Cytotec for PP hemmorhage

[mendomidwife]

Any midwives here have experience using Cytotec rectally for pp hemmorhage? If so - what dosage was used? Was Pitocin given first?

Carla

[maxmama]

On our unit we use 800mcg PR for PPH. Pit usually simultaneous if they have a line, otherwise we usually wait a minute to see if the miso works. It almost always does if the bleeding really is uterine (sulcus tears can be tricksy that way).

[memiles]

I'm curious to see responses to this. My sister had her first yesterday and it was the first time I've seen miso used for PPH. She had pit going from the moment baby was born. When the doc asked for the miso, the nurse got 4 tablets and asked how many she wanted. The doc used all 4, and my sister was miserable afterward.

[maxmama]

Originally Posted by memiles

I'm curious to see responses to this. My sister had her first yesterday and it was the first time I've seen miso used for PPH. She had pit going from the moment baby was born. When the doc asked for the miso, the nurse got 4 tablets and asked how many she wanted. The doc used all 4, and my sister was miserable afterward.

Ah yes, "active management". We don't do that.

You will cramp with miso. And it hurts. But if it's truly a PPH, I'd take cramps over a transfusion any day.

[mendomidwife]

Originally Posted by maxmama

On our unit we use 800mcg PR for PPH. Pit usually simultaneous if they have a line, otherwise we usually wait a minute to see if the miso works. It almost always does if the bleeding really is uterine (sulcus tears can be tricksy that way).

Thanks, that is what I wanted to know.

Carla

[Malga]

I have seen in used on our unit as a last ditch effort (next step is surgerical ablation or hysterectomy) so only used in severe cases of PPH. All other tools used first. 800mcg miso rectal. But, there is not real research or protocols behind this.

[maxmama]

Originally Posted by Malga

I have seen in used on our unit as a last ditch effort (next step is surgerical ablation or hysterectomy) so only used in severe cases of PPH. All other tools used first. 800mcg miso rectal. But, there is not real research or protocols behind this.

Hm. It's our first choice, for the most part, because it works like turning off a faucet in most PPH. Hemabate is awful. We use the shot put a lot too for pressure on the ute.

[BeckiCNM]

Originally Posted by Malga

I have seen in used on our unit as a last ditch effort (next step is surgerical ablation or hysterectomy) so only used in severe cases of PPH. All other tools used first. 800mcg miso rectal. But, there is not real research or protocols behind this.

I use it before methergine - and very rarely use methergine now. Absolutely would I use it before hemabate (nasty stuff). Miso has the advantage too of not being contraindicated in the woman with high blood pressure (like methergine) or in the woman with asthma (like hemabate) and I have many with both of these, it seems.

I find it works very quickly and most women don't complain of too many side effects. The research I've seen is that it seems to be comparable to methergine in outcomes.

Honestly, its best effect for me seems to be the placebo effect. If I ask the nurse to have the pills in the room at the time of birth, I don't ever seem to need them.

FYI, WHO recommends 600mcg for the dose. I've seen anywhere from 400 to 1000mcg used, most common dose is 800, I think.

[Malga]

Could you link the WHO recommendation? From what I've seen the FDA discourages use of miso as it is not approved for any prenatal use (induction or PPH). And also I haven't found any studies proving its efficacy.

[mendomidwife]

I asked because a very good midwife friend of mine moonlights at Kaiser and she mentioned that they use it there. She and I used to attended homebirths together for 13 years and managed a few nasty pp hemmorrhages. She thought it would work better than the old...Pitocin...Methergine...Hemabate routine. I don't keep Hemabate on hand because I believe it has to be refrigerated. I do keep Methergine, but it is contraindicated with elevated BP and as the previous posters stated - Methergine and Hemabate are nasty and make women feel terrible.
I would only consider using Cytotec for a serious hemmorrhage. The dose they use at Kaiser is 800mg also.

Carla

[maxmama]

Originally Posted by Malga

Could you link the WHO recommendation? From what I've seen the FDA discourages use of miso as it is not approved for any prenatal use (induction or PPH). And also I haven't found any studies proving its efficacy.

PPH is not prenatal usage.

Also, that the FDA discourages off-label use to me is not the kiss of death. Domperidone, for example, cannot be compounded legally in this country as a galactagogue, but that doesn't mean that it doesn't work well, nor that it isn't safe. No medication is completely without risk.

The risk with prenatal use of miso is primarily uterine rupture and/or fetal distress. Neither is a concern postpartum, as the uterus has already contracted significantly, is at minimal risk of rupture and there is no fetus to worry about. So where's the issue? That the manufacturer doesn't want the liability of testing for prenatal use for a drug long off-patent does not, to me, mean that it's not a useful drug.

[Malga]

Maxmama~ What I meant to say is "perinatal" are anytime a women is pregnant or postpartum. I have to say that using things off-label does make me nervous because basically we are using medication without it being researched correctly, without knowing side-effects, and long-term effects. Its like basically making mothers research experiements without their consent. Ok, I'll get off my soapbox ....

But, has anyone seen any research backing up miso use for PPH? The research I saw said that it was not significantly effective.

[BeckiCNM]

Originally Posted by Malga

Maxmama~ What I meant to say is "perinatal" are anytime a women is pregnant or postpartum. I have to say that using things off-label does make me nervous because basically we are using medication without it being researched correctly, without knowing side-effects, and long-term effects. Its like basically making mothers research experiements without their consent. Ok, I'll get off my soapbox ....

But, has anyone seen any research backing up miso use for PPH? The research I saw said that it was not significantly effective.

