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Nagai A, Shiko Y, Noguchi S, Ikeda Y, Kawasaki Y, Mazda Y. Protocolized oxytocin infusion for elective cesarean delivery: a retrospective before-and-after study. J Anesth 2024; 38:425-433. [PMID: 38517531 PMCID: PMC11284190 DOI: 10.1007/s00540-024-03329-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 02/15/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE To elucidate the clinical impact of the novel oxytocin protocol using a syringe pump with a stratified dose compared with the conventional practice of putting oxytocin into the bag. METHODS This is a retrospective cohort study. We collected the data of the patients who underwent elective cesarean delivery under neuraxial anesthesia between June 2019 and May 2020. The patients were allocated to two groups according to oxytocin administration methods; the control group (the attending anesthesiologist put oxytocin 5-10 units in the infusion bag and adjusted manually after childbirth) and the protocol group (the oxytocin protocol gave oxytocin bolus 1 or 3 units depending on the PPH risk, followed by 5 or 10 unit h-1 via a syringe pump). We compared the total amount of oxytocin within 24 h postpartum, estimated blood loss, and adverse clinical events within 24 h postpartum between the two groups. RESULTS During the study period, 262 parturients were included. Oxytocin doses of intraoperative and postoperative were significantly lower in the protocol group (9.7 vs. 11.7 units, intraoperative, 15.9 vs. 18 units, postoperative). The subgroup analyses showed that the impact was more remarkable in the low PPH risk than in the high PPH risk. The multivariate linear regression analyses also confirmed the difference. The groups had no significant difference in blood loss, requirement of additional uterotonics, and other adverse events. CONCLUSIONS Our oxytocin infusion protocol significantly reduced oxytocin requirements in elective cesarean delivery under neuraxial anesthesia without increasing blood loss. However, we could not find other clinical benefits of the novel protocol.
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Affiliation(s)
- Azusa Nagai
- Department of Obstetric Anesthesiology, Center for Maternal-Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Yuki Shiko
- Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Shohei Noguchi
- Department of Obstetric Anesthesiology, Center for Maternal-Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Yusuke Ikeda
- Department of Obstetric Anesthesiology, Center for Maternal-Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Yohei Kawasaki
- Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
- Faculty of Nursing, Japanese Red Cross College of Nursing, Tokyo, Japan
| | - Yusuke Mazda
- Department of Obstetric Anesthesiology, Center for Maternal-Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan.
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Torloni MR, Betran AP, Vazquez Corona M, Bohren M, Widmer M. What do healthcare providers think of the quality of uterotonics? A mixed-methods systematic review. BMJ Open 2023; 13:e068442. [PMID: 37899165 PMCID: PMC10618966 DOI: 10.1136/bmjopen-2022-068442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 10/09/2023] [Indexed: 10/31/2023] Open
Abstract
OBJECTIVES To synthesise evidence on the perceptions of healthcare providers (HCPs) about the quality of oxytocin and misoprostol available in their settings, and their actions as a result of these perceptions. DESIGN Mixed-methods systematic review. ELIGIBILITY CRITERIA We included quantitative and qualitative studies reporting HCPs' perceptions about oxytocin or misoprostol quality. DATA SOURCES We searched CINAHL, Cochrane Library, Ebscohost, Embase, PubMed, Global Index Medicus, Portal regional BVS, PsycNET, Scopus and Web of Science from inception to 31 March 2022 and grey literature. RISK OF BIAS We used the Center for Evidence-Based Management critical appraisal tool for surveys. For qualitative studies, we used the Critical Appraisal Skills Programme tool. DATA EXTRACTION AND SYNTHESIS Two independent reviewers performed study selection, data extraction and quality assessment. We conducted separate quantitative and qualitative syntheses and integrated the evidence into a narrative synthesis (convergent segregated review design). RESULTS We included five (three quantitative and two qualitative) studies, of moderate or high quality, conducted in low-income and middle-income countries (LMICs). In the three quantitative studies (N=7065 participants), 8.2-21.3% of HCPs had experienced problems due to known/suspected low-quality oxytocin and 3.3% due to low-quality misoprostol. In the two qualitative studies, perception of oxytocin quality varied. In quantitative studies, when confronted with suspected/known low-quality oxytocin, 29-78% of HCPs would inform a supervisor, 62% would document this in writing, 45-54% would change to another drug and 5-37% would double the dose of oxytocin. Qualitative evidence suggests that many HCPs do not formally report suspected low-quality oxytocin or misoprostol, and use higher doses or additional uterotonics. CONCLUSIONS A proportion of HCPs from LMICs perceive oxytocin to be of low quality. There is very limited evidence on their perceptions about misoprostol. Many HCPs do not report suspected low-quality uterotonics but change to another medicine or double the dose of oxytocin. PROSPERO REGISTRATION NUMBER CRD42022323812.
