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Patel M. Postpartum Hemorrhage: Enhancing Outcomes for Mothers by Effective Management. J Obstet Gynaecol India 2024; 74:191-195. [PMID: 38974747 PMCID: PMC11224172 DOI: 10.1007/s13224-024-02022-3] [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: 05/31/2024] [Accepted: 06/13/2024] [Indexed: 07/09/2024] Open
Abstract
Postpartum hemorrhage (PPH) remains a significant contributor to maternal morbidity and mortality worldwide. In India, PPH affects approximately 12% of women. The prevention and management of PPH are the significant challenges in obstetrics, with accurate assessment of blood loss and timely intervention being critical. Active Management of the Third Stage of Labor is a gold standard strategy for prevention. Recent advancements in PPH management include the use of recombinant activated factor VIIa, which has shown promise in decreasing the need for invasive procedures and second-line therapies. Additionally, surgical and radiological interventions have been effective in cases of refractory PPH. Overall, ongoing research and advancements in PPH management continue to enhance the quality of care and maternal outcomes experiencing this potentially life-threatening complication of childbirth. This editorial explores prevention and management of Atonic PPH with encompassing medical and surgical strategies, to enhance understanding and optimize clinical care for mothers at risk of this obstetric emergency.
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Affiliation(s)
- Madhuri Patel
- Clinical Associate, Nowrosjee Wadia Maternity Hosp, Mumbai, India
- Mahatma Gandhi Memorial Hospital, Parel, Mumbai, India
- Grant Medical College and Sir J.J. Group of Hospitals, Mumbai, India
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Sharma JC, Kollabathula P, Jindal S, Anupma A, Sarkar A, Jaggarwal S, Chandra R, Parashar L. Application of a Negative Intrauterine Pressure Suction Device for Prophylactic Management of Atonic Postpartum Hemorrhage: A Quality Improvement Study. Cureus 2023; 15:e42631. [PMID: 37644944 PMCID: PMC10460915 DOI: 10.7759/cureus.42631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. PPH-preventing interventions need to be prioritized and can be integrated with conventional methods of PPH prevention. The introduction of negative intrauterine pressure using a suction cannula can be one of the cheapest modalities to decrease PPH secondary to uterine atonicity. This method has brought a renaissance to practical obstetrics in low-middle income countries (LMIC), where the cost and availability of uterotonics are major health issues. METHODS It was a prospective quality improvement (QI) study conducted in the labor and delivery wards of a tertiary care medical institute and teaching center over the duration of one year. We aimed to assess the decrease in the incidence of atonic PPH with a negative intrauterine pressure suction device (NIPSD) integrated with active management of the third stage of labor (AMTSL) in the prevention of atonic PPH following normal vaginal delivery in low-risk antenatal women. In the initial six months, routine AMTSL was instituted for all consenting women (group 1). In the next six months, NIPSD was integrated with AMTSL (group 2). Data pertaining to the amount of blood loss, the incidence of primary PPH, uterine tone, fall in hemoglobin and hematocrit levels post-delivery, need for blood transfusion, and doctor and patient satisfaction were tabulated for all patients. RESULTS A total of 1324 consenting women were eligible for enrollment during the study time frame. In the initial six months (baseline period, group 1), 715 participants were subjected to routine AMTSL in the third stage of labor. During the intervention phase (group 2), 609 parturient women were recruited. There was no significant difference in baseline parameters between the two groups. With the introduction of NIPSD to routine AMTSL, there was a significant decrease in the average volume of blood loss during vaginal delivery (group 1 = 389.45+65.42 ml, group 2 = 216.66+34.27 ml; p-value = 0.012). The incidence of atonic PPH was reduced by more than 75% (group 1 = 13 women, group 2 = 3 women; p-value = 0.001) after the introduction of NIPSD complementing routine AMTSL. The introduction of NIPSD has also been instrumental in reducing the cost burden on patient and hospital expenditures. The net benefit of its introduction resulted in a reduction of the overall cost burden of blood transfusions by around 70%. CONCLUSION PPH is a public health problem, and measures to reduce PPH must be implemented to decrease this health burden. In countries with low resources, complementing routine AMTSL with NIPSD can be instrumental in decreasing the incidence of PPH. Considering its cost-effectiveness and reusability, LMIC can adopt NIPSD as a routine measure in all vaginal deliveries.
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Affiliation(s)
- Jagadish C Sharma
- Obstetrics and Gynecology, Employees' State Insurance Corporation (ESIC) Medical College and Hospital, Faridabad, Faridabad, IND
| | - Pragathi Kollabathula
- Obstetrics and Gynecology, Employees' State Insurance Corporation (ESIC) Medical College and Hospital, Faridabad, Faridabad, IND
| | - Sonam Jindal
- Obstetrics and Gynecology, Employees' State Insurance Corporation (ESIC) Medical college and Hospital, Faridabad, Faridabad, IND
| | - Anupma Anupma
- Obstetrics and Gynecology, Employees' State Insurance Corporation (ESIC) Medical College and Hospital, Faridabad, Faridabad, IND
| | - Avir Sarkar
- Obstetrics and Gynecology, Employees' State Insurance Corporation (ESIC) Medical College and Hospital, Faridabad, Faridabad, IND
| | - Saroj Jaggarwal
- Obstetrics and Gynecology, Employees' State Insurance Corporation (ESIC) Medical College and Hospital, Faridabad, Faridabad, IND
| | - Ramesh Chandra
- Obstetrics and Gynecology, Employees' State Insurance Corporation (ESIC) Medical College and Hospital, Faridabad, Faridabad, IND
| | - Lokesh Parashar
- Community Medicine, Employees' State Insurance Corporation (ESIC) Medical College and Hospital, Faridabad, Faridabad, IND
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Anaposala S, Kalluru PKR, Calderon Martinez E, Bhavanthi S, Gundoji CR. Postpartum Hemorrhage and Tranexamic Acid: A Literature Review. Cureus 2023; 15:e38736. [PMID: 37292548 PMCID: PMC10247241 DOI: 10.7759/cureus.38736] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 06/10/2023] Open
Abstract
This review aims to explore the postpartum hemorrhage (PPH) burden and the efficacy of prophylactic tranexamic acid (TXA) in PPH and recent indications of TXA. A comprehensive review of the literature was conducted using a combination of Medical Subject Headings keywords including "Postpartum haemorrhage," "Tranexamic acid," and "Cesarean section." PPH has been explored for epidemiology, risk factors, and pathophysiology in the first part of the article. Recent indications of TXA, obstetric indications, and the role of TXA as prophylaxis for PPH are discussed in the second part of this article. TXA has many indications apart from obstetric indications and shows a significant effect in controlling bleeding. Furthermore, TXA is more efficient in preventing PPH if administered during the final stage of labor and is a valuable option for managing obstetric bleeding.
