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Acta Medica Mediterranea, 2013, 29: 301
VAGINAL BLEEDING AFTER USE OF SINGLE DOSE ORAL DICLOFENAC/MISOPROSTOL COMBINATION
OZLEM DIKME1, OZGUR DIKME2, HAKAN TOPACOGLU3
1
MD, Emergency Physician, Department of Emergency Medicine, Istabul Education and Research Hospital, Istanbul, Turkey - 2MD,
Emergency Physician, Department of Emergency Medicine, Istanbul Education and Research Hospital, Istanbul, Turkey - 3MD,
Associate Professor, Department of Emergency Medicine, Istanbul Education and Research Hospital, Istanbul, Turkey
[Sanguinamento vaginale a causa di Misoprostol]
ABSTRACT
Misoprostol is a synthetic prostaglandin E1 analogue. It can be used in both gastroenterological and obstetrical and gynecological conditions. In gastroenterology use, misoprostol therapy is indicated in patients who have duodenal or gastric ulcer due to
use of non-steroidal anti-inflammatory drugs (NSAIDs). In this article, we presented and discussed the case of a non-pregnant
woman suffering from with vaginal bleeding after absuming just a single oral dose of diclofenac/misoprostol combination. There
are no cases reported in the literature of vaginal bleeding that developed after misoprostol intake. The drug phase studies have
been reported to be vaginal bleeding as a result of a minor side effect of misoprostol. However, there is no report about any relationship between vaginal bleeding and the duration of misoprostol use. In our case, minor vaginal bleeding has emerged six hours
after ingestion of a single oral dose use.
Key words: Misoprostol, vaginal bleeding, emergency department.
Received March 05, 2013; Accepted April 25, 2013
Background
Misoprostol is a synthetic prostaglandin-E1
analogue. It can be used in both gastroenterological
and gynecological conditions. In gastroenterologic
use, misoprostol therapy indicated in patients who
have duodenal or gastric ulcer due to use nonsteroidal anti-inflammatory drugs (NSAIDs). It acts
upon gastric parietal cells, inhibiting the secretion of
gastric acid. It is only indicated for use by people
who are both taking NSAIDs and are at high risk for
NSAIDs induced ulcers. It is sometimes prescribed
with NSAIDs to prevent their common adverse
effect of gastric ulceration. Misoprostol also binds to
myometrial cells to cause strong myometrial contractions leading to expulsion of tissue. This agent causes cervical ripening with softening and dilation of the
cervix. In obstetri, misoprostol is commonly used for
labor induction and also used to prevent and treat
post partum hemorrhage, to soften the cervix prior to
the insertion of intrauterine devices(1-4).
Misoprostol tablets were developed to be used
orally. Vaginal, rectal, sublingual and buccal routes
have been used extensively in obstetric and gynecological applications. After oral administration, misoprostol rapidly and almost completely absorbed from
gastrointestinal tract(1). The effect of misoprostol on
uterine contractility was well studied by GemzellDanielsson et al and Aronsson et al(5-6). After a single
dose of oral misoprostol there is an increase in uterin
tonus and then begin uterine contractions. Develop
cervical ripening. However, the effects of misoprostol on the always present studies on pregnant
patients, in patients with non-pregnant uterine
cramping and cervical ripening is developing data
are reported(7-9).
Misoprostol is a safe and well-tolerated drug.
The most commonly reported adverse effects are
diarrhea abdominal pain, nausea, flatulence,
headache, dyspepsia, vomiting and constipation. All
of these side effects are self-limited. The toxic dose
is unknown. However, a case report has identified a
woman who died of multiorgan failure following an
overdose of misoprostol(10). Also, high-dose use,
known to have developed fever and rash. However,
no report in the literature to cause vaginal bleeding
302
was recorded. On the contrary used in the prevention
and treatement of postpartum hemorrhage reported.
In this article, we presented and discussed a
non-pregnant woman with vaginal bleeding after
take a single oral dose diclofenac/misoprostol combination.
Case presentation
A 36 year old female patient was admitted to
the emergency department (ED) with complaints of
non-traumatic right knee pain. Her medical history
and family history were unremarkable. She had no
history of medication. Upon admission her vital
signs were within normal range. Physical examination was normal. There was no swelling and local
temperature increase on the right knee. The knee had
normal range of motion. Also, stress tests and ballotman sign were negative. Oral diclofenac/misoprostol
combination in 50 mg/200 mcg doses was prescribed
and patient was discharged. Six hours later after the
single dose using, she was admitted to ED with
minor vaginal bleeding. Upon re-admission her vital
signs and physical examination were within normal
range (blood pressure 110/70 mmHg, heart rate
82/min, respiratory rate 14/min, temperature
36,6C°). Her gynecological history was unremarkable. She said that six days before the date of the last
menstrual period. Pregnancy test was negative.
Laboratory examination did not demonstrate nor
hepatic neither renal dysfunction. Also, there wasn't
thrombocytopenia and coagulopathy. There were no
pathological signs of gynecological examination and
pelvic ultrasonography. This situation was evaluated
a drug side effect. Bleeding did not continue along
follow up in the ED. Diclofenac/misoprostol combination drug treatment was stopped and she was discharged.
Discussion
There were no cases reported in the literature of
vaginal bleeding that developed after misoprostol
intake. However, the drug phase studies have been
reported to be vaginal bleeding as a result of a side
effect of misoprostol. Vaginal bleeding as a side
effect of medication reported in the literature, no data
about the relationship between the duration of drug
use was found. In our case, minor vaginal bleeding
has emerged six hours after ingestion of a single oral
dose of use. The most common side effects following the ingestion of misoprostol are poor taste in the
Ozlem Dikme, Ozgur Dikme et Al
mouth, self-limiting diarrhea, nausea and vomiting.
Also, the use of high doses of misoprostol may cause
high fever and rash. Vaginal bleeding and uterine
cramping pain are less frequent. In addition, uterine
rupture has been reported following the ingestion of
a single dose of oral misoprostol. Misoprostol may
be used in the treatment of postpartum hemorrhage
and should be known, women of childbearing age in
the use of a single dose may cause to vaginal bleeding. Observed in the literature to be notified and the
case is not considered life-threatening vaginal bleeding due to oral misoprostol.
Conclusion
As a result, the use of a single dose of misoprostol in pre-and post-menopausal women can be
urogenital side effects such as vaginal bleeding, and
this situation should be kept in mind.
References
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Tang OS, Gemzell-Danielsson K, Ho PC. Misoprostol:
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2)
Blanchard K, Clark S, Winikoff B et al. Misoprostol for
Women’s Health: A Review. Obstetrics & Gynecology
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Tang OS, Schweer H, Seyberth HW et al.
Pharmacokinetics of different routes of administration
of misoprostol. Hum Reprod 2002; 17: 332-336.
4)
Bocanegra TS, Weaver AL, Tindall EA et al.
Diclofenac/misoprostol compared with diclofenac in the
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Gemzell-Danielsson K, Marions L, Rodriguez A et al.
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Aronsson A, Bygdeman M, Gemzell-Danielsson K. Effects
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routes of administration. Hum Reprod 2004; 19: 81-4.
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Choksuchat C. Clinical Use of Misoprostol in
Nonpregnant Women: Review Article. J Minim
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Zieman M, Fong SK, Benowitz NL et al. Absorption
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Request reprints from:
OZLEM DIKME, MD.
Istanbul Education and Research Hospital
Org. Abdurrahman Nafiz Gürman cad. Fatih. Istanbul
(Turkey)