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Affiliation(s)
- Maria Regina Torloni
- Evidence Based Healthcare Post-Graduate Program, São Paulo Federal University, São Paulo, Brazil
| | - Ana Pilar Betran
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Martha Vazquez Corona
- Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Meghan Bohren
- Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Mariana Widmer
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
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3
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Stämpfli D, Dommrich R, Orbach-Zinger S, Burden AM, Heesen M. An explorative analysis of pharmacovigilance data of oxytocin and its analogue carbetocin, with a focus on haemodynamic adverse effects. Int J Clin Pharm 2023:10.1007/s11096-023-01587-9. [PMID: 37162656 PMCID: PMC10366022 DOI: 10.1007/s11096-023-01587-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/27/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Oxytocin and its analogue carbetocin are uterotonics whose prophylactic use is recommended to prevent postpartum haemorrhage, which is one of the leading causes of maternal deaths worldwide. However, both drugs can cause specific adverse effects and haemodynamic challenges. AIM The aim of this work was to exploratively examine reports of adverse drug events of both drugs and to establish a comparative haemodynamic profile. METHOD Using data extracted from the World Health Organization's pharmacovigilance database VigiBase, a descriptive analysis was performed of all reports for oxytocin and carbetocin as a suspected or interacting drug followed by a disproportionality analysis for haemodynamic events. Reporting odds ratios (ROR) of carbetocin for hypertension, hypotension, tachycardia, and bradycardia were calculated, with oxytocin-related reports serving as comparators. RESULTS Oxytocin and carbetocin were mentioned as suspected or interacting drugs in 11,258 and 374 reports, respectively. Resulting RORs for carbetocin were 3.45 (95%CI: 1.72-6.92) for hypertension, 2.65 (1.64-4.28) for hypotension, 2.84 (1.79-4.49) for tachycardia, and 2.00 (0.87-4.60) for bradycardia, when compared to oxytocin. Of 231 patients for whom oxytocin-related tachycardia was reported, 2.6% died, and of 91 patients for whom bradycardia was reported, 2.2% died. No deaths were reported with carbetocin for any of the haemodynamic adverse events. CONCLUSION Compared to oxytocin, carbetocin showed an elevated reporting for adverse hypertension, hypotension, and tachycardia in pharmacovigilance data. Clinicians should be aware of their patients' individual susceptibility and the possibility of haemodynamic deterioration until causal inferences are possible.
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Affiliation(s)
- Dominik Stämpfli
- Pharmacoepidemiology, Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Vladimir-Prelog-Weg 4, 8093, Zürich, Switzerland.
- Hospital Pharmacy, Kantonsspital Baden, Baden, Switzerland.
| | - Rebecca Dommrich
- Pharmacoepidemiology, Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Vladimir-Prelog-Weg 4, 8093, Zürich, Switzerland
| | - Sharon Orbach-Zinger
- Department of Anesthesia, Beilinson Hospital, Rabin Medical Center Associated With Sakler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Andrea M Burden
- Pharmacoepidemiology, Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Vladimir-Prelog-Weg 4, 8093, Zürich, Switzerland
| | - Michael Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
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4
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Bláha J, Bartošová T. Epidemiology and definition of PPH worldwide. Best Pract Res Clin Anaesthesiol 2022; 36:325-339. [PMID: 36513428 DOI: 10.1016/j.bpa.2022.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 10/17/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022]
Abstract
Postpartum/peripartum hemorrhage (PPH) is an obstetric emergency complicating 1-10% of all deliveries and is a leading cause of maternal mortality and morbidity worldwide. However, the incidence of PPH differs widely according to the definition and criteria used, the way of measuring postpartum blood loss, and the population being studied with the highest numbers in developing countries. Despite all the significant progress in healthcare, the incidence of PPH is rising due to an incomplete implementation of guidelines, resulting in treatment delays and suboptimal care. A consensus clinical definition of PPH is needed to enable awareness, early recognition, and initiation of appropriate intensive treatment. Unfortunately, the most used definition of PPH based on blood loss ≥500 ml after delivery suffers from inaccuracies in blood loss quantification and is not clinically relevant in most cases, as the amount of blood loss does not fully reflect the severity of bleeding.