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Tesfaye Diro A, Abdissa Fufa D, Geremew H. Prevalence of cultural malpractice during the perinatal period and its determinants among reproductive age women in southwest Ethiopia: A community-based cross-sectional study. Front Public Health 2023; 11:1064583. [PMID: 37006564 PMCID: PMC10064011 DOI: 10.3389/fpubh.2023.1064583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/28/2023] [Indexed: 03/19/2023] Open
Abstract
BackgroundCultural malpractices are accepted cultural norms and socially shared practices that have a negative impact on health. Cultural malpractices vary in type and number in different communities. This study aimed to determine the prevalence of cultural malpractice during the perinatal period and identify its predictors among reproductive-age women in rural communities of southwestern Ethiopia.MethodsA community-based cross-sectional study was conducted from May 5 to 31, 2019 in Semen Bench district, southwestern Ethiopia; among reproductive-age women who had experienced at least one prior delivery. A systematic random sampling technique was employed to select 422 women for the interview. After collection, the data were entered into EpiData and exported to STATA-14 for further analysis. Descriptive analyses were performed and presented in texts and tables. Besides, binary and multivariable logistic regressions were computed to identify determinants of cultural malpractice.ResultA total of 414 women completed the survey, resulting in a response rate of 98%. We found that 26.33% (95% CI: 22.15, 30.85%) had food taboos during pregnancy, 31.88% (95% CI: 27.42, 36.61%) delivered their last child at home, and 33.82% (95% CI: 29.27, 38.6%) practiced pre-lacteal feeding. Lack of formal education (AOR: 11.22, 95% CI: 6.24, 20.15), lack of ANC follow-up (AOR: 10.82, 95% CI: 5.46, 21.42), rural residence (AOR: 6.23, 95% CI: 2.18, 17.78), and avoiding colostrum (AOR: 21.94, 95% CI: 9.73, 49.48) were significantly associated with cultural malpractice during the perinatal period.ConclusionThe prevalence of cultural malpractice is notably high in the study area. Hence, community-based measures including expansion of education and promotion of maternal health services are important to reduce cultural malpractice during the perinatal period.
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Affiliation(s)
| | - Dinaol Abdissa Fufa
- School of Public Health, College of Health and Medical Sciences, Mizan-Tepi University, Mizan-Aman, Ethiopia
| | - Habtamu Geremew
- College of Health Science, Oda Bultum University, Chiro, Ethiopia
- *Correspondence: Habtamu Geremew
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Zenebe GA, Zenebe WA, Ewunie TM, Dires S. Primary postpartum hemorrhage and associated factors among delivering women in Gedeo Zone, Southern Ethiopia. Front Med (Lausanne) 2023; 10:1096501. [PMID: 36865062 PMCID: PMC9971489 DOI: 10.3389/fmed.2023.1096501] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 01/25/2023] [Indexed: 02/16/2023] Open
Abstract
Introduction Primary postpartum hemorrhage is still the main cause of maternal death worldwide, especially in low-resource nations like Ethiopia where there are insufficient healthcare facilities and a shortage of skilled medical personnel. Data on the prevalence of primary postpartum hemorrhage in the study population are scarce or non-existent. Objective The aim of this study was to assess the prevalence of primary postpartum hemorrhage and its associated factors among delivering women in Gedeo Zone, Southern Ethiopia, in 2021. Methods A facility-based cross-sectional study was carried out from January 1 to March 30, 2021, in public health facilities in the Gedeo Zone. A randomly selected 577 participants were involved in the study. Data were gathered using an interview-administered, pre-tested, structured questionnaire. The gathered information was imported into Epi Info 3.5.1 and analyzed with SPSS 23. Descriptive data was presented using tables and graphs. A logistic regression model was fitted. A bivariable and multivariable logistic regression model was computed to identify the presence and strength of association. To run multivariable logistic regression analyses, variables with P-values of <0.2 were used. The odds ratio, a 95% confidence interval (CI), and a P-value of <0.05 were used to identify variables that were associated with primary postpartum hemorrhage. Results The magnitude of primary postpartum hemorrhage was 4.2% (95% CI: 2.4-6.0). Postpartum hemorrhage was significantly associated with current antepartum hemorrhage (AOR = 11.67; 95%CI: 7.17-16.17), twin delivery (AOR = 6.59, 95%CI: 1.48-11.70), uterine atony (AOR = 8.45, 95%CI: 4.35-12.55), and prolonged labor (AOR = 5.6, 95%CI: 2.9-8.50). Conclusions The prevalence of primary postpartum hemorrhages in the Gedeo Zone, Southern Ethiopia was 4.2%. Current ante partum hemorrhage, twin delivery, uterine atony, and prolonged labor were predictors of primary postpartum hemorrhage. The results back up the necessity for care in the early postpartum period so that clinicians may quickly identify any issues, prevent and start treating excessive blood loss early, and, taking into account the aforementioned factors, possibly reduce the frequency of primary postpartum hemorrhage.
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Affiliation(s)
- Getachew Assefa Zenebe
- Department of Public Health, School of Public Health, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia,*Correspondence: Getachew Assefa Zenebe ✉
| | - Wagaye Alemu Zenebe
- Department of Public Health, School of Public Health, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Temesgen Muche Ewunie
- Department of Human Nutrition, School of Public Health, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Selamawit Dires
- Department of Reproductive Health, School of Public Health, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
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Marabele PM, Maputle MS, Ramathuba DU, Netshikweta L. Cultural Factors Contributing to Maternal Mortality Rate in Rural Villages of Limpopo Province, South Africa. Int J Womens Health 2020; 12:691-699. [PMID: 32943943 PMCID: PMC7468369 DOI: 10.2147/ijwh.s231514] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 03/30/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The understanding of the link between cultural affairs and maternal health is critical to save the lives of women. The South African maternal mortality rate (MMR) target for 2015 was 38/100,000 live births. In 2017, South Africa had 1,222 maternal deaths. The purpose was to determine the perceived cultural factors contributing to MMR in rural villages in Mopani District. METHODS This qualitative research and non-probability purposive sampling was used to select participants who met the inclusion criteria. Thirty women, age 40 years and above childbearing age, who had given birth in their lifetime, were sampled. Data were collected through in-depth individual interviews at the women's homes. Probing to elicit more information was conducted focusing on hemorrhage, hypertension and risk of contracting human immunodeficiency virus (HIV). Data were analyzed through open coding methods. Trustworthiness was ensured by Guba and Lincoln's criteria, credibility, dependability, confirmability, and transferability. RESULTS From the study three themes emerged from the data as cultural factors relating to heavy, red post-delivery bleeding perceived as cleaning-out of the womb. With hypertension, gaining weight rapidly before the 20th week of gestation not reported as a pregnancy was still culturally concealed. Contracting HIV, women were exposed to unsafe sex practices due to cultural expectations of having children as a sign of femininity. DISCUSSION The formulation of culture congruent interventions to promote good and acceptable cultural practices that cannot harm the physical and mental status of women was recommended to reduce unplanned deaths among them.
