Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: a double-blind, randomised, non-inferiority trial

Shenghua decoction for postpartum hemorrhage attributed to uterine atony: An observational study

This retrospective study aimed to investigate the preventive effects of Shenghua decoction (SHD) for postpartum hemorrhage (PPH) attributed to uterine atony (UA). Records of 84 patients were retrospectively analyzed, with 42 assigned to the treatment group and 42 to the control group. Both groups received carbetocin, and patients in the treatment group additionally underwent SHD. Primary endpoints included blood loss and changes in hemoglobin levels. Secondary endpoints encompassed the number of patients requiring uterine massage, additional oxytocic drugs, pulse rate, respiratory rate, systolic blood pressure, and treatment-related adverse events. Patients in the treatment group exhibited superior outcomes in terms of blood loss (P < .01), hemoglobin levels (P = .03), and pulse rate (P < .01) compared to those in the control group. However, no significant differences were observed in the number of patients requiring uterine massage (P = .13), the number of patients needing additional oxytocic drugs (P = .19), respiratory rate (P = .05), and systolic blood pressure (P = .80) between the 2 groups. There were no significant disparities in treatment-related adverse events between the 2 groups. The findings of this study suggest that the preventive effects of SHD combined with carbetocin were superior to those of carbetocin alone for preventing postpartum hemorrhage. However, high-quality prospective studies are needed to validate and confirm these results.

Sublingual Misoprostol-Induced Rhabdomyolysis and Convulsions in Postpartum Hemorrhage: A Case Report and Literature Review

Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality, primarily attributed to uterine atony. Both the World Health Organization (WHO) and the International Federation of Gynecology and Obstetrics (FIGO) endorse the use of misoprostol not only for the prevention but also for the treatment of PPH. However, the administration of misoprostol is commonly associated with transient pyrexia, attributed to a shift in the hypothalamic set point observed in certain animal studies. Misoprostol-induced hyperpyrexia can occasionally manifest with a prodrome of shivering, particularly when administered via the sublingual route, which achieves a higher and faster maximum plasma concentration compared to vaginal and rectal routes. General management strategies to reduce fever involve removing clothing and blankets, applying cool compresses, administering oral acetaminophen, and ensuring adequate hydration. While some cases have reported misoprostol-induced convulsions, hyperpyrexia leading to convulsions and subsequent rhabdomyolysis is a rare and potentially lethal side effect. In this case presentation, we emphasize a scenario where misoprostol was employed for the treatment of PPH but led to rhabdomyolysis. Our goal is to highlight the side effects of misoprostol and the significance of considering the initial combination of misoprostol with anti-pyretic management to minimize the risk of hyperthermia-related side effects and prevent additional severe complications.

Intravenous versus intramuscular oxytocin injection for preventing uterine atonic primary postpartum haemorrhage in third stage of labour: A double-blind randomised controlled trial

Objectives

To compare the efficacy and safety of intravenous and intramuscular oxytocin in preventing atonic primary postpartum haemorrhage in the third stage of labour.

Methods

A double-blind randomised clinical study on consenting women without risk factors for primary postpartum haemorrhage in labour at term. Two hundred and thirty-two women were randomly allotted into intravenous (n = 115) and intramuscular (n = 117) oxytocin groups in the active management of the third stage of labour. All participants received 10 IU of oxytocin, either IV or IM, and 1 ml of water for injection as a placebo via a route alternate to that of administration of oxytocin within 1 min of the baby's delivery. The primary outcome measures were mean postpartum blood loss and haematocrit change. Trial Registration No.: PACTR201902721929705.

Results

The baseline socio-demographic and clinical characteristics were similar between the two groups (p > 0.05). There was no statistically significant difference between the two groups with regards to the mean postpartum blood loss (254.17 ± 34.85 ml versus 249.4 ± 39.88 ml; p = 0.210), haematocrit change (2.4 (0.8%) versus 2.1 (0.6%); p = 0.412) or adverse effects (p > 0.05). However, the use of additional uterotonics was significantly higher in the intravenous group (25 (21.73%) versus 17 (14.53%); p = 0.032).

Conclusion

Although oxytocin in both study groups showed similar efficacy in terms of preventing atonic primary postpartum haemorrhage, participants who received intravenous oxytocin were more likely to require additional uterotonics to reduce their likelihood of having an atonic primary postpartum haemorrhage. However, both routes have similar side effect profiles.

Misoprostol-Induced Fever and Unnecessary Antibiotic Prescribing: A Retrospective Study

INTRODUCTION

Misoprostol is widely used for medication abortion and postpartum hemorrhage. However, it has been associated with the adverse effect of fever, which can pose challenges in management and potentially contribute to unnecessary antibiotic use. The incidence of misoprostol-induced fever in the context of medical abortion has not been extensively studied.

METHODS

This retrospective cohort study aimed to determine the incidence of fever following misoprostol administration at a tertiary care hospital in Saudi Arabia. The study included female patients who received misoprostol for pregnancy termination or management of missed or incomplete abortion between January 2017 and December 2019. Data on demographics, misoprostol dosage and route, fever characteristics, outcome of abortion, and antibiotic use were collected. Statistical analysis was preformed using appropriate tests.

RESULTS

A total of 213 patients were included in the study. The incidence of fever post-misoprostol administration was 8%. Patients who developed fever had a higher gestational age and received higher doses of misoprostol. However, no significant associations were found between other patient variables and fever incidence. Antibiotic therapy was administered to a almost half of the patients who developed fever post-misoprostol but was determined to be unnecessary in all cases.

CONCLUSION

This study contributes to the understanding of misoprostol-induced fever in the context of medical abortion. Further research is needed to explore strategies for reducing unnecessary antibiotic use in this population.

Epidemiology and definition of PPH worldwide

Postpartum/peripartum hemorrhage (PPH) is an obstetric emergency complicating 1-10% of all deliveries and is a leading cause of maternal mortality and morbidity worldwide. However, the incidence of PPH differs widely according to the definition and criteria used, the way of measuring postpartum blood loss, and the population being studied with the highest numbers in developing countries. Despite all the significant progress in healthcare, the incidence of PPH is rising due to an incomplete implementation of guidelines, resulting in treatment delays and suboptimal care. A consensus clinical definition of PPH is needed to enable awareness, early recognition, and initiation of appropriate intensive treatment. Unfortunately, the most used definition of PPH based on blood loss ≥500 ml after delivery suffers from inaccuracies in blood loss quantification and is not clinically relevant in most cases, as the amount of blood loss does not fully reflect the severity of bleeding.

Promptness of oxytocin administration for first-line treatment of postpartum hemorrhage: a national vignette-based study among midwives

Background

Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality worldwide. Midwives play a key role in the initial management of PPH. Uterotonic agents are widely used in its prevention and treatment, with oxytocin the first-line agent. Nonetheless, a standardized guideline for optimal dose and rate of administration has not been clearly defined. The aim of this study was to investigate French midwives’ practices regarding first-line oxytocin treatment and the factors influencing its delayed administration.

Methods

This multicenter study was based on clinical vignettes of PPH management collected using an anonymous online questionnaire. A random sample of midwives from 145 maternity units in France from 15 randomly selected perinatal networks were invited to participate by email. The Previously validated case vignettes described two different scenarios of severe PPH. Vignette 1 described a typical immediate, severe PPH, and vignette 2 a less typical case of severe but gradual PPH They were constructed in three successive steps and included multiple-choice questions proposing several types of clinical practice options at each stage. For each vignette separately, we analyzed the lack of prompt oxytocin administration and the factors contributing to them, that is, characteristics of the midwives and organizational features of maternity units. Bivariate analysis and multivariable logistic regression analysis were applied.

Results

In all, 450 midwives from 87 maternity units provided complete responses. Lack of promptness was observed in 21.6% of responses (N = 97) in Vignette 1 and in 13.8% (N = 62) in Vignette 2 (p < .05). After multivariate analysis, the risk of delay was lower among with midwives working in university maternity hospitals (ORa 0.47, 95% 0.21, 0.97) and in units with 1500 to 2500 births per year (ORa 0.49, 95% CI 0.26, 0.90) for Vignette 1. We also noticed that delay increased with the midwives’ years of experience (per 10-year period) (ORa 1.30, 95% CI 1.01, 1.69).

