Discussion
blood loss, pyrexia, shivering, PPH
BLOOD LOSS, ADVERSE EFFECTS
In this study, the combined use of sublingual misoprostol and IV oxytocin was equally effective as the combined use of IV tranexamic acid and oxytocin in decreasing blood loss in high-risk women undergoing CS. Meanwhile, compared to using oxytocin alone, both protocols were superior in reducing the amount of blood loss.Hemapirya L et al. (2020) reached similar results, although they included 200 low-risk women candidates for LSCS, who were randomised equally randomised into two groups; the study group in which tranexamic acid was given before skin incision at a dose of 10 ml/kg in 100 ml saline, and a control group which was given the standard 10 IU oxytocin intravenously following the delivery of the baby. The study group had less blood loss and higher post-operative haemoglobin when compared to the control group [In a meta-analysis by Simonazzi et al. (2016) that included 2365 women from nine trials, the pre-operative use of tranexamic acid was associated with lower blood loss, less haemoglobin drop and lower incidence of PPH; when compared to the control who had oxytocin alone [Regarding the role of adding sublingual misoprostol to oxytocin in preventing PPH, previous studies revealed similar results to our findings [In a former study, Fekih et al. (2009) compared the role of sublingual misoprostol administration (in a dose of 200 mcg) at cord clamping together with oxytocin at a dose of 20 U (10 U bolus dose and 10 U infusion in 500 ml lactated Ringer), with that of giving oxytocin alone at the same dose in 250 low-risk women undergoing elective CS. The combined misoprostol and oxytocin group showed less blood loss and less haemoglobin drop than the oxytocin-only group. Again, the combined misoprostol and oxytocin group showed more adverse effects, such as shivering and pyrexia [Although we found that pre-operative use of sublingual misoprostol was equally effective as that of intravenous tranexamic acid to prevent PPH in high-risk women undergoing CS, a previous study by Tabatabaie et al. (2021) revealed that misoprostol is more effective than tranexamic acid in reducing the blood loss intra- and post-operatively [The strength of our study is comparing the effectiveness and safety of sublingual misoprostol to that of IV tranexamic acid, as well as to that of oxytocin alone in preventing PPH IN high-risk pregnant women undergoing CS. Our randomised study had a large sample size, and we used different methods to evaluate the effectiveness of each management protocol. However, the main limitation is that our study was open-label, and our population had various risk factors. Also, we did not study the effect of different doses of misoprostol.