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Affiliation(s)
| | - Maria Sonto Maputle
- Department of Advanced Nursing Science, University of Venda, Thohoyandou, South Africa
| | | | - Lizzy Netshikweta
- Department of Advanced Nursing Science, University of Venda, Thohoyandou, South Africa
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Oladapo OT, Blum J, Abalos E, Okusanya BO. Advance misoprostol distribution to pregnant women for preventing and treating postpartum haemorrhage. Hippokratia 2020. [DOI: 10.1002/14651858.cd009336.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Olufemi T Oladapo
- 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; World Health Organization; Geneva Switzerland
| | | | - Edgardo Abalos
- Centro Rosarino de Estudios Perinatales (CREP); Rosario Argentina
| | - Babasola O Okusanya
- Experimental and Maternal Medicine Unit, Department of Obstetrics and Gynaecology; Faculty of Clinical Sciences, College of Medicine, University of Lagos, Idi-Araba; Lagos Nigeria
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Oladapo OT, Blum J, Abalos E, Okusanya BO. Advance misoprostol distribution to pregnant women for preventing and treating postpartum haemorrhage. Cochrane Database Syst Rev 2020; 6:CD009336. [PMID: 35819305 PMCID: PMC7390441 DOI: 10.1002/14651858.cd009336.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Advance community distribution of misoprostol for preventing or treating postpartum haemorrhage (PPH) has become an attractive strategy to expand uterotonic coverage to places where conventional uterotonic use is not feasible. However, the value and safety of this strategy remain contentious. This is an update of a Cochrane Review first published in 2012. OBJECTIVES To assess the effectiveness and safety of the strategy of advance misoprostol distribution to pregnant women for the prevention or treatment of PPH in non-facility births. SEARCH METHODS For this update, we searched the Cochrane Pregnancy and Childbirth Trial Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (19 December 2019), and reference lists of retrieved studies. SELECTION CRITERIA We included randomised, cluster-randomised or quasi-randomised controlled trials of advance misoprostol distribution to pregnant women compared with usual (or standard) care for the prevention or treatment of PPH in non-facility births. We excluded studies without any form of random design and those that were available in abstract form only. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias in included studies. Two review authors independently assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS Two studies conducted in rural Uganda met the inclusion criteria for this review. One was a stepped-wedge cluster-randomised trial (involving 2466 women) which assessed the effectiveness and safety of misoprostol distribution to pregnant women compared with standard care for PPH prevention during non-facility births. The other study (involving 748 women) was a pilot individually randomised placebo-controlled trial which assessed the logistics and feasibility of community antenatal distribution of misoprostol, as well as the effectiveness and safety of self-administration of misoprostol for PPH prevention. Only 271 (11%) of women in the cluster-randomised trial and 299 (40%) of the women in the individually randomised trial had non-facility births. Data from the two studies could not be meta-analysed as the data available from the stepped-wedge trial were not adjusted for the study design. Therefore, the analysed effects of advance misoprostol distribution on PPH prevention largely reflect the findings of the placebo-controlled trial. Neither of the included studies addressed advance misoprostol distribution for the treatment of PPH. Primary outcomes Severe PPH was not reported in the studies. In both the intervention and standard care arms of the two studies, no cases of severe maternal morbidity or death were recorded among women who had a non-facility birth. Secondary outcomes Compared with standard care, it is uncertain whether advance misoprostol distribution has any effect on blood transfusion (no events, 1 study, 299 women), the number of women not using misoprostol (2% in the advance distribution group versus 4% in the usual care group; risk ratio (RR) 0.50, 95% confidence interval (CI) 0.13 to 1.95, 1 study, 299 women), the number of women not using misoprostol correctly (RR 4.86, 95% CI 0.24 to 100.46, 1 study, 290 women), inappropriate use of misoprostol (RR 4.97, 95% CI 0.24 to 102.59, 1 study, 299 women) or maternal transfer or referral to a health facility (RR 0.66, 95% CI 0.11 to 3.91, 1 study, 299 women). Compared with standard care, it is uncertain whether advance misoprostol provision increases the number of women experiencing minor adverse effects: shivering/chills (RR 1.84, CI 95% 1.35 to 2.50, 1 study, 299 women), fever (RR 1.87, 95% CI 1.16 to 3.00, 1 study, 299 women), or diarrhoea (RR 3.92, 95% CI 0.44 to 34.64, 1 study, 299 women); major adverse effects: placenta retention (RR 1.49, 95% CI 0.25 to 8.79, 1 study, 299 women) or hospital admission for longer than 24 hours (RR 0.99, 95% CI 0.66 to 15.73, 1 study, 299 women) after non-facility birth. For all the outcomes included in the 'Summary of findings' table, we assessed the certainty of the evidence as very low, according to GRADE criteria. AUTHORS' CONCLUSIONS Whilst it might be considered reasonable and feasible to provide advance misoprostol to pregnant women where there are no suitable alternative options for the prevention or treatment of PPH, the evidence on the benefits and harms of this approach remains uncertain. Expansion of uterotonic coverage through this strategy should be cautiously implemented either in the context of rigorous research or with targeted monitoring and evaluation of its impact.
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Affiliation(s)
- Olufemi T Oladapo
- 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, World Health Organization, Geneva, Switzerland
| | | | - Edgardo Abalos
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Babasola O Okusanya
- Experimental and Maternal Medicine Unit, Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
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Sweed M, El-Said M, Abou-Gamrah A, Ali M. Comparison between 200, 400 and 600 microgram rectal misoprostol before cesarian section: A randomized clinical trial. J Obstet Gynaecol Res 2019; 45:585-591. [PMID: 30618101 DOI: 10.1111/jog.13883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 11/18/2018] [Indexed: 11/29/2022]
Abstract
AIM Compare the effectiveness of administration of different doses of rectal misoprostol before cesarean section to reduce intra- and postoperative blood loss. METHODS A double-blind randomized clinical trial including 453 term pregnant woman scheduled for elective cesarean section where participants received either 200-, 400- or 600-μg misoprostol rectally before cesarean section. Study medications were administered after catheter insertion and shortly before skin incision. Primary outcome measures were intraoperative blood loss. RESULTS The intraoperative blood loss was higher in patients who received 200-μg misoprostol (464.6 ± 143.1 mL) than those who received 400 or 600 μg, yet, no statistical difference was found between the 400- (359.3 ± 120.9 mL) and 600-μg groups (330.8 ± 133.8 mL). The incidence of side effects as fever and chills increases with increasing the dose of misoprostol. CONCLUSION Rectal administration of misoprostol for the prevention of post-partum hemorrhage and decreasing intraoperative blood loss during caesarian section is a good alternative to other uterotonics. Yet, the best dose to be used needs further research to be agreed upon.
