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Yu XW, Wang CS, Zhang GM. Shenghua decoction for postpartum hemorrhage attributed to uterine atony: An observational study. Medicine (Baltimore) 2024; 103:e39351. [PMID: 39183400 PMCID: PMC11346844 DOI: 10.1097/md.0000000000039351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 05/06/2024] [Accepted: 07/26/2024] [Indexed: 08/27/2024] Open
Abstract
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.
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Affiliation(s)
- Xi-Wen Yu
- Department of Acupuncture and Moxibustion, Baicheng Medical College, Baicheng, China
| | - Cheng-Si Wang
- College of Mathematical Sciences, Shanghai Jiaotong University, Shanghai, China
| | - Gui-Mei Zhang
- School Hospital, Changchun Medical College, Changchun, China
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2
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Okaforcha EI, Eleje GU, Ikechebelu JI, Ezeama CO, Igbodike EP, Ugwu EO, Okpala BC, Mbachu II, Umeononihu OS, Ogabido CA, Onwusulu DN, Oguejiofor CB, Okafor CC, Olisa CL, Ikwuka DC, Ofor IJ, Okafor CG. Intravenous versus intramuscular oxytocin injection for preventing uterine atonic primary postpartum haemorrhage in third stage of labour: A double-blind randomised controlled trial. SAGE Open Med 2024; 12:20503121241230484. [PMID: 38406581 PMCID: PMC10894536 DOI: 10.1177/20503121241230484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/18/2024] [Indexed: 02/27/2024] Open
Abstract
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.
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Affiliation(s)
| | - George Uchenna Eleje
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University, Awka, Nigeria
| | - Joseph Ifeanyichukwu Ikechebelu
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University, Awka, Nigeria
| | - Chukwuemeka Okwudili Ezeama
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University, Awka, Nigeria
| | | | - Emmanuel Onyebuchi Ugwu
- Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Nigeria
| | - Boniface Chukwuneme Okpala
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University, Awka, Nigeria
| | - Ikechukwu Innocent Mbachu
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University, Awka, Nigeria
| | - Osita Samuel Umeononihu
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University, Awka, Nigeria
| | - Chukwudi Anthony Ogabido
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University, Awka, Nigeria
| | - Daniel Nnaemeka Onwusulu
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University, Awka, Nigeria
| | - Charlotte Blanche Oguejiofor
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University, Awka, Nigeria
| | | | - Chinedu Lawrence Olisa
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - David Chibuike Ikwuka
- Department of Medical Physiology, College of Medicine and Health Sciences, University of Rwanda, Huye, Rwanda
| | | | - Chigozie Geoffrey Okafor
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
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Abu Esba LC, Al Mardawi G, Al Mardawi E, Almadhi FM, Ardah HI. Misoprostol-Induced Fever and Unnecessary Antibiotic Prescribing: A Retrospective Study. Infect Dis Ther 2023; 12:2259-2268. [PMID: 37704800 PMCID: PMC10581965 DOI: 10.1007/s40121-023-00865-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/24/2023] [Indexed: 09/15/2023] Open
Abstract
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.
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Affiliation(s)
- Laila Carolina Abu Esba
- King Abdulaziz Medical City, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Ghada Al Mardawi
- King Abdulaziz Medical City, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Elham Al Mardawi
- Department of Obstetric and Gynecology, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Fay Musaed Almadhi
- King Abdulaziz Medical City, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Husam I. Ardah
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Bláha J, Bartošová T. Epidemiology and definition of PPH worldwide. Best Pract Res Clin Anaesthesiol 2022; 36:325-339. [PMID: 36513428 DOI: 10.1016/j.bpa.2022.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 10/17/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022]
Abstract
Postpartum/peripartum hemorrhage (PPH) is an obstetric emergency complicating 1-10% of all deliveries and is a leading cause of maternal mortality and morbidity worldwide. However, the incidence of PPH differs widely according to the definition and criteria used, the way of measuring postpartum blood loss, and the population being studied with the highest numbers in developing countries. Despite all the significant progress in healthcare, the incidence of PPH is rising due to an incomplete implementation of guidelines, resulting in treatment delays and suboptimal care. A consensus clinical definition of PPH is needed to enable awareness, early recognition, and initiation of appropriate intensive treatment. Unfortunately, the most used definition of PPH based on blood loss ≥500 ml after delivery suffers from inaccuracies in blood loss quantification and is not clinically relevant in most cases, as the amount of blood loss does not fully reflect the severity of bleeding.
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Affiliation(s)
- Jan Bláha
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
| | - Tereza Bartošová
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
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5
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Postpartum Hemorrhage: A Comprehensive Review of Guidelines. Obstet Gynecol Surv 2022; 77:665-682. [DOI: 10.1097/ogx.0000000000001061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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6
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Voillequin S, Rozenberg P, Ravaud P, Rousseau A. Promptness of oxytocin administration for first-line treatment of postpartum hemorrhage: a national vignette-based study among midwives. BMC Pregnancy Childbirth 2022; 22:353. [PMID: 35461215 PMCID: PMC9034651 DOI: 10.1186/s12884-022-04648-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/31/2022] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- S Voillequin
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France. .,INSERM UMR1018 "Clinical Epidemiology Team", Research Center on Epidemiology and Population Health (CESP), UVSQ, Paris Saclay University, Villejuif, France. .,Midwifery Department, Strasbourg University, Strasbourg, France.
| | - P Rozenberg
- INSERM UMR1018 "Clinical Epidemiology Team", Research Center on Epidemiology and Population Health (CESP), UVSQ, Paris Saclay University, Villejuif, France.,Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
| | - Ph Ravaud
- INSERM UMR1153, Centre of Research Epidemiology and Statistics (CRESS), Université de Paris, Paris, France.,Center for Clinical Epidemiology, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Hôtel Dieu, Paris, France
| | - A Rousseau
- INSERM UMR1018 "Clinical Epidemiology Team", Research Center on Epidemiology and Population Health (CESP), UVSQ, Paris Saclay University, Villejuif, France.,Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
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7
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World Health Organization Recommendation for Using Uterine Balloon Tamponade to Treat Postpartum Hemorrhage. Obstet Gynecol 2022; 139:458-462. [PMID: 35115478 PMCID: PMC8843394 DOI: 10.1097/aog.0000000000004674] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/11/2021] [Indexed: 11/26/2022]
Abstract
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.
