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Profound Hyperthermia After Postpartum Rectal Misoprostol Administration.

We read with interest the case report by Drs. Kaiser and Royer. As the authors note, high fevers after misoprostol use are rare, self-limiting, and follow a predictable pattern that mimics the medicine’s pharmacokinetic profile. Several case series and reports describe similar fever patterns, with a peak temperature accompanied by shivering during the first 2 hours of administration followed by a slow temperature decline. There is now evidence of a possible genetic explanation for the occurrence of misoprostolinduced high fevers among some women. Research has revealed a genetic predisposition to misoprostol’s thermoregulatory effect noted among Latin American carriers of two specific genes. The occurrence of side effects, including shivering and delirium, is not a “toxic effect” from the medicine, but rather is explained by the fever itself. Genetic factors affecting transport of misoprostol through the blood–brain barrier may be implicated. It would be interesting to note the ethnicity of the woman in the case report by Kaiser and Royer. The authors also describe rectal use of misoprostol, which persists in American College of Obstetricians and Gynecologists’ guidelines despite scant data on this route of administration. There is now strong evidence for use of 800 micrograms sublingual misoprostol for postpartum hemorrhage treatment, and this regimen is internationally recognized by the World Health Organization and the International Federation of Gynecology and Obstetrics as an effective alternative to intravenous oxytocin. In light of this growing evidence base, regimens in guidelines should be updated. Additionally, raising awareness of the expected course and resolution of fever is important to minimize health care provider concerns and avoid unnecessary actions, including inappropriate antibiotic use, referral, or both.