Introduction: Postpartum hemorrhage remains a major cause of maternal morbidity and mortality, with caesarean section being associated with increased intraoperative blood loss. Pharmacological agents such as misoprostol and tranexamic acid have been used prophylactically to reduce blood loss during lower segment caesarean section (LSCS); however, evidence directly comparing their efficacy is limited. This study is aimed compared the efficacy and safety of sublingual misoprostol and intravenous tranexamic acid in reducing intraoperative blood loss during primary LSCS.

Materials and Methods: This hospital-based, open-label, randomized controlled trial included 140 women with singleton term pregnancies undergoing primary LSCS. Participants were randomized equally to receive either 600 μg sublingual misoprostol or 1 g intravenous tranexamic acid immediately before skin incision. The primary outcome was intraoperative blood loss measured using a standardized gravimetric method. Secondary outcomes included postoperative fall in haemoglobin, requirement for additional uterotonic agents or blood transfusion, and adverse drug effects.

Results: Baseline demographic and obstetric characteristics were comparable between the two groups. Mean intraoperative blood loss was significantly lower in the misoprostol group than in the tranexamic acid group (316.0 ± 158.0 mL vs. 518.5 ± 233.1 mL; p < 0.001). Women receiving misoprostol also had a significantly smaller postoperative fall in haemoglobin and required fewer additional uterotonic agents (2 (2.9%) vs. 11 (15.7%); p = 0.009) and blood transfusions (1 (1.4%) vs. 9 (12.9%); p = 0.016). Fever and shivering were more common with misoprostol, whereas hypotension occurred more frequently in the tranexamic acid group (all p < 0.05).

Conclusion: Sublingual 600 μg misoprostol was more effective than 1 g intravenous tranexamic acid in reducing intraoperative blood loss during primary LSCS. It was associated with a smaller postoperative decline in haemoglobin and a reduced need for additional uterotonic agents and blood transfusion, while maintaining an acceptable safety profile. These findings support the use of sublingual misoprostol as an effective and economical option for preventing excessive blood loss during primary LSCS.

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