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Pacagnella RC, Borovac-Pinheiro A, Silveira C, Siani Morais S, Argenton JLP, Souza JP, Weeks AD, Cecatti JG. The golden hour for postpartum hemorrhage: Results from a prospective cohort study. Int J Gynaecol Obstet 2021; 156:450-458. [PMID: 34254311 DOI: 10.1002/ijgo.13823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the predictive capacity of vital signs for the diagnosis of postpartum hemorrhage (PPH). METHODS A prospective cohort study performed at the University of Campinas, Brazil, between February 2015 and March 2016 with women who delivered vaginally. Vital signs and postpartum bleeding were collected over 24 h. Exploratory data analysis was performed plus receiver operating characteristic curve analysis where the areas under the curve was used to determine the best cutoff points for sensitivity, specificity, likelihood ratio, and diagnostic odds ratio. RESULTS For the 270 women recruited, mean blood loss after 120 min was 427.49 ± 335.57 ml, while 84 (31.1%) and 22 (8.1%) women had blood loss ≥500 and ≥1000 ml, respectively. Heart rate cutoff point of 105 bpm measured between 21-40 min after birth identified blood loss ≥1000 ml with 90% specificity. A shock index (SI) of 0.965 at 41-60 min after birth identified blood loss ≥500 and ≥1000 ml within 2 h with approximately 95% specificity. CONCLUSION Shock index and heart rate measured after birth showed high specificity with low sensitivity to identify PPH. In clinical practice, "The rule of 1s" should receive special attention: SI ≥1, or heart rate >100 bpm, or estimated blood loss ≥1 L.
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Affiliation(s)
- Rodolfo C Pacagnella
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Anderson Borovac-Pinheiro
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Carla Silveira
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Sirlei Siani Morais
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | | | - Joao Paulo Souza
- Department of Social Medicine, Ribeirao Preto Medical School, University of São Paulo, Ribeirao Preto, Brazil
| | - Andrew D Weeks
- Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - José G Cecatti
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
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Borovac-Pinheiro A, Priyadarshani P, Burke TF. A review of postpartum hemorrhage in low-income countries and implications for strengthening health systems. Int J Gynaecol Obstet 2021; 154:393-399. [PMID: 33529365 DOI: 10.1002/ijgo.13618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/13/2020] [Accepted: 01/21/2021] [Indexed: 11/09/2022]
Abstract
Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality worldwide. Disparities in PPH-associated survival between high and low-/middle-income countries reflect an imperative for low-resource countries to improve strategies for rapid diagnosis and treatment. A review of current PPH diagnosis, prevention, treatment, and access to care in low-income countries has been used to understand, extract, and report the challenges that public health systems face in trying to solve the marked global disparity in PPH outcomes. Improvement in PPH survival begins with holistic strengthening of each step along the continuum of care in health systems and should include performance feedback measures and quality-of-care research.
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Affiliation(s)
- Anderson Borovac-Pinheiro
- Global Health Innovation Lab, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Preeti Priyadarshani
- Global Health Innovation Lab, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Gorakhpur, India
| | - Thomas F Burke
- Global Health Innovation Lab, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard T, H. Chan School of Public Health, Boston, MA, USA
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Mary M, Jafarey S, Dabash R, Kamal I, Rabbani A, Abbas D, Durocher J, Tan YL, Winikoff B. 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. Matern Child Health J 2020; 25:118-126. [PMID: 33242210 PMCID: PMC7822773 DOI: 10.1007/s10995-020-03047-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 12/03/2022]
Abstract
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.
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Affiliation(s)
- Meighan Mary
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA.
| | - Sadiqua Jafarey
- National Committee for Maternal and Neonatal Health, Karachi, Pakistan
| | - Rasha Dabash
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Imtiaz Kamal
- National Committee for Maternal and Neonatal Health, Karachi, Pakistan
| | - Arjumand Rabbani
- National Committee for Maternal and Neonatal Health, Karachi, Pakistan
| | - Dina Abbas
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Jill Durocher
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Yi-Ling Tan
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Beverly Winikoff
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
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11
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Parry Smith WR, Papadopoulou A, Thomas E, Tobias A, Price MJ, Meher S, Alfirevic Z, Weeks AD, Hofmeyr GJ, Gülmezoglu AM, Widmer M, Oladapo OT, Vogel JP, Althabe F, Coomarasamy A, Gallos ID. Uterotonic agents for first-line treatment of postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev 2020; 11:CD012754. [PMID: 33232518 PMCID: PMC8130992 DOI: 10.1002/14651858.cd012754.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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®.
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Affiliation(s)
- William R Parry Smith
- WHO Collaborating Centre for Global Women's Health Research, Institute of Metabolism and Systems Research, School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Argyro Papadopoulou
- WHO Collaborating Centre for Global Women's Health Research, Institute of Metabolism and Systems Research, School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Eleanor Thomas
- WHO Collaborating Centre for Global Women's Health Research, Institute of Metabolism and Systems Research, School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Aurelio Tobias
- WHO Collaborating Centre for Global Women's Health Research, Institute of Metabolism and Systems Research, School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Malcolm J Price
- WHO Collaborating Centre for Global Women's Health Research, Institute of Metabolism and Systems Research, School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Zarko Alfirevic
- Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Andrew D Weeks
- Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, University of Botswana; University of Fort Hare, University of the Witwatersrand, Eastern Cape Department of Health, East London, South Africa
| | | | - Mariana Widmer
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Joshua P Vogel
- Maternal and Child Health, Burnet Institute, Melbourne, Australia
| | - Fernando Althabe
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Arri Coomarasamy
- WHO Collaborating Centre for Global Women's Health Research, Institute of Metabolism and Systems Research, School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- WHO Collaborating Centre for Global Women's Health Research, Institute of Metabolism and Systems Research, School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Abbas DF, Mirzazada S, Durocher J, Pamiri S, Byrne ME, Winikoff B. 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. Reprod Health 2020; 17:88. [PMID: 32503556 PMCID: PMC7275481 DOI: 10.1186/s12978-020-00933-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/24/2020] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Dina F Abbas
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Shafiq Mirzazada
- Academic Projects Afghanistan, Aga Khan University, Co French Medical Institute for Children, Ali Abad, Kabul, Afghanistan
| | - Jill Durocher
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA.
| | - Shahfaqir Pamiri
- Aga Khan Health Services Afghanistan (AKHS-A), An Agency of the Aga Khan Development Network (AKDN), Baghlan, Afghanistan
| | - Meagan E Byrne
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Beverly Winikoff
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
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13
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Anger HA, Dabash R, Hassanein N, Darwish E, Ramadan MC, Nawar M, Charles D, Breebaart M, Winikoff B. 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. BMC Pregnancy Childbirth 2020; 20:317. [PMID: 32448257 PMCID: PMC7245883 DOI: 10.1186/s12884-020-03008-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 05/11/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Holly A Anger
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA.
