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Objective To assess the safety and efficacy of preoperative rectal misoprostol for the prevention of intraoperative and postoperative blood loss in women undergoing elective cesarean delivery. Methods A single‐blind randomized controlled trial of 200 full‐term pregnant women scheduled for elective cesarean delivery. Computer‐generated randomization allocated women to receive 400 μg rectal misoprostol at urinary catheter insertion plus 400 μg rectally after abdominal closure (preoperative group, n=100) or 800 μg of rectal misoprostol after abdominal closure (postoperative group, n=100). Primary outcome was intraoperative blood loss. Results Intraoperative blood loss was significantly lower in the preoperative misoprostol group compared with the postoperative group (528.7 ± 114.8 mL vs 788.6 ± 165.8 mL; P<0.001). Blood loss during the first 24 hours after delivery was also lower in the preoperative group (199.3 ± 84.5 mL vs 302.9 ± 125.6 mL; P<0.001). Fewer women in the preoperative group needed additional uterotonics (7 vs 21; P<0.001). After delivery, the decrease in both hemoglobin and hematocrit levels was significantly less in the preoperative group (−6.8 vs −12.8% and −6.05 vs −17.8%, respectively; P<0.001). Conclusion Preoperative rectal administration of misoprostol significantly reduced intraoperative and postoperative blood loss during and after elective cesarean delivery. ClinicalTrial.gov ID: NCT03680339. Date of registration 9/2018

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