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Maged AM, Wali AA, Metwally AA, Salah N. The efficacy of misoprostol in reducing intraoperative blood loss in women undergoing elective cesarean section. A systematic review and meta-analysis. J Obstet Gynaecol Res 2022; 48:2038-2070. [PMID: 35661336 DOI: 10.1111/jog.15318] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/07/2022] [Accepted: 05/18/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the efficacy of misoprostol to minimized blood loss during and after cesarean delivery (CD). SEARCH STRATEGY Screening of MEDLINE, EMBASE, Web of Science, the Cochrane Central Register of Controlled Trials from inception to February 2021 using the keywords related to misoprostol, CD, postpartum hemorrhage, and intraoperative blood loss and their MeSH terms. SELECTION CRITERIA Only RCTs were included. Participants included women undergoing CD whether elective or selective. Thirty studies including 6593 women, 26 in English, 2 in Thai, 1 in French, and 1 in Chinese. DATA COLLECTION AND ANALYSIS Data from all selected studies were extracted independently by two authors. Data extracted included location of the trial, sample size, inclusion and exclusion criteria, participants characteristics, intervention details including timing, dose, and route of drug administration. Outcomes assessed included estimated intraoperative and postoperative blood loss, occurrence of postpartum hemorrhage, the need for additional uterotonics, and hemoglobin difference. MAIN RESULTS Four studies (968 women) compared preoperative to postoperative misoprostol and found a mean difference in intraoperative blood loss of -205.00 (-339.22, -70.77), p = 0.003 and in postoperative blood loss -216.27 (-347.08, -85.46), p < 0.001 and a significantly lower need for additional uterotonics with a risk ratio of 0.54 (0.46, 0.64), p < 0.00001. Twenty-two studies (4701 participants) compared misoprostol to oxytocin. There was a mean difference in intraoperative blood loss of -108.43 (-156.04, -60.82), p < 0.0001. Nine of these trials with 1978 participants evaluated postoperative blood loss. These found a mean difference of -64.12 (-116.19, -12.04) with a p = 0.02. Fourteen trials with 3166 participants measured the difference between preoperative and postoperative hemoglobin. These found a mean difference of -0.25 (-0.35, -0.15) with a p < 0.001. Twenty trials with 4416 participants measured the need for administration of additional uterotonics. These found a risk ratio of 0.62 (0.49, 0.78) with a p value of <0.001. CONCLUSION The combined use of misoprostol and oxytocin during CD is effective in reducing blood loss during and after CD.
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Affiliation(s)
- Ahmed M Maged
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Giza, Egypt
| | - Ahmed A Wali
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Giza, Egypt
| | - Ahmed A Metwally
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Giza, Egypt
| | - Noha Salah
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Giza, Egypt
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Cole NM, Abushoshah I, Fields KG, Carusi DA, Robinson JN, Bateman BT, Farber MK. The interrater reliability and agreement of a 0 to 10 uterine tone score in cesarean delivery. Am J Obstet Gynecol MFM 2021; 3:100342. [PMID: 33652161 DOI: 10.1016/j.ajogmf.2021.100342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/14/2021] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Postpartum hemorrhage is a leading source of maternal morbidity and mortality worldwide with uterine atony identified as the underlying cause in up to 80% of cases. Several measures have been utilized to report uterine tone. The most commonly reported measure is a 0 to 10 numeric rating scale, but this scale has not been tested for reliability or agreement between different raters. OBJECTIVE The primary purpose of this study was to evaluate the interrater reliability and agreement of the 0 to 10 visual numeric rating scale of uterine tone during cesarean delivery. A secondary purpose was to obtain estimates of scale responsiveness and minimal clinically important difference. STUDY DESIGN Between August and November of 2018, obstetricians used a 0 to 10 numeric rating score to independently rate uterine tone at 3 and 10 minutes after cesarean delivery by palpation of the uterus. Of note, "0" represented "no tone" and "10" represented excellent tone. Each obstetrician independently and blinded to the other's