Efficacy and safety of rectal misoprostol versus intravenous oxytocin on reducing blood loss in cesarean section: A PRISMA-compliant systematic review and meta-analysis of randomized clinical trials

Blood loss is an inevitable complication and a major contributor to maternal morbidity and mortality at cesarean deliveries. We detected a potential preference regarding the efficacy and safety of rectal misoprostol over oxytocin as a uterotonic agent. We searched PubMed, Scopus, Web of Science, Cochrane, and other databases for the relevant trials from inception to September 2022. We included randomized clinical trials (RCTs) that compared rectal misoprostol versus intravenous oxytocin to control bleeding in women undergoing cesarean delivery. Our primary outcomes were the intra- and postoperative blood loss, and hemoglobin drop after delivery. Secondary outcomes included the need for blood transfusion, need for additional uterotonics, difference in operative time, as well as safety outcomes such as the incidence of shivering, pyrexia, nausea, and vomiting. Our search strategy revealed 1007 unique records, of them we retrieved full texts of 19 articles to check their adherence to our eligibility criteria. Seven RCTs with 1,090 participants were included. We found a significant reduction in postoperative blood loss [MD: -27.9; 95% confidence interval (CI): (-53.85, -2.10); p=0.03], and Hb drop after delivery [MD: -11; 95% CI: (-0.19, -0.03); p=0.01]. There is no significant difference regarding intraoperative blood loss, operative time, need for blood transfusion, or need for additional uterotonics. We could not find a significant difference between the two groups regarding safety outcomes, except for a higher shivering incidence in the misoprostol group [RR: 0.33; 95% CI; (0.16, 0.70); p=0.004]. We found a significant reduction in postoperative blood loss with a potentially favorable safety profile in women who administrated rectal misoprostol compared with oxytocin administration. Our findings recommend and prefer rectal misoprostol as a cheaper and effective uterotonic agent over oxytocin, which is expensive and requires an adequate cold chain for transportation and storage.