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Affiliation(s)
- Mohamed Sweed
- Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
| | - Mourad El-Said
- Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
| | - Amgad Abou-Gamrah
- Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
| | - Mohamad Ali
- Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
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Gallos ID, Papadopoulou A, Man R, Athanasopoulos N, Tobias A, Price MJ, Williams MJ, Diaz V, Pasquale J, Chamillard M, Widmer M, Tunçalp Ö, Hofmeyr GJ, Althabe F, Gülmezoglu AM, Vogel JP, Oladapo OT, Coomarasamy A. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev 2018; 12:CD011689. [PMID: 30569545 PMCID: PMC6388086 DOI: 10.1002/14651858.cd011689.pub3] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Prophylactic uterotonic agents can prevent PPH, and are routinely recommended. The current World Health Organization (WHO) recommendation for preventing PPH is 10 IU (international units) of intramuscular or intravenous oxytocin. There are several uterotonic agents for preventing PPH but there is still uncertainty about which agent is most effective with the least side effects. This is an update of a Cochrane Review which was first published in April 2018 and was updated to incorporate results from a recent large WHO trial. OBJECTIVES To identify the most effective uterotonic agent(s) to prevent PPH with the least side effects, and generate a ranking according to their effectiveness and side-effect profile. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (24 May 2018), and reference lists of retrieved studies. SELECTION CRITERIA All randomised controlled trials or cluster-randomised trials comparing the effectiveness and side effects of uterotonic agents with other uterotonic agents, placebo or no treatment for preventing PPH were eligible for inclusion. Quasi-randomised trials were excluded. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. DATA COLLECTION AND ANALYSIS At least three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for preventing PPH ≥ 500 mL and PPH ≥ 1000 mL as primary outcomes. Secondary outcomes included blood loss and related outcomes, morbidity outcomes, maternal well-being and satisfaction and side effects. Primary outcomes were also reported for pre-specified subgroups, stratifying by mode of birth, prior risk of PPH, healthcare setting, dosage, regimen and route of administration. We performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available agents. MAIN RESULTS The network meta-analysis included 196 trials (135,559 women) involving seven uterotonic agents and placebo or no treatment, conducted across 53 countries (including high-, middle- and low-income countries). Most trials were performed in a hospital setting (187/196, 95.4%) with women undergoing a vaginal birth (71.5%, 140/196).Relative effects from the network meta-analysis suggested that all agents were effective for preventing PPH ≥ 500 mL when compared with placebo or no treatment. The three highest ranked uterotonic agents for prevention of PPH ≥ 500 mL were ergometrine plus oxytocin combination, misoprostol plus oxytocin combination and carbetocin. There is evidence that ergometrine plus oxytocin (RR 0.70, 95% CI 0.59 to 0.84, moderate certainty), carbetocin (RR 0.72, 95% CI 0.56 to 0.93, moderate certainty) and misoprostol plus oxytocin (RR 0.70, 95% CI 0.58 to 0.86, low certainty) may reduce PPH ≥ 500 mL compared with oxytocin. Low-certainty evidence suggests that misoprostol, injectable prostaglandins, and ergometrine may make little or no difference to this outcome compared with oxytocin.All agents except ergometrine and injectable prostaglandins were effective for preventing PPH ≥ 1000 mL when compared with placebo or no treatment. High-certainty evidence suggests that ergometrine plus oxytocin (RR 0.83, 95% CI 0.66 to 1.03) and misoprostol plus oxytocin (RR 0.88, 95% CI 0.70 to 1.11) make little or no difference in the outcome of PPH ≥ 1000 mL compared with oxytocin. Low-certainty evidence suggests that ergometrine may make little or no difference to this outcome compared with oxytocin meanwhile the evidence on carbetocin was of very low certainty. High-certainty evidence suggests that misoprostol is less effective in preventing PPH ≥ 1000 mL when compared with oxytocin (RR 1.19, 95% CI 1.01 to 1.42). Despite the comparable relative treatment effects between all uterotonics (except misoprostol) and oxytocin, ergometrine plus oxytocin, misoprostol plus oxytocin combinations and carbetocin were the highest ranked agents for PPH ≥ 1000 mL.Misoprostol plus oxytocin reduces the use of additional uterotonics (RR 0.56, 95% CI 0.42 to 0.73, high certainty) and probably also reduces the risk of blood transfusion (RR 0.51, 95% CI 0.37 to 0.70, moderate certainty) when compared with oxytocin. Carbetocin, injectable prostaglandins and ergometrine plus oxytocin may also reduce the use of additional uterotonics but the certainty of the evidence is low. No meaningful differences could be detected between all agents for maternal deaths or severe morbidity as these outcomes were rare in the included randomised trials where they were reported.The two combination regimens were associated with important side effects. When compared with oxytocin, misoprostol plus oxytocin combination increases the likelihood of vomiting (RR 2.11, 95% CI 1.39 to 3.18, high certainty) and fever (RR 3.14, 95% CI 2.20 to 4.49, moderate certainty). Ergometrine plus oxytocin increases the likelihood of vomiting (RR 2.93, 95% CI 2.08 to 4.13, moderate certainty) and may make little or no difference to the risk of hypertension, however absolute effects varied considerably and the certainty of the evidence was low for this outcome.Subgroup analyses did not reveal important subgroup differences by mode of birth (caesarean versus vaginal birth), setting (hospital versus community), risk of PPH (high versus low risk for PPH), dose of misoprostol (≥ 600 mcg versus < 600 mcg) and regimen of oxytocin (bolus versus bolus plus infusion versus infusion only). AUTHORS' CONCLUSIONS All agents were generally effective for preventing PPH when compared with placebo or no treatment. Ergometrine plus oxytocin combination, carbetocin, and misoprostol plus oxytocin combination may have some additional desirable effects compared with the current standard oxytocin. The two combination regimens, however, are associated with significant side effects. Carbetocin may be more effective than oxytocin for some outcomes without an increase in side effects.
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Affiliation(s)
- Ioannis D Gallos
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Argyro Papadopoulou
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Rebecca Man
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Nikolaos Athanasopoulos
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Aurelio Tobias
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Malcolm J Price
- University of BirminghamSchool of Health and Population SciencesBirminghamUKB15 2TG
| | - Myfanwy J Williams
- University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthLiverpoolUK
| | - Virginia Diaz
- Centro Rosarino de Estudios Perinatales (CREP)Moreno 878, 6to pisoRosarioSanta FeArgentinaS2000DKR
| | - Julia Pasquale
- Centro Rosarino de Estudios Perinatales (CREP)Moreno 878, 6to pisoRosarioSanta FeArgentinaS2000DKR
| | - Monica Chamillard
- Centro Rosarino de Estudios Perinatales (CREP)Moreno 878, 6to pisoRosarioSanta FeArgentinaS2000DKR
| | - Mariana Widmer
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Özge Tunçalp
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - G Justus Hofmeyr
- Walter Sisulu University, University of Fort Hare, University of the Witwatersrand, Eastern Cape Department of HealthEast LondonSouth Africa
| | | | - Ahmet Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Joshua P Vogel
- Burnet InstituteMaternal and Child Health85 Commercial RoadMelbourneAustralia
| | - Olufemi T Oladapo
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Arri Coomarasamy
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