score pointed to a numeric rating scale held by the anesthesiologist through a clear sterile drape. Intraclass correlation coefficients and Bland-Altman analysis were used to assess interrater reliability and agreement, respectively. Standardized response mean and standard error of measurement were used to obtain estimates of responsiveness and minimal clinically important difference, respectively. RESULTS A total of 82 and 84 pairs of scores were collected at 3 and 10 minutes, respectively, from pairs of 62 unique obstetricians. The mean±standard deviation difference in scores between rater 1 and rater 2 was 0.4±1.4 at 3 minutes and 0.1±1.1 at 10 minutes. Intraclass correlation coefficients for a future single rater (intraclass correlation coefficient [1, 1]) at 3 and 10 minutes were 0.67 (95% confidence interval, 0.53-0.77) and 0.61 (95% confidence interval, 0.46-0.73), and for the average between 2 future raters (intraclass correlation coefficient [1, 2]), they were 0.80 (95% confidence interval, 0.71-0.87) and 0.76 (95% confidence interval, 0.63-0.84), indicating good and excellent reliability, respectively. Bland-Altman analysis estimated 95% limit of agreement between raters of -2.4 (95% confidence interval, -3.0 to -1.9) to 3.1 (95% confidence interval, 2.6-3.7) at 3 minutes and -2.1 (95% confidence interval, -2.5 to -1.7) to 2.4 (95% confidence interval, 2.0-2.8) at 10 minutes, consistent with good interrater agreement at both time points. The standardized response mean from 3 to 10 minutes after delivery was 1.1 (n=81). Standard error of measurement was 1.0 (95% confidence interval, 0.9-1.1) at 3 minutes and 0.8 (95% confidence interval, 0.7-0.9) at 10 minutes. CONCLUSION The 0 to 10 numeric rating scale for uterine tone demonstrated good to excellent interrater reliability with 1 and 2 raters, respectively, and good interrater agreement. The scale was responsive to within-parturient change in tone, and preliminary estimates of the minimal clinically important difference were obtained. The 0 to 10 numeric rating scale for uterine tone may be a reliable, standardized tool for future research in reporting degree of uterotonic contraction during cesarean delivery.
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Affiliation(s)
- Naida M Cole
- Department of Anesthesiology, Perioperative and Pain Medicine (Drs Cole and Abushoshah, Ms Fields, and Drs Bateman and Farber).
| | - Ibrahim Abushoshah
- Department of Anesthesiology, Perioperative and Pain Medicine (Drs Cole and Abushoshah, Ms Fields, and Drs Bateman and Farber); Department of Anesthesia and Critical Care, King Abdulaziz University, King Abdulaziz University Hospital, Jeddhah, Saudi Arabia (Dr Abushoshah)
| | - Kara G Fields
- Department of Anesthesiology, Perioperative and Pain Medicine (Drs Cole and Abushoshah, Ms Fields, and Drs Bateman and Farber)
| | | | - Julian N Robinson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (Dr Robinson)
| | - Brian T Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine (Drs Cole and Abushoshah, Ms Fields, and Drs Bateman and Farber); Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (Dr Bateman), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michaela K Farber
- Department of Anesthesiology, Perioperative and Pain Medicine (Drs Cole and Abushoshah, Ms Fields, and Drs Bateman and Farber)
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Gallos I, Williams H, Price M, Pickering K, Merriel A, Tobias A, Lissauer D, Gee H, Tunçalp Ö, Gyte G, Moorthy V, Roberts T, Deeks J, Hofmeyr J, Gülmezoglu M, Coomarasamy A. Uterotonic drugs to prevent postpartum haemorrhage: a network meta-analysis. Health Technol Assess 2020; 23:1-356. [PMID: 30821683 DOI: 10.3310/hta23090] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Prophylactic uterotonic drugs can reduce blood loss and are routinely recommended. There are several uterotonic drugs for preventing PPH, but it is still debatable which drug or combination of drugs is the most effective. OBJECTIVES To identify the most effective and cost-effective uterotonic drug(s) to prevent PPH, and generate a ranking according to their effectiveness and side-effect profile. METHODS The Cochrane Pregnancy and Childbirth's Trials Register (1 June 2015), ClinicalTrials.gov and the World Health Organization (WHO)'s International Clinical Trials Registry Platform (ICTRP) were searched for unpublished trial reports (30 June 2015). In addition, reference lists of retrieved studies (updated October 2017) were searched for