| | - Rasha Dabash
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA
| | | | - Emad Darwish
- Faculty of Medicine, Alexandria University, 17 Champollion St, El Messalah, Alexandria, Egypt
| | | | - Medhat Nawar
- El Beheira Governorate, Ministry of Health and Population, Damanhour, Egypt
| | - Dyanna Charles
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA
| | | | - Beverly Winikoff
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA
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14
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Durocher J, Aguirre JD, Dzuba IG, Mirta Morales E, Carroli G, Esquivel J, Martin R, Berecoechea C, Winikoff B. High fever after sublingual administration of misoprostol for treatment of post-partum haemorrhage: a hospital-based, prospective observational study in Argentina. Trop Med Int Health 2020; 25:714-722. [PMID: 32155681 PMCID: PMC7317539 DOI: 10.1111/tmi.13389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - Jesica Esquivel
- Hospital Materno Neonatal E.T. de Vidal, Corrientes, Argentina
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15
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Diop A, Abbas D, Ngoc NTN, Martin R, Razafi A, Tuyet HTD, Winikoff B. A double-blind, randomized controlled trial to explore oral tranexamic acid as adjunct for the treatment for postpartum hemorrhage. Reprod Health 2020; 17:34. [PMID: 32143721 PMCID: PMC7060559 DOI: 10.1186/s12978-020-0887-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 02/18/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Ayisha Diop
- Gynuity Health Projects, 220 E. 42nd Street Suite 710, New York, NY 10017 USA
| | - Dina Abbas
- Gynuity Health Projects, 220 E. 42nd Street Suite 710, New York, NY 10017 USA
| | - Nguyen thi Nhu Ngoc
- Center for Research and Consultancy in Reproductive Health (CRCRH), 38A Nguyễn Lâm. Ward 6 District 10, Ho Chi Minh City, Vietnam
| | - Roxanne Martin
- Gynuity Health Projects, 220 E. 42nd Street Suite 710, New York, NY 10017 USA
| | - Ange Razafi
- Maternité Hopital Regional El Hadji Ahmadou Sakhir Ndieguene De Thiès, Thiès, Senegal
| | | | - Beverly Winikoff
- Gynuity Health Projects, 220 E. 42nd Street Suite 710, New York, NY 10017 USA
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Numfor E, Fobellah NN, Tochie JN, Njim T, Ndesso SA. Oxytocin Versus Misoprostol Plus Oxytocin in the Prevention of Postpartum Hemorrhage at a Semi-Urban Hospital in sub-Saharan Africa: A Retrospective Cohort Study. Int J MCH AIDS 2020; 9:287-296. [PMID: 32913668 PMCID: PMC7472564 DOI: 10.21106/ijma.365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Emmanuel Numfor
- School of Health and Human Sciences, Saint Monica University Higher Institute, Buea, Cameroon
| | - Nkengafac Nyiawung Fobellah
- School of Health and Human Sciences, Saint Monica University Higher Institute, Buea, Cameroon and Department of General Medicine, Bangem District Hospital, Bangem, Cameroon
| | - Joel Noutakdie Tochie
- Department of Anaesthesiology and Critical Care Medicine, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon and Human Research Education and Networking, Yaoundé, Cameroon
| | - Tsi Njim
- Health and Human Development (2HD) Research Network, Douala, Cameroon
| | - Sylvester Atanga Ndesso
- School of Health and Human Sciences, Saint Monica University Higher Institute, Buea, Cameroon
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Koch DM, Rattmann YD. Use of misoprostol in the treatment of postpartum hemorrhage: a pharmacoepidemiological approach. EINSTEIN-SAO PAULO 2019; 18:eAO5029. [PMID: 31721897 PMCID: PMC6896658 DOI: 10.31744/einstein_journal/2020ao5029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 06/27/2019] [Indexed: 11/05/2022] Open
Abstract
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.
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Meher S. How should we diagnose and assess the severity of PPH in clinical trials? Best Pract Res Clin Obstet Gynaecol 2019; 61:41-54. [DOI: 10.1016/j.bpobgyn.2019.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 03/31/2019] [Accepted: 04/17/2019] [Indexed: 01/12/2023]
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Anger H, Durocher J, Dabash R, Winikoff B. How well do postpartum blood loss and common definitions of postpartum hemorrhage correlate with postpartum anemia and fall in hemoglobin? PLoS One 2019; 14:e0221216. [PMID: 31437195 PMCID: PMC6705817 DOI: 10.1371/journal.pone.0221216] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/30/2019] [Indexed: 11/28/2022] Open
Abstract
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 (rs) 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: rs = -0.220, multi-country trials: rs = -0.271) and postpartum hemoglobin (Pakistan: rs = -0.220, multi-country trials: rs = -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.
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Affiliation(s)
- Holly Anger
- Gynuity Health Projects, New York, NY, United States of America
- * E-mail:
| | - Jill Durocher
- Gynuity Health Projects, New York, NY, United States of America
| | - Rasha Dabash
- Gynuity Health Projects, New York, NY, United States of America
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Aflaifel NB, Chandhiok N, Fawole B, Geller SE, Weeks AD. Use of histograms to assess the efficacy of uterotonic treatment for post-partum haemorrhage: A feasibility study. Best Pract Res Clin Obstet Gynaecol 2019; 61:15-27. [PMID: 31204091 DOI: 10.1016/j.bpobgyn.2019.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/25/2019] [Accepted: 04/28/2019] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Nasreen B Aflaifel
- Sanyu Research Unit, University Department of Women's and Children's Health Liverpool Women's Hospital, Liverpool, UK; Department of Obstetrics and Gynaecology, University of Omar Al Mukhtar, Al Bida, Libya
| | - Nomita Chandhiok
- Division of Reproductive Health and Nutrition, Indian Council of Medical Research, New Delhi, India
| | - Bukola Fawole
- Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria
| | - Stacie E Geller
- Department of Obstetrics and Gynecology, University of Arizona, Chicago, USA
| | - Andrew D Weeks
- Sanyu Research Unit, University Department of Women's and Children's Health Liverpool Women's Hospital, Liverpool, UK.