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Affiliation(s)
- Jan Bláha
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
| | - Tereza Bartošová
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
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5
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Jenkins D, Cancel A, Layloff T. Mean kinetic temperature evaluations through simulated temperature excursions and risk assessment with oral dosage usage for health programs. BMC Public Health 2022; 22:300. [PMID: 35164726 PMCID: PMC8842539 DOI: 10.1186/s12889-022-12660-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/27/2022] [Indexed: 11/25/2022] Open
Abstract
Background Temperature excursions occur during the transport and storage of pharmaceuticals, and often result in considerable losses for public health programs operating in countries with limited resources. After a temperature excursion has been identified, often products are discarded without any additional risk assessments. Consulting the manufacturer is the preferred approach but can be challenging depending on the responsiveness of the manufacturer. However, decisions are often required quickly depending on program needs and available stock in country. Methods To provide further guidance, simulations have been conducted based on mean kinetic temperature evaluations using accepted default kinetic parameters to assess loss of shelf-life for scenarios involving various levels of temperature excursions on a model pharmaceutical at different recommended storage conditions, shelf-life, and long-term storage conditions. Results Although an immediate loss to shelf-life occurred with excursions when the product was stored at the maximum allowed temperature, more extended excursion could be withstood before loss of shelf-life was detected when long-term storage was maintained at temperatures below the maximum storage condition for the product. With the assumption that a shelf-life loss of 2 weeks was negligible when managing program stock, a risk assessment was conducted to outline the various times that excursions at different temperatures could be considered low risk to the program. Conclusions Depending on the level of the temperature excursion and the guidance provided by the manufacturer, public health programs will have further information with this assessment to guide decisions that impact safety to the end user and resource management due to temperature excursions that can occur. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-12660-9.
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Affiliation(s)
- David Jenkins
- Product Quality and Compliance, FHI 360, 2810 Meridian Parkway, Suite 160, Durham, NC, 27713, USA.
| | - Aida Cancel
- Product Quality and Compliance, FHI 360, 2810 Meridian Parkway, Suite 160, Durham, NC, 27713, USA
| | - Thomas Layloff
- Retired, formerly with Product Quality and Compliance, FHI 360, 2810 Meridian Parkway, Suite 160, Durham, NC, 27713, USA
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6
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Ghasemisarabbadieh M, Gizurarson S, Sveinbjörnsson BR. The effect of trehalose, antioxidants, and acetate buffer concentration on oxytocin stability. J Pept Sci 2021; 27:e3324. [PMID: 33768618 DOI: 10.1002/psc.3324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/11/2021] [Accepted: 03/13/2021] [Indexed: 11/06/2022]
Abstract
Oxytocin is a cyclic nonapeptide used to induce labor and prevent bleeding after childbirth. Due to its instability, storage and transport of oxytocin formulations can be problematic in hot/tropical climates. The aim of this study was to investigate the effect of trehalose and select antioxidants (uric acid, butylated hydroxytoluene, and l-ascorbic acid) on oxytocin stability in solution. The effect of buffer composition and acetate buffer concentration was also studied. Acetate buffer was found to work better than citrate/phosphate buffer for the oxytocin stability. Lower acetate buffer concentrations (0.025 M or less) were also found to yield improved oxytocin stability compared to higher concentrations. Although known degradation pathways of oxytocin include oxidation, the antioxidants uric acid and butylated hydroxytoluene had negligible effect on the oxytocin stability while l-ascorbic acid led to significantly faster degradation. Despite trehalose's reputation as a great stabilizer for biomolecules, it also had small to negligible effect on oxytocin stability at concentrations up to 1 M in acetate buffer. These results were surprising given the present literature on trehalose as a stabilizer for various biomolecules, including proteins and lipids.