Conclusions

This study using clinical vignettes showed delays in oxytocin administration for first-line treatment of PPH. Because delay in treatment is a major cause of preventable maternal morbidity in PPH, these findings suggest that continuing training of midwives should be considered, especially in small maternity units.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04648-5.

Comparison of Clinical Efficacy and Safety between Misoprostol and Oxytocin in the Prevention of Postpartum Hemorrhage: A Meta-Analysis

In order to systematically evaluate the clinical efficacy and safety of misoprostol versus oxytocin in the prevention of postpartum hemorrhage, this paper provides evidence-based reference for clinical medication, computerized retrieval of Chinese biomedical literature database (CBM), PubMed, Embase, Cochrane Library, and clinical trials. The retrieval period is from the establishment of each database to October 1, 2021. Published randomized controlled trials (RCTS) are included in this study. The literature is screened and evaluated according to inclusion and exclusion criteria, and meta-analysis is performed using RevMan 5.3 software. A total of 13 RCTS are included, with a total of 24754 parturients. The meta-analysis shows the average blood loss (SMD = 0.10, 95% CI (-0.11, 0.32), P=0.35), the time of the third stage of labor (SMD = 0, 95% CI (-0.07, 0.08), P=0.95), and blood transfusion rate (RR = 0.80, 95% CI (0.63, 1.02), P=0.07). However, the incidences of shivering (RR = 2.61, 95% CI (1.79, 0.81), P < 0.00001) and vomiting (RR = 2.78, 95% CI (1.85, 4.18), P < 0.00001) are significantly higher than those in oxytocin group. The effect of misoprostol on preventing postpartum hemorrhage is similar to that of oxytocin, but the incidence of adverse reactions is high, and the occurrence of adverse reactions should be closely watched in the use process. Due to the limitations of the included studies, multicenter, large-sample, and high-quality RCTS are still needed in the future to further verify this conclusion.

Uterine atony

PURPOSE OF REVIEW

Postpartum hemorrhage (PPH) is the leading preventable cause of maternal morbidity and mortality worldwide. Uterine atony is identified as the underlying etiology in up to 80% of PPH. This serves as a contemporary review of the epidemiology, risk factors, pathophysiology, and treatment of uterine atony.

RECENT FINDINGS

Rates of postpartum hemorrhage continue to rise worldwide with the largest fraction attributed to uterine atony. A simple 0-10 numerical rating score for uterine tone was recently validated for use during cesarean delivery and may allow for more standardized assessment in clinical and research settings. The optimal prophylactic dose of oxytocin differs depending on the patient population, but less than 5 units and as low as a fraction of one unit is needed for PPH prevention, with an increased requirements within that range for cesarean birth, those on magnesium, and advanced maternal age. Carbetocin is an appropriate alternative to oxytocin. Misoprostol shows limited to no efficacy for uterine atony in recent studies. Several uncontrolled case studies demonstrate novel mechanical and surgical interventions for treating uterine atony.

SUMMARY

There is a critical, unmet need for contemporary, controlled studies to address the increasing threat of atonic PPH.

World Health Organization Recommendation for Using Uterine Balloon Tamponade to Treat Postpartum Hemorrhage

The World Health Organization recommends that balloon tamponade should be used only where other supportive interventions are available if needed.

The World Health Organization (WHO) recently published a new recommendation on the use of the uterine balloon tamponade for the treatment of postpartum hemorrhage. The recommendation that uterine balloon tamponade should be used only where there is already access to other postpartum hemorrhage treatments (including immediate recourse to surgery) has proved controversial. It is especially problematic for those working in low-level health care facilities in under-resourced settings, where there are already programs that have introduced low-cost uterine balloon tamponade devices for use, even in settings where recourse to surgical interventions is not possible. However, there are now two separate randomized trials that both unexpectedly show unfavorable outcomes in these settings when a condom catheter uterine balloon tamponade device was introduced. Considering the balance of potential benefits and these safety concerns, the WHO postpartum hemorrhage guideline panel therefore recommends that uterine balloon tamponade should be used only in contexts where other supportive postpartum hemorrhage interventions are available if needed.

Refractory uterine atony: still a problem after all these years

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality, and uterine atony is the leading cause of postpartum hemorrhage. Risk factors for uterine atony include induced or augmented labor, preeclampsia, chorio-amnionitis, obesity, multiple gestation, polyhydramnios, and prolonged second stage of labor. Although a risk assessment is recommended for all parturients, many women with uterine atony do not have risk factors, making uterine atony difficult to predict. Oxytocin is the first-line drug for prevention and treatment of uterine atony. It is a routine component of the active management of the third stage of labor. An oxytocin bolus dose as low as 1 IU is sufficient to produce satisfactory uterine tone in almost all women undergoing elective cesarean delivery. However, a higher bolus dose (3 IU) or infusion rate is recommended for women undergoing intrapartum cesarean delivery. Carbetocin, available in many countries, is a synthetic oxytocin analog with a longer duration than oxytocin that allows bolus administration without an infusion. Second line uterotonic agents include ergot alkaloids (ergometrine and methylergonovine) and the prostaglandins, carboprost and misoprostol. These drugs work by a different mechanism to oxytocin and should be administered early for uterine atony refractory to oxytocin. Rigorous studies are lacking, but methylergonovine and carboprost are likely superior to misoprostol. Currently, the choice of second-line agent should be based on their adverse effect profile and patient comorbidities. Surgical and radiologic management of uterine atony includes uterine tamponade using balloon catheters and compression sutures, and percutaneous transcatheter arterial embolization.

The Safety and Feasibility of a Family First Aid Approach for the Management of Postpartum Hemorrhage in Home Births: A Pre-post Intervention Study in Rural Pakistan

Objective

To evaluate the safety and feasibility of a Family First Aid approach whereby women and their families are provided misoprostol in advance to manage postpartum hemorrhage (PPH) in home births.

Methods

A 12-month prospective, pre-post intervention study was conducted from February 2017 to February 2018. Women in their second and third trimesters were enrolled at home visits. Participants and their families received educational materials and were counseled on how to diagnose excessive bleeding and the importance of seeking care at a facility if PPH occurs. In the intervention phase, participants were also given misoprostol and counselled on how to administer the four 200 mcg tablets for first aid in case of PPH. Participants were followed-up postpartum to collect data on use of misoprostol for Family First Aid at home deliveries (primary outcome) and record maternal and perinatal outcomes.

Results

Of the 4008 participants enrolled, 97% were successfully followed-up postpartum. Half of the participants in each phase delivered at home. Among home deliveries, the odds of reporting PPH almost doubled among in the intervention phase (OR 1.98; CI 1.43, 2.76). Among those reporting PPH, women in the intervention phase were significantly more likely to have received PPH treatment (OR 10.49; CI 3.37, 32.71) and 90% administered the dose correctly. No maternal deaths, invasive procedures or surgery were reported in either phase after home deliveries.

Conclusions

The Family First Aid approach is a safe and feasible model of care that provides timely PPH treatment to women delivering at home in rural communities.

Uterotonic agents for first-line treatment of postpartum haemorrhage: a network meta-analysis

BACKGROUND

Postpartum haemorrhage (PPH), defined as a blood loss of 500 mL or more after birth, is the leading cause of maternal death worldwide. The World Health Organization (WHO) recommends that all women giving birth should receive a prophylactic uterotonic agent. Despite the routine administration of a uterotonic agent for prevention, PPH remains a common complication causing one-quarter of all maternal deaths globally. When prevention fails and PPH occurs, further administration of uterotonic agents as 'first-line' treatment is recommended. However, there is uncertainty about which uterotonic agent is best for the 'first-line' treatment of PPH.

OBJECTIVES

To identify the most effective uterotonic agent(s) with the least side-effects for PPH treatment, and generate a meaningful ranking among all available agents according to their relative effectiveness and side-effect profile.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 May 2020), and the reference lists of all retrieved studies.

