loss, need for transfusion and post op Hb (gm/dl). In the first group without misoprostol mean
blood loss was 370ml + 170.233 SD and mean post-op Hb was 10.34 + 0.4102 SD. In the group with misprostol the
mean blood loss was 310cc + 197.284 SD and mean postoperative Hb was 10.761 + 0.4998 SD. Six percetn of misoprostol group and 28% of no misoprostol needed transfusion.
Conclusion: More studies are needed to establish the benefits of preoperative misoprostol before routine use of this
drug is recommended.
Key Words: Misoprostol, Preoperative, Blood Loss, Transfusion.
apparently reduces to uterine blood flow, increases Misoprostol, a prostaglandin E1 analogue has Myometral contractions in uterine atonic postpartum been widely used in clinical practice of Obstetrics & Gynaecology. It stimulates uterine contractions and this Caesarean section and myomectomy.1,2 Use of increase in myometrial contractions will lead to misoprostol appeared to be beneficial in reducing contraction of the vessels supplying the uterus and blood loss during Laproscopic Assisted Vaginal leiomyoma1. Abdominal hysterectomies are performed Hystrectomy (LAVH) for large uterine Myomas.
for various indications like polymenorrhagia,endometrial Hyperplasia, menorrhagia and fibroid uterus. Uterine leiomyoma is the commonest benign This was a hospital based interventional study.
tumour affecting women in reproductive age around The study was conducted in the department of Obst & 20-50% can cause symptoms that warrant treatment.
Gynae, Khyber Teaching Hospital from March 2010 to Different medical therapies like Gonadotrophin November 2012. A total of 100 cases were studied in Releasing Hormone (GnRH) analogues, mifepristone, this comparative trial. Randomly selected 50 patients progestins and androgens have been tried. Total had preoperative use of tablet misoprostol 400 mcg (2 abdominal hysterectomy is the definitive treatment.
tablets) 20 minutes prior to start of surgery and these Significant operative blood loss that required blood were compared to 50 other patients in whom no transfusion is not uncommonly encountered after Trans misoprostol was used before or during surgery. Out of these 50 cases in each group 25 were abdominalhysterectomies and 25 were myomectomies. Blood loss was measured by reading the level in suction bottle & using a standard 500 c.c kidney tray for blood and clots. The inclusion criteria was Symptomatic woman Khyber Teaching Hospital, Peshawar - PakistanCell: +92-300-5937571 undergoing total abdominal hysterectomy and myomectomy due to various Benign gynaecological J. Med. Sci. (Peshawar, Print) October 2013, Vol. 21, No. 4 study the mean blood loss for cases without contraindication to misoprostol, mitral stenosis, severe misoprostol was 370ml and mean postoperative Hb asthma, severe hypertension,known Allergy to was 10.34 gm/dl. Mean blood loss for group with prostaglandin or a known history of pelvic or ovarian misoprostol was 310cc (with S.D 197.284) and mean endometriosis. Pre-operative investigations including postoperative Hb was 10.76 gm/dl. Study by Celik et Hb gm%, urine R/E, random blood sugar, clotting al has shown that preoperative misoprostol reduces profile, HBS Ag, HCV screen, X-Ray chest, ECG.
intraoperative blood loss and need for blood Post-operative Hb was done on second postoperative transfusion1. This use of misoprostol as an effective day(after 48 hrs –for all patients). Blood transfusion method to decrease blood loss during myomectomy during surgery was recorded on proforma. Data was is also noted in the Cochrane database5. In our study administration of misoprostol was done by rectal route.
This administration by rectal route may allow the drug to be absorbed without and may avoid any adverse A total of 100 cases were studied. In 50 patients, effect of oral route and has a longer half-life than oral preoperative per rectal insertion of misoprostol 400 mcg was carried out and 50 cases without its use were In our study 28% of patients in group without studied for comparison. The main outcome measures misoprostol needed transfusion compared to 6% in were approximate per operative blood loss, need for group where misoprostol was used. Comparable transfusion during surgery and post op Hb (gm/dl). In results are shown by Cheinarong et al8, Chaij et al9 the first group without misoprostol mean blood loss and kalogiamedes10 where there was decreased blood was 370ml + 170.233 SD mean post-op Hb was 10.34 loss and hence lesser transfusions. Other studies of + 0.4102 SD. In the group with misprostol the mean American surveillance of hysterectomies11 and Carter blood loss was 310cc + 197.284 SD and mean JE12 show varying results. Also Ishrat S et al from Dhaka postoperative Hb was 10.761 + 0.4998 SD. Six also state that single preoperative dose of misoprostol percent of misoprostol group and 28% of no is a reliable method for reducing intra operative blood loss and need for transfusion13. Becherd DE14 and Gold berg et al15 have used of misoprostol in gynaecological patients in the group with use of misoprostol did not operations and found it useful like in our results.