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Fawzy AEMA, Swelem M, Abdelrehim AI, Titeli S, Elghazal ZS, El-Gahwagi MM, Ben Amour AS. Active management of third stage of labor by intravenous ergometrine and rectal versus sublingual misoprostol (a double-center study). ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2012.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Abd El-Moneim A. Fawzy
- El-Shatby University Maternity Hospital, Department of Obstetrics and Gynecology , University of Alexandria , Egypt
| | - Manal Swelem
- El-Shatby University Maternity Hospital, Department of Obstetrics and Gynecology , University of Alexandria , Egypt
| | - Amr I. Abdelrehim
- El-Shatby University Maternity Hospital, Department of Obstetrics and Gynecology , University of Alexandria , Egypt
| | - Salem Titeli
- Al-Jamhoriya Hospital, Department of Obstetrics and Gynecology , University of Benghazi , Libya
| | - Zahya S. Elghazal
- Al-Jamhoriya Hospital, Department of Obstetrics and Gynecology , University of Benghazi , Libya
| | - Milad M. El-Gahwagi
- Al-Jamhoriya Hospital, Department of Obstetrics and Gynecology , University of Benghazi , Libya
| | - Asma S. Ben Amour
- Al-Jamhoriya Hospital, Department of Obstetrics and Gynecology , University of Benghazi , Libya
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Abbas DF, Jehan N, Diop A, Durocher J, Byrne ME, Zuberi N, Ahmed Z, Walraven G, Winikoff B. Using misoprostol to treat postpartum hemorrhage in home deliveries attended by traditional birth attendants. Int J Gynaecol Obstet 2019; 144:290-296. [PMID: 30582753 DOI: 10.1002/ijgo.12756] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 07/29/2018] [Accepted: 12/21/2018] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - Nadeem Zuberi
- Department of Obstetrics and Gynecology, The Aga Khan University, Karachi, Pakistan
| | - Zafar Ahmed
- Aga Khan Health Service, Islamabad, Pakistan
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Thorneloe B, Carvalho JCA, Downey K, Balki M. Uterotonic drug usage in Canada: a snapshot of the practice in obstetric units of university-affiliated hospitals. Int J Obstet Anesth 2018; 37:45-51. [PMID: 30396679 DOI: 10.1016/j.ijoa.2018.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/25/2018] [Accepted: 09/03/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The objective of this study was to determine the pattern of uterotonic drug usage in obstetric units of university-affiliated hospitals in Canada. METHODS This was a prospective observational study conducted in the form of an electronic survey. The target group consisted of chiefs or directors of Obstetrics and Anaesthesia at university-affiliated hospitals across Canada. The survey was sent out between November 2016 and January 2017, using the program 'SurveyMonkey'. Data on institutional obstetric practices and usage of uterotonic agents were collected. RESULTS The survey was sent to 92 obstetricians and anesthesiologists from 46 institutions, of which 33 clinicians from 24 institutions responded. About 65% of clinicians were unaware of the rate of postpartum hemorrhage in their institution. The first-line agent for vaginal deliveries was reported as oxytocin by 94% and carbetocin by 6% of physicians. For women at low-risk for postpartum hemorrhage when undergoing cesarean deliveries (CD), 66% reported oxytocin as the first-line uterotonic, while 34% reported carbetocin. For CDs at high-risk of postpartum hemorrhage, 60% of physicians reported oxytocin and 40% reported using carbetocin initially. The use of second-line uterotonics was also variable. The choice of uterotonic was mainly based on perceived efficacy and Society of Obstetricians and Gynaecologists of Canada guidelines. CONCLUSION There is a lack of a unified approach to the use of uterotonic drugs for postpartum hemorrhage management in Canada. To improve the management of postpartum hemorrhage due to uterine atony, an evidence-based approach to usage and consensus between obstetricians and anesthesiologists is warranted.
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Affiliation(s)
- B Thorneloe
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Canada
| | - J C A Carvalho
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Canada; Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Canada
| | - K Downey
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Canada
| | - M Balki
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Canada; Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Canada; Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Canada.
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Perrin C, Hounga L, Geissbuhler A. Systematic review to identify proxy indicators to quantify the impact of eHealth tools on maternal and neonatal health outcomes in low-income and middle-income countries including Delphi consensus. BMJ Open 2018; 8:e022262. [PMID: 30121608 PMCID: PMC6104789 DOI: 10.1136/bmjopen-2018-022262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/18/2018] [Accepted: 07/26/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To identify interventions that could serve as reliable proxy indicators to measure eHealth impact on maternal and neonatal outcomes. DESIGN Systematic review and Delphi study. METHODS We searched PubMed, Embase and Cochrane from January 1990 to May 2016 for studies and reviews that evaluated interventions aimed at improving maternal/neonatal health and reducing mortality. Interventions that are not low-income and middle-income context appropriate and that cannot currently be diagnosed, managed or impacted by eHealth (eg, via telemedicine distance diagnostic or e-learning) were excluded. We used the Cochrane risk of bias, Risk Of Bias In Non- randomised Studies - of Interventions and ROBIS tool to assess the risk of bias. A three-step modified Delphi method was added to identify additional proxy indicators and prioritise the results, involving a panel of 13 experts from different regions, representing obstetricians and neonatologists. RESULTS We included 44 studies and reviews, identifying 40 potential proxy indicators with a positive impact on maternal/neonatal outcomes. The Delphi experts completed and prioritised these, resulting in a list of 77 potential proxy indicators. CONCLUSIONS The proxy indicators propose relevant outcome measures to evaluate if eHealth tools directly affect maternal/neonatal outcomes. Some proxy indicators require mapping to the local context, practices and available resources. The local mapping facilitates the utilisation of the proxy indicators in various contexts while allowing the systematic collection of data from different projects and programmes. Based on the mapping, the same proxy indicator can be used for different contexts, allowing it to measure what is locally and temporally relevant, making the proxy indicator sustainable. PROSPERO REGISTRATION NUMBER CRD42015027351.