SELECTION CRITERIA

All randomised controlled trials or cluster-randomised trials comparing the effectiveness and safety of uterotonic agents with other uterotonic agents for the treatment of PPH were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for inclusion, extracted data and assessed each trial for risk of bias. Our primary outcomes were additional blood loss of 500 mL or more after recruitment to the trial until cessation of active bleeding and the composite outcome of maternal death or severe morbidity. Secondary outcomes included blood loss-related outcomes, morbidity outcomes, and patient-reported outcomes. We performed pairwise meta-analyses and indirect comparisons, where possible, but due to the limited number of included studies, we were unable to conduct the planned network meta-analysis. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

Seven trials, involving 3738 women in 10 countries, were included in this review. All trials were conducted in hospital settings. Randomised women gave birth vaginally, except in one small trial, where women gave birth either vaginally or by caesarean section. Across the seven trials (14 trial arms) the following agents were used: six trial arms used oxytocin alone; four trial arms used misoprostol plus oxytocin; three trial arms used misoprostol; one trial arm used Syntometrine® (oxytocin and ergometrine fixed-dose combination) plus oxytocin infusion. Pairwise meta-analysis of two trials (1787 participants), suggests that misoprostol, as first-line treatment uterotonic agent, probably increases the risk of blood transfusion (risk ratio (RR) 1.47, 95% confidence interval (CI) 1.02 to 2.14, moderate-certainty) compared with oxytocin. Low-certainty evidence suggests that misoprostol administration may increase the incidence of additional blood loss of 1000 mL or more (RR 2.57, 95% CI 1.00 to 6.64). The data comparing misoprostol with oxytocin is imprecise, with a wide range of treatment effects for the additional blood loss of 500 mL or more (RR 1.66, 95% CI 0.69 to 4.02, low-certainty), maternal death or severe morbidity (RR 1.98, 95% CI 0.36 to 10.72, low-certainty, based on one study n = 809 participants, as the second study had zero events), and the use of additional uterotonics (RR 1.30, 95% CI 0.57 to 2.94, low-certainty). The risk of side-effects may be increased with the use of misoprostol compared with oxytocin: vomiting (2 trials, 1787 participants, RR 2.47, 95% CI 1.37 to 4.47, high-certainty) and fever (2 trials, 1787 participants, RR 3.43, 95% CI 0.65 to 18.18, low-certainty). According to pairwise meta-analysis of four trials (1881 participants) generating high-certainty evidence, misoprostol plus oxytocin makes little or no difference to the use of additional uterotonics (RR 0.99, 95% CI 0.94 to 1.05) and to blood transfusion (RR 0.95, 95% CI 0.77 to 1.17) compared with oxytocin. We cannot rule out an important benefit of using the misoprostol plus oxytocin combination over oxytocin alone, for additional blood loss of 500 mL or more (RR 0.84, 95% CI 0.66 to 1.06, moderate-certainty). We also cannot rule out important benefits or harms for additional blood loss of 1000 mL or more (RR 0.76, 95% CI 0.43 to 1.34, moderate-certainty, 3 trials, 1814 participants, one study reported zero events), and maternal mortality or severe morbidity (RR 1.09, 95% CI 0.35 to 3.39, moderate-certainty). Misoprostol plus oxytocin increases the incidence of fever (4 trials, 1866 participants, RR 3.07, 95% CI 2.62 to 3.61, high-certainty), and vomiting (2 trials, 1482 participants, RR 1.85, 95% CI 1.16 to 2.95, high-certainty) compared with oxytocin alone. For all outcomes of interest, the available evidence on the misoprostol versus Syntometrine® plus oxytocin combination was of very low-certainty and these effects remain unclear. Although network meta-analysis was not performed, we were able to compare the misoprostol plus oxytocin combination with misoprostol alone through the common comparator of oxytocin. This indirect comparison suggests that the misoprostol plus oxytocin combination probably reduces the risk of blood transfusion (RR 0.65, 95% CI 0.42 to 0.99, moderate-certainty) and may reduce the risk of additional blood loss of 1000 mL or more (RR 0.30, 95% CI 0.10 to 0.89, low-certainty) compared with misoprostol alone. The combination makes little or no difference to vomiting (RR 0.75, 95% CI 0.35 to 1.59, high-certainty) compared with misoprostol alone. Misoprostol plus oxytocin compared to misoprostol alone are compatible with a wide range of treatment effects for additional blood loss of 500 mL or more (RR 0.51, 95% CI 0.20 to 1.26, low-certainty), maternal mortality or severe morbidity (RR 0.55, 95% CI 0.07 to 4.24, low-certainty), use of additional uterotonics (RR 0.76, 95% CI 0.33 to 1.73, low-certainty), and fever (RR 0.90, 95% CI 0.17 to 4.77, low-certainty).

AUTHORS' CONCLUSIONS

The available evidence suggests that oxytocin used as first-line treatment of PPH probably is more effective than misoprostol with less side-effects. Adding misoprostol to the conventional treatment of oxytocin probably makes little or no difference to effectiveness outcomes, and is also associated with more side-effects. The evidence for most uterotonic agents used as first-line treatment of PPH is limited, with no evidence found for commonly used agents, such as injectable prostaglandins, ergometrine, and Syntometrine®.

Intravenous versus intramuscular prophylactic oxytocin for the third stage of labour

BACKGROUND

There is general agreement that oxytocin given either through the intravenous or intramuscular route is effective in reducing postpartum blood loss. However, it is unclear whether the subtle differences between the mode of action of these routes have any effect on maternal and infant outcomes. This review was first published in 2012 and last updated in 2018.

OBJECTIVES

To determine the comparative effectiveness and safety of oxytocin administered intravenously or intramuscularly for prophylactic management of the third stage of labour after vaginal birth.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (19 December 2019), and reference lists of retrieved studies.

SELECTION CRITERIA

Eligible studies were randomised trials comparing intravenous with intramuscular oxytocin for prophylactic management of the third stage of labour after vaginal birth. We excluded quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the certainty of the evidence with the GRADE approach.

MAIN RESULTS

Seven trials, involving 7817 women, met the inclusion criteria for this review. The trials compared intravenous versus intramuscular administration of oxytocin just after the birth of the anterior shoulder or soon after the birth of the baby. All trials were conducted in hospital settings and included women with term pregnancies, undergoing a vaginal birth. Overall, the included studies were at moderate or low risk of bias, with two trials providing clear information on allocation concealment and blinding. For GRADE outcomes, the certainty of the evidence was generally moderate to high, except from two cases where the certainty of the evidence was either low or very low. High-certainty evidence suggests that intravenous administration of oxytocin in the third stage of labour compared with intramuscular administration carries a lower risk for postpartum haemorrhage (PPH) ≥ 500 mL (average risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.92; six trials; 7731 women) and blood transfusion (average RR 0.44, 95% CI 0.26 to 0.77; four trials; 6684 women). Intravenous administration of oxytocin probably reduces the risk of PPH ≥ 1000 mL, although the 95% CI crosses the line of no-effect (average RR 0.65, 95% CI 0.39 to 1.08; four trials; 6681 women; moderate-certainty evidence). In all studies but one, there was a reduction in the risk of PPH ≥ 1000 mL with intravenous oxytocin. The study that found a large increase with intravenous administration was small (256 women), and contributed only 3% of total events. Once this small study was removed from the meta-analysis, heterogeneity was eliminated and the treatment effect favoured intravenous oxytocin (average RR 0.61, 95% CI 0.42 to 0.88; three trials; 6425 women; high-certainty evidence). Additionally, a sensitivity analysis, exploring the effect of risk of bias by restricting analysis to those studies rated as 'low risk of bias' for random sequence generation and allocation concealment, found that the prophylactic administration of intravenous oxytocin reduces the risk for PPH ≥ 1000 mL, compared with intramuscular oxytocin (average RR 0.64, 95% CI 0.43 to 0.94; two trials; 1512 women). The two routes of oxytocin administration may be comparable in terms of additional uterotonic use (average RR 0.78, 95% CI 0.49 to 1.25; six trials; 7327 women; low-certainty evidence). Although intravenous compared with intramuscular administration of oxytocin probably results in a lower risk for serious maternal morbidity (e.g. hysterectomy, organ failure, coma, intensive care unit admissions), the confidence interval suggests a substantial reduction, but also touches the line of no-effect. This suggests that there may be no reduction in serious maternal morbidity (average RR 0.47, 95% CI 0.22 to 1.00; four trials; 7028 women; moderate-certainty evidence). Most events occurred in one study from Ireland reporting high dependency unit admissions, whereas in the remaining three studies there was only one case of uvular oedema. There were no maternal deaths reported in any of the included studies (very low-certainty evidence). There is probably little or no difference in the risk of hypotension between intravenous and intramuscular administration of oxytocin (RR 1.01, 95% CI 0.88 to 1.15; four trials; 6468 women; moderate-certainty evidence). Subgroup analyses based on the mode of administration of intravenous oxytocin (bolus injection or infusion) versus intramuscular oxytocin did not show any substantial differences on the primary outcomes. Similarly, additional subgroup analyses based on whether oxytocin was used alone or as part of active management of the third stage of labour (AMTSL) did not show any substantial differences between the two routes of administration.