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Gallos ID, Williams HM, Price MJ, Merriel A, Gee H, Lissauer D, Moorthy V, Tobias A, Deeks JJ, Widmer M, Tunçalp Ö, Gülmezoglu AM, Hofmeyr GJ, Coomarasamy A. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev 2018; 4:CD011689. [PMID: 29693726 PMCID: PMC6494487 DOI: 10.1002/14651858.cd011689.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Prophylactic uterotonic drugs can prevent PPH, and are routinely recommended. There are several uterotonic drugs for preventing PPH but it is still debatable which drug is best. OBJECTIVES To identify the most effective uterotonic drug(s) to prevent PPH, and generate a ranking according to their effectiveness and side-effect profile. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (1 June 2015), ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) for unpublished trial reports (30 June 2015) and reference lists of retrieved studies. SELECTION CRITERIA All randomised controlled comparisons or cluster trials of effectiveness or side-effects of uterotonic drugs for preventing PPH.Quasi-randomised trials and cross-over trials are not eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS At least three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for preventing PPH ≥ 500 mL and PPH ≥ 1000 mL as primary outcomes. We performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available drugs. We stratified our primary outcomes according to mode of birth, prior risk of PPH, healthcare setting, dosage, regimen and route of drug administration, to detect subgroup effects.The absolute risks in the oxytocin are based on meta-analyses of proportions from the studies included in this review and the risks in the intervention groups were based on the assumed risk in the oxytocin group and the relative effects of the interventions. MAIN RESULTS This network meta-analysis included 140 randomised trials with data from 88,947 women. There are two large ongoing studies. The trials were mostly carried out in hospital settings and recruited women who were predominantly more than 37 weeks of gestation having a vaginal birth. The majority of trials were assessed to have uncertain risk of bias due to poor reporting of study design. This primarily impacted on our confidence in comparisons involving carbetocin trials more than other uterotonics.The three most effective drugs for prevention of PPH ≥ 500 mL were ergometrine plus oxytocin combination, carbetocin, and misoprostol plus oxytocin combination. These three options were more effective at preventing PPH ≥ 500 mL compared with oxytocin, the drug currently recommended by the WHO (ergometrine plus oxytocin risk ratio (RR) 0.69 (95% confidence interval (CI) 0.57 to 0.83), moderate-quality evidence; carbetocin RR 0.72 (95% CI 0.52 to 1.00), very low-quality evidence; misoprostol plus oxytocin RR 0.73 (95% CI 0.60 to 0.90), moderate-quality evidence). Based on these results, about 10.5% women given oxytocin would experience a PPH of ≥ 500 mL compared with 7.2% given ergometrine plus oxytocin combination, 7.6% given carbetocin, and 7.7% given misoprostol plus oxytocin. Oxytocin was ranked fourth with close to 0% cumulative probability of being ranked in the top three for PPH ≥ 500 mL.The outcomes and rankings for the outcome of PPH ≥ 1000 mL were similar to those of PPH ≥ 500 mL. with the evidence for ergometrine plus oxytocin combination being more effective than oxytocin (RR 0.77 (95% CI 0.61 to 0.95), high-quality evidence) being more certain than that for carbetocin (RR 0.70 (95% CI 0.38 to 1.28), low-quality evidence), or misoprostol plus oxytocin combination (RR 0.90 (95% CI 0.72 to 1.14), moderate-quality evidence)There were no meaningful differences between all drugs for maternal deaths or severe morbidity as these outcomes were so rare in the included randomised trials.Two combination regimens had the poorest rankings for side-effects. Specifically, the ergometrine plus oxytocin combination had the higher risk for vomiting (RR 3.10 (95% CI 2.11 to 4.56), high-quality evidence; 1.9% versus 0.6%) and hypertension [RR 1.77 (95% CI 0.55 to 5.66), low-quality evidence; 1.2% versus 0.7%), while the misoprostol plus oxytocin combination had the higher risk for fever (RR 3.18 (95% CI 2.22 to 4.55), moderate-quality evidence; 11.4% versus 3.6%) when compared with oxytocin. Carbetocin had similar risk for side-effects compared with oxytocin although the quality evidence was very low for vomiting and for fever, and was low for hypertension. AUTHORS' CONCLUSIONS Ergometrine plus oxytocin combination, carbetocin, and misoprostol plus oxytocin combination were more effective for preventing PPH ≥ 500 mL than the current standard oxytocin. Ergometrine plus oxytocin combination was more effective for preventing PPH ≥ 1000 mL than oxytocin. Misoprostol plus oxytocin combination evidence is less consistent and may relate to different routes and doses of misoprostol used in the studies. Carbetocin had the most favourable side-effect profile amongst the top three options; however, most carbetocin trials were small and at high risk of bias.Amongst the 11 ongoing studies listed in this review there are two key studies that will inform a future update of this review. The first is a WHO-led multi-centre study comparing the effectiveness of a room temperature stable carbetocin versus oxytocin (administered intramuscularly) for preventing PPH in women having a vaginal birth. The trial includes around 30,000 women from 10 countries. The other is a UK-based trial recruiting more than 6000 women to a three-arm trial comparing carbetocin, oxytocin and ergometrine plus oxytocin combination. Both trials are expected to report in 2018.Consultation with our consumer group demonstrated the need for more research into PPH outcomes identified as priorities for women and their families, such as women's views regarding the drugs used, clinical signs of excessive blood loss, neonatal unit admissions and breastfeeding at discharge. To date, trials have rarely investigated these outcomes. Consumers also considered the side-effects of uterotonic drugs to be important but these were often not reported. A forthcoming set of core outcomes relating to PPH will identify outcomes to prioritise in trial reporting and will inform futures updates of this review. We urge all trialists to consider measuring these outcomes for each drug in all future randomised trials. Lastly, future evidence synthesis research could compare the effects of different dosages and routes of administration for the most effective drugs.
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Affiliation(s)
- Ioannis D Gallos
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Helen M Williams
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Malcolm J Price
- University of BirminghamSchool of Health and Population SciencesBirminghamUKB15 2TG
| | - Abi Merriel
- University of BristolBristol Medical SchoolDepartment of Women's and Children's HealthThe ChilternsSouthmead HospitalUKBS10 5NB
| | - Harold Gee
- 20 St Agnes RoadMoseleyBirminghamUKB13 9PW
| | - David Lissauer
- University of BirminghamSchool of Clinical and Experimental MedicineC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Vidhya Moorthy
- Sandwell and West Birmingham NHS TrustDepartment of Obstetrics and GynaecologyCity HospitalDudley RoadBirminghamUKB18 7QH
| | - Aurelio Tobias
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchEdgbastonBirminghamUKB15 2TT
| | - Mariana Widmer
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Özge Tunçalp
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Ahmet Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - G Justus Hofmeyr
- Walter Sisulu University, University of the Witwatersrand, Eastern Cape Department of HealthEast LondonSouth Africa
| | - Arri Coomarasamy
- University of BirminghamTommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems ResearchC/o Academic Unit, 3rd Floor, Birmingham Women's Hospital Foundation TrustMindelsohn WayBirminghamUKB15 2TG
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Lakshmi SJD, Abraham R. Role of Prophylactic Tranexamic Acid in Reducing Blood Loss during Elective Caesarean Section: A Randomized Controlled Study. J Clin Diagn Res 2016; 10:QC17-QC21. [PMID: 28208943 PMCID: PMC5296516 DOI: 10.7860/jcdr/2016/21702.9050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 09/30/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Obstetric haemorrhage accounts for 20-25% of maternal mortality and morbidity. Anti-fibrinolytics are being widely used in field of surgery. It is also used to reduce heavy menstrual blood loss. AIM To analyse the effectiveness of Tranexamic Acid (TXA) in reducing blood loss during elective caesarean section. MATERIALS AND METHODS This interventional, randomized, parallel group study was done in the Department of Obstetrics and Gynaecolgy, PSG IMSR, Coimbatore, from June 2014 to May 2015. It was conducted on 120 women undergoing caesarean section. They were allocated to either Study or Control group by computer generated random number tables. TXA was given prior to surgery in study group in addition to the routine care {10 units of oxytocin added to the intravenous drip soon after baby delivery} whereas, the control group had routine care alone. Blood loss was measured in both groups by gravimetric method. Haemoglobin before and after surgery was estimated and the percentage of difference was compared. STATISTICAL ANALYSIS Primary outcome variables were volume of blood loss and percentage fall in haemoglobin before and after surgery. Secondary outcomes were duration of surgery, proportion of subjects with >500ml of blood loss, need for additional uterotonics and side effects. Unpaired t-test and Chi-square test were used to compare the outcome variables. RESULTS There was significant reduction in blood loss calculated from placental delivery till end of surgery: 347.17ml in study group versus 517.72ml in control group (p<0.001). Another parameter studied was the percentage of fall in haemoglobin before and after surgery and the number of subjects who had more than 10% fall in haemoglobin. 9.3% of subjects in study group and 39% of subjects in control group had more than 10% fall in haemoglobin (p<0.01). There were no immediate post-operative complications to the mother and neonate. CONCLUSION TXA significantly reduced the amount of blood loss during Lower Segment Caesarean Section (LSCS). Use of TXA was not associated with adverse effects. Thus, TXA can be used safely and effectively in subjects undergoing LSCS.