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Affiliation(s)
- Caroline Perrin
- Department of Radiology and Medical Informatics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Lothaire Hounga
- Department of Radiology and Medical Informatics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Antoine Geissbuhler
- Department of Radiology and Medical Informatics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Implementing at-scale, community-based distribution of misoprostol tablets to mothers in the third stage of labor for the prevention of postpartum haemorrhage in Sokoto State, Nigeria: Early results and lessons learned. PLoS One 2017; 12:e0170739. [PMID: 28234894 PMCID: PMC5325195 DOI: 10.1371/journal.pone.0170739] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 01/10/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is a leading cause of maternal death in Sokoto State, Nigeria, where 95% of women give birth outside of a health facility. Although pilot schemes have demonstrated the value of community-based distribution of misoprostol for the prevention of PPH, none have provided practical insight on taking such programs to scale. METHODS A community-based system for the distribution of misoprostol tablets (in 600ug) and chlorhexidine digluconate gel 7.1% to mother-newborn dyads was introduced by state government officials and community leaders throughout Sokoto State in April 2013, with the potential to reach an estimated 190,467 annual births. A simple outcome form that collected distribution and consumption data was used to assess the percentage of mothers that received misoprostol at labor through December 2014. Mothers' conditions were tracked through 6 weeks postpartum. Verbal autopsies were conducted on associated maternal deaths. RESULTS Misoprostol distribution was successfully introduced and reached mothers in labor in all 244 wards in Sokoto State. Community data collection systems were successfully operational in all 244 wards with reliable capacity to record maternal deaths. 70,982 women or 22% of expected births received misoprostol from April 2013 to December 2014. Between April and December 2013, 33 women (< 1%) reported that heavy bleeding persisted after misoprostol use and were promptly referred. There were a total of 11 deaths in the 2013 cohort which were confirmed as maternal deaths by verbal autopsies. Between January and December of 2014, a total 434 women (1.25%) that ingested misoprostol reported associated side effects. CONCLUSION It is feasible and safe to utilize government guidelines on results-based primary health care to successfully introduce community distribution of life saving misoprostol at scale to reduce PPH and improve maternal outcomes. Lessons from Sokoto State's at-scale program implementation, to assure every mother's right to uterotonics, can inform scale-up elsewhere in Nigeria.
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Abstract
Peripartum hemorrhage (PPH) is a frequent obstetric emergency situation with increasing incidence in the last decades. It requires a fast, coordinated and interdisciplinary management. This life-threatening situation is often recognized too late and not adequately treated (too little is done too late); therefore, it is important to be aware of the most important risk factors for PPH known as the 4 Ts (i.e. tonus, trauma, tissue and thrombin). Due to the special patient population there is only little evidence-based data on hemostatic therapy in this situation; therefore, the currently available studies on the therapy of PPH is discussed.
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Kerr R, Eckert LO, Winikoff B, Durocher J, Meher S, Fawcus S, Mundle S, Mol B, Arulkumaran S, Khan K, Wandwabwa J, Kochhar S, Weeks A. Postpartum haemorrhage: Case definition and guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2016; 34:6102-6109. [PMID: 27431424 PMCID: PMC5139805 DOI: 10.1016/j.vaccine.2016.03.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/15/2016] [Indexed: 12/02/2022]
Affiliation(s)
| | | | | | | | | | - Sue Fawcus
- Mowbray Maternity Hospital, South Africa
| | | | - Ben Mol
- University of Adelaide, Australia
| | | | - Khalid Khan
- Barts and The London School of Medicine and Dentistry, UK
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28
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Kerr RS, Weeks AD. Postpartum haemorrhage: a single definition is no longer enough. BJOG 2016; 124:723-726. [DOI: 10.1111/1471-0528.14417] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2016] [Indexed: 11/29/2022]
Affiliation(s)
- RS Kerr
- Sanyu Research Unit; Department of Women's and Children's Health; University of Liverpool; Liverpool Women's Hospital; Liverpool UK
| | - AD Weeks
- Sanyu Research Unit; Department of Women's and Children's Health; University of Liverpool; Liverpool Women's Hospital; Liverpool UK
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29
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Prata N, Weidert K. Efficacy of misoprostol for the treatment of postpartum hemorrhage: current knowledge and implications for health care planning. Int J Womens Health 2016; 8:341-9. [PMID: 27536161 PMCID: PMC4973720 DOI: 10.2147/ijwh.s89315] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Ndola Prata
- Bixby Center for Population, Health and Sustainability, School of Public Health, University of California at Berkeley, Berkeley, CA, USA
| | - Karen Weidert
- Bixby Center for Population, Health and Sustainability, School of Public Health, University of California at Berkeley, Berkeley, CA, USA
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Maternal characteristics and clinical diagnoses influence obstetrical outcomes in Indonesia. Matern Child Health J 2016; 19:1624-33. [PMID: 25656716 DOI: 10.1007/s10995-015-1673-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
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.
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Frye LJ, Byrne ME, Winikoff B. A crossover pharmacokinetic study of misoprostol by the oral, sublingual and buccal routes. EUR J CONTRACEP REPR 2016; 21:265-8. [DOI: 10.3109/13625187.2016.1168799] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Raghavan S, Geller S, Miller S, Goudar SS, Anger H, Yadavannavar MC, Dabash R, Bidri SR, Gudadinni MR, Udgiri R, Koch AR, Bellad MB, Winikoff B. Misoprostol for primary versus secondary prevention of postpartum haemorrhage: a cluster-randomised non-inferiority community trial. BJOG 2016; 123:120-7. [PMID: 26333044 PMCID: PMC5014137 DOI: 10.1111/1471-0528.13540] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2015] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
| | - S Geller
- University of Illinois at ChicagoChicagoILUSA
| | - S Miller
- University of CaliforniaSan FranciscoCAUSA
| | - SS Goudar
- KLE University's Jawaharlal Nehru Medical CollegeBelgaumIndia
| | - H Anger
- Gynuity Health ProjectsNew YorkNYUSA
| | - MC Yadavannavar
- BLDE University's Sri B. M. Patil Medical CollegeBijapurIndia
| | - R Dabash
- Gynuity Health ProjectsNew YorkNYUSA
| | - SR Bidri
- BLDE University's Sri B. M. Patil Medical CollegeBijapurIndia
| | - MR Gudadinni
- BLDE University's Sri B. M. Patil Medical CollegeBijapurIndia
| | - R Udgiri
- BLDE University's Sri B. M. Patil Medical CollegeBijapurIndia
| | - AR Koch
- University of Illinois at ChicagoChicagoILUSA
| | - MB Bellad
- KLE University's Jawaharlal Nehru Medical CollegeBelgaumIndia
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Weeks AD, Ditai J, Ononge S, Faragher B, Frye LJ, Durocher J, Mirembe FM, Byamugisha J, Winikoff B, Alfirevic Z. The MamaMiso study of self-administered misoprostol to prevent bleeding after childbirth in rural Uganda: a community-based, placebo-controlled randomised trial. BMC Pregnancy Childbirth 2015; 15:219. [PMID: 26370443 PMCID: PMC4570250 DOI: 10.1186/s12884-015-0650-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 09/07/2015] [Indexed: 11/16/2022] Open
Abstract
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).