AUTHORS' CONCLUSIONS

Intravenous administration of oxytocin is more effective than its intramuscular administration in preventing PPH during vaginal birth. Intravenous oxytocin administration presents no additional safety concerns and has a comparable side effects profile with its intramuscular administration. Future studies should consider the acceptability, feasibility and resource use for the intervention, especially in low-resource settings.

Testing a home-based model of care using misoprostol for prevention and treatment of postpartum hemorrhage: results from a randomized placebo-controlled trial conducted in Badakhshan province, Afghanistan

Background

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. In Afghanistan, where most births take place at home without the assistance of a skilled birth attendant, there is a need for options to manage PPH in community-based settings. Misoprostol, a uterotonic that has been used as prophylaxis at the household level and has also been proven to be effective in treating PPH in hospital settings, is one possible option.

Methods

A double-blind, randomized placebo-controlled trial was conducted in six districts in Badakhshan Province, Afghanistan to test the effectiveness and safety of administering 800mcg sublingual misoprostol to women after a home birth for treatment of excessive blood loss. Consenting women were enrolled prior to delivery and given 600mcg misoprostol to self-administer orally as prophylaxis. Community health workers (CHW) were trained to observe for signs of PPH after delivery and if PPH was diagnosed, administer the study medication (misoprostol or placebo) and immediately refer the woman. A hemoglobin (Hb) decline of 2 g/dL or greater, measured pre- and post-delivery, served as the primary outcome; side effects, additional interventions, and transfer rates were also analyzed.

Results

Among the 1884 women who delivered at home, nearly all (98.7%) reported self-use of misoprostol for PPH prevention. A small fraction was diagnosed with PPH (4.4%, 82/1884) and was administered treatment. Hb outcomes, including the proportion of women with a Hb drop of 2 g/dL or greater, were similar between the study groups (misoprostol: 56.4% (22/39), placebo: 60.6% (20/33), p = 0.45). Significantly more women randomized to receive misoprostol experienced shivering (82.5% vs. placebo: 61.5%, p = 0.03). Other side effects were similar between study groups and none required treatment, including among the subset of 39 women, who received misoprostol for both of its PPH indications.

Conclusions

While the study did not document a clinical benefit associated with misoprostol for treatment of PPH, study findings suggest that use of misoprostol for both prevention and treatment in the same birth as well as its use by lay level providers in home births does not result in any safety concerns.

Trial registration

This trial was registered with ClinicalTrials.gov, number NCT01508429 Registered on December 1, 2011.

A cluster-randomized, non-inferiority trial comparing use of misoprostol for universal prophylaxis vs. secondary prevention of postpartum hemorrhage among community level births in Egypt

Background

Previous community-based research shows that secondary prevention of postpartum hemorrhage (PPH) with misoprostol only given to women with above-average measured blood loss produces similar clinical outcomes compared to routine administration of misoprostol for prevention of PPH. Given the difficulty of routinely measuring blood loss for all deliveries, more operational models of secondary prevention are needed.

Methods

This cluster-randomized, non-inferiority trial included women giving birth with nurse-midwives at home or in Primary Health Units (PHUs) in rural Egypt. Two PPH management approaches were compared: 1) 600mcg oral misoprostol given to all women after delivery (i.e. primary prevention, current standard of care); 2) 800mcg sublingual misoprostol given only to women with 350-500 ml postpartum blood loss estimated using an underpad (i.e. secondary prevention). The primary outcome was mean change in pre- and post-delivery hemoglobin. Secondary outcomes included hemoglobin ≥2 g/dL and other PPH interventions.

Results

Misoprostol was administered after delivery to 100% (1555/1555) and 10.7% (117/1099) of women in primary and secondary prevention clusters, respectively. The mean drop in pre- to post-delivery hemoglobin was 0.37 (SD: 0.91) and 0.45 (SD: 0.76) among women in primary and secondary prevention clusters, respectively (difference adjusted for clustering = 0.01, one-sided 95% CI: < 0.27, p = 0.535). There were no statistically significant differences in secondary outcomes, including hemoglobin drop ≥2 g/dL, PPH diagnosis, transfer to higher level, or other interventions.

Conclusions

Misoprostol for secondary prevention of PPH is comparable to universal prophylaxis and can be implemented using local materials, such as underpads.

Trial registration

Clinicaltrials.gov NCT02226588, date of registration 27 August 2014.

High fever after sublingual administration of misoprostol for treatment of post-partum haemorrhage: a hospital-based, prospective observational study in Argentina

Objective

To characterise the occurrence of fever (≥38.0°C) after treatment for post‐partum haemorrhage (PPH) with sublingual misoprostol 800 mcg in Latin America, where elevated rates of misoprostol’s thermoregulatory effects and recipients’ increased susceptibility to high fever have been documented.

Methods

A prospective observational study in hospitals in Argentina enrolled consenting women with atonic PPH after vaginal delivery, eligible to receive misoprostol. Corporal temperature was assessed at 30, 60, 90 and 120 min post‐treatment; other effects were recorded. The incidence of high fever ≥ 40.0°C (primary outcome) was compared to the rate observed previously in Ecuador. Logistic regressions were performed to identify clinical and population‐based predictors of misoprostol‐induced fever.

Results

Transient shivering and fever were experienced by 75.5% (37/49) of treated participants and described as acceptable by three‐quarters of women interviewed (35/47). The high fever rate was 12.2% (6/49), [95% Confidence Interval (CI) 4.6, 24.8], compared to Ecuador’s rate following misoprostol treatment (35.6% (58/163) [95% CI 28.3, 43.5], P = 0.002). Significant predictors of misoprostol‐induced fever (model dependent) were as follows: pre‐delivery haemoglobin < 11.0g/dl, rapid placental expulsion, and higher age of the woman. No serious outcomes were reported prior to discharge.

Conclusions

Misoprostol to treat PPH in Argentina resulted in a significantly lower rate of high fever than in Ecuador, although both are notably higher than rates seen elsewhere. A greater understanding of misoprostol’s side effects and factors involved in their occurrence, including genetics, will help alleviate concerns. The onset of shivering may be the simplest way to know if fever can also be expected.

A double-blind, randomized controlled trial to explore oral tranexamic acid as adjunct for the treatment for postpartum hemorrhage

BACKGROUND

Oral tranexamic acid (TXA), if effective in reducing blood loss after delivery for women experiencing primary PPH, could be administered where parenteral administration is not feasible. This trial assessed the efficacy, safety, and acceptability of oral TXA when used as an adjunct to sublingual misoprostol to treat postpartum hemorrhage (PPH) following vaginal delivery.

METHODS

From October 2016 to January 2018, women presenting at four hospitals in Senegal and Vietnam for vaginal delivery were screened for enrollment in the trial. Women diagnosed with postpartum hemorrhage (defined as blood loss ≥700 ml) were randomized to receive either oral TXA (1950 mg) or placebo in addition to 800 mcg sublingual misoprostol. Postpartum blood loss was measured using a calibrated drape. Blood loss for all PPH cases was recorded for 2 h after administration of the drugs. The primary outcome measure was the proportion of women with bleeding controlled with the trial regimen without recourse to further treatment. Secondary outcomes including the rate of severe PPH, mean/median blood loss, use of additional uterotonics and/or interventions side effects, and acceptability were also recorded.

RESULTS

Of the 258 women who received treatment for PPH, 128 received placebo and misoprostol and 130 received TXA and misoprostol. The proportion of women who had active bleeding controlled with trial drugs alone and no additional interventions was similar in both groups: 77(60.2%) placebo; 74 (56.9%) TXA, p = 0.59). Use of other interventions to control bleeding, including uterotonics, did not differ significantly between groups. Median blood loss at PPH diagnosis was 700 ml in both groups. Uterine atony alone or in addition to another cause contributed to over 90% of PPH cases reported (92.2% placebo vs. 91.5% TXA), other causes included perineal and cervical lacerations and retained placenta. Reports of side effects and acceptability were similar in the two groups.

