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Parry Smith WR, Papadopoulou A, Thomas E, Tobias A, Price MJ, Meher S, Alfirevic Z, Weeks AD, Hofmeyr GJ, Gülmezoglu AM, Widmer M, Oladapo OT, Vogel JP, Althabe F, Coomarasamy A, Gallos ID.
Cochrane Database of Systemic Reviews, 2020.

Authors conclude that the available evidence suggests that oxytocin used as first-line treatment of PPH is probably more effective than misoprostol with less side effects. Adding misoprostol to the conventional treatment of oxytocin probably makes little or no difference to effectiveness outcomes, and is also associated with more side-effects. The evidence for most uterotonic agents used as first-line treatment of PPH is limited, with no evidence found for commonly used agents, such as injectable prostaglandins, ergometrine, and Syntometrine®. 

Key Takeaways (based on 7 hospital-based trials, involving 3738 women in 10 countries)

  • Misoprostol, as first‐line treatment uterotonic agent:
    • Probably increases the risk of blood transfusion compared with oxytocin.
    • May increase the incidence of additional blood loss of 1000 mL or more.
    • May result in increased risk of vomiting and fever compared with oxytocin.
  • Misoprostol plus oxytocin:
    • Makes little or no difference to the use of additional uterotonics and to blood transfusion compared with oxytocin.
    • Cannot rule out an important benefit of using the combination over oxytocin alone for additional blood loss of 500 mL or more, additional blood loss of 1000 mL or more, maternal mortality, or severe morbidity.
    • Increases the incidence of fever and vomiting compared with oxytocin alone.
    • The combination makes little or no difference to vomiting compared with misoprostol alone.
    • Probably reduces the risk of blood transfusion and may reduce the risk of additional blood loss of 1000 mL or more compared with misoprostol alone.
    • The combination is compatible with a wide range of treatment effects for additional blood loss of 500 mL or more, maternal mortality or severe morbidity, use of additional uterotonics, and fever compared to misoprostol alone.