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Affiliation(s)
- Andrew D Weeks
- Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK.
| | - James Ditai
- Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital; and Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK.
| | - Sam Ononge
- Department of Obstetrics and Gynaecology, Makerere University College of Health Science, P.O Box 7072, Kampala, Uganda.
| | - Brian Faragher
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Laura J Frye
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA.
| | - Jill Durocher
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA.
| | - Florence M Mirembe
- Department of Obstetrics and Gynaecology, Makerere University College of Health Science, P.O Box 7072, Kampala, Uganda.
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Makerere University College of Health Science, P.O Box 7072, Kampala, Uganda.
| | - Beverly Winikoff
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA.
| | - Zarko Alfirevic
- Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK.
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Alfirevic A, Durocher J, Elati A, León W, Dickens D, Rädisch S, Box H, Siccardi M, Curley P, Xinarianos G, Ardeshana A, Owen A, Zhang JE, Pirmohamed M, Alfirevic Z, Weeks A, Winikoff B. Misoprostol-induced fever and genetic polymorphisms in drug transporters SLCO1B1 and ABCC4 in women of Latin American and European ancestry. Pharmacogenomics 2015; 16:919-28. [PMID: 26122863 DOI: 10.2217/pgs.15.53] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Ana Alfirevic
- The Wolfson Centre for Personalised Medicine, Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Block A, Waterhouse Buildings, 1-5 Brownlow Street, Ashton Street, Liverpool, L69 3GL, UK
| | | | - Anisa Elati
- Department of Women's & Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK
| | - Wilfrido León
- Hospital Gineco-Obstétrico Isidro Ayora, Av Colombia N14-66 y Sodiro Quito, Ecuador
| | - David Dickens
- The Wolfson Centre for Personalised Medicine, Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Block A, Waterhouse Buildings, 1-5 Brownlow Street, Ashton Street, Liverpool, L69 3GL, UK
| | - Steffen Rädisch
- The Wolfson Centre for Personalised Medicine, Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Block A, Waterhouse Buildings, 1-5 Brownlow Street, Ashton Street, Liverpool, L69 3GL, UK
| | - Helen Box
- The Wolfson Centre for Personalised Medicine, Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Block A, Waterhouse Buildings, 1-5 Brownlow Street, Ashton Street, Liverpool, L69 3GL, UK
| | - Marco Siccardi
- The Wolfson Centre for Personalised Medicine, Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Block A, Waterhouse Buildings, 1-5 Brownlow Street, Ashton Street, Liverpool, L69 3GL, UK
| | - Paul Curley
- The Wolfson Centre for Personalised Medicine, Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Block A, Waterhouse Buildings, 1-5 Brownlow Street, Ashton Street, Liverpool, L69 3GL, UK
| | - George Xinarianos
- The Wolfson Centre for Personalised Medicine, Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Block A, Waterhouse Buildings, 1-5 Brownlow Street, Ashton Street, Liverpool, L69 3GL, UK
| | - Arjun Ardeshana
- The Wolfson Centre for Personalised Medicine, Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Block A, Waterhouse Buildings, 1-5 Brownlow Street, Ashton Street, Liverpool, L69 3GL, UK
| | - Andrew Owen
- The Wolfson Centre for Personalised Medicine, Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Block A, Waterhouse Buildings, 1-5 Brownlow Street, Ashton Street, Liverpool, L69 3GL, UK
| | - J Eunice Zhang
- The Wolfson Centre for Personalised Medicine, Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Block A, Waterhouse Buildings, 1-5 Brownlow Street, Ashton Street, Liverpool, L69 3GL, UK
| | - Munir Pirmohamed
- The Wolfson Centre for Personalised Medicine, Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Block A, Waterhouse Buildings, 1-5 Brownlow Street, Ashton Street, Liverpool, L69 3GL, UK
| | - Zarko Alfirevic
- Department of Women's & Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK
| | - Andrew Weeks
- Department of Women's & Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK
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Abstract
Abstract
Worldwide, ∼800 women die every day from preventable causes related to pregnancy or childbirth. The single most common cause is severe bleeding, which can kill a healthy woman within hours if care is substandard or delayed. Improved antenatal practices have led to the early identification of at-risk women and modern technology and new techniques have enabled effective management strategies so that now, in the western world, most of the morbidity and mortality arises from those cases which occur unexpectedly and could not have been predicted. Prompt and effective management and multidisciplinary involvement is paramount to save the lives of these women. We use a case report to illustrate and discuss the main elements of management of this condition.
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The Effect of Combined Oxytocin-Misoprostol Versus Oxytocin and Misoprostol Alone in Reducing Blood Loss at Cesarean Delivery: A Prospective Randomized Double-Blind Study. J Obstet Gynaecol India 2015; 65:376-81. [PMID: 26663995 DOI: 10.1007/s13224-014-0607-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 09/15/2014] [Indexed: 10/24/2022] Open
Abstract
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.
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Morel O, Perdriolle-Galet E, Mézan de Malartic C, Gauchotte E, Moncollin M, Patte C, Chabot-Lecoanet AC. Prise en charge obstétricale en cas d’hémorragie du post-partum qui persiste malgré les mesures initiales ou qui est sévère d’emblée, après accouchement par voie basse. ACTA ACUST UNITED AC 2014; 43:1019-29. [DOI: 10.1016/j.jgyn.2014.09.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Weeks A. The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next? BJOG 2014; 122:202-10. [PMID: 25289730 DOI: 10.1111/1471-0528.13098] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2014] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- A Weeks
- Sanyu Research Unit, Department of Women's and Children's Health, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
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Ambardekar S, Shochet T, Bracken H, Coyaji K, Winikoff B. Calibrated delivery drape versus indirect gravimetric technique for the measurement of blood loss after delivery: a randomized trial. BMC Pregnancy Childbirth 2014; 14:276. [PMID: 25128176 PMCID: PMC4141098 DOI: 10.1186/1471-2393-14-276] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 08/05/2014] [Indexed: 11/12/2022] Open
Abstract
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.
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Joshi M, Ananth CV. The line of 'no difference' is not engraved in stone: the utility of non-inferiority clinical trials. BJOG 2014; 121:920-2. [PMID: 24958567 DOI: 10.1111/1471-0528.12809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2014] [Indexed: 11/27/2022]
Affiliation(s)
- M Joshi
- Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, London, UK
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Safety and efficacy of misoprostol versus oxytocin for the prevention of postpartum hemorrhage. J Pregnancy 2014; 2014:713879. [PMID: 24734184 PMCID: PMC3964754 DOI: 10.1155/2014/713879] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 01/13/2014] [Accepted: 01/30/2014] [Indexed: 11/17/2022] Open
Abstract
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.