need any Transfusion, where as 3 (6%) patients needed transfusion in the other group. In the group where nomisoprostol was used 36 (72%) patients needed no transfusion and 14 (28%) patients needed transfusion.
benefits of misoprostol when used in Myomectomy or hysterectomy procedures before routine use of this myomectomies & 5 were hysterectomies. Out of these 14, 11 needed 1 pint of blood and 3 needed 2 transfusions so in the patients needing transfusion 6%of misoprostol group and 28% of the group with no We found misoprostol to be an easy and cost misoprostol needed transfusion. P value = 0.0893. By effective agent to be used but our results were conventional criteria the difference is considered to be evaluated through SPSS version 10 and P value was not quite significant. Statistically so we believe that 0.0893. By conventional criteria the differences in our larger multi centered studies should be conducted.
study between the two groups was considered to benot quite significant statistically, so we believe that larger multicenter trials should be conducted.
Heavy menstrual flow and anaemia are common symptoms of patients with myomatous uterus or inDysfunctional Uterine Bleeding (DUB). Reducing the Celik H, Sapnaz E, use of a single preoperative dose misoprostol is efficacious for patients who undergo blood loss during surgery decreases the need for blood abdominal myomectomy, Fertile sterile 2003 79 (5): transfusion and decreases postoperative morbidity.
The major effect of misoprostol is on the myometriumand the cervix. Increased uterine contractility directly Acharya G, Al-Samunarai MT, Patel N, Al-Harik A, affects uterine vasculature that stems from both Kiservd T. A randomized controlled trial comparing uterine artery and utero-ovarian anastomosis, effect of oral misoprostol and intravenous syntocinon on intra operative blood loss during decreasing blood supply to the uterus and myomas3.
caesarean section. Actaobstet and gynaecol 1999; constricted uterine vasculature due to uterine contraction and vasoconstricive effect of misoprostol Chi-huangcheu, Gwo-Bug wu, JahYaoliu. Effect of results in reducing intra operative blood loss4. In our utero tonics on intra operative blood loss during J. Med. Sci. (Peshawar, Print) October 2013, Vol. 21, No. 4 lapro-scopy assisted vaginal delivery-randomize J. Obstet Gynaecol Reprod Biol. 2011 158(1): controlled trial. BJOG 2006; 113: 47-52.
Baxter GS, Clayton JK, Coleman RA, Marshalek, Kalogiannidis 1, Xizomeritis P, Prapas N, Prapas Y.
Sangha R, Senior J. Characterization of the Intra vaginal misoprostol reduces intra operative prostanoidreceptors mediating constriction and blood loss in minimally invasive myomectomy: a relaxation of human isolated uterine artery. Br J randomized clinical trial. Clin Exp. Obstet Gynaecol Kongnyuy EJ, Wiysonge CS. Intervention to reduce Lepine LA, Hills SD, March Banks PA, et al.
hemmorrhage during myomectomy for fibroids.
Hysterectomy surveillance United States. CDC Cochrane Data base Sys Rev. 2009. CD005355.
surveillance summaries, 1997. Morb Mortal wkly Khan RU, El Rafacy H. Pharnacokikenitics and adverse effect profile of rectally administered Carter JE, Ryoo J, Katz A. Laproscopic assisted misoprostol in third stage of labour. Obstet and vaginal hysterectomy: a case control comparative study with total abdominal hysterectomy. JAM Associate gynaecology laproscopic 1994; 1; Zieman M, Fong SK, Benowitz NL, Bankster D, Darney PD. Absorption kinetics of misoprostol with oral or vaginal administration. Obstetrics and Ishrat S, Islam F. Misoprostol in obstetrics and gynaecology – a clinical review J Dhaka Med Coll.
Choksuchat C. Clinical use of misoprostol in non-pregnant women: Review Article. Journal of Bechard DE, Spirlet M. Use of misoprostol in minimally invasive gynaecology, July 2010, Vol 17; gynaecology and obstetrics. Gynecol Obstet Fetal Chai J, How E, LI CF, Pun TC, Young SB, HOPC. A Goldberg AB, Carusi DA, Meckstroth KR.
pilot study of pre-operative misoprostol in Misoprostol in gynaecology Currwomens Health reducing operative loss during hysterectomy. Eur It is mandatory to submit the manuscripts at thefollowing website of JMS. It is quick, convenient,cheap, requirement of HEC and paperless.
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J. Med. Sci. (Peshawar, Print) October 2013, Vol. 21, No. 4

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