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Affiliation(s)
- SJ Dhivya Lakshmi
- Junior Resident, Department of Obstetrics and Gynecology, Peelamedu Samanaidu Govindasaminaidu Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Reena Abraham
- Professor, Department of Obstetrics and Gynecology, Peelamedu Samanaidu Govindasaminaidu Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
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Owiredu WKBA, Osakunor DNM, Turpin CA, Owusu-Afriyie O. Laboratory prediction of primary postpartum haemorrhage: a comparative cohort study. BMC Pregnancy Childbirth 2016; 16:17. [PMID: 26810108 PMCID: PMC4727344 DOI: 10.1186/s12884-016-0805-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 01/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is the leading cause of maternal deaths, the world over. The aim of this study was to determine laboratory parameters that could serve as risk factors for primary PPH. METHODS This comparative cohort study involved 350 pregnant women at term who were recruited consecutively from the Komfo Anokye Teaching Hospital, Kumasi, Ghana. PPH was defined as a measured blood loss ≥ 500 ml or enough to cause haemodynamic shock. Basic demographic data was gathered and blood was collected for laboratory assays before delivery. Univariate and multivariate logistic regression models were used to identify variables that were significantly associated with primary PPH. RESULTS Of the total recruited study participants (350), five declined to participate and 74 went through caesarean section, episiotomy or instrumental deliveries and were excluded. Of the remaining (271) study participants who went through spontaneous vaginal delivery, fifty five (55) were diagnosed with primary PPH (Group 1) and the remaining 216 were those who did not have PPH (Group 2). Demographic characteristics did not differ between the two groups (P > 0.05). Univariate analysis showed that AST (P = 0.043), urea (P < 0.001), creatinine (P = 0.002), urea-to-creatinine ratio (P = 0.014) and the proportion of abnormal peripheral blood smear (P < 0.001) was higher among women in Group 1 compared to those in Group 2. Women in Group 1 had a significantly lower haemoglobin concentration (10.7 g/dL) compared to those in Group 2 (12.1g/dL). Upon multivariate analysis, an abnormal peripheral blood smear (AOR = 2.9672), Hb, (AOR = 0.5791), moderate to severe anaemia (Hb <10 g/dL) (AOR = 3.1385), Urea (AOR = 3.6435) and intra-renal azotaemia (AOR = 0.1893) remained significant. CONCLUSION Many laboratory parameters are associated with primary PPH but only a few are independent risk factors. A total clinical work-up including laboratory evaluation of the independent blood variables identified in this study will help a great deal to identify individuals at high risk for PPH.
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Affiliation(s)
- William K B A Owiredu
- Department of Molecular Medicine, School of Medical Sciences (SMS), Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana.
| | - Derick N M Osakunor
- Department of Molecular Medicine, School of Medical Sciences (SMS), Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
| | - Cornelius A Turpin
- Department of Obstetrics and Gynaecology, Komfo Anokye Teaching Hospital (KATH)/SMS, KNUST, Kumasi, Ghana
| | - Osei Owusu-Afriyie
- Department of Molecular Medicine, School of Medical Sciences (SMS), Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
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Quaiyum A, Gazi R, Hossain S, Wirtz A, Saha NC. Feasibility, acceptability, and programme effectiveness of misoprostol for prevention of postpartum haemorrhage in rural bangladesh: a quasiexperimental study. Int J Reprod Med 2014; 2014:580949. [PMID: 25763402 PMCID: PMC4334073 DOI: 10.1155/2014/580949] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 03/11/2014] [Indexed: 11/25/2022] Open
Abstract
We explored the feasibility of distributing misoprostol tablets using two strategies in prevention of postpartum haemorrhage (PPH) among women residing in the Abhoynagar subdistrict of Bangladesh. We conducted a quasiexperimental study with a posttest design and nonequivalent comparison and intervention groups. Paramedics distributed three misoprostol tablets, one delivery mat (Quaiyum's delivery mat), a packet of five standardized sanitary pads, and one lidded plastic container with detailed counseling on their use. All materials except misoprostol were also provided with counseling sessions to the control group participants. Postpartum blood loss was measured by paramedics using standardized method. This study has demonstrated community acceptability to misoprostol tablets for the prevention of PPH that reduced overall volume of blood loss after childbirth. Likewise, the delivery mat and pad were found to be useful to mothers as tools for assessing the amount of blood loss after delivery and informing care-seeking decisions. Further studies should be undertaken to explore whether government outreach health workers can be trained to effectively distribute misoprostol tablets among rural women of Bangladesh. Such a study should explore and identify the programmatic requirements to integrate this within the existing reproductive health program of the Government of Bangladesh.
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Affiliation(s)
| | - Rukhsana Gazi
- Centre for Equity and Health Systems, icddr,b, Mohakhali C/A, Dhaka 1212, Bangladesh
| | - Shahed Hossain
- Centre for Equity and Health Systems, icddr,b, Mohakhali C/A, Dhaka 1212, Bangladesh
| | - Andrea Wirtz
- Department of Epidemiology, The Centre for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street/E7144, Baltimore, MD 21205, USA
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Robinson N, Kapungu C, Carnahan L, Geller S. Recommendations for scale-up of community-based misoprostol distribution programs. Int J Gynaecol Obstet 2014; 125:285-8. [PMID: 24680582 DOI: 10.1016/j.ijgo.2013.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Revised: 12/18/2013] [Accepted: 02/25/2014] [Indexed: 10/25/2022]
Abstract
Community-based distribution of misoprostol for prevention of postpartum hemorrhage (PPH) in resource-poor settings has been shown to be safe and effective. However, global recommendations for prenatal distribution and monitoring within a community setting are not yet available. In order to successfully translate misoprostol and PPH research into policy and practice, several critical points must be considered. A focus on engaging the community, emphasizing the safe nature of community-based misoprostol distribution, supply chain management, effective distribution, coverage, and monitoring plans are essential elements to community-based misoprostol program introduction, expansion, or scale-up.
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Affiliation(s)
- Nuriya Robinson
- Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, USA.