CONCLUSION

Adjunct use of oral TXA with misoprostol to treat PPH resulted in similar clinical and acceptability outcomes when compared to treatment with misoprostol alone.

TRIAL REGISTRATION

This trial was registered with ClinicalTrials.gov, number NCT02805426. Registered on 3 September 2016.

Oxytocin Versus Misoprostol Plus Oxytocin in the Prevention of Postpartum Hemorrhage at a Semi-Urban Hospital in sub-Saharan Africa: A Retrospective Cohort Study

BACKGROUND

Post-partum hemorrhage (PPH) is a leading cause of maternal mortality. Its first-line of prevention often entails uterotonic drugs like oxytocin and misoprostol which constitute a core point of management in low-resource settings of sub-Saharan Africa. This study aimed to assess the effectiveness of oxytocin alone compared with oxytocin plus misoprostol in two different eras (before and after the advert of misoprostol) of a semi-urban Cameroonian hospital.

METHODS

This was a retrospective cohort study carried out between January 2015 to April 2015 and between January 2016 to April 2016 on a group of parturients (group A) who received only oxytocin and another administered oxytocin and misoprostol (group B), respectively. All participants delivered at the Bamenda Regional Hospital, Cameroon. The two different periods represent the era before and after the implementation of misoprostol in the prevention of PPH in this semi-urban hospital. Socio-demographic data, clinical characteristics and details of delivery as well as risk factors for PPH were studied from obstetric records.

RESULTS

We studied the obstetric records of 1778 parturients were studied; 857 in group A and 879 in group B. Their mean age was 26.3 ±5.2 years. Both groups were comparable in several baseline sociodemographic and clinical characteristics. The prevalence of PPH was 2.7% (3.4% vs 2.2%; p = 0.0744). The risk of PPH in the oxytocin only group was about 1.5 times higher than in the oxytocin plus misoprostol group. The estimated blood loss between the two groups was statistically significant (1100 ± 150 vs 800 ± 100 ml, p< 0.0001). The active management of the third stage of labor without misoprostol was the only risk factor for PPH.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

The implementation of misoprostol plus oxytocin in the prevention of PPH in this low-resource setting improved the obstetrical outcome by reducing the risk and the amount of blood loss during delivery.

Use of misoprostol in the treatment of postpartum hemorrhage: a pharmacoepidemiological approach

OBJECTIVE

To characterize the use of the drug misoprostol for treatment of postpartum hemorrhage in pregnant women.

METHODS

A descriptive observational study was carried out with secondary data from pregnant women who used misoprostol to treat postpartum hemorrhage in a reference public maternity, from July 2015 to June 2017. Clinical and sociodemographic profiles of pregnant women, how misoprostol was used and success rate in controling postpartum hemorrhage were characterized.

RESULTS

A total of 717 prescriptions of misoprostol were identified. Of these, 10% were for treatment of postpartum hemorrhage. The majority of pregnant women were young adults, married, with complete high school education, white, residing in urban areas, multiparous (68.1%) and 25% had previous cesarean sections. The mean gestational age was 39 weeks and 51.4% had a cesarean section. There was prophylactic use of oxytocin in 47.2% of women. Treatment of postpartum hemorrhage was successful in 84.7% of women. Of these, 79.2% also used oxytocin and 54.2% methylergonovine. Only 13.5% of pregnant women had less than five prenatal visits, and the main cause of postpartum hemorrhage was uterine atony. There were 13 complications after hemorrhage, 15.3% required blood transfusion and there was one case of maternal death.

CONCLUSION

Misoprostol showed to be effective and safe for treating postpartum hemorrhage.

How well do postpartum blood loss and common definitions of postpartum hemorrhage correlate with postpartum anemia and fall in hemoglobin?

Objective

We aimed to better understand how well postpartum blood loss and common postpartum hemorrhage (PPH) definitions (i.e. blood loss ≥500ml = PPH, ≥1000ml = “severe” PPH) correlate with postpartum anemia and fall in hemoglobin.

Methods

Secondary analysis of data from three randomized trials that objectively measured postpartum blood loss and pre- and post-delivery hemoglobin among vaginal deliveries: one trial included 1056 home-births in Pakistan and two multi-country hospital-based trials included 1279 women diagnosed with PPH. We calculated Spearman’s correlation coefficients (r_s) for blood loss with hemoglobin drop and postpartum hemoglobin, and we compared PPH blood loss markers (≥500ml, ≥1000ml) with large hemoglobin drops (≥2 g/dL) and the threshold for moderate postpartum anemia (<10g/dL).

Results

In the Pakistan study and the multi-country trials, blood loss was weakly correlated with hemoglobin drop (Pakistan: r_s = -0.220, multi-country trials: r_s = -0.271) and postpartum hemoglobin (Pakistan: r_s = -0.220, multi-country trials: r_s = -0.316). In both the Pakistan and multi-country trials, hemoglobin drop ≥2 g/dL occurred in less than half of women with 500–999 ml blood loss (55/175 [31%] and 302/725 [42%], respectively) and was more common among women who bled ≥1000ml (19/28 [68%] and 347/554 [63%], respectively). Similarly, in the Pakistan and multi-country trials, postpartum anemia <10 g/dL was less frequent among women who bled 500–999 ml (55/175 [31%] and 390/725 [54%], respectively) and more frequent among women with ≥1000ml blood loss (20/28 [71%] and 416/554 [75%], respectively).

Conclusions

Postpartum morbidity as measured by hemoglobin markers was common for women with blood loss ≥1000ml and relatively infrequent among women with blood loss 500-999ml. These findings reinforce the importance of severe PPH as the preferred outcome to be used in research. The weak correlation between blood loss and hemoglobin markers also suggests that this relationship is not straightforward and should be carefully interpreted.

Use of histograms to assess the efficacy of uterotonic treatment for post-partum haemorrhage: A feasibility study

Post-partum haemorrhage (PPH) is a major pathological condition leading to mortality of women worldwide. Its initial treatment has largely been focused on uterotonics. This paper examines the use of histograms to assess the efficacy of uterotonic treatment for PPH. Previous examinations of large datasets in which women were treated at 700 ml of measured blood loss according to strict protocols have shown a quantifiable peak in the histogram at 700-800 ml following treatment. It is not clear whether this is commonly seen in other studies. The main aim was therefore to assess whether post-treatment peaks are routinely seen in postpartum blood loss histograms and whether the peaks are seen only in treated women. Four datasets of more than 1000 women with measured blood loss were identified and the original data examined. The secondary peak was not only seen in histograms attributed to treatment, but also many of the histograms where women had not received uterotonic treatment. Many women received treatment despite having blood loss of less than 500 ml, and many women who stopped bleeding with final blood losses of more than 500 ml did not receive any uterotonics. The routine use of histogram analysis to assess the efficiency of uterotonic therapy is not recommended. The paper also provides further insights into clinical practice, with clinicians frequently using uterotonic therapies even when the volume of the blood loss is low. This demonstrates how uterotonic use in practice is often not linked to the standard 500 ml definition of post-partum haemorrhage.

Using misoprostol to treat postpartum hemorrhage in home deliveries attended by traditional birth attendants

OBJECTIVE

To explore the clinical and programmatic feasibility of using 800 μg of sublingual misoprostol to prevent and treat postpartum hemorrhage (PPH) during home delivery.

METHODS

The present double-blind randomized controlled trial included women who underwent home deliveries in Chitral district, Khyber Pakhtunkhwa province, Pakistan, after presenting at healthcare facilities during the third trimester of pregnancy between May 28, 2012, and November 27, 2014. Participants were randomized in a 1:1 ratio to receive either 800 μg of misoprostol or placebo sublingually if PPH was diagnosed, having previously received a prophylactic oral dose of 600 μg misoprostol. The primary outcome, hemoglobin decrease of 20 g/L or greater from pre- to post-delivery assessment, was compared on a modified intention-to-treat basis.

