A systematic review and meta-analysis of randomized trials comparing carbetocin to oxytocin in prevention of postpartum hemorrhage after cesarean delivery in low-risk women

OBJECTIVES

To evaluate the efficacy and safety of Carbetocin compared to oxytocin in prevention of postpartum hemorrhage (PPH) after low-risk cesarean delivery (CD).

SEARCH STRATEGY

Screening of Medline, Web Of Science, Scopus, Google scholar, and clinical trials registry till January 2024 using the key words related to carbetocin, blood loss, PPH, Cesarean section and their MeSH terms was done.

SELECTION CRITERIA

This study included all RCTs conducted on women with low risk for developing PPH after CD and compared the administration of carbetocin to oxytocin without any language limitation. These studies compared carbetocin to oxytocin alone or oxytocin combined with misoprostol. The review included all doses and routes of carbetocin and oxytocin administration.

DATA COLLECTION AND ANALYSIS

The extracted data included study settings, the participants' size and characteristics, intervention details of both the study and control groups especially data about the dose route and timing of drug administration, the outcome parameters and trial registration details The reported outcomes included the requirement of additional uterotonic agents or blood transfusion, the difference between preoperative and postoperative hemoglobin, the occurrence of PPH, blood loss and drug adverse effects.

MAIN RESULTS

Seventeen studies including 3667 participants were included. The need for additional uterotonic agents was evaluated in 14 studies with 3154 participants and revealed an OR of 0.53 with 95% CI of 0.39 and 0.72 (p < 0.001, I2 41%). The incidence of PPH was reported in 11 studies with 2228 participants and revealed an Odd ratio of 1.08 with 95%CI of [0.81, 1.44] (p = 0.61, I2 0%). The hemoglobin drop after the operation was evaluated in 3 studies with 1240 participants and revealed an MD of -0.08 with 95% CI of -0.10 and - 0.06 (p < 0.001, I2 0%). The need for blood transfusion was evaluated in 9 studies with 1936 participants and revealed an OR of 0.57 with 95% CI of 0.34 and 0.97 (p = 0.04, I2 0%).

CONCLUSION

Carbetocin administration during CD in women with low risk for PPH is associated with less need for additional uterotonic agents (moderate evidence), less need for blood transfusion (high evidence) and lower hemoglobin drop (high evidence) when compared to those who underwent oxytocin administration without an increase in adverse effects.

The value of misoprostol administration before intrauterine contraceptive device insertion: a systematic review and meta-analysis

Objectives

To assess the value of misoprostol administration before IUD insertion.

Search strategy

Screening of PubMed, Scopus, Web Of Science, ScienceDirect, and clinical trials registry till April 2024 using the keywords misoprostol, prostaglandin E1 analogue, IUD, IUCD, intrauterine device, IUD insertion, and their MeSH terms.

Selection criteria

All RCTs that included misoprostol administration before IUD insertion. All doses, routes, and times of administration of misoprostol compared to placebo, analgesics, or other prostaglandins were included. This review included 19 RCTs including 2743 women (1333 had misoprostol administration and 1410 comparators (1281 received placebo, 16 received diclofenac, 43 received dinoglandin, and 70 received lignocaine).

Data collection and analysis

The extracted data included location setting, number of participants randomized and analyzed, participants selection criteria, the exact intervention details (including misoprostol dose, route and timing of administration, the comparator group details, and type of IUD inserted), primary and secondary outcomes of the trial ( including pain score, easiness of insertion score, the need for analgesics, the need for additional measures as cervical dilatation, failure of insertion, complications of the insertions process, and drug side effects), risk of bias of the included studies, and trial registration number and site.

Main results

Failure of IUD insertion was evaluated in 9 studies with 1350 participants and revealed an odd ratio (OR) of 0.87 with 0.39–1.98 95% CI, P value = 0.75, and I2 score = 45%.

The easiness score of insertion was evaluated in 7 studies with 780 participants and revealed an OR of − 1.12 with − 1.73 to 0.52 95% CI, P value < 0.001, and I2 score = 87%.

The pain VAS was evaluated in 13 studies with 1776 participants and revealed a mean difference (MD) of − 0.23 with − 0.77 to 0.31 95% CI, P value = 0.41, and I2 score = 90%.

The participants satisfaction score was evaluated in 3 studies with 366 participants and revealed a MD of 1.64 with 0.68–2.60 95% CI, P value < 0.001, and I2 score = 91%.

The need for analgesics and additional measures as cervical dilatation were evaluated in 7 and 4 studies with 813 and 295 participants respectively. The reported OR (95% CI), P values, and I2 scores were 0.58 (0.32–1.03) and 0.79 (0.33–1.92), 0.06 and 0.61, and 48% and 35% respectively.

Conclusion

Misoprostol administration before IUD insertion was associated with higher easiness score, higher women satisfaction score, and higher side effects named nausea, vomiting, cramps, shivering, headache, and fever compared to placebo administration.

Registration number

CRD42022364291.