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Affiliation(s)
- Mostafa Ghasemisarabbadieh
- Faculty of Pharmaceutical Sciences, School of Health Sciences, University of Iceland, Reykjavik, Iceland.,Department of Chemistry, Science Institute, University of Iceland, Reykjavik, Iceland.,Calor ehf, Reykjavik, Iceland
| | - Sveinbjörn Gizurarson
- Faculty of Pharmaceutical Sciences, School of Health Sciences, University of Iceland, Reykjavik, Iceland.,Calor ehf, Reykjavik, Iceland.,Department of Pharmacy, College of Medicine, University of Malawi, Blantyre, Malawi
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7
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Parpex G, Khediri Z, Michel P, Visbecq JN, Duviquet MJ, Poncelet C. Postpartum hemorrhage: Could oxytocin be the cause? Results from a morbidity and mortality review to enhance quality, safety, and relevance of care. Eur J Obstet Gynecol Reprod Biol 2021; 258:299-303. [PMID: 33498003 DOI: 10.1016/j.ejogrb.2021.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/07/2021] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION A sudden postpartum hemorrhage (PPH) increase has been subjectively observed during summer 2018 in our level-3 maternity, despite following all official recommendations for PPH care. This observation led us to conduct a morbi-mortality review to understand morbidity increase reasons. METHODS We conducted a first retrospective comparative cohort study from 2017 to 2018 to compare PPH rates. We conducted a second comparative study to determine the factors that may have led to an increase in PPH. One of the initial hypotheses of increased PPH was related to the weakness of oxytocin, exposed to high outside temperatures. The eight-day delivery records were analyzed, as follow: the high-frequency period of PPH (EXPOSED), the batch replacement of oxytocin (NON EXPOSED), and the same period of the previous year (1 YEAR BEFORE). We studied all known PPH risk factors: preconception, pregnancy, childbirth, and human, climatic, or material organizational factors in this maternity. RESULTS 322 women were included: 111, 92, and 119 in the EXPOSED, NON EXPOSED, and 1 YEAR BEFORE groups, respectively. Sociodemographic data of the 3 groups were not different. The rate of PPH in the EXPOSED was significantly higher than that of NON EXPOSED, and 1 YEAR BEFORE: 20.7 %, 7.6 %, and 5.8 %, respectively (p = 0.0077). In the multivariate analysis, the reduction in PPH (EXPOSED vs NON EXPOSED) after changing the oxytocin batch was significant (OR 0.38 [0.14-0.91], p = 0.039). CONCLUSION Changing oxytocin batches during this hot period reduced significantly the PPH rate and maternal morbidity in our experience.
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Affiliation(s)
- Guillaume Parpex
- Department of Obstetrics and Gynaecology, René Dubos Hospital, Cergy-Pontoise, France.