RESULTS

There were 49 patients allocated to receive misoprostol and 38 allocated to receive placebo; the incidence of a 20 g/L decrease in hemoglobin was similar between the groups (20/43 [47%] vs 19/33 [58%], respectively; P=0.335).

CONCLUSION

There was no significant difference in clinical outcomes between the two trial arms. ClinicalTrials.gov:NCT01485562.

Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis

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.

Intramuscular versus intravenous prophylactic oxytocin for the third stage of labour

BACKGROUND

There is general agreement that oxytocin given either through the intramuscular or intravenous route is effective in reducing postpartum blood loss. However, it is unclear whether the subtle differences between the mode of action of these routes have any effect on maternal and infant outcomes. This is an update of a review first published in 2012.

OBJECTIVES

To determine the comparative effectiveness and safety of oxytocin administered intramuscularly or intravenously for prophylactic management of the third stage of labour after vaginal birth.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (7 September 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials comparing intramuscular with intravenous oxytocin for prophylactic management of the third stage of labour after vaginal birth. We excluded quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

Three studies with 1306 women are included in the review and compared intramuscular versus intravenous oxytocin administered just after the birth of the anterior shoulder or soon after the birth of the baby. Studies were carried out in hospital settings in Turkey and Thailand and recruited women with singleton, term pregnancies. Overall, the included studies were at moderate risk of bias: none of the studies provided clear information on allocation concealment or attempted to blind staff or women. For GRADE outcomes the quality of the evidence was very low, with downgrading due to study design limitations and imprecision of effect estimates.Only one study reported severe postpartum haemorrhage (blood loss 1000 mL or more) and showed no clear difference between the intramuscular and intravenous oxytocin groups (risk ratio (RR) 0.11, 95% confidence interval (CI) 0.01 to 2.04; 256 women; very low-quality evidence). No woman required hysterectomy in either group in one study (no estimable data, very low-quality evidence), and in another study one woman in each group received a blood transfusion (RR 1.00, 95% CI 0.06 to 15.82; 256 women; very low-quality evidence). Other important outcomes (maternal death, hypotension, maternal dissatisfaction with the intervention and neonatal jaundice) were not reported by any of the included studies. There were no clear differences between groups for other prespecified secondary outcomes reported (postpartum haemorrhage 500 mL or more, use of additional uterotonics, retained placenta or manual removal of the placenta).

AUTHORS' CONCLUSIONS

Very low-quality evidence indicates no clear difference between the comparative benefits and risks of intramuscular and intravenous oxytocin when given to prevent excessive blood loss after vaginal birth. Appropriately designed randomised trials with adequate sample sizes are needed to assess whether the route of prophylactic oxytocin after vaginal birth affects maternal or infant outcomes. Such studies could be large enough to detect clinically important differences in major side effects that have been reported in observational studies and should also consider the acceptability of the intervention to mothers and providers as important outcomes.

Design and statistical considerations for studies evaluating the efficacy of a single dose of the human papillomavirus (HPV) vaccine

Cervical cancer is a leading cause of cancer mortality in women worldwide. Human papillomavirus (HPV) types 16 and 18 cause about 70% of all cervical cancers. Clinical trials have demonstrated that three doses of either commercially available HPV vaccine, Cervarix ® or Gardasil ®, prevent most new HPV 16/18 infections and associated precancerous lesions. Based on evidence of immunological non-inferiority, 2-dose regimens have been licensed for adolescents in the United States, European Union, and elsewhere. However, if a single dose were effective, vaccine costs would be reduced substantially and the logistics of vaccination would be greatly simplified, enabling vaccination programs in developing countries. The National Cancer Institute (NCI) and the Agencia Costarricense de Investigaciones Biomédicas (ACIB) are conducting, with support from the Bill & Melinda Gates Foundation and the International Agency for Research on Cancer (IARC), a large 24,000 girl study to evaluate the efficacy of a 1-dose regimen. The first component of the study is a four-year non-inferiority trial comparing 1- to 2-dose regimens of the two licensed vaccines. The second component is an observational study that estimates the vaccine efficacy (VE) of each regimen by comparing the HPV infection rates in the trial arms to those in a contemporaneous survey group of unvaccinated girls. In this paper, we describe the design and statistical analysis for this study. We explain the advantage of defining non-inferiority on the absolute risk scale when the expected event rate is near 0 and, given this definition, suggest an approach to account for missing clinic visits. We then describe the problem of estimating VE in the absence of a randomized placebo arm and offer our solution.

Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis

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.

Use of a Visual Aid in addition to a Collector Bag to Evaluate Postpartum Blood loss: A Prospective Simulation Study

Postpartum hemorrhage (PPH) is one of the most common causes of mortality in obstetrics worldwide. The accuracy of estimated blood loss is a priority in determining appropriate treatment. Will the additional use of a visual aid improve physicians' accuracy in estimating blood loss compared to the use of a collector bag and baby scale alone? Simulation training sessions created three vaginal delivery scenarios for participants to estimate volumes of blood loss: firstly, using only a collector bag and a baby weight scale and secondly, adding a visual aid depicting known volumes of blood. The primary endpoint was to determine if participants could accurately evaluate blood loss within a 20% error margin. The addition of the visual estimator resulted in overestimation of blood loss. The rates of participants' estimations were significantly more accurate when using the collector bag with the baby weight scale without the addition of the visual aid; 85.5% versus 33.3% (p < 0.01) for 350 mL, 88.4% versus 50.7% (p < 0.01) for 1100 mL and 88.4% versus 78.3% (p < 0.01) for 2500 mL, respectively. Additional use of a visual aid with a collector bag does not seem to be useful in improving the accuracy in the estimation of blood loss.

Postpartum haemorrhage: prevention and treatment

INTRODUCTION

Postpartum hemorrhage (PPH) is one of the leading causes of maternal death and severe maternal morbidity worldwide and strategies to prevent and treat PPH vary among international authorities. Areas covered: This review seeks to provide a global overview of PPH (incidence, causes, risk factors), prevention (active management of the third stage of labor and prohemostatic agents), treatment (first, second and third-line measures to control PPH), by also underlining recommendations elaborated by international authorities and using algorithms. Expert commentary: When available, oxytocin is considered the drug of first choice for both prevention and treatment of PPH, while peripartum hysterectomy remains the ultimate life-saving procedure if pharmacological and resuscitation measures fail. Nevertheless, the level of evidence for preventing and treating PPH is globally low. The emergency nature of PPH makes randomized controlled trials (RCT) logistically difficult. Population-based observational studies should be encouraged as they can usefully strengthen the evidence base, particularly for components of PPH treatment that are difficult or impossible to assess through RCT.

Stakeholder Analysis of Community Distribution of Misoprostol in Lao PDR: A Qualitative Study

Background

Globally, significant progress has been made in reducing maternal mortality, yet in many low-resource contexts it remains unacceptably high. Many of these deaths are due to postpartum haemorrhage and are preventable with access to essential obstetric care. Where there are barriers to access, maternal deaths could be prevented if community-level misoprostol was available. The purpose of this study was to explore perceptions of stakeholders regarding misoprostol use in the Lao People’s Democratic Republic, a setting with high maternal mortality.

Methods

Semi-structured interviews were conducted with 35 stakeholders in the capital, Vientiane and in one northern province identified as a site for a possible intervention. The sample included international and national stakeholders involved in policy-making and providing maternal and reproductive health services.

Findings

Most stakeholders supported a pilot program for community distribution of misoprostol but levels of awareness of the drug’s use in preventing postpartum haemorrhage and level of influence over policy direction varied considerably. Some international organizations, all identified as powerful in influencing policy, were ambivalent about the use of community distribution of misoprostol. Concerns related to the capacity of village health workers or lay people to safely administer misoprostol, whether its distribution would undermine efforts to improve access to safe delivery services and active management of the third stage of labour, the ease with which prescription drugs can be bought over the counter, and technical, logistical, and financial constraints.

Conclusion

Access to appropriate oxytocic drugs is a matter of health equity. In settings without access to essential obstetrical care, misoprostol represents a viable solution for the prevention of postpartum haemorrhage. Understanding stakeholders’ perspectives and their legitimate concerns on misoprostol can inform interventions in order to assuage these concerns and enable disadvantaged women to access misoprostol and its potentially life-saving benefits.