| | - Chisina Kapungu
- Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, USA; Center for Research on Women and Gender, University of Illinois at Chicago, Chicago, USA
| | - Leslie Carnahan
- Center for Research on Women and Gender, University of Illinois at Chicago, Chicago, USA
| | - Stacie Geller
- Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, USA; Center for Research on Women and Gender, University of Illinois at Chicago, Chicago, USA
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Geller S, Carnahan L, Akosah E, Asare G, Agyemang R, Dickson R, Kapungu C, Owusu-Ansah L, Robinson N, Mensah-Homiah J. Community-based distribution of misoprostol to prevent postpartum haemorrhage at home births: results from operations research in rural Ghana. BJOG 2013; 121:319-25. [DOI: 10.1111/1471-0528.12447] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2013] [Indexed: 11/29/2022]
Affiliation(s)
- S Geller
- Department of Obstetrics and Gynecology; University of Illinois at Chicago; Chicago IL USA
- Center for Research on Women and Gender; University of Illinois at Chicago; Chicago IL USA
| | - L Carnahan
- Center for Research on Women and Gender; University of Illinois at Chicago; Chicago IL USA
| | - E Akosah
- Millennium Villages Project; Bonsaaso Ghana
| | - G Asare
- Ghana Health Service; Accra Ghana
| | - R Agyemang
- Millennium Villages Project; Bonsaaso Ghana
| | | | - C Kapungu
- Department of Obstetrics and Gynecology; University of Illinois at Chicago; Chicago IL USA
- Center for Research on Women and Gender; University of Illinois at Chicago; Chicago IL USA
| | | | - N Robinson
- Department of Obstetrics and Gynecology; University of Illinois at Chicago; Chicago IL USA
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Hofmeyr GJ, Gülmezoglu AM, Novikova N, Lawrie TA. Postpartum misoprostol for preventing maternal mortality and morbidity. Cochrane Database Syst Rev 2013:CD008982. [PMID: 23857523 DOI: 10.1002/14651858.cd008982.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The primary objective of postpartum haemorrhage (PPH) prevention and treatment is to reduce maternal deaths. Misoprostol has the major public health advantage over injectable medication that it can more easily be distributed at community level. Because misoprostol might have adverse effects unrelated to blood loss which might impact on mortality or severe morbidity, it is important to continue surveillance of all relevant evidence from randomised trials. This is particularly important as misoprostol is being introduced on a large scale for PPH prevention in low-income countries, and is commonly used for PPH treatment in well-resourced settings as well. OBJECTIVES To review maternal deaths and severe morbidity in all randomised trials of misoprostol for prevention or treatment of PPH. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 January 2013). SELECTION CRITERIA We included randomised trials including pregnant women who received misoprostol in the postpartum period, versus placebo/no treatment or other uterotonics for prevention or treatment of PPH, and reporting on maternal death, severe morbidity or pyrexia.We planned to include cluster- and quasi-randomised trials in the analysis, as a very large number of women will be needed to obtain robust estimates of maternal mortality but we did not identify any for this version of the review. In future updates of this review we will include trials reported only as abstracts if sufficient information is available from the abstract or from the authors. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and extracted data. MAIN RESULTS We included 78 studies (59,216 women) and excluded 34 studies.There was no statistically significant difference in maternal mortality for misoprostol compared with control groups overall (31 studies; 11/19,715 versus 4/20,076 deaths; risk ratio (RR) 2.08, 95% confidence interval (CI) 0.82 to 5.28); or for the trials of misoprostol versus placebo: 10 studies, 6/4626 versus 1/4707 ; RR 2.70; 95% CI 0.72 to 10.11; or for misoprostol versus other uterotonics: 21 studies, 5/15,089 versus 3/15,369 (19/100,000); RR 1.54; 95% CI 0.40 to 5.92. All 11 deaths in the misoprostol arms occurred in studies of misoprostol ≥ 600 µg.There was a statistically significant difference in the composite outcome 'maternal death or severe morbidity' for the comparison of misoprostol versus placebo (12 studies; average RR 1.70, 95% CI 1.02 to 2.81; Tau² = 0.00, I² = 0%) but not for the comparison of misoprostol versus other uterotonics (17 studies; average RR 1.50, 95% CI 0.50 to 4.52; Tau² = 1.81, I² = 69%). When we excluded hyperpyrexia from the composite outcome in exploratory analyses, there was no significant difference in either of these comparisons.Pyrexia > 38°C was increased with misoprostol compared with controls (56 studies, 2776/25,647 (10.8%) versus 614/26,800 (2.3%); average RR 3.97, 95% CI 3.13 to 5.04; Tau² = 0.47, I² = 80%). The effect was greater for trials using misoprostol 600 µg or more (27 studies; 2197/17,864 (12.3%) versus 422/18,161 (2.3%); average RR 4.64; 95% CI 3.33 to 6.46; Tau² = 0.51, I² = 86%) than for those using misoprostol 400 µg or less (31 studies; 525/6751 (7.8%) versus 185/7668 (2.4%); average RR 3.07; 95% CI 2.25 to 4.18; Tau² = 0.29, I² = 58%). AUTHORS' CONCLUSIONS Misoprostol does not appear to increase or reduce severe morbidity (excluding hyperpyrexia) when used to prevent or treat PPH. Misoprostol did not increase or decrease maternal mortality. However, misoprostol is associated with an increased risk of pyrexia, particularly in dosages of 600 µg or more. Given that misoprostol is used prophylactically in very large numbers of healthy women, the greatest emphasis should be placed on limiting adverse effects. In this context, the findings of this review support the use of the lowest effective dose. As for any new medication being used on a large scale, continued vigilance for adverse effects is essential and there is a need for large randomised trials to further elucidate both the relative effectiveness and the risks of various dosages of misoprostol.
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Affiliation(s)
- G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of FortHare, Eastern Cape Department of Health, East London, South
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Kapungu CT, Mensah-Homiah J, Akosah E, Asare G, Carnahan L, Frimpong MA, Mensah-Bonsu P, Ohemeng-Dapaah S, Owusu-Ansah L, Geller SE. A community-based continuum of care model for the prevention of postpartum hemorrhage in rural Ghana. Int J Gynaecol Obstet 2012. [DOI: 10.1016/j.ijgo.2012.08.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
BACKGROUND Prostaglandins have mainly been used for postpartum haemorrhage (PPH) when other measures fail. Misoprostol, a new and inexpensive prostaglandin E1 analogue, has been suggested as an alternative for routine management of the third stage of labour. OBJECTIVES To assess the effects of prophylactic prostaglandin use in the third stage of labour. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 January 2011). We updated this search on 25 May 2012 and added the results to the awaiting classification section. SELECTION CRITERIA Randomised trials comparing a prostaglandin agent with another uterotonic or no prophylactic uterotonic (nothing or placebo) as part of management of the third stage of labour. The primary outcomes were blood loss 1000 mL or more and the use of additional uterotonics. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility and trial quality and extracted data. MAIN RESULTS We included 72 trials (52,678 women). Oral or sublingual misoprostol compared with placebo is effective in reducing severe PPH (oral: seven trials, 6225 women, not totalled due to significant heterogeneity; sublingual: risk ratio (RR) 0.66; 95% confidence interval (CI) 0.45 to 0.98; one trial, 661 women) and blood transfusion (oral: RR 0.31; 95% CI 0.10 to 0.94; four trials, 3519 women).Compared with conventional injectable uterotonics, oral misoprostol was associated with higher risk of severe PPH (RR 1.33; 95% CI 1.16 to 1.52; 17 trials, 29,797 women) and use of additional uterotonics, but with a trend to fewer blood transfusions (RR 0.84; 95% CI 0.66 to 1.06; 15 trials; 28,213 women). Additional uterotonic data were not totalled due to heterogeneity. Misoprostol use is associated with significant increases in shivering and a temperature of 38º Celsius compared with both placebo and other uterotonics. AUTHORS' CONCLUSIONS Oral or sublingual misoprostol shows promising results when compared with placebo in reducing blood loss after delivery. The margin of benefit may be affected by whether other components of the management of the third stage of labour are used or not. As side-effects are dose-related, research should be directed towards establishing the lowest effective dose for routine use, and the optimal route of administration.Neither intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the management of the third stage of labour especially for low-risk women; however, evidence has been building for the use of oral misoprostol to be effective and safe in areas with low access to facilities and skilled healthcare providers and future research on misoprostol use in the community should focus on implementation issues.