randomised trials evaluating uterotonic drugs for preventing PPH. The study estimated relative effects and rankings for preventing PPH, defined as blood loss of ≥ 500 ml and ≥ 1000 ml. Pairwise meta-analyses and network meta-analysis were performed to determine the relative effects and rankings of all available drugs and combinations thereof [ergometrine, misoprostol (Cytotec®; Pfizer Inc., New York, NY, USA), misoprostol plus oxytocin (Syntocinon®; Novartis International AG, Basel, Switzerland), carbetocin (Pabal®; Ferring Pharmaceuticals, Saint-Prex, Switzerland), ergometrine plus oxytocin (Syntometrine®; Alliance Pharma plc, Chippenham, UK), oxytocin, and a placebo or no treatment]. Primary outcomes were stratified according to the mode of birth, prior risk of PPH, health-care setting, drug dosage, regimen and route of drug administration. Sensitivity analyses were performed according to study quality and funding source, among others. A model-based economic evaluation compared the relative cost-effectiveness separately for vaginal births and caesareans with or without including side effects. RESULTS From 137 randomised trials and 87,466 women, ergometrine plus oxytocin, carbetocin and misoprostol plus oxytocin were found to reduce the risk of PPH blood loss of ≥ 500 ml compared with the standard drug, oxytocin [ergometrine plus oxytocin: risk ratio (RR) 0.69, 95% confidence interval (CI) 0.57 to 0.83; carbetocin: RR 0.72, 95% CI 0.52 to 1.00; misoprostol plus oxytocin: RR 0.73, 95% CI 0.6 to 0.9]. Each of these three strategies had 100% cumulative probability of being ranked first, second or third most effective. Oxytocin was ranked fourth, with an almost 0% cumulative probability of being ranked in the top three. Similar rankings were noted for the reduction of PPH blood loss of ≥ 1000 ml (ergometrine plus oxytocin: RR 0.77, 95% CI 0.61 to 0.95; carbetocin: RR 0.70, 95% CI 0.38 to 1.28; misoprostol plus oxytocin: RR 0.90, 95% CI 0.72 to 1.14), and most secondary outcomes. Ergometrine plus oxytocin and misoprostol plus oxytocin had the poorest ranking for side effects. Carbetocin had a favourable side-effect profile, which was similar to oxytocin. However, the analysis was restricted to high-quality studies, carbetocin lost its ranking and was comparable to oxytocin. The relative cost-effectiveness of the alternative strategies is inconclusive, and the results are affected by both the uncertainty and inconsistency in the data reported on adverse events. For vaginal delivery, when assuming no adverse events, ergometrine plus oxytocin is less costly and more effective than all strategies except carbetocin. The strategy of carbetocin is both more effective and more costly than all other strategies. When taking adverse events into consideration, all prevention strategies, except oxytocin, are more costly and less effective than carbetocin. For delivery by caesarean section, with and without adverse events, the relative cost-effectiveness is different, again because of the uncertainty in the available data. LIMITATIONS There was considerable uncertainty in findings within the planned subgroup analyses, and subgroup effects cannot be ruled out. CONCLUSIONS Ergometrine plus oxytocin, carbetocin and misoprostol plus oxytocin are more effective uterotonic drug strategies for preventing PPH than the current standard, oxytocin. Ergometrine plus oxytocin and misoprostol plus oxytocin cause significant side effects. Carbetocin has a favourable side-effect profile, which was similar to oxytocin. However, most carbetocin trials are small and of poor quality. There is a need for a large high-quality trial comparing carbetocin with oxytocin; such a trial is currently being conducted by the WHO. The relative cost-effectiveness is inconclusive, and results are affected by uncertainty and inconsistency in adverse events data. STUDY REGISTRATION This study is registered as PROSPERO CRD42015020005; Cochrane Pregnancy and Childbirth Group (substudy) reference number 0871; PROSPERO-Cochrane (substudy) reference number CRD42015026568; and sponsor reference number ERN_13-1414 (University of Birmingham, Birmingham, UK). FUNDING Funding for this study was provided by the National Institute for Health Research Health Technology Assessment programme in a research award to the University of Birmingham and supported by the UK charity Ammalife (UK-registered charity 1120236). The funders of the study had no role in study design, data collection, data synthesis, interpretation or writing of the report.