| | - Zied Khediri
- Department of Obstetrics and Gynaecology, René Dubos Hospital, Cergy-Pontoise, France
| | - Philippe Michel
- Department of Resuscitation and Intensive Care, René Dubos Hospital, Cergy-Pontoise, France
| | | | - Marie-José Duviquet
- Department of Obstetrics and Gynaecology, René Dubos Hospital, Cergy-Pontoise, France
| | - Christophe Poncelet
- Department of Obstetrics and Gynaecology, René Dubos Hospital, Cergy-Pontoise, France; University Sorbonne Paris Cité, University Paris 13, Bobigny, France
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8
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Bizimana T, Hagen N, Gnegel G, Kayumba PC, Heide L. Quality of oxytocin and misoprostol in health facilities of Rwanda. PLoS One 2021; 16:e0245054. [PMID: 33417602 PMCID: PMC7793248 DOI: 10.1371/journal.pone.0245054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/21/2020] [Indexed: 11/18/2022] Open
Abstract
Sustainable Development Goal 3.1 calls for a reduction of the maternal mortality ratio to less than 70 per 100,000 live births by 2030. The most important cause of maternal mortality is post-partum haemorrhage (PPH). Oxytocin injections and misoprostol tablets are medicines of first choice for the management of PPH in low- and middle-income countries (LMICs). Unfortunately, both substances are chemically unstable, and previous studies have revealed serious quality problems of these medicines in LMICs. The present study is the first report on their quality in Rwanda. From 40 randomly selected health facilities (hospitals, health centers, retail pharmacies and private clinics) in different parts of Rwanda, as well as from six wholesalers and government stores, oxytocin injections and misoprostol tablets were collected. Oxytocin storage temperatures in the health facilities were monitored for six months using temperature data loggers, and found to correctly follow the storage requirements stated by the manufacturers (2–8°C, or room temperature) with few minor deviations. Oxytocin injections (57 samples, representing seven batches of four brands) were tested for their oxytocin content and pH value according to the United States Pharmacopeia. Twenty-four samples from three European manufacturers passed all tests. However, all nine samples of one batch of a Chinese manufacturer showed an excessive content of oxytocin (range 117.2–121.5% of the declared amount). Another batch of the same manufacturer showed extreme variations of the concentration of the preservative benzyl alcohol. Misoprostol tablets (25 samples, representing ten batches of six brands) were tested for content and dissolution according to the International Pharmacopoeia. Fifteen samples passed, but all 10 samples of two brands from India failed with extreme deviations, containing only 42.5–48.7% of the stated amount of misoprostol. In conclusion, oxytocin quality in Rwanda was better than reported from other African countries. However, two extremely substandard brands of misoprostol tablets were found. The Rwandan authorities reacted quickly and efficiently, and recalled these substandard medicines from the market. For oxytocin and misoprostol, with their well-known problems of quality and stability, procurement should possibly be restricted to medicines which are WHO-prequalified or which have been manufactured in countries with stringent regulatory authorities.
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Affiliation(s)
- Thomas Bizimana
- Department of Pharmacy, School of Medicine and Pharmacy, College of Medicine and Health Sciences (CMHS), University of Rwanda, Kigali, Rwanda
| | - Nhomsai Hagen
- Pharmaceutical Institute, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Gesa Gnegel
- Pharmaceutical Institute, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Pierre Claver Kayumba
- East African Community Regional Centre of Excellence for Vaccines, Immunizations and Health Supply Chain Management (EAC RCE-VIHSCM), University of Rwanda, Kigali, Rwanda
| | - Lutz Heide
- Pharmaceutical Institute, Eberhard Karls University Tübingen, Tübingen, Germany
- * E-mail:
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9
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de Vries EL, van Tetering AAC, van der Hout MB, Derijks LJJ, Sseguya SP, Namagembe I, Byamugisha J, Oei SG. Storage conditions of oxytocin in a tropical climate in a low-income country. Int J Gynaecol Obstet 2020; 154:44-48. [PMID: 33251616 DOI: 10.1002/ijgo.13505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 10/10/2020] [Accepted: 11/26/2020] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To establish the storage conditions of oxytocin in a health facility in a low-income country with a tropical climate, as suboptimal storage may lead to ineffectiveness of drugs essential to prevent and treat postpartum hemorrhage. METHODS At Mulago National Referral Hospital (28 000-33 000 deliveries/year) in Kampala, Uganda, temperature logging Safe-Rx cards were placed in boxes of oxytocin and in every known storage location. The route of the boxes through the hospital was tracked for 54 days, and storage conditions were observed. RESULTS Oxytocin was stored within the recommended temperature range (2°C-8°C) 24% of the time. The average temperature measured within the oxytocin boxes was 18.2°C, with a minimum of -2.3°C and maximum of 30.4°C. Six out of twelve known storage places had a refrigerator, but not one location stored medication at the recommended temperature constantly. The average temperature in the storage places ranged from 9.5°C to 27.6°C, with a minimum temperature of 2.3°C and maximum of 30.9°C. CONCLUSION Oxytocin is not stored in the recommended temperature range for the majority of time. The presence of refrigerators does not ensure adherence to advised temperature storage conditions.
