الفهرس 
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Abstract
In fact, cesarean delivery is the commonest major surgical procedure all over the world, with an incidence ranging from 20:30% all over the world. PPH is a major cause of maternal morbidity & mortality, particularly in developing countries with a reported range of from <5:10% or more. Recent studies report an elevated rate of PPH that has been attributed to an increase in the rate of CS. (Sweed et al., 2018). Misoprostol (15-deoxy-16-hydroxy-16-methyl prostaglandin E1 [PGE1]) is one of the synthetic prostaglandin E1 analogues including induction of labour and medical termination of pregnancy
The use of traditional uterotonics is generally accepted in the prevention of PPH after cesarean delivery. Misoprostol is a synthetic PGE1 analogue with strong uterotonic activity and few side effects at therapeutic doses. It has gained wide use for a lot of obstetrics and gynecological indications. Misoprostol is characterized by ITS low cost, safe, stable, easily used (orally, vaginally, buccal or rectally), fast absorption, and its effect on the uterus. While the role of misoprostol in the reduction of PPH is still indisputable, its route of administration has been a subject of intense debate regarding the most effective route of administration and the adverse effects.
This is a prospective study that included a total of 100 pregnant women who were admitted to the department of obstetrics and gynecology, Beni-Suef university hospital and Maghagha general hospital during the period from August 2018 to May 2019. The objective of this study was to compare the effects of sublingual misoprostol versus rectal on the Hb level before and after CS due to intraoperative and postoperative blood loss. All the included women underwent CS elective or emergency under spinal anesthesia. They were classified to two equal groups:
group (I): Sublingual misoprostol: included 50 cases administrated preoperatively with 400 mcg misoprostol sublingually at the time of induction of spinal anesthesia.
group (II): Rectal misoprostol: included 50 cases administrated preoperatively with 400 mcg misoprostol rectally after insertion of a urinary catheter.
The obtained results are summarized as follows:
The results of the present study revealed that there were no significant differences between groups as regard age (p=0.55), parity (p=0.94), gestational age (p=0.60), and the number of previous caesarean deliveries (p=0.64).
The results of our study showed that women of rectal misoprostol group (group II) had a significantly higher amount of intraoperative blood loss compared to cases of sublingual misoprostol group (group I), (581 ± 196 vs. 456 ± 187 ml in group II and I, respectively), (P≤0.01).
No significant differences were found between groups regarding preoperative Hb level (10.86 ± 0.90 g/dl. in group I vs. 10.92 ± 0.92 g/dl in group II, p=0.74) and also postoperative Hb level (10.28 ± 0.88 g/dl. in group I vs. 10.14 ± 0.67 g/dl in group II, p=0.39). However, an obvious, highly significant reduction was noticed in the postoperative Hb level in both groups (P≤0.01). The percentage of Hb decrease in rectal misoprostol group (group II) was higher than the sublingual misoprostol group (group I).
The same trend of Hb results was found in Hct, the results demonstrated that there were no significant differences between groups regarding preoperative Hct (33.4 ± 2.1 % in group I vs. 33.7 ± 1.9 % in group II, p=0.64) and also postoperative Hct (32.1 ± 2.1 % in group I vs. 31.5 ± 2.7 % in group II, p=0.21). However, a highly significant reduction was found in postoperative Hct % in both groups (P≤0.01). Also, the percentage of Hct reduction was higher in the rectal misoprostol group (group II) compared to the sublingual misoprostol group (group I).
Regarding the side effects of misoprostol, shivering, and nausea were almost similar between groups with no significant difference. However, the incidence of vomiting was significantly higher in the group (I) compared to the group (II) (15 cases vs. 6 cases).
As regards the need for additional uterotonics, the results showed that 7 cases (14.0%) in rectal misoprostol group needed uterotonics versus only 3 cases (6.0%) in the sublingual misoprostol group. The difference between the group was not significant (p=0.18).