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Affiliation(s)
- Özge Tunçalp
- Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Prata N, Hamza S, Bell S, Karasek D, Vahidnia F, Holston M. Inability to predict postpartum hemorrhage: insights from Egyptian intervention data. BMC Pregnancy Childbirth 2011; 11:97. [PMID: 22123123 PMCID: PMC3276439 DOI: 10.1186/1471-2393-11-97] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 11/28/2011] [Indexed: 11/10/2022] Open
Abstract
Background Knowledge on how well we can predict primary postpartum hemorrhage (PPH) can help policy makers and health providers design current delivery protocols and PPH case management. The purpose of this paper is to identify risk factors and determine predictive probabilities of those risk factors for primary PPH among women expecting singleton vaginal deliveries in Egypt. Methods From a prospective cohort study, 2510 pregnant women were recruited over a six-month period in Egypt in 2004. PPH was defined as blood loss ≥ 500 ml. Measures of blood loss were made every 20 minutes for the first 4 hours after delivery using a calibrated under the buttocks drape. Using all variables available in the patients' charts, we divided them in ante-partum and intra-partum factors. We employed logistic regression to analyze socio-demographic, medical and past obstetric history, and labor and delivery outcomes as potential PPH risk factors. Post-model predicted probabilities were estimated using the identified risk factors. Results We found a total of 93 cases of primary PPH. In multivariate models, ante-partum hemoglobin, history of previous PPH, labor augmentation and prolonged labor were significantly associated with PPH. Post model probability estimates showed that even among women with three or more risk factors, PPH could only be predicted in 10% of the cases. Conclusions The predictive probability of ante-partum and intra-partum risk factors for PPH is very low. Prevention of PPH to all women is highly recommended.
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Affiliation(s)
- Ndola Prata
- Bixby Center for Population, Health and Sustainability, School of Public Health, University of California at Berkeley, 229 Warren Hall, UC-Berkeley, Berkeley, CA 94720-7360, USA.
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Widmer M, Blum J, Hofmeyr GJ, Carroli G, Abdel-Aleem H, Lumbiganon P, Nguyen TNN, Wojdyla D, Thinkhamrop J, Singata M, Mignini LE, Abdel-Aleem MA, Tran ST, Winikoff B. Misoprostol as an adjunct to standard uterotonics for treatment of post-partum haemorrhage: a multicentre, double-blind randomised trial. Lancet 2010; 375:1808-13. [PMID: 20494730 DOI: 10.1016/s0140-6736(10)60348-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Post-partum haemorrhage is a leading cause of global maternal morbidity and mortality. Misoprostol, a prostaglandin analogue with uterotonic activity, is an attractive option for treatment because it is stable, active orally, and inexpensive. We aimed to assess the effectiveness of misoprostol as an adjunct to standard uterotonics compared with standard uterotonics alone for treatment of post-partum haemorrhage. METHODS Women delivering vaginally who had clinically diagnosed post-partum haemorrhage due to uterine atony were enrolled from participating hospitals in Argentina, Egypt, South Africa, Thailand, and Vietnam between July, 2005, and August, 2008. Computer-generated randomisation was used to assign women to receive 600 microg misoprostol or matching placebo sublingually; both groups were also given routine injectable uterotonics. Allocation was concealed by distribution of sealed and sequentially numbered treatment packs in the order that women were enrolled. Providers and women were masked to treatment assignment. The primary outcome was blood loss of 500 mL or more within 60 min after randomisation. Analysis was by intention to treat. This study is registered, number ISRCTN34455240. FINDINGS 1422 women were assigned to receive misoprostol (n=705) or placebo (n=717). The proportion of women with blood loss of 500 mL or more within 60 min was similar between the misoprostol group (100 [14%]) and the placebo group (100 [14%]; relative risk 1.02, 95% CI 0.79-1.32). In the first 60 min, an increased proportion of women on misoprostol versus placebo, had shivering (455/704 [65%] vs 230/717 [32%]; 2.01, 1.79-2.27) and body temperature of 38 degrees C or higher (303/704 [43%] vs 107/717 [15%]; 2.88, 2.37-2.50). INTERPRETATION Findings from this study do not support clinical use of 600 microg sublingual misoprostol in addition to standard injectable uterotonics for treatment of post-partum haemorrhage. FUNDING Bill & Melinda Gates Foundation, and UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.
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Affiliation(s)
- Mariana Widmer
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland.
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Sekhavat L, Firuzabadi RD, Zarchi MK. Effect of postpartum oxygen inhalation on vaginal blood loss. J Matern Fetal Neonatal Med 2010; 22:1072-6. [DOI: 10.3109/14767050902906394] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Fortney JA. Two safe motherhood papers: editor's comment. Int J Gynaecol Obstet 2008; 103:275. [PMID: 18922526 DOI: 10.1016/j.ijgo.2008.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Averting maternal death and disability. Int J Gynaecol Obstet 2008; 101:93. [PMID: 18289542 DOI: 10.1016/j.ijgo.2008.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
BACKGROUND Prostaglandins have mainly been used for postpartum haemorrhage (PPH) when other measures fail. Misoprostol, a new and inexpensive prostaglandin E1 analogue, has been suggested as an alternative for routine management of the third stage of labour. OBJECTIVES To assess the effects of prophylactic prostaglandin use in the third stage of labour. SEARCH STRATEGY The Cochrane Pregnancy and Childbirth Group's Trials Register (February 2007) and PubMed (July 2006). SELECTION CRITERIA Randomized trials comparing a prostaglandin agent with another uterotonic or no prophylactic uterotonic (nothing or placebo) as part of management of the third stage of labour. The primary outcomes were blood loss 1000 ml or more and the use of additional uterotonics. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility and trial quality and extracted data. MAIN RESULTS Thirty-seven misoprostol and nine intramuscular prostaglandin trials (42,621 women) were included. Oral (seven trials, 2849 women) or sublingual misoprostol (relative risk (RR) 0.66; 95% confidence interval (CI) 0.45 to 0.98; one trial, 661 women) compared to placebo may be effective in reducing severe PPH and blood transfusion (RR 0.31; 95% CI 0.10 to 0.94; five oral misoprostol trials, 3519 women). The severe PPH analysis of oral misoprostol trials was not totalled due to significant heterogeneity. Compared to conventional injectable uterotonics, oral misoprostol was associated with higher risk of severe PPH (RR 1.32; 95% CI 1.16 to 1.51; 16 trials, 29,042 women) and use of additional uterotonics but with fewer blood transfusions (RR 0.81; 95% CI 0.64 to 1.02; 15 trials, 27,858 women). Additional uterotonic data were not totalled due to heterogeneity. Misoprostol use is associated with significant increases in shivering and a temperature of 38 degrees Celsius. There are scarce data comparing injectable prostaglandins with the conventional injectable uterotonics on severe PPH and the use of additional uterotonics, the primary outcomes of this review. AUTHORS' CONCLUSIONS Misoprostol orally or sublingually at a dose of 600 mcg shows promising results when compared to placebo in reducing blood loss after delivery. The margin of benefit may be affected by whether other components of management of the third stage of labour are used or not. As side-effects are dose-related, research should be directed towards establishing the lowest effective dose for routine use, and the optimal route of administration. Neither intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the management of the third stage of labour especially for low-risk women.
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Affiliation(s)
- A M Gülmezoglu
- Research Training in Human Reproduction (HRP), UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development andDepartment of Reproductive Health and Research, World Health Organization, Geneva 27, Switzerland, 1211.
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