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Affiliation(s)
- Ioannis Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Helen Williams
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Malcolm Price
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Karen Pickering
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Abi Merriel
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Aurelio Tobias
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - David Lissauer
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Harry Gee
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Özge Tunçalp
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Gillian Gyte
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Centre for Women's Health Research, Liverpool Women's NHS Foundation Trust, Liverpool, UK.,National Childbirth Trust, London, UK
| | - Vidhya Moorthy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Tracy Roberts
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jonathan Deeks
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Justus Hofmeyr
- Effective Care Research Unit, University of the Witwatersrand/Fort Hare, Eastern Cape Department of Health, East London, South Africa
| | - Metin Gülmezoglu
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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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: 57] [Impact Index Per Article: 9.5] [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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Sweed MS, El-Saied MM, Abou-Gamrah AE, El-Sabaa HA, Abdel-Hamid MM, Hemeda H, Mansour AM, Shawky ME, El-Sayed MA, Mohamed RM. Rectal vs. sublingual misoprostol before cesarean section: double-blind, three-arm, randomized clinical trial. Arch Gynecol Obstet 2018; 298:1115-1122. [PMID: 30291483 DOI: 10.1007/s00404-018-4894-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 09/06/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The commonest surgical procedure for women is cesarean delivery. Postpartum hemorrhage and intra-operative blood during cesarean delivery is a major concern to all obstetricians. This study was conducted to assess the efficacy of the adjuvant use of misoprostol and oxytocin in decreasing intra-operative blood loss in cesarean delivery. METHODS This was a double-blinded randomized clinical trial including 636 term pregnant woman scheduled for cesarean section at Ain Shams University Maternity Hospital, Cairo, Egypt, between February 2013 and February 2014. Participants received either 400-μg misoprostol rectally or sublingually or placebo before cesarean section together with 5-IU oxytocin IV. The main outcome measure was intra-operative blood loss. Difference between the three groups was analyzed using one-way ANOVA test (for numeric variables) and Chi-square test (for categorical variables). P < 0.05 was considered statistically significant. RESULTS Intra-operative blood loss was higher in patients who did not receive misoprostol (Placebo Group) (295-1075 ml, 641.7 ± 135.7) than those who received it, regardless the route of administration, rectal (135-830 ml, 457.5 ± 140.7; P < 0.001), and sublingual (135-680 ml, 357.8 ± 129.7; P < 0.001). In addition, sublingual route was associated with significantly lower estimated intra-operative blood loss compared to rectal administration (P < 0.001). CONCLUSIONS Misoprostol with oxytocin is an effective drug-combination for decreasing intra-operative blood loss during cesarian section with clinical superiority to sublingual over rectal route.
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Affiliation(s)
- Mohamed S Sweed
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt.
