Misoprostol Tragedy

Science makes progress all the time. There are places where the progress does not touch. There are other places where it touches with some distortion. And there are still others where dictators shoot it down with a circular. Misoprostol is a wonderful invention. It is great for facilitating ripening of the cervix for abortions and deliveries. It also manages atonic postpartum hemorrhage. After it was established in the developed countries for a long time, and we longed to have it for managing our patients for also a long time, the drug controller finally consented to have it in the market. The part of the world that had remained untouched by this invention finally got a nod to be touched. Science has its discipline, and for optimum results, the rules must be followed. Unfortunately a number of bosses refused to use it or let their juniors use it all over the city. Just like the forbidden fruit, a forbidden drug is also tempting. So without sound knowledge about the rules about the use of the drug, a large number of junior doctors started using it the way the med reps told them to use it. When they could not get the 25 mcg tablets for cervical ripening, they broke a 200 mcg tablet to get 25 mcg (a feat!) and inserted it in the birth passages of women to be delivered. Instead of every 4 hours, they inserted it every 1 or 2 hours when they were in a hurry for whatever reason. Some uteri ruptured, some women became seriously ill, and allegedly some of them died. The drug developed a bad reputation. In the meantime the government got worried about a high maternal mortality rate, which had been high even before misoprostol appeared on the scene. It asked the administrators to reduce it. The administrators asked the health department to find out the causes of maternal mortality and control them. The health department suddenly realized that they had to do this work. So it admonished all public sector hospitals for not sending copies of indoor papers of all mothers who had died in the last one year. How they analyzed the papers in a month is beyond imagination. But they took out a circular for all health posts, asking them to give calcium, iron, tetanus toxoid etc to all pregnant women, to have regular check-ups, and STOP USE OF MISOPROSTOL. They sent a copy of that circular to us too. We were stumped that health department consisting of clerical people and doctors who had minimal contact with treating patients and almost no contact with progress in science told teachers and practitioners in a tertiary lever healthcare institute to stop use of misoprostol. We stopped it, because we get salary to do our job, and the administrators decide how we should do our specialized jobs. When I met the key person who had taken out the circular, I asked the reason for stopping the use of misoprostol. The answer was because it killed women. I asked if the statement was evidence-based. She had not heard of evidence-based medicine. She said the evidence was found in the photocopies of indoor papers of women who had died in childbirth. Many had been treated with misoprostol. So much for evidence-based obstetric practice in the financial capitol of the country! the evidence in support of this statement. I asked meaning of telling the postgraduate teachers what they should not be doing. The answer was that it was not meant for us, but only for junior doctors working in periphery. I asked why they could not be trained on the proper use of the drug instead of stopping the use of the drug. There was no answer. My understanding of the situation is that the government wanted action, so some action was taken and a report to that effect was sent to the government. It was symptomatic treatment of the problem (that too highly inappropriate one) rather than radical cure. Well, we get what we deserve.