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Affiliation(s)
- Ella Larissa de Vries
- Department of Gynecology and Obstetrics, Máxima Medical Center, Veldhoven, the Netherlands
| | | | - M Beatrijs van der Hout
- Department of Gynecology and Obstetrics, Máxima Medical Center, Veldhoven, the Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | | | - Simon Peter Sseguya
- Department of Pharmacy, Mulago National Referral and Teaching Hospital, Kampala, Uganda
| | - Imelda Namagembe
- Directorate of Obstetrics and Gynecology, Mulago National Referral and Teaching Hospital, Kampala, Uganda
| | - Josaphat Byamugisha
- Department of Gynecology and Obstetrics, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - S Guid Oei
- Department of Gynecology and Obstetrics, Máxima Medical Center, Veldhoven, the Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
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10
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Lambert P, McIntosh MP, Widmer M, Evans L, Rauscher M, Kuwana R, Theunissen F, Yeager B, Petach H. Oxytocin quality: evidence to support updated global recommendations on oxytocin for postpartum hemorrhage. J Pharm Policy Pract 2020; 13:14. [PMID: 32467764 PMCID: PMC7227300 DOI: 10.1186/s40545-020-00205-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 03/05/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The use of quality injectable oxytocin effectively prevents and treats postpartum hemorrhage, the leading cause of maternal death worldwide. In low- and middle-income countries (LMICs), characteristics of oxytocin-specifically its heat sensitivity-challenge efforts to ensure its quality throughout the health supply chain. In 2019, WHO, UNFPA and UNICEF released a joint-statement to clarify and recommend that oxytocin should be kept in the cold chain (between 2 and 8 °C) during transportation and storage; however, confusion among stakeholders in LMICs persists. OBJECTIVES AND METHODS To further support recommendations in the WHO/UNFPA/UNICEF joint-statement, this paper reviews results of oxytocin quality testing in LMICs, evaluates product stability considerations for its management and considers quality risks for oxytocin injection throughout the health supply chain. This paper concludes with a set of recommended actions to address the challenges in maintaining quality for a heat sensitive pharmaceutical product. RESULTS Due to the heat sensitivity of oxytocin, its quality may be degraded at numerous points along the health supply chain including: At the point of manufacture, due to poor quality active pharmaceutical ingredients; lack of sterile manufacturing environments; or low-quality manufacturing processesDuring storage and distribution, due to lack of temperature control in the supply chain, including cold chain at the end user health facilitySafeguarding the quality of oxytocin falls under the purview of national medicines regulatory authorities; however, regulators in LMICs may not adhere to good regulatory practices. CONCLUSIONS Storing oxytocin from 2 to 8 °C throughout the supply chain is important for maintaining its quality. While short temperature excursions may not harm product quality, the cumulative heat exposure is generally not tracked and leads to degradation. National and sub-national policies must prioritize procurement of quality oxytocin and require its appropriate storage and management.
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Affiliation(s)
- Peter Lambert
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Michelle P McIntosh
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Mariana Widmer
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Lawrence Evans
- Promoting Quality of Medicines Plus Program, U.S. Pharmacopeial Convention, Rockville, MD USA
| | - Megan Rauscher
- Global Health Supply Chain Program-Procurement and Management Project, Chemonics International, 251 18th Street South, Suite 1200, Arlington, VA 22202 USA
| | - Rutendo Kuwana
- Regulatory Systems Support, World Health Organization, Geneva, Switzerland
| | | | - Beth Yeager
- Promoting Quality of Medicines Plus Program, U.S. Pharmacopeial Convention, Rockville, MD USA
| | - Helen Petach
- Office of Maternal and Child Health and Nutrition, Bureau for Global Health, United States Agency for International Development, Washington, DC USA
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11
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Navarro SM, Sibiya A, Nourian MM, Stewart KA, Ottesen TD, Price RR. Addressing Supply Chain Management Issues in Cost-effective Maternal and Pediatric Global Surgery: A Call to Action. Int J MCH AIDS 2020; 9:77-80. [PMID: 32123631 PMCID: PMC7031878 DOI: 10.21106/ijma.295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Persistent global disparities in maternal and neonatal outcomes exist, in part, due to a lack of access to safe surgery. This commentary examines the relative need for increased focus on access to safe maternal and pediatric surgery globally, starting with a focus on cost-effective surgeries. There is a need to understand context-specific surgeries for regions, including understanding regional versus tertiary development. Most important is a need to understand the crucial role of supply chain management (SCM) in developing better access to maternal and pediatric surgery in limited resource settings. We evaluate the role of SCM in global surgery and global health, and the current landscape of inefficiency. We outline specific findings and takeaways from recent solutions developed in pediatric and maternal surgery to address SCM inefficiencies. We then examine the applicability to other settings and look at the future. Our goal is to summarize the challenges that exist today in a global setting to provide better access to maternal and pediatric surgery and outline solutions relying on structural, SCM-related framework.