Efficacy of misoprostol for the treatment of postpartum hemorrhage: current knowledge and implications for health care planning

BACKGROUND

A myriad of interventions exist to treat postpartum hemorrhage (PPH), ranging from uterotonics and hemostatics to surgical and aortic compression devices. Nonetheless, PPH remains the leading cause of maternal mortality worldwide. The purpose of this article is to review the available evidence on the efficacy of misoprostol for the treatment of primary PPH and discuss implications for health care planning.

DATA AND METHODS

Using PubMed, Web of Science, and GoogleScholar, we reviewed the literature on randomized controlled trials of interventions to treat PPH with misoprostol and non-randomized field trials with controls. We discuss the current knowledge and implications for health care planning, especially in resource-poor settings.

RESULTS

The treatment of PPH with 800 μg of misoprostol is equivalent to 40 IU of intravenous oxytocin in women who have received oxytocin for the prevention of PPH. The same dose might be an option for the treatment of PPH in women who did not receive oxytocin for the prevention of PPH and do not have access to oxytocin for treatment. Adding misoprostol to standard uterotonics has no additional benefits to women being treated for PPH, but the beneficial adjunctive role of misoprostol to conventional uterotonics is important in reducing intra- and postoperative hemorrhage during cesarean section.

CONCLUSION

Misoprostol is an effective uterotonic agent in the treatment of PPH. Clinical guidelines and treatment protocols should be updated to reflect the current knowledge on the efficacy of misoprostol for the treatment of PPH with 800 μg sublingually.

Maternal characteristics and clinical diagnoses influence obstetrical outcomes in Indonesia

This Indonesian study evaluates associations between near-miss status/death with maternal demographic, health care characteristics, and obstetrical complications, comparing results using retrospective and prospective data. The main outcome measures were obstetric conditions and socio-economic factors to predict near-miss/death. We abstracted all obstetric admissions (1,358 retrospective and 1,240 prospective) from two district hospitals in East Java, Indonesia between 4/1/2009 and 5/15/2010. Prospective data added socio-economic status, access to care and referral patterns. Reduced logistic models were constructed, and multivariate analyses used to assess association of risk variables to outcome. Using multivariate analysis, variables associated with risk of near-miss/death include postpartum hemorrhage (retrospective AOR 5.41, 95 % CI 2.64-11.08; prospective AOR 10.45, 95 % CI 5.59-19.52) and severe preeclampsia/eclampsia (retrospective AOR 1.94, 95 % CI 1.05-3.57; prospective AOR 3.26, 95 % CI 1.79-5.94). Associations with near-miss/death were seen for antepartum hemorrhage in retrospective data (AOR 9.34, 95 % CI 4.34-20.13), and prospectively for poverty (AOR 2.17, 95 % CI 1.33-3.54) and delivering outside the hospital (AOR 2.04, 95 % CI 1.08-3.82). Postpartum hemorrhage and severe preeclampsia/eclampsia are leading causes of near-miss/death in Indonesia. Poverty and delivery outside the hospital are significant risk factors. Prompt recognition of complications, timely referrals, standardized care protocols, prompt hospital triage, and structured provider education may reduce obstetric mortality and morbidity. Retrospective data were reliable, but prospective data provided valuable information about barriers to care and referral patterns.

Misoprostol for primary versus secondary prevention of postpartum haemorrhage: a cluster-randomised non-inferiority community trial

OBJECTIVE

To assess whether secondary prevention, which preemptively treats women with above-average postpartum bleeding, is non-inferior to universal prophylaxis.

DESIGN

A cluster-randomised non-inferiority community trial.

SETTING

Health sub-centres and home deliveries in the Bijapur district of Karnataka, India.

POPULATION

Women with low-risk pregnancies who were eligible for delivery with an Auxiliary Nurse Midwife at home or sub-centre and who consented to be part of the study.

METHODS

Auxiliary Nurse Midwifes were randomised to secondary prevention using 800 mcg sublingual misoprostol administered to women with postpartum blood loss ≥350 ml or to universal prophylaxis using 600 mcg oral misoprostol administered to all women during the third stage of labour.

MAIN OUTCOME MEASURES

Postpartum haemoglobin ≤7.8 g/dl, mean postpartum blood loss and postpartum haemoglobin, postpartum haemorrhage rate, transfer to higher-level facilities, acceptability and feasibility of the intervention.

RESULTS

Misoprostol was administered to 99.7% of women as primary prevention. In secondary prevention, 92 (4.7%) women had postpartum bleeding ≥350 ml, of which 90 (97.8%) received misoprostol. The proportion of women with postpartum haemoglobin ≤7.8 g/dl was 5.9 and 8.8% in secondary and primary prevention clusters, respectively [difference -2.9%, one-sided 95% confidence interval (CI) <1.3%]. Postpartum transfer and haemorrhage rates were low (<1%) in both groups. Shivering was more common in primary prevention clusters (P = 0.013).

CONCLUSION

Secondary prevention of postpartum haemorrhage with misoprostol is non-inferior to universal prophylaxis based on the primary outcome of postpartum haemoglobin. Secondary prevention could be a good alternative to universal prophylaxis as it medicates fewer women and is an acceptable and feasible strategy at the community level.

TWEETABLE ABSTRACT

Secondary prevention of postpartum haemorrhage with misoprostol is non-inferior to universal prophylaxis.

The MamaMiso study of self-administered misoprostol to prevent bleeding after childbirth in rural Uganda: a community-based, placebo-controlled randomised trial

Background

600 mcg of oral misoprostol reduces the incidence of postpartum haemorrhage (PPH), but in previous research this medication has been administered by health workers. It is unclear whether it is also safe and effective when self-administered by women.

Methods

This placebo-controlled, double-blind randomised trial enrolled consenting women of at least 34 weeks gestation, recruited over a 2-month period in Mbale District, Eastern Uganda. Participants had their haemoglobin measured antenatally and were given either 600mcg misoprostol or placebo to take home and use immediately after birth in the event of delivery at home. The primary clinical outcome was the incidence of fall in haemoglobin of over 20 % in home births followed-up within 5 days.

Results

748 women were randomised to either misoprostol (374) or placebo (374). Of those enrolled, 57 % delivered at a health facility and 43 % delivered at home. 82 % of all medicine packs were retrieved at postnatal follow-up and 97 % of women delivering at home reported self-administration of the medicine. Two women in the misoprostol group took the study medication antenatally without adverse effects. There was no significant difference between the study groups in the drop of maternal haemoglobin by >20 % (misoprostol 9.4 % vs placebo 7.5 %, risk ratio 1.11, 95 % confidence interval 0.717 to 1.719). There was significantly more fever and shivering in the misoprostol group, but women found the medication highly acceptable.

Conclusions

This study has shown that antenatally distributed, self-administered misoprostol can be appropriately taken by study participants. The rarity of the primary outcome means that a very large sample size would be required to demonstrate clinical effectiveness.

Trial registration

This study was registered with the ISRCTN Register (ISRCTN70408620).

Prevention and management of postpartum hemorrhage: a comparison of 4 national guidelines

OBJECTIVE

The purpose of this study was to compare 4 national guidelines for the prevention and management of postpartum hemorrhage (PPH).

STUDY DESIGN

We performed a descriptive analysis of guidelines from the American College of Obstetrician and Gynecologists practice bulletin, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Royal College of Obstetrician and Gynaecologists (RCOG), and the Society of Obstetricians and Gynaecologists of Canada on PPH to determine differences, if any, with regard to definitions, risk factors, prevention, treatment, and resuscitation.

RESULTS

PPH was defined differently in all 4 guidelines. Risk factors that were emphasized in the guidelines conferred a high risk of catastrophic bleeding (eg, previous cesarean delivery and placenta previa). All organizations, except the American College of Obstetrician and Gynecologists, recommended active management of the third stage of labor for primary prevention of PPH in all vaginal deliveries. Oxytocin was recommended universally as the medication of choice for PPH prevention in vaginal deliveries. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists and RCOG recommended development of a massive transfusion protocol to manage PPH resuscitation. Recommendations for nonsurgical treatment strategies such as uterine packing and balloon tamponade varied across all guidelines. All organizations recommended transfer to a tertiary care facility for suspicion of abnormal placentation. Specific indications for hysterectomy were not available in any guideline, with RCOG recommending hysterectomy "sooner rather than later" with the assistance of a second consultant.