| | - Mourad M El-Saied
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| | - Amgad E Abou-Gamrah
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| | - Haitham A El-Sabaa
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| | | | - Hossam Hemeda
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| | - Ahmed M Mansour
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| | - Mohamed E Shawky
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| | - Medhat A El-Sayed
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
| | - Radwa M Mohamed
- Obstetrics and Gynecology Department, Ain Shams University, Cairo, 16646, Egypt
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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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Chaudhuri P, Majumdar A. A randomized trial of sublingual misoprostol to augment routine third-stage management among women at risk of postpartum hemorrhage. Int J Gynaecol Obstet 2015; 132:191-5. [PMID: 26613819 DOI: 10.1016/j.ijgo.2015.06.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 06/18/2015] [Accepted: 10/20/2015] [Indexed: 10/22/2022]
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8
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Chaudhuri P, Majumdar A. Sublingual misoprostol as an adjunct to oxytocin during cesarean delivery in women at risk of postpartum hemorrhage. Int J Gynaecol Obstet 2014; 128:48-52. [DOI: 10.1016/j.ijgo.2014.07.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 07/20/2014] [Accepted: 09/05/2014] [Indexed: 11/27/2022]
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9
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Is the Time of administration of misoprostol of value? The uterotonic effect of misoprostol given pre- and post-operative after elective cesarean section. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2014. [DOI: 10.1016/j.mefs.2013.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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10
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Conde-Agudelo A, Nieto A, Rosas-Bermudez A, Romero R. Misoprostol to reduce intraoperative and postoperative hemorrhage during cesarean delivery: a systematic review and metaanalysis. Am J Obstet Gynecol 2013; 209:40.e1-40.e17. [PMID: 23507545 DOI: 10.1016/j.ajog.2013.03.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 02/26/2013] [Accepted: 03/13/2013] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of prophylactic misoprostol use at cesarean delivery for reducing intraoperative and postoperative hemorrhage. STUDY DESIGN Systematic review and metaanalysis of randomized controlled trials. RESULTS Seventeen studies (3174 women) were included of which 7 evaluated misoprostol vs oxytocin and 8 evaluated misoprostol plus oxytocin vs oxytocin alone. Overall, there were no significant differences in intraoperative and postoperative hemorrhage between sublingual or oral misoprostol and oxytocin. Rectal misoprostol, compared with oxytocin, was associated with a significant reduction in intraoperative and postoperative hemorrhage. The combined use of sublingual misoprostol and oxytocin, compared with the use of oxytocin alone, was associated with a significant reduction in the mean decrease in hematocrit (mean difference, -2.1%; 95% confidence interval, -3.4 to -0.8) and use of additional uterotonic agents (relative risk, 0.33; 95% confidence interval, 0.18-0.62). Compared with oxytocin alone, buccal misoprostol plus oxytocin reduced the use of additional uterotonic agents; rectal misoprostol plus oxytocin decreased intraoperative and postoperative blood loss, mean fall in hematocrit, and use of additional uterotonic agents; and intrauterine misoprostol plus oxytocin reduced the mean fall in hemoglobin and hematocrit. Women receiving misoprostol, alone or combined with oxytocin, had a higher risk of shivering and pyrexia. CONCLUSION Misoprostol combined with oxytocin appears to be more effective than oxytocin alone in reducing intraoperative and postoperative hemorrhage during cesarean section. There were no significant differences in intraoperative and postoperative hemorrhage when misoprostol was compared to oxytocin. However, these findings were based on a few trials with methodological limitations.
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Affiliation(s)
- Agustín Conde-Agudelo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI
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Tucker SC, Honn KV. Emerging targets in lipid-based therapy. Biochem Pharmacol 2013; 85:673-688. [PMID: 23261527 PMCID: PMC4106802 DOI: 10.1016/j.bcp.2012.11.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 11/29/2012] [Accepted: 11/30/2012] [Indexed: 02/07/2023]
Abstract
The use of prostaglandins and NSAIDS in the clinic has proven that lipid mediators and their associated pathways make attractive therapeutic targets. When contemplating therapies involving lipid pathways, several basic agents come to mind. There are the enzymes and accessory proteins that lead to the metabolism of lipid substrates, provided through diet or through actions of lipases, the subsequent lipid products, and finally the lipid sensors or receptors. There is abundant evidence that molecules along this lipid continuum can serve as prognostic and diagnostic indicators and are in fact viable therapeutic targets. Furthermore, lipids themselves can be used as therapeutics. Despite this, the vernacular dialog pertaining to "biomarkers" does not routinely include mention of lipids, though this is rapidly changing. Collectively these agents are becoming more appreciated for their respective roles in diverse disease processes from cancer to preterm labor and are receiving their due appreciation after decades of ground work in the lipid field. By relating examples of disease processes that result from dysfunction along the lipid continuum, as well as examples of lipid therapies and emerging technologies, this review is meant to inspire further reading and discovery.
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Affiliation(s)
- Stephanie C Tucker
- Department of Pathology, Wayne State University School of Medicine, and Karmanos Cancer Institute, Detroit, MI 48202, USA.
| | - Kenneth V Honn
- Department of Pathology, Wayne State University School of Medicine, and Karmanos Cancer Institute, Detroit, MI 48202, USA; Department of Chemistry, Wayne State University School of Medicine, and Karmanos Cancer Institute, Detroit, MI 48202, USA.
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