Misoprostol, although originally introduced as a therapy for gastric ulcers, is now widely used in reproductive health. For some indications it is now the optimal choice, whilst for others it provides an important alternative, especially in low-resource settings. The optimal dose varies widely from 20 to 600 mcg depending on the indication and gestation. Use of the correct dose is important, too low a dose will be ineffective and overdosage can be dangerous for mother and baby. Evidence-based information about the safest regimens for multiple pregnancy indications are therefore provided in this review.

Objective To compare the postpartum uterine activity and side effects of various doses of sublingual misoprostol and intramuscular oxytocin.Design Single centre, randomised trial.Setting Zliten Teaching Hospital in Libya.Population Forty-nine women who did not receive oxytocics in labour and who delivered vaginally.Methods Thirty-five women were randomised to receive 200, 400 or 600 mcg of sublingual misoprostol PPH prophylaxis immediately following delivery. These were compared with 14 consecutive women given 10 IU of intramuscular oxytocin. Immediately after placental delivery, a Koala intra uterine pressure catheter was inserted transcervically into the uterine cavity.Main outcomes measures The uterine pressure (in Montevideo units) measured over 120 minutes. Other outcomes included temperature and measured blood loss.Results Women's age, parity, gestational age and neonatal birth weight were not significantly different between the four groups. There was no difference in intrauterine pressure between the three misoprostol doses. However, the uterine pressure was significantly lower than oxytocin with all three doses for the first 10 minutes (P < 0.008) and significantly higher than oxytocin from 50 to 120 minutes (P < 0.008). A dose-related rise in the body temperature and chills was observed in the misoprostol groups, with 8.3%, 8.3% and 45% of women experiencing a fever >39°C with the 200, 400, and 600 mcg doses respectively.Conclusion Intramuscular oxytocin has the highest immediate post partum uterine activity. Lower doses of misoprostol may be as effective as high doses and with fewer side effects. Clinical outcomes with low-dose misoprostol should be further explored (ISRCTN97277056). The study number is for the RCT reported in this paper.

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Genetic variability in ABCC4 may contribute to misoprostol-induced fever in pregnant women. Original submitted 21 January 2015; Revision submitted 24 April 2015.