I can't speak for every drug, but in the case of miso, the reason it is not FDA approved is not because it hasn't been studied, or because we don't know the side effects of it, or because we don't have some idea what the long term effects are. It is not FDA approved because there is no manufacturer that wants to go through the long, tedious, and very expensive process to get FDA approval for use in labor for a drug that A) is generic and won't make them any money and B) has documented adverse outcomes. The FDA itself states that off label use of medications (in general, not speaking specificially of cytotec) is appropriate if there is clinical research to back up the use.

Try here - http://www.pphprevention.org/overview.php - for some of the evidence. The research I've seen indicates that pitocin should be the first drug used because it is more effective than cytotec or methergine, and that cytotec and methergine are at least equally effective as second line medications.

[Midwife Kris]

Here's a good misoprostol website: http://misoprostol.org/

[bobandjess99]

My midwife (homebirth CNM) told me when we were discussing it that she now prefers cytotec for PPH, because of what maxmama said - it works right away and wonderfully. She said she doesn't even use pitocin/methergine anymore unless for some reason she would feel a specific circumstance would warrant it. So it is her primary method now. I'm sorry, she did not tell me the dosage she uses.

[courtenay_e]

Originally Posted by maxmama

Ah yes, "active management". We don't do that.

You will cramp with miso. And it hurts. But if it's truly a PPH, I'd take cramps over a transfusion any day.

Please, I'm not trying to be snarky, but maxmama...have you ever personally experienced pph? Have you ever had miso "cramps"? I have had both. I'll take the transfusion, actually. I thought I was going to die when I was given misoprostal, it hurt so bad. And, honestly, I'm not exaggerating or being dramatic. I have had two completely unmedicated labor/births. They were NOTHING like the misoprostal "cramps." Heaven, actually, in comparison. Yes, I would allow it to be used on me if the alternative was death, but, if there are other alternatives available, such as pit and methergine, I'll take those instead.

Pitocin and methergine worked, in copious amounts (methergine was IM as well as IU)...and actually did cause an asthmatic reaction, as well...but as I said, they used HUGE amounts of vasoconstrictors on me (I remember the OB saying something along the lines of "enough to kill an elephant"...).

Just a thought, from a birth worker who has had pph and cytotek used on my person.

[the_lissa]

I had pit, methrgine, an miso used on me before I had a d&c. I lost so much blood they thought I might need a transfusion, but my cbc was really high.

I didn't have any cramps or any sort of pain at all afterwards.

[maxmama]

Originally Posted by courtenay_e

Please, I'm not trying to be snarky, but maxmama...have you ever personally experienced pph? Have you ever had miso "cramps"? I have had both. I'll take the transfusion, actually. I thought I was going to die when I was given misoprostal, it hurt so bad. And, honestly, I'm not exaggerating or being dramatic. I have had two completely unmedicated labor/births. They were NOTHING like the misoprostal "cramps." Heaven, actually, in comparison. Yes, I would allow it to be used on me if the alternative was death, but, if there are other alternatives available, such as pit and methergine, I'll take those instead.

Pitocin and methergine worked, in copious amounts (methergine was IM as well as IU)...and actually did cause an asthmatic reaction, as well...but as I said, they used HUGE amounts of vasoconstrictors on me (I remember the OB saying something along the lines of "enough to kill an elephant"...).

Just a thought, from a birth worker who has had pph and cytotek used on my person.

Yes, and yes.

I bled after my miscarriage enough to need a transfusion. Because of that transfusion, I am Kell-sensitized and had a hideous pregnancy with my daughter.

I had miso after my second c-section and honestly had no cramps beyond the normal afterpains.

Obviously, my experience with PPH and cytotec are individual and YMMV. But given the risks of a transfusion (and I did need one; I dropped my crit from 42 to 18 in a week and was passing out from sitting up), I would take cramping (however painful), which can be managed. There's no managing my Kell antibodies now. I'd rather have had killer cramps and taken enough percocet to need an O2 sat before I'd get another transfusion, if I have the choice.

Oh, and all oxytocics, including pit and methergine as well as miso, will make you cramp. It's how they work, and they do have an additive effect. So it's hard to say which of the oxytocics, or just the cumulative amounts, created your pain.

[mendomidwife]

courtney-e,

I appreciate your input, especially since it is from personal experience.

Could it be that you are particularly sensitive to Prostaglandins? I have seen women who cramp terribly from Pitocin and/or Methergine - and others who barley cramp at all. I have also had to give women 2 doses of Pitocin followed by Methergine to get the bleeding stopped - and afterwards they cramp terribly - but they aren't bleeding out. If you had enough "to kill an elephant" - it could very well have been a cumulative effect.

I have to say though - I would have to recommend pain management over a blood transfusion any day. I have seen far too many problems from blood transfusions.

Carla

[courtenay_e]

You know, that was spoken more out of emotion than clarity in thought. You are right, transfusions are dangerous. And, frankly, because I REFUSED my transfusion, I was able to later undergo a bone marrow harvest to save a random man's life...and had I had the transfusion, I would have been disallowed from doing that. So, probably, no, I wouldn't refuse, after all.

Perhaps, though, as practitioners, we might warn the mothers...something like, "I am in the process of giving you a drug called cytotek. It should stop the bleeding, and has the potential to cause significant cramping." ? I've seen midwives do this with homeopathy, with herbs...it would have been appreciated if the staff dealing with my bleed-out had given me that little bit of preparation, as well...

And I have seen bleed-outs that look like you're running a faucet full blast, so I know that there is NOT ALWAYS the benefit of taking that time...but when there is, if you've never had it used on you, please know that it has the potential for horrifically painful cramps, and warn your clients (before or after administration) accordingly, if you can.

Yes, this is an emotion charged issue for me...I just want practitioners to be aware that it CAN be a terrible experience (on top of the fact that they're hemorraging at all, which is surreal at best, REALLY scary at worst).