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Affiliation(s)
- Sergio M Navarro
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Said Business School, University of Oxford, Oxford, UK.,Global Surgery Student Alliance (GSSA), Boston, MA, USA
| | - Andile Sibiya
- Said Business School, University of Oxford, Oxford, UK
| | - Maziar M Nourian
- Global Surgery Student Alliance (GSSA), Boston, MA, USA.,Department of Anesthesia, Vanderbilt School of Medicine, Nashville, TN, USA
| | - Kelsey A Stewart
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, MN, USA
| | - Taylor D Ottesen
- Global Surgery Student Alliance (GSSA), Boston, MA, USA.,Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Raymond R Price
- Center for Global Surgery, University of Utah, Salt Lake City, UT, USA
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Nguyen TH, Lambert P, Minhas RS, McEvoy C, Deadman K, Wright P, Prankerd RJ, Mogatle S, McIntosh MP. Temperature stability of oxytocin ampoules labelled for storage at 2°C-8°C and below 25°C: an observational assessment under controlled accelerated and temperature cycling conditions. BMJ Open 2019; 9:e029083. [PMID: 31350247 PMCID: PMC6661635 DOI: 10.1136/bmjopen-2019-029083] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Oxytocin, administered via injection, is recommended by WHO for the prevention and treatment of postpartum haemorrhage. However, the susceptibility of oxytocin injection to thermal degradation has led WHO and UNICEF to recommend cold-chain storage of all oxytocin products. Nevertheless, some oxytocin products supplied to the global market are labelled for storage at ≤25°C, often with a shorter shelf-life relative to products labelled for refrigeration. Differences in labelled storage requirements can lead to uncertainties among stakeholders around the relative stability of oxytocin products and specifically whether ≤25°C products are more resistant to degradation. Such confusion can potentially influence policies associated with procurement, distribution, storage and the use of oxytocin in resource-poor settings. OBJECTIVES To compare the stability of oxytocin injection ampoules formulated for storage at ≤25°C with those labelled for refrigerated storage. DESIGN Accelerated and temperature cycling stability studies were performed with oxytocin ampoules procured by the United Nations Population Fund (UNFPA) from four manufacturers. METHOD Using oxytocin ampoules procured by UNFPA, accelerated stability (up to 120 days) and temperature cycling (up to 135 days between elevated and refrigerated temperatures) studies were performed at 30°C, 40°C and 50°C. Oxytocin content was quantified using a validated HPLC-UV method. RESULTS All ampoules evaluated exhibited similar stability profiles under accelerated degradation conditions with the exception of one product formulated for ≤25°C storage, where the rate of degradation increased at 50°C relative to other formulations. Similar degradation trends at elevated temperatures were observed during temperature cycling, while no significant degradation was observed during refrigerated periods of the study. CONCLUSION Oxytocin ampoules formulated for non-refrigerated storage demonstrated comparable stability to those labelled for refrigerated storage and should not be interpreted by stakeholders as offering a more stable alternative. Furthermore, these products should not be procured for use in territories with high ambient temperatures, where all oxytocin injection products should be supplied and stored under refrigerated conditions.