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Mousa HA, Blum J, Abou El Senoun G, Shakur H, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev 2014; 2014:CD003249. [PMID: 24523225 PMCID: PMC6483801 DOI: 10.1002/14651858.cd003249.pub3] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Hatem A Mousa
- Leicester Royal InfirmaryUniversity Department of Obstetrics and Gynaecology, Fetal and Maternal Medicine UnitInfirmary SquareLeicesterUKLE1 5WW
| | - Jennifer Blum
- Gynuity Health Projects15 East 26th St, Suite 801New YorkUSA10010
| | - Ghada Abou El Senoun
- Queen's Medical Centre, Nottingham University HospitalDepartment of Obstetrics and GynaecologyDerby RoadNottinghamNottinghamshireUKNG7 2UH
| | - Haleema Shakur
- London School of Hygiene & Tropical MedicineClinical Trials UnitKeppel StreetLondonUKWC1E 7HT
| | - Zarko Alfirevic
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Misoprostol : utilisation hors AMM dans la prise en charge de l’hémorragie du post-partum. ACTA ACUST UNITED AC 2014; 43:179-89. [DOI: 10.1016/j.jgyn.2013.11.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Pulmonary delivery of an ultra-fine oxytocin dry powder formulation: potential for treatment of postpartum haemorrhage in developing countries. PLoS One 2013; 8:e82965. [PMID: 24376618 PMCID: PMC3871608 DOI: 10.1371/journal.pone.0082965] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 10/29/2013] [Indexed: 12/01/2022] Open
Abstract
Oxytocin is recommended by the World Health Organisation as the most effective uterotonic for the prevention and treatment of postpartum haemorrhage. The requirement for parenteral administration by trained healthcare providers and the need for the drug solution to be maintained under cold-chain storage limit the use of oxytocin in the developing world. In this study, a spray-dried ultrafine formulation of oxytocin was developed with an optimal particle size diameter (1-5 µm) to facilitate aerosolised delivery via the lungs. A powder formulation of oxytocin, using mannitol, glycine and leucine as carriers, was prepared with a volume-based median particle diameter of 1.9 µm. Oxytocin content in the formulation was assayed using high-performance liquid chromatography-mass spectroscopy and was found to be unchanged after spray-drying. Ex vivo contractility studies utilising human and ovine uterine tissue indicated no difference in the bioactivity of oxytocin before and after spray-drying. Uterine electromyographic (EMG) activity in postpartum ewes following pulmonary (in vivo) administration of oxytocin closely mimicked that observed immediately postpartum (0-12 h following normal vaginal delivery of the lamb). In comparison to the intramuscular injection, pulmonary administration of an oxytocin dry powder formulation to postpartum ewes resulted in generally similar EMG responses, however a more rapid onset of uterine EMG activity was observed following pulmonary administration (129 ± 18 s) than intramuscular injection (275 ± 22 s). This is the first study to demonstrate the potential for oxytocin to elicit uterine activity after systemic absorption as an aerosolised powder from the lungs. Aerosolised oxytocin has the potential to provide a stable and easy to administer delivery system for effective prevention and treatment of postpartum haemorrhage in resource-poor settings in the developing world.
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Ghinea N, Lipworth W, Little M, Kerridge I, Day R. Overcoming Entrenched Disagreements: the Case of Misoprostol for Post-Partum Haemorrhage. Dev World Bioeth 2013; 15:48-54. [DOI: 10.1111/dewb.12040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mukta M, Sahay PB. Role of Misoprostol 600 mcg Oral in Active Management of Third Stage of Labor: A Comparative Study with Oxytocin 10 IU i.m. J Obstet Gynaecol India 2013; 63:325-7. [PMID: 24431668 PMCID: PMC3798442 DOI: 10.1007/s13224-012-0330-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Accepted: 11/20/2012] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES To compare oral misopostol 600 mcg with 10 IU units oxytocin i.m. in the active management of the third stage of labor. MATERIALS AND METHODS A total of 200 pregnant women of 34-42 weeks of gestation delivering vaginally in the Rajendra Institute of Medical Sciences, Ranchi, were selected for study. Hundred women received oral misoprostol 600 mg and 100 women received i.m. oxytocin 10 IU immediately after delivery of the baby and cord clamping by the method of randomization. RESULTS In the misoprostol group, mean blood loss is 145 ml, mean duration of the third stage of labor is 3.76 min, and mean fall in hemoglobin is 0.55 g/dl. In the oxytocin group, mean blood loss in 125.6 ml, mean duration of the third stage of labor in 3.50 min, and mean fall in hemoglobin is 0.48 g/dl. There was no significant difference between the two groups with regard to the above-mentioned factors. There were 8 cases of PPH in the misoprostol group and 6 cases in the oxytocin group. Twenty-two cases in the misoprostol group and 16 cases in the oxytocin group required additional oxytocics. Adverse effects like shivering and pyrexia were more in the misoprostol group. CONCLUSION Oral misoprostol is as effective as oxytocin in AMTSL and can be used safely in vaginal deliveries for prevention of PPH, especially in non-institutional deliveries and in places of low resource settings.
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Affiliation(s)
- Mani Mukta
- />Department of Obstetrics and Gynaecology, Rajendra Institute of Medical Sciences, Ranchi, India
- />C/O: Dr. Arun Kumar, A-1, Aishwarya Residency, Argora Kathal More Road, Deepatoli, Pundag, Infront of Al-Rahmat Sun City, Ranchi, 834004 Jharkhand India
| | - Priti Bala Sahay
- />Department of Obstetrics and Gynaecology, Rajendra Institute of Medical Sciences, Ranchi, India
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Tewatia R, Rani S, Srivastav U, Makhija B. Sublingual misoprostol versus intravenous oxytocin in prevention of post-partum hemorrhage. Arch Gynecol Obstet 2013; 289:739-42. [PMID: 24045979 DOI: 10.1007/s00404-013-3026-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 09/06/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Post-partum hemorrhage (PPH) is the most common direct cause of maternal mortality and timely intervention can save many lives. OBJECTIVE To compare the effectiveness of sublingual misoprostol to intravenous oxytocin in preventing post-partum hemorrhage in low risk vaginal birth. METHODS One hundred patients with no risk factor for PPH were randomly allocated to receive 600 μg misoprostol administered sublingually or 10 IU of intravenous oxytocin immediately after the delivery of baby. Main outcome measures were post-partum blood loss, drop in hemoglobin in 24 h, duration of third stage of labor, and drug-related adverse effects. RESULTS Mean age, parity and gestational age were similar in both groups. Mean blood loss was significantly lower in oxytocin group (114.28 ± 26.75 versus 149.50 ± 30.78 ml; p = 0.00). Drop in hemoglobin was 0.31 ± 0.16 versus 0.49 ± 0.21 g% (p = 0.01) in oxytocin and misoprostol group, respectively. Duration of third stage labor was shorter in oxytocin group (median 5 min, IQR: 4.5-5.5 versus 5.5 min, IQR: 5-6 min, p < 0.01). Although fever and shivering were common adverse effects with misoprostol but were not clinically significant. CONCLUSION Intravenous oxytocin is more efficacious than sublingual misoprostol in preventing PPH in institutional deliveries.