CONCLUSION

Substantial variation exists in PPH prevention and management guidelines among 4 national organizations that highlights the need for better evidence and more consistent synthesis of the available evidence with regard to a leading cause of maternal death.

Misoprostol-induced fever and genetic polymorphisms in drug transporters SLCO1B1 and ABCC4 in women of Latin American and European ancestry

AIM

Misoprostol, a prostaglandin analogue used for the treatment of postpartum hemorrhage and termination of pregnancy, can cause high fevers. Genetic susceptibility may play a role in misoprostol-induced fever.

SUBJECTS & METHODS

Body temperature of women treated with misoprostol for termination of pregnancy in the UK (n = 107) and for postpartum hemorrhage in Ecuador (n = 50) was measured. Genotyping for 33 single nucleotide polymorphisms in 15 candidate genes was performed. Additionally, we investigated the transport of radiolabeled misoprostol acid across biological membranes in vitro.

RESULTS

The ABCC4 single nucleotide polymorphism rs11568658 was associated with misoprostol-induced fever. Misoprostol acid was transported across a blood-brain barrier model by MRP4 and SLCO1B1.

CONCLUSION

Genetic variability in ABCC4 may contribute to misoprostol-induced fever in pregnant women. Original submitted 21 January 2015; Revision submitted 24 April 2015.

The Effect of Combined Oxytocin-Misoprostol Versus Oxytocin and Misoprostol Alone in Reducing Blood Loss at Cesarean Delivery: A Prospective Randomized Double-Blind Study

PURPOSE

To compare the effect of combined oxytocin-misoprostol versus oxytocin and misoprostol alone in reducing blood loss at cesarean delivery.

METHODS

One hundred fifty patients of 18-40 years with singleton term pregnancies scheduled for cesarean section under spinal anesthesia were recruited in a prospective double-blind randomized clinical trial to one of the three following groups to receive 20 IU infusion of oxytocin (group O), 400-µg sublingual misoprostol tablets (group M) or 200-µg misoprostol plus 5 IU bolus intravenous oxytocin (group MO) after delivery. The hemoglobin level before surgery and 24 h after surgery, the need for additional oxytocic therapy, and the incidence of adverse effects were recorded.

RESULTS

The mean blood loss during surgery was significantly lower in group MO compared to other groups (P = 0.04). Comparison of mean arterial pressure (P = 0.38) and heart rate (P = 0.23) changes during spinal anesthesia and surgery failed to reveal any statistically significant differences between all groups through repeated measure analysis.

CONCLUSION

The use of combined lower dose of misoprostol-oxytocin significantly reduced the amount of blood loss during and after the lower segment cesarean section compared to higher dose of oxytocin and misoprostol alone, and its use was not associated with any serious side effects.

The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next?

Postpartum haemorrhage (PPH) remains a major cause of maternal deaths worldwide, and is estimated to cause the death of a woman every 10 minutes. This review presents the latest clinical advice, including new evidence on controlled cord traction, misoprostol, and oxytocin. The controversy around the diagnosis of PPH, the limitations of universal prophylaxis, and novel ways to provide obstetric first aid are also presented. It ends with a call to develop high-quality front-line obstetric services that can deal rapidly with unexpected haemorrhages as well as minimising blood loss at critical times: major abruption, placenta praevia, and caesarean for prolonged labour.

Calibrated delivery drape versus indirect gravimetric technique for the measurement of blood loss after delivery: a randomized trial

Background

Trials of interventions for PPH prevention and treatment rely on different measurement methods for the quantification of blood loss and identification of PPH. This study’s objective was to compare measures of blood loss obtained from two different measurement protocols frequently used in studies.

Methods

Nine hundred women presenting for vaginal delivery were randomized to a direct method (a calibrated delivery drape) or an indirect method (a shallow bedpan placed below the buttocks and weighing the collected blood and blood-soaked gauze/pads). Blood loss was measured from immediately after delivery for at least one hour or until active bleeding stopped.

Results

Significantly greater mean blood loss was recorded by the direct than by the indirect measurement technique (253.9 mL and 195.3 mL, respectively; difference = 58.6 mL (95% CI: 31–86); p < 0.001). Almost twice as many women in the direct than in the indirect group measured blood loss > 500 mL (8.7% vs. 4.7%, p = 0.02).

Conclusions

The study suggests a real and significant difference in blood loss measurement between these methods. Research using blood loss measurement as an endpoint needs to be interpreted taking measurement technique into consideration.

Trial registration

This study has been registered at clinicaltrials.gov as NCT01885845.

Safety and efficacy of misoprostol versus oxytocin for the prevention of postpartum hemorrhage

Postpartum hemorrhage (PPH) is the commonest cause of maternal death worldwide. Studies suggest that the use of misoprostol may be beneficial in clinical settings where oxytocin is unavailable. The aim of this study was to compare the safety and efficacy of oxytocin and misoprostol when used in the prevention of PPH. In a double-blind randomized controlled trial, 400 pregnant women who had a vaginal delivery were assigned into two groups: to receive either 20 IU of oxytocin in 1000 mL Ringer's solution and two placebo tablets or 400 mcg oral misoprostol (as two tablets) and 2 mL normal saline in 1000 mL Ringer's solution. The quantity of blood loss was higher in the oxytocin group in comparison to the misoprostol group. There was no significant difference in the decrease in hematocrit and hemoglobin between the two groups. Although there was no significant difference in the need for transfusions between the two groups, the patients in the oxytocin group had greater need for additional oxytocin. Results from this study indicate that it may be considered as an alternative for oxytocin in low resource clinical settings. This study is registered with ClinicalTrials.gov NCT01863706.

Treatment for primary postpartum haemorrhage

BACKGROUND

Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries.

OBJECTIVES

To assess the effectiveness and safety of any intervention used for the treatment of primary PPH.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2013).

SELECTION CRITERIA

Randomised controlled trials comparing any interventions for the treatment of primary PPH.

DATA COLLECTION AND ANALYSIS

We assessed studies for eligibility and quality and extracted data independently. We contacted authors of the included studies to request more information.

MAIN RESULTS

Ten randomised clinical trials (RCTs) with a total of 4052 participants fulfilled our inclusion criteria and were included in this review.Four RCTs (1881 participants) compared misoprostol with placebo given in addition to conventional uterotonics. Adjunctive use of misoprostol (in the dose of 600 to 1000 mcg) with simultaneous administration of additional uterotonics did not provide additional benefit for our primary outcomes including maternal mortality (risk ratio (RR) 6.16, 95% confidence interval (CI) 0.75 to 50.85), serious maternal morbidity (RR 0.34, 95% CI 0.01 to 8.31), admission to intensive care (RR 0.79, 95% CI 0.30 to 2.11) or hysterectomy (RR 0.93, 95% CI 0.16 to 5.41).  Two RCTs (1787 participants) compared 800 mcg sublingual misoprostol versus oxytocin infusion as primary PPH treatment; one trial included women who had received prophylactic uterotonics, and the other did not. Primary outcomes did not differ between the two groups, although women given sublingual misoprostol were more likely to have additional blood loss of at least 1000 mL (RR 2.65, 95% CI 1.04 to 6.75). Misoprostol was associated with a significant increase in vomiting and shivering.Two trials attempted to test the effectiveness of estrogen and tranexamic acid, respectively, but were too small for any meaningful comparisons of pre-specified outcomes.One study compared lower segment compression but was too small to assess impact on primary outcomes.We did not identify any trials evaluating surgical techniques or radiological interventions for women with primary PPH unresponsive to uterotonics and/or haemostatics.

AUTHORS' CONCLUSIONS

Clinical trials included in the current review were not adequately powered to assess impact on the primary outcome measures. Compared with misoprostol, oxytocin infusion is more effective and causes fewer side effects when used as first-line therapy for the treatment of primary PPH. When used after prophylactic uterotonics, misoprostol and oxytocin infusion worked similarly. The review suggests that among women who received oxytocin for the treatment of primary PPH, adjunctive use of misoprostol confers no added benefit.The role of tranexamic acid and compression methods requires further evaluation. Furthermore, future studies should focus on the best way to treat women who fail to respond to uterotonic therapy.