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Affiliation(s)
- Tri-Hung Nguyen
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Peter Lambert
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Rajpreet Singh Minhas
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Claire McEvoy
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Kim Deadman
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Philip Wright
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Richard J Prankerd
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Seloi Mogatle
- Procurement Services Branch, United Nations Population Fund, Copenhagen, Denmark
| | - Michelle P McIntosh
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
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Heesen M, Carvalho B, Carvalho JCA, Duvekot JJ, Dyer RA, Lucas DN, McDonnell N, Orbach‐Zinger S, Kinsella SM. International consensus statement on the use of uterotonic agents during caesarean section. Anaesthesia 2019; 74:1305-1319. [DOI: 10.1111/anae.14757] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2019] [Indexed: 01/21/2023]
Affiliation(s)
- M. Heesen
- Department of Anaesthesia Kantonsspital Baden Switzerland
| | - B. Carvalho
- Department of Anesthesiology Stanford University School of Medicine Stanford CAUSA
| | - J. C. A. Carvalho
- Department of Anaesthesia and Department of Obstetrics and Gynaecology University of Toronto ONCanada
| | - J. J. Duvekot
- Department of Obstetrics and Gynecology Erasmus Medical Centre Rotterdam Rotterdamthe Netherlands
| | - R. A. Dyer
- Department of Anaesthesia and Peri‐operative Medicine University of Cape Town Cape TownSouth Africa
| | - D. N. Lucas
- Department of Anaesthesia Northwick Park Hospital Harrow UK
| | - N. McDonnell
- Department of Anaesthesia and Pain Medicine King Edward Memorial Hospital for Women Subiaco WA Australia
| | - S. Orbach‐Zinger
- Department of Anaesthesia Beilinson Hospital, Petach Tikvah, and Sackler Medical School Tel Aviv University Tel Aviv Israel
| | - S. M. Kinsella
- Department of Anaesthesia St Michael's Hospital Bristol UK
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Lambert P, Nguyen TH, McEvoy C, Minhas RS, Wright P, Deadman K, Masururu LM, McIntosh MP. Quality of oxytocin ampoules available in health care facilities in the Democratic Republic of Congo: an exploratory study in five provinces. J Glob Health 2018; 8:020415. [PMID: 30202518 PMCID: PMC6126516 DOI: 10.7189/jogh.08.020415] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Oxytocin injection is the first line therapy for the prevention and treatment of postpartum haemorrhage (PPH), the leading cause of maternal mortality. Currently access to high quality oxytocin in low and middle-income countries (LMICs) is compromised by variable manufacturing quality and the requirement for cold chain supply and storage to prevent product deterioration. Previous studies of oxytocin ampoules sampled from Africa, the region with highest maternal mortality rates, indicate that over half do not contain the specified amount of oxytocin. International efforts continue to further understand the issues relating to oxytocin quality in LMICs and this study is the first to assess oxytocin quality in the Democratic Republic of Congo (DRC), a country that bears one of the highest global rates of maternal mortality (693 maternal deaths per 100 000 live births). Importantly, the study methodology includes the use of investigative analytical techniques to understand the cause of quality deficiencies and inform remedial measures. Methods The study involved sampling of oxytocin injection ampoules from public and private health care facilities (n = 15) in urban and rural areas within five provinces of the DRC. Where available, each sample comprised 20 ampoules of oxytocin injection (10 IU/mL) with smaller numbers collected where supplies were limited. Sample collection used overt sampling and mystery shopper approaches, as appropriate. Analysis of ampoules for oxytocin content and known degradation products utilised validated HPLC and LCMS methods, respectively. Sterility testing was conducted in accordance with the United States Pharmacopeia monograph. Results Eighty percent of ampoules collected contained less than 90% of the specified content. Known degradation products of oxytocin were identified, indicating likely exposure to elevated temperatures post-manufacture. All samples contained an unknown impurity at a level of approximately 12.3% (8.0-20.5%) of the oxytocin main band peak. No samples failed sterility testing. Conclusions There is evidence of a high prevalence of poor quality oxytocin ampoules in health facilities in the DRC likely resulting from both manufacturing quality issues and uncontrolled storage. A more comprehensive post-marketing surveillance study of oxytocin quality is warranted.
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Affiliation(s)
- Peter Lambert
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Tri-Hung Nguyen
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Claire McEvoy
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Rajpreet Singh Minhas
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Philip Wright
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Kim Deadman
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | | | - Michelle P McIntosh
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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