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Affiliation(s)
- Renu Tewatia
- Department of Obstetrics and Gynecology, Government Medical College and Hospital, Chandigarh, India
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Hofmeyr GJ, Gülmezoglu AM, Novikova N, Lawrie TA. Postpartum misoprostol for preventing maternal mortality and morbidity. Cochrane Database Syst Rev 2013:CD008982. [PMID: 23857523 DOI: 10.1002/14651858.cd008982.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The primary objective of postpartum haemorrhage (PPH) prevention and treatment is to reduce maternal deaths. Misoprostol has the major public health advantage over injectable medication that it can more easily be distributed at community level. Because misoprostol might have adverse effects unrelated to blood loss which might impact on mortality or severe morbidity, it is important to continue surveillance of all relevant evidence from randomised trials. This is particularly important as misoprostol is being introduced on a large scale for PPH prevention in low-income countries, and is commonly used for PPH treatment in well-resourced settings as well. OBJECTIVES To review maternal deaths and severe morbidity in all randomised trials of misoprostol for prevention or treatment of PPH. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 January 2013). SELECTION CRITERIA We included randomised trials including pregnant women who received misoprostol in the postpartum period, versus placebo/no treatment or other uterotonics for prevention or treatment of PPH, and reporting on maternal death, severe morbidity or pyrexia.We planned to include cluster- and quasi-randomised trials in the analysis, as a very large number of women will be needed to obtain robust estimates of maternal mortality but we did not identify any for this version of the review. In future updates of this review we will include trials reported only as abstracts if sufficient information is available from the abstract or from the authors. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and extracted data. MAIN RESULTS We included 78 studies (59,216 women) and excluded 34 studies.There was no statistically significant difference in maternal mortality for misoprostol compared with control groups overall (31 studies; 11/19,715 versus 4/20,076 deaths; risk ratio (RR) 2.08, 95% confidence interval (CI) 0.82 to 5.28); or for the trials of misoprostol versus placebo: 10 studies, 6/4626 versus 1/4707 ; RR 2.70; 95% CI 0.72 to 10.11; or for misoprostol versus other uterotonics: 21 studies, 5/15,089 versus 3/15,369 (19/100,000); RR 1.54; 95% CI 0.40 to 5.92. All 11 deaths in the misoprostol arms occurred in studies of misoprostol ≥ 600 µg.There was a statistically significant difference in the composite outcome 'maternal death or severe morbidity' for the comparison of misoprostol versus placebo (12 studies; average RR 1.70, 95% CI 1.02 to 2.81; Tau² = 0.00, I² = 0%) but not for the comparison of misoprostol versus other uterotonics (17 studies; average RR 1.50, 95% CI 0.50 to 4.52; Tau² = 1.81, I² = 69%). When we excluded hyperpyrexia from the composite outcome in exploratory analyses, there was no significant difference in either of these comparisons.Pyrexia > 38°C was increased with misoprostol compared with controls (56 studies, 2776/25,647 (10.8%) versus 614/26,800 (2.3%); average RR 3.97, 95% CI 3.13 to 5.04; Tau² = 0.47, I² = 80%). The effect was greater for trials using misoprostol 600 µg or more (27 studies; 2197/17,864 (12.3%) versus 422/18,161 (2.3%); average RR 4.64; 95% CI 3.33 to 6.46; Tau² = 0.51, I² = 86%) than for those using misoprostol 400 µg or less (31 studies; 525/6751 (7.8%) versus 185/7668 (2.4%); average RR 3.07; 95% CI 2.25 to 4.18; Tau² = 0.29, I² = 58%). AUTHORS' CONCLUSIONS Misoprostol does not appear to increase or reduce severe morbidity (excluding hyperpyrexia) when used to prevent or treat PPH. Misoprostol did not increase or decrease maternal mortality. However, misoprostol is associated with an increased risk of pyrexia, particularly in dosages of 600 µg or more. Given that misoprostol is used prophylactically in very large numbers of healthy women, the greatest emphasis should be placed on limiting adverse effects. In this context, the findings of this review support the use of the lowest effective dose. As for any new medication being used on a large scale, continued vigilance for adverse effects is essential and there is a need for large randomised trials to further elucidate both the relative effectiveness and the risks of various dosages of misoprostol.
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Affiliation(s)
- G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of FortHare, Eastern Cape Department of Health, East London, South
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Al-Sawaf A, El-Mazny A, Shohayeb A. A randomised controlled trial of sublingual misoprostol and intramuscular oxytocin for prevention of postpartum haemorrhage. J OBSTET GYNAECOL 2013; 33:277-9. [DOI: 10.3109/01443615.2012.755503] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gibbins KJ, Albright CM, Rouse DJ. Postpartum hemorrhage in the developed world: whither misoprostol? Am J Obstet Gynecol 2013; 208:181-3. [PMID: 22901709 DOI: 10.1016/j.ajog.2012.07.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 07/03/2012] [Accepted: 07/27/2012] [Indexed: 10/28/2022]
Abstract
We reviewed the literature to determine the optimal medical treatment of postpartum hemorrhage caused by uterine atony. Of the available uterotonics, only misoprostol and oxytocin have undergone rigorous comparative study. Of the 2, misoprostol is inferior: 2 recent well-done randomized trials with enrollment of more than 2200 patients demonstrated that, in situations in which prophylactic oxytocin has already been utilized, additional oxytocin is as effective as or better than misoprostol in terminating bleeding, while avoiding the high rate of fever (22-58%) associated with misoprostol. The second of these trials demonstrated that misoprostol does not augment the effect of oxytocin. We conclude that in settings in which oxytocin is available, oxytocin should remain the mainstay of both prophylaxis and first-line treatment of postpartum hemorrhage caused by uterine atony. In the developed world, the use of misoprostol for postpartum